1

fiziologiuri mSobiarobis

marTva

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

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klinikuri praqtikis erovnuli rekomendacia (gaidlaini)

`fiziologiuri mSobiarobis marTva” miRebulia klinikuri

praqtikis erovnuli rekomendaciebis (gaidlainebi) da

daavadebaTa marTvis saxelmwifo standartebis (protokolebi)

SemuSavebis, Sefasebis da danergvis erovnuli sabWos 2007

wlis 21 martis #1 sxdomaze da damtkicebulia saqarTvelos

Sromis, janmrTelobisa da socialuri dacvis ministris 2007

wlis 27 agvistos # 261/o brZanebiT.

3

fiziologiuri mSobiarobis marTva

klinikuri rekomendaciebis zogadi mizani

am rekomendaciis mizans warmoadgens: • meanebis, bebia qalebis, menejerebis da sxva dainteresebuli

pirebisaTvis uaxlesi samecniero mtkicebebze dafuZnebuli

informaciis miwodeba fiziologiurad mimdinare mSobiarobis

marTvis sakiTxebis Sesaxeb;

• fiziologiuri mSobiarobis procesSi dausabuTebeli

Carevebis raodenobis Semcireba (mSobiarobis

demedikalizacia);

• orsulebisa da maTi ojaxis wevrebis sanitaruli ganaTlebis

gaumjobeseba fiziologiuri mSobiarobis dros.

ganxiluli klinikuri sakiTxebi

mocemuli klinikuri rekomendaciebi ar ganixilaven im

garTulebebs, romlebic SeiZleba warmoiSvas mSobiarobis dros da

mSobiarobis Semdgomi periodis marTvis Taviseburebebs.

gaidlaini gankuTvnilia

mocemuli klinikuri rekomendaciebi gankuTnilia mean-

ginekologebisaTvis, ojaxis eqimebisa, bebia-qalebisa da

eqTnebisaTvis.

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1998 w. janmo/evropis perinataluri daxmarebis samuSao jgufis meore

Sexvedraze 3 Camoyalibda perinataluri daxmarebis principebi, romlis

Tanaxmadac fiziologiurad mimdinare orsulobisa da mSobiarobis

dros unda moxdes daxmarebis demedikalizacia da yvela Careva ki

eyrdnobodes mtkicebulebebze dafuZnebul monacemebs. am principebis

mixedviT orsuloba ganixileba, rogorc fiziologiuri movlena, da ara

rogorc daavadeba. sxva sityvebiT, mSobiaroba winaswar ar unda

ganixilebodes, rogorc problema, xolo axalSobili – rogorc

pacienti. miuxedavad amisa, dRevandel dRemde sameano praqtikaSi

xSirad gamoiyeneba Carevebi, romlebic dafuZnebulia sakuTar

gamocdilebasa da STabeWdilebebze da ar efuZneba samecniero

mtkicebulebes. Lklinikur rekomndaciebSi Sejamebulia bolo

mtkicebulebebi, romlis safuZvelze unda iyos agebuli Tanamedrove

sameano daxmareba.

normaluri mSobiarobis marTvis mizans warmoadgens dedisa da

axalSobilis janmrTelobis dacva Carevebis minimaluri raodenobiT. es

midgoma moicavs Semdegs:

normaluri mSobiarobis dros unda arsebobdes mniSvnelovani mizezi

bunebriv procesSi CarevisaTvis.

zedamxedvelobass aqvs oTxi mizani:

• qalis, misi partnioris da ojaxis wevrebis mxardaWera mSobiarobis

da misi Semdgomi periodis dros;

• mSobiare qalze zedamxedveloba, nayofis mdgomareobis monitoringi

da nayofis mdgomareobis Sefaseba mSobiarobis dros, risk

faqtorebis Sefaseba, problemebis adreuli gamovlena;

• saWiroebisamebr mcire intervenciebis Catareba, amniotomia da

epiziotomia, axalSobilis movla mSobiarobis Semdeg;

• im SemTxvevaSi, Tu saxezea aSkara risk faqtorebi da SesaZlebelia

Camoyalibdes garTulebebi, mSobiaris gadagzavna marTvis ufro

maRali donis klinikaSi.

5

definicia

farTod gavrcelebuli azria, rom mSobiarobis Sefaseba SesaZlebelia

mxolod retrospeqtulad mSobiarobis Semdeg. am koncefcias aqvs

ramodenime uaryofiTi mxare: fiziologiur movlenas aqcevs samedicino

procedurad, zRudavs qalis Tavisuflebas, zrdis arasaWiro Carevebis

sixSires. aseTi midgomis ganxorcieleba saWiroebs mSobiare qalTa didi

raodenobis koncentrirebas teqnikurad kargad aRWurvil

saavadmyofoebSi, Sesabamisi xarjebis gaweviT. fiziologiuri mSobiarobis koncefciis gansazRvrebisas mxedvelobaSi

unda iyos miRebuli ori mniSvnelovani faqtori: orsulobisa da

mSobiarobis dros arsebuli risk-faqtorebi da mSobiarobis

mimdinareoba. mSobiarobamde SeuZlebelia imis gansazRvra, Tu romel

qals Camouyalibdeba garTulebebi. sxva mxriv, mravali qali, romelic

TiTqos imyofeba maRali riskis jgufSi, mSobiarobs garTulebebis

gareSe. mocemul klinikur rekomendaciebSi fiziologiuri mSobiaroba

ganisazRvreba, rogorc, erTnayofiani mSobiaroba dabali riskis

jgufis orsulebSi samSobiaro moqmedebis TviTnebiTi dawyebiT da

progresirebiT, 37 dan -42 kviris vadamde, nayofis TaviT

winamdebareobiT, dedisa da axalSobilis damakmayofilebeli

mdgomareobiT mSobiarobis Semdeg. 4

ra Tqma unda, yovelive zemod aRniSnuli SeiZleba moxdes maRali riskis

jgufis orsulebSi, romlis ganxilva ar Sedis mocemuli klinikuri

rekomendaciebis miznebSi. jdomiT winmdebareoba Tu 36 kviraze ar

moxerxda profilaqtikuri garegani mobruneba Tavze, unda CaiTvalos

paTolofiur mimdinare orsulobad, romlis ganxilva agreTve ar Sedis

mocemuli klinikuri rekomendaciebis miznebSi.

