Causes of postpartum hypotonic bleeding. Multiple births What is birth parity?

The answers to this question on forums and social networks are only confusing, because the information given by women who have gone through this period varies greatly. The fact is that the process of giving birth to a baby is different for each mother and depends on many reasons.

Duration of labor

The duration of labor is different for each woman in labor. It is never possible to predict how long labor will last, or whether violent contractions will occur. The average duration of labor from the first contraction or breaking of water in primiparous women is 7-12 hours. For women giving birth to a second child, it is about 7-8 hours. The third and subsequent births usually follow the scenario of the second ones or a little faster; there are no special patterns for them.

As you know, childbirth consists of three stages or periods: contractions, pushing and the afterbirth period. Read more. The main duration of time occurs in the first period - contractions. It is the speed, dynamics of opening, smoothing and thinning of the cervix that depends on the parity (that is, the number) of childbirth. In multiparous women, the cervix may be slightly open by several centimeters within a few weeks.

In women giving birth for the first time, the internal pharynx begins to open first, and only then the external pharynx. Thus, the cervix opens as if from the inside. So, the speed of cervical dilatation depends on:

1. birth parity;
2. the psychological state of the woman - fear or, conversely, a positive attitude towards childbirth;
3. the presence of anomalies, tumors or scar changes in the uterus and cervix (history of cesarean section, scar deformities of the cervix, coagulated cervical syndrome, myomatous nodes, bicornuate uterus);
4. the presence of concomitant diseases: hypothyroidism, arterial hypertension, heart disease, fever, and so on;
5. the presence of complications of pregnancy and childbirth: premature birth, polyhydramnios, gestosis, large fetus, weakness or incoordination of labor;
6. the use of stimulant drugs and techniques: oxytocin, prostaglandins, amniotomy.

The period of pushing is not directly dependent on the parity of births. The speed of expulsion of the fetus depends to a large extent on the strength of contractions and pushing, the size of the fetus and its presentation and, importantly, the behavior of the woman herself.

On average, the pushing period takes from 5 to 30 minutes.

The succession period is absolutely independent of the number of previous births. The placenta with membranes leaves the uterine cavity on average 5-60 minutes after the birth of the child. From the moment the placenta is born, labor can be considered complete.

Rapid labor: concept, causes and complications

Some women dream of giving birth in two hours and enjoy listening to friends' stories about quick labor.

Birth in first-time mothers, which occurs within 4-6 hours, is considered fast. For experienced mothers, this figure is 2-4 hours. Rapid labor is identified as a separate pathology of labor. Their duration in primiparous and multiparous women is less than four and two hours, respectively. In fact, there is nothing good in such childbirth. A child who literally flies through the birth canal does not have time to adapt to changes in pressure, oxygen and carbon dioxide levels, and is more susceptible to injury.

1. Causes of rapid labor:
2. heredity;
3. characteristics of the nervous system of a particular woman;
4. hormonal disorders, such as hyperthyroidism, excess of endogenous factors that provoke childbirth;

improper use of medications to induce labor, opening of amniotic fluid. Consequences of rapid labor

1. exist for both the child and the mother:
2. fetal hypoxia during childbirth due to excessive pressure of the contracting uterus on the vessels of the placenta and the umbilical cord;
3. newborn: clavicle fracture, cephalohematoma, cerebral hemorrhage;
4. maternal birth injuries: ruptures of the cervix, vagina, perineum;

premature placental abruption and massive bleeding.

The concept of protracted labor has changed many times over the centuries. Even the ancient healer Hippocrates said that a woman giving birth should not see more than one sunrise, that is, normal childbirth should not last more than a day. In modern interpretation, labor that lasts more than 18 hours is considered protracted for first-time women. For women giving birth again - more than 12 hours.

However, these figures vary in different manuals; great emphasis is placed on the duration of the so-called “water-free interval”. After the discharge of amniotic fluid, no more than 12 hours should pass, otherwise there is a risk of infection of the uterine cavity, membranes and fetus.

Causes of prolonged labor

1. pregnancy post-term for more than 42 weeks;
2. premature birth, when uterine activity is insufficient for adequate labor;
3. fatigue, poor sleep and nutrition of a pregnant woman;
4. psychological unpreparedness of the expectant mother for childbirth;
5. abnormalities of the uterus, scar changes in the uterus and cervix;
6. incorrect presentation of the fetus or insertion of the head;
7. a narrow pelvis in a woman in labor;
8. overdistension of the uterus due to excess amniotic fluid, a fetus with a large body weight, multiple pregnancy;
9. deficiency of endogenous hormones oxytocin and prostaglandins;
10. improper use of medications to induce labor;
11. irrational amniotomy during childbirth.

Obstetricians are very wary of protracted labor. This is understandable, because long labor exposes mother and child to many risks:

1. fetal hypoxia, up to intrauterine asphyxia;
2. birth injuries to the fetus caused by prolonged compression of the head in the birth canal;
3. infection of the fetus, uterine cavity;
4. the formation of genitourinary or rectal fistulas in a woman with prolonged standing of the fetal head in the birth canal.

The best option would be spontaneous, self-initiated labor, a fetus of normal size, adequate behavior of the woman in labor and competent management of the birth by medical staff.

Alexandra Pechkovskaya, obstetrician-gynecologist, especially for website

Useful video:

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Parity: second pregnancy. The first pregnancy was at the age of 21; due to family circumstances, an abortion was performed at 12 weeks; no complications were observed.

Secretory function: vaginal discharge is mucous in small quantities and odorless. Colpitis, inflammatory processes in the genital area, itching, burning in the vulva or vagina were not noted.

The pregnant woman and her husband have no bad habits at the moment. The patient smoked light cigarettes for 8 years (from 16 to 23 years).

Husband's age: 40 years (2nd marriage, from 1st marriage has 3 children, ages 21, 20 and 15 years)

Husband's blood type: A(I)

Rhesus affiliation of the husband: + (positive)

Allergic history: allergic reactions in the form of skin itching, rash, urticaria, angioedema after the administration of any medications or food intake were not observed in either the patient or her relatives.

She did not tolerate blood transfusions.

The condition is satisfactory, consciousness is clear, the position is active, the constitution is normosthenic.

Height 162 cm, weight 56 ​​kg before pregnancy, 57.5 kg at the time of hospitalization. BMI = 56/(1.62)2 = 21.33 before pregnancy. Body temperature 36.60C. The skin and visible mucous membranes are moist and clean. Subcutaneous fatty tissue is moderately developed. There is no peripheral edema. Lymph nodes are not palpable.

Tanner's mammary glands correspond to the mature breast stage.

The muscles are developed satisfactorily, the tone is preserved. The muscles are painless on palpation. The joints are not changed.

Respiratory system.

