We are expecting the baby on time! Or what is isthmic-cervical insufficiency?

A mother's preparation for childbirth takes place on all fronts - not only moral, but also physiological. For example, before childbirth there are often so-called. Braxton-Hicks contractions, or preparatory contractions. This is how the body prepares for the real first contractions. When real contractions begin, the cervix adapts to produce a baby. There are two definitions for this process: “smoothing” (shortening) and “opening” (expansion). In this article we will tell you about cervical effacement. This way you will better understand what complex processes occur in the body and how they help you at each stage.

What does cervical effacement mean?

What is smoothing? Let's start with an excursion into anatomy. The cervix is ​​a narrow, long section of the uterus that opens into the vagina at one end and into the uterine cavity at the other. As a rule, the cervix is ​​tightly closed and elongated (usually its length is 3.5-4 centimeters). When contractions begin, the cervix flattens, relaxes and shortens. This phenomenon is called "smoothing".

The degree of smoothing is monitored by an obstetrician during a vaginal examination. It is impossible to check this on your own. However, do not worry, this is a completely natural phenomenon that will be monitored by a doctor.

Signs of the onset of labor

Correct and timely birth should occur from the 38th week. If all the factors have worked in the woman’s body to begin proper labor:

• The hormonal background
  is . The production of the hormone that maintains pregnancy - progesterone - decreases and the complex of estrogens - female sex hormones that stimulate labor - increases.
• The uterus begins to contract.
  A hormone is produced - oxytocin, the main hormone that is responsible for contractions of the uterus and triggers labor. The descending head of the fetus puts pressure on the cervical canal, and the production of hormones in the blood increases muscle tone, and the uterus begins to contract
• Maturation of the placenta.
  The placenta is popularly known as the “child’s place” in the uterus. She is responsible for the baby’s nutrition, the connection between mother and child, and maintains a safe environment for the development of the fetus. When the placenta has completed its functions, the process of aging and degeneration in the mature placenta begins.
• Fruit maturity.
  A large amount of metabolic products accumulates in the baby’s body and the rate of formation and maintenance of amniotic fluid at the same level slows down. The baby is experiencing discomfort.

Thanks to the above factors, the birth process begins.
There are precursors to childbirth. What it is? A woman may experience pain similar to contractions, the distinctive feature is that the pain begins and ends in a chaotic manner. These are false contractions. The period of contractions is always the same in time; the closer the moment of expulsion of the fetus, the more intense the contractions become and the time between them is reduced. False contractions prepare the muscles for intense contraction during childbirth. The os of the uterus opens. Another harbinger is a moment of “calm”. The child has less and less room to move.

When the uterine os opens slightly, the mucous plug is released.

Throughout her pregnancy, she protected the baby from infections entering the uterine cavity. The plug is a thick clot of mucus, light in color with streaks of blood, sometimes it can be light brown. The plug may come out from 2 weeks to several hours before the onset of labor.

The true signs of early labor are contractions.

Contractions are the first stage of labor. During contractions, the cervix dilates. The vagina and uterus become one for the passage of the baby through the birth canal. At the first sign of contractions, nagging pain appears in the lower abdomen and lower back. Their intensity and duration increases. The period between contractions is the same. For primigravidas, the first stage of labor can last up to 12 hours. Then the amniotic fluid is released. This may happen immediately or gradually. In any case, the woman in labor should immediately enter the maternity hospital under the supervision of doctors. In the absence of pathologies during pregnancy, the water is light, colorless, and may contain impurities of fetal lubricant. If there is postmaturity, prolonged labor and other reasons, the water becomes greenish in color, may smell unpleasant, and contain particles of meconium (original feces).

However, as described above, it does not always happen in this sequence. Each birth occurs differently, everything is individual for each woman. In some cases, the assistance of a midwife and a doctor will be required. A common problem during childbirth is poor cervical dilatation. This is a consequence of women’s health problems, hormonal imbalance and many other reasons.

What is the cervix?

The cervix is ​​a very important part of the female reproductive system.
This is the lowest part of the uterus, bordering the vagina. The cervix is ​​divided into two zones - the vaginal and supravaginal. The cervical canal is located in the center of the cervix. It has an external and internal mouth. During a gynecological examination, the external os is visible. During pregnancy, the cervix performs important functions; a mucous plug is formed in it, which protects the uterus from infections, and also holds the fetus inside the uterus due to its length; in addition, it must be strong enough to carry the baby throughout the entire pregnancy.

Maturation and opening

During normal pregnancy, the cervix is ​​dense, ranging from 3 to 5 centimeters in length.
Its canal is closed and filled with a mucus plug. In the 3rd trimester of pregnancy, from 34-36 weeks, ripening of the cervix begins. It includes several processes:

• Shortening
• Softening
• Centering the cervix along the axis of the birth canal
• Opening of the internal and external pharynx

When the cervix ripens, the fetal head descends into the pelvis and creates pressure on the cervix and its dilation occurs.
It begins with the opening of the internal pharynx. In multiparous women, the internal and external pharynx may open almost simultaneously. The fetal head then moves forward and opens the external os. The neck is shortened, smoothed, and the canal allows two or more fingers to pass through. For delivery, the cervix must dilate 10-12 cm.

How is revealing different from smoothing?

The degree of opening is expressed in centimeters, and the maximum opening corresponds to 10 centimeters.

During labor, the obstetrician will observe how much the cervix is ​​effaced and dilated. During a vaginal birth, the cervix should be completely effaced and dilated by 10 centimeters.

