Regulation of labor during its anomalies

Use of antispasmodics

The emergence of the national science of the use of antispasmodics in obstetric practice is seventy years old. Back in 1923 Academician AP Nikolaev proposed to use for analgesia in childbirth a spasmolytic, recommended by prof. VF Snegirev with dysmenorrhea, - Indian hemp. Somewhat later, as indicated by AP Nikolaev (1964), belladonna, spasmalgin, was widely distributed.

Currently, there are a number of highly effective domestic and foreign antispasmodics. At the same time, from an infinite number of different drugs studied and applied over the past few years, only a few who have stood the test of wide practice on the basis of their effectiveness, harmlessness for both the mother and the child and the ease of implementation can be offered now. For example, the mentioned Indian hemp, which according to modern ideas belongs to the group of tranquilizers ("fiction"), from the therapeutic point of view does not matter, but it is important from the toxicological point of view.

While widely discussing and suggesting a number of antispasmodics for use in obstetrical practice, the scientists then simultaneously tried to outline the range of conditions in obstetrics in which the use of antispasmodics is most appropriate. However, excessive use of antispasmodics can not be considered justified. This is especially true for those drugs that are also quite good analgesics (promedol, drugs of the morphine group, etc.) and can lead to depression of the respiratory center in newborns if these drugs were injected less than one hour before the birth of the child.

Thus, it can be considered that the use of antispasmodics in a number of parturient women is one of the methods of rational management of labor. A number of drugs, analgesics, antispasmodics and their combinations in connection with the protective effect on motor activity of the uterus acquires a preventive value in certain types of inadequate delivery
of the uterus and prevent the protracted course of labor.

At the present stage, there are significant opportunities through the use of modern antispasmodics to solve the problem of preventing prolonged labor and timely correcting the violations of contractile activity of the uterus. Thus, the use of promedol and other substances.

For the first time in the national obstetrical literature, the question of the acceleration of normal births was posed by AP Nikolaev, K. K. Skrobansky, M. S. Malinovsky, E. I. Kvater.

KK Skrobansky (1936) recognized the idea of accelerating childbirth as extremely valuable, but recommended that it be implemented only with cautious, non-cosmetic methods that modern obstetrics has.

AP Nikolaev (1959), attaching great importance to the use of spasmolytic drugs in obstetric practice, believes that they are the basis of drug anesthetization of labor.

In general, the appointment of antispasmodics is shown:

• women who have undergone complete psycho-prophylactic training, but show signs of weakness, imbalance of the nervous system; past or incomplete, or in quality unsatisfactory preparation; finally, prepared for parturient women with the phenomena of general hypoplasia or insufficient development of the genital organs, too young and elderly women. In such cases, antispasmodic drugs are used at the beginning of the culmination phase of the disclosure period in order to prevent labor pains and only partly to eliminate them, i.e. For therapeutic purposes;
• women who have not undergone psycho-preventive training, or as an independent painkiller with pains already developed, or as a means, the use of which serves as a background for the more successful and complete action of other painkillers. In these cases, antispasmodics should be used, as a rule, when the cervix is opened 4 cm or more. In both cases, these drugs have a pronounced positive effect and contribute to the highly painful course of the birth act, especially since many of them, such as promedol, are also more or less pronounced along with antispasmodic properties analgesic and partially narcotic properties.

The most widespread in the 1960s was spasmolytics of the lidol type, which is currently not manufactured, but instead it was synthesized by a more effective medication - promedol, which has a greater (2-5 times) efficacy and does not give side-effects of toxicity.

Abroad and up to now, analogues of lidol - dolantin, pethidine, demerol, dolasal. Particularly widespread pethidine. Studies show that there are significant differences in the mental state of women who have received psycho-preventive preparation for childbirth and have not gone through it. Probably, this can be explained, on the one hand, by insufficiently thorough psychoprophylactic preparation (2-3 conversations). On the other hand, a certain value, of course, can have the fact that the power of verbal influence is not always sufficient to change the direction of the emotional and psychic reactions of pregnant women and parturient women in the right direction.

In addition, we found a relationship between the psychosomatic state of the pregnant woman and the mother and the nature of the contractile activity of the uterus. Proceeding from this, it is necessary to study more widely the possibilities of correcting the contractile function of the uterus by central anticholinergics, for example, spasmolytic, with spasmolytic and tranquilizing action, as well as benzodiazepine derivatives (sibazone, phenazepam, nosepam), which can prevent the anomalies of labor.

Some doctors recommend using more drugs such as tifen, aprofen. In this case, the most rapid and complete spasmolytic and analgesic effect of the combination of aprofen (1% solution - 1 ml) with promedol (1-2 ml of a 2% solution), when these drugs and their combinations are injected directly into the thickness of the posterior lip of the cervix.

