RU2441592C1 - Method for labor by n.v. sokolova - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention is referred to the field of medicine, namely to obstetrics, and can be used for labor with accounting of the fetus state. The ultrasound diagnostics of the fetus resistance to intrauterine hypoxia is performed during the act of breathing movements of its ribs. In case of detection of absence of breathing movements during contractions followed by the periods of fetus activity between contractions the level of intrauterine hypoxia shall be declared safe and if the performance persists the physiologic childbirth is performed. In case during contractions there is the period of breathing movements and multiple movements of limbs instead of initial immobility period the state is classified as hypoxic damage of fetus brain cortex and the woman is asked to breathe continuously until the umbilical cord is cut and if the performance persist the physiologic childbirth is performed in conditions of continuous breathing of the woman. If the movement activity of the fetus persists during constructions with the background of continuous breathing of the woman, the finger pulp on one of the fetus' hands is visualized additionally using ultrasound and with its echogenicity unchanging the woman is asked to breathe continuously, and in case of performance persisting the labor is performed in the short span of time. Lowered echogenicity of subcutaneous fat of the finger pulp during constrictions is considering the hypoxia endangering the vitality of brain cortex of fetus and in case of performance persisting immediate labor is performed.

EFFECT: method provides for timely labor due to increased effectiveness, precision and safety of evaluation of fetus' state during labor.

1 dwg, 1 ex

Description

The invention relates to medicine, in particular to obstetrics, and can be used to increase the likelihood of having a healthy baby.

There is a method of evaluating the resistance of the fetus to hypoxia in the third trimester of pregnancy, including laying a woman in a supine position, finding places on the surface of her abdomen, applying to which an ultrasound sensor simultaneously receives on the device screen an image of the fetal chest in a sagittal section and registration of a dopplerogram from the chest of the aorta, fix the sensor in this position, begin continuous monitoring of the dynamics of the Dopplerogram and the mobility of the rib arches of the chest of the fetus, after which they ask the woman to take 2-3 deep breaths and exhale and hold the breath on a deep breath for the maximum possible period of time, measure the duration of the breath hold in seconds against the background of a progressive decrease in the amplitude of the waves of the dopplerogram and until the onset of the act of respiratory movements of the ribs of the fetus, after which they ask the woman resume breathing and give an opinion on the poor or good resistance of the fetus to hypoxia, respectively, with a short or long delay (A.L. Urakov, N.A. Urakova, N.V. Sokolova, N.V. Sokolov, M. Y. Gausknecht, A.Yu. Gausknecht. A method for assessing fetal resistance to hypoxia according to M.Yu. Gausknecht. Application No. 20108573/14 (0026425), filed May 7, 2010).

The method has low efficiency, safety and accuracy of determining the timeliness of delivery in favor of the fetus during its intrauterine hypoxia, because it does not ensure continuity of breathing by a woman during labor during the threat of intrauterine hypoxia of the fetus, does not provide timely detection of various mobility of the fetus and the motor activity of its limbs, the opening process cam, monitoring the echogenicity of subcutaneous fat of the fingertips and the onset of acrocyanosis of the fingertips . In this regard, the increase in restored hemoglobin in the blood of the fetus during childbirth remains uncontrolled, so part of the fetus is born healthy by accident, and the other part of the fetus is born with irreversible hypoxic damage to the cerebral cortex due to ignorance.

A known method for diagnosing the condition of the fetus in childbirth, in which simultaneously carry out registration of cardiotocography (CTG) of the fetus and direct registration of its ECG. When registering a pathological CTG and simultaneously an ECG without deviations, the need for urgent delivery within 1.5-2 hours is diagnosed, and when registering a pathological CTG and ECG with deviations from the norm, the need for immediate delivery is diagnosed (RU 2294136 C2).

