Programmed childbirth

In recent years, interest in programmed birth has increased again.

In a number of cases, the artificial delivery is performed on time without medical indications, when the fetus has reached full maturity, and there are no signs of spontaneous delivery. Such preventive labor excitement in normal pregnancy is called programmed delivery.

The programmed termination of term pregnancy is now produced on average in 10-15% of pregnant women, and year after year with better results for both the mother and the child compared to the expectant management of spontaneous labor.

The main condition for the success of programmed births is the precise determination of the gestational age, the state of the fetus, and the readiness of the mother's organism for delivery. It was established that the echographic determination of the biparietal diameter of the fetal head is a more accurate indicator for predicting the date of delivery than the date of the last menstruation, therefore, ultrasound data is also used in practice.

Advantages of programmed delivery are:

• mother's preparedness, good mental state;
• childbirth during the day, when there is a well-rested trained staff of the clan unit;
• intensive monitoring from the onset of labor;
• shortened length of labor.

Negative aspects of programmed delivery:

• encumbrance of the mother with methods of induction;
• more frequent anomalies of insertion of the fetal head;
• violations of contractile activity of the uterus;
• hypotension of the uterus after childbirth.

In cases of complications, they may be due to programmed births. However, these complications are quite rare and most often depend on an inadequate assessment of the situation prior to induction.

Prerequisites for programmed delivery:

• fetal head presentation;
• term pregnancy (40 weeks, or 280 days);
• the mass of the fruit (calculated by means of ultrasound) is not less than 3000 g;
• the fetal head inserted into the small pelvis;
• mature cervix;
• readiness of the uterus for the appearance of regular uterine contractions (shown with the help of cardiotocography data).

It is especially important to observe these conditions in primiparous women.

Technique of carrying out programmed delivery

The following procedure is used.

On the eve, ultrasound examination, cardiotocography, determination of maturity of the cervix, amnioscopy.

Induction. 7.00 h - an enema, a shower, a woman is transferred to a generic unit.

8.00 am - amniotomy, cardiotocography.

9.00 h - oxytocin, 5 units / 500 ml isotonic sodium chloride solution intravenously, drip.

Childbirth, cardiotocography (determination of pH from the fetal head), pudendal anesthesia, anesthesia (nitrous oxide, etc.).

Studies also show that program genera allow you to choose the optimal time for delivery, which is especially important, according to the authors, with severe gestosis and extragenital pathology. Labor takes place on working days and working hours. Programmatic delivery in primiparas can reduce the frequency of prolonged labor, improve outcomes for the mother and fetus.

It is believed that active management of labor is indicated in uncomplicated full-term pregnancy in order to reduce perinatal losses; in pregnant women with extragenital and obstetric pathology for improving obstetric and perinatal indicators, and is absolutely indicated (!) in extreme situations, as prevention of maternal morbidity and mortality. Delivery in uncomplicated pregnancy as a preventive maintenance of its overdrafting is performed after reaching 39 weeks with a mature fetus and prepared cervix at an arbitrarily chosen time, optimal for the woman and medical personnel; begins with an amniotomy early in the morning, after a full sleep. With the development of regular labor, which usually begins within 2-3 hours, the births are under constant monitoring control of the nature of birth pains, the condition of the parturient woman and intrauterine fetus, conduct adequate anesthesia and measures aimed at preventing complications in childbirth.

The delivery of pregnant women with extragenital and obstetric pathology is performed by the authors according to the program of births developed in each particular case. It includes:

• preparation of the organism of the pregnant woman and the fetus for delivery;
• determination of the optimal timing of delivery for the mother and fetus, depending on the nature and severity of the pathology;
• method of induction of childbirth in accordance with the willingness of the body of the pregnant woman to give birth;
• an individually selected method of anesthetizing labor;
• the need for participation in the delivery of highly qualified specialists - therapists, anaesthesiologists, neon-tologs and others;
• specific recommendations for the management of I and II birth periods.

When managing complicated births, the following recommendations should be observed:

• - In the presence of extragenital diseases, the drawing up of a plan for the management of childbirth, as a rule, involves a physician-therapist;
• - to solve the problem of anesthesia of labor and surgical interventions jointly with an anesthesiologist.