The approximate duration of dilation can be determined as follows: after the transition to the active phase of labor, the average speed of dilation is 1-2 centimeters per hour. Of course, every birth is different and this is just a guideline. If the doctor thinks that the labor process has stopped or the baby is in danger, a caesarean section may be indicated.

Symptoms and diagnosis of ICN

There are no specific symptoms of isthmic-cervical insufficiency. A pregnant woman may be bothered by heaviness in the lower abdomen or lumbar region, and the urge to urinate may become more frequent due to the pressure of the fetus on the bladder. However, most often the expectant mother does not worry about anything.

The diagnosis of isthmic-cervical insufficiency is made mainly during pregnancy, since only during pregnancy there are objective conditions for assessing the function of the cervix and its isthmic region. Outside of pregnancy, doctors perform a number of special tests to detect ICI. An X-ray examination of the uterus is performed on days 18-20 of the cycle, and the degree of dilation of the cervical canal in the second phase of the menstrual cycle is assessed using special instruments.

During pregnancy, transvaginal ultrasound . In this case, the length of the cervix is ​​measured. A cervical length of less than 3 cm at a gestational age of less than 20 weeks requires that a woman be classified as a high-risk group for ICI and careful monitoring of such a patient.

In women carrying twins or triplets up to 28 weeks of pregnancy, a cervical length of more than 37 mm in primigravidas and more than 45 mm in multigravidas is considered normal. In multiparous women, the length of the cervix at 17-20 weeks of pregnancy should be more than 29 mm.

An absolute sign of the presence of isthmic-cervical insufficiency is shortening of the cervix to 2 cm or less . The measurement of cervical length is influenced by various factors - for example, the tone of the uterus and the height of the placenta. In addition, it is important how the ultrasound doctor evaluates the length of the cervix. The most accurate results are obtained with transvaginal (that is, examination with a sensor inserted into the patient’s vagina) access. This method of examining the cervix is ​​absolutely safe for the further course of pregnancy and cannot cause the threat of miscarriage or other complications.

When examining the cervix through the abdominal wall, that is, transabdominally, measurements of the length of the cervix are approximately half a centimeter higher than those during a transvaginal examination, in addition, the change in its length is affected by the degree of filling of the bladder. In addition to the length of the cervix, an ultrasound examination evaluates the condition of the internal pharynx, whether there is an opening of the pharynx and protrusion of the fetal bladder into the cervical canal.

However, it is not correct to diagnose isthmic-cervical insufficiency only based on the results of an ultrasound examination. Examination of the cervix by a gynecologist provides more accurate information. The examination is carried out in a gynecological chair. In this case, the doctor evaluates the length of the vaginal part of the cervix, its density, and the degree of opening of the cervical canal.

Can Braxton Hicks contractions cause effacement?

If you've had infrequent, irregular contractions over the past few months, this does not mean that your cervix is ​​effacing or dilating and that labor is imminent. They are also called Braxton-Hicks contractions, or “preparatory”, “false” contractions. Braxton Hicks contractions do not affect the cervix in any way. This is just a workout that helps the body prepare for real childbirth.

Training contractions have characteristic features that will help distinguish them from the harbingers of labor, labor pains.

Treatment options for ICN

In order to prevent premature birth in case of isthmic-cervical insufficiency, progesterone preparations (DUFASTON, UTROZHESTAN) are prescribed from 20 to 34 weeks of pregnancy, a hormone produced in the placenta and supporting pregnancy.

There are two ways to treat isthmic-cervical insufficiency. These are non-surgical and surgical methods.

Non-surgical methods include the introduction into the vagina of special obstetric pessaries - rings that are placed on the cervix and prevent its further opening, supporting the presenting part of the fetus. Non-surgical methods have a number of advantages - they do not require hospitalization or anesthesia and are easy to use. Pessaries are usually used after 28 weeks of pregnancy. Before inserting the ring, be sure to take a smear of the flora to identify and treat a possible inflammatory process. After the introduction of an obstetric pessary, it is necessary to treat the vagina and ring with antiseptic solutions every 2-3 weeks to prevent the development of infection. However, this method may not always be applicable. In case of severe isthmic-cervical insufficiency, the use of rings is ineffective. They are also not used when the amniotic sac bulges into the cervical canal.

In these cases, treatment is carried out by suturing the cervix.

Indications for surgical correction of ICI:

• the presence of previously spontaneous miscarriages and premature births in the 2-3 trimesters
• cervical insufficiency progressing according to clinical examination, cervical length less than 25 mm according to transvaginal ultrasound.

Contraindications to surgical treatment:

• increased excitability of the uterus, tone
• diseases that are a contraindication for continuing pregnancy, for example, severe liver diseases, cardiovascular diseases, infectious, genetic diseases,
• bleeding,
• fetal malformations,
• the presence of pathogenic flora in the vagina, inflammation of the vagina.

Stitching of the cervix is ​​usually performed between 13 and 27 weeks of pregnancy. The timing of the operation is determined individually by the attending physician. The most favorable period for surgical treatment is from the 15th to the 19th week of pregnancy, when the opening of the cervix is ​​not very pronounced and the amniotic sac does not bulge into the canal.

Stitching of the cervix is ​​performed under general anesthesia. In some cases, for example, when the lower pole of the fertilized egg bulges into the cervical canal, after surgery, in order to prevent possible infection of the membranes, a course of antibiotics is prescribed. If the postoperative period is uncomplicated, the pregnant woman is discharged home 5-7 days after the operation. However, every 2 weeks the antenatal clinic doctor must examine the cervix and take smears for flora.