The shape of the nose, neck, and larynx is not changed. Breathing through the nose is free. The chest is normosthenic. When breathing, the excursion of the chest is symmetrical. Mixed type of breathing. NPV 18 per minute. Breathing is rhythmic.

Comparative percussion of the lungs revealed no pathology.

Vesicular breathing is heard in both lungs. No wheezing, adverse respiratory sounds, crepitus, or pleural friction noise are heard. Bronchophony is the same on both sides.

Circulatory organs.

There is no visible pulsation in the heart, jugular fossa or epigastric region.

The apical impulse is of moderate strength, localized in the 5th intercostal space 1.5 cm medially from the midclavicular line. The cardiac impulse and epigastric pulsation are not palpable.

Borders of relative dullness of the heart: the right one is located in the 4th intercostal space along the right edge of the sternum, the left is located in the 5th intercostal space 2 cm inward from the left midclavicular line and coincides with the apical impulse, the upper one is at the level of the 3rd rib outward from the parasternal line. The configuration of dullness is normal.

Heart sounds are heard well and rhythmic. The pulsation of the carotid arteries coincides with ventricular systole.

Heart rate=PS=76 per minute. The pulse is rhythmic and well filled. Same on both hands.

Blood pressure in both brachial arteries is 110/70 mm. rt. Art.

No changes in peripheral veins were detected.

Digestive organs.

The tongue is of normal color, the condition of the papillary layer is normal, the tonsils do not extend beyond the palatine arches, the mucous membrane is pink.

On palpation, the abdomen is soft and painless. Symptoms of peritoneal irritation are negative.

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Thus, based on the above, during physiological pregnancy it is advisable to conduct a full clinical and laboratory examination, however, the frequency of tests performed can be reduced, for example, a general blood test can be done only 2 times during pregnancy (at the first appearance and at 30-32 weeks) , if there are no deviations from the norm in the indicators.

An individual approach to monitoring a pregnant woman has social and economic feasibility:

On the one hand, it saves time

female patients: fewer visits and clinical and laboratory examinations during pregnancy, keeping a self-monitoring diary - accordingly, the woman spends less time in queues to see a doctor;

On the other hand, saving money on some routine types of examination, the effectiveness and necessity of which has not been proven by multicenter randomized studies, increases the monetary quotas for carrying out the examination methods necessary for each specific patient according to indications.

LITERATURE

1.Mogilevkina I.A. Providing assistance during complicated pregnancy and childbirth. - M., 2003.

2. Serov V.N., Markin S.A. Critical conditions in obstetrics. - M.: Medizdat, 2003. - 704 p.

3. Serov V.N., Strizhakov A.N., Markin S.A. Guide to practical obstetrics. - M.: MIA, 1997. - 424 p.

4. Enkin M., Cairs M., Neilson J. Guide to effective care during pregnancy and childbirth. - St. Petersburg: Petropolis, 2003. - 477 p.

5.Villar J., Lydon-Rochelle M.T., Gulmezoglu A.M. Duration of treatment for asymptomatic bacteriuria during pregnancy. - Internet: http://www.cochrane.dk

THE MODERN APPROACHES TO OBSERVATION OF THE WOMEN WITH PHYSIOLOGICAL CURRENT OF PREGNANCY FROM POSITIONS EVIDENCE-BASED MEDICINE

V.V. Sukhovskaja, N.V. Protopopova (Russia, Irkutsk State Medical University)

On the basis of carried out controllable of researches in the framework of evidence-based medicine is determined medical, social and economic feasibility of change of some positions of observation behind the woman at physiologically proceeding pregnancy. So, the observation of such pregnant women by a midwife with higher education is possible, quantity of visitings for pregnancy the period can be reduced up to 4- 6 times, but the obligatory to observation in the antenatal period with an explanation of expediency of various methods of research.

© SAFAROVA A.A., KRAVCHUK N.V., PROTOPOPOVA N.V. -

STRUCTURE OF OBSTETRIC RISK FACTORS IN THE REGION DEPENDING ON PARITY

A.A. Safarova, N.V. Kravchuk, N.V. Protopopova (Russia, Irkutsk, State Medical University)

Summary. An analysis of individual cards and birth histories of 1090 primigravidas, 760 multiparous primiparas and 950 multiparous women showed that placental insufficiency with clinical manifestations in the form of IUGR of the fetus and chronic intrauterine hypoxia and gestosis occurred significantly more often in the group of primiparous women compared to multiparous women, which may indicate about the presence of common pathophysiological mechanisms for the formation of these pregnancy complications.

Key words: pregnancy, obstetric risk factors, parity.

Despite the fact that the degree of obstetric and perinatal risk is assessed over a long period of time, it is not always possible to predict the development of maternal and fetal complications during pregnancy.

We set out to identify the risk factors that are significant for our region, taking into account the parity of pregnancy and childbirth.

Materials and methods. To achieve this goal, we analyzed 2800

Individual cards and birth histories of patients observed during pregnancy and delivery in the conditions of the Irkutsk Regional Perinatal Center in 1995 - 2004.

Results and discussion. At the most favorable age (20-24 years) there were 37.6% primigravidas, 27.6% multiparous primiparas and only 8.4% multiparous (Table 1). Father's age over 40 years was observed with approximately the same frequency in all analyzed groups.

A significantly higher frequency of occupational hazards in the mother (p<0,05) оказалась в группе повторнородящих пациенток. В основном это связано с работой на компьютере, психоэмоциональным напряжением. Профессиональные вредности у отца ребенка отмечены нами примерно с одинаковой частотой во всех трех группах.

From our point of view, a small number of multipregnant women reported smoking both before and during pregnancy. 1.3% of multigravidas had drug addiction. None of the patients admitted the fact of alcohol abuse.

Significantly higher frequency of single women (p<0,05) оказалась в группе повторнобе-ременных первородящих (15,8% против 6,4% среди первобеременных и 6,3% повторнородящих).

All patients had at least secondary education. More than half of the patients had higher education, with some advantage going to primigravida women, but only every fifth patient indicated emotional stress as a risk factor in all three groups.

Every tenth multipregnant woman had a body weight 25% higher than normal, while in the group of primigravidas it was only 6.4%.

When analyzing the obstetric and gynecological history, the following was revealed. If more than half of multiparous first-time mothers (71%) had abortions before their first birth, then in the group of multiparous women - only 11.6%. On the other hand, it should be noted that 31.6% of multiparous primiparous women had a history of frozen pregnancy, while in the group of multiparous women only 9.5% of patients had a history of frozen pregnancy (p<0,001).

The highest incidence of infertility for more than 2-5 years was found in primigravida patients (12.8%), the lowest in multiparous patients (7.4%).

Multiparous primigravidas (11.8%) had a history of tumors of the uterus and ovaries 2 times more often than multiparous women (6.3%). First of all, we are talking about uterine fibroids, and therefore 1.3% of multigravidas had a conservative myomectomy before the actual pregnancy. This pathology was significantly less likely to be a risk factor in first-time pregnant women (2.8%) (p<0,05).