sxva da sxva monacemebiT mSobiare qalTa daaxloebiT 70-80% SeiZleba

ganvixiloT, rogorc garTulebebis ganviTarebis TvalsazrisiT dabali

riskis mqone. 5;6;7. 2004 wlis monacemebiT8 samSobiaro saxlebSi

miRebuli 45554 mSobiarobidan 73,4 % iyo fiziologiuri, xolo 26,6%

paTologiuri

zogadi procedurebi hospitalizaciamde

mimReb ganyofilebaSi daxvedra

arsebobs mravali rekomendacia, romelTa mizania samSobiaro saxlSi

qalis moTavsebasTan dakavSirebiT qalis mxriv gancdili stresisa da

uxerxulobis Semcireba. Zalian mniSvnelovania, rom samedicino

personalma gamoavlinos keTilganwyoba da mxardaWera qalisa da misi

Tanxmlebi pirebis mimarT. Cveulebrivad, rodesac qali Tavsdeba

samSobiaroSi, mas sTavazoben, gamoicvalos tansacmeli. mravali

qalisaTvis ufro misaRebia, TviTon miitanos tansacmeli da TeTreuli

da ar Caicvas saavadmyofos xalaTi, rac mas exmareba individualobis

SenarCunebaSi.

bebiaqalma da eqimma orsuls unda miawodon informacia da auxsnan yvela

im procedurisa da gamokvlevis azri, romelic mas unda Cautardes.

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qalis gasinjva:

• saWiroa konfidencialur pirobebSi (mSvid garemoSi, gareSe pirebis

daswrebisa da mnaxvelTa uecari Semosvlis akrZalviT);

• misi teqnikisa da procedurebis miznis da prognozuli

mniSvnelobis winaswari axsniT, moqmedebebis komentirebiT;

mxedvelobaSi iyos miRebuli da Sesruldes qalis survili

gasinjva Catardes axloblebis garemocvaSi,

• yvela moqmedeba Catardes mxadaWerisa da keTilmosurneobis

garemoSi.

Tu mimReb ganyofilebaSi dadgindeba, rom mSobiaroba jer ar dawyebula,

SesaZlebelia orsulis saxlSi gagzavna an sxva ganyofilebaSi

moTavseba. sasurvelia, samSobiaro blokSi moTavsdnen qalebi aqtiuri

mSobiarobiT maTi zedmeti nerviulobisa da arasaWiro Carevebis Tavidan

asacileblad.

meta analizma sadac CarTuli iyo 209 qali 9 aCvena, rom qalebi,

romlebic randomizirebulebi iyvnen mSobiarobis simptomebis dawyebis

Sefasebis jgufSi dayves ufro naklebi dro samSobiaro blokSi

(gansxvaveba — 5.20 saaTi, 95% СI -7.06, -3.34), ufro naklebi iyo

mSobiarobaSi oqsitocinis gamoyenebis sixSire (OOR 0.45, 95% СI 0.25-0.80) da analgeziis sixSire (OR 0.36, 95% СI 0.16-0.78) im qalebTan SedarebiT,

romlebic pirdapir moaTavses samSobiaro blokSi. qalebma mSobiarobis

simptomebis dawyebis Sefasebis jgufidan aRniSnes mSobiarobisas ufro

maRali zedamxedvelobis done (gansxvaveba 16.00, 95% СI 7.52- 24.48). ar aris sakmarisi mtkicebulebebi Sefasebis efeqtis zegavlenaze sakeisro

kveTisa da dedisa da axalSobilis gamosavalis mniSvnelovan aspeqtebze.

zemoT aRniSnulidan gamomdinare mSobiarobis Sefasebis programebs,

romlebic gadaavadebs qalis moTavsebas samSobiaro blokSi aqtiur

mSobiarobamde, SeuZliaT dadebiTi zedavlena moaxdinon vadamitanili

orsul qalebze. mizanSewonilia agreTve e. w. samSobiaro gegmis Sedgena,

romelic moicavs Semdeg 3 aspeqts:

1. qalis survilebi normaluri mSobiarobis dros

qals SesaZlebloba unda hqondes airCios misTvis sasurveli garemo

mSobiarobisaTvis, vin daaswros mSobiarobas da ra pozaSi imSobiaros,

isargeblos burTiT WinTvebis dros, airCios sasurveli musika, videos

gadaReba, foto, Sxapis miReba, auziT sargebloba.

2. qalis survili axalSobilis movlasTan dakavSirebiT uSualod

mSobiarobis Semdeg da dabadebidan pirveli dReebis ganmavlobaSi

am punqtSi SesaZloa visaubroT Semdeg sakiTxebze: vin unda gadaWras

Wiplari? bavSvi moTavsdes Tqvens mucelze mSobiarobis Semdeg? gindaT

Tu ara bavSvi maSinve kveboT ZuZuTi? sad gindaT, daiZinos bavSvma

TqvenTan Tu bavSvTa ganyofilebaSi?

saavadmyofoebSi arsebobs axalSobilTa movlis mravali variantebi,

mSobiarem unda icodeT maT Sesaxeb da amoirCioT is varianti, romelic

Seesabameba mis survilebs.

