Management of obstructed labor

Childbirth, the final stage of pregnancy, is the stage in which responsibility for its successful outcome for the mother and fetus rests with the maternity hospital physician. It especially increases in childbirth complicated by the presence of one or another pathology in the mother. The correct decision on the tactics of childbirth management in these cases should be based not only on the high level of knowledge and experience of the obstetrician, but also on a detailed familiarization with all the features of the mother, taking into account her age, profession, obstetric and family history, the presence or absence of certain pregnancy complications and associated diseases, the condition of the fetus, and, in indicated cases, the conclusion of related specialists. In this case, the physician's orientation should be quick.

First of all, the main position of the doctor in each specific case of childbirth must be clearly defined - whether to conduct it conservatively and naturally without surgical intervention; adhere to a conservative-expectant tactic, allowing for the possible need to switch to surgical delivery, or, finally, consider surgical intervention appropriate from the very beginning.

In addition, when familiarizing yourself with all the data, you should foresee possible complications during labor and plan appropriate preventive measures in advance, and recommend a method of labor pain relief together with the anesthesiologist. At the same time, it should be taken into account that it is not always possible to foresee all the complications that may arise during labor. Therefore, the planned long-term plan for labor management may sometimes be subject to quite significant changes or additions in the future. However, in most cases, such "unexpected" complications can be foreseen if pregnant women are well examined before labor and the characteristics of each of them are taken into account when drawing up a labor management plan. Thus, the problem of predicting and timely preventing complications during labor continues to be relevant in modern obstetrics.

A documented plan for labor management should, as a rule, contain a complete clinical diagnosis (gestation period, its complications, diseases associated with pregnancy, features of the obstetric history). Below is a conclusion indicating:

• the specific features of this particular case, justifying the tactics of managing childbirth;
• formulation of labor management tactics;
• recommended preventive measures;
• method of pain relief during childbirth.

The inclusion of “features of obstetric history” in the diagnosis is aimed at focusing the doctor’s attention on such important data for the management of labor as cesarean section, habitual prematurity, stillbirth in the anamnesis, etc.

It is believed that the delivery plan should be developed in the process of monitoring the pregnant woman, taking into account the identified pre- and antenatal risk factors. First of all, the doctor should clearly determine the level of the maternity hospital for the woman in labor. It is also important to determine the term of delivery. The next cardinal aspect in drawing up a delivery plan, according to the authors, is the choice of the method, determined by the prognosis of probable complications. The quality of predicting labor is directly dependent on the obstetrician's ability to associative thinking. For a certain category of women, the question of choosing a method of delivery should be decided from the standpoint of a planned cesarean section.

In recent years, attempts have been made to predict labor using a scoring system. To a certain extent, this proposal is justified, but the recommended systems do not take into account a number of other factors that may influence the outcome of labor.

Factors to consider when planning the management of complicated labor

Age. The main attention should be paid to primiparous women aged 30 and above. They are otherwise called old, sometimes elderly, primiparous (in foreign literature - mature primiparous). No less attention should be paid to the second age group - young primiparous, under 18 years of age.

Profession. The professional factor may be of importance for the outcome of pregnancy and childbirth. Currently, there are numerous studies on the impact of harmful factors on the mother and fetus. In this regard, doctors serving industrial enterprises should be of great help and promptly enter the relevant information into the pregnant woman's exchange card.

Obstetric history. This refers to a complicated obstetric history (abortions, stillbirths, early infant mortality, fetal malformations, habitual premature birth, uterine surgeries, birth trauma, birth of physically and mentally disabled children, hemolytic disease, etc.).

Uterine scar. It is necessary to clarify the duration and method of the operation - corporal or in the lower segment of the uterus, what were the previous indications for a cesarean section, how the healing of the surgical wound proceeded (for example, secondary healing indicates the inadequacy of the uterine scar, but primary healing does not always indicate its completeness).

It is important to determine the location of the placenta using ultrasound data, since its location in the area of the surgical scar is known to be dangerous, predisposing it to failure; to determine whether there are any clinical manifestations of a threatening rupture of the uterus during this pregnancy, since they are often erased. Of particular importance is the appearance of pain in the area of the surgical field, usually localized, and sharply increasing during contractions. They can be accompanied by thinning of the scar, the appearance of signs of disruption of the vital activity of the fetus, weakness of labor, restless behavior of the woman in labor, etc. The appearance of bloody discharge from the genital tract signals the already occurred rupture of the uterus.

A more complex issue is the tactics of labor management in women who have undergone laparotomy in the past due to uterine rupture during labor. L. S. Persianinov points out the need to consider the issue of the adequacy of the uterus in each individual case, to take such a pregnant woman or woman in labor under special control and to promptly detect signs of a threatening rupture. The same alertness should be shown in women in labor who have undergone conservative myomectomy in the past, especially with opening of the uterine cavity, as well as in persons who have had perforation of the uterus and removal of the fallopian tube with excision of its uterine end in the past. These provisions are important, because, as N. N. Vaganov (1993) points out, the number of cases of uterine rupture has not decreased to date, and the twofold excess of the European level and indicators of maternal mortality in developed countries dictates the need for such alertness.