Regulation of labor activity in its anomalies

Use of antispasmodics

The emergence of domestic science on the use of antispasmodics in obstetric practice is seventy years old. As early as 1923, Academician A. P. Nikolaev proposed using an antispasmodic recommended by Professor V. F. Snegirev for dysmenorrhea - Indian hemp - for pain relief during labor. Somewhat later, as A. P. Nikolaev (1964) points out, belladonna and spazmalgin became widespread.

At present, there are a number of highly effective domestic and foreign antispasmodics. At the same time, from the infinite number of different drugs studied and used over the past years, only a few can be proposed at present, which have stood the test of widespread practice based on their effectiveness, harmlessness for both mother and child, and ease of use. For example, the aforementioned Indian hemp, which according to modern concepts belongs to the group of tranquilizers ("fantasies"), is of no importance from a therapeutic point of view, but is important from a toxicological point of view.

Having widely discussed and proposed a number of antispasmodics for use in obstetric practice, scientists subsequently simultaneously tried to outline the range of conditions in obstetrics in which the use of antispasmodics is most appropriate. However, excessive use of antispasmodics cannot be considered justified. This is especially true for those drugs that are also fairly good analgesics (promedol, morphine group drugs, etc.) and can lead to depression of the respiratory center in newborns if these drugs were administered less than an hour before the birth of the child.

Thus, it can be considered that in a number of women in labor the use of antispasmodics is one of the methods of rational labor management. A number of narcotics, analgesics, antispasmodics and their combinations in connection with the protective effect on the motor activity of the uterus acquire a prophylactic value in some types of insufficiency of labor
activity of the uterus and prevention of a protracted labor.

At the present stage, there are significant opportunities to solve the problem of preventing protracted labor and timely correction of uterine contractile dysfunction by using modern antispasmodics. Thus, by using promedol and other substances.

For the first time in Russian obstetric literature, the question of accelerating normal labor was raised by A. P. Nikolaev, K. K. Skrobansky, M. S. Malinovsky, and E. I. Kvater.

K.K. Skrobansky (1936) recognized the idea of accelerating labor as extremely valuable, but recommended implementing it only by gentle, non-traumatic methods available in modern obstetrics.

A.P. Nikolaev (1959), attaching great importance to the use of antispasmodics in obstetric practice, believes that they are the basis of drug-induced pain relief during labor.

Basically, the prescription of antispasmodics is indicated:

• women in labor who have undergone complete psychoprophylactic preparation, but who show signs of weakness, imbalance of the nervous system; those who have undergone either incomplete or unsatisfactory preparation; finally, prepared women in labor with signs of general hypoplasia or insufficient development of the genitals, very young and elderly women. In such cases, antispasmodics are used at the beginning of the culmination phase of the dilation period for the purpose of preventing labor pains and only partly to eliminate them, i.e. for therapeutic purposes;
• women in labor who have not undergone psychoprophylactic training, either as an independent painkiller for pain that has already developed, or as a means, the use of which serves as a background for a more successful and complete effect of other painkillers. In these cases, antispasmodics should be used, as a rule, when the cervix is dilated by 4 cm or more. In both cases, these drugs have a pronounced positive effect and greatly contribute to a less painful course of labor, especially since many of them, such as promedol, along with antispasmodic properties also have more or less pronounced analgesic and partially narcotic properties.

The most widespread antispasmodics in the 60s were those of the lidol type, which is no longer produced, and instead a more effective drug was synthesized - promedol, which has greater (2-5 times) effectiveness and does not have toxic side effects.

Abroad, analogues of lidol are still used - dolantin, pethidine, demerol, dolasal. Pethidine has become especially widespread. Research shows that there are no reliable differences in the mental state of women who have undergone psychoprophylactic preparation for childbirth and those who have not. This can probably be explained, on the one hand, by insufficiently thorough psychoprophylactic preparation (2-3 conversations). On the other hand, of course, the fact that the power of verbal influence is not always sufficient to change the nature of the emotional and mental reactions of pregnant women and women in labor in the desired direction may have a certain significance.

In addition, we have identified a relationship between the psychosomatic state of a pregnant woman and a woman in labor and the nature of the contractile activity of the uterus. Based on this, it is necessary to more widely study the possibilities of correcting the contractile function of the uterus with central anticholinergics, such as spasmolytin, which has an antispasmodic and tranquilizing effect, as well as derivatives of the benzodiazepine series (sibazon, phenazepam, nozepam), which can be a preventive measure against abnormalities in labor.