The most common complication after surgical correction of isthmic-cervical insufficiency is cutting through the cervical tissue with a thread. This can occur if the cervix is ​​affected by an inflammatory process or if uterine contractions begin, that is, labor. To avoid uterine contractions after suturing, many patients are prescribed tocolytics - drugs that relieve uterine tone.

Sutures from the cervix are removed at 37–38 weeks of pregnancy. This is done when examining the cervix in a gynecological chair. The suture removal procedure is usually completely painless.

FAQ

How do you know that the cervix is ​​effacing?

If you have already started having regular, frequent contractions, you can assume that the body has started the process of smoothing and dilating the cervix. During childbirth, the degree of smoothing and opening is controlled by the obstetrician.

Can you feel your cervix opening and/or effacing?

At the first signs of labor, and with them the smoothing and opening of the cervix, you may experience discomfort, mild cramps, or you may not feel anything at all. The process of smoothing and dilation of the cervix can only be monitored transvaginally, usually by a doctor.

Effacement in itself is not a sign of labor. This is a physiological change that tells your doctor where you are in the labor process. Knowing what's going on in your body is helpful, but it's important to remember that your doctor knows best, so just relax and concentrate. Very soon you will have a long-awaited baby, and all the physiological details will no longer be so important.

How to speed up the dilatation of the cervix before childbirth?

You can speed up the dilatation of the cervix using either medicinal or non-medicinal methods. You can carry out natural stimulation yourself, but be extremely careful.

Non-drug methods

Home stimulation

There are several ways to influence the process at home:

• Walk more, do household chores, prefer taking the stairs to the elevator. Regular walking helps the fetal head move lower, and as a result, stimulates the opening of the cervix.
• Perform simple exercises (but do not overdo it): these can be squats, bends, turns, exercises on a fitball. You can swim in the pool and do yoga for pregnant women.
• Sexual intercourse provokes the production of oxytocin, which stimulates uterine activity. And the seminal fluid contains prostaglandins - these hormones also contribute to better dilation.
• Nipple stimulation – when nipples are stimulated, oxytocin is also released.
• Eat more salads dressed with vegetable oil. The oil helps digestion, improves the elasticity of blood vessels and softens the tissues of the birth canal.
• Empty your bowels and bladder in a timely manner.

I also recommend taking a warm bath, practicing breathing exercises and acupressure - massage of certain points.

Natural stimulation in the maternity hospital

If contractions have already begun and you are in the delivery room, you can use special poses and exercises to quickly open the birth canal:

• Kneel down and lean on a chair or headboard. Legs should be spread.
• Sit on an exercise ball with your legs spread apart. When you feel a contraction, deviate first to the left, then to the right.
• Squat with your knees wide apart. You can lean on the back of a chair or bed.
• While sitting on the exercise ball, spread your knees wide and rotate your hips while springing on the ball.
• Sit on a chair facing the back. During the contraction, grab the back of the chair and slightly tilt your body forward. Be sure to place something soft on the chair, for example, a folded blanket.
• Get on all fours and slightly arch your lower back during the contraction.

With slow expansion of the uterine pharynx, you can’t just lie or sit. Even if you have forgotten all the poses and exercises, just start walking around the room or swaying your hips while standing.

Medications

Doctors may recommend medicinal methods of stimulation. These include:

• Synthetic prostaglandins. This substance is released in the form of a gel or suppository. It is injected into the cervix to soften and speed up labor.
• Amniotomy. This is a puncture of the amniotic sac in order to cause the rupture of amniotic fluid. Due to this, the fetus moves lower and puts pressure on the internal pharynx.
• Oxytocin injection. The drug is administered intravenously to intensify contractions.

It is important for every expectant mother to know and understand what happens to her body during pregnancy and childbirth, which processes are natural and which are pathological, when there is no reason to be afraid, and when to immediately consult a doctor. We discuss these and many other topics in more detail in the online course “Easy Childbirth Without Fear.” During the course, together with other specialists, I will tell you everything about preparing for childbirth: how to get rid of fears, how to prepare the body, what to expect and what to fear. In addition, you will receive psychological support from other mothers by joining a private online chat. Come to the course and learn how to give birth easily.

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Methods affecting the contractile activity of the uterus

In this group, the most popular among obstetricians are amniotomy and synthetically produced analogues of natural hormones, in particular oxytocin.

Amniotomy

- opening of the amniotic sac. It is performed during a vaginal examination using a sterile plastic instrument that resembles a hook. This procedure is painless because the amniotic sac is devoid of pain receptors. The mechanism of action of amniotomy is not fully understood. It is assumed that opening the amniotic sac, firstly, promotes mechanical irritation of the birth canal by the fetal head, and secondly, indirectly stimulates the production of prostaglandins, which enhance labor. Information about the effectiveness of amniotomy is conflicting. In general, the prevailing opinion is that amniotomy, even without combination with other methods of stimulation, reduces the duration of labor. But this method is not always effective. And if doctors come to the conclusion that a given woman in labor requires stimulation, but the amniotic sac is still intact, an amniotomy will be performed first, and after that, if necessary, they will resort to the help of birth-stimulating drugs.

If the amniotomy proceeds without complications, it does not affect the child’s condition in any way. Amniotomy is considered a safe method, and any complications are quite rare. Nevertheless they exist.

An amniotomy can be thought of as cutting open a well-inflated balloon. It becomes clear why in some cases of both amniotomy and spontaneous rupture of the bladder, prolapse of the umbilical cord occurs. This complication threatens the development of acute oxygen deficiency in the fetus due to compression of the umbilical cord between the fetal head and the birth canal. This situation requires emergency medical intervention.

