What is dangerous for the mother of premature birth

The duration of a normal pregnancy is 40 weeks, or 280 days. If labor begins at the age of 28 to 37 weeks of pregnancy, they are considered premature. In preterm birth, a premature baby weighing more than 1000 g is born, able to exist outside the mother's womb with appropriate care and treatment.

According to the recommendations of the World Health Organization (WHO), births from 22 to 37 weeks of pregnancy (fetal weight 500 g or more) are premature. There are very early premature births (22-27 weeks), early (28-33 weeks) and premature birth (34-37 weeks). In our country, childbirth at 22-27 weeks is not considered premature, but medical care is provided in a maternity hospital, and also take all the necessary measures to care for the fetus. A child born in such an early period (22 to 23 weeks) is considered a fetus during the first 7 days of life. Only after a week, in case the baby could adapt to the extra-uterine conditions of existence, he is considered a child. In modern obstetrics, the frequency of preterm labor not only does not decrease, but tends to increase due to the increase in the number of multiple pregnancies, the widespread use of assisted reproductive technologies. What are the real causes of premature birth, learn in the article on the topic "What is dangerous for the mother of premature birth."

Causes

The causes of preterm birth are quite diverse, they can be divided into two groups - socio-biological (non-medical) and medical. For socio-biological reasons are harmful habits (use of alcohol, drugs, smoking during pregnancy), low socio-economic level of life of the future mother, harmful working conditions (the presence of radiation, vibration, noise, irregular schedule, work at night), and also malnutrition, the state of chronic stress.

The main medical reasons include:

• Infection (is one of the most significant causes leading to early termination of pregnancy). To premature birth can lead to both acute and chronic infection (bacterial and viral). It can be common infectious diseases of internal organs (pneumonia - pneumonia, pyelonephritis - inflammation of the kidneys, etc.), then the infection penetrates the fetus through the placenta; or infection of the genitals (chlamydia, trichomoniasis, gonorrhea, herpes, etc.), then an infection from the vagina can penetrate the fetal egg ascending way.

• Weighed in obstetrical anamnesis (abortions, miscarriages - interruption of pregnancy up to 22 weeks and premature birth in the past) and / or gynecological history (inflammatory diseases of female genitalia, uterine myoma - tumor of the muscular layer of the uterus, hormonal disorders, genital infantilism - underdevelopment of genital organs, malformations of the uterus).

• Isthmicocervical insufficiency - inadequacy of cervical uterine blockage due to traumatization with abortions, discontinuities in previous births, etc.

• Extragenital pathology (diseases of internal organs) - endocrine pathology (obesity, diabetes, thyroid diseases), severe diseases of the cardiovascular system, kidneys and other organs. To this group of causes include thrombophilic conditions (diseases associated with an increase in the activity of the blood coagulation system), in which the risk of premature detachment of the placenta, thrombosis (clogging of blood clots of the blood vessels of the placenta), leading to premature birth is dramatically increased.

• Complicated course of pregnancy (gestosis - toxicosis of the second half of pregnancy, severe forms of fetoplacental insufficiency, causes leading to overgrowth of the uterus - polyhydramnios, multiple pregnancies).

Symptomatic of the onset of premature birth

A sign of the onset of labor will be the appearance of regular cramping pains in the lower abdomen, which over time become stronger, prolonged and frequent. In the beginning, when the pains in the abdomen are weak and rare enough, mucous or mucocutaneous bleeding can appear from the vagina, which indicate structural changes (shortening and smoothing) of the cervix. A fairly frequent variant of the development of events may be premature discharge of amniotic fluid, while a clear or yellowish liquid is released from the vagina, the amount of which can vary from a teaspoon to a glass or more. Outpouring of amniotic fluid may be accompanied by pain in the lower abdomen, and can occur in the total absence of an increase in the tone of the uterus. As a rule, the outflow of amniotic fluid is caused by infection of the lower pole of the fetal bladder in an ascending manner (infection comes from the vagina). The appearance of any of the above symptoms is the basis for calling an "ambulance" and urgent hospitalization in the maternity hospital, as the sooner the future mother is in a medical facility, the more chances to keep the pregnancy. If there is no possibility to prolong the pregnancy, all conditions for careful delivery will be created in the maternity hospital, reducing the risk of complications for the mother and fetus, as well as for nursing the premature newborn.