The method has low efficiency, safety and accuracy of determining the timeliness of delivery during fetal hypoxia of the fetus, since it does not ensure continuity of breathing by a woman during labor during the threat of fetal hypoxia of the fetus, does not provide timely detection of various mobility of the fetus and motor activity of its limbs, the process of opening the cam, monitoring echogenicity of subcutaneous fat of the fingertips and the appearance of acrocyanosis of the fingertips grasps and attempts. And registration of fetal CTG and ECG with the detection of abnormal CTG and ECG with abnormalities does not provide timely detection of a critical level of decrease in oxyhemoglobin and increased restored hemoglobin in the fetal blood at the end of labor and labor, since these indicators of cardiac and uterine activity are secondary to the level restored hemoglobin in the blood of the mother and the fetus, on the one hand, and the intensity of the motor activity of the fetus, on the other hand. Moreover, CTG and ECG are not a direct reflection of the level of restored hemoglobin in the circulating blood of the fetus and acrocyanosis. In this regard, the level of restored hemoglobin in the circulating blood of the fetus and the appearance of cyanotic tissue in various parts of the fetal body during childbirth remains uncontrolled, so some of the fetuses are born healthy by chance with a pink color of the skin, and the other part of the fetus is born with irreversible hypoxic damage to the cerebral cortex and with blue skin color due to the ignorance of obstetricians.

The known technology of medical benefits during pregnancy for delivery according to the general rules (Obstetrics: Textbook / G.M. Saveliev, V.I. Kulakov, A.N. Strizhakov and others. Edited by G.M.Savelyeva. - M .: Medicine , 2000 .-- 816 p.).

The technology has low efficiency, safety and accuracy in determining the time of delivery, which ensures the birth of a healthy baby without hypoxic damage to the cortex of its brain, since it does not provide for determining the level of restored hemoglobin in the circulating blood of the fetus and the acrocinazone of the fingers of his hands during intrauterine hypoxia, aggravated by a woman holding her breath end of labor and effort. In this regard, the dynamics of the level of oxygen saturation of the circulating blood of the fetus, the level of restored hemoglobin in the circulating blood of the fetus and the level of blood supply to the tissues of the fingers of his hands with a high content of restored hemoglobin and with the development of acrocyanosis remain uncontrolled during childbirth. Therefore, part of the fetus is born healthy by chance, and the other part of the fetus is born with irreversible hypoxic damage to the cerebral cortex due to the ignorance of obstetricians.

Known technology for effective care during pregnancy and childbirth according to general rules (Murray Enkin et al. Guidelines for effective care during pregnancy and childbirth. Translation from English. Ed. A.V. Mikhailov. St. Petersburg: Petropolis Publishing House , 2003 .-- 480 p.).

This technology has low efficiency, safety and accuracy in determining the time of delivery, which ensures the birth of a healthy baby without hypoxic damage to the cerebral cortex, since it does not provide for determining the level of restored hemoglobin in the circulating blood of the fetus and the acrocinazone of the fingers of his hands during intrauterine hypoxia, aggravated by a woman holding her breath towards the end of contractions and attempts. In this regard, in the course of childbirth, the dynamics of the level of oxygen saturation of the circulating blood of the fetus, the level of restored hemoglobin in the circulating blood of the fetus and the level of blood supply to the tissues of the fingers of the extremities with an increased content of restored hemoglobin, leading to the development of acrocyanosis, remain uncontrolled. Therefore, part of the fetus is born healthy by chance, and the other part of the fetus is born with irreversible hypoxic damage to the cerebral cortex due to the ignorance of obstetricians.

These shortcomings reduce the effectiveness, safety and accuracy of determining the timeliness of delivery and increase the likelihood of hypoxic damage to the cortex of the fetus due to a woman holding her breath during attempts, lack of control over the motor activity of the fetus during and between contractions and the appearance of acrocyanosis of the fingertips.

The objective of the invention is to increase efficiency, safety and accuracy due to the continuity of a woman’s breathing, monitoring of the fetal motor activity and visualization of acrocyanosis of his fingers.