Blood vessels, including quite large ones, run along the surface of the fetal bladder. Therefore, if a blind incision of the bladder damages such a vessel, bleeding is possible, in some cases threatening the life of the child.

To avoid complications, amniotomy during childbirth is, if possible, carried out after the fetal head enters the pelvis, squeezing the amniotic sac and the vessels passing along its surface. This prevents bleeding and prolapse of the umbilical cord.

If, despite amniotomy, labor does not resume, the likelihood of infection of the uterus and fetus increases, which is now not protected by the membranes and amniotic fluid.

Oxytocin

- a synthesized analogue of the hormone produced by the pituitary gland. The action of oxytocin is based on its ability to stimulate contractions of the muscle fibers of the uterus. It is used to artificially induce labor, with weakness of labor throughout labor, with postpartum hemorrhage, and to stimulate lactation. To avoid severe complications, oxytocin is not used in cases of fetal position anomaly and clinically narrow pelvis, when the size of the pelvic ring is insufficient for spontaneous childbirth.

Oxytocin is used in the form of tablets, but more often - in the form of a solution for intramuscular and subcutaneous injections and especially intravenous administration. The last option for using the drug is the most common. True, it has a significant drawback: a woman with a connected drip system (“drip”) is very limited in her movements.

Different women respond differently to the same dose of oxytocin, so there is no standard regimen for using this drug. Doses are selected individually, therefore, when using oxytocin there is always a danger of overdose with side effects.

Oxytocin has no effect on the readiness of the cervix to dilate. In addition, in most women, after oxytocin begins to act, labor pain intensifies, so, as a rule, it is used in combination with antispasmodics (drugs that relax the muscles of the uterus).

Oxytocin is not used if it is undesirable or impossible to give birth to a child through the natural birth canal, abnormal fetal position, hypersensitivity to the drug, placenta previa, the presence of scars on the uterus, etc.

The most common side effect of oxytocin is excessive contractile activity of the uterus, which can lead to poor circulation in this organ and, as a result, to a lack of oxygen in the fetus.

Ways to prepare the cervix for childbirth

Glagoleva E.A., Mikhailova O.I., Balushkina A.A.

The problem of a rational approach to pre-induction preparation of the cervix is ​​one of the most complex and pressing in modern obstetrics. The readiness of a woman’s body for childbirth is determined by a number of signs, the appearance of which indicates the possibility of spontaneous onset of labor in the near future or allows one to count on a positive effect from the use of labor inducers [1,4,9,12].

Timely and correct assessment of the state of readiness (“maturity”) of the cervix for childbirth is of great importance in determining the prognosis of the course of the upcoming labor and especially in clarifying the indications and timing for induction of labor. This is primarily due to the fact that the condition of the cervix is ​​a reliable indicator of the readiness of a pregnant woman’s body for childbirth. If the degree of maturity of the cervix is ​​poorly or insufficiently expressed, spontaneous onset of labor in the near future is unlikely. On the other hand, with premature rupture of water and an immature cervix at the beginning and middle of the first stage of labor, pathological deviations in the contractile activity of the uterus may be observed, which manifest themselves in hypertonicity of the lower segment, in the absence of synergism of contractions of all parts of the uterus, etc. In this state, spontaneously beginning labor takes on a pathological (protracted) course associated with the development of discoordinated labor, its weakness, etc. According to the literature [3,5,13], with an immature or insufficiently mature cervix, labor in 57.2% of cases is accompanied by premature rupture of water, in 44.2% - by anomalies of labor, and as a result, in 16.3% of cases it is carried out surgical interventions.

The presence of an immature cervix before timely birth is 16.5% in primiparous women, and 3.5% in multiparous women [2,6,8]. However, with concomitant somatic diseases, these indicators increase. For example, with class II obesity during full-term pregnancy, an immature cervix occurs in 15.4% of cases, with class III obesity – in 30.4%. In addition, in case of extragenital pathology (hypertension, heart disease, diabetes mellitus, etc.) and complicated pregnancy (preeclampsia, postmaturity, chronic fetal hypoxia, immunocompromised pregnancy, etc.), there is often a need for early delivery. In such cases, before induction of labor, it is necessary to prepare the cervix for labor [2,4,7,11].

Back in 1960, studies were conducted that showed that all changes in the cervix during pregnancy, childbirth and the postpartum period can be explained by connective tissue transformations. The cervix is ​​a heterogeneous organ consisting of fibroconnective tissue, smooth muscle fibers, epithelium of blood vessels and crypts that penetrate deeply into the stromal tissue. The upper part of the cervix contains more smooth muscle fibers, and in its vaginal part fibrous tissue predominates. The extracellular basis of the fibrous connective tissue of the cervix is ​​made up of collagen fibers and elastin, separated by a ground substance. Collagen gives the fabric stability, and elastin provides its elasticity. During pregnancy, muscle tissue is gradually replaced by connective tissue, “young” collagen fibers are formed, which are highly hydrophilic and flexible, which ensures cervical resistance and the uterus plays the role of a fetal receptacle. By the time of delivery, the concentration of collagen decreases and its physicochemical properties change. Degradation (partial resorption) of collagen is the main sign of a ripening cervix. In 1978, increased amounts of partially degraded collagen were found in biopsies taken from the cervix before and immediately after delivery, whereas it was low in biopsies obtained from non-pregnant fertile women. The process of collagen degradation is caused by the surface-concentric cleavage of molecules from the core fibers in combination with the destruction of some of them. Partial resorption of collagen fibers, changes in the concentration of glycoprotein and glycosaminoglycan begin in the vaginal part of the cervix, spreading gradually from the external pharynx to the internal pharynx. This observation made it possible to put forward the concept of the connective tissue “nucleus” of the cervix, the presence of which explains why, in the process of “maturation,” the area of ​​the internal pharynx softens and opens last. By childbirth, a system of branched lacunae located in the thickness of the tissue of the cervix reaches extraordinary development. An increase in cervical volume was detected due to the deposition of arterial blood in them. This creates a dilatation effect that exerts a force on the internal structure of the cervix and provides “additional stretching” of the cylindrical part of the lower segment of the uterus. The moderate effect of post-stretching is one of the mechanisms of cervical ripening. Changes in the microvasculature of the cervix are used by many researchers to assess its maturity. These structural and biochemical changes are the basis for the appearance of clinical signs of cervical maturity [1,2,10].