The introduction of drugs in this dosage at the opening of the uterine throat for 2.5-3 fingers (5-6 cm) usually provides a "soft", painless and sufficiently rapid (up to full) opening for 1-3 hours. The advantage of administering the drugs directly into the body neck, and moreover in the back of her lip is that the latter is very rich in sensitive interoceptors. The irritation of the interoreceptors of the cervix reflexively causes the separation of the posterior lobe of the pituitary gland into the blood of oxytocin (the phenomenon of Firposson, 1944). Therefore, this way of introducing antispasmodic substances not only does not weaken the contractile activity of the uterus, but even strengthens it. In addition, with the introduction of medicinal substances into the posterior lip of the cervix, their absorption is very fast and complete, since there is a rich network of venous vessels and the substances that enter it are not destroyed by the liver, because the portal circulation of blood passes by.

In this regard, it is important to take into account the data on peripheral neuroendocrinology of the cervical autonomic nervous system. Data on the relationship between the sympathetic cervical anterior ganglion and the mediobal hypothalamus are discussed, as well as new experimental data showing how the peripheral autonomic nervous system of the cervical region modulates the activity of the endocrine organs. The authors cite data on the influence of sympathetic innervation on the secretion of adenohypophyseal, thyroid and parathyroid hormones and on the effect of the parasympathetic nervous system on the secretion of thyroid hormones and parathyroid glands. This type of regulation also appears to refer to the regional autonomic nerves of the adrenal glands, gonads and pancreatic islets. Thus, the cervical autonomic nerves form a parallel path through which the brain communicates with the endocrine system.

Entered intramuscularly or, as usual, under the skin, spasmolytic agents either in themselves cause quite sufficient pain in labor or create an excellent basis (background) for other agents and measures, if their application is required.

Based on the data available in the literature on the successful use of hyaluronidase in obstetrics. A pronounced antispasmodic and analgesic effect of lipase was noted. In this case, the combination of lipase with novocaine, aprofen and promedol provides in most cases an excellent and good antispasmodic and analgesic effect. This favorable effect of the combined use of hyaluronidase (lidase) with aprofen and promedol for facilitating and accelerating the opening of the cervix and, at the same time, for the anesthesia of labor, allows the author to recommend this technique for use in clinical practice.

A step forward in the theoretical and methodological sense was the use of combined use of promedol, tecodyne, vitamin B1 and cardiacol in normal delivery. Vitamin B1 in this scheme is used as a means that normalizes the processes of carbohydrate metabolism and synthesis of acetylcholine necessary for normal flow. The result of these properties of vitamin B1 is its ability to strengthen the contractile activity of the uterus (body), which, while simultaneously relaxing the neck muscles under the influence of promedol leads to an acceleration of childbirth. Cardiazole stimulates the vasomotor and respiratory centers of the fetus and, improving the blood circulation of the parturient woman, accelerates blood flow in the vessels of the placenta, thereby improving blood supply and gas exchange of the fetus. This method is recommended by the author only during normal delivery.

For individual cases of birth, the use of suppositories (suppositories) of different composition has not lost its significance. In the composition of suppositories, antispasmodic and analgesic agents usually play a major role. In clinical practice, the most widely used candles recommended by Academician KK Skrobansky (candle No. 1), having the following composition: 0.04 g of extract of belladonna, 0.3 g of antipyrine, 0.02 g of antipyrone , cocoa butter - 1.5 g. Some authors replaced the antipyrine with amidopyrine, which had a higher effect. The composition of suppositories is designed for a multifaceted effect: spasmolytic - belladonna or atropine, promedol, warning impairment of labor or stimulating - proserin, quinine, pachycapin and general sedation.

The use of these suppositories has shown the simplicity and ease of application, the speed of action, the effectiveness with regard to shortening the duration of labor, enhancing labor activity and harmlessness for the mother and fetus. Already after 10-15 minutes, and often 5-6 minutes after the introduction of the suppository into the rectum, the maternity is calmed down, the ordering of its behavior, noticeable regulation, and sometimes the intensification of labor, pain relief with a slight drowsy condition between contractions. The advantage of rectal administration of medicinal substances in comparison with their intake is as follows:

• with the introduction of drugs inside can not avoid the change and destruction of the drugs used under the influence of gastric juice;
• medicinal substances introduced into the rectum can manifest themselves more quickly and more strongly due to especially favorable conditions of absorption through the rectal mucosa (a rich venous network).

