How long does it take for the cervix to dilate? The readiness of the body for childbirth: the main role is played by the opening of the cervix

The first stage of labor is the longest. In primiparas, it is from 8 to 10 hours, in multiparous - 6-7 hours. At the same time, the latent phase of labor (from the onset of contractions to the opening of the cervix by 4 cm) accounts for 5-6 hours (an average of 5.4 hours in primiparous and 4.5 hours in multiparous). This phase is painless or painless.

Conducting childbirth in the period of dilatation of the cervix

Contractions are established initially with a frequency of 1-2 in 10 minutes, the tone of the uterus is 10 mm Hg. Art. The duration of contraction of the uterus (systole of contractions) is 30-40 s, relaxation (diastole of contractions) is 2-3 times longer (80-120 s). Intrauterine pressure during contractions rises to 25-30 mm Hg. Art.

This phase is characterized by prolonged relaxation of the uterus after each contraction, especially the isthmus (lower segment and cervix), since each contraction causes the cervical tissue to move into the structure of the lower segment, as a result of which the length of the cervix decreases (the cervix shortens), and the lower segment of the uterus stretches , lengthens.

The presenting part is tightly fixed in the entrance of the small pelvis. The fetal bladder gradually, like a hydraulic wedge, is introduced into the area of ​​\u200b\u200bthe internal os, contributing to the opening of the cervix.

Cervical dilation period - latent phase

The latent phase in primiparas is always longer than in multiparas, which basically increases the total duration of labor. By the end of the latent phase, the neck is completely or almost completely smoothed out. The rate of cervical dilatation in the latent phase of labor is 0.35 cm/h.

Any medical correction in the latent phase of childbirth is not required. But in women of late or young age, in the presence of a burdened obstetric and gynecological history, any complicating factors, it is advisable to promote the processes of cervical dilatation and relaxation of the lower segment. For this purpose, rectal suppositories with antispasmodic drugs (papaverine, no-shpa, baralgin) are prescribed, 1 every hour No. 3.

Cervical dilation period - active phase

In the active phase (opening of the cervix from 4 to 8 cm), there is a gradual increase in the tone of the uterus (up to 11-12 mm Hg). The frequency of contractions increases to 3-5 in 10 minutes, the duration of systole and diastole equalizes to 60-90 s. Intrauterine pressure during contractions rises to 40-50 mm Hg. Art. The duration of the active phase is almost the same in primiparous and multiparous women and is 3-4 hours. The active phase is characterized by intense labor and rapid opening of the uterine os. The opening rate is 1.5-2 cm / h in the primiparous and 2.5-3.0 cm / h in the multiparous. At the same time, the fetal head moves along the birth canal. At the end of the active phase, there is a complete or almost complete opening of the uterine os. The cervix completely merges with the lower segment of the uterus, the edges of the uterine os are at the level of the spinal plane.

The fetal head moves along the birth canal synchronously with the opening of the uterine os. So, at 6 cm of opening of the uterine os, the head is located in a small segment at the entrance of the small pelvis or is +1 cm away from the spinal plane. At 8 cm of opening, the fetal head descends as a segment into the entrance of the small pelvis (+2 cm). When fully opened, it is located in the pelvic cavity, most often already on the pelvic floor. With coordinated labor activity in the active phase of labor, reciprocity (conjugation) of the activity of the upper and lower segments of the uterus takes place. Contraction of the fundus and body of the uterus is accompanied by active relaxation of the lower segment of the uterus. The curve of the external hysterography, reflecting the state of the lower segment, has a curve opposite to the upper segment (mirror reflection).

The intensity of labor activity in this phase increases, the tone and frequency of contractions also increase, the rate of cervical dilatation is maximum, contractions most often become painful. In the active phase of labor, it is especially important to maintain the normal basal tone of the uterus, since with hypertonicity of the myometrium (13 mm Hg or more), the frequency of contractions increases above normal values ​​(over 5 per 10 minutes), and the amplitude (strength) of the contraction decreases. This leads to ruptures of the cervix, disruption of the uterine, uteroplacental and fetal-placental blood flow, fetal hypoxia. There may also be a decrease in basal tone (less than 10 mm Hg), leading to a decrease in the frequency of contractions and a decrease in intrauterine pressure. Childbirth with both options is delayed.

The outflow of amniotic fluid with uterine hypertonicity helps to reduce intramyometrial pressure and can normalize uterine contractions. In order to determine the nature of the violations of contractions that have arisen, one should first of all evaluate the tone of the myometrium (decreased, increased, normal), as well as the rhythm, frequency, duration and strength of the contraction. Labor activity is the work of the uterus (of course, and the whole body of the woman in labor), aimed at opening the birth canal, promoting and expelling the fetus, separating and isolating the placenta.

This work is carried out mainly due to the mechanical contractile function of the uterus and is provided with the necessary energy of biochemical, metabolic, oxidative processes, intensification of the activity of the cardiovascular, respiratory, neuroendocrine and autonomic nervous systems. With an average amplitude of contraction of the upper segment of the uterus, which is 50 mm Hg. Art., normal basal tone of the uterus in 10-12 mm Hg. Art., the number of contractions in childbirth ranges from 240 to 300 (24-30 contractions per hour). This work often causes fatigue, fatigue in a woman in labor, especially since the contractions are almost always painful, they begin at night, which the woman spends in anxiety and excitement.

In the active phase of labor, it is necessary to use drug anesthesia (oxygen-oxide analgesia or a single administration of promedol 20 mg) in combination with antispasmodic drugs. The latter are especially useful for the prevention of cervical rupture, smoother opening of the cervix and stretching of the vaginal walls. Antispasmodics (no-shpa 4 ml or baralgin 5 ml) are administered either intravenously by drip or intravenously simultaneously (2 ml with glucose solution).

Amniotic fluid - outpouring

The fetal bladder bursts at the height of one of the contractions when opening 6-8 cm. 150-200 ml of light (transparent) amniotic fluid is poured out.

If there was no spontaneous outflow of amniotic fluid, then when the uterine os is opened by 6-8 cm, an artificial amniotomy is performed. However, in this case, it is advisable to pre-administer antispasmodic drugs so that too rapid a decrease in the volume of the uterus does not provoke hypertonic contraction dysfunction.

Amniotomy is accompanied by a short-term decline in uteroplacental blood flow and a change in the heart rate of the fetus (often bradycardia). Therefore, in addition to antispasmodics, 40.0 ml of a 40% glucose solution and 5 ml of a 5% ascorbic acid solution, 150 mg of cocarboxylase are prescribed before amniotomy, which maintain the energy level and oxygenation of the fetus.

Cervical dilation period - third phase

The third phase of the first stage of labor (not expressed in all women in labor) is called the deceleration phase. It is determined from the moment of opening the cervix by 8 cm and continues until the full (10-12 cm) opening of the uterine os. Its duration is from 20 to 60 minutes.

In this short phase of slowing down labor activity, the tone of the uterus changes (increases by another 2-3 mm), the strength (amplitude) of contractions weakens somewhat, the frequency remains the same (from 4.4 to 5 contractions in 10 minutes).

The physiological essence of this phase is that the contractile activity of the uterus is rebuilt to the function of fetal expulsion. The entire uterus acts in the same direction. Uterine contractions occur synchronously from the bottom to the uterine os. The task is one - to expel the fetus from the birth canal. At the same time, all departments and layers of the uterus contract and relax.

The deceleration phase is considered transitional from the first stage of labor to the second. The delayed phase of labor is based on two factors of biological expediency: one is the need for a slower (careful) advancement of the fetal head through the spinal plane - the narrowest part of the closed bone ring of the pelvis, and the second - in the accumulation of the energy potential of the uterus for the most intensive work on a relatively a short period of time.