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3. qali survilebi gauTvaliswinebeli movlenebis SemTxvevaSi

aravis ar unda fiqri imis Sesaxeb, rom movlenebi SeiZleba cudad

warimarTos, magram Tu es xdeba, ukeTesia, amisaTvis yvela momzadebuli

iyos da ar gakeTdes naCqarevi gadawyvetilebebi. qalma aseve unda

ifiqros iseTi SesaZlo garTulebis Sesaxeb, rogoricaa naadrevi

mSobiaroba.

saWiroa Tu ara nawlavebis rutinuli momzadeba da boqvenis gaparsva

rodesac qali Tavsdeba samSobiaroSi, mas Tavdapirvelad uzomaven

arteriul wnevas, puls, temperaturas, moismineba nayofis guliscema,

ris Semdegac xdeba qalis vaginaluri gasinjva. Semdeg mas amzadeben

mSobiarobisaTvis: ukeTeben gamwmend oynas, Cabanen da gaparsaven sasqeso

organoebs.

pulsisa da arteriuli wnevis maCveneblebma, SesaZlebelia garkveuli

zegavlena iqonion mSobiarobis gamosavalze, amitom maTi gazomva

aucilebelia, Tumca procedurebis arsi unda aexsnas rogorc qals, aseve

mis partniors. Ggamwmendi oynebi farTod gamoiyeneba saSvilosnos

SekumSvebis stimulaciisa da nawlavebis gaTavisuflebis mizniT, aseve

Tavis winmsvlelobis gasaadvileblad da mSobiarisa da axalSobilis

nawlavebis SigTavsiT inficirebis riskis dasaqveiTeblad. Ees procedura

farTod aris gavrcelebuli, Tumca kvlevebma aCvenes, rom, is

usargebloa da aris mSobiarisaTvis diskomfortisa da uxerxulobis

momtani. ori kvlevis sistematurma mimoxilvam 10, romelic moicavda 665

qals aCvena, rom ar aris gansxvaveba dedis da axalSobilebis

inficirebis sixSireSi. (OR 0.61, 95% СI 0.36- 1.04) sasqeso organoebis gaparsva TiTqos mimarTulia inficirebis albaTobis

dasaqveiTeblad da Sorisze nakerebis dadebis gasaadvileblad, magram ar arsebobs mecnierulad dadasturebuli monacemebi am mosazrebis

dasamtkiceblad. Qqalebi am proceduris dros ganicdian diskomforts,

xolo SidsiTa da B da C hepatitiT inficirebis albaToba matulobs. 11;12. sistematuri mimoxilva 13 romelic moicavs 2 rkk-s 389 qals Cautarda

alternatiulad kanis momzadeba da Sorisis gaparsva (sakontrolo

jgufi) an mxolod vulvaruli Tmis SekreWa (eqsperimentuli jgufi).

meore kvlevaSi, romelic moicavda 150 qals, Sedarebuli iyo Sorisis

gaparsva grZeli Tmebis SeWrasTan. orive kvlevis pirvelad gamosavals

warmoadgenda dedis febriliteti. Ggansxvaveba ar iqna gamovlenili am

jgufebs Soris (OR 1.26 95%, CI 0.75-2.12). ufro mcire moculobis kvlevaSi qalebs, romelTac ar CautardaT

gaparsva, aRmoaCndaT naklebi gram-negatiuri kolonizacia im qalebTan

SedarebiT, romelTac CautardaT boqvenis gaparsva. (OR 0.43, 95% CI 0.20-0.92) miuxedavad amisa, zogjer aris situaciebi, rodesac gamwmendi oynis

gakeTeba aucileblad iTvleba an qali iTxovs mis gakeTebas. am

SemTxvevaSi saWiroa gvaxsovdes, rom ar arsebobs romelime medikamentis

Seyvanis raime upiratesobani Cveulebriv wyalTan SedarebiT.

yovel konkretul SemTxvevaSi personalma qalTan erTad unda

gadawyvitos am manipulacebis Catareba.

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mSobiare qalebSi gamwmendi oynisa da boqvenis gaparsvis

upiratesobis sasargeblod ar arsebobs mtkicebulebebi

kveba mSobiarobis dros

mSobiaris kvebasTan dakavSirebiT arsebobs sxvadasxva mosazrebebi.

kuWis SigTavsis aspiraciis (mendelsonis sindromis) saSiSroeba

endotraqealuri narkozis aucileblobis SemTxvevaSi iZulebuls xdis

mSobiarobis dros SeizRudos sakvebisa da siTxis miReba. qalTa

umravlesobisaTvis es SezRudva ar aris rTuli gadasatani, Tumca maTi

umravlesoba ganicdis wyurvilis grZnobas.

damtkicebulia, rom mSobiarobis dros sakvebis SezRudva ar iZleva

garantias zemoT aRniSnuli sindromis Camoyalibebisagan Tavis

dasacavad. 14;14-16;17. ramodenime kvlevam sxvadasxva farmakologiuri

saSualebebis meSveobiT kuWis SigTavsis cvlilebasa da mSobiarobis

dros sakvebis SezRudvaze ar gamoavlina 100%-iani garantia mendelsonis

sindromisgan. calkeuli meTodis gamoyenebisas pH maCvenebelTa

cvalebadoba sakmaod didi iyo da mkvlevarTa monacemebiT, antacidebis

aucilebeli profilaqtikuri miReba ar iZleva garantias zemoT

aRniSnuli sindromis Camoyalibebisagan Tavis dasacavad.