This is very important, as, according to the research, there is an increase in the number of cesarean sections to 7.4%. However, in 1/3 of cases, operative delivery is performed urgently. Under these conditions, adequate preoperative preparation, a rational kind of anesthesia, and tragic technical errors are often not provided. The number of deaths as a result of anesthesia benefits has increased dangerously;

• speaking about the shortening of the II period (the period of attempts), we mean basically the imposition of output forceps or an output vacuum extractor, in single cases - the application of forceps or vacuum extractor cavities. In individual parturient women, perineotomy can be limited. If it is necessary to completely eliminate the period of attempts, the issue of delivery by caesarean section should be discussed;
• when there is evidence of signs of impairment of the fetus, it is the threatening asphyxia of the fetus. In this case, the birth of a child without signs of asphyxia should be regarded as evidence of the timeliness of the measures taken. Birth in asphyxia testifies to being late with the use of medical and preventive measures;
• in the presence of severe extragenital pathology, especially cardiovascular pathology, the presence of a general practitioner during labor is necessary;
• Suspicion of the possibility in the consecutive or early postnatal periods of bleeding due to hypofibrinogenemia requires the provision of a maternity ward with all the necessary means of combating it, preventive and curative in such cases. This also applies to bleeding hypotonic.

Programmed management of labor during pathological pregnancy is closely connected with such concepts as biorhythms of an organism, chronophysiology, chronopathology, chronotherapy and chronopharmacology.

It is known that childbirth often begins and ends at night. Medicinal substances act differently depending on the time of their administration. If the mother has no desynchronization in the course of pregnancy, i.e., a mismatch between the components of the biorhythmic system of the mother and the fetus, the gestation, the onset and the course of childbirth proceed safely. The question of indications for the management of programmed delivery in the physiological and pathological course of pregnancy has not been sufficiently studied to date. It is especially relevant for pregnant high-risk groups of maternal and perinatal mortality. Some doctors conduct programmed births with a division into the preparatory period for them and their management. Programmed births are carried out on weekdays, the induction begins at 5-6 hours, which allows you to finish childbirth during the day. Usually, after 3 hours from the onset of induction and the opening of the cervix for at least 3 cm, amniotomy is performed, with the intravenous drip of oxytocin, or PGF2a, or quilted. Programmatic delivery, according to the authors, has great advantages (in comparison with spontaneous), especially for pregnant women with various obstetric and extragenital pathologies and do not have a negative effect on the fetus. The technique of carrying out programmed delivery with delayed development (hypotrophy) of the fetus has also been developed. The delivery of such pregnant women is 37-38 weeks gestation. Birth stimulation is carried out with full maturation of the cervix and with observance of all conditions of the programmed delivery. The genus is initiated with a whole fetal bladder. The drug of choice for induction is the prostenon (PGE2). The drug favorably differs from oxytocin in that it dilates the blood vessels of the placenta, accelerates utero-placental circulation, and, according to research, activates the enzymes of the direct pathway for the oxidation of carbohydrates in the fetal liver and in the placenta, which improves the energy supply of the fetus. Oxytocin can cause a spasm of the vessels of the uterus, obstruct uterine-placental circulation and cause a state of hypoxia in the fetus. Proved that the stimulating effect of the prostenon on the uterus is removed by papaverine, which provides increased uteroplacental blood circulation, contributes to the normalization of the oxygen balance of the fetus.

The maintenance of programmed delivery is as follows:

• the choice of the day and time of the day for the induction of labor, taking into account the biorhythms of labor, the mode of work of the staff of the maternity ward;
• compilation of an individual birth program (selection of uterotonic drugs) with predicting their outcome, as well as taking into account the psychoemotional state of the pregnant and fetus;
• monitoring monitoring of the nature of labor and fetus;
• careful anesthesia of labor, better epidural anesthesia;
• ensuring a constant mutual positive connection between the doctor, the lead child, and the mother;
• objective informing the mother in childbirth about the condition of the fetus during delivery;
• rational high-calorie nutrition of the woman in childbirth;
• favorable conditions in the delivery room and favorable attitude of the staff to the mother in childbirth;
• absolute observance in the delivery room of aseptic and antiseptic rules;
• readiness and serviceability of equipment for emergency assistance to a newborn in case of birth in asphyxia;
• presence in the delivery room of one-group blood for transfusion and the recruitment of medications in case of need of emergency care to the puerperium.

Preterm termination of pregnancy involves the intervention of an obstetrician for a different period of pregnancy, including last week before the occurrence of spontaneous labor, with the expectation of getting a viable child. Scheduled deliveries at an optimal time give good outcomes for the mother and child.

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