The course of premature birth

The most frequent complications of the course of premature birth are anomalies of labor (weakness, discoordination of labor, rapid or rapid delivery), premature discharge of amniotic fluid, development of intrauterine fetal hypoxia (lack of oxygen).

Fast delivery

For premature births, a rapid and even rapid flow is characteristic. This circumstance is due, first, to the fact that for the birth of a premature fetus, a smaller opening of the cervix (6-8 cm) is sufficient than with timely delivery (10-12 cm). Secondly, it was found that the contractile activity of the uterus in preterm delivery is about 2 times greater than the activity at birth in time. Third, the small-sized fetus moves faster through the birth canal. In this case, frequent, painful, prolonged fights are noted. If the average duration of timely delivery is 10-12 hours, then premature birth lasts 7-8 hours or less. The rapid course of labor is a serious anomaly, which even with timely delivery can lead to the development of hypoxia (oxygen starvation) of the fetus. Active contractile activity of the uterus leads to a decrease in uteroplacental blood flow, which is the consequence of hypoxia of the fetus, and also has a pronounced mechanical effect on the fragile organism of the premature baby. In addition, with rapid passage through the birth canals, the fetal head does not have time to adapt to the proper degree, which results in traumatization of the cervical spine, as well as hemorrhage under the membranes of the fetal brain during childbirth. As a result of these injuries, a premature baby experiences difficulties in adapting to new (extrauterine) conditions of life, which is most often manifested by neurological disorders and requires careful monitoring and baking. Due to the rapid progress of the child, there may be ruptures of soft birth canal (ruptures of the cervix, vagina, labia) due to the fact that the tissues do not have time to adapt properly to the size of the fetus.

Weakness of labor. A more rare complication of premature birth is the weakness of labor, when the frequency and strength of contractions is reduced, which significantly increases the duration of labor and also adversely affects the fetal status of the fetus (hypoxia develops). Discoordinated labor activity. In addition to excessively turbulent or weak labor activity, discordant generic activity is observed less frequently in premature births - the kind of anomalies of the birth act, in which the order of contraction of the uterus muscles is disturbed (normally the contraction begins at the corner of the uterus and spreads from the top down). In the case of discordant labor, sharply painful contractions are noted, in the intervals between which the uterus does not completely relax, which leads to the development of intrauterine hypoxia of the fetus. Incorrect position of the fetus. In premature births, fetal abnormalities are more likely (for example, pelvic presentations) due to the small size of the fetus in relation to the size of the uterine cavity.

Premature discharge of amniotic fluid. This complication occurs with premature births quite often and is caused by isthmicocervical insufficiency or infection. Part of the bladder, turned into the vagina, under the influence of infection undergoes inflammatory changes, becomes fragile, and the rupture of membranes occurs. The outpouring of amniotic fluid often occurs unexpectedly, while the liquid is released from the vagina (from a wet spot on the laundry to the flowing waters in large quantities). The color of amniotic fluid can be light and transparent (which is evidence of a satisfactory condition of the fetus), in some cases, water can acquire a green color, be turbid, with an unpleasant odor (which is considered a sign of intrauterine fetal hypoxia or infection).

Infections

Infectious complications in childbirth or in the puerperium during premature birth are observed much more often than during childbirth on time. This may be due to the prolonged course of labor (with weakness of labor), a long duration of anhydrous period - more than 12 hours (as often after the outflow of amniotic fluid before the onset of labor can take many hours), as well as the initial presence in the body of a pregnant infection, which became the cause of premature birth. The most frequent infectious complications are postpartum endometritis (inflammation of the uterus), suppuration of the sutures after suturing rills. Very rare, but severe complications can be peritonitis (inflammation of the peritoneum) and sepsis (generalized spread of infection throughout the body).

Management of preterm labor

Since for the organism of a premature baby labor is a strong stress, the management of premature births has a number of fundamental differences from the management of labor in a full-term pregnancy. The main "motto" that guides obstetricians is the most careful, expectant management in the management of preterm labor, the absence of any intervention without significant reasons.

Preservation of pregnancy

At the stage of threatening or beginning premature birth, if there are no contraindications (such as the outflow of amniotic fluid, serious complications of pregnancy, the opening of the cervix more than 5 cm, the presence of infection, etc.), treatment aimed at maintaining pregnancy is performed. Currently, obstetricians are equipped with effective drugs that suppress the contractile activity of the uterus - tocolytic (the most widely used drug of this group is HINIPRAL). To rapidly reduce the uterine tone, tocolytics begin to be injected intravenously, after a decrease in the tone they switch to taking these drugs in the form of tablets.