mSobiaroba iTxovs energetikul danaxarjebs. imis gamo, rom winaswar ar

SeiZleba ganisazRvros mSobiarobis xangrZlivoba, energiis wyaro

mudmivad unda iyos Sevsebuli. mSobiarobis dros sakvebis mkveTrma

SezRudvam SeiZleba gamoiwvios dehidratacia da acidozi, romlis

profilaqtikisaTvisac gamoiyeneba glukozisa da sxva xsnarebis

intravenuri Seyvana. dedis mdgomareobaze aseTi kvebis zegavlena

Sefasebulia ramodenime randomizirebul kvlevaSi 18-20;21 . SesaZlebelia, glukozis donis momatebam gamoiwvios insulinis donis momateba dedis

sisxlSi, rac, Tavis mxriv iwvevs glukozis donis momatebas nayofis

sisxlSi, rasac moyveba pH donis daqveiTeba Wiplaris arteriaSi.

hiperinsulinemias Tan sdevs hipoglikemiis ganviTareba da es aReniSneba

im axalSobilebs, romelTa dedebsac gaukeTdaT 25 gram glukozaze meti

mSobiarobis dros, xolo umarilo xsnarebis gadametebuli gamoyeneba

iwvevs rogorc nayofis, ise dedis hiponatriemias. amis garda,

intravenuri infuzia zRudavs dedis Tavisufal gadaadgilebas da xels

uSlis mSobiarobis bunebriv mimdinareobas.

mSobiarobis dros dehidratacia da acidozi SeiZleba Tavidan aviciloT

siTxis da advilad mosanelebeli sakvebis miRebiT. ZiriTadad, qalebi

TviTon intuiciurad Tavs izRudaven sakvebis gadametebuli miRebisagan,

da iReben mxolod siTxes, namcxvarsa da Sokolads.

amgvarad, unda aRiniSnos, rom mSobiaris kvebis sakiTxi aris Zalzed

mniSvnelovani da amave dros, Zalzed variabeluri sakiTxi. rogorc Cans,

Tanamedrve midgoma qals aZlevs arCevans samedicino personalTan

gasaubrebis Semdeg TviTon gadawyvitos sakiTxi dasaSvebi sakvebisa da

sasmelis raodenobis miRebis Sesaxeb fiziologiuri mSobiarobis

dros.22;23

A

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ar arsebobs safuZveli fiziologiuri mSobiarobis dros SeizRudos siTxeebis da sakvebis miReba.

fsiqologiuri mxardaWera mSobiarobis dros

bebiaqalebis daxmarebiT qalTa fsiqologiuri da fizikuri mxardaWeris

Sesaxeb Catarebulma randomizirebulma kvlevebma aCvenes, rom damxmaresa

da mSobiares Soris kargi fsiqologiuri kontaqtis arseboba (mudmivi

gverdze yofna da mxardaWera, mSobiaris komfortis gasaumjobesebeli

zomebis CaTvliT zurgis masaJi, mSobiarobis meqanizmis axsna)

mniSvnelovnad aumjobesebs mSobiarobis mimdinareobas: mokldeba

mSobiarobis dro, naklebi raodenobiT gamoiyeneba analgeziis mizniT

gamosayenebeli medikamentebis raodenoba, aseve operaciuli

mSobiarobebis raodenoba, mcirdeba aseve bavSvTa raodenoba, romlebic

ibadebian apgaris SkaliT 7 balze naklebi SefasebiT 24; 25-27.

Catarda 15 rkk, romelSic monawileobda 12 791 qali, 25;28 sadac

Sedarebuli iyo mSobiarisa da masTan mudmivad myofi zedamxedvelis

praqtika mSobiarobis Cveulebriv zedamxedvelobasTan. sistemur

mimoxilvaSi yvelaze didi kvlevis CarTvam damatebiT gamoavlina

Semdegi: erTi-erTze zedamxedveloba profesionalis an

araprofesionalis mier, axloblebTan erTad an maT gareSe, dadebiT

zegavlenas axdens mSobiarobis dros samedicino Carevebis sixSireze da

dedis emociur mdgomareobaze. kvlevam aCvena, rom qalebs, romelTac

uweven mudmiv mxardaWeras, ufro iSviaTad esaWiroebaT

analgezia/anesTezia, operaciuli saSosmxrivi mSobiaroba, sakeisro kveTa

(yvela gansxvaveba statistikurad sarwmunoa) da aseve mcirdeba

mSobiarobasTan dakavSirebuli ukmayofileba (OOR 0.73, 95%, СI ( 0.65-0.83).

samwuxarod, mocemuli suraTi mkveTrad gansxvavdeba imisgan, romelic

dRes SeimCneva samSobiaro saxlebSi. qalebi mSobiarobis dros Tavs

grZnoben izolirebulad, garSemortymulebi arian ra rTuli

eleqtronuli aparaturiT saTanado megobruli mxardaWeris gareSe.

garda amisa, Tu gaviTvaliswinebT mravaladgilian mSobiarobamdel

palatebs, rTulia qalisaTvis privatulobis uzrunvelyofa mSobiarobis

dros.

radgan arsebobs ojaxis wevrebisa da naTesavebis garemocvaSi

mSobiarobis garkveuli upiratesobani, amitom aucilebelia saavadmyofos

pirobebSi Seiqmnas garemo, romelic miaxloebulia saxlis pirobebTan

e.w. samSobiaro oTaxebi - sawolebiT, televizoriT, savarZeli-

sarweveliT da fardebiT.