The higher frequency of isthmic-cervical insufficiency in the group of multiparous primiparous women (5.3%) compared to multiparous women (1.1%), in our opinion, is directly related to the frequency of pregnancy termination before childbirth (medical abortions, spontaneous miscarriages, missed pregnancies).

As for such a group of risk factors as extragenital pathology, our analysis showed the following. History of infections occurred with equal frequency in all

analyzed groups. Primigravidas had significantly (p<0,05) более низкую частоту пороков сердца (1,8 % против 5,3% повторно беременных первородящих и 7,4% повторнородящих). Частота гипертонической болезни оказалась наибольшей (13,7%) среди повторнородящих и наименьшей (9,2%) - у первобеременных. Артериальная гипотония не имела достоверных различий по частоте в анализируемых группах и составила соответственно 3,7%, 5,3%, 3,7%. В целом заболевания сердечно-сосудистой системы, входящие в группы акушерского риска, имели место у 14,7% первобе-ременных, 22,2% повторнобеременных первородящих и у 24,3% повторнородящих. Мы не выявили достоверной разницы в частоте заболеваний почек у пациенток анализируемых групп. Практически каждая пятая пациентка имела данную патологию, однако обострение заболевания при беременности чаще произошло у первобеременных (6,3%) и реже всего - у повторнородящих (4,2%).

Among endocrine pathologies, diseases of the thyroid gland prevail, mainly diffuse enlargement of the thyroid gland in a state of euthyroidism. This fact is explained by regional characteristics (iodine-deficient region).

Also noteworthy is the high percentage of iron deficiency anemia (every third pregnant woman).

The frequency of chronic specific infections (syphilis and tuberculosis, mainly syphilis) was found to be significantly higher in the group of multigravida primigravidas (5.3%) compared to primigravidas (1.8%) (p<0,05). В то же время, частота острых инфекций при беременности оказалась достоверно выше среди первобеременных (37,6%) по сравнению с повторнородящими (15,8%) (р<0,05).

Severe early toxicosis was significantly less common (0.9%) in primigravidas compared to multigravidas, primiparas (7.9%) and multiparas (5.3%). On the other hand, gestosis among multiparous women occurred in only 4.4% (of which only 1.1% - in the form of nephropathy), while in primigravidas - in 11.9%, in multiparous primigravidas - in 18.4% cases (p<0,05).

We also noticed that, by analogy with gestosis, placental insufficiency with clinical manifestation in the form of IUGR of the fetus occurred significantly more often in primigravidas (primigravidas - 7.3%, multigravidas - 11.8;%) compared to multiparous women (3, 2%). A similar situation applies to such a clinical manifestation of placental insufficiency as fetal hypoxia (11% in primigravidas, 15.8% in multiparous primigravidas, and only 7.4% in multiparous women). Based on this, it can be assumed that there are common pathophysiological mechanisms for the formation of these complications.

Table 1

Obstetric risk factors in OPC patients depending on parity

Criteria First-time pregnant women (n=1090) Repeated first-time pregnant women (n=760) Multiparous women (n=950)

ANTENATAL PERIOD

Socio-biological

Mother's age

<20 200 (18,4%) 30 (3,9%) -

25-29 350 (32,1%) 350 (46,1%) 360 (37,9%)

30-34 90 (8,3%) 110 (14,5%) 430 (45,3%)

35-39 20 (1,8%) 50 (6,6%) 40 (4,2%)

>40 20 (1,8%) 10 (1,3%) 40 (4,2%)

Father's age

<20 40 (3,7%) - -

>40 60 (5,5%) 40 (5,3%) 50 (5,3%)

Prof. harmfulness

Father's 105 (9.4%) 85 (10.7%) 120 (12.3%)

In mother 200 (18.3%) 150 (19.7%) 270 (28.4%)

Bad habits - 30 (3.9%) 20 (2.1%)

Marital status: single 70 (6.4%) 120 (15.8%) 60 (6.3%)

Education

Initial - - -

Higher 680 (62.4%) 420 (55.3%) 530 (55.8%)

Emotional stress 250 (22.9%) 170 (22.4%) 190 (20.0%)

Mother's height and weight indicators: Height 150 and less Weight 25% above normal 70 (6.4%) 80 (10.5%) 90 (9.5%)

Obstetric and gynecological history

0 1090 (100%) - -

4-7 - 60 (7,9%) 210 (22,1%)

Abortion before first birth

1 - 400 (52,6%) 60 (6,3%)

2 - 70 (9,2%) 30 (3,2%)

3 - 70 (9,2%) 20 (2,1%)

Abortion before repeat. childbirth - - 160(16.8%)

Premature birth

1 - - 140 (14,7%)

Stillbirth

Frozen pregnancy - 240 (31.6%) 90(9.5%)

Death in the neonatal period - - -

Developmental anomalies in children - - 30 (3.2%)

Neurological disorders - - 30 (3.2%)

Children's weight<2500 и >4000 - - 130 (13,7%)

Complicated course of previous births - - 180 (18.9%)

Infertility for more than 2-5 years 140 (12.8%) 70 (9.2%) 70 (7.4%)

Scar on the uterus after surgery - 10 (1.3%) 170 (17.9)

Tumors of the uterus and ovaries 30 (2.8%) 90 (11.8%) 60 (6.3%)

ICN - 40 (5.3%) 10 (1.1%)

Uterine malformations - - 20 (2.1%)

Extragenital diseases of the mother

History of infections 150 (13.8%) 120 (15.8%) 120 (12.6%)

Zab-I SSS

Heart defects, NCo 10 (0.9%) 40 (5.3%) 70 (7.4%)

Heart defects, NC+ 10 (0.9%) - -

Hypertension 100 (9.2%) 90 (11.8%) 130 (13.7%)

Arter. hypotension 40 (3.7%) 40 (5.3%) 30 (3.2%)

Kidney diseases

Before pregnancy 210 (19.3%) 160 (21.1%) 200 (21.1%)

Exacerbation during pregnancy 70 (6.4%) 40 (5.3%) 40 (4.2%)

Endocrinopathies

Prediabetes 20 (1.8%) 10 (1.3%) 10 (1.1%)

Diabetes in relatives - 50 (6.6%) 10 (1.1%)

Diabetes - - 10 (1.1%)

Posterior thyroid gland 900 (82.8%) 733 (96.4%) 894 (93.6%)

Adrenal obstruction - - -

Anemia 340 (31.2%) 270 (35.5%) 270 (28.4%)

Coagulopathies - - -

Myopia and other eye diseases 170 (15.6%) 150 (19.7%) 130 (13.7%)

Chr. spec. inf. 20 (1.8%) 40 (5.3%) 30 (3.2%)