Some doctors recommend using more drugs such as tifen, aprofen. In this case, the fastest and most complete antispasmodic and analgesic effect is achieved by combining aprofen (1% solution - 1 ml) with promedol (1-2 ml of 2% solution), when the above drugs and their combinations are injected directly into the thickness of the posterior lip of the cervix.

The introduction of drugs in the specified dosage when the cervix is 2.5-3 fingers (5-6 cm) apart usually ensures a "soft", slightly painful and fairly rapid (to complete) dilation within 1-3 hours. The advantage of introducing drugs directly into the thickness of the cervix, and specifically into its posterior lip, is that the latter is very rich in sensitive interoreceptors. Irritation of the interoreceptors of the cervix reflexively causes the posterior pituitary gland to release oxytocin into the blood (Ferposson phenomenon, 1944). Consequently, this method of introducing antispasmodic substances not only does not weaken the contractile activity of the uterus, but even enhances it. In addition, when introducing drugs into the posterior lip of the cervix, their absorption occurs very quickly and completely, since there is a rich network of venous vessels here and the substances that enter it are not destroyed by the liver, since they bypass the portal circulation.

In this regard, it is important to consider the data on the peripheral neuroendocrinology of the cervical autonomic nervous system. The data on the connection between the sympathetic cervical anterior ganglion and the mediobasal 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 present data on the influence of sympathetic innervation on the secretion of adenohypophyseal, thyroid and parathyroid hormones and on the influence of the parasympathetic nervous system on the secretion of hormones of the thyroid and parathyroid glands. This type of regulation apparently also applies to the regional autonomic nerves of the adrenal glands, gonads and pancreatic islets. Thus, the cervical autonomic nerves form a parallel pathway through which the brain communicates with the endocrine system.

Antispasmodics administered intramuscularly or, as usual, subcutaneously either provide sufficient pain relief during labor or create an excellent basis (background) for other drugs and measures, if their use 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 is noted. At the same time, the combination of lipase with novocaine, aprofen and promedol provides in most cases an excellent and good antispasmodic and analgesic effect. Such a favorable effect of the combined use of hyaluronidase (lidase) with aprofen and promedol to facilitate and accelerate the opening of the cervix and, at the same time, for pain relief during labor allows the author to recommend this method for use in clinical practice.

A step forward in the theoretical and methodological respect was the use of a combined application of promedol, tekodin, vitamin B1 and cardiazol in normal childbirth. Vitamin B1 in this scheme is used as a means of normalizing the processes of carbohydrate metabolism and acetylcholine synthesis necessary for the normal course. The result of these properties of vitamin B1 is its ability to enhance the contractile activity of the uterus (body), which, with the simultaneous relaxation of the cervical muscles under the influence of promedol, leads to an acceleration of labor. Cardiazol stimulates the vasomotor and respiratory centers of the fetus and, improving the blood circulation of the woman in labor, accelerates the blood flow in the vessels of the placenta, thereby improving the blood supply and gas exchange of the fetus. The author recommends using this method only in normal childbirth.

For individual cases of childbirth, the use of suppositories of various compositions has not lost its significance. The main role in the composition of suppositories is usually played by antispasmodic and analgesic agents. In clinical practice, at one time, the most widely used suppositories were those recommended by Academician K. K. Skrobansky (suppository No. 1), which had the following composition: belladonna extract - 0.04 g, antipyrine - 0.3 g, pantopon - 0.02 g, cocoa butter - 1.5 g. Some authors replaced antipyrine with amidopyrine, which had a higher effect. The composition of suppositories is designed for a versatile effect: antispasmodic - belladonna or atropine, promedol, preventing weakening of labor or stimulating - proserin, quinine, pachycarpine and a general sedative effect.

The use of the above suppositories has shown their simplicity and convenience of use, speed of action, effectiveness in terms of shortening the duration of labor, intensifying labor activity, and harmlessness to the mother and fetus. Already after 10-15 minutes, and often after 5-6 minutes after inserting the suppository into the rectum, the woman in labor calms down, her behavior becomes more orderly, labor activity is noticeably regulated and sometimes intensified, pain relief with a slight drowsy state between contractions occurs. The advantage of rectal administration of drugs compared to their oral administration is as follows:

• when administering medications internally, it is impossible to avoid the change and destruction of the drugs used under the influence of gastric juice;
• Medicinal substances introduced into the rectum can exert their effect more quickly and powerfully due to the particularly favorable conditions of absorption through the rectal mucosa (rich venous network).

These judgments remain relevant today. A well-known part of the negative effects of drugs is associated with the unjustifiably wide use of parenteral routes of administration, in which it is impossible to completely get rid of mechanical impurities, haptens and even antigens entering the body. Intravenous administrations are especially unfavorable, in which there is no biological filtration of the drug.