sistemur mimoxilvaSi29, romelSic CarTuli iyo 8677 qali, maTi 19-77%

gadayvanili mSobiarobis dros saxlis msgavs garemo pirobebidan

samSobiaro blokSi. qalebi, romlebmac imSobiares saxlis msgavs

garemoSi, ufro naklebad saWiroebdnen tkivilgamayuCebeli saSualebebis

miRebas, ufro naklebad aRiniSneboda maTi imobilizacia mSobiarobis

dros, aseve SeiniSneboda nayofis guliscemis darRvevis naklebi sixSire,

naklebi operaciuli mSobiaroba, isini ufro kmayofilni iyvnen

meTvalyureobiT. gamovlinda ufro maRali perinataluri sikvdilianobis

A

10

sixSire saxlis msgavs pirobebSi mSobiarobis dros {p=0.066}. Sedegebma aCvena, rom rodesac qalebi mSobiarobdnen saxlis msgavs pirobebSi, isini

ufro mets moZraobdnen mSobiarobis pirvel periodSi da ufro xSirad

mSobiarobdnen swor an naxevrad dawolil pozaSi. es ori faqtori

albaT ganapirobebs mSobiarobis aRZvris, analgeziis, operaciuli

mSobiarobis da nayofis guliscemis anomaliebis mniSvnelovan

daqveiTebas. saxlis msgavs pirobebSi mSobiarobis danergva SeiZleba

iyos xarj-efeqturi alternativa tradiciuli samSobiaro blokisa,

Tumca is saWiroebs yuradRebas gansakuTrebiT gazrdili perinataluri

sikvdilianobis TvalsazrisiT.

samecniero-teqnikuri progresis ganviTarebasTan erTad orsulTa

samedicino daxmareba xorcieldeba mxolod mean-ginekologTa mier. aseTi

midgomis upiratesobani seriozuli eWvis qveS eqceva. mSobiarobis dros

mean-ginekologTa da bebiaqalTa mier gaweuli daxmarebis SedarebiTma

analizma aCvena, rom bebiaqalebs mSobiaroba miyavT ufro

konservatulad, ufro naklebi sixSiriT SeimCneva mSobiarobis

stimulacia, operaciuli saSosmxrivi mSobiaroba, (maSebi da vakuum

eqstraqcia), aseve klebulobs epiziotomiis sixSire da axalSobilTa

raodenoba, romlebic saWiroeben reanimacias da intensiuri Terapiis

ganyofilebebSi gadayvanas. ar gamovlenila gansxvaveba mSobiarobis

aRZvrisa da sakeisro kveTis sixSireebs Soris.

naTelia, rom qalebi fiziologiurad mimdinare orsulobiT ar aris

aucilebeli iyvnen mean-ginekologis meTvalyureobis qveS.

specialistebma, romlebic meTvalyureoben dabali da maRali riskis

jgufis orsulebs, unda gaakeTon rTuli arCevani: moaxdinon

koncentracia an mxolod maRali riskis jgufis orsulebze an

fiziologiur orsulebze (rac Seadgens SemTxvevaTa umravlesobas), ris

drosac isini swrafad dakargaven kvalifikacias.

bebiaqalebi da ojaxis eqimebi Tavidanve orientirebulebi arian dabali

riskis jgufis orsulebisaTvis daxmarebis aRmosaCenad, urTierTobis

procesSi ufro axlos ecnobian orsulis individualur Tvisebebs,

amitom maT mier gaweuli daxmarebis xasiaTi ufro pasuxobs orsulTa

umravlesobis moTxovnebs, vidre mean-ginekologis mier aRmoCenili

daxmareba.

orsulebi xSirad gamoxataven survils, orsulobisa da mSobiarobis

dros daxmareba miiRon erTi da imave pirisagan, visTanac isini amyareben

axlo urTierTobas. randomizirebuli kvlevebis Sedegebma 29 aCvena, rom

aseT orsulebs mSobiarobisas aReniSnebaT vaginaluri gasinjvis da

medikamentozuri stimulaciis mniSvnelovnad naklebi sixSire, mcirdeba

aseve bavSvTa raodenoba, romlebic ibadebian apgaris SkaliT 7 qulaze

naklebi SefasebiT, xolo mSobiarobis xangrZlivoba mcirdeba. Aamas

garda, aseTi qalebi ufro momzadebulebi arian mSobiarobisa da

axalSobilis movlisaTvis.

mudmivi mxardaWera mSobiarobis dros, romelsac axorcielebs

samedicino personali (eqimi, bebiaqali) mSobiaris axlobelTan

erTad, amcirebs samedicino Carevebis ricxvs mSobiarobis dros

da aseve aumjobesebs qalis mdgomareobas.

A

11

samSobiaro tkivilebi

miuxedavad imisa, rom yvela qali ganicdis tkivilebs mSobiarobis dros,

maTi reaqcia tkivilze meryeobs farTo sazRvrebSi. Kklinikuri kvlevebis

monacemebiT, garTulebuli mSobiaroba, romelic mimdinareobs

samSobiaro moqmedebis diskoordinaciiT, mSobiarobis aRZvriT,

mSobiarobis stimulaciiT da operaciuli gziT ufro mtkivneulia.

bebiaqalisa da mean-ginekologisaTvis, romelsac miyavs mSobiaroba,

mniSvnelovania qalisaTvis daxmarebis aRmoCena tkivilebis Semsubuqebis

mizniT. miuxedavad imisa, rom amis miRweva SesaZlebelia medikamentebis

saSualebiT, ufro mniSvnelovania aramedikamentozuri gautkivareba,

romelic iwyeba qalisa da misi partnioris antenataluri momzadebis

procesSi. gamovlenilia, rom mSobiarobisaTvis mosamzadebel

programebSi monawileoba mniSvnelovnad aqveiTebs mSobiarobis

gautkivarebisaTvis medikamentozuri saSualebebis gamoyenebis sixSires30.

