Management of preterm labor

Based on the literature, it is advisable to adhere to the following principles in the management of preterm labor.

1. Immediately after the admission of a woman to the maternity ward, regardless of the period of labor, for the prevention and treatment of fetal asphyxia, intravenous drip infusion is administered to her 200 mg of sighetine in 300 ml of sterile isotonic sodium chloride solution or 5% glucose solution at 8-12 cap / min for 2 -3 hours

It is necessary to emphasize the importance of implementing measures aimed at preventing preterm neonates with respiratory distress syndrome and intracranial hemorrhages, which are the most frequent causes of death in children of this group. According to studies, hyaline membranes are found in 22.4% of newborn deaths (in most cases, preterm infants - 92%). "Immaturity" of the lungs in the fetuses is one of the main indications for the prevention of respiratory distress syndrome in premature newborns.

The degree of maturation of the fetal lung tissue can be revealed by a change in the concentration of lecithin and sphingomyelin in the amniotic fluid.

2. Maturation of surfactants can be accelerated by the influence of corticosteroids, which increase the production of surfactants, accelerate the differentiation of alveolar cells, improve the vascularization of the alveoli, and ultimately contribute to the maintenance of normal pulmonary ventilation. It was found that in women with premature pregnancy after treatment with glucocorticoids, the ratio of lecithin / sphingomyelin significantly increased compared with that in the pregnant control group who did not receive the indicated treatment. This makes it possible to reduce the incidence of early neonatal mortality of premature infants from respiratory distress syndrome by several times in comparison with the group of newborns in untreated women. They should be prescribed only in the event of a threat of labor before the 32-week gestation period.

Indications for preventive measures aimed at accelerating the maturation of the fetal lungs and preventing the syndrome of respiratory disorders and hyaline membranes, in the first place should be considered: the beginning of premature birth; premature discharge of water in case of premature pregnancy; the need for early termination of pregnancy according to indications from the mother and fetus, especially in pregnant women suffering from diabetes, late toxicosis or rhesus-conflict in a burdened obstetric anamnesis.

The method of prophylactic treatment with dexamethasone, which should take into account not only the duration of pregnancy, but also the mass of the fetus. 24-48 hours before the expected termination of premature birth, a woman is prescribed dexamethasone 3 tablets (1 tablet contains 0.5 mg of the substance) 4 times a day (after 6 hours). Treatment is carried out for 2 consecutive days. To ensure the effectiveness of the treatment used, it is advisable to carry out therapy aimed at prolonging the pregnancy for at least 2-3 days. To do this, you can use cholinolytics (metacin, tropacin), magnesium sulfate, beta-adrenomimetiki (partusisten, orciprenaline sulfate), sedatives and painkillers. If premature birth is expected in 3-5 days, dexamethasone is prescribed 2 tablets 4 times a day (after meals) 3 days in a row. Treatment with dexamethasone is contraindicated in the severe form of nephropathy, exacerbation of peptic ulcer of the stomach and duodenum.

In the presence of irregular contractions and the absence of structural changes in the cervix, 0.02 g (4 ml of 0.5% solution) of seduxen in 20 ml of sterile isotonic sodium chloride solution is intravenously injected slowly, at a rate of 0.005 g of the drug for 1 minute. Simultaneously intramuscularly administered 0.05 g (2 ml of a 2.5% solution) of diprazine or dimedrol (3 ml of a 1% solution).

3. With regular bouts and opening of the uterine throat to 4 cm, it is necessary to use beta-adrenomimetics (partusisten). In the management of preterm labor, drug treatment is prescribed according to the following scheme: the combination of 0.025 g (1 ml of a 2.5% solution) prolazil, 0.05 g (2 ml 2.5% solution) of diprasine and 1 ml of a 2% solution of promedol intramuscularly in one syringe . This combination is used in the absence of a pronounced psychomotor agitation. In parturient women with severe psychomotor agitation the following combination of substances is used: 0.025 g of aminazine (1 ml of a 2.5% solution), 0.05 g of diprasine (2 ml of a 2.5% solution) or 0.03 g (3 ml of a 1% solution) dimedrol, 0.02 g of promedol (1 ml of a 2% solution) intramuscularly in one syringe. At the same time, antispasmodics are prescribed differentially, taking into account the nature of the labor activity. With uncoordinated uterine contractions and a protracted course of the birth act, with an increased basal (basic) tone of the uterus, a solution of baralgina in a dose of 5 ml of a standard solution intramuscularly or intravenously in 20 ml of a 40% solution of glucose is used.