The delayed phase of the first stage of labor is isolated so that the doctor does not rush to diagnose the secondary weakness of labor and does not apply unindicated labor stimulation.

During the entire first stage of labor, the condition of the mother and her fetus is constantly monitored. They monitor the intensity and effectiveness of labor activity (the number of contractions in 10 minutes, the duration of contraction and relaxation of the uterus, its tone), the condition of the woman in labor (health, pulse rate, respiration, blood pressure, temperature, discharge from the genital tract).

The period of cervical dilatation - the condition of the bladder and intestines

In childbirth, it is necessary to monitor the function of the bladder and intestines. Overflow of the bladder and rectum prevents the normal course of the period of disclosure and expulsion, the release of the placenta. Overflow of the bladder can occur due to its atony, in which the woman does not feel the urge to urinate, and also due to the pressing of the urethra against the pubic symphysis by the fetal head. In order to prevent overflow of the bladder, the woman in labor is offered to urinate every 2-3 hours. In the absence of independent urination, they resort to catheterization. Timely emptying of the lower intestine is important (enemas before childbirth and during their protracted course). In the history of childbirth, the presence or absence of spontaneous urination every 2 hours is noted. Difficulty or lack of urination is a sign of pathology.

Vaginal examination during childbirth

A vaginal examination during childbirth is performed to maintain a partogram (WHO, 1993), orientation in the insertion and advancement of the head, assessment of the location of the sutures and fontanelles, i.e., to clarify the obstetric situation.

Mandatory vaginal examinations are indicated in the following situations:

• when a woman enters the maternity hospital;
• with the discharge of amniotic fluid;
• with the onset of labor (assessment of the condition and disclosure of the cervix);
• with anomalies of labor activity (weakening or excessively strong, painful contractions, as well as early onset attempts);
• before anesthesia (find out the cause of painful contractions);
• with the appearance of bloody discharge from the birth canal.

The results of the vaginal examination reflect the effectiveness of labor activity (the degree of opening of the uterine os, the advancement of the fetal head), the biomechanism of childbirth.

You should not be afraid of frequent vaginal examinations, it is much more important to ensure their complete safety in terms of asepsis, antisepsis and atraumaticity (carry out with cleanly washed hands, in sterile gloves using disinfectant solutions, sterile liquid vaseline oil). Research must be carried out gently, carefully and painlessly.

During vaginal examination during childbirth, attention should be paid not only to the degree of cervical dilatation, the position of the sutures and fontanelles of the fetus, the pelvic bones and its capacity, but also to the condition of the edges of the cervix.

During normal labor, the edges of the cervix are thin, soft, easily extensible. In a fight, the edges of the neck do not tighten, which indicates a good relaxation of the tissues; the fetal bladder is well expressed. In a pause between contractions, the tension of the fetal bladder weakens, and through the fetal membranes it is possible to determine the identification points on the head: the sagittal suture, the posterior (small) fontanelle, the wire point.

The position of the woman in childbirth

Particular attention deserves the position of the woman in childbirth. Historical evidence shows that the supine position has been predominantly common in France since the 17th century, when Marie de Medici, the daughter-in-law of Countess Duchesse Monpezier, Marie de Medici, gave birth in this position in the presence of the royal court midwife, Louise Burgois, and the barber-obstetrician, Julien Clémont. Childbirth in the presence of a man led to the spread in the higher spheres of the position of the woman in labor on her back. This custom was widely promoted by such famous obstetricians as Pare and Morisot. Childbirth on the back has become a tradition for a number of centuries. Obstetric practice readily accepted this method as beneficial and convenient, first of all, for the obstetrician (it is more convenient to conduct a vaginal examination, listen to the fetal heartbeat, carry out cardiac monitoring, etc.).

However, a comprehensive assessment of the various positions of the woman in labor, carried out independently in 3 centers (Germany, Spain and the USA), showed that the position of the woman in labor on her back is not the most beneficial for the contractile activity of the uterus (contractions weaken), for the fetus (uteroplacental blood flow decreases ) and for the woman herself (danger of compression of the inferior vena cava). In this regard, most obstetricians recommend that women in labor in the first stage of labor sit, walk (for short periods of time), stand or lie on their side. In the future, apparently, it will be possible for a woman in labor to stay in a warm pool in the first stage of labor.

You can get up and walk with whole or outflowing waters, but with a tightly fixed fetal head in the pelvic inlet.

If the localization of the placenta is known (according to ultrasound data), then the position of the woman in labor on the side where the back of the fetus is located is optimal. In this position, the frequency and intensity of contractions do not decrease, the basal tone of the uterus remains normal. In addition, studies have shown that this position improves the blood supply to the uterus, uterine and uteroplacental blood flow. The fetus is always located facing the placenta.

A woman in labor in the first stage of labor

In the first stage of labor, in the active phase of cervical dilatation, a woman in labor can perform psychoprophylactic analgesia techniques. Feeding a woman in labor during childbirth is not recommended for a number of reasons: the food reflex during childbirth is suppressed. During childbirth, a situation may arise in which anesthesia is required. The latter creates a risk of regurgitation (aspiration of the contents of the stomach) and the development of Mendelssohn's syndrome.

During childbirth, the position and advancement of the head in relation to the plane of the entrance of the small pelvis and in relation to the spinal plane (the narrowest plane of the small pelvis) are constantly assessed. They listen to the fetal heartbeat (the results are recorded in the history of childbirth), but most often they carry out constant cardiomonitoring. Coordinated contractions of the uterus during childbirth provide a normal biomechanism of labor.

Identification points at different positions of the fetal head

Recall the identification points at different positions of the fetal head in relation to the main planes of the pelvis.

1. Head above the entrance of the small pelvis. The entire head is located above the entrance of the small pelvis, movable or pressed against the entrance of the small pelvis. During vaginal examination: the pelvis is free, the head is high, does not interfere with the palpation of the border (nameless) lines of the pelvis, the cape (if it is achievable), the inner surface of the sacrum and the pubic symphysis. Sagittal suture in transverse size at the same distance from the pubic symphysis and promontory, anterior and posterior fontanels at the same level (with occipital presentation). In relation to the spinal plane, the head is in position -3 or -2 cm.

2. The head at the entrance of the small pelvis with a small segment. The head is motionless. Most of it is above the entrance to the pelvis, a small segment of the head is below the plane of the entrance to the pelvis. During vaginal examination: the sacral cavity is free, you can approach the promontory with a bent finger. The inner surface of the pubic symphysis is accessible for examination, the posterior fontanelle is lower than the anterior one (flexion). The sagittal suture is transverse or slightly oblique. In relation to the spinal plane, the head is -1 cm apart.

3. Head at the entrance of the small pelvis with a large segment. With an external examination, it is determined that the head with its largest circumference (large segment) has descended into the cavity of the small pelvis.

The smaller segment of the head is palpated from above. During vaginal examination, the head covers the upper third of the pubic symphysis and sacrum, the cape is not achievable, the ischial spines are easily palpable. The head is bent, the posterior fontanel is lower than the anterior, the sagittal suture is in one of the oblique dimensions. In relation to the spinal plane - "O".

4. Head in a wide part of the pelvic cavity. With an external examination, only a small part of the head is probed. During vaginal examination - the head of the largest circumference passed the plane of the wide part of the pelvic cavity; 2/3 of the inner surface of the pubic symphysis and the upper half of the sacral cavity are occupied by the head. The vertebrae SIV and Sv and the ischial spines are freely palpable. The sagittal suture is located in one of the oblique dimensions. In relation to the spinal plane, the head is +1 cm apart.

5. Head in the narrow part of the pelvic cavity. During vaginal examination, it is determined that the two upper thirds of the sacral cavity and the entire inner surface of the pubic symphysis are occupied by the head. Only vertebrae SIV and SV are palpable. The sagittal suture is in an oblique size, closer to a straight one. The head with the lower pole is in the +2 cm position.