samwuxarod, antenataluri momzadebis sxva dadebiTi efeqtis gamovlena

ver moxerxda.

mSobiarobis dros fsiqologiur daxmarebasTan erTad, romelic

gansakuTrebiT mniSvnelovania, arsebobs ramodenime sxva midgoma. pirvel

rigSi qals unda mivceT saSualeba mSobiarobis dros TviTon amoirCios

nebismieri poza, mas SeuZlia idges, ijdes an iaros gansakuTrebiT

mSobiarobis pirveli periodis ganmavlobaSi. zogierTi qali Svebas

grZnobs Tbili abazanisa an Sxapis miRebis, masaJisa an zurgze xelis

mosmis Semdeg. aseTive Sedegs iZleva sunTqviTi varjiSebi da relaqsacia,

romelTa saSualebiTac xdeba qalis yuradRebis gadatana. aseTi

moqmedebebi usafrTxoa da SesaZlebelia maTi farTo gamoyeneba.

mSobiarobis gautkivarebis medikamenturi meTodebi

mSobiarobis medikamenturi gautkivareba farTod gamoiyeneba da misi

dadebiTi efeqti damtkicebulia mravali gamokvlevebiT. samwuxarod,

medikamenturi gautkivarebis ��negatiuri efeqti ar aris kargad

Seswavlili. zogierTi dawesebulebebis monacemebiT medikamenturi

gautkivareba gamoiyeneba fiziologiuri mSobiarobis dros 20-80%-Si31.

sainhalacio anesTetikebis gamoyenebis sixSire bolo xanebSi Semcirda

(sul ufro xSirad is icvleba periduruli analgeziiT); gansakuTrebiT

xSirad am dros gamoiyeneba azotis qveJangi JangbadTan erTad

proporciiT 50%:50%-ze. Yyvela medikamenti, romelic gamoiyeneba

gautkivarebis mizniT, gaivlis placentur bariers da SesaZlebelia

gamoiwvios nayofis sunTqviTi depresia da tvinis funqciebis moSla,

aseve ZuZuTi kvebis survilis gaqroba. mag.: seduqseni iwvevs neonatalur

depresias, saSvilosnos hipotoniasa da hipoTermias32;33;34; 35.

periduruli anesTeziis sxavdasxva variantebi (epiduruli, kaudaluri,

kombinirebuli epidurul-spinaluri) farTod gamoiyeneba mSobiarobis

dros. am tipis anesTeziis upiratesobani kargad aris dadasturebuli.

periduruli anesTeziis gamoyenebisaTvis aucilebelia 24 saaTiani

anesTeziologiuri meTvalyureoba, aRWurviloba da momzadebuli

personali. Ddamtkicebul upiratesobebTan erTad mSobiarobis dros

periduruli anesTeziis gamoyeneba dakavSirebulia rig arasasurvel

12

momentebTan: xangrZlivdeba mSobiarobis pirveli periodi, ufro xSirad

gamoiyeneba oqsitocini, mSobiarobis meore periodSi WinTviTi refleqsis

daqveiTebis gamo matulobs Rrusa da gamosavlis maSebis

gamoyenebis36sixSire.

gamovlinda sakeisro kveTis sixSiris momateba periduruli anesTeziis

gamoyenebisas37, gansakuTrebiT, Tu misi gamoyeneba iwyeboda saSvilosnos

yelis 5 sm-ze naklebi gaxsnis dros.

eWvgareSea, rom periduruli anesTezia Zalzed efeqturia paTologiuri

mSobiarobis dros, magram Tu is gamoiyeneba fiziologiuri

mSobiarobisas, ibadeba kiTxva - SeiZleba Tu ara aseT mSobiarobas

vuwodoT fiziologiuri? periduruli anesTeziis gamoyeneba aris naTeli

magaliTi normaluri mSobiarobis “medikalizaciisa,, rac normalur

fiziologiur process gadaaqcevs samedicino procedurad. aseTi

transformacia gamowveulia kulturuli faqtorebiTa da adaT-wesebiT.

ase, magaliTad, aSS-Si da did britaneTSi qalTa umravlesoba

mSobiarobs periduruli anesTeziis gamoyenebiT. amave dros, holandiaSi

qalTa 30%-ze meti mSobiarobs saxlSi medikamenturi gautkivarebis

gareSe, xolo saavadmyofoSi mSobiarobis SemTxvevaSi maTi mxolod

mcire raodenoba iRebs medikamentur gautkivarebas.

normaluri mSobiarobis marTvisas ufro mizanSewonilad iTvleba

gautkivarebis aramedikamenturi meTodebis gamoyeneba, farmakologiurma

meTodebma ar unda Seicvalon mSobiarisaTvis gaweuli personaluri

yuradReba da saTuTi mopyroba.

fiziologiuri mSobiarobis dros sasurvelia gautkivarebis

arafarmakologiuri meTodebis gamoyeneba. gamtareblobiTi

analgeziis gamoyeneba axangrZlivebs mSobiarobas, zrdis

oqsitocinis gamoyenebisa da operaciuli saSosmxrivi

mSobiarobis sixSires.

nayofis mdgomareobis Sefaseba

nayofis mdgomareobis Sefaseba warmoadgens mSobiarobis marTvis

ganuyofel nawils. Nnayofis distresis ganviTareba - guliscemis

sixSiris cvalebadoba 160-is zeviT da100-120 qveviT an gulicemis ritmis

darRveva, romelic ZiriTadad hipoqsiiTaa gamowveuli, SeimCneva

fiziologiuri mSobiarobis drosac ki.