Ostr. inf. during pregnancy 410 (37.6%) 180 (23.7%) 150 (15.8%)

Complications of pregnancy

Severe wound toxicosis 10 (0.9%) 60 (7.9%) 50 (5.3%)

UPB 330 (30.3%) 370 (48.7%) 290 (30.5%)

Late toxicosis

Dropsy 50 (4.6%) 80 (10.5%) 30 (3.2%)

Nephropathy 80 (7.3%) 60 (7.9%) 10 (1.1%)

Preeclampsia - - -

Eclampsia - - -

Combined toxicosis 10 (0.9%) 30 (3.9%) 10 (1.1%)

Rh negative blood 150 (13.8%) 70 (9.2%) 80 (8.4%)

Rhesus AVO sensib. - - -

Polyhydramnios 100 (9.2%) 80 (10.5%) 80 (8.4%)

Oligohydramnios 80 (7.3%) 90 (11.8%) 30 (3.2%)

Breech presentation 30 (2.8%) 40 (5.3%) 20 (2.1%)

Multiple pregnancy 40 (3.7%) 10 (1.3%) 30 (3.2%)

Transferability - - -

Multi-practice physician. 420 (38.5%) 460 (60.5%) 340 (35.8%)

Fetal assessment

Fetal hypotrophy 80 (7.3%) 90 (11.8%) 30 (3.2%)

Fetal hypoxia 120 (11%) 12 0(15.8%) 70 (7.4%)

INTRANATAL PERIOD

Mother's side

Nephropathy 100 (9.2%) 80 (10.5%) 10 (1.1%)

Preeclampsia - - -

Eclampsia - - -

Untimely outflow of water 130 (11.9%) 80 (10.5%) 160 (16.8%)

Weakness in family activities 60 (5.5%) 40 (5.3%) -

Quick birth 30 (2.8%) - 30 (3.2%)

Labor induction, stimulation of labor. activities 100 (9.2%) 50 (6.6%) 50 (5.3%)

Clinical narrow pelvis - 10 (1.3%) -

Threatened uterine rupture - - -

From the placenta

Placenta previa

Partial - 10 (1.3%) 10 (1.1%)

Full - 10 (1.3%) -

PONRP - - -

From the fetus

Premature birth

28-30 weeks - - 20 (2.1%)

34-35 weeks - 20 (2.6%) 20(2.1%)

36-37 weeks 40 (3.7%) 50 (6.6%) 50 (5.3%)

Umbilical cord pathology

Dropping out - - -

Entanglement 40 (3.7%) 40 (5.3%) 40 (4.2%)

Breech presentation

Benefits - 10 (1.3%) -

Surgical interventions

Caesarean section 220 (20.2%) 280 (36.8%) 210 (22.1%)

Difficulty removing the shoulders - 10 (1.3%) -

General anesthesia during childbirth 220 (20.2%) 280 (36.8%) 210 (22.1%)

STRUCTURE OF RISK FACTORS OF OBSTETRICS IN REGION DEPENDING ON PARITY

A.A. Safarova, N.V. Kravchuk, N.V. Protopopova (Russia, Irkutsk State Medical University)

The analysis of individual cards and histories of labor at 1090 first-pregnant, 760 second-pregnant and first-labor women and 950 second-labor women are shown, that placentary insufficiency with clinical displays as delay of intra-uterine development of fetus and chronic intra-uterine hypoxia and gestoses is authentic took place in group of first-labor women in comparison with second-labor women more often, that may test to the presence of general pathophysiology mechanisms of formation of these complications of pregnancy.

© OMOLOEVA T.S., KRIVOVA V.N., SAVVATEEVA V.G., APOSTOLOVA A.D., GOVORINA T.V. -

ANALYSIS OF EXPERIENCE IN ASSESSING THE REPRODUCTIVE HEALTH OF BOYS, ADOLESCENTS, AND YOUTHS IN PEDIATRIC PRACTICE

T.S. Omoloeva, V.N. Krivova, V.G. Savvateeva, A.D. Apostolova, T.V. Govorina (Russia, Irkutsk, State Medical University, City Children's Clinics No. 2 and 3).

Summary. The main problems of modern andrological care for children and adolescents are presented, the role of the pediatrician in the protection of reproductive health is shown, and an analysis of the reproductive health of boys and adolescents is carried out based on the results of clinical examination.

Key words: boys, adolescents, andrology, reproductive health.

Obstetric and gynecological pathology in ICD-10 is mainly reflected in classes XV “Pregnancy, childbirth and the postpartum period” (headings O00-O99) and XIV “Diseases of the genitourinary system” (headings No. 70–77, No. 80–98). But it is also included in other classes, in particular I, II, IV, XVII.

Pregnancy, childbirth, and the postpartum period are not diseases, but special transient conditions of a woman’s health.

Each of the gestational periods can occur against the background of the woman’s complete health or against the background of an emerging or pre-existing genital or extragenital disease. In addition, during pregnancy, pathological processes that are unique to the gestation period may appear (for example, eclampsia).

Based on the definition of diagnosis, it can include both body conditions and diseases. The priority concept is disease, since it will have a decisive influence on medical actions aimed at eliminating the pathological process. Of course, the background against which the disease developed - pregnancy, childbirth, the postpartum period - should also be reflected in the diagnosis.

In obstetrics The first place in the diagnosis is the condition (pregnancy or childbirth) in which the patient is at the time of examination.

1.1. If the diagnosis is “Pregnancy”, it is necessary to indicate the duration of pregnancy in weeks.

1.2. In the case of a diagnosis: “Childbirth” it is indicated, first of all, what it is:

A) By term - urgent (with a gestational age of 37-42 weeks), premature (with a gestational age of 22 to 36 weeks and 6 days), late (with a gestational age of 42 weeks or more if there are signs of postmaturity in the fetus). The diagnosis also always indicates the gestational age in weeks (for example: “Premature birth I at 35 weeks).

B) According to the score (parity) – first, second, third, etc.

II. Complications of pregnancy or labor are placed in second place in the diagnosis according to the degree of their significance, or in the order of their occurrence - premature rupture of membranes, primary weakness of labor, acute fetal hypoxia, etc.

III. All concomitant extragenital pathology is placed in third place, indicating the degree of severity and stage of the disease

V. If the patient has a history of medical abortions, miscarriages, previous gynecological diseases (inflammation of the uterine appendages, menstrual disorders, inflammatory processes of the uterus of specific and nonspecific etiology), the abbreviation is included in the diagnosis: OAA - burdened obstetric history, SOAA - particularly burdened obstetric history (if there is a history of antenatal or intrapartum fetal death), or OGA - aggravated gynecological history.

When formulating a clinical diagnosis in gynecology all diseases are indicated in order of importance for the patient at the time of treatment of the pathology that causes the greatest complaints and danger to her health. The main disease is placed in first place, complications of the main disease in second place, and concomitant diseases in third place. This is followed by therapeutic and diagnostic interventions, if they were undertaken.