6. Head in the outlet of the pelvis. On external examination, the head is not palpable. The sacral cavity is completely filled with the head, the sciatic spines are not defined, the sagittal suture is located in the direct size of the exit of the small pelvis (in relation to the "0" plane +3 cm).

Stimulation is the artificial induction of labor at various stages of pregnancy and the activation of labor activity already during childbirth. This procedure may be required if the duration of labor increases, which occurs if either the first stage of labor (cervical dilatation) or the second (expulsion of the fetus) is lengthened. Since not every "delay" in labor requires stimulation, doctors must analyze the situation, understand its causes and act accordingly.

When observing childbirth, the doctor pays attention to the following points:

1. The presence of contractions, their frequency, duration and strength. Objectively, these signs are confirmed by palpation of the abdomen (uterus), according to the readings of the tocodynamometer device, which allows you to accurately record the frequency and duration of contractions, as well as using a special intrauterine catheter to determine the pressure in the uterus against the background of contractions (the latter method is used very rarely).
2. Opening of the cervix- this is the most accurate criterion for the normal course of childbirth. Opening is usually measured in centimeters. The minimum dilation is 0 cm when the cervix is ​​closed, the maximum is 10 cm when the cervix is ​​fully dilated. However, this indicator is not completely reliable, since even the same doctor can have different opening values, not to mention different doctors examining the same woman (the width of the doctor’s fingers serves as a guideline in determining the degree of opening in centimeters; 1 finger approximately corresponds to 2 cm, 3 fingers - 6 cm, etc.). It is believed that the normal rate of cervical dilatation in the active phase of labor is 1-1.5 cm/h. If the opening is slower, then the woman in labor may need some kind of stimulating effect. However, the actions of doctors are determined not only by the degree of disclosure, but also by the condition of the woman.
3. Advancement of the presenting part of the fetus (usually the head). It is determined by palpation of the abdomen and / or vaginal examination.

With the normal size of the pelvis, the correct position of the fetus and the absence of factors that prevent the birth of a child through the natural birth canal, the protracted form of childbirth is facilitated by:

• sedatives;
• painkillers;
• the position of the woman in labor on her back;
• woman's fear of pain;
• some diseases of pregnant women.

In addition, there are indications for artificial induction of labor:

• post-term pregnancy, especially if there are signs of fetal disorders or pathological changes in the placenta,
• in some situations - late toxicosis,
• premature detachment of the placenta (direct threat to the life of the fetus),
• premature discharge of amniotic fluid (since the likelihood of infection through the cervix increases), certain diseases (for example, severe diabetes mellitus), etc.

Your actions during pregnancy and childbirth

The desire to give birth safely should not remain a dream that is not supported by concrete actions. Moderate physical activity during pregnancy, physical exercises that train the abdominal muscles, perineum, breathing exercises, the ability to relax - all this one way or another will have a beneficial effect on the course of childbirth. Knowledge about the course of childbirth, the correct behavior in them will reduce the fear of childbirth, therefore, you will be able to influence the process of the birth of your child to a greater extent. The listed useful knowledge and skills are quite effective methods of stimulating labor.

If you have the opportunity to choose the conditions for childbirth and the possibility of choosing a maternity hospital, one of the selection criteria should be the ability to walk during childbirth (of course, if you have no contraindications to this). It has been proven that the supine position increases the duration of labor, since one of the factors for the opening of the cervix - the pressure of the fetus on the cervix is ​​not realized. In the USA, studies have been conducted that have shown that freedom of movement (the ability to walk, sit in different positions) can be no less effective than drug stimulation in childbirth!

If you have the opportunity to get acquainted with the room where the birth will take place, use it. Surprisingly, the factor of preliminary acquaintance with the maternity ward also has a beneficial effect on the process of childbirth (this was also revealed by the meticulous Americans in their studies).

During childbirth, you can use the old but scientifically proven method - nipple stimulation. At the same time, the body increases the production of oxytocin, a hormone that stimulates labor activity, which largely determines the course of childbirth and their successful outcome. It is this circumstance that can explain the fact that breastfeeding immediately after birth accelerates the birth of a child's place and reduces the likelihood of postpartum hemorrhage. If, according to doctors, your pregnancy is gradually becoming overdue, and there are no signs of approaching delivery, you can also resort to this method.

Unfortunately, it is impossible to guarantee the effect, but there will be no harm from this method (of course, if you do not overdo it, because during this period the nipples are easy to injure).

Increased physical activity can also trigger the onset of labor. But this "method of stimulation" is fraught with obvious danger to the life of the mother and child.

The actions of doctors during childbirth

It should be said that the frequency of drug stimulation is growing from year to year. There are several reasons for this. The main ones are the state of health of women and the desire of doctors to minimize the risk to the fetus. If you would like medicines to be used during your birth only when absolutely necessary, discuss this with your doctor. In addition, different maternity hospitals have their own "favorite" methods of stimulation. You may find it useful to know which method of stimulation is preferred by obstetricians in the maternity hospital of your choice.

So, what methods of labor stimulation do doctors have in their arsenal? All of them can be formally divided into those that stimulate the contractility of the uterus, and those that affect the opening of the cervix. Sedatives stand somewhat apart. Fear of pain can slow down labor activity. Therefore, by muffling negative emotions, in some situations it is possible to restore the normal course of childbirth.

Methods affecting the contractile activity of the uterus

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

Amniotomy- opening of the fetal bladder. It is performed during a vaginal examination with a sterile plastic hook-like instrument. This procedure is painless, since the fetal bladder is devoid of pain receptors. The mechanism of action of amniotomy is not fully understood. It is assumed that the opening of the fetal bladder, firstly, contributes to the mechanical irritation of the birth canal by the fetal head, and secondly, indirectly stimulates the production of prostaglandins that enhance labor activity. Information about the effectiveness of amniotomy is contradictory. 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 this woman in labor needs stimulation, and the fetal bladder is still intact, an amniotomy will be performed first, and after it, if necessary, they resort to the help of labor-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, any complications are quite rare. Nevertheless, they exist.

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

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

In order to avoid complications, they try to carry out amniotomy, if possible, after the fetal head enters the small pelvis, squeezing the fetal bladder and the vessels passing along its surface. This prevents bleeding and prolapse of the umbilical cord.

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

Oxytocin- 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 for artificial induction of labor, with weakness of labor throughout the entire period of labor, with postpartum hemorrhage, to stimulate lactation. In order to avoid severe complications, oxytocin is not used for anomalies in the position of the fetus and a clinically narrow pelvis, when the size of the pelvic ring is insufficient for independent 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 use of the drug is the most common. True, he has a significant drawback: a woman with a connected drip system (“dropper”) is very limited in her movements.

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

Oxytocin does not affect the readiness of the cervix to dilate. In addition, in most women, after oxytocin begins to act, labor pain intensifies, therefore, 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 have a child through the birth canal, the fetus is in the wrong 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 impaired blood circulation in this organ, and, as a result, to a lack of oxygen in the fetus.

Methods affecting the cervix

In some women, the reason for the slow course of labor is the unpreparedness of the cervix for disclosure - in the language of doctors, its resistance, or immaturity. The most common method to help the uterus "ripen" is the use of prostaglandins.

Prostaglandins are hormones that have a pronounced effect on reproductive function. In small quantities, they are found in almost all tissues of the body, but most of them in seminal fluid and amniotic fluid. Prostaglandins are able to stimulate smooth muscles, including the fallopian tubes, uterus and cervix. The drugs of this group, like oxytocin, are administered in different ways. However, routes of administration leading to systemic effects of these drugs (tablets, intravenous solutions) are not very common. This is because, by stimulating the uterus with approximately the same effect as oxytocin, they lead to a greater number of side effects (nausea, vomiting, diarrhea, fever, excessive stimulation of uterine contractions, etc.) and, moreover, are more expensive. Therefore, prostaglandins are more often used not for stimulation during childbirth, but for artificial termination of pregnancy in the early stages, artificial induction of labor during almost full-term or full-term pregnancy.

