Determination of the condition of the cervix according to the Bishop scale

• - up to 6 points - immature;
• - 6-8 points - maturing;
• - 9 points or more - mature.

Induction methods depending on cervical maturity

Mifepristone is used only for antenatal fetal death.

I. Immature cervix (Bishop score less than 6 points)

• 3. Prostaglandins E2 - dinoprostone.

Intravaginal use:

Intracervical use:

Labor induction by administering oxytocin intravenously after 6-12 hours from the moment of using prostaglandins.

Rules for using misoprostol:

• - informing the pregnant woman and obtaining written consent;
• - after the administration of prostaglandin, you must lie down for 30 minutes;
• - conduct CTG control or auscultation of the fetus;
• - when conditions arise (mature cervix), transfer to the maternity unit and perform an amniotomy. In the absence of spontaneous labor within 2 hours, begin labor induction with oxytocin according to the schedule.

Complications during labor induction:

• 1. Hyperstimulation.
• 2. Abruption of a normally located placenta.
• 3. Uterine rupture.

The use of prostaglandin F2 (enzaprost) for the purpose of labor induction and labor stimulation is contraindicated, as it has side effects:

• 1. Hypertonicity of the uterus up to tetanus.
• 2. Nausea, vomiting.
• 3. Hypertension.
• 4. Tachycardia, bradycardia, arrhythmia.
• 5. Allergic reactions, bronchospasm and others.

If there is hyperstimulation of the uterus, immediately stop administering oxytocin, place the woman on her left side, and provide oxygen supply at a rate of 8 l/min. Carry out an infusion of saline solution 500 ml over 15 minutes, carry out acute tocolysis (hexoprenoline), or administer salbutamol 10 mg intravenously drip 1.0 liter saline. solution 10 drops per minute.

From the moment contractions appear, it is necessary to monitor the fetal heart rate using CTG.

II. Ripe cervix (Bishop scale 6-8 points)

• 1. Natural dilators (kelp) - 1 time per day until the cervix ripens, up to a maximum of 3 days.
• 2. Prostaglandins E2 - misoprostol - 25-50 mcg (% or % of 200 mcg tablets) every 6 hours intravaginally (into the posterior vaginal vault) until the cervix ripens. Do not use more than 50 mcg per administration. Do not exceed the total daily dose of 200 mcg.

Prostaglandins E2 - dinoprostone.

Intravaginal use:

• - 1 mg and again 1 mg or 2 mg after six hours if necessary;
• - 1 mg every six hours for up to 3 doses;
• - 2 mg every six hours for up to 3 doses;
• - 2 mg every 12 hours for up to 3 doses.

Intracervical use:

• - 0.5 mg every six hours for up to 3 doses;
• - 0.5 mg every six hours for up to 4 doses (over two days);
• - 0.5 mg 3 times a day for up to two days.

Administration of oxytocin intravenously after 6-12 hours from the moment of application of prostaglandins.

III. Mature cervix (Bishop score 9 or more):

• 1. Digital detachment of the lower pole of the amniotic sac.
• 2. Amniotomy.
• 3. Oxytocin infusion after amniotomy, after 2 hours in the absence of spontaneous labor.
• 1. Digital detachment of the lower pole of the amniotic sac is performed before labor induction begins. The method is easy to implement. No cost required.

The patient should be informed that:

• - the procedure may be painful;
• - does not increase the risk of infection;
• - DRPO is possible;
• - bleeding with a low-lying placenta or membrane attachment of the umbilical cord vessels.

Technique for separating membranes from the lower pole of the uterus:

• - place the patient on her back;
• - insert 1 or 2 fingers into the cervical canal and use sawing movements to separate the membranes from the cervical canal and the lower segment of the uterus;
• - make sure that there are no pathological discharges (blood, water);
• - help the pregnant woman stand up;
• 2. Amniotomy - artificial opening of the membranes using a special instrument.

Conditions for amniotomy:

• - cephalic presentation of the fetus;
• - confidence in the correspondence of the fetal head to the given pelvis;
• - compliance with infection prevention rules.

In case of polyhydramnios, to prevent PONRP and umbilical cord prolapse, amniotomy should be performed with caution. Amniotic fluid must be drained slowly (along the arm).

Disadvantages of amniotomy:

Increased risk:

• - ascending infection, prolapse of umbilical cord loops;
• - vertical transmission of infection, such as HIV;
• - bleeding.

Unpredictable and sometimes long interval of time before the onset of labor.

Effective only in 50% of cases.