The underlying disease is something that, by itself or through its complications, was the reason for seeking medical help, the reason for hospitalization, or led to death. It is indicated in the diagnosis in the form of a specific nosological form and is not replaced by a syndrome or a list of symptoms if they are not included in the classification.

When making a diagnosis, the underlying disease is as detailed as possible. To do this, etiological, pathogenetic, functional and morphological components are connected to the nosological unit.

Complications of the underlying disease are pathological processes and conditions that are pathogenetically related to the underlying disease, but form clinical syndromes, anatomical and functional changes that are qualitatively different from its main manifestations. They are included in the diagnosis in a sequence that reflects their relationship with the underlying disease.

Concomitant diseases are diseases that the patient has that are not related to the main disease etiologically, pathogenetically and have a different nomenclature classification. When registering them, just as with the main disease, the main morphological manifestations and detected complications are listed.

Surgical methods of treatment and special diagnostic methods - surgical actions and other therapeutic and diagnostic procedures undertaken in connection with the underlying disease or its complications. They are also included in the diagnosis, recorded after “concomitant diseases”, indicating the date of the operation. If there were several operations, they are noted in chronological order.

A multiple pregnancy is a pregnancy in which two or more fetuses develop in a woman’s body.

The birth of two or more children is called multiple births.

EPIDEMIOLOGY

The incidence of multiple pregnancy in most European countries ranges from 0.7 to 1.5%. The widespread introduction of assisted reproductive technologies has led to a change in the ratio of spontaneous and induced multiple pregnancies: 70 and 30% in the 80s versus 50 and 50% in the late 90s, respectively.

The main factors contributing to multiple pregnancy include: maternal age over 30–35 years, hereditary factor (maternal), high parity, uterine development abnormalities (doubling), onset pregnancy immediately after stopping the use of oral contraceptives, while using to stimulate ovulation during IVF.

Prevention of multiple pregnancy is possible only with the use of assisted reproductive technologies and is to limit the number of embryos transferred.

CLASSIFICATION

Depending on the number of fetuses in a multiple pregnancy, they speak of twins, triplets, quadruples, etc.

There are two types of twins: fraternal (dizygotic) and identical (monozygotic). Children born from fraternal twins are called “twins” (in foreign literature - “fraternal” or “not identical”), and children from identical twins - twins (in foreign literature - “identical”). “Twins” can be one or the same and different sexes, while “twins” are only same-sex.

Fraternal twins are the result of fertilization of two eggs, the maturation of which, as a rule, occurs in during one ovulatory cycle in both one and both ovaries.

The literature describes cases of “superfetation” (the interval between fertilization of two eggs is more than one menstrual cycle) and “superfecundation” (fertilization of eggs occurs within one ovulatory cycle, but as a result of various sexual acts). In case of dizygotic twins, each embryo/fetus their own placenta is formed, and each of them is surrounded by its own amniotic and chorionic membranes, Thus, the interfertal septum consists of four layers. Such fraternal twins are called bichorionic biamniotic. The frequency of fraternal twins (among twins) is 70%.

In identical twins, one egg is fertilized. The number of placentas formed in this type of twins depends on the period of division of the single fertilized egg (Fig. 211). If division occurs within the first three days after fertilization (up to the morula stage), then two embryos, two amnions, two chorion/placenta. The interfetal septum, as in fraternal twins, consists of four layers. like this identical twins are also called bichorionic biamniotic twins.

Rice. 21-1. Types of placentation during multiple pregnancy. a - bichorionic biamniotic twins; b - monochorionic biamniotic twins; c - monochorionic monoamniotic twins

When egg division occurs within 3–8 days after fertilization (at the blastocyst stage), then two embryos are formed, two amnions, but one chorion/placenta. The interfetal septum consists of two layers of amnion. This type of identical twins is called monochorionic biamniotic.

When the egg divides in the interval 8–13 days after fertilization, one chorion and two embryos are formed, surrounded by a single amniotic membrane, that is, there is no interfetal septum. So identical twins are called monochorionic monoamniotic.

The result of the division of a fertilized egg at a later date (after the 13th day), when the embryonic discs - conjoined twins.

Thus, both fraternal and identical twins can be bichorionic, while monochorionic - only identical. Examination of the placenta/placentas and membranes after birth does not always make it possible to accurately establish zygosity. If there are four interfertal membranes (which is possible with both mono and dizygotic twins), only the different sexes of the children clearly indicate dizygosity. In the same time the presence of two interfetal membranes clearly indicates monozygotic twins.

In case of same-sex children, zygosity can be established with an additional blood test (including HLA- typing) or examination of skin biopsies of children.

DIAGNOSTICS

Before the introduction of ultrasound into obstetric practice, the diagnosis of multiple pregnancy was often made late in pregnancy or even during labor.

It is possible to assume the presence of a multiple pregnancy in patients whose uterine size exceeds the gestational norm, both during vaginal examination (in the early stages) and during external obstetric examination (in the later stages). In the second half of pregnancy, it is sometimes possible to palpate many small parts of the fetus and two (or more) large voting parts (fetal heads). Auscultatory signs of multiple pregnancy are fetal heart sounds heard in different parts of the uterus. The cardiac activity of fetuses during multiple pregnancy can be recorded simultaneously using special cardiac monitors for twins (equipped with two sensors).

The basis for diagnosing multiple pregnancies in modern obstetrics is ultrasound. Ultrasound diagnosis of multiple pregnancy is possible starting in the early stages of pregnancy (4–5 weeks) and is based on visualization of several fertilized eggs and embryos in the uterine cavity.

To develop the correct tactics for managing pregnancy and childbirth during multiple pregnancy, early (in the first trimester) determination of chorionicity (the number of placentas) is crucial.

It is chorionicity (and not zygosity) that determines the course of pregnancy, its outcomes, perinatal morbidity and PS. The most unfavorable in terms of perinatal complications is monochorionic multiple pregnancy, which is observed in 65% of cases of identical twins. PS in monochorionic twins, regardless of zygosity, is 3–4 times higher than in bichorionic twins.

The presence of two separately located placentas and a thick interfetal septum (more than 2 mm) serve as a reliable criterion for bichorionic twins. When identifying a single “placental mass,” it is necessary to differentiate the “single placenta” (monochorionic twins) from two fused ones (bichorionic twins).

The presence of specific ultrasound criteria: T and l signs that form at the base of the interfetal septum, with a high degree of reliability, allow a diagnosis of mono or bichorionic twins.

Identification of the l sign by ultrasound at any stage of gestation indicates a bichorionic type of placentation (Fig. 212),

The T-sign indicates monochorionicity. It should be taken into account that after 16 weeks of pregnancy the sign becomes less accessible for research.