Palpation determination of the condition of the cervix is ​​not only a reliable method of assessing a pregnant woman’s readiness for childbirth, but also the simplest. For the first time in 1942, De Snoo proposed calling the cervix “ripe for childbirth” when loosening, shortening and gaping of the cervical canal is detected in it by palpation. Later, they also began to take into account the location of the cervix relative to the wire axis of the small pelvis and the location of the presenting part of the fetus. In our country, methods for assessing the “maturity” of the cervix during vaginal examination were developed by M.V. Fedorova (1969), A.P. Golubev (1972), G.G. Khechinashvili (1974), etc. Quite often in Russia the M.S. scheme is used. Burnhill (1962) modified by E.A. Chernukha. With this technique, during vaginal examination, the consistency of the cervix, its length, its location in relation to the pelvic axis and the patency of the cervical canal are determined. Each sign is scored from 0 to 2 points. With a total score of 0–2 points, the cervix should be considered immature, 3–4 points – insufficiently mature, 5–8 points – mature. However, the E.N. scale is most widely used abroad. Bishop (1964), where, in addition to the above characteristics, the location of the presenting part of the fetus is taken into account. Each sign is scored from 0 to 2 points. With a score of 0–4 points, the cervix is ​​considered immature, 5 points – insufficiently mature, more than 5 – mature [2, 4, 6].

In connection with the above, methods of preparing the cervix for childbirth when its maturity is insufficiently expressed and the need for rapid delivery are becoming relevant. Despite the availability of various methods for preparing the cervix for childbirth, research in this area continues.

If an “immature” cervix is ​​determined at 39 weeks, then the following measures can be taken to prepare the cervix for childbirth:

• non-drug methods;

• instrumental (methods of acupuncture, massage, intranasal electrical stimulation, acupuncture, electrical stimulation of the nipples of the mammary glands, etc.);

• local use of prostaglandins;

• introduction of kelp;

• prescription of antispasmodics.

Non-medicinal methods of preparing the cervix for childbirth after 36 weeks include regular sexual activity without a condom. Sperm softens the cervix, preparing it for childbirth. This is why a condom is necessary during pregnancy itself. Many doctors believe that sex is the best way to prepare the cervix for childbirth. From 34 weeks you can take evening primrose oil in capsules - 1 per day, from 36 weeks - 2, from 39 - 3 capsules per day. Drink a collection of herbs to prepare the cervix for childbirth: rose hips (chopped) – 1 tbsp. – St. John's wort herb – 2 tsp. – dried herb – 1 tbsp. – hawthorn fruits (chopped) – 1 tsp. – motherwort herb – 1 tbsp. – birch buds – 1 tsp. – horsetail herb – 1 tbsp. – lingonberry leaves 2 tbsp. – strawberry fruits or leaves – 1 tsp. Pour 1 liter of boiling water. Boil for 30 seconds. Leave for 10–15 minutes. Strain and drink 100 ml hot 3 times a day for 30 minutes. before meals for 35 days. 10 days break and again 35 days. Those. 80 days before the expected date of birth. It is also recommended to prepare salads seasoned with vegetable oil, brew and drink raspberry leaves, tea from raspberry leaves - 1 tsp. per glass of boiling water. At 36 weeks, 1 cup per day, at 37 – 2, from 38 to 3, from 40 – 4 cups per day. After 40 weeks, you can drink sage and use tampons with sage (it is advisable to consult your doctor about this).

The development of medicinal methods of preparation for childbirth is based on the fact that the main factors in the development of labor are hormonal factors: maternal (oxytocin, prostaglandins), placental (estrogens and progesterone) and fetal hormones of the adrenal cortex and posterior pituitary gland, which change the metabolism of steroids at the level of the placenta. hormones (decreased progesterone production and increased estrogen levels).

PGs are local hormones and are synthesized in many tissues: seminal vesicles, uterus, brain, platelets, myocardium, endocrine glands. The most important physiological effect of PGs is their ability to cause smooth muscle contraction.

The initial purpose of using PG was to soften and smooth the cervix, i.e. its maturation, which makes it easier to induce labor. If this could be achieved, the usual method of inducing labor could begin. Later, initiated cervical ripening began to be perceived as the actual induction of timely labor, without separating these processes.

The indication for prescribing PG is an “immature” cervix. Moreover, they are most often used when the degree of “maturity” of the cervix according to Bishop is 0–4 points. Various routes of administration of prostaglandins have been proposed. The initially used intravenous route of PG administration is effective. However, it has been revealed that this method of administration requires relatively large doses, since prostaglandins are quickly inactivated in the lungs and, in addition, side effects often occur (in particular, tachycardia, nausea, vomiting, diarrhea, pallor of the skin, muscle tremors, etc. ). The desire to avoid such nonspecific (systemic) complications led to the creation of dosage forms for topical use.