Currently, the method of introducing a viscous gel or suppositories containing prostaglandins into the vagina or cervical canal is widely used. With this method of administration, side effects are minimal, and the effect on cervical dilatation is significant. It is also important that with the local administration of this labor stimulator, the movements of the woman are not limited.

Of course, there are a lot of means that enhance labor activity. Many of them are very rarely used during childbirth, but are used as a means of combating postpartum bleeding, which occurs due to insufficient contraction of the uterus (its hypotension). Among them are herbal preparations (ergot, common barberry, nettle, shepherd's purse herb, spherophysin, etc.). Some funds have lost ground in recent years. This applies, for example, to artificially synthesized estrogen hormones, the effectiveness of which is inferior to oxytocin. There are methods that affect the course of childbirth, but require additional research, such as acupuncture.

Unfortunately, a method that, in all its parameters, would suit both obstetricians and their patients, does not yet exist, just as there are no two similar women in labor. Therefore, the choice of the method of labor stimulation remains with the doctor, who makes the decision, taking into account the conditions of the course of pregnancy, childbirth and the individual characteristics of the woman.

Tatyana Zamyatnina
Obstetrician-gynecologist,
doctor of the highest category,
medical center "MEDSWIS"

Discussion

no, well, it’s necessary - then I was shot with oxytocin, if I had contractions, but the neck didn’t open properly ?? good article, thanks!

Thanks for the great article. Everything is available written and now it became clear what and why.

This is almost the first time I have read a coherent article on stimulation, listing the various methods of stimulation, their pros and cons. And then most of the articles on this subject are more of an "educational" nature - that if a doctor prescribes stimulation, then it means that it is necessary, but in fact there is zero information. Thanks for the clarification, I think a lot of people are interested!

How long does it take for a woman to give birth. after she was put on a drip to induce labor.

Comment on the article "Childbirth with stimulation"

Need advice on pacing. Second and subsequent births. Stimulation of labor without indications .... Medical issues. Pregnancy and childbirth. yeah, that's kind of all about her for now...

Discussion

I was given a pill in the hospital to soften the cervix. I don't remember the name. Now I am very sorry, because. one intervention leads to another. The softness of the neck directly depends on the readiness of the baby to be born. The neck is not ready, so he is not ready.
I gave birth at 43 weeks and 4 days. After that, I read on the website of the Nikitin family that they had read a lot of literature on this issue and it turned out that my term was not the limit. I feel like I would give birth one of these days. But since The term was, according to the doctors, unrealistic, I succumbed to their persuasion, which I greatly regret now. In my case, everything worked out, but they did pierce my bladder, and then vying with each other insisted that the waters had gone down, there was a threat of infection for the child, and at the same time they did not forget to climb into me to check every half an hour, they climbed everything, in the other hand they easily held a non-sterile mobile phone. What they didn’t offer me to inject, not believing that I myself was giving birth, than they just didn’t intimidate me. At the end, they set a deadline - half an hour, if there is no full opening, then they will be taken to a caesarean section. All I needed was to be left alone. The doctors will come out for half an hour, there are contractions, they come - the contractions become less frequent. In the end, I kicked them out, and everything went on as usual. In their half an hour I kept within. But how many nerves, worries it cost me. Those. instead of focusing on childbirth, I fought to defend my position to give birth on my own for several hours. And all this happened in one of the best maternity hospitals in Vidnoye, where people from Moscow come to give birth, under the leadership of the "wonderful" doctor Myamisheva, with whom I so wanted to give birth before.
Now I have completely repulsed the desire to give birth in the presence of doctors.
All the doctors counted my cycle on paper and could not take it for granted that this happens, and 2 ultrasounds in the first and second trimester confirmed my terms. They did not believe that this happens, and at the time of discharge they gave me 2 papers in which it was written that I had an urgent birth at 41 weeks.
They also frightened me with the fact that the child was supposedly suffocating inside, that there would be a post-maturity, in the antenatal clinic, the doctor generally stated that after 38 weeks it was dangerous for the child to be upside down, in the maternity hospital they put a CTG sensor in such a way that the child began to shudder, and from this the result of the CTG turned out to be terrible, she ran away with bulging eyes and came running with this pill. They didn’t want to redo the CTG, they agreed only after I took the pill. It turned out that my CTG was normal, just before that the child did not like the position of the sensor on his body.
I'm not calling you to anything, it's up to you, I just described my experience. By the way, my child was born with a weight that was far from overweight (3600 was not even gained).
I wish you a calm, easy, independent birth!!! The main thing is to tune in correctly.

Candles "Buscopan". Helped me very well. 2 candles a day is enough (morning and night).

Stimulation of childbirth. I don't understand why a woman is allowed to go up to 42 weeks and then still has to induce labor.

Discussion

what do you mean by stimulation - oxytocin? it gives uninterrupted contractions, which are not only difficult for the mother, but also for the child, as he experiences constant and excessive compression, for which he may not be ready. natural contractions are always softer and intermittent.
bubble burst? the cervix does not always open after it, the whole EX often ends. or opens but the tissues are not elastic enough, hence tears and/or episio. by the way, in cases of premature birth, episio is almost always done, although the babies are tiny, but the tissues are not ready yet.
it is better to prepare for childbirth and give birth when the time comes. You can always monitor the condition of the baby, umbilical cord and placenta on additional ultrasound.
I gave birth at almost 41 weeks, a large baby 4250g, without breaks and cuts. preparing for childbirth, breathing correctly, pushing correctly, helping her baby, and he helped me. I wish you easy natural childbirth :)

Now half of the children, if not more, with hypoxia without any walking and stimulation. Plus, not every woman will agree to stimulate, and for this you need to go to the maternity hospital in advance, and there are not always places there. Everything is individual

What is stimulation? Stimulation is the acceleration of labor by injecting an additional dose of the hormone oxytocin intravenously, which should be produced during childbirth ...

Stimulation of labor without indications .... Medical issues. Pregnancy and childbirth. Stimulation of childbirth without indications... Almost a horror story, but it's better to know than not to know!!!

The main organ in a woman's body, without which it would be impossible to endure and give birth to a baby, is the uterus. The uterus is a hollow muscular organ. It distinguishes 3 main parts: bottom, body and neck. As you can see, the cervix is ​​an integral part of the main organ during pregnancy, respectively, the normal course of the processes of gestation and natural childbirth will also depend directly on its condition. How? Let's figure it out.

Cervix during pregnancy

The cervix is ​​a tube connecting the uterus and the vagina, the ends of which end in holes (the internal pharynx opens into the uterus, the external one opens into the vagina), and the cervical canal passes inside. Normally, throughout almost the entire period of pregnancy, it should have a dense texture with a tightly closed cervical canal, which allows you to keep the fetus in the uterine cavity, as well as protect it from the penetration of infections from the vagina.

information Only a few weeks before the date of the expected birth, the cervix begins to undergo changes that will later allow the baby to move freely through the woman's birth canal and be born unhindered.

Sometimes these changes can start ahead of schedule. The opening of the cervix during pregnancy is a poor diagnostic sign that threatens the loss of a child or premature birth. The reasons for this condition are often:

• Burdened obstetric history (abortions, miscarriages in the early and late stages);
• Injuries of the cervix (operations, childbirth with a large fetus, ruptures in previous births);
• Cervical erosion;
• Hormonal disorders (progesterone deficiency).

Softening and opening of the cervix should occur immediately before childbirth!