At the primary weakness of labor activity against the background of normal or hypotonic uterus, it is advisable to use a solution of halidor in a dose of 0.05 g intravenously slowly in 20 ml of 40% glucose solution. In fast delivery, a combination of central and peripheral H-anticholinergics is prescribed: spasmolithine at a dose of 0.1 grams inwards in combination with a 1.5% ganglone solution (2-4 ml) intramuscularly or intravenously.

Treatment partusistenom must begin, usually with a long intravenous drip infusion. Dosage of the drug should be individual, taking into account the action and tolerability of the drug. The optimum dose should be considered from 1 to 3 μg / min partusisten. However, in some cases, it is required to increase the dose from 0.5 to 4 μg / min.

Method: for preparation of the infusion solution, 1 ampoule of partuscene (10 ml of the standard solution contains 0.5 mg) should be diluted in 250 ml of sterile isotonic sodium chloride solution or 5 % glucose solution. It should be noted that 20 drops correspond to 1 ml (2 μg partusisten), and 10 drops, respectively, 1 μg partusisten. After the end of infusion therapy partusistenom immediately oral prescribed 1 tablet of the same drug, containing 0.005 g, every 3-4 hours (6-8 tablets per day). During the use of partusisten, the pulse rate and arterial pressure should be monitored regularly, as well as the fetal heart rate.

Contraindications for the use of partusisten are thyrotoxicosis, diabetes mellitus, glaucoma, intrauterine infection, cardiovascular diseases, especially those accompanied by tachycardia and heart rhythm disturbances.

The effectiveness of the treatment of premature termination of pregnancy or coordinated labor in preterm labor can be increased by the infusion of domestic anticholinergics - metacin.

Method: 1-2 ml of 0.1% methacin solution (the dose of methacine depends on the severity of this pathology) is diluted in 250 ml of isotonic sodium chloride solution and injected intravenously at a frequency of 10 to 20 cap / min for several hours. In the presence of indications, methacin therapy can be combined with the use of other drugs - antispasmodics, anesthetics. Contraindications for the use of metacin is glaucoma.

4. In the II period of labor, attempts are regulated depending on their frequency and strength. In violent attempts, deep respiratory movements are recommended, and, if necessary, etheric-oxygen anesthesia.

For the prevention of cerebral circulation disorders in the fetus, the primipara are recommended to cut the perineum. Strong pressure on the fetal head when taking birth should be avoided.

It is also recommended to perform pudendal-paravaginal anesthesia, which facilitates the elimination of discordant labor and the removal of pelvic floor muscles.

In the management of premature births, it is necessary to take into account the etiological factors of miscarriage, anomalies of labor, in each case, to apply measures to prevent premature amelioration of amniotic fluid.

Particular attention should be paid to medical intranatal protection of the fetus, careful management of the first and second stages of labor with the use of modern analgesics, antispasmodics and beta-adrenomimetics, which will reduce perinatal mortality and morbidity in premature infants.

In the management of premature births, it is necessary to take into account the acceleration of the intrauterine fetus in case of premature pregnancy, which means the accelerated development of the fetus, not caused by the manifestation of any disease, for example, diabetes maternal. The established fact in recent years is an increase in the growth and weight of full-term newborns and the possibility of accelerated development of the fetus in case of premature pregnancy. Thus, almost 40 % of children with gestational age of up to 36 weeks were born with newborns weighing more than 2500 grams, height (length) - 47 cm. Among the reasons for the acceleration of the fetus is the improvement of working conditions and lifestyle as a result of socioeconomic transformations in a number of countries.

The organization of specialized departments (maternity hospitals) or perinatal centers is of great importance for improving the management of preterm labor based on modern scientific and practical achievements, which is an important stage in the organization of maternal and child health. For premature infants, intensive care wards should be established, conditions for preventing and treating hypoxia and posthypoxic conditions of newborns caused by the pathology of pregnancy and childbirth in their mothers, the prevention of infectious-septic diseases.

[1], [2], [3], [4], [5]