Gels and vaginal suppositories are the most commonly used dosage forms of PG for topical use. Less commonly used are tablets, cervical caps, and vaginal rings. Experience with the use of the gel has shown a longer duration of action of the drug and a significant reduction in the frequency of side effects. Typically, local administration of one dose of PG is performed the day before the planned induction of labor. Thus, most studies have attempted to speed up the process of cervical ripening (which physiologically can last several days) and accommodate it within 18–24 hours.

It should be noted that quite often a significant proportion of patients develop labor without further treatment and with intact membranes. In the majority of those pregnant women who failed to induce labor, there is a significant improvement in the degree of “readiness” of the cervix, and after the administration of oxytocin, the time interval between the induction of labor and the birth of the child is significantly reduced.

Local application of prostaglandins involves the following routes of administration: extraamnial, intravaginal and intracervical. In recent years, it is the local use of GHGs that has become most widespread. However, in most clinics the extra-amnial method is not used due to the large number of complications (premature rupture of water, placental abruption, myometrial hypertonicity, etc.).

In obstetric practice, the most commonly used PG is PGE2 (dinoprostone), less often PGE1 (misoprostol), which is almost exclusively used for intravaginal administration. PGF2 α is rarely used nowadays due to higher therapeutic doses, which lead to an increased incidence of side effects and reduce effectiveness.

The effectiveness of a single use of PG depends on the dose, route of administration (intravaginal, intracervical or extra-amnial) and the pharmaceutical form of the drug (tablets, suppositories, gels). With repeated use of PG, the effectiveness of cervical ripening increases significantly. For example, with daily administration of vaginal suppositories with 0.1 mg of enzaprost (PGF2 α), cervical ripening is observed in 92.2% of women in labor. In this case, the authors use a very different interval between procedures (as a rule, it is a 4-6 hour interval). Large intervals (1–2 days) are used in outpatient practice.

The doses used in practical medicine and the frequency of their administration are selected so that with maximum efficiency there is a minimum number of side effects. In general, uterine hypertonicity is the most common complication: from 0.8% to 1.6–3.6%. Frequent cramping pains in the lower abdomen and lower back occur much more often (up to 38%), which do not affect the health of the mother and fetus and do not require medical intervention.

There are contraindications for prescribing PG: bronchial asthma, active phase of ulcerative colitis, glaucoma, sickle cell anemia, tuberculosis, bleeding disorders, fibroids and uterine malformations.

Considering the above, we can conclude that prostaglandins have the following advantages: 1) PG is a highly effective agent for cervical ripening; 2) cause not only ripening of the cervix, but also induction of labor; 3) when used correctly, they rarely cause side effects; 4) relatively easy to use (especially vaginal forms of drugs that can be administered independently on an outpatient basis).

Along with the noted advantages, the use of PG has its disadvantages: 1) the presence of a fairly large list of contraindications for use; 2) with an individual overdose, side effects are possible in both the mother and the fetus; 3) special equipment is needed to diagnose the main complications; 4) relatively high price of one procedure.

A mixed method of preparing the cervix includes the use of natural and artificial kelp.

Natural kelp is seaweed that is found in the northern and Far Eastern seas. In obstetrics and gynecology, two types of kelp are used: Laminaria digitata (digitate) and Laminaria japonica (Japanese).

The main active principle of kelp is polysaccharides (mainly sodium, calcium and magnesium salts of alginic acids). Alginic acids are polyuronides in chemical structure and are linear polymers. Thanks to polysaccharides, dried kelp is able to quickly absorb water from the environment, increasing in size. In addition to these polysaccharides, kelp contains proteins, amino acids, mannitol, microelements (including iodine), and vitamins.

Sticks 6–7 cm long and 2–3 mm in diameter are made from specially processed kelp. A strong silk thread is passed through the stick, through which the used dilator is removed. Due to its hygroscopicity, already 3–4 hours after entering the liquid, kelp swells in diameter, reaching a maximum expansion of 3–5 times after 24 hours, and its consistency turns from dense to much softer and resembles rubber. An important positive feature is that, expanding the cervical canal to 9–12 mm, the kelp after swelling remains unchanged in length.

Laminaria acts on the cervix not only by applying radial force, but also by removing water from the cervical stroma. As mentioned above, the cervix is ​​formed mainly of fibrous connective tissue. Dense muscle constitutes little more than 15% of the cervical mass and is not concentrated into muscle. Most cervical tissue consists of long, complex proteoglycan molecules stretched across hyaluronic acid cores. The side chains of the hyaluronic acid core are loaded, and due to the fact that the load is uneven, the molecule curls into a long spiral. Inside the spiral molecules are water molecules. The process of cervical dilatation appears to involve the extraction of water molecules from coils of helical molecules.

The disadvantages of using kelp are the acute pain that rarely accompanies their administration, as well as moderate, spastic pain when the sticks are in the cervical canal. Possible displacement of the sticks in the vagina, pinching of the swollen kelp in the cervix.

Thus, an analysis of the literature data made it possible to determine the following positive aspects of using kelp to prepare the cervix for childbirth: a fairly high efficiency of cervical ripening, a low incidence of complications and side effects, a relatively low cost of kelp sticks, the presence of a complex of biologically active substances that have a beneficial effect on mucous membrane. At the same time, kelp has the following disadvantages: an indefinite number of sticks are required for sufficient expansion of the cervical canal (from 2-3 to 10-12), it takes a fairly long time to obtain a clinical effect (up to 16-24 hours or more), there is a risk of infectious complications, as well as allergic reactions [2,3,6].

