RU2241498C1 - Method for treating discoordination of parturient activity - Google Patents

Abstract

FIELD: medicine, obstetrics.

SUBSTANCE: one should apply a catheter into perineural fiber in the middle layer of small pelvis between sacrospinal ligament and pyriform muscle to introduce the first dose of anesthetic at uterine opening for 3-5 cm at the volume of 20-25 ml 1%-lidocaine, then - repeated doses in 1.5-2 h till achieving curative effect by not exceeding total dosage of 1%-lidocaine in 80 ml. The present innovation considerably decreases spastic uterine state, normalizes contractile uterine activity, prevents fetal depression that, in its turn, helps for physiological delivery at the background of adequate anesthesia.

EFFECT: higher efficiency of therapy.

2 ex

Description

The invention relates to medicine and can be used in obstetrics and gynecology for the treatment of discoordination of labor.

Given the violation of the leading regulatory role of the central nervous system in the development of this type of anomaly of labor, it is necessary to completely relieve general muscle and mental tension, restore autonomic balance, and eliminate constant pain. Therefore, in order to treat the discoordination of labor, methods are used that combine the antispasmodic and analgesic effects.

The method of ataralgesia is known (V.V. Abramchenko. Active management of labor. St. Petersburg, “Special Literature”, 1996. - P.660). When establishing a diagnosis of discoordination of labor, regardless of the size of the opening of the uterine pharynx, 5 ml of isotonic sodium chloride solution is administered intravenously, and intramuscularly, 2-3 ml (15-22.5 mg) of dipidolor and 3-4 ml (15-20 mg) of seduxen (depending on the body weight of the woman in labor). Re-administration of drugs, as a rule, is not required, since labor is becoming coordinated.

Disadvantages: The effect of the use of large doses of benzodiazepam derivatives can persist for several days in the newborn and can be expressed in hypotension, lethargy, inhibition of the sucking reflex and violation of thermoregulation, leading to hapothermia. A low dose of seduxen (not more than 10 mg) can lead to variability in heart rate and muscle tone.

The well-known method of neuroleptanalgesia (V.I. Kulakov et al. Anesthesia for childbirth - "TRIADA-X", 2002 - S.60) provides a kind of mental rest, satisfactory analgesia, and stabilization of hemodynamic parameters.

Fentanyl is administered intramuscularly at a dose of 0.5-1.0 ml of a 0.005% solution in combination with drogeridol 2.5-5.0 mg (1.0-2.0 ml). If necessary, a repeated dose is administered after 3-4 hours.

Disadvantages: the possibility of developing drug-induced fetal depression. Do not prescribe for hypertension of the pulmonary circulation, pulmonary failure, bronchial asthma.

The known method of electroanalgesia (V.I. Kulakov and coauthors. Anesthesia for childbirth - "TRIADA-X", 2002. - S.81-82), which allows to achieve a stable vegetative balance, to avoid allergic reactions that may occur when using pharmacological drugs.

For medical analgesia in case of fatigue during childbirth, domestic devices “Electronarkon-1” and “Lenar” are used. Before applying the electrodes, 15 minutes before the start of the pulse current, premedication with promedol 2% -1 ml (25 mg), methacin 0.1% - 1 ml (1 mg) is performed. Before applying electrodes, the skin of the forehead and neck is wiped with alcohol. Under the electrodes are placed gauze napkins in 8-10 layers (3 by 3 cm), soaked in 0.9% sodium chloride solution. The cathode is superimposed on the forehead, the anode on the area of the mastoid processes. After fixing the electrodes, the device is connected. The pulse repetition rate is set within 750 Hz, the pulse duration of 0.5 ms. Then the pulse current slowly increases to threshold sensations in the area of the electrodes. Every 15-20 minutes it is necessary to increase the average current value by turning the "pulse current" knob or by increasing the pulse repetition rate to 1000-1500 Hz. The average current value for this pathology is 0.8-1.2 mA with a session duration of 1.5-2 hours.

The disadvantages of the method: effective only in the treatment of discoordination of labor activity of the I degree in women with a low threshold of pain sensitivity; appropriate equipment is required.

The known method of using fluorotan inhalation in case of excessive labor (V.V. Abramchenko Active management of childbirth. St. Petersburg, “Special literature”, 1996. - S.661).

Fluorotan is supplied in a concentration of 1.5-2.0 vol.%. In this case, the use of fluorotan leads literally in the first 2-5 minutes to the normalization of labor, with an increase in the concentration of fluorotan to 2 vol.% Or more, an almost complete cessation of labor occurs.