Disclosure

In the process of progression of pregnancy in the cervix, there is a partial replacement of muscle tissue with connective tissue. "Young" collagen fibers are formed, which have increased flexibility and extensibility than similar ones outside of pregnancy. Some of them are absorbed, forming the main substance, which leads to an increase in the hydrophilicity of the tissue. Clinically, this is manifested by loosening and shortening of the cervix and gaping of the cervical canal.

Preparation of the cervix for childbirth begins at about 32-34 weeks of pregnancy. It begins to soften along the periphery, but the area of ​​dense tissue along the cervical canal is still preserved. In nulliparous women, during vaginal examination, the external os can pass the tip of the finger, in multiparous women, the canal becomes passable to the internal os for 1 finger. Already by 36-38 weeks, the cervix is ​​\u200b\u200balmost completely softened. The fetus begins to descend into the small pelvis, with its weight it creates a certain pressure on the neck, which helps to further open it.

The opening of the neck begins with the internal pharynx. In primiparas, the canal takes the form of a truncated cone with the base facing upwards. The fruit, gradually moving forward, stretches the external pharynx. In multiparous women, the opening of the cervix is ​​easier and faster, due to the fact that the external os by the end of pregnancy is most often already open by 1 finger. In them, the opening of the external and internal pharynx occurs almost simultaneously.

Immediately before the onset of labor, the cervix of the uterus, both in primiparous and multiparous women, is sharply shortened (smoothed), exhausted, the canal is passed by 2 fingers or more. Gradually, there is a complete opening of the cervix up to 10-12 cm, which allows the head of the fetus and its trunk to pass through the birth canal.

Possible problems

Starting from the 37-38th week of pregnancy, the dominant of pregnancy is replaced by the dominant of childbirth, and the uterus turns from a fetus-place into an expelling organ. Some pregnant women are very afraid of the date of birth, building a psychological barrier to the formation of that very necessary dominant. Against the background of nervous overstrain and the lack of proper psychoprophylactic preparation for childbirth, a woman experiences inhibition of the production of the necessary hormones. The cervix remains unchanged, and the preparation for childbirth of the body is delayed.

For a complete and normal opening of the cervix, the development of regular labor activity is necessary. If weakness of labor pains develops, the process of opening the neck also stops. Not infrequently, this happens with polyhydramnios (overdistension of the uterus occurs and, as a result, a decrease in its contractility) or oligohydramnios (a flaccid or flat fetal bladder does not allow the neck to be properly affected).

Women over the age of 35 are at risk of this problem. In their case, the cause may be the rigidity (decrease in elasticity) of the tissues.

remember The general condition of a woman's body before childbirth plays an important role. The presence of extragenital endocrine diseases (diabetes mellitus, hypothyroidism, obesity) often leads to the development of complications during childbirth.

Stimulation of the preparation of the cervix for childbirth

Often, just before the date of the expected birth, after visiting the doctor, a woman may find out that her cervix is ​​\u200b\u200b“not mature” and there is a need to artificially prepare her for childbirth. This issue becomes especially relevant after the 40th week of pregnancy, since at these times the placenta depletes its functionality, which leads to fetal hypoxia.

Stimulation of this process can be carried out by two methods: drug and non-drug.

Medical method allows you to achieve the desired result with the help of medicines and only in a hospital setting.

• Introduction to the cervical canal of kelp sticks. Sticks of kelp (seaweed) are placed in the cervical canal for its entire length. Under the influence of moisture, after about 4-5 hours, they begin to swell, mechanically opening the channel. Laminaria also secrete endogenous prostaglandins necessary for the maturation of the cervix. Gradual mechanical and biochemical action of kelp sticks leads to quick and careful preparation of the cervix for childbirth;
• Introduction to the cervical canal of synthetic prostaglandin in the form of candles or gel. Allows you to achieve the desired effect within a few hours;
• In a hospital setting, amniotomy(piercing of the amniotic sac). After this procedure, the anterior waters leave, the fetal head descends, the pressure on the neck increases, and the opening begins to occur faster.

Non-drug method can be used at home, but you should be extremely careful and take into account all the pros and cons.

• Cleansing enema. Its use irritates the back wall of the uterus, causing it to contract. It was also noticed that after this procedure, the mucosal plug is discharged, and the opening of the cervix begins. But it can be done only for those women whose expected date of birth has already come or gone;
• Sex. Natural labor stimulant. Firstly, it causes contraction of the muscles of the uterus, increasing blood flow to it. Secondly, semen contains prostaglandins, the "hormone of childbirth." Contraindication: departed (high probability of infection);
• Physical exercise. Long walks, cleaning the house, climbing stairs to the upper floors. Contraindicated in hypertension, placenta previa.

Now you know how, when and why the cervix is ​​prepared for childbirth. You know the reasons why this might not happen and how you can fix it. Having the information, you can correct or prevent the possible occurrence of problems. Do not forget one thing: it is better to do this in consultation with your doctor!

As it turns out, the issue of cervical dilatation, the timing and size of the opening in centimeters or transverse fingers, and how to interpret it, worries all pregnant women. However, many do not know the exact answer. We will try to cover this topic as much as possible and start with anatomical features.

The uterus is an important organ of the female reproductive system and consists of the body of the uterus and the cervix. The cervix is ​​a muscular tubular formation that starts from the body of the uterus and opens into the vagina. The part of the cervix that is visible when viewed in mirrors is called the vaginal part. The internal os is the transition of the cervix into the uterine cavity, and the external os is the border between the cervix and the vagina. In these places, the muscular part is more pronounced.

During pregnancy, some of the muscle fibers in the cervix are replaced by connective tissue. The newly formed "young" collagen fibers are extensible and elastic, with their excessive formation, the cervix shortens, and the internal os begins to expand.

Normally, throughout pregnancy, the cervix is ​​long (about 35 - 45 mm), and the internal os is closed. This position helps prevent spontaneous miscarriage, and also protects against the penetration of infection into the uterine cavity.

Only a few weeks before the expected date of birth (PDR), the cervix changes its structure, gradually becoming softer and shorter. If shortening, softening of the cervix and expansion of the internal os occurs during pregnancy, then this condition threatens to terminate the pregnancy or premature birth.

Causes of premature shortening of the cervix:

Burdened obstetric history (abortions, miscarriages at different times, history of preterm birth, especially very early preterm birth up to 28 weeks)

Aggravated gynecological history (infertility, polycystic ovary syndrome and other gynecological diseases)

Injuries of the cervix (surgery, ruptures in previous births, delivery of a large fetus)

Norms for the cervix by timing

Up to 32 weeks: the cervix is ​​preserved (length 40 mm or more), dense, the internal os is closed (according to the results of ultrasound). During vaginal examination, the cervix is ​​dense, deviated posteriorly from the wire axis of the pelvis, the external os is closed.

The wire axis of the pelvis is a line connecting the midpoints of all direct dimensions of the pelvis. Since the sacrum has a bend, and then the birth canal is represented by the muscular-fascial part, the wire axis of the pelvis is represented by a curved line resembling a fishhook in shape.

32-36 weeks: the cervix begins to soften in the peripheral sections, but the area of ​​\u200b\u200bthe internal pharynx is dense. The length of the cervix is ​​approximately 30 mm or more, the internal os is closed (according to ultrasound). On vaginal examination, the cervix is ​​described as "dense" or "unevenly softened" (closer to 36 weeks), tilted backwards or located along the wire axis of the pelvis, the external os in primiparas can pass the tip of a finger, in multiparous passes 1 finger into the cervical canal.

From 37 weeks: the cervix is ​​\u200b\u200b“mature” or “ripening”, that is, soft, shortened to 25 mm or less, the pharynx begins to expand (the length of the neck, a funnel-shaped expansion of the uterine pharynx, is described by ultrasound). On vaginal examination, the external os may pass 1 or 2 fingers, the cervix is ​​described as "softened" or "unevenly softened", located along the wire axis of the pelvis. The fetus in this period begins to descend with its head into the small pelvis and presses harder on the neck, which contributes to its maturation.