Amniotomy technique:

• - inform the pregnant woman and obtain written consent;
• - listen to the fetal heartbeat for one minute;
• - place the patient on her back;
• - place a clean vessel under the basin;
• - insert the index and middle finger of one hand into the cervical canal, separate the membranes from the lower segment of the uterus;
• - with the other hand, take the jaw of the bullet forceps and insert it into the cervical canal between the index and middle fingers of the other hand, trying not to touch the soft tissues;
• - pick up the shells and open them, slowly release the water;
• - conduct an inspection of amniotic fluid (quantity, color, impurities);
• - listen and evaluate the fetal heartbeat;
• - enter data into the birth history.
• 3. Oxytocin infusion. It is carried out only when the amniotic sac is opened:
  • - carried out only in a hospital in the delivery unit. The midwife is present at all times;
  • - maintaining a partogram by a doctor or midwife from the moment the patient enters the delivery unit;
  • - when inducing labor with prostaglandins, follow up with an infusion of oxytocin no earlier than 6-12 hours later;
  • - control infusions using an infusion pump if possible;
  • - carry out strict monitoring of the fetus’s condition: CTG monitor continuously; in the absence of a device - auscultation of the fetal heartbeat every 15 minutes, assessment of contractions every 30 minutes;
  • - if hypertonicity or signs of a threatening condition of the fetus occur, immediately stop administering the drug;
  • - the time of onset of labor induction must be documented in the birth history.

Oxytocin administration regimen:

• - 5 units of oxytocin diluted in 500 ml of isotonic solution;
• - start administration with 4 drops/min., which corresponds to approximately 2 mU/min.;
• - increase the infusion rate every 30 minutes. (the dose increases - see table No. 1) until reaching: 3 contractions in 10 minutes. lasting 40 seconds. and more;
• - maintain the dose of oxytocin at the concentration that turned out to be sufficient and continue the administration of oxytocin until delivery and the first 30 minutes. after childbirth;
• - periodic CTG recording is required (every hour, lasting at least 15 minutes, excluding special cases when continuous monitoring is indicated).
• - in case of hyperstimulation (any contractions lasting more than 60 seconds with a frequency of 5 or more in 10 minutes): stop the oxytocin infusion and IV slowly over 5-10 minutes. carry out tocolysis with hexaprenoline at a dose of 10 μg, previously dissolved in 10 ml of 0.9% NaCl;
• - adequate contractions are more often achieved at an injection rate of 12 mU/min, which approximately corresponds to 20 drops/min;
• - the maximum permissible rate of oxytocin administration is 20 mU/min. (40 drops/min.);
• - in exceptional cases when it is necessary to exceed this concentration, it should not be more than 32 mU/min. (64 drops/min.);
• - the effectiveness of induction is assessed 4 hours after the start of oxytocin administration.

Oxytocin solution: 5 units of oxytocin in 500 ml of saline.

Concentration: 10 mIU/ml.

IV dose of oxytocin, calculated per drop: 1 ml = 20 drops.

Table No. 1

	Dose of oxytocin	Drops per minute	Infusion volume per hour (ml/hour)
5 units in 500 ml saline (10 mIU/ml)

If after using oxytocin at a dose of 32 mU/min. labor has not established itself, in primiparous women it is possible to use higher concentrations of oxytocin in a dose of 10 units in 500 ml of saline at a rate of 30 drops/min. (30 mU/min.). Increase the rate of administration by 10 drops every 30 minutes until adequate labor is established (see Table No. 2).

Oxytocin solution: 10 units of oxytocin in 500 ml of saline.

Concentration: 20 mIU/ml.

IV dose of oxytocin, converted into drops: 1 ml = 20 drops.

Table No. 2

Oxytocin solution concentration	Oxytocin dose m/unit/min.	Drops per minute	Infusion volume per hour (ml/hour)
10 units in 500 ml of saline (20 mIU/ml)

If good labor activity is not established at a delivery speed of 60 drops/min. (60 mU/min.), delivery by cesarean section is indicated.

If after using oxytocin at a dose of 32 mU/min. labor activity has not been established in women who give birth repeatedly and in women with a scar on the uterus; delivery by cesarean section is necessary.

Labor stimulation is an increase in labor activity at a gestational age of 22 weeks or more.

Indication: weakness of labor.

Contraindications:

• - hypersensitivity to the drug;
• - a scar on the uterus after a corporal caesarean section;
• - obstructive labor (clinically narrow pelvis);
• - PONRP;
• - incorrect position and presentation of the fetus;
• - threatening uterine rupture;
• - threatening condition of the fetus.

The use of prostaglandins for the purpose of labor stimulation is contraindicated.