The disadvantage of this method is that the use of fluorotan is not an etiopathogenetic method of treating excessive labor. If the cause of excessive labor is not eliminated, as well as if fluorotan inhalations last less than 20-30 minutes, after termination of fluorotan inhalation excessive labor can again occur.

The known method of using β-mimetics (tocolysis) to eliminate the basal uterine hypertonicity (And S. Sidorova. Physiology and pitologic generic activity. - Moscow, MEDpress, 2000. - S.285-286, 290).

The therapeutic dose of one of the drugs (partusisten, alupent, brikanil) is dissolved in 300 ml or 500 ml of a 5% glucose solution or isotonic sodium chloride solution and is administered intravenously slowly initially 5-8 drops per minute, then every 15 minutes the frequency of drops is increased by 5- 8. reaching a maximum frequency of 35-40 drops per minute. After 20-30 minutes, the contractions almost completely stop. Tocolysis is completed 30 minutes after the start of the complete cessation of labor. After some time, the contractions independently resume against the background of normal uterine tone with a normal frequency and duration. In the event that after tocolysis, labor activity has become weak, myometrial tone is reduced, contractions are rare, short, proceed to careful rhodostimulation with prostaglandin E ₂ preparations.

The disadvantages of the method are contraindications to the appointment of β-mimetics in puerperas with concomitant somatic pathology (cardiovascular pathology, diabetes mellitus, thyrotoxicosis) and a number of side effects of these drugs, the absence of anesthetic effect, and the possible need for further rhodostamulation.

The closest way to the claimed is a method of prolonged epidural analgesia (VV. Abramchenko. Active management of childbirth. - St. Petersburg, "Special Literature", 1996. - S.661-662).

The principle of action of epidural anesthesia in childbirth is that a local anesthetic solution is injected into the epidural space and blocks the subdural nerves in segments T10 to L1, inhibits the effects of oxytocin and PG _2a , and has an antispasmodic and analgesic effect. It is shown at the opening of the uterine pharynx by 3-5 cm. Before the blockade begins, it is necessary to infuse 500-1000 ml of crystalloid solutions.

Puncture and catheterization of the epidural space is performed in the position of the woman in labor on her side with the legs brought to the stomach or sitting. For puncture, the gap between L3-L4, or between L2-L3 in the midline of the back can be used. After identification of the epidural space (test of failure and loss of resistance, free catheter insertion, absence of solution flowing out of the needle), anesthetic test vine (2-3 ml of 2% trimecaine solution or equivalent doses of lidocaine) is introduced through the needle. 5 minutes after establishing the absence of signs of spinal blockade, a fluoroplastic catheter is inserted through the needle in the cranial direction 2-3 segments above the puncture (T11-T12 or T12-L1), the needle is removed and a dose of anesthetic is introduced through the catheter (10 ml of a 2% solution of trimecaic or 15 ml of 1% lidocaine solution). Repeated administration of the anesthetic through the catheter is carried out with the resumption of pain. Typically, the administered dose of anesthetic causes analgesia for 40-60 minutes.

The disadvantages of the method are the difficulties of identification of the epidural space, associated with a significant increase in pressure in the epidural space in pregnant women, increase the risk of anesthetic getting into the subdural space with the development of total spinal block and the risk of intravascular administration of anesthetic with manifestation of cardiac and neurotoxicity of local anesthetics. With random puncture of the dura mater (the frequency of this complication, even in experimental hands, is 0.5-1%), postpartum headache and pain in the back develop. The possibility of developing a one-sided block with a lateral arrangement of the catheter. Anatomical and technical difficulties in performing a puncture (anatomical abnormalities, obesity). Relaxation of the muscles of the pelvic floor can lead to the impossibility of internal rotation of the head, reduces the patient's ability to effective attempts, which often leads to weakness of the forced period of labor.

The objective of the present invention is the creation of a technically simple, slightly traumatic, with minimal impact on the mother and newborn, an effective way to treat discoordination of labor through the implementation of the "differential block" - autonomic, sensory.

The task is achieved in that in the I stage of labor an extended blockade of the lumbosacral plexus is performed by installing a catheter in the perineural tissue of the middle floor of the small pelvis between the sacrospinous ligament and piriformis muscle and the first dose of local anesthetic is introduced when the uterine opening is 3-5 cm in 20-25 ml of 1% lidocaine; then, if necessary, repeated doses after 1.5-2 hours until the therapeutic effect is achieved, not exceeding the total dose of 1% lidocaine in 80 ml.