The essence of the method of delivery according to general rules, including ultrasound diagnostics of the fetus's resistance to intrauterine hypoxia by the time of the onset of the act of respiratory movements of its ribs during the period of short-term and reversible hypoxia with the conclusion of good or poor fetal resistance to hypoxia for a long or short period of time, respectively, and accordingly, by physiological delivery in an indefinite period of time or by medical delivery in a short period The belt consists in the fact that the time interval of the onset of the act of respiratory movements of the ribs of the fetus is determined repeatedly during contractions, the conclusion about the safe level of intrauterine hypoxia and the possibility of having a healthy baby during physiological birth is issued when periods of immobility of the fetus and the absence of respiratory movements of the ribs during contractions are detected alternating with periods of physiological motor activity of the fetus between contractions, the conclusion about the possibility of intrauterine hypoxic damage to the cortex of the fetal brain and the need for delivery in a short period of time is given when replacing the initial period of fetal immobility during contractions during the period of respiratory movements of the ribs and repeated flexion-extensor movements of the extremities, while to prevent hypoxic damage to the cerebral cortex, the woman is recommended to keep breathing continuous up to before cutting the umbilical cord and control the time of the onset of the act of respiratory movements of the ribs and the appearance of motor activity fetal lumps during contractions, when periods of complete fetal immobility during contractions are revealed, alternating with periods of motor activity between contractions, in the absence of respiratory movements of the ribs during contractions, a conclusion is drawn on the possibility of having a healthy baby during physiological birth in a woman’s continuous breathing, and with the appearance of motor activity of the fetus during contractions on the background of continuous breathing in a woman, an additional assessment is made of the condition of the fingers of the fetus’s hands, when the open during contractions, visualize with the help of an ultrasound a small pillow of one of the fingers of the fetus’s hand and monitor the echogenicity of her subcutaneous fat, after which, with constant echogenicity, they give a conclusion about the absence of finger acrocyanosis, intrauterine hypoxia, which is dangerous for the viability of the fetal cerebral cortex, and about the possibility the birth of a healthy child during physiological birth while maintaining continuous breathing in a woman, and with a decrease in echogenicity during labor, a conclusion is drawn on the increase in the level of recovery Hemoglobin in the circulating blood of the fetus to a level that causes acrocyanosis of his fingers and threatens the viability of the cortex of his brain, and the need for immediate delivery.

In the claimed method, the determination by ultrasound of the time interval between the occurrence of the act of respiratory movements of the ribs of the fetus and the beginning of the woman holding the breath during contractions ensures a high accuracy in assessing the adaptive ability of the fetus for intrauterine hypoxia, since the holding of the breath of the woman during contractions maximizes the level of restored hemoglobin in the circulating blood the fetus and deepens its intrauterine hypoxia. Therefore, assessing the condition of the fetus at the deepest level of intrauterine hypoxia increases the accuracy of diagnosis and prediction of its condition during childbirth and eliminates hypoxic damage to the cerebral cortex during accidental holding of a woman’s breathing during attempts by chance or ignorance.

By issuing a conclusion about the safe level of intrauterine hypoxia and the possibility of having a healthy baby during physiological birth when ultrasound reveals periods of fetal immobility and the absence of respiratory movements of the ribs during contractions alternating with periods of physiological physical activity of the fetus between contractions, high safety and accuracy are ensured way. The fact is that in this case, the complete immobility of the fetus during contractions indicates its adequate adaptation to the period of profound intrauterine hypoxia, aimed at saving oxygen consumption, and the physiological mobility of the fetus between contractions indicates that the fetus is alive and that there is no dangerous between contractions for viability, fetal hypoxia level.

By issuing a conclusion about the possibility of intrauterine hypoxic damage to the cerebral cortex and the need for delivery in a short period of time when the period of respiratory movements of the ribs and repeated flexion-extensor movements of the limbs appears during contractions after a preliminary period of immobility, the method is highly safe, since there is a period of immobility the fetus at the beginning of contractions indicates its adequate adaptation to an in-depth level in the morning hypoxia and the absence of hypoxic damage to the cerebral cortex, and then the appearance at the end of the bout of the period of respiratory movements of the ribs and multiple flexion-extensor movements of the arms and / or legs of the fetus indicates an increase in the level of hypoxia in the fetus that occurs at the end of contractions despite preliminary immobility fetus and saving oxygen consumption. Delivery in a short period of time under these conditions ensures the birth of a healthy baby.

Due to the recommendation to keep breathing continuous right up to cutting the umbilical cord issued to a woman, the efficiency and safety of the method are increased, since the continuity of breathing eliminates breath holding during attempts and other circumstances during the birth of the fetus, which eliminates the deepening of the level of intrauterine hypoxia, which is possible when the breath is held by atmospheric air before cutting the umbilical cord.