Rice. 21-2. Ultrasound criteria for chorionicity (a - λ-sign, b - T-sign).

In later stages of pregnancy (II–III trimesters), accurate diagnosis of chorionicity is possible only in the presence of two separately located placentas. In the presence of a single placental mass (one placenta or fused placentas), echography often overdiagnoses the monochorionic type of placentation.

It is also necessary, starting from the early stages, to conduct comparative ultrasound fetometry to predict FGR in later stages of pregnancy. According to ultrasound fetometry data during multiple pregnancies, the physiological development of both fetuses is distinguished; dissociated (discordant) development of fruits (difference in weight of 20% or more); growth retardation of both fetuses.

In addition to fetometry, as in singleton pregnancy, it is necessary to pay attention to assessing the structure and degree of maturity of the placenta/placentas, the amount of OM in both amnions. Taking into account that in multiple pregnancies, velamentous attachment of the umbilical cord and other anomalies of its development are often observed, it is necessary to examine the places where the umbilical cords exit from the fetal surface of the placenta/placentas.

Particular attention is paid to assessing the anatomy of the fetuses to exclude congenital birth defects, and in the case of monoamniotic twins, to exclude conjoined twins.

Considering the ineffectiveness of biochemical prenatal screening in multiple pregnancies (higher levels of AFP, bhCG, PL, estriol compared to singleton pregnancies), the identification of ultrasound markers of congenital birth defects, including the study of the nuchal translucency in fetuses, is of particular importance. The presence of nuchal edema in one of the fetuses with identical twins cannot be considered as an absolute indicator of a high risk of chromosomal pathology, since it may be one of the early echographic signs of a severe form of fetofetal blood transfusion syndrome (FHTS).

One of the important points for choosing the optimal delivery tactics for multiple pregnancies is determining the position and presentation of the fetuses by the end of pregnancy. Most often, both fetuses are in a longitudinal position (80%): cephalocephalic, pelvic-pelvic, cephalopelvic, pelvic-cephalic. The following variants of fruit position are less common: one in a longitudinal position, the second in a transverse position; both are in a transverse position.

To assess the condition of fetuses in multiple pregnancy, generally accepted methods of functional diagnostics are used: CTG, Doppler blood flow in the vessels of the mother-placental system.

COURSE OF MULTIPLE PREGNANCY

Multiple pregnancy is a serious test for a woman’s body: the cardiovascular system, lungs, liver, kidneys and other organs function under great strain. Maternal morbidity and MS during multiple pregnancy increases 3–7 times compared to singleton pregnancy; Moreover, the higher the order of multiple pregnancy, the higher the risk of maternal complications.

In women with concomitant somatic diseases, their exacerbation is noted in almost 100% of cases. The incidence of gestosis in women with multiple pregnancies reaches 45%. In multiple pregnancies, gestosis, as a rule, occurs earlier and is more severe than in singleton pregnancies, which is explained by an increase in the volume of the placental mass (“hyperplacentosis”).

In a significant number of pregnant women with twins, hypertension and edema develop due to an excessive increase in intravascular volume, and they are mistakenly classified as pregnant women with preeclampsia. In such cases, the glomerular filtration rate is increased, proteinuria is insignificant or absent, and a decrease in the Ht value over time indicates an increased plasma volume. These pregnant women experience significant improvement with bed rest.

Anemia, the incidence of which in pregnant women with twins reaches 50–100%, is considered a “common” complication, which is associated with an increase in intravascular volume. Since its main element is an increase in plasma volume (to a greater extent than in a singleton pregnancy), the end result is a decrease in the Ht value and Hb level, especially in the second trimester of pregnancy; physiological anemia with multiple pregnancy is more pronounced. The significant increase in erythropoiesis during twin pregnancy may deplete limited iron stores in some patients and act as a trigger for the development of iron deficiency anemia. The best way to distinguish physiological hydremia from true iron deficiency anemia during twin pregnancy is to examine blood smears.

The course of a multiple pregnancy is often complicated by growth retardation of one of the fetuses, the frequency of which is 10 times higher than that in singleton pregnancies and is 34 and 23% for mono and bichorionic twins, respectively. The frequency of growth retardation for both fetuses is more pronounced depending on the type of placentation: 7.5% for monochorionic twins and 1.7% for bichorionic twins.

One of the most common complications of multiple pregnancies is premature birth, which may be a consequence of uterine overdistension. Moreover, the more fetuses, the more often premature births are observed. So, with twins, labor usually occurs at 36–37 weeks, with triplets - at 33.5 weeks, with quadruples - at 31 weeks.

MANAGEMENT OF MULTIPLE PREGNANCY

Patients with multiple pregnancies should visit antenatal clinics more often than with singletons: 2 times a month until 28 weeks (when they issue a certificate of incapacity for pregnancy and childbirth), after 28 weeks - once every 7–10 days. During pregnancy, patients must visit a therapist three times.

Considering the increased need for calories, proteins, minerals, vitamins during multiple pregnancy, special attention must be paid to the issues of complete balanced nutrition for the pregnant woman. Optimal for multiple pregnancies, as opposed to singleton pregnancies, the total gain is 20–22 kg.

Pregnant women with multiple pregnancies are prescribed antianemic therapy from 16–20 weeks (oral intake of iron-containing drugs at a dose of 60–100 mg/day and folic acid - 1 mg/day for three months).

To prevent premature birth, pregnant women with multiple pregnancies are recommended to limit physical activity and increase the duration of daytime rest (three times for 1–2 hours). Expanding the indications for issuing sick leave.

To predict preterm birth, it is necessary to examine the condition of the cervix. In this case, the method of choice is transvaginal cervicography, which allows, in addition to assessing the length of the cervix, to determine the condition of the internal pharynx, which is impossible with manual examination (Fig. 213). Gestation periods from 22–24 to 25–27 weeks are “critical” for pregnant women with multiple pregnancies regarding the risk of premature birth. With a cervical length of £34 mm at 22–24 weeks, there is an increased risk of preterm birth before 36 weeks; The risk criterion for preterm birth at 32–35 weeks is the cervical length of £27 mm, and the risk criterion for “early” preterm birth (before 32 weeks) is £19 mm.

Rice. 21-3. Pregnancy 30 weeks, twins, sharply shortened cervix with threat of premature birth (echogram).

Early diagnosis of FGR requires careful dynamic ultrasound monitoring.

To develop tactics for managing pregnancy and childbirth, in addition to fetometry, in case of multiple pregnancy, as well as in singleton pregnancy, assessment of the condition of the fetuses (CTG, Doppler blood flow in the mother-placental system, biophysical profile) is of great importance. Determining the amount of OM (high and low water) in both amnions becomes essential.

