Prevention and treatment of premature rupture of amniotic fluid and loss of umbilical cord loops

From the moment of receipt of the pregnant woman or the mother in childbirth, a bed regimen and an elevated position of the woman's pelvis are prescribed in the hospital. Relatively often with the first contractions, and often before their onset, there is an outflow of water and the prolapse of the umbilical cord loops. The latter is especially dangerous with a small opening of the uterine throat. Dropped umbilical cord can be tried to fill with a purely gluteal presentation. When leger presentation, such attempts are unsuccessful (there is no fitting belt), so do not do this. If the prolapse of the umbilical cord loops occurs at the opening of the uterine pharynx to 6-7 cm in the primiparous and 5-6 cm in the repetitive, after an unsuccessful attempt to fill the umbilical cord, a caesarean section should be performed. If the umbilical cord loops fall at the end of the first stage of labor, conservative management of them is permissible. In this case, the umbilical cord dropped from the genital cleft should be gently wrapped in a sterile napkin moistened with a warm isotonic sodium chloride solution; when the fetal heart is changed, it is necessary to extract it.

[1], [2], [3]

Treatment of abnormalities of labor

In case of untimely outflow of amniotic fluid and lack of biological readiness for childbirth (immature cervix uteri, etc.) for 2-3 h preparation for childbirth is carried out: prostaglandin E2 is injected into the posterior vagina of the vagina in the form of a gel in a dose of 3 mg, and also the administration of estrogens - folliculin solution in oil for injection 0.05% - 1 ml or 0.1% - 1 ml intramuscularly; with the purpose of faster maturation of the cervix and increased uteroplacental blood flow and transport function of the placenta, infusion therapy with sygetin is recommended by the method: sygetic 1% - 20 ml in 500 ml of isotonic sodium chloride solution or in 500 ml of 5% glucose solution is administered intravenously at a frequency of 8- 12 drops / min, on average for 2-2.5 hours; simultaneously with the purpose of suppressing the contractile activity of myometrium, a solution of diazepam 0.5% - 2 ml is injected intravenously, slowly, prepared with isotonic sodium chloride solution (10 ml at a rate of 1 ml of the drug for 1 min to avoid diplopia or light dizziness arising from rapid administration of the drug). In this case, it must be remembered that seduxen should not be administered in a mixture with other drugs, as it quickly precipitates.

The optimal dose of estrogens has been established in studies, and is 250-300 U / kg body weight. In order to create an estrogenic background, it is advisable to use estrogen preparations containing mainly estradiol and estradiol fractions-estradiol dipropionate, estradiol enatate, ethinyl-estradiol and others, but folliculin containing a mixture of estrone, estradiol and estriol should not be used, since estriol has a relaxing effect on the myometrium .

In case of untimely outflow of amniotic fluid and biological readiness for childbirth (mature cervix of the uterus, high excitability, etc.) immediately, with the immature cervix of the uterus - 1 hour after the preparation for delivery begins stimulation.

When deciding on the necessity of rhodostimulation, it should be borne in mind that the average length of labor should not exceed 16-16 hours in primiparas, 12-14 hours in re-birth, and those cases in which labor did not occur within 12 hours after the outflow of amniotic fluid cesarean section).

Methods of stimulation of labor

Inside give castor oil 30-60 g and after 30 minutes prescribe a cleansing enema. Immediately after emptying the intestine, the mother gives the quinine hydrochloride 0.15 g every 15 minutes, 4 times and then intramuscularly injected oxytocin in fractions of 0.2 ml every 20 minutes, with only 5 injections. If the effect is insufficient, after 2 hours repeat rhodostimulation in the same scheme and in the same doses, but without the use of castor oil and cleansing enema.

In the absence of sufficient effect from rhodostimulation with quinine-oxytocin and fatigue of the mother in childbirth, it is necessary to provide a medication sleep-rest for 5-6 hours with the preliminary creation of an estrogen-vitamin-glucose-calcium background and the introduction of intravaginally prostaglandin E, in the form of a gel that promotes an increase in the number of oxytocin receptors in myometrium. After the full awakening of the woman in labor, the scheme of rhinostimulation with quinine-oxytocin can be repeated or intravenously administered oxytocin or prostaglandin.