To assess the neck as “mature” or “immature”, a special table (Bishop scale) is used, where the parameters of the neck are evaluated in points. Now the most commonly used modified Bishop scale (simplified).

Interpretation:

0 - 2 points - the cervix is ​​"immature";
3 - 4 points - the cervix is ​​"not mature enough"
5 - 8 points - the cervix is ​​"mature"

The maturation of the cervix begins with the area of ​​​​the internal os. In primiparous and multiparous, the process occurs a little differently.

In primiparas (A), the cervical canal becomes like a truncated cone, with its wide part facing upwards. The head of the fetus, going down and moving forward, gradually stretches the external pharynx.

In multiparous (B), the expansion of the external and internal os occurs simultaneously, so repeated births, as a rule, proceed faster.

1 - internal pharynx
2 - external pharynx

Cervix during childbirth

Everything that we have described above refers to the condition of the cervix during pregnancy. During pregnancy, the terms "shortening the cervix", "expansion of the internal os", "maturity of the cervix" are used. Directly the term "opening" or "opening" (which means the same thing) begins to be used only with the onset of childbirth.

By the time of birth, the cervix, gradually shortening, is completely smoothed out. That is, it ceases to exist as an anatomical structure. The long tubular structure is completely smoothed out and only the concept of "internal cervical os" remains. Here is its disclosure and is considered in centimeters. As labor activity develops, the edges of the internal os become thinner, softer, more pliable, which makes it easier for the fetal head to stretch them.

Depending on the degree of opening of the internal pharynx, childbirth is divided into periods I and II:

I stage of labor so it is called - "the period of disclosure of the internal pharynx of the cervix." The first period is divided into phases.

In the latent (hidden) phase, the internal pharynx gradually opens up to 3-4 cm. Contractions during this period are moderately painful or painless, short, occur after 6-10 minutes.

Then the active phase of the first stage of labor begins - the rate of opening of the uterine os should be at least 1 cm per hour in primiparas and at least 2 cm per hour in multiparous ones, contractions in this period become more frequent and occur every 2 to 5 minutes, become longer ( 25 - 45 seconds), strong and painful.

The internal os should open up to 10 - 12 cm, then it is called "full opening / disclosure" and the II stage of labor begins.

II stage of labor called the period of "expulsion of the fetus."

At this stage, the uterine os is fully opened, and the fetal head begins to move along the birth canal to the exit.

The dynamics of the opening of the uterine os is reflected in the partogram, which is conducted from the beginning of the latent phase and is filled out after each obstetric examination.

A partogram is a method of graphical description of childbirth, in which cervical dilatation in centimeters, time in hours, progress of the fetus along the pelvic planes, quality of contractions, color of amniotic water and fetal heartbeat are reflected in the form of a graph. Below is a simplified version of the partogram, which reflects only the parameters of interest to us in this topic, that is, the opening of the uterine os in time.

In order to clarify the obstetric situation, the doctor conducts an internal obstetric study, the frequency of which depends on the period and phase of childbirth. In the latent phase of the first period, the examination is carried out 1 time in 6 hours, in the active phase of the first period 1 time in 2-4 hours, in the second period 1 time per hour. With the development of any deviation from the physiological course of childbirth, the examination is performed according to indications in dynamics (the frequency of examinations is determined by the doctor in charge of childbirth, examination by a council of doctors is possible).

Pathologies associated with the process of opening the cervix:

1) Pathological condition associated with shortening of the cervix and / or expansion of the internal os during pregnancy:

2) Pathology of the opening of the cervix in the preliminary period.

The preliminary period is a condition with rare, weak cramping pains in the lower abdomen and in the lower back, develops during full-term pregnancy and a mature cervix, lasts about 6-8 hours and gradually passes into the first stage of labor. The preliminary period is not observed in all women.

The pathological preliminary period is irregular short painful contractions with a mature cervix that last more than 8 hours and do not lead to smoothing of the cervix.

3) Pathology of cervical dilatation during childbirth.

-weakness of the ancestral forces. Weakness of tribal forces is insufficient in strength, duration and regularity of the contractile activity of the uterus. The weakness of labor activity is manifested by a slow rate of cervical dilatation, rare, short, insufficient contractions that do not lead to the advancement of the fetus. This diagnosis is made on the basis of observation of the pregnant woman, the results of cardiotocography (CTG) and vaginal examination data. The figure below shows the result of CTG with the weakness of the tribal forces, as we see the contractions here of weak strength and short. For comparison with the norm, we present the figure below.

The primary weakness of the tribal forces is a state when contractions initially did not acquire sufficient effectiveness.

The secondary weakness of the tribal forces is a condition in which the developed regular and effective labor activity fades and becomes ineffective.

- discoordination of labor activity. Discoordination of labor activity is a pathological condition in which there is no coordination between contractions of different parts of the uterus, contractions are uncoordinated and can be very painful due to their unproductiveness (the fetal head does not move along the birth canal). For example, the fundus of the uterus is actively contracting, but there is no sufficient opening of the cervix (uterine os), or the cervix is ​​opening, but the fundus of the uterus is not effectively reduced. The figure below shows the result of CTG with discoordinated labor activity, contractions have different strengths and frequency.

A form of discoordination of labor activity, in which the body of the uterus is actively contracting, and the cervix does not have sufficient opening due to cicatricial changes (the consequences of abortions, old ruptures, cauterization of erosion) or an undiagnosed condition (there is no indication of cervical pathology or trauma in the anamnesis), is called dystocia cervix. This form of pathology is characterized by painful unproductive contractions, pain in the sacrum. With an internal obstetric examination, the doctor sees a spasm of the uterine os during a contraction and rigidity of the edges of the internal os of the cervix (density, inflexibility).

- rapid and rapid childbirth. Normally, the duration of the birth process is 9 - 12 hours, in multiparous women it can be less, about 7 - 10 hours.

In primiparas, delivery is considered to be fast delivery less than 6 hours, and rapid - less than 4 hours.

In multiparous women, births less than 4 hours are considered quick, and births less than 2 hours are considered rapid.

Rapid and rapid labor is characterized by an accelerated rate of opening of the cervix and expulsion of the fetus. In some cases, this is a blessing, since delay threatens with complications (pathologies of the umbilical cord, placenta, and others). But often, due to the rapid pace of childbirth, the child does not have time to correctly go through all the stages of the biomechanism of childbirth (adaptation of the soft bones of the child’s skull to all the bends of the mother’s pelvic bones, timely rotations of the body and head, flexion and extension of the head), and the risk of birth injury is increased (as in mother and newborn).

Treatment for premature cervical dilatation:

1) Isthmic - cervical insufficiency it is treated by placing circular sutures on the cervix (from 20 weeks) or by installing an obstetric pessary (from about 15-18 weeks).

2) Pathological preliminary period. After the observation period (8 hours) and the absence of dynamics during a second vaginal examination, an amniotomy is performed (opening of the fetal bladder). If the cervix remains shortened but not flattened, then oxytocin may be administered to induce labor. If the neck is smoothed out, but there is no regular labor activity, then they speak of the transition of the pathological preliminary period into the primary weakness of labor activity.

3) Weakness of tribal forces. Amniotomy is performed as the first therapeutic measure for weak labor activity. After amniotomy, dynamic monitoring of the woman in labor, counting contractions, CTG - monitoring the condition of the fetus and obstetric examination after 2 hours are shown. If there is no effect, drug treatment is indicated.

With primary weakness, labor induction is performed, with secondary weakness, labor intensification is performed. In both cases, the drug oxytocin is used, the difference is in the initial dose and the rate of drug delivery through the infusion pump (drip dosed administration). In the absence of the effect of treatment, delivery by caesarean section is indicated.