In most cases, according to the literature, to prepare the cervix for childbirth, you can limit yourself to prescribing antispasmodics from 38 weeks of pregnancy. One of the most commonly prescribed is hyoscine butyl bromide.

Hyoscine butyl bromide is a selective blocker of m-cholinergic receptors; m-anticholinergic, antispasmodic. Reduces the tone of the smooth muscles of internal organs, reduces their contractile activity, and causes a decrease in the secretion of exocrine glands. Hyoscine butyl bromide is a semi-synthetic derivative of hyoscyamine, an alkaloid found in belladonna, henbane, datura, and scopolia; quaternary ammonium compound.

One of the main indications for the use of this drug in obstetric practice is the preparation of the cervix for childbirth during full-term pregnancy, as well as its antispasmodic effect to accelerate the dilatation of the cervix during childbirth.

The main characteristic of hyoscine butyl bromide is the ability to cause local muscle relaxation due to the effect on smooth muscle m-cholinergic receptors (intracellular calcium current is suppressed) in combination with poor absorption into the systemic circulation. Taking into account the selectivity of hyoscine butyl bromide (impact only on the m-cholinergic receptors of spasmodic muscles) and its low bioavailability, international practice has experience of its use in cases of late dilatation of the uterine pharynx during childbirth. It is noted that in some cases its effect exceeds the effect of drotaverine and papaverine. Many years of clinical experience has been accumulated in the use of hyoscine butyl bromide in obstetrics, reflected in the Cochrane Library database. In 1952, the results of its clinical use in obstetrics practice in Germany were described. It has been established that the use of hyoscine butyl bromide to prepare the cervix for childbirth has a beneficial effect on its course and outcome. In 2005, results were obtained indicating the high effectiveness of hyoscine butyl bromide in shortening the duration of the first stage of labor (dilatation period) in women who received hyoscine butyl bromide suppositories during the active phase of labor, compared with those women in labor who were not prescribed hyoscine butyl bromide. The duration of the first stage of labor in the first group was 123.86±68.89 minutes, in the second group – 368.05±133.0 minutes (p<0.05) [1,2,5,13].

Thus, the experience we have accumulated and data from domestic and foreign literature indicate that the administration of the m-cholinergic receptor-selective antispasmodic hyoscine butylbromide in the form of rectal suppositories, which has a good range of effectiveness and tolerability, is a highly effective means for preparing the cervix for childbirth at full term. pregnancy, as well as to accelerate the dilatation of the cervix during childbirth.

Literature

1. Abramchenko V.V., Abramyan R.A. Induction of labor and its regulation by prostaglandins. Guide for doctors, Elbi: St. Petersburg, 2005, 288c.

2. Glagoleva E.A. Preparation of the cervix for childbirth (comparative effectiveness of the use of dinoprostone, Dilapan and natural kelp): Abstract. diss. Ph.D. honey. Sciences, M., 2000.– 27 p.

3. Gutikov L.V., Liskovi V.A. The use of kelp to prepare the cervix for childbirth with mild preeclampsia. // Obstetrics and gynecology. – 2006. – No. 5. – P. 47–49.

4. Kuzminykh T.I., Ailamazyan E.K. Preparing pregnant women for childbirth. Methodological manual, Publishing House N-L, St. Petersburg, 2007, 36 p.

5. Sidorova I.S., Makarov I.O., Edogova A.B. and others. The effectiveness of induction of labor using vaginal gel Prostin E2. // Bulletin of the Russian Association of Obstetricians and Gynecologists. – 2000. – No. 2. – P. 33–35.

6. Sinchikhin S.P., Mamiev O.B., Ogul L.A. and others. Comparative assessment of the effectiveness of various methods of preparing the cervix for childbirth. // Problems of reproduction. – 2009. – No. 4. – P. 12–17.

7. Allen R, O'Brien BM. Uses of misoprostol in obstetrics and gynecology. Rev Obstet Gynecol. 2009, 2(3):159–68.

8. Chammas MF, Nguyen TM, Vasavada RA et al. Sequential use of Preepidil and extra–amniotic saline infusion for the induction of labor in NULLiparous women with very low Bishop scores. J Matern Fetal Med. 2001, 10(3):193–6.

9. Church S, Van Meter A, Whitfield R. Dinoprostone compared with misoprostol for cervical ripening for induction of labor at term. J Midwifery Women's Health. 2009, 54(5):405–11.

10. Denoual-Ziad C, Hors Y, Delande I et al. Comparative efficacy of vaginal insert and dinoprostone gel for cervical ripening at term in current practice. Gynecol Obstet Biol Reprod (Paris). 2005, 34(1 Pt 1):62–8.

11. Facchinetti F, Venturini P, Fazzio M, Volpe A. Elective cervical ripening in women beyond the 290th day of pregnancy: a randomized trial comparing 2 dinoprostone preparations. J Reprod Med. 2007, 52(10):945–9.

12. Facchinetti F, Venturini P, Verocchi G, Volpe A. Comparison of two preparations of dinoprostone for pre-induction of labor in NULLiparous women with very unfavorable cervical condition: a randomized clinical trial. Eur J Obstet Gynecol Reprod Biol. 2005, 119(2):189–93.

13. Vollebregt A, van't Hof DB, Exalto N. Prepidil compared to Propess for cervical ripening. Eur J Obstet Gynecol Reprod Biol. 2002, 104(2):116–9.

What happens to a woman's body during childbirth?