Prevention of complications. In the case of a pronounced threat of interruption of pregnancy at a period of less than 34 weeks, the respiratory distress syndrome of the newborn (respiratory disorders due to insufficient maturity of the lung tissue) is prevented by prescribing the pregnant hormones of the adrenal cortex-glucocorticoids (PREHNYOLOH, DEXAMETHANON, BETAMETAZON). The rate of prevention of the syndrome of respiratory distress of the fetus takes 24 hours on average (various schemes for the appointment of glucocorticoids have been developed - from 8 hours to 2 days, the choice of which is made depending on the specific obstetric situation). These drugs contribute to the acceleration of the maturation of pulmonary surfactant in the fetus, since it is the lack of this surfactant located in the alveoli - the pulmonary "gas bubbles" through which the gas exchange between the blood and air - and preventing the lung from decompressing on inhalation causes the development of respiratory disorders premature neonate. It is established that at the gestation period of more than 34 weeks, the fetal lungs already have enough surfactant. so there is no need to prevent respiratory distress syndrome. In the arsenal of obstetricians and neonatologists, surfactant preparations are currently available (KUROSURF, SURFANTANT BL), with the introduction of which premature newborns can significantly reduce the incidence and severity of the respiratory distress syndrome. During childbirth, careful monitoring is carried out both for the status of the parturient woman (temperature, blood pressure, if necessary, a clinical blood test is performed), and for the fetal status of the fetus by cardiotocography (two sensors recording the tone of the uterus and cardiac activity of the fetus , which allows an effective evaluation of the intrauterine "state of health" of the fetus), as well as by regularly listening to the fetal heart tones through the anterior abdominal wall. Prevention of intrauterine hypoxia of the fetus is carried out, for this purpose they are prescribed to PIRACETAMES, ASKORBINE ACID, COCAROXYLASE, ACTO-VEGIN.

Anesthesia

An adequate condition for the correct management of preterm labor is adequate anesthesia, since pain leads to the development of vascular spasm, which certainly has a negative effect on the premature fetus, for which labor is a strong stressful situation. With the aim of anesthetizing births, spasmolytics and analgesics, epidural anesthesia (the method of anesthesia, in which the drug is injected into the epidural space) are used. The injection is performed in the lumbar region, a space between the wall of the spine and a hard shell covering the spinal cord, a catheter is inserted, and an anesthetic agent is administered. Considering the fact that narcotic analgesics (for example, PROMEDOL) can have a depressing effect on the fetal respiratory center, the use of this group of drugs is not advisable. Epidural anesthesia has proven itself in the management of preterm birth, as it contributes to the improvement of uteroplacental blood flow, having a beneficial effect on the fetal status of the fetus and helping it to overcome the birth stress in relatively "comfortable" conditions.

Rhythmostimulation

The next peculiarity of the tactics of labor in the case of premature pregnancy is a very cautious attitude toward rhodostimulation when the weakness of labor is developed. If timely delivery begins with rhodostimulation, it must continue until the end of childbirth, then in case of premature birth a sparing technique is used: during normalization of labor, stimulation is discontinued, since stimulation for the fragile organism of a premature fetus may cause intrauterine hypoxia.

Keeping the period of attempts

In the period of expulsion of the fetus (the period of attempts) for the purpose of the most careful extraction of the fetus, the births are taken without protecting the perineum from ruptures (the so-called obstetric manual), and the perineal incision is cut to minimize the compression of the fetal head by the tissues of the birth canal - episiotomy. At birth, a neonatologist is always present, ready to provide emergency care for a newborn and carry out resuscitation if necessary.

Caesarean section operation

It is quite difficult to determine the indications for a cesarean section during preterm labor, especially if the gestation period is less than 34 weeks. In modern obstetrics, delivery by caesarean section with an under-term pregnancy of up to 34 weeks in the vast majority of cases is carried out according to absolute indications - that is, in situations that threaten the life of the mother. Absolute indications include premature placental abruption, placenta previa (the placenta covers the cervix, and births are not possible through natural birth canals), transverse position of the fetus, etc. The need for operative delivery in the interests of the fetus in case of premature pregnancy is made collegially (with the participation of several specialists) taking into account the prognosis for the further life of the child and with the possibility of providing skilled neonatal care for the newborn.