sanayofe siTxis Sefaseba

sanayofe siTxeSi mekoniumis aRmoCena SesaZlebelia miuTiTebdes nayofis

distresze, aseve mkvdradSobadobis, neonataluri avadobisa da

sikvdilianobis sixSiris momatebaze38-42

sanayofe garsebis darRvevis Semdeg mekoniumis aRmoCena dakavSirebulia

perinataluri avadobisa da sikvdilianobis riskis momatebasTan.

sanayofe wylebis xasiaTi sanayofo buStis spontanuri darRvevisas

mSobiarobis dawyebisas maSinve unda iyos Sefasebuli da mekoniumis

arseboba unda gaxdes nayofze intensiuri dakvirvebis safuZveli.

A

13

amnioinfuzia warmoadgens Wiplaris miWyletis simptomebis Tavidan

acilebis efeqtur meTods mSobiarobis procesSi oligohidramnionis

arsebobisas.

sistematurma mimoxilvam43, romelic exeboda amnioinfuzias

mSobiarobisas mekonialuri sanayofo siTxis arsebobisas Seamcira:

mekoniumiT sanayofo siTxis SeRebva (RR 0.03, 95%, CI 0.01-0.15), nayofis

guliscemis variabeluri deceleraciis sixSire (RR 0.65, 95% CI 0.49 to 0.88), sakeisro kveTis sixSire (RR 0.82, 95% CI 0.69 to 1.97). perinataluri

sikvdilianobis arc erTi SemTxveva ar iqna gamovlenili.

profilaqtikuri amnioinfuzia oligohidramnionis dros dakavSirebulia

perinataluri gamosavlis gaumjobesebasTan, magram Wiplaris kompresiis

niSnebis ar arsebobisas amnioinfuzia ar unda iyos gamoyenebuli.

beta-mimetikebis daniSvna Seswavlili iyo nayofis mosalodneli

distresis dros da SesaZloa is warmoadgendes sasargeblo meTods

drois mogebis mizniT mSobiaobis marTvis Semdgomi taqtikis

gansazRvrisaTvis, Tumca sistematurma mimoxilvam 44 gvaCvena, rom

jgufSi, sadac gamoiyeneboda tokolitikebi, Semcirda nayofis

guliscemis anomaliebi (RR- 0.26, 95% CI 0.13 CI 0.53).beta-mimetikebiT

mkurnalobam magniumis sulfatTan SedarebiT Seamcira saSvilosnos

kumSvadoba (RR-0.07, CI-0.00-1.10)

nayofis distresis ganviTarebisas sasurvelia mSobiarobis swrafi

damTavreba. magram zogjer nayofis guliscemis mravali darRveva qreba

ubralo konservatuli RonisZiebebis Catarebis Semdeg, magaliTad

iseTebis, rogorebicaa: dedis sxeulis mdebareobis Secvla (marcxena

gverdze moTavseba), oqsitocinis Seyvanis Sewyveta saSvilosno-

placenturi sisxlis mimoqcevis gasaumjobeseblad.

Jangbadis moklevadiani daniSvnis efeqturoba Sefasda sistematur

mimoxilvaSi45, romelic mimarTuli iyo Jangbadis profilaqtikuri

daniSvnis efeqturobis Sesafaseblad mSobiarobis dros. Wiplaris

sisxlis pH-is paTologiuri maCveneblebi (7,2-ze naklebi) bevrad ufro

xSirad gamovlinda oqsigenaciis jgufSi, vidre sakontrolo jgufSi. (RR 3,51, 95%, CI 1,34-9.19) sxva statistikurad mniSvnelovani gansxvaveba

jgufebs Soris ar gamovlenila. miRebuli iyo urTierTsawinaaRmdego

monacemebi Jangbadis miwodebis xangrZlivobasa da Wiplaris arteriis pH-is maCveneblebs Soris. Mamgvarad, mSobiarobis dros jangbadis

profilaqtikuri gamoyenebisaTvis ar arsebobs sakmarisi mtkicebulebebi,

iseve rogorc nayofis distresis samkurnalod.

nayofis guliscema

nayofis gulicemis auskultaciuri da eleqtronuli dakvirvebis

meTodebis Sedareba

nayofis guliscemasa da mis mdgomareobas Soris kavSiri kargad aris

dadasturebuli. arsebobs nayofis guliscemis gamokvlevis ori meTodi:

uwyveti eleqtronuli monitoringi da garegani auskultacia sameano

stetoskopiT. A auskultacia ZiriTadad tardeba 15-30 wT-Si erTxel

mSobiarobis pirveli periodis ganmavlobaSi da yoveli WinTvis Semdeg

meore periodSi. Aam meTodis upiratesobas warmoadgens misi simartive -

14

es aris Sesaferisi ubralo teqnologiis magaliTi, romelic martivia

gamoyenebaSi.