By repeatedly (after issuing a recommendation to a woman about maintaining her breathing continuity up to cutting off the umbilical cord) controlling the time of occurrence of the act of respiratory movements of the ribs and the motor activity of the fetal limbs during contractions, the efficiency, safety and accuracy of the method are increased, as the information that improves tactics of effective and safe is expanded delivery. The fact is that normalizing the condition of the fetus under these conditions ensures the birth of a healthy baby in physiological birth without additional effects on the mother and fetus, and the absence of normalization indicates a lack of measures to prevent deep intrauterine hypoxia of the fetus. So, if an ultrasound reveals a period of complete immobility of the fetus during labor, which is then replaced by a period of its motor activity between contractions, in the absence of respiratory movements of the ribs during labor, a conclusion is made about the possibility of having a healthy baby during physiological birth in a woman's continuous breathing, since this “behavior” of the fetus inside the womb indicates the absence of a deep level of hypoxia and the absence of hypoxic damage to the fetal cortex. On the other hand, the identification of fetal motor activity during contractions, which occurs despite continuous breathing in a woman, indicates the lack of effectiveness of the fetal self-defense due to its adaptive immobility, the threat of deepening intrauterine hypoxia by the end of contractions and attempts, and the need to study the likelihood of developing finger acrocyanosis hands of the fetus.

The claimed method provides an additional assessment of the degree of intrauterine oxygen deficiency due to information obtained by ultrasound examination of the condition of the hands of the fetus. The fact is that in the amniotic fluid inside the uterus, the hands of the fetus have the greatest freedom for their movement and therefore their motor activity is most demonstrative and indicative. At the same time, the fetal hands are clenched into a fist at a safe level of hypoxia, and when a dangerous level of hypoxia is reached, the hands are unclenched. Therefore, the choice of hands as an object for monitoring as an indicator of deep hypoxia in the fetus increases sensitivity, and therefore the accuracy, efficiency and safety of the method.

When unclenching fists during contractions, it becomes possible to examine the condition of the pads of one of the fingers of the hand of the fetus using ultrasound, and monitoring the echogenicity of her subcutaneous fat ensures determination of the critical values for the increase in the amount of restored hemoglobin in the blood of her subcutaneous venules and capillaries, since with a real decrease in oxygen concentration in the fetal arterial blood during intrauterine hypoxia, it is the distal phalanges of the fingers that are the first to "turn blue" due to the "blue" located in their blood, which manifests acrocyanosis tips of the fingers of the fetus. Ultrasonic monitoring of the echogenicity of the subcutaneous fat of the fingertips during hypoxia and ischemia ensures the detection of their cyanosis because the ultrasonic echogenicity of arterial blood decreases when it is converted into venous blood, and vice versa, blood echogenicity increases with an increase in the concentration of oxyhemoglobin in it.

By monitoring the echogenicity of the finger pads during childbirth, the safety and accuracy of the method are increased, since this provides information about the appearance of a critically high level of restored hemoglobin in the fetal blood.

By identifying the invariance of ultrasonic echogenicity of the subcutaneous fat of the fetal fingertip during childbirth, the accuracy of issuing a conclusion about the absence of an excessively deep level of intrauterine hypoxia of the fetus and the possibility of having a healthy baby during physiological birth while maintaining continuous breathing in the woman is increased.

And finally, due to the detection of acrocyanosis by reduced ultrasonic echogenicity of the subcutaneous fat of the fetal finger pad during contractions and attempts, the accuracy of issuing a conclusion about the dangerous level of intrauterine hypoxia of the fetus, which can cause hypoxic damage to the cerebral cortex, and the need for immediate delivery, increases which, in turn, provides an increase in the efficiency, safety and accuracy of the method, since it ensures timely delivery and the birth of a healthy baby without hypoxic damage to the cerebral cortex.