SPECIFIC COMPLICATIONS OF MULTIPLE PREGNANCY. CONTROL TACTICS

In case of multiple pregnancy, it is possible to develop specific complications that are not typical for singleton pregnancy: FPG, reverse arterial perfusion, intrauterine death of one of the fetuses, congenital malformation of one of the fetuses, conjoined twins, chromosomal pathology of one of the fetuses.
FFH, first described by Schatz in 1982, complicates the course of 5–25% of monozygotic multiple pregnancies. PS in SFG reaches 60–100% of cases.

FPG (its morphological substrate is anastomosing vessels between two fetal circulatory systems) is a specific complication for monozygotic twins with a monochorionic type of placentation, which is observed in 63–74% of cases of identical multiple pregnancies. The likelihood of anastomoses occurring in monozygotic twins with a bichorionic type of placentation is no greater than in dizygotic twins.

SFFG is characterized by arteriovenous anastomoses located not on the surface, but in the thickness of the placenta, which almost always pass through the capillary bed of the cotyledon. The severity of FFH (mild, moderate, severe) depends on the degree of blood redistribution through these anastomoses, which vary in size, number and direction.

The main triggering factor for the development of FFH is the pathology of the development of the placenta of one of the fetuses, which becomes a donor. An increase in peripheral resistance of the placental blood flow leads to shunting of blood to another fetal recipient. Thus, the condition of the donor fetus is impaired as a result of hypovolemia due to blood loss and hypoxia due to placental insufficiency. The fetus compensates for the increase in blood volume with polyuria. In this case, an increase in colloid osmotic pressure leads to excessive flow of fluid from the maternal bed through the placenta.

As a result, the state of the recipient fetus is impaired due to heart failure caused by hypervolemia.

DIAGNOSIS OF FETOPETAL BLOOD TRANSFUSION SYNDROME

Traditionally, for many years, the diagnosis of FFH was made retrospectively in the neonatal period based on differences in Hb content (50 g/L or more) in the peripheral blood of twins and differences in the weight of newborns (20% or more). However, a significant difference in the Hb level and the weight of newborns is also characteristic of some bichorionic twins, and therefore in recent years these indicators have ceased to be considered as signs of FFH.

Based on ultrasound criteria, stages of FFPG have been developed (Quintero R. et al, 1999), which are used in practice to determine pregnancy management tactics:

Stage I: the bladder of the donor fetus is identified;
Stage II: the bladder of the donor fetus is not determined, the state of the blood flow (in the umbilical cord artery and/or venous duct) is non-critical;
Stage III: critical state of blood flow (in the umbilical cord artery and/or ductus venosus) in the fetal donor and/or recipient;
Stage IV: hydrops in the recipient fetus;
Stage V: antenatal death of one or both fetuses.

Pathognomonic echographic signs of severe FFH are: the presence of a large bladder in the recipient fetus with polyuria against the background of severe polyhydramnios and the “absence” of the bladder in the donor fetus with anuria, which is characterized by a decrease in motor activity against the background of severe oligohydramnios.

The method of choice in the treatment of severe FPG is laser coagulation of the anastomosing vessels of the placenta under echographic control, the so-called sonoendoscopic technique. The effectiveness of endoscopic laser coagulation therapy for SFG (birth of at least one living child) is 70%. This method involves transabdominal insertion of a fetoscope into the amniotic cavity of the recipient fetus. The combination of ultrasound observation and direct visual inspection through a fetoscope allows for examination of the chorionic plate along the entire interfetal septum, identification and coagulation of anastomosing vessels. The surgical intervention is completed by draining the OM until their quantity normalizes. With the help of endoscopic laser coagulation, it is possible to prolong pregnancy by an average of 14 weeks, which leads to a reduction in intrauterine fetal death from 90 to 29%.

An alternative tactic for managing pregnant women with severe FFH in the absence of the possibility of laser coagulation of the anastomosing vessels of the placenta is drainage of an excess amount of AF from the amniotic cavity of the recipient fetus. This palliative method of treatment, which can be used repeatedly in the dynamics of pregnancy, does not eliminate the cause of FPG, but helps to reduce intra-amniotic pressure and thereby compression, as a rule, of the membrane-attached umbilical cord and superficial vessels of the placenta, which to a certain extent improves the condition of both the donor fetus and recipient fetus. The positive effects of amniodrainage include prolongation of pregnancy as a result of a decrease in intrauterine volume.

The effectiveness of amniodrainage performed under ultrasound guidance is 30–83%. The main and most important difference in perinatal outcomes between endoscopic laser photocoagulation and repeated amniodrainage is the incidence of neurological disorders in surviving children (5% versus 18–37%, respectively).

Intrauterine death of one of the fetuses during multiple pregnancy can be observed at any stage of gestation and the result can be the “death” of one fertilized egg in the first trimester, which is noted in 20% of cases, and a “paper fetus” in the second trimester of pregnancy. The average incidence of death of one or both fetuses in early gestation is 5% (2% in singleton pregnancies). Frequency of late (in the II and III trimesters) pregnancy) intrauterine death of one of the fetuses is 0.5–6.8% for twins and 11.0–17.0% for triplets.

The main causes of late intrauterine death in monochorionic placentation are SFFG, and in bichorionic placentation - FGR and tunical attachment of the umbilical cord. Moreover, the frequency of intrauterine fetal death in monochorionic twins is 2 times higher than that in bichorionic multiple pregnancies.

If one of the fetuses dies in the first trimester of pregnancy, in 24% of cases the second one may also die or a spontaneous abortion may occur, however, in most cases there may be no adverse consequences for the development of the second fetus.

If one of the fetuses dies in the II–III trimesters of pregnancy, premature termination of pregnancy is possible due to the release of cytokines and PGs by the “dead” placenta. Brain damage also poses a huge risk to the surviving fetus, which is caused by severe hypotension due to the redistribution of blood (“bleeding”) from the living fetus to the fetoplacental complex of the deceased.

In case of intrauterine death of one of the fetuses in bichorionic twins, prolongation of pregnancy is considered optimal (Fig. 214). With the monochorionic type of placentation, the only way to save a viable fetus is a CS performed as quickly as possible after the death of one of the fetuses, when brain damage to the surviving fetus has not yet occurred. In case of intrauterine death of one of the fetuses from a monochorionic twin at an earlier stage (before viability is achieved), the method of choice is immediate occlusion of the umbilical cord of the dead fetus.

Rice. 21-4. Bichorionic twins. Antenatal death of one of the fetuses at 22 weeks.

The tactics for managing multiple pregnancies that are discordant for congenital malformation of the fetus depend on the severity of the defect, the gestational age of the fetus at the time of diagnosis and, most importantly, the type of placentation. In case of bichorionic twins, selective feticide of the sick fetus is possible (intracardiac administration of potassium chloride solution under ultrasound control), however, given the unsafety of the invasive procedure, if the defect is absolutely lethal (for example, anencephaly), expectant management should also be considered in order to reduce the risk of the procedure for second fruit.