A patient undergoing labor and delivery should never be left alone.

Grade:

up to 6 points – immature

6-8 points - maturing

9 points or more - mature

Induction methods depending on cervical maturity

Mifepristone used only in cases of antenatal fetal death

I. Immature cervix (Bishop score less than 6 points)

1.1.1. Natural dilators (kelp) - 1 time per day until the cervix ripens, up to a maximum of 3 days

1.1.2. Prostaglandins E 1 - Misoprostol - 25-50 mcg (⅛ or ¼ tablet 200 mcg) every 6 hours intravaginally (into the posterior vaginal fornix) until the cervix ripens. Do not use more than 50 mcg per administration. Do not exceed the total daily dose of 200 mcg

1.1.3. Prostaglandins E 2 - Dinoprostone

Labor induction by administering oxytocin intravenously after 6-8 hours from the moment of using prostaglandins.

Rules for using misoprostol:

· informing the pregnant woman and obtaining written consent

After the administration of prostaglandin, you must lie down for 30 minutes

Conduct CTG control or auscultation of the fetus after 30 minutes

· when conditions arise (mature cervix), transfer to the maternity unit and perform an amniotomy. In the absence of spontaneous labor within 2 hours, begin labor induction with oxytocin according to the scheme

Complications during labor induction:

· Hyperstimulation

Abruption of a normally located placenta

· Uterine rupture

Usage prostaglandin F 2 α (enzaprost) for the purpose of labor induction and labor stimulation is contraindicated, as it has side effects:

Hypertonicity of the uterus up to tetanus

Nausea, vomiting

· Hypertension

Tachycardia, bradycardia, arrhythmia

· Allergic reactions, bronchospasm and others

With uterine hyperstimulation– immediately stop the administration of oxytocin, place the woman on her left side, provide oxygen supply at a rate of 8 l/min. Carry out an infusion of 500 ml of saline solution over 15 minutes, carry out acute tocolysis (hexoprenoline), or administer 10 mg of salbutamol intravenously in 1.0 liter of saline solution, 10 drops per minute.

From the moment contractions appear, it is necessary to monitor the fetal heart rate using CTG

II. Maturing cervix (Bishop scale 6-8 points)

1.1.4. Natural dilators (kelp) - 1 time per day until the cervix ripens, up to a maximum of 3 days

1.1.5. Prostaglandins E 1 - Misoprostol - 25-50 mcg (⅛ or ¼ tablet 200 mcg) every 6 hours intravaginally (into the posterior vaginal fornix) until the cervix ripens. Do not use more than 50 mcg per administration. Do not exceed the total daily dose of 200 mcg

1.1.6. Prostaglandins E 2 - Dinoprostone

▪ Intravaginal use:

1 mg and repeat 1 mg or 2 mg after six hours as needed

1 mg every six hours for up to 3 doses

2 mg every six hours for up to 3 doses

2 mg every 12 hours for up to 3 doses

▪ Intracervical use:

0.5 mg every six hours for up to 3 doses

0.5 mg every six hours for up to 4 doses (over two days)

0.5 mg 3 times a day for up to two days

Administration of oxytocin intravenously after 6-12 hours from the date of application of prostaglandins.

Up to 6 points - immature;

- 6-8 points - maturing;

9 points or more - mature.

Diagnosis: 3 Pregnancy 41 weeks. Gestational hypertension without significant proteinuria. Varicose veins.

In terms of:

According to the planned plan, induction of labor began: 11/23/2016, 06:00 min Tab. misoprostol 25 mcg into the posterior vaginal fornix.

Bishop scale

With the onset of regular labor, labor should be carried out according to the partogram,

CTG monitoring of fetal condition.

If a threatening condition occurs in the pregnant woman, the fetus should be delivered by cesarean section

06 h. 00 min.

No complaints.

Body temperature is 36.4 0 C. Breathing is spontaneous, respiratory rate is 18 per minute, auscultation can be heard in all fields. Heart sounds are muffled and rhythmic.

Pulse 80 beats per minute. Blood pressure 120/80 mmHg (2) The tongue is clean and moist. The abdomen is soft, enlarged due to the pregnant uterus, and painless. The liver and spleen are not palpable. The effleurage symptom is negative on both sides.

Obstetric status

The uterus is of regular ovoid shape with clear contours, not excitable

without local pain.

The position of the fetus is longitudinal, the fetal head is presented above the entrance to the pelvis. There is no fetal heartbeat.

PV: The cervix is ​​closed, the length of the cervix is ​​3 cm, the consistency of the cervix is ​​dense, the location is average. Location of the presenting part of the head

3 cm above the sit bones.