How to behave?

The behavior of the parturient woman in the process of preterm delivery does not differ significantly from the behavior with timely delivery. If the doctor permits, you can walk around the ward, take comfortable body positions that ease the pain in bouts, using massage techniques (circling the stomach in a clockwise direction, rubbing the sacrum, etc.), breathe deeply at the moment of the fight. In some cases (for example, with pelvic presentation of the fetus) it is recommended to be lying in bed. In this case, the best option will be lying on its side, since this situation excludes the squeezing of large vessels (which may result in the development of intrauterine fetal suffering), and also prevents the fetus from moving too fast through the birth canal. Most importantly - keep calm and positive attitude, listen carefully and follow the recommendations of midwives and doctors.

Premature baby

The child, born as a result of premature birth, has signs of prematurity, the severity of which is determined in the aggregate at birth - weight less than 2500 g, growth less than 45 cm, abundance of cheese lubricant on the skin, soft nasal and ear cartilage, girls do not cover large labia small , in boys the testicles are not lowered into the scrotum, the nail plates do not reach the fingertips. At birth, the child is examined by a neonatologist in the delivery room and transferred to the Intensive Care Unit or Neonatal Resuscitation for further monitoring and treatment. As a rule, premature babies are placed in a kuvez - a special incubator with transparent walls, which maintains temperature, humidity, oxygen content in the optimal for the baby limits. Being in the kuveze promotes a more smooth flow of the adaptation period of the newborn outside the mother's body. The longer the gestation period and the weight of the baby at birth, the more favorable the prognosis. If necessary, the newborn is transferred from the maternity hospital to the children's hospital for the second stage of nursing. There are maternity hospitals specialized in the management of preterm delivery and nursing of premature newborns, equipped with modern complex equipment for infants, obstetricians and neonatologists have accumulated extensive experience in the treatment and delivery of such medical institutions, which allows to significantly improve the outcomes for both mother and for a child. Women with a high risk of premature birth should be given birth in those obstetrical institutions, where all conditions exist for providing full-scale resuscitation assistance to a premature newborn (Kuveza, ventilators, and specialists of the appropriate level).

Adaptation to new conditions of life outside the womb of a premature baby is more severe and longer than for a full-term baby. This is due to the immaturity of organs and systems, reduced ability to self-regulation, insufficient development of the immune system. At present, significant success has been achieved in the care of premature newborns: surfactant preparations have appeared in the arsenal of doctors, which, when introduced to a child, can significantly reduce the risk of respiratory distress syndrome, maternity hospitals are supplemented with sophisticated equipment to provide high-tech care (kuvezes, ventilators, etc.), which allows to improve outcomes and prognosis for the further growth and development of the child.

Preventing premature birth

The main measures aimed at the prevention of preterm birth are conducted at the level of the women's consultation, since it is the qualitative monitoring of the course of pregnancy that allows you to predict and diagnose the threat of its interruption in time. The measures for the prevention of preterm labor include:

• Pregnancy planning with the provision of preliminary training, which consists in the treatment of existing somatic diseases, the treatment of chronic foci of infection, so that at the moment of pregnancy the organism of the expectant mother is in the optimal state for the child's bearing.

• Early registration with a woman's consultation and regular monitoring of pregnancy progression. This is especially true if in the past a woman already had miscarriages, premature births, abortions.

• Treatment of foci of infection, especially colpitis (inflammatory processes of the vagina), detected during pregnancy, since the most frequent way that provokes the development of preterm birth is ascending (infection from the vagina rises and infects the lower pole of the fetal bladder).

• Timely prevention and treatment of complications of pregnancy (such as placental insufficiency, gestosis - toxicosis of the second half of pregnancy, pyelonephritis - inflammation of the kidneys, etc.).

• Ultrasonic monitoring of intrauterine fetal status and pregnancy progression (ultrasound can be used to measure the length and condition of the cervical canal for the timely diagnosis of ischemic-cervical insufficiency).

• If there are signs of a threat of abortion, timely hospitalization and treatment with prevention of respiratory distress syndrome in the fetus. Now we know what is dangerous for the mother of premature birth.