The novelty of the method

1. The therapeutic effect in the discoordination of labor is achieved by the fact that in the first stage of labor, when the uterine pharynx is opened, a catheter is inserted into the perineural tissue of the middle floor of the pelvis between the sacrospinous ligament and piriformis muscle and a first dose of local anesthetic of 20 -25 ml of 1% lidocaine. A large representation of connective tissue tissue, the preserved tone of the piriformis, determine the spread of local anesthetic into the pelvic cavity to the lumbosacral plexus. The pharmacological effect of local anesthetics on the lumbosacral plexus causes the development of a “differential block” of the autonomic and sensory, which leads to the restoration of the disturbed equilibrium of the autonomic nervous system during discoordination of labor, providing an antispasmodic and analgesic effect, which significantly reduces and sometimes eliminates the spastic state of the uterus without additional prescription of antispasmodics.

2. Catheterization of the cellular space allows, if necessary, repeated summing up of the local anesthetic to the lumbosacral plexus, which are performed after 1.5-2 hours and continue until the therapeutic effect is achieved, not exceeding the total dose of lidocap 1% in 80 ml.

Doses of lidocaine and the mode of its administration were selected as a result of clinical studies, taking into account its pharmacodynamics and maximum dose, as well as taking into account the indispensable condition - the entry of a sufficient volume and concentration of local anesthetic into the cellular space of the middle floor of the small pelvis until its cavity busy with the fetus.

The method is as follows.

When establishing a diagnosis - discoordination of labor and the degree of this pathology, first of all, the question of whether it is advisable to continue the delivery of labor through the natural birth canal, with outcomes for the mother and fetus, is decided. Having decided on the conservative management of labor, a woman in labor, when the uterine pharynx is opened 3-5 cm after eliminating the inferior fetal bladder, catheterizes the perineural fiber of the middle floor of the pelvis and block the lumbosacral plexus.

The patient's position on the back, lower limbs are straight and are located along the body. The skin of the site of the alleged injection is treated with an antiseptic solution. The upper edge of the greater trochanter is palpated and, departing from it 2-3 cm more cranially, the skin and subcutaneous tissue are infiltrated with a solution of novocaine 0.25% 3-5 ml to the depth of the intramuscular needle. Access to the lumbosacral joint is provided by a 10-12 cm long needle for cerebrospinal anesthesia, which is a conductor stylet and is located in the lumen of a thermoplastic intravenous catheter, the inner diameter of which corresponds to the outer diameter of the needle, while the tip of the needle protrudes above the catheter. A wound channel is formed preventively with a thicker needle in the soft tissues. Then, a needle for spinal anesthesia with a catheter in the frontal plane is inserted, perpendicular to the body axis to a depth until it contacts the ilium. When the needle is advanced all the way to the bone, the soft tissues are additionally infiltrated with a 0.25% novocaine solution (up to 10 ml total). Sliding the sharp end of the needle along the surface of the ilium, continue to immerse the needle in the tissue until the performer has a feeling of loss of resistance, which serves as a criterion for identifying the position of the end of the needle in the desired area, and the first dose of anesthetic (20-25 ml of 1% lidocaine) is injected into the perineural fiber of the middle floor of the pelvis, between the sacrospinous ligament and piriformis muscle. Then, holding the catheter, carefully remove the needle. At the end of the catheter put on a "cap". The catheter is fixed to the thigh skin with a band-aid (the band-aid is cut into three parts, the middle part fixes the catheter, the other two to the skin).

If necessary (the continuing clinic of labor discoordination, the resumption of pain), re-summarize the local anesthetic (20-25 ml of 1% lidocaine) to the lumbosacral plexus through a catheter, which is performed after 1.5-2 hours and continues until the therapeutic effect is achieved not exceeding the total dose of lidocaine 1% in 80 ml.

Catheterization of the perineural neural tissue of the middle floor of the pelvis is performed when the uterine pharynx is opened by 3-5 cm. When the catheter is opened for 6 cm or more, it is not practical to insert a catheter; as the claimed method has a pronounced antispasmodic effect, significantly reducing the spastic state of the uterus, favorably affecting the rate of opening of the uterine pharynx.

Clinical examples

Example No. 1

A woman in labor V., 19 years old, history of childbirth No. 278, was admitted to the maternity unit in the first period of urgent delivery. On examination, labor is discoordinated: contractions uneven in frequency, strength and duration, sharply painful; pain in the lumbar region between contractions remains; opening of the uterine pharynx 3-4 cm, the edges of the cervix are dense, thick, amniotomy is performed. In order to treat discoordinacin of labor, catheterization of the perineural fiber of the middle floor of the pelvis and blockade of the lumbosacral plexus were performed.

