Tactics of managing complicated births

Births that complete pregnancy are the stage in which the responsibility for a successful outcome for the mother and fetus is borne by the doctor of the maternity hospital. It especially increases in childbirth, complicated by the presence of a particular pathology in the mother. The correct decision on the tactics of giving birth in these cases should be based not only on the high level of knowledge and experience of the obstetrician, but also on the detailed familiarization with all the characteristics of the parturient woman, referring to her age, profession, obstetric and family history, the presence or absence of those or other complications of pregnancy and related diseases, the condition of the fetus, in the cases shown, the conclusion of related specialists. In this case, the doctor's orientation should be fast.

First of all, the basic position of the doctor in each specific case of delivery should be clearly defined - whether to conduct them conservatively-naturally without surgical intervention; to adhere to conservative-expectant tactics, allowing a possible need for transition to surgical delivery, or, finally, from the very beginning consider surgical intervention expedient.

In addition, when you are familiar with all the data should be possible complications in the process of delivery and in advance to outline the appropriate preventive measures, together with an anesthesiologist to recommend a method of anesthetizing labor. At the same time, it must be taken into account that it is not always possible to anticipate in advance all the complications that may occur during the birth act. Therefore, the planned long-term plan for the management of childbirth may later undergo a rather significant change or addition. However, in most cases, such "unexpected" complications can be provided if pregnant women are well-surveyed before the delivery, and the peculiarities of each of them were taken into account when drawing up a birth plan. Thus, the problem of predicting and timely prevention of complications during delivery continues to be relevant in modern obstetrics.

A documented birth management plan should normally contain a complete clinical diagnosis (gestational age, its complications, pregnancy-related diseases, and obstetrical history). Below is a conclusion, which indicates:

• features of this particular case, justifying the tactics of giving birth;
• the formulation of the tactics of conducting labor;
• recommended preventive measures;
• method of analgesia of childbirth.

The introduction of the diagnosis "features of the obstetric anamnesis" is aimed at fixing the doctor's attention to such important data for conducting labor as a caesarean section, habitual miscarriage, stillbirth in the anamnesis,

It is considered that the plan of delivery should be formed in the process of monitoring the pregnant woman taking into account the detected pre- and antenatal risk factors. First of all, the doctor should clearly determine the level of the obstetrical institution for the woman in labor. It is also important to determine the term of delivery. The next cardinal aspect in drawing up the plan of delivery, according to the authors, is the choice of the method, determined by the forecast of probable complications. The quality of the prediction of labor is directly dependent on the capacity of the obstetrician for associative thinking. In a certain category of women, the choice of the method of delivery should be decided from the perspective of a planned cesarean section.

In recent years, attempts have been made to predict delivery with scores in scores. To some extent this proposal is justified, however, the recommended systems do not provide for a number of other factors that may influence the outcome of childbirth.

Factors to be taken into account when planning the tactics of conducting complicated births

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

Profession. A professional factor may not be indifferent to the outcome of pregnancy and childbirth. At present, there are numerous studies on the effects of harmful factors on the mother and fetus. In this regard, doctors serving industrial enterprises and providing timely information on the pregnant woman's card should be of great help.

Obstetric anamnesis. This refers to a burdened obstetric anamnesis (abortions, stillbirths, early infant mortality, malformations in the fetus, habitual miscarriages of pregnancy, surgical interventions on the uterus, birth trauma, the birth of physically and mentally disabled children, hemolytic disease, etc.).

Scar on the uterus. It is necessary to clarify the prescription and methodology of the operation - corporal or in the lower segment of the uterus, which was in the past indications for cesarean section, how the healing wound was healing (for example, secondary healing signals the inferiority of the scar on the uterus, however, the primary healing does not always indicate its usefulness ).

It is important to determine the location of the placenta according to ultrasound, since a known danger is its localization in the area of the operating scar, having to its insolvency; to determine whether there are any clinical manifestations of a threatening rupture of the uterus in this pregnancy, since they are often erased. Particularly important is the appearance of pain in the field of the operating field, usually localized, and sharply increasing during the bout. They may be accompanied by a thinning of the scar, the appearance of signs of impairment of the fetus, the weakness of labor, the restless behavior of the parturient woman, etc. The appearance of bloody discharge from the genital tract signals the already broken uterus rupture.

More difficult is the question of the tactics of giving birth in women who have undergone last time abortion due to rupture of the uterus during childbirth. LS Persianinov points out the need for each individual case to think over the question of the usefulness of the uterus, to take such pregnant or parturient women under special control and to catch signs of a threatening rupture in a timely manner. The same vigilance should be manifested in women who have undergone a conservative myomectomy in the past, especially with the opening of the uterine cavity, as well as in persons who had had a perforation of the uterus in the past and removal of the fallopian tube with excision of the uterine end. These provisions are important, for as N. N. Vaganov (1993) points out, until now the number of cases of uterine rupture has not decreased, and the double excess of the European level and the indicators of the developed countries of maternal mortality dictates the need for such alertness.