These judgments remain relevant at the present time. The known part of the negative phenomena from medicines is connected with unjustifiably wide use of parenteral ways of introduction at which it is impossible to completely get rid of entering into an organism of mechanical impurities, haptens and even antigens. Especially unfavorable are intravenous injections, in which there is no biological filtration of the drug.

The introduction of drugs through the mouth is associated with the promotion of them through many organs. Before the medicinal substances enter the general bloodstream, they must pass the stomach, small intestine, liver. Even in the case of oral administration (by mouth) of solutions on an empty stomach, they enter the large circulation on an average of 30 minutes and, when passing through the liver, are destroyed to some extent and adsorbed in it, and can also damage it. When ingesting (through the mouth) powders and especially tablets, there is the greatest likelihood of their local irritant effect on the gastric mucosa.

Rectal administration (suppositories or solutions) to obtain a systemic effect is confirmed only for those drugs that can be absorbed in the lower parts of the rectum through the lower hemorrhoidal veins that flow into the common venous system. The substances entering the systemic circulation through the upper parts of the rectum pass through the upper hemorrhoidal veins and pass through the portal vein into the liver. How the absorption from the rectum will occur is difficult to predict, since it depends on the distribution of the drug in this area. As a rule, either the same doses of medicinal substances as when ingesting are required, or somewhat larger.

Advantages are that if the drug irritates the gastric mucosa, it can be used in candles, for example, euphyllin, indomethacin.

The disadvantages are mainly the psychological impact on the patient, since this way of introduction may not like or like him too much. With repeated administration of the drug, the intestinal mucosa may become irritated or even inflamed. Absorption may be inadequate, especially if fecal masses are present in the rectum.

It is believed that it is very rational to use the method of birth acceleration based on shortening the duration of the first stage of labor by prescribing medications that accelerate and facilitate the processes of opening the cervix. In addition, it is advisable to strive for simultaneous use and painkillers. When choosing the path that should be chosen for a midwife to facilitate and speed up the processes of opening the cervix, doctors recommend that you preferably use the option of reducing the tone of the parasympathetic nervous system by a number of medications (belladonna, promedol, etc.). This, in their opinion, inevitably entails an accelerated, facilitated course of cervical dilatation and, undoubtedly, requires less contractile activity of the uterus. The most appropriate is considered the combined use of funds that ensure the occurrence of the greatest possible compliance of the cervix with drugs that increase the contractile activity of the uterine musculature.

To reduce the duration of normal delivery, some doctors recommend the following scheme for accelerating labor:

• The mother gives 60.0 ml of castor oil and after 2 hours they put a cleansing enema. One hour before the cleansing enema, 0.2 g of quinine is given every 30 minutes, only 5 times (i.e., only 1.0 g);
• after the action of the intestine between the last two methods of quinine, the mother gives 50 ml of a 40% solution of glucose and 10 ml of a 10% solution of calcium chloride (according to Khmelevsky) into the vein;
• 100 mg of vitamin B1 intramuscularly is administered intramuscularly after the last powder of quinine to the laborer and, if necessary, after another hour, another 60 mg (according to Shubu). The effect of vitamin B1, apparently, is based on the ability of this vitamin to normalize carbohydrate metabolism and eliminate muscle fatigue, resulting from the accumulation of lactic and pyruvic acids; In addition, vitamin B! Oppresses cholinesterase and promotes sensitization to the synthesis of acetylcholine.

The second scheme for the acceleration of normal delivery is the use of folliculin, pituitrin, carbocholine, and quinine. It consists of the following:

• The mother is injected intramuscularly with 10,000 units of folliculin;
• after 30 minutes give inside 0.001 g of carbocholine (persistent acetylcholine derivative) with sugar;
• 15 minutes later, 0.15 ml of pituitrin is injected intramuscularly and 0.15 g of quinine hydrochloride is administered inward;
• an hour after the onset of stimulation, 0.001 g of carbocholine and 0.15 g of quinine are administered concomitantly;
• 15 minutes later, carbocholine and quinine are given in the same dosage and 0.15 ml of pituitrin is injected intramuscularly the second time after 15 minutes.

In accordance with the idea of the primary innervation of the cervix by the parasympathetic nervous system, opinions were repeatedly expressed about the possibility of its relaxation by using atropine in the delivery and thus shortening the duration of labor. However, these representations are purely schematic. Subsequent clinical studies have shown that atropine has no antispasmodic effect in the process of the generic act.

With a prolonged preliminar period and protracted births, a set of therapeutic and prophylactic measures was used to normalize the higher vegetative centers, including the appointment of anticholinergic drugs, central anticholinergics in combination with ATP, ascorbic acid, potassium orotate and estrogens, in order to normalize activity sympathetic link sympathic-adrenal system. This, according to the authors, contributes to the independent development of labor in this contingent of pregnant and parturient women.