A woman in childbirth in a horizontal position on her back with extended lower limbs. A point of injection of the injection needle was localized by palpation, which was localized 2.5 cm above the upper edge of the greater trochanter. The skin and subcutaneous tissue are infiltrated with a solution of novocaine 0.25% - 4 ml to the depth of the intramuscular needle. A wound channel is formed through a “lemon peel” with a thicker needle in the soft tissues, through which a needle for spinal anesthesia with a catheter is inserted (the needle is a stylet-guide and located in the lumen of a thermoplastic intravenous catheter, the inner diameter of which corresponds to the outer diameter of the needle, with the tip of the needle protrudes above the catheter) in the frontal plane, perpendicular to the axis of the body to a depth of contact with the body of the ilium. When the needle is advanced all the way to the bone, the soft tissues are additionally infiltrated with a 0.25% solution of novocaine 6 ml. With further immersion of the needle in the tissue and the appearance of a feeling of loss of resistance, 24 ml of 1% lidocaine was introduced. Then, holding the catheter, the needle was carefully removed. A “plug” is attached to the end of the catheter. The catheter is fixed to the thigh skin with a band-aid.

After 5 minutes, the pain in the lumbar region disappeared, after 17 minutes a full analgesic effect occurred, the woman's behavior was calm, labor activity became coordinated, and the fetal state according to CTG was compensated.

After 97 minutes, the resumption of pain, contractions are frequent after 1-2 minutes, but the dynamics of cervical dilatation are insufficient (1cm in 1.5 hours). When the uterine pharynx was opened by 4-5 cm, a repeated bolus injection of 20 ml of 1% lidocaine was made through a catheter inserted into the perineural fiber of the middle floor of the small pelvis.

After 13 minutes, an analgesic effect occurred, the contractions were coordinated. After 3 hours and 40 minutes, the patient was delivered by a full-term boy with an Apgar score of 7-8 points. The total duration of labor was 8 hours and 45 minutes. I period - 8 hours, II-40 min, III-5 min. Complications from the mother and the newborn were not noted.

Example No. 2

A mother of birth G., 28 years old, history of childbirth No. 141, was in the maternity ward with a diagnosis of the first period of premature birth at 36 weeks, prenatal discharge of water against the background of an “immature” cervix, a long anhydrous period; background - addiction. The onset of childbirth against the background of rhodostimulation with stenon. Childbirth was complicated by dystocia of the cervix. They were treated with antispasmodics (no-spa 4 ml, atropine 0.1% -1 ml, gshatifillin 0.2% -1 ml), promedol 2% -1 ml, sibazon 10 mg iv. The effect of the treatment is negligible. Spastic contraction of the uterine throat persists. The behavior of the woman in labor is inadequate, extremely excited.

In order to treat cervical dystocia, catheterization of the perineural tissue of the middle floor of the pelvis and blockage of the lumbosacral plexus by administering lidocaine 1% - 24 ml according to the previously described method when opening the uterine pharynx by 3-4 cm was not required Re-introduction of anesthetic - after 35 min preterm birth occurred with a score on the Apgar scale of 7 points. There were no ruptures of the cervix. The total duration of labor was 8 hours 10 minutes, I period 7 hours 50 minutes, II 15 minutes, III 5 minutes. Complications from the mother and the newborn were not noted.

The method was applied on the basis of the municipal clinical maternity hospital No. 2 of Novokuznetsk. At the time of filing an application for the invention, the proposed method for the treatment of discoordination of labor was applied in 13 women in labor. In 2 cases, childbirth ended with cesarean section with full opening of the uterine pharynx due to clinical discrepancy. In 11 cases, delivery through the natural birth canal. In this case, the maternal injuries are minimal (in 2 cases of cervical rupture of the 1st degree), the children born had an Apgar score of 7-9 points. Thus, the objective of the invention, which consists in creating a technically uncomplicated, slightly traumatic, with minimal impact on the body of the mother and newborn effective way of treating discoordination of labor, is fully implemented.

Moreover, the claimed method

- does not have a depressing effect on the fetus, stabilizes the hemodynamics of the mother,

- there is no risk of introducing a local anesthetic into the lumen of a large vessel, given the anatomical features of the area of the injection site,

- the duration of the second stage of labor does not increase, does not lead to weakness of the labor period,

- there is no need to preventively infuse crystalloid solutions,

- technically simple, can be performed by an obstetrician-gynecologist.

Claims (1)

A method for treating labor discoordination, including a blockade of the lumbosacral plexus in the first stage of labor, characterized in that a catheter is inserted into the perineural tissue of the middle floor of the pelvis between the sacroospole ligament and piriformis muscle and the first dose of anesthetic is introduced when the uterine opening is performed at 3- 5 cm in a volume of 20-25 ml of 1% lidocaine, then repeated doses after 1.5-2 hours until a therapeutic effect is achieved, not exceeding the total dose of 1% lidocaine in 80 ml.