4) Discoordination of labor (cervical dystocia). With the development of discoordinated labor activity, a woman in labor must be given pain relief, narcotic analgesics are used (promedol intravenously at an individual dose under the control of CTG) or therapeutic epidural anesthesia (single administration of an anesthetic or prolonged anesthesia with periodic administration of the drug). The type of anesthesia is chosen individually after a joint examination by an obstetrician-gynecologist and an anesthesiologist-resuscitator. In the absence of the effect of treatment, delivery by caesarean section is indicated.

5) Rapid and rapid childbirth. In this case, the most important thing is to be in a maternity facility. It is impossible to stop childbirth, but it is necessary to carefully monitor the condition of the mother and fetus. Carry out cardiotocography (the main thing is to clarify the condition of the fetus, whether there is hypoxia), if necessary, ultrasound (suspecting placental abruption). In the case of rapid delivery, a neonatologist (micropediatrician) must be present in the delivery room and there must be conditions for resuscitation of the newborn. Cesarean section is indicated in the event of an urgent clinical situation (placental abruption, acute hypoxia or fetal asphyxia that has begun)

After reading the article, you realized how important and unique the formation of the cervix is. Pathologies of the cervix and, in particular, the pathology of cervical dilatation, unfortunately, occur and will occur, but any deviations from the norm are treated the more successfully the sooner you consult a doctor. And then the chances of maintaining your health and the timely birth of a healthy baby increase significantly. Look after yourself and be healthy!

Obstetrician-gynecologist Petrova A.V.

Normal and timely labor never begins suddenly and violently. On the eve of childbirth, a woman experiences their precursors, and the uterus and her cervix prepare for the birth process. In particular, the cervix begins to "ripen" and expand, that is, it enters the stage of opening the uterine os. Childbirth is a complex and lengthy process and largely depends on the interaction of the uterus, cervix and the state of the hormonal background, which determines their successful completion.

The cervix is...

The lower part of the uterus is called its cervix, which looks like a narrow cylinder and connects the uterine cavity with the vagina. Directly in the neck, the vaginal part is distinguished - the visible part that protrudes into the vagina below its arches. And also there is supravaginal - the upper part, located above the arches. In the cervix passes the cervical (cervical) canal, the upper end of it is called the internal pharynx, respectively, the lower end is the outer one. During pregnancy, there is a mucous plug in the cervical canal, the function of which is to prevent the penetration of infection from the vagina into the uterine cavity.

The uterus is the female reproductive organ, the main purpose of which is the bearing of the fetus (fetal container). The uterus consists of 3 layers: the inner one is represented by the endometrium, the middle one is the muscular tissue and the outer one is the serous membrane. The main mass of the uterus is the muscular layer, which hypertrophies and grows during gestation. The myometrium of the uterus has a contractile function, due to which contractions occur, the cervix (uterine os) opens and the fetus is expelled from the uterine cavity during the birth act.

Periods of childbirth

The birth process lasts quite a long time, and normally in primiparous women in labor it is 10-12 hours, while in multiparous women it lasts about 6-8 hours. Childbirth itself includes three periods:

• I period - the period of contractions (opening of the uterine os);
• II period is called the period of attempts (the period of expulsion of the fetus);
• III period - this is the period of separation and discharge of the child's place (afterbirth), therefore it is called the afterbirth period.

The longest stage of the birth act is the period of opening of the uterine os. It is caused by uterine contractions, during which the fetal bladder is formed, the fetal head moves along the pelvic ring and cervical opening is provided.

Contraction period

First, contractions arise and are established - no more than 2 in 10 minutes. Moreover, the duration of uterine contraction reaches 30 - 40 seconds, and relaxation of the uterus 80 - 120 seconds. Prolonged relaxation of the uterine muscles after each contraction ensures the transition of the cervical tissues into the structure of the lower uterine segment, as a result of which the length of the visible part of the cervix decreases (it shortens), and the lower uterine segment itself is stretched and lengthened.

As a result of the ongoing processes, the presenting part of the fetus (usually the head) is fixed at the entrance to the small pelvis, separating the amniotic fluid, as a result, anterior and posterior waters are formed. A fetal bladder is formed (contains anterior waters), which acts as a hydraulic wedge, wedged into the internal os, opening it.

In first-borns, the latent phase of disclosure is always longer than in women giving birth for the second time, which causes a longer total duration of labor. Completion of the latent phase is marked by complete or almost complete smoothing of the neck.

The active phase begins with 4 cm of cervical dilatation and lasts up to 8 cm. At the same time, contractions become more frequent and their number reaches 3–5 in 10 minutes, the periods of contraction and relaxation of the uterus equalize and amount to 60–90 seconds. The active phase lasts for primiparous and multiparous 3-4 hours. It is in the active phase that labor activity becomes intense, and the cervix opens quickly. The fetal head moves along the birth canal, the cervix has completely passed into the lower uterine segment (merged with it), by the end of the active phase, the opening of the uterine os is complete or almost complete (within 8–10 cm).

At the end of the active phase, the fetal bladder opens and the water is poured out. If the cervical opening has reached 8 - 10 cm and the water has departed - this is called a timely outflow of water, the discharge of water at the opening of up to 7 cm is called early, with 10 or more cm of opening of the pharynx, an amniotomy is indicated (the procedure for opening the fetal bladder), which is called a belated outflow of water.

Terminology

The opening of the cervix does not have any symptoms, only a doctor can determine it by conducting a vaginal examination.

To understand how the process of softening, shortening and smoothing the neck is progressing, one should decide on obstetric terms. In the recent past, obstetricians determined the opening of the uterine os in the fingers. Roughly speaking, how many fingers the uterine pharynx passes through, such is the opening. On average, the width of the "obstetric finger" is 2 cm, but, as you know, everyone's fingers are different, so measuring the opening in cm is considered more accurate. So:

• if the cervix is ​​​​opened by 1 finger, then they say about the opening of 2 - 3 cm;
• if the opening of the uterine os has reached 3–4 cm, this is equivalent to opening the cervix by 2 fingers, which, as a rule, is diagnosed already at the beginning of regular labor (at least 3 contractions in 10 minutes);
• an almost complete opening is indicated by the opening of the neck by 8 cm or by 4 fingers;
• full disclosure is fixed when the cervix is ​​completely smoothed (the edges are thin) and passable for 5 fingers or 10 cm (the head descends to the pelvic floor, turning with an arrow-shaped seam in a straight size, there is an irresistible desire to push - it's time to go to the delivery room for the birth of a baby - the beginning of the second period childbirth).

How does the cervix mature?

The harbingers of childbirth that have appeared indicate the imminent onset of the birth act (from about 2 weeks to 2 hours):

• the bottom of the uterus descends (for 2-3 weeks before the onset of contractions), which is explained by the pressing of the presenting part of the fetus to the small pelvis, a woman feels this sign by easing breathing;
• the pressed head of the fetus presses on the pelvic organs (bladder, intestines), which leads to frequent urination and constipation;
• increased excitability of the uterus (the uterus “hardens” when the fetus moves, the woman moves abruptly, or when the abdomen is stroked / pinched);
• appearance is possible - they are irregular and rare, pulling and short;
• the cervix begins to "ripen" - softens, skips the tip of the finger, shortens and "centers".

The opening of the cervix before childbirth proceeds very slowly and gradually over a month, and intensifies on the last day - two on the eve of childbirth. In nulliparous women, the dilatation of the cervical canal is about 2 cm, while in multiparous women, the dilatation exceeds 2 cm.