The administration of drugs through the mouth is associated with their movement through many organs. Before the drugs enter the general bloodstream, they must pass through the stomach, small intestine, and liver. Even in the case of oral administration of solutions on an empty stomach, they enter the systemic circulation on average after 30 minutes and when passing through the liver, they are to a certain extent destroyed and adsorbed in it, and can also damage it. When taking powders and especially tablets internally (through the mouth), there is the greatest probability of their local irritating effect on the gastric mucosa.

Rectal administration (suppositories or solutions) for the purpose of obtaining a systemic effect is confirmed only for those drugs that can be absorbed in the lower rectum through the lower hemorrhoidal veins that flow into the general venous system. Substances entering the systemic bloodstream through the upper rectum pass through the upper hemorrhoidal veins and first enter the liver through the portal vein. It is difficult to predict which route will be absorbed from the rectum, since it depends on the distribution of the drug in this area. As a rule, either the same doses of drugs as when taken orally, or slightly larger ones, are required.

The advantages are that if the drug irritates the gastric mucosa, it can be used in suppositories, for example, euphyllin, indomethacin.

The disadvantages mainly lie in the psychological impact on the patient, as this route of administration may be disliked or liked too much. With repeated administration of the drug, the intestinal mucosa may become irritated or even inflamed. Absorption may be insufficient, especially if there is fecal matter in the rectum.

It is believed that it is quite rational to use the method of accelerating labor based on shortening the duration of the first stage of labor by prescribing medications that accelerate and facilitate the processes of cervical dilation. In addition, it is advisable to strive for the simultaneous use of painkillers. When choosing the path that an obstetrician should choose to facilitate and accelerate the processes of cervical dilation, doctors recommend using the option of reducing the tone of the parasympathetic nervous system with a number of drugs (belladonna, promedol, etc.). In their opinion, this inevitably entails an accelerated, facilitated course of cervical dilation and, undoubtedly, requires less contractile activity of the uterus. The most appropriate is considered to be a combined use of agents that ensure the emergence of the greatest possible compliance of the cervix with drugs that increase the contractile activity of the uterine muscles.

To shorten the duration of normal labor, some doctors recommend using the following scheme to speed up labor:

• the woman in labor is given 60.0 ml of castor oil and after 2 hours a cleansing enema is given. An hour before the cleansing enema, quinine is given at 0.2 g every 30 minutes, 5 times in total (i.e. 1.0 g in total);
• after bowel movement between the last two doses of quinine, the woman in labor is given 50 ml of a 40% glucose solution and 10 ml of a 10% calcium chloride solution (according to Khmelevsky) intravenously;
• Following the last quinine powder, the woman in labor is given 100 mg of vitamin B1 intramuscularly and, if necessary, another 60 mg after 1 hour (according to Shub). The action of vitamin B1 is apparently based on the ability of this vitamin to normalize carbohydrate metabolism and eliminate muscle fatigue that occurs as a result of the accumulation of lactic and pyruvic acids; in addition, vitamin B! Inhibits cholinesterase and promotes sensitization to the synthesis of acetylcholine.

The second scheme for accelerating normal labor is the use of folliculin, pituitrin, carbachol and quinine. It consists of the following:

• the woman in labor is given 10,000 IU of folliculin intramuscularly;
• after 30 minutes, 0.001 g of carbachol (a stable derivative of acetylcholine) with sugar is given orally;
• 15 minutes after this, 0.15 ml of pituitrin is administered intramuscularly and 0.15 g of quinine hydrochloride is given orally;
• one hour after the start of stimulation, 0.001 g of carbacholine and 0.15 g of quinine are administered orally simultaneously;
• 15 minutes after this, carbacholine and quinine are given in the same dosage, and after another 15 minutes, 0.15 ml of pituitrin is administered intramuscularly for the second time.

In accordance with the concept of predominant innervation of the cervix by the parasympathetic nervous system, opinions have been repeatedly expressed about the possibility of relaxing it by using atropine during labor and thereby shortening the duration of labor. However, these ideas are purely schematic. Subsequent clinical studies have shown that atropine does not have an antispasmodic effect during labor.

In the case of a protracted preliminary period and protracted labor, in order to normalize the higher vegetative centers, a complex of therapeutic and prophylactic measures was used, including, along with the creation of a therapeutic and protective regimen, the administration of cholinolytic agents - central cholinolytics in combination with ATP, ascorbic acid, potassium orotate and estrogens in the expectation of normalizing the activity of the sympathetic link of the sympathetic-adrenal system. This, in the opinion of the authors, contributes to the independent development of labor in this contingent of pregnant women and women in labor.