Example. Patient K., 34 years old, was admitted to the maternity hospital for urgent deliveries during full-term pregnancy with fetaplacental insufficiency of the I degree (FPI Ib). After hospitalization and observation of the woman in labor, the weakness of the uterine labor was diagnosed, and there was a threat of intrauterine hypoxia of the fetus. In order to determine the fetal resistance to hypoxia, they laid the woman lying on her back, found a place on the surface of her abdomen, by applying to which an ultrasound sensor was received on the screen of the ALOKA SSD-ALPHA 10 device using a convex sensor with a frequency of 3-7 MHz simultaneously image of the fetal chest sagittal section and registration of the dopplerogram from the thoracic aorta, recorded the sensor in this position and began continuous monitoring of the dynamics of the dopplerogram and the mobility of the rib arches of the chest of the fetus. Between the next contractions, they asked the woman to take 2-3 deep breaths-exhale and hold her breath in deep breath for the maximum possible period of time, measured the duration of the breath-holding in seconds against the background of a progressive decrease in the amplitude of the dopplerogram waves and up to the moment of the onset of the act of respiratory movements of the ribs of the fetus , which was 30 seconds, after which they asked the woman to resume breathing and issued an opinion on the good resistance of the fetus to hypoxia. However, it was not possible to determine the dynamics of the state of the fetus during childbirth, its adaptive ability to the process of multiple contractions and relaxation of the uterus, and it was not possible to accurately determine the remaining time reserve, which ensures the birth of a healthy baby in physiological births.

Due to the lack of effectiveness of the applied method, it was decided to conduct childbirth according to general rules. For this purpose, an attempt was made to register CTG and ECG of the fetus by direct method. When registering a cardiotocogram, an abnormal CTG was detected (STV 2.8), and fetal ECG registration by a direct method was impossible due to the preservation of the fetal bladder and insufficient disclosure of the cervix. In this regard, the obtained data was not enough to determine the dynamics of the fetus and its adaptive abilities for intrauterine hypoxia during childbirth, as well as to determine the reserve of time during which the fetal cerebral cortex can remain viable until the delivery is completed. Therefore, an autopsy of the fetal bladder was performed, while about 300 ml of amniotic fluid flowed out. After 3 hours, an internal obstetric and cervical examination was performed. In this case, a lack of dynamics of the opening of the cervix was revealed. In this regard, to stimulate labor, intravenously, a solution of 1 ml of enzaprost in 400 ml of 0.9% sodium chloride was introduced at a rate of 6 drops per minute. After 3 hours with active labor, a second internal obstetric study was performed. Positive dynamics in the opening of the cervix was noted. Throughout the continuation of childbirth, they continued to produce intranatal hourly CTG. Since data were obtained indicating fetal hypoxia of the fetus, to optimize the birth and increase the likelihood of having a healthy baby, the woman was breathed with moistened oxygen, and 10 ml of riboxin, 100 mg of cocarboxylase and 10 ml of 5% ascorbic acid were injected intravenously. Despite these measures, data on intrauterine hypoxia of the fetus did not disappear, although CTG indicators improved slightly (STV 4.7), moreover, periods of short-term decrease in fetal heart rate began to be detected immediately after each contractions. The threat of hypoxic damage to the cerebral cortex has increased.

In this regard, it was decided to apply the developed method of delivery. To this end, using ultrasound, they began to determine the time interval of the onset of the act of respiratory movements of the ribs of the fetus repeatedly during contractions. It turned out that after 1 second after the onset of labor, the fetus became motionless, after 10 seconds the act of respiratory movements of the ribs of the fetus occurred, and after 15 seconds multiple flexion-extensor movements of the limbs of the fetus appeared. The fight lasted 25 seconds. After the bout ended, the fetal motor activity returned to normal. At the same time, it turned out that during the fight, the woman was additionally pushing, while holding her breath on inhalation for 15 seconds. On this basis, a conclusion was drawn about the possibility of intrauterine hypoxic damage to the cerebral cortex and the need for delivery in a short period of time. To prevent hypoxic damage to the cerebral cortex, the fetus was recommended to the woman to keep her breathing continuous until the cutting of the umbilical cord.

After this, the time of the onset of the act of respiratory movements of the ribs and the appearance of motor activity of the limbs of the fetus during contractions were re-determined. It turned out that against the background of continuous breathing with moistened oxygen, the fetus became motionless 1 second after the onset of labor, after 13-17 seconds the act of respiratory movements of the ribs of the fetus occurred, and after 20-22 seconds multiple flexion-extensor movements of the fetal arms and legs appeared. After the completion of the matchmaking, the fetal motor activity returned to normal. In this fight lasted about 40 seconds, and the interval between them was about 6 minutes.