Determination of the condition of the cervix according to the Bishop scale

- up to 6 points - immature;

6-8 points - maturing;

9 points or more - mature.

Diagnosis: 6th pregnancy 23 weeks.

Antenatal fetal death.

Induction with drugs.

In terms of:

According to the planned plan, induction of labor continued: 06/22/2016, 06:00 min

entered Tab. misoprostol 50 mcg into the posterior vaginal fornix.

Continue induction of labor according to the protocol according to the degree of cervical maturity

Bishop scale

With the onset of regular labor, labor should be carried out according to the partogram

Active management of the 3rd stage of labor

If a pregnant woman is in a threatening condition, deliver by caesarean section

Obstetrician-gynecologist: Isaev M.M.

06 h.00 min.

Joint examination with the responsible duty doctor Serik E.S.

Complaints of pain in the lower abdomen.

General condition is satisfactory.

The skin and visible mucous membranes are pale pink in color and clean.

Body temperature is 36.6 0 C. Breathing is spontaneous, respiratory rate is 18 per minute, auscultation can be heard in all fields. Heart sounds are muffled and rhythmic.

Pulse 70 beats per minute. Blood pressure 120/80 mmHg (2) The tongue is clean and moist. The abdomen is soft, enlarged due to the pregnant uterus, and painless. The liver and spleen are not palpable. The effleurage symptom is negative on both sides.

Obstetric status: There is no regular labor activity.

The uterus has a regular ovoid shape with clear contours, is slightly excitable,

without local pain.

The position of the 1st, 2nd fetus is longitudinal, the head of the 1st fetus is presented to the entrance to the pelvis. The heartbeat of the 1st fetus is rhythmic up to 140 beats. per minute.

There is no heartbeat of the 2nd fetus.

PV: The cervix is ​​dilated by 1-2 cm, the length of the cervix is ​​1-2 cm, the consistency of the cervix is ​​partially softened, the location is average. The location of the presenting part of the head is 2 cm above the ischium. The amniotic sac is intact.

Discoordinated labor activity. Diagnosis. Doctor's tactics.

Discoordination of labor – hypertensive uterine dysfunction. These include:

1.hypertonicity of the lower segment of the uterus (reverse gradient),

2.convulsive contractions (uterine tetany),

3.circulatory dystocia (contraction ring).

The essence: displacement of the pacemaker from the uterine angle to the lower part of the uterus or the formation of several pacemakers that distribute impulses in different directions, disrupting the synchronicity of contraction and relaxation of individual parts of the uterus.

1. violation of the formation of the generic dominant and => lack of “maturity” of the cervix at the beginning of labor; 2.dystocia of the cervix (its rigidity, scar degeneration); 3.increased excitability of the woman in labor, leading to a disruption in the formation of the pacemaker; 4. disruption of the innervation of the uterus; 5.genital infantilism.

Clinic based diagnosis:

1.immature cervix at the onset of labor;

2.high basal tone of the uterus with possible tetanus of the uterus (in a state of tension, does not relax);

3. frequent, intense, painful contractions; pain in the lumbar region; (Hysterography - contractions are unequal in strength and duration, pain, different intervals.)

4.lack of dilatation of the cervix or its dynamics;

5. swelling of the cervix;

6. long standing of the presenting part of the fetus at the entrance to the pelvis;

7.untimely rupture of amniotic fluid.

Discoordination can lead to weakness of labor. Complications: uteroplacental blood flow is disrupted and acute fetal hypoxia and ischemic-traumatic damage to its central nervous system develop.

Treatment. It is carried out while monitoring the condition of the fetus.

In the 1st stage of labor - regional anesthesia. For tetanus of the uterus + β-AM (), inhalation halogenated anesthetics (fluorotane, enflurane, isoflurane), nitroglycerin preparations (nitroglycerin, isoket). If epidural anesthesia is not possible => antispasmodics (no-spa, baralgin, buscopan), painkillers (promedol) every 3-4 hours, sedatives (seduxen). Psychotherapy, physiotherapy (electroanalgesia). An early amniotomy is performed (if the cervix is ​​mature). If all methods are ineffective => caesarean section. Uterotonics cannot be administered.

At the 2nd stage of childbirth, epidural anesthesia is continued, or pudendal anesthesia is performed; if indicated, episiotomy is performed.

A differential diagnosis is made with cervical dystonia, which is a consequence of the operation - diathermocoagulation. (cervical dystrophy is formed and this prevents its opening).

Internal obstetric examination. Indications, technique, assessment of the degree of maturity of the cervix.