Refusal to use quinine in the schemes of rhodostimulation, as suggested by some modern obstetricians, seems premature, for, as shown by the studies of MD Kursky et al. (1988), quinine in the concentration range 10 ~ ³ -10 ~ ² M sharply increased the rate of passive Ca ²⁺ release from the vesicles of the sarcolemma, while sygetin did not influence this process in the same concentration range. The fact that quinine enhances the rate of release of Ca ^{2+ ions} accumulated by passive equilibration or in an ATP-dependent process indicates an increase in the calcium permeability of membrane vesicles. Quinine increases the nonspecific permeability of the sarcolemma.

For rodovozbuzhdeniya can also be used by the method of ME Barats. intramuscularly inject folliculin solution in oil for injection 0.05% - 1 ml or 0.1% - 1 ml 3 times at intervals of 8-12 hours. After 6 hours, the woman is given 60 g of castor oil and after 1 hour - cleansing enema , after another 1 h - quinine hydrochloride 0.15 g - 8 times at intervals of 20 min, then oxytocin 0.2 ml intramuscularly b injections, every 20 min. Fruit blister is not recommended. Do not recommend for pelvic presentation, even a purely gluteal, to begin birth with an amniotomy.

Rhodostimulation by intravenous administration of oxytocin

In the absence of the effect of rhodostimulation by the method of "quinine-oxytocin," it is advisable to resort to intravenous administration of oxytocin with the opening of the fetal bladder. To this end, 5 units of oxytocin are diluted in 500 ml of 5% glucose solution, thoroughly mixing. Intravenous administration of oxytocin should start with a minimum dose of 8-12 cap / min. If there is no increase in labor activity every 45 minutes -1 hour, the dose of oxytocin gradually increases by 4-6 drops, not exceeding 40 drops / min. With intravenous administration of oxytocin, constant monitoring of the midwife and obstetrician is necessary. Oxytocin is contraindicated in polyhydramnios, multiple pregnancies, nephropathy of the third degree, pre-eclampsia, in the presence of a postoperative scar on the uterus, narrow pelvis, etc.

When applying oxytocin intravenously in the II stage of labor, it begins to be injected from 8-10 cap / min with a gradual increase in the dose every 5-10 minutes for 5 drops, bringing the rate of oxytocin injection no more than 40 drops / min; the total dose is 10 units with 500 ml of 5% glucose solution.

It is believed that when making a decision on the possibility of vaginal delivery, the midwife should not be afraid of carrying out stimulation of labor with oxytocin in cases when it is necessary for treatment with a prolonged latent phase or a delayed active phase of labor. Other abnormalities of labor, such as a secondary cervical opening stop or a violation of the character of the lowering of the fetus, serve as an indication for the caesarean section. The authors also believe that the course of labor in pelvic presentation should be monitored using monitor electronic equipment, and with obvious signs of fetal distress, caesarean section is required. In pelvic presentation in childbirth, there is often an appearance of vaguely pronounced variable decelerations. They are an indicator of fetal distress only in those cases where they are more pronounced, arise against a background of low fetal pH values, or accompany on the curve of the PSP registration of pathological variability from impact to shock. To determine the pH of a fetus with a pelvic presentation, the blood can be obtained from the present buttocks.

Stimulation by prostaglandins

Apply a solution of prostaglandin F2 (enzaprost), which is prepared immediately before administration by the following procedure: 0.005 g of the drug is dissolved in 500 ml of a 5% solution of glucose, resulting in an enzaprost concentration of 10 μg / ml. The solution must be started with minimal doses - from 12-16 drops / min (10 μg / min), followed by a gradual increase in the drop frequency by 4-6 every 10-20 minutes. The maximum dose of enzaprost should not exceed 25-30 μg / min.

In case of premature overflow of amniotic fluid in women with premature pregnancy, labor initiation should begin 4-6 hours after the outflow of water.