On this basis, it was concluded that the risk of intrauterine hypoxic damage to the cerebral cortex was preserved and that delivery was necessary in a short period of time. To determine the depth of fetal hypoxia of the fetus and the degree of hypoxic threat, an assessment was made of the condition of the fingers of the fetus. Observing the left hand with the help of ultrasound, it turned out that after 20-22 seconds after the contractions began, multiple bending-extensible movements of the legs and hands of the fetus appeared, the fist was unclenched with the fingers fully extended, which the fetus clenched again 11 seconds after the bout ended . With the opened hand of the left hand of the fetus, using ultrasound, it was possible to visualize the small pillow of the middle finger and monitor the ultrasonic echogenicity of its subcutaneous fat during and after contractions. At the same time, it was found that the echogenicity of subcutaneous fat of the fingertip during the bout was lower than after it. In this regard, a conclusion was issued on increasing the level of restored hemoglobin in the circulating blood of the fetus during contractions to the level that causes acrocyanosis of his fingers. On this basis, it was concluded that hypoxic damage to the cerebral cortex was highly likely during subsequent longer contractions and the need for immediate delivery. Childbirth was completed by cesarean section. A boy was born weighing 3 kg 350 g, 51 cm tall with pink colored skin, cried immediately, with an Apgar score of 9 points.

Thus, the proposed method due to the continuity of breathing of a woman, monitoring the motor activity of the fetus and visualization of acrocyanosis of his fingers can improve the efficiency, safety and accuracy of the method of delivery.

Claims (1)

The method of delivery, taking into account the assessment of the condition of the fetus, including ultrasound diagnostics of the fetal resistance to intrauterine hypoxia by the time of the onset of the act of respiratory movements of its ribs during the period of short-term and reversible hypoxia with the conclusion of good or poor fetal resistance to hypoxia for a long or short period of time, respectively, and delivery, respectively, by physiological delivery in an indefinite period of time or by medical delivery in a short period by time, characterized in that they carry out ultrasound diagnostics of the fetal resistance to intrauterine hypoxia by the time of the onset of the act of respiratory movements of its ribs, while the time interval of the onset of the act of respiratory movements of the ribs of the fetus is determined repeatedly during contractions, with the initial detection of periods of immobility of the fetus and the absence of respiratory movements ribs during contractions, alternating with periods of physiological motor activity of the fetus between contractions, the level of intrauterine hypoxia is assessed as safe, they predict the possibility of having a healthy baby and, while maintaining indicators, conduct physiological births; when during the contractions the period of respiratory movements of the ribs and multiple flexion-extensor movements of the limbs is established, instead of the initial period of fetal immobility, the condition is assessed as intrauterine hypoxic damage to the cerebral cortex, and to prevent hypoxic damage to the cerebral cortex, the woman is asked to keep breathing continuous until the umbilical cord is cut off , repeatedly control the time of the onset of the act of respiratory movements of the ribs and the appearance of the motor actively the fetal limbs during contractions, with the subsequent identification of the normalization of the fetus during continuous breathing in a woman, namely, periods of fetal immobility and lack of respiratory movements of the ribs during contractions, alternating with periods of physiological physical activity of the fetus between contractions, they predict the possibility of having a healthy baby and preservation of indicators carry out physiological childbirth in conditions of continuous breathing in a woman; while maintaining the motor activity of the fetus during contractions against the background of continuous breathing, women additionally assess the condition of the fetal fingers, while unclenching fists during contractions visualize the pillow of one of the fetal fingers and monitor the echogenicity of her subcutaneous fat, after which invariable echogenicity assess its condition as the absence of acrocyanosis of the fingers and the condition of the fetus as intrauterine hypoxia, dangerous for the viability of the cerebral cortex, ask the woman continues to keep breathing continuous until the umbilical cord is cut, and while maintaining the indicators, delivery is carried out in a short period of time; and a decrease in the echogenicity of subcutaneous fat of the fingertips during contractions is assessed as an increase in the level of restored hemoglobin in the fetal circulating blood to a level that causes acrocyanosis of his fingers, which threatens the viability of his cerebral cortex, and immediately maintain delivery.