Childbirth is a painful process for a woman. When the time of birth comes, the baby's head begins to put pressure on the walls of the uterus, they stretch, as a result of which the cervix gradually opens. With each contraction, the opening increases, and after the amniotic fluid is poured out and the cervix opens by 4–7 cm, the contractions of the uterus intensify. The baby will be able to “get out” of the womb only when the cervix is ​​dilated by 7–10 cm. Contractions and pushing help the baby to be born.

During delivery, conditions are created that promote irritation of the nerve endings of the uterus, which is how pain occurs. The source of pain is also the compression of blood vessels during uterine spasms and expulsion of the fetus, since they contain a huge number of nerve cells. Referred pain most often occurs in the lower abdomen, in the lower back, sacrum, hips and groin.

How is the birth going?

After the water breaks and the head is inserted, to assess the correspondence of the size of the fetal head to the mother’s pelvis during labor, the doctor must check Vasten’s sign and can inform the expectant mother about the results. The woman lies on her back. The doctor places one palm on the surface of the symphysis pubis, the other on the area of ​​the presenting head. If the sizes of the mother's pelvis and the fetal head correspond, the anterior surface of the head is located below the plane of the symphysis (pubic symphysis), i.e., the head extends under the pubic bone (Vasten's sign is negative). If the anterior surface of the head is flush with the symphysis (flush Vasten's sign), there is a slight size discrepancy. If there is a discrepancy between the sizes of the mother's pelvis and the fetal head, the anterior surface of the head is located above the plane of the symphysis (Vasten's sign is positive). A negative Vasten sign indicates a good match between the sizes of the woman’s head and pelvis. With the second option, a favorable outcome of childbirth through the natural birth canal is possible, subject to certain conditions:

• good labor activity;
• average fruit size;
• no signs of post-maturity;
• good fetal condition during childbirth;
• presence of light waters;
• good configuration of the head and its correct insertion when passing through the pelvic cavity.

A positive sign indicates that the mother’s pelvis is an obstacle to the passage of the fetus and natural childbirth is impossible in this case.

During a vaginal examination, the doctor evaluates how the fetal head is positioned. If everything goes well, then most likely you will not hear anything from the doctor on this score; if he wants to emphasize that everything is normal, he will say that the fetus is occipital presented. Normally, the fetal head descends into the pelvic cavity in a state of flexion, that is, the baby’s chin is pressed to the sternum, and the point in front of the birth canal is the back of the fetal head. In this case, it passes through all the planes of the pelvis with its smallest circumference quite easily. There are incorrect types of cephalic presentation, when the head is extended and either the forehead or the face of the fetus enters the pelvic cavity first. These types of cephalic presentation are called frontal and facial. In these cases, childbirth often ends with a cesarean section in order to reduce trauma to the fetus and mother. But with a small degree of extension of the head, good labor activity, and small size of the fetus, natural delivery is possible.

A woman may hear the expressions “front view”, “rear view”. No worries. With a cephalic presentation, this means that in the anterior view, the back of the fetal head faces the anterior wall of the uterus, and in the posterior view, it faces backward. Both options are normal, but in the latter case the pushing lasts longer.

After an external vaginal examination, the doctor can tell you how the head is moving through the birth canal.

The head is pressed against the entrance to the pelvis. Two weeks before the onset of labor in primiparous women, the fetal head begins to descend and press against the entrance to the pelvis. Due to this, pressure on the lower segment and cervix increases, which promotes the ripening of the latter. In multiparous women, the head drops 1-3 days or even several hours before the onset of labor.

The head is a small segment at the entrance to the small pelvis. In this obstetric situation, the head is motionless, its largest part is located above the plane of the entrance to the pelvis, it can still be palpated through the anterior abdominal wall. This happens in the first stage of labor - during contractions.

The head is a large segment at the entrance to the small pelvis. In this case, it is located with its large circumference in the plane of the entrance to the small pelvis; it can hardly be felt through the anterior abdominal wall, but during a vaginal examination the doctor can clearly identify it, as well as all the sutures and fontanelles. This is how the head is positioned at the end of the first stage of labor before pushing begins.

The head in the pelvic cavity is not detected during external examination; during vaginal examination, the doctor sees that it fills the entire pelvic cavity. This obstetric situation is observed during the pushing period.

Do I need to call?

At 39-40 and 40-41 weeks, a woman should have no reason to worry. If a pregnant woman at this stage turns to a doctor with a request to stimulate labor with medications, she will not be understood and the request will not be fulfilled. In order for labor to be complete, all stages of internal preparation for it must be completed naturally. Stimulation with medications in a maternity hospital occurs only in post-term pregnancy, after 42 weeks of pregnancy.

From the same position, doctors consider it inappropriate to try to speed up the process of childbirth at home. The fact that the expectant mother is very tired of carrying her precious child, that it is becoming increasingly difficult for her to walk, sit, and sleep, is understandable and arouses sympathy. But giving birth at the time provided by nature for a particular woman and her baby is the most optimal solution to the problem.

As you know, the ability to wait is one of the most difficult, and therefore women’s impatience and attempts to actively provoke childbirth can also be understood, but it can hardly be approved.

Before taking anything from grandma’s advice or advice from the Internet, a woman should be sure that she has no contraindications. The baby should be positioned correctly in the uterus, in a cephalic position.

There should be no placental abruption even in the anamnesis in the early stages. The amniotic sac should be intact and there should be no leakage of water. A woman’s blood pressure should be normal and her hormonal levels should be sufficient for labor to proceed normally. Agree, not a single pregnant woman can say with confidence that all these conditions are met in her body.