In monochorionic placentation, the presence of interfetal transplacental anastomoses excludes the possibility of selective feticide using a solution of potassium chloride due to the danger of it getting into the dead fetus into a living one.

In case of monochorionic twins, other methods of feticide of a sick fetus are used: injection of pure alcohol into the intra-abdominal part of the umbilical artery, ligation of the umbilical cord during fetoscopy, endoscopic laser coagulation, introduction of a thrombogenic coil under echographic control, embolization of the sick fetus. The optimal tactics for managing monochorionic twins with discordance in relation to congenital birth defects is considered to be occlusion of the umbilical cord vessels of the sick fetus (Fig. 215).

Rice. 21-5. Endoscopic occlusion of umbilical cord vessels.

Conjoined twins are a specific developmental defect characteristic of monochorionic monoamniotic pregnancy. This is a rare pathology, the frequency of which is 1% of monochorionic twins.

The most common types of fusion include: thoracopagus (fusion in the chest area), omphalopagus (fusion in the navel and xiphoid cartilage), craniopagus (fusion of homologous parts of the skull), pygopagus and ischiopagus (fusion of the lateral and lower sections of the coccyx and sacrum), as well as incomplete divergence (split in only one part of the body).

The prognosis for conjoined twins depends on the location, degree of union, and the presence of concomitant developmental defects. In this regard, to more accurately establish the potential survival of children and their separation, in addition to ultrasound, additional research methods such as echocardiography and MRI are needed.

If conjoined twins are diagnosed in utero (in the early stages), the pregnancy is terminated. If surgical separation of newborns is possible and the mothers consent, expectant management is chosen when managing such a pregnancy.

Chromosomal pathology in dizygotic multiple pregnancies (in each fetus) is observed with the same frequency as in singleton pregnancies, and the possibility of affecting at least one of the fetuses is doubled.

In identical twins, the risk of chromosomal pathology is the same as in a singleton pregnancy, and in most cases both fetuses are affected.

If the tactics for managing pregnant women with twins with diagnosed trisomy of both fetuses is clear - termination of pregnancy, then if the fetuses are discordant with respect to chromosomal pathology, either selective feticide of the diseased fetus or prolongation of pregnancy without any intervention is possible. Tactics are entirely based on the relative risk of selective feticide, which can cause miscarriage, premature birth, and the death of a healthy fetus. The issue of prolonging pregnancy while carrying a known sick child must be decided taking into account the wishes of the pregnant woman and her family.

COURSE AND MANAGEMENT OF LABOR

The course of labor in multiple pregnancies is characterized by a high frequency of complications: primary and secondary weakness of labor, premature rupture of the uterus, loss of umbilical cord loops and small parts of the fetus. One of the serious complications of the intrapartum period is PONRP of the first or second fetus. The cause of abruption after the birth of the first fetus may be a rapid decrease in the volume of the uterus and a decrease in intrauterine pressure, which is especially dangerous in monochorionic twins.

A rare (1 in 800 twin pregnancies) but severe intrapartum complication is fetal collision with the breech presentation of the first fetus and the cephalic presentation of the second. In this case, the head of one fetus clings to the head of the second and they simultaneously enter the pelvic inlet. In case of twin collisions, the method of choice is an emergency CS.

In the postpartum and early postpartum period, hypotonic bleeding is possible due to overextension of the uterus.

The method of delivery for twins depends on the presentation of the fetuses. The optimal method of delivery for cephalic/cephalic presentation of both fetuses is vaginal delivery, and for the transverse position of the first fetus - CS. Breech presentation of the first fetus in first-time mothers is also an indication for CS.

In case of cephalic presentation of the first and pelvic presentation of the second, the method of choice is delivery through the birth canal. During childbirth, external rotation of the second fetus is possible with its transfer to a cephalic presentation under ultrasound control.

The transverse position of the second fetus is currently considered by many obstetricians as an indication for CS on the second fetus, although with sufficient qualifications of the doctor, the combined rotation of the second fetus on the leg, followed by its removal, is not difficult.

A clear knowledge of the type of placentation is important for determining labor management tactics, since in monochorionic twins, along with a high frequency of FFH, there is a high risk of acute intrapartum transfusion, which can be fatal for the second fetus (severe acute hypovolemia with subsequent brain damage, anemia, intrapartum death), therefore, the possibility of delivery of patients with monochorionic twins by CS cannot be excluded.

The greatest risk in relation to PS is the birth of monochorionic monoamniotic twins, which requires particularly careful ultrasound monitoring of the growth and condition of the fetuses and in which, in addition to the specific complications inherent in monochorionic twins, umbilical cord torsion is often observed.

The optimal method of delivery for this type of multiple pregnancy is considered to be a CS at 33–34 weeks of pregnancy. Delivery of conjoined twins is also carried out by CS (if this complication was diagnosed late).

In addition, the indication for a planned CS in case of twins is considered to be severe overdistension of the uterus due to large children (total weight of the fetuses 6 kg or more) or polyhydramnios. During pregnancy with three or more fetuses, delivery by CS at 34–35 weeks is also indicated.

When conducting vaginal delivery, it is necessary to carefully monitor the patient's condition and constantly monitor the cardiac activity of both fetuses. Childbirth in case of multiple pregnancy is preferably carried out in the position of the woman in labor on her side in order to avoid the development of compression syndrome of the inferior vena cava.

After the birth of the first child, external obstetric and vaginal examinations are performed to clarify the obstetric situation and the position of the second fetus. It is also advisable to perform an ultrasound.

When the fetus is in a longitudinal position, the amniotic sac is opened, slowly releasing the OB; In the future, childbirth is carried out as usual.

The question of CS during childbirth in a multiple pregnancy may arise for other reasons: persistent weakness of labor, prolapse of small parts of the fetus, umbilical cord loops in cephalic presentation, symptoms of acute hypoxia of one of the fetuses, placental abruption, and others.

During multiple births, it is imperative to prevent bleeding in the afterbirth and postpartum periods.

PATIENT EDUCATION

Every patient with a multiple pregnancy should be aware of the importance of a nutritious diet (3500 kcal per day), and special attention should be paid to the need for preventive intake of iron supplements.

Patients with multiple births should know that the total weight gain during pregnancy should be at least 18–20 kg, while weight gain in the first half of pregnancy (at least 10 kg) is important to ensure the physiological growth of the fetus.

All patients with multiple pregnancies should be informed about possible complications, primarily miscarriage. It is necessary to explain to the woman the need to comply with a protective regime, including a decrease in physical activity and mandatory daytime rest (three times for 1–2 hours).

Pregnant women with monochorionic twins should undergo testing, including ultrasound, more often than with bichorionic twins to identify early signs of FFTG. These patients should be informed about the possibility of surgical correction of this complication.