To determine the maturity of the cervix, a scale developed by Bishop is used, which includes an assessment of the following criteria:

• the consistency (density) of the neck: if it is dense, it is regarded as 0 points, if it is softened along the periphery, but the inner pharynx is dense - 1 point, soft both inside and out - 2 points;
• the length of the neck (the process of its shortening) - if it exceeds 2 cm - 0 points, the length reaches 1 - 2 cm - a score of 1 point, the neck is shortened and does not reach 1 cm in length - 2 points;
• patency of the cervical canal: closed external pharynx or skips the tip of a finger - score 0 points, the cervical canal is passable to a closed internal pharynx - this is estimated at 1 point, and if the canal passes one or 2 fingers through the internal pharynx - it is estimated at 2 points;
• how the neck is located in relation to the wire axis of the pelvis: directed backwards - 0 points, shifted anteriorly - 1 point, located in the middle or "centered" - 2 points.

When summing the points, the maturity of the cervix is ​​​​estimated. An immature neck is considered with a score of 0 - 2 points, 3 - 4 points is regarded as an insufficiently mature or ripening neck, and with 5 - 8 points they speak of a mature neck.

Vaginal examination

To determine the degree of readiness of the cervix and not only, the doctor conducts a mandatory vaginal examination (upon admission to the maternity hospital and at 38-39 weeks at the appointment at the antenatal clinic).

If a woman is already in the maternity ward, a vaginal examination to determine the process of opening the uterine os every 4 to 6 hours or according to emergency indications:

• discharge of amniotic fluid;
• carrying out a possible amniotomy (weak birth forces, or a flat fetal bladder);
• with the development of anomalies of generic forces (clinically narrow pelvis, excessive labor activity, discoordination);
• before regional anesthesia (EDA, SMA) to determine the cause of painful contractions;
• the occurrence of discharge with blood from the genital tract;
• in the case of established regular labor activity (preliminary period that turned into contractions).

When conducting a vaginal examination, the obstetrician evaluates the condition of the cervix: its degree of disclosure, smoothing, thickness and extensibility of the cervical edges, as well as the presence of scars on the soft tissues of the genital tract. In addition, the capacity of the pelvis is assessed, the presenting part of the fetus and its insertion are palpated (localization of the swept suture on the head and fontanelles), the advancement of the presenting part, the presence of bone deformities and exostoses. Be sure to evaluate the fetal bladder (integrity, functionality).

According to the subjective signs of disclosure and the data of the vaginal examination, a partogram of childbirth is compiled and maintained. Contractions are considered subjective signs of childbirth, in particular, the opening of the uterine os. Criteria for evaluating contractions include their duration and frequency, severity and uterine activity (the latter is determined instrumentally). Partogram of childbirth allows you to visually record the dynamics of the opening of the uterine os. A graph is drawn up, along which the duration of labor is indicated in hours, and the cervical dilatation in cm is indicated vertically. Based on the partogram, the latent and active phases of labor can be distinguished. The steep rise of the curve indicates the effectiveness of the birth act.

If the cervix dilates prematurely

The opening of the cervix during pregnancy, that is, long after childbirth, is called isthmic-cervical insufficiency. This pathology is characterized by the fact that both the cervix and the isthmus do not fulfill their main function in the process of gestation - obturator. In this case, the neck softens, shortens and smoothes, which does not allow the fetus to be kept in the fetus and leads to spontaneous abortion. Termination of pregnancy, as a rule, occurs in 2 - 3 trimesters. The failure of the cervix is ​​evidenced by the fact of its shortening to 25 mm or less at 20-30 weeks of gestation.

Isthmic-cervical insufficiency is organic and functional. The organic form of the pathology develops as a result of various cervical injuries - artificial abortions (see), cervical ruptures during childbirth, surgical methods for treating cervical diseases. The functional form of the disease is due either to a hormonal imbalance or an increased load on the neck and isthmus during pregnancy (multiple pregnancies, excess water or a large fetus).

How to keep a pregnancy when dilating the cervix

But even with a cervical opening of 1 - 2 fingers in a period of 28 weeks or more, it is likely to keep the pregnancy, or at least prolong it until the birth of a completely viable fetus. In such cases are appointed:

• bed rest;
• emotional peace;
• sedatives;
• antispasmodics (magne-B6, no-shpa,);
• tocolytics (ginipral, partusisten).

Be sure to carry out treatment aimed at the production of surfactant in the lungs of the fetus (glucocorticoids are prescribed), which accelerates their maturation.

In addition, treatment and prevention of further premature opening of the cervix is ​​​​surgical - stitches are applied to the neck, which are removed at 37 weeks.

The cervix is ​​immature - what then?

The opposite situation is possible, when the cervix is ​​“not ready” for childbirth. That is, the hour X has come (the estimated date of birth), and even several days or weeks have passed, but there are no structural changes in the cervix, it remains long, dense, rejected backwards or forwards, and the internal pharynx is impassable or passes the tip of the finger. How do doctors act in this case?

All methods of influencing the neck, leading to its maturation, are divided into drug and non-drug. Medical methods include the introduction into the vagina or into the cervix of special gels and suppositories with prostaglandins. Prostaglandins are hormones that accelerate the process of maturation of the cervix, increase the excitability of the uterus, and in childbirth, their intravenous administration is practiced in case of weakness of the birth forces. Local administration of prostaglandins has no systemic effect (no side effects) and contributes to the shortening and smoothing of the neck.

Of the non-drug methods of stimulating the opening of the cervix, the following are used:

Sticks - kelp

Sticks are made from dried kelp algae, which are highly hygroscopic (absorb water well). Such a number of sticks are introduced into the cervical canal so that they fill it tightly. As the sticks absorb liquid, they swell and stretch the cervix, causing it to dilate.

Foley catheter

The catheter for opening the cervix is ​​represented by a flexible tube with a balloon fixed at one end. A catheter with a balloon at the end is inserted into the cervical canal by a doctor, the balloon is filled with air and left in the neck for 24 hours. Mechanical action on the neck stimulates its opening, as well as the production of prostaglandins. The method is very painful and increases the risk of infection of the birth canal.

Cleansing enema

Unfortunately, in some maternity hospitals they refused to conduct a cleansing enema for a woman who came to give birth, but in vain. The free intestine, as well as its peristalsis during defecation, increases the excitability of the uterus, increases its tone, and, consequently, accelerates the process of opening the cervix.

Question answer

How can you speed up the opening of the cervix at home?

• prolonged walks in the fresh air increase the excitability of the uterus and the production of prostaglandins, and the presenting part of the baby is fixed at the entrance to the small pelvis, further stimulating the opening of the cervix;
• watch the bladder and intestines, avoid constipation and prolonged abstinence from urination;
• eat more salads from fresh vegetables seasoned with vegetable oil;
• take a decoction of raspberry leaves;
• stimulate the nipples (when they are irritated, oxytocin is released, which causes uterine contractions).
• Are there any specific neck opening exercises?

At home, walking up the stairs, swimming and diving, bending and turning the torso accelerates the maturation of the neck. It is also recommended to take a warm bath, massage the ear and little finger, breathing exercises and exercises to strengthen the perineal muscles, and yoga. In maternity hospitals there are special gymnastic balls, the seat and jumps on which, during the period of contractions, accelerate the opening of the uterine os.

Does sex really help prepare the cervix for childbirth?

Yes, having sex in the last days and weeks of pregnancy (subject to the integrity of the fetal bladder and the presence of a mucous plug in the cervical canal) contributes to the maturation of the cervix. First, during orgasm, oxytocin is released, which stimulates uterine activity. And, secondly, the semen contains prostaglandins, which have a beneficial effect on the process of maturation of the cervix.

At what opening do attempts begin?

Pushing is a voluntary contraction of the abdominal muscles. The desire to push arises in a woman in labor already at 8 cm. But until the cervix opens completely (10 cm), and the head sinks to the bottom of the small pelvis (that is, it can be felt by a doctor by pressing on the labia) - you can’t push.