Internal obstetric examination is performed with one hand (two fingers, index and middle, four - half-hand, whole hand). Internal examination makes it possible to determine the presenting part, the state of the birth canal, observe the dynamics of cervical dilatation during childbirth, the mechanism of insertion and advancement of the presenting part, etc. In women in labor, a vaginal examination is performed upon admission to the obstetric institution, and after the rupture of amniotic fluid. In the future, vaginal examination is performed only when indicated.

Internal examination begins with examination of the external genitalia (hair growth, development, swelling of the vulva, varicose veins), the perineum (its height, rigidity, presence of scars) and the vestibule of the vagina. The phalanges of the middle and index fingers are inserted into the vagina and examined (lumen width and length, folding and extensibility of the vaginal walls, the presence of scars, tumors, septa and other pathological conditions). Then the cervix is ​​found and its shape, size, consistency, degree of maturity, shortening, softening, location along the longitudinal axis of the pelvis, and patency of the pharynx for the finger are determined.

During the examination during labor, the degree of smoothness of the cervix (preserved, shortened, smoothed), the degree of opening of the pharynx in centimeters, and the condition of the edges of the pharynx (soft or dense, thick or thin) are determined. In women in labor, a vaginal examination determines the condition of the fetal bladder (integrity, loss of integrity, degree of tension, amount of anterior water). Determine the presenting part (buttocks, head, legs), where they are located (above the entrance to the small pelvis, at the entrance with a small or large segment, in the cavity, at the pelvic outlet). Identification points on the head are sutures, fontanelles, and at the pelvic end - the sacrum and coccyx. Palpation of the inner surface of the pelvic walls makes it possible to identify deformation of its bones, exostoses and judge the capacity of the pelvis.

At the end of the study, if the presenting part is high, measure the diagonal conjugata (conjugata diagonalis), the distance between the promontory and the lower edge of the symphysis (normally 13 cm). To do this, with the fingers inserted into the vagina, they try to reach the promontory and touch it with the end of the middle finger; the index finger of the free hand is brought under the lower edge of the symphysis and the place on the hand that is in direct contact with the lower edge of the pubic arch is marked. Then remove the fingers from the vagina and wash them. The assistant measures the marked distance on the hand with a centimeter tape or a hip meter. By the size of the diagonal conjugate one can judge the size of the true conjugate.

Classification of cervical maturity according to G.G. Khechinashvili:

· Immature cervix - softening is noticeable only at the periphery. The cervix is ​​dense along the cervical canal, and in some cases - in all parts. The vaginal part is preserved or slightly shortened, located sacrally. The external pharynx is closed or allows the tip of the finger to pass through, determined at a level corresponding to the middle between the upper and lower edges of the symphysis pubis.

· The ripening cervix is ​​not completely softened; a patch of dense tissue is still noticeable along the cervical canal, especially in the area of ​​the internal os. The vaginal part of the cervix is ​​slightly shortened; in primigravidas, the external os allows the tip of the finger to pass through. Less often, we pass the cervical canal for the finger to the internal os or with difficulty beyond the internal os. There is a difference of more than 1 cm between the length of the vaginal part of the cervix and the length of the cervical canal. A sharp transition of the cervical canal to the lower segment in the area of ​​the internal pharynx is noticeable. The presenting part is not clearly palpated through the fornix. The wall of the vaginal part of the cervix is ​​still quite wide (up to 1.5 cm), the vaginal part of the cervix is ​​located away from the wire axis of the pelvis. The external pharynx is defined at the level of the lower edge of the symphysis or slightly higher.

· The not fully ripened cervix is ​​almost completely softened, only in the area of ​​the internal pharynx is an area of ​​dense tissue still visible. In all cases, the canal can be passed through the internal os for one finger, but with difficulty in first-time mothers. There is no smooth transition of the cervical canal to the lower segment. The presenting part is palpated through the arches quite clearly. The wall of the vaginal part of the cervix is ​​noticeably thinned (up to 1 cm), and the vaginal part itself is located closer to the wire axis of the pelvis. The external pharynx is defined at the level of the lower edge of the symphysis, sometimes lower, but not reaching the level of the ischial spines.

· The mature cervix is ​​completely softened, shortened or sharply shortened, the cervical canal freely passes one finger or more, is not curved, smoothly passes to the lower segment of the uterus in the area of ​​the internal pharynx. The presenting part of the fetus is quite clearly palpated through the fornix. The wall of the vaginal part of the cervix is ​​significantly thinned (up to 4–5 mm), the vaginal part is located strictly along the axis of the pelvis, the external os is defined at the level of the ischial spines.