When prescribing stimulating medications, of which oxytocin is one of the most effective, it is necessary (!) to combine it with the prescription of antispasmodics in established labor. This equally applies to uncoordinated labor, which is manifested mainly by asynchronous contractions of the uterus (body), hypertonicity of its lower segment and other symptoms, where it is necessary to use antispasmodics more widely, taking into account the specific effects of pharmacological drugs on the fetus. Undoubtedly, the use of antispasmodics, subject to strict indications for their prescription during pregnancy and labor in women in labor with abnormal labor, is very advisable.

The search for substances that have both gangliolytic and antispasmodic effects is important, since the work of a number of authors has shown the lack of effectiveness in labor of antispasmodics from the M-anticholinergic group (atropine, platifillin, scopolamine), which are still used by some obstetricians to this day.

Research has convincingly shown that some effects of parasympathetic nerves are not at all removed by atropine - the effect of the pelvic nerve on the uterus and other organs. In the author's opinion, this can be explained by the fact that the nerve endings release acetylcholine inside the innervated cell or, in any case, so close to the cholinergic receptor that atropine cannot 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 labor, where, according to internal hysterography, after the introduction of atropine, no change in the frequency, intensity and tone of uterine contractions was noted, and no coordination of uterine contractions was detected. Therefore, new drugs with an antispasmodic effect are needed for scientific and practical obstetrics, i.e., the ability to remove those effects of parasympathetic nerves that are not removed by atropine. It is important to pay attention to another circumstance: some substances that have an antispasmodic effect in an experiment are often ineffective in a clinic.

The value of antispasmodics is that they help reduce the main tension of the uterine muscle during the pause between contractions, and due to this, the contractile activity of the uterus is carried out more economically and productively. In addition, it is advisable to use a combination of antispasmodics during labor, but with different points of application of action.

The most widespread methods in domestic obstetrics are combined methods of using some antispasmodics from the group of ganglionic blocking agents (aprofen, diprofen, gangleron, kvateron, pentamine, etc.) with oxytotic agents (oxytocin, prostaglandins, pituitrin, quinine, etc.) both before and after the use of uterotropic agents. Most clinical and experimental studies have shown the expediency of such administration of oxytotic and antispasmodic agents. Sometimes it is advisable to simultaneously with a slight digital dilation of the uterine os intravenously administer antispasmodics, especially myotropic action (no-shpa, papaverine, halidor, baralgin), to provide a pronounced antispasmodic effect.

When using antispasmodics, a number of positive effects have been noted:

• shortening the overall duration of labor;
• reduction in the incidence of prolonged labor;
• elimination in a large number of cases of uncoordinated labor, cervical dystopia, and excessive labor;
• reduction in the frequency of operative deliveries, fetal and neonatal asphyxia;
• reduction in the frequency of bleeding in the afterbirth and early postpartum periods.

In the presence of weak labor activity in women in labor with pronounced psychomotor agitation, we use a combination of dynesin at a dose of 100 mg orally, kvateron - 30 mg orally and promedol - 20 mg subcutaneously. The combination of these drugs is used when regular labor activity is established and the uterine os is dilated by 3-4 cm. Note that there was no relationship between the average duration of labor before and after the introduction of the combination of dynesin, kvateron and promedol in the dosages we used and the degree of dilation of the uterine os by the beginning of the introduction of antispasmodics. More significant is the presence of regular labor activity, and not the degree of dilation of the uterine os. In 1/2 of the women in labor, the combination of these drugs was carried out against the background of labor-stimulating therapy, and in % of the women in labor, these drugs, which have a central and peripheral anticholinergic effect, were used immediately after the end of the introduction of labor-stimulating drugs.

The conducted clinical analysis showed that, despite the introduction of these substances, labor stimulation was effective in all cases. Weakening of labor was also not noted in those cases when the introduction of dynesin, kvateron and promedol was preceded by drug labor stimulation. These clinical observations are confirmed by hysterographic studies. It is also extremely important that after the introduction of antispasmodics, a clear dominance of the fundus of the uterus over the underlying sections is noted, and its contractile activity is not impaired. At the same time, one feature was also revealed - 1 hour after the introduction of the specified agents, uterine contractions in the lower segment acquire a more regular character, i.e. a more coordinated type of uterine contractions appears. No negative effect of this combination of substances on the condition of the fetus and the newborn child was noted. In the condition and behavior of newborns, both at the time of birth and in the following days, no deviations in their development were observed. Cardiotocography also did not reveal any deviations in the condition of the fetus.

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