When prescribing stimulant medications, of which one of the most effective is oxytocin, it must necessarily (!) Combine with the appointment of antispasmodics with established labor. Equally, this concerns discoordinated labor, manifested mainly by unsynchronous contractions of the uterus (body), hypertension of its lower segment and other symptoms, where it is necessary to use more widely spasmolytic drugs taking into account the specific effects of pharmacological preparations on the fetus. Undoubtedly, the use of antispasmodics with strict adherence to their purpose during pregnancy and childbirth in parturient women with abnormalities of labor is very appropriate.

The search for substances that have both ganglionic and spasmolytic effects is important, because the work of a number of authors has shown the lack of efficacy in labor in antispasmodics from the M-cholinolytics group (atropine, platyphylline, scopolamine), which are still used by some midwives.

Studies convincingly show that some of the effects of parasympathetic nerves are not at all removed atropine - the action of the pelvic nerve on the uterus and other organs. According to the author, this can be explained by the fact that the endings of the nerves secrete acetylcholine within the innervated cell or, at least so close to the cholinergic receptor, that atropine can not penetrate to the "site of action" and successfully compete with acetylcholine for the receptor ("Theory of proximity "). These experimental data were confirmed by the use of atropine in childbirth, where, according to internal hysterography, no changes in the frequency, intensity, and tone of uterine contractions were noted after atropine administration, there was no coordination of uterine contractions. Therefore, for scientific and practical obstetrics, new drugs with spasmolytic action, that is, the ability to remove those effects of parasympathetic nerves that are not removed by atropine, are needed. It is important to pay attention to another circumstance - some substances that have spasmolytic effects in the experiment, in the clinic, are often ineffective.

The value of antispasmodics is that they help reduce the main stress of the uterine muscle during a pause between contractions, and as a result, the contractile activity of the uterus is more economical and productive. In addition, it is advisable to use in the birth of a combination of antispasmodics, but with different points of application of the action.

The most common in the national obstetrics were combined methods of using some spasmolytic drugs from the group of ganglion blocking agents (aprofen, diprofen, gangleron, quaterone, pentamine, etc.) with oxytocic (oxytocin, prostaglandins, pituitrin, quinine, etc.) both before and after application uterotrophic agents. The majority of clinical and experimental studies have shown the expediency of such an assignment of oxytochemical and antispasmodic agents. Sometimes it is advisable simultaneously with a light finger expansion of the uterine throat to simultaneously inject intravenously spasmolytics, especially myotropic action (no-shpa, papaverine, halidor, baralgin) to exert a pronounced antispasmodic effect.

When using antispasmodics, a number of positive effects were noted:

• shortening of the total length of labor;
• reduction in the frequency of prolonged labor;
• elimination in a large number of observations of non-coordinated labor, cervical dystopia, excessive labor;
• decrease in the frequency of operative delivery, asphyxia of the fetus and newborn;
• decrease in the frequency of bleeding in the consecutive and early postpartum periods.

In the presence of weakness in labor activity in parturient women with severe psychomotor agitation, we use a combination of dinezine in a dose of 100 mg inwards, a quaterone - 30 mg inwards and promedol - 20 mg subcutaneously. The combination of these drugs is used in the establishment of regular labor and the opening of the uterine throat for 3-4 cm. Note that the relationship between the average duration of labor before and after the introduction of a combination of dinezine, quaternon and promedol in the dosages used by us and the degree of opening of the uterine throat to the onset of antispasmodic no funds have been identified. More important is the presence of regular labor, not the degree of opening of the uterine throat. In 1 1/2 births, a combination of these drugs was performed against the background of rhodostimulating therapy, and in% of women in labor, these drugs, with central and peripheral cholinolytic action, were applied immediately after the end of the introduction of rhythm-stimulating agents.

The clinical analysis showed that, despite the administration of these substances, rhodostimulation was in all cases effective. The weakening of labor was not noted also in those cases when the introduction of dinezine, quaternon and promedol was preceded by drug-induced rhodostimulation. These clinical observations are confirmed by hysterographic studies. It is also very important that after the introduction of antispasmodics, there is a clear dominance of the uterine fundus over the underlying sections, there is no violation of its contractile activity. In this case, one feature is also revealed: one hour after the introduction of these means, uterine contractions in the region of the lower segment become more regular, ie, a more coordinated type of uterine contractions appears. The negative effect of this combination of substances on the condition of the fetus and the newborn child was not noted. In the state and behavior of newborns, both at birth and during the following days, there were no deviations in their development. Cardiotocography also showed no abnormalities in the fetal condition.

[1], [2], [3], [4]