Management of preterm labor

Based on the literature, it is advisable to adhere to the following principles when managing preterm labor.

1. Immediately after the woman is admitted to the maternity ward, regardless of the stage of labor, in order to prevent and treat fetal asphyxia, she is given 200 mg of sigetin intravenously in 300 ml of sterile isotonic sodium chloride solution or 5% glucose solution at 8-12 drops/min for 2-3 hours.

It is necessary to emphasize the importance of implementing measures aimed at preventing premature infants from respiratory distress syndrome and intracranial hemorrhages, which are the most common causes of death in children of this group. According to research data, hyaline membranes are found in 22.4% of deceased newborns (in most cases, in premature infants - 92%). The "immaturity" of the lungs in fetuses is one of the main indications for the prevention of respiratory distress syndrome in premature infants.

The degree of maturation of the fetal lung tissue can be determined by changes in the concentration of lecithin and sphingomyelin in the amniotic fluid.

2. Surfactant maturation can be accelerated by corticosteroids, which enhance surfactant production, accelerate alveolar cell differentiation, improve alveolar vascularization, and ultimately help maintain normal pulmonary ventilation. It has been established that in women with premature pregnancy, after treatment with glucocorticoids, the lecithin/sphingomyelin ratio increases significantly compared to that in pregnant women in the control group who did not receive the indicated treatment. This allows for a reduction in the incidence of early neonatal mortality in premature infants from respiratory distress syndrome several times compared to the group of newborns in untreated women. They should be prescribed only in cases of threatened labor before 32 weeks of pregnancy.

Indications for preventive measures aimed at accelerating the maturation of the fetal lungs and preventing respiratory distress syndrome and hyaline membranes should primarily be considered: the onset of premature labor; premature rupture of membranes in premature pregnancy; the need for early termination of pregnancy according to indications from the mother and fetus, especially in pregnant women suffering from diabetes mellitus, late toxicosis or Rhesus incompatibility with a burdened obstetric history.

The method of carrying out preventive treatment with dexamethasone, in which it is necessary to take into account not only the gestational age, but also the weight of the fetus. 24-48 hours before the expected end of premature labor, the woman is prescribed dexamethasone 3 tablets (1 tablet contains 0.5 mg of the substance) 4 times a day (every 6 hours). The treatment is carried out 2 days in a row. To ensure the effectiveness of the applied treatment, it is desirable to carry out therapy aimed at prolonging the pregnancy for at least 2-3 days. For this purpose, anticholinergics (metacin, tropacin), magnesium sulfate, beta-adrenergic agonists (partusisten, orciprenaline sulfate), sedatives and analgesics can be used. If premature labor is expected in 3-5 days, dexamethasone is prescribed 2 tablets 4 times a day (after meals) for 3 days in a row. Treatment with dexamethasone is contraindicated in severe forms of nephropathy, exacerbation of gastric ulcer and duodenal ulcer.

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

3. With regular contractions and opening of the cervical os to 4 cm, beta-adrenergic agonists (partusisten) should be used. In the management of premature labor, drug therapy is prescribed according to the following scheme: a combination of 0.025 g (1 ml of a 2.5% solution) of prolazil, 0.05 g (2 ml of a 2.5% solution) of diprazine and 1 ml of a 2% solution of promedol intramuscularly in one syringe. This combination is used in the absence of severe psychomotor agitation. In women in labor 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 diprazine (2 ml of a 2.5% solution) or 0.03 g (3 ml of a 1% solution) of diphenhydramine, 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 labor. In case of uncoordinated uterine contractions and protracted labor, with increased basal (main) uterine tone, a baralgin solution is used in a dose of 5 ml of a standard solution intramuscularly or intravenously in 20 ml of a 40% glucose solution.

In case of primary weakness of labor activity against the background of normo- or hypotonia of the uterus, it is advisable to use a solution of halidore in a dose of 0.05 g intravenously slowly in 20 ml of a 40% glucose solution. In case of rapid labor, a combination of central and peripheral N-anticholinergics is prescribed: spasmolytin in a dose of 0.1 g orally in combination with a 1.5% solution of gangleron (2-4 ml) intramuscularly or intravenously.

Treatment with partusisten should usually be started with a long-term intravenous drip infusion. The dosage of the drug should be individual, taking into account the action and tolerability of the drug. The optimal dose should be considered from 1 to 3 mcg/min of partusisten. However, in some cases it is necessary to increase the dose from 0.5 to 4 mcg/min.

Methodology: to prepare the infusion solution, dilute 1 ampoule of partusisten (10 ml of standard solution contains 0.5 mg) in 250 ml of sterile isotonic sodium chloride solution or 5 % glucose solution. It should be taken into account that 20 drops correspond to 1 ml (2 mcg of partusisten), and 10 drops correspond to 1 mcg of partusisten. After completion of infusion therapy with partusisten, immediately administer 1 tablet of the same drug containing 0.005 g orally every 3-4 hours (6-8 tablets per day). During the use of partusisten, regularly monitor the pulse rate and blood pressure, as well as the nature of the fetal heartbeat.

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 treatment of the onset of premature termination of pregnancy or coordinated labor during premature birth can be increased by infusion of the domestic anticholinergic drug metacin.

Method: 1-2 ml of 0.1% metacin solution (the dose of metacin depends on the severity of the pathology) is diluted in 250 ml of isotonic sodium chloride solution and administered intravenously by drip at a frequency of 10 to 20 drops/min for several hours. If indicated, metacin therapy can be combined with other drugs - antispasmodics, anesthetics. Glaucoma is a contraindication to the use of metacin.

4. In the second stage of labor, pushing is regulated depending on its frequency and strength. In case of violent pushing, deep breathing movements are recommended, and if necessary, ether-oxygen anesthesia.

To prevent cerebrovascular accidents in the fetus, primiparous women are recommended to undergo perineal dissection. Strong pressure on the fetus's head during delivery should be avoided.

It is also recommended to perform pudendal-paravaginal anesthesia, which helps to eliminate uncoordinated labor activity and relieve resistance of the pelvic floor muscles.

When managing premature births, it is necessary to take into account the etiological factors of miscarriage, abnormalities of labor, and in each specific case, apply measures to prevent premature rupture of amniotic fluid.

Particular attention should be paid to intranatal drug protection of the fetus, careful management of the first and second stages of labor using modern painkillers, antispasmodics and beta-adrenergic agonists, which will reduce perinatal mortality and morbidity in premature babies.

When managing premature births, it is necessary to take into account the acceleration of the intrauterine fetus in premature pregnancy, which should be understood as the accelerated development of the intrauterine fetus, not caused by manifestations of any disease, such as diabetes mellitus of the mother. An established fact in recent years is the increase in the height and weight of full-term newborns and the possibility of accelerated development of the fetus in premature pregnancy. Thus, almost 40 % of children with a pregnancy period of up to 36 weeks gave birth to newborns whose weight exceeded 2500 g, height (length) - 47 cm. Among the reasons for the acceleration of the intrauterine fetus, a prominent place belongs to the improvement of working conditions and lifestyle as a result of socio-economic changes in a number of countries.

Of great importance for improving the management of premature births based on modern scientific and practical achievements is the organization of specialized departments (maternity hospitals) or perinatal centers, which is an important stage in organizing the protection of the health of mother and child. For premature babies, intensive care wards (departments), conditions for the prevention and treatment of hypoxia and post-hypoxic conditions of newborns caused by pathology of pregnancy and childbirth in their mothers, and the prevention of infectious and septic diseases should be created.

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