eleqtronuli monitoris gamoyeneba nayofis guliscemis Sesafaseblad

aucilebelia maRali riskis orsulobisa da mSobiarobis dros. Tumca am

dros miRebuli informacia ufro zustia, misi interpretacia

kardiotaqogramebis monacemebiT ufro rTulia. 46;47

am meTodis mgrZnobeloba distresis gamovlenis TvalsazrisiT maRalia,

magram specifiuroba - dabali48. Ees imas niSnavs, rom meTodi iZleva didi

raodenobiT cru-dadebiT Sedegebs da Sesabamisad, ufro didi

raodenobiT iwvevs aramizanmimarTul Carevebs mSobiarobis procesSi,

gansakuTrebiT, Tu monitoringi gamoiyeneba dabali risk-jgufis

orsulebSi. 49;50 rigma prospeqtulma sakontrolo kvlevebma ar

gamoavlina gansxvaveba ubralo auskultaciasa da nayofis guliscemis

eleqtronul kontrols Soris, aRiniSna sakeisro kveTis ufro maRali

maCvenebeli eleqtronuli kontrolis gamoyenebis jgufSi. sistematiur

mimoxilvaSi51 sadac Sedioda 12 rkk 37 000 qalis monawileobiT da

tardeboda auskultaciis da mudmivi kardiotokografiis Sedareba ar

gamovlinda mniSvnelovani gansxvaveba perinataluri sikvdilianobis

saerTo sixSireSi (RR 0.85, 95% CI 0.59-1,23, n=33 513, 11 kvleva), magram 2-jer

Semcirda neonataluri cerebraruli damblis ganviTarebis sixSire. (RR 0.50, 95% CI 0.31-0,80, n=32 386, 2 kvleva), Tumca aranairi gansxvaveba ar iqna

gamovlenili cerebrul damblis sixSireebs Soris (RR 1,74, 95%, CI 0,97-3,11, n=13 252, 2 kvleva). mniSvnelovnad (66%-iT) gaizarda sakeisro kveTis

sixSire mudmivi kardiotokografiis gamoyenebisas (RR 1,66, 95%, CI 1,30-2,13, n=18 761, 10 kvleva), ramdenadme gaizarda operaciuli saSosmxrivi

mSobiarobis ricxvi (RR 1,16, 95%, CI 1,01-1,32, n=18 151, 9 kvleva).

eWvgareSea, rom nayofis guliscemis uwyveti eleqtronuli monitoringis

Catareba sakeisro kveTisa da operaciuli saSosmxrivi mSobiarobis

gazrdili ricxvis fonze, sadavos xdis mis gamoyenebis fiziologiurad

mimdinare mSobiarobis dros.

am monacemebs gaaCniaT Zalian mniSvnelovani zegavlena dakvirvebis

meTodis amorCevis sakiTxSi fiziologiuri mSobiarobis dros. amorCevis

meTodi nayofis guliscemis dakvirvebis mizniT fiziologiuri

mSobiarobis dros unda iyos wyvetili auskultaciis meTodi. Tumca,

iqac ki, sadac aris eleqtronuli kontrolis saSualeba, auskultaciuri

meTodi unda iyos arCevanis meTodi fiziologiuri mSobiarobis dros.

mxolod im mSobiarobis dros, rodesac saWiro xdeba mSobiarobis aRZvra

an stimulacia, an mekoniumis aRmoCenis dros, eWvgareSea eleqtronuli

meTodis upiratesobani. Ffiziologiuri mSobiarobis dros eleqtronuli

monitoringi mniSvnelovnad zrdis mSobiarobis procesSi Carevebis

raodenobas mis gamosavalze dadasturebuli dadebiTi efeqtis gareSe,

garda amisa, is warmoadgens qalisaTvis damatebiTi diskomfortis

wyaros. N

nayofis winamdebare Tavidan aRebuli sisxlis gamokvleva

es gamokvleva, romlis mizania mSobiarobaSi nayofis hipoqsiis Sefaseba

Seiswavlis nayofis mJava-tutovan wonasworobas pH-is maCvenebelis saxiT.

15

arsebobs garkveuli eWvebi am meTodis sizustesTan dakavSirebiT,

gansakuTrebiT winamdebare nayofis Tavze samSobiaro simsivnis

Camoyalibebisas, Tumca, nayofis guliscemis eleqtronul kontrolTan

erTad meTodma daadastura Tavisi klinikuri efeqturoba. is SeiZleba

gamoyenebuli iyos mxolod nayofis guliscemis cvlilebis SemTxvevaSi .

meTodi saWiroebs rTul aRWurvilobas, trenirebuli personalis

arsebobas da sakmaod arakomfortulia mSobiarisaTvis. Eeleqtrodis

Seyvanisas zogjer SesaZlebelia warmoiqmnas iseTi garTulebebi,

rogoricaa infeqcia da sisxldena nayofis Tavidan. da bolos, is

moiTxovs 24 saaTiani laboratoriuli samsaxuris arsebobas.

axlaxan Catarebulma kvlevebma aCvenes, rom Tavis kanSi laqtatis

dadgena aris pH-is kargi ganmsazRvreli, im upiratesobiT, rom is ufro

advilad Casatarebelia, ufro iafia da ufro iSviaTadaa dakavSirebuli

teqnikur siZneleebTan. laqtatis gansazRvrisaTvis saWiroa mxolod 5

mikrolitri sisxli52.

am meTodebis gamoyeneba ZiriTadad SemoisazRvreba dawesebulebebiT,

romlebic gankuTvnilia maRali riskis orsulebisaTvis. meTodis roli

fiziologiuri mSobiarobis marTvisas SezRudulia.

sanitarul-epidemiologiuri reJimi

sadac ar unda Catardes mSobiaroba, sisufTave warmoadgens

umniSvnelovanes da aucilebel pirobas. Tumca ar aris sterilobis

dacvis aucilebloba, unda moxdes xelebis saguldagulod dabana sapniT

da wyliT.Uunda mieqces yuradReba mSobiare qalis da mSobiarobis

marTvaSi CarTuli personalis higienasac. kvlevebma aCvenes, rom

regularuli baqteriologiuri kontroli da mtareblobis eradikacia ar

axdens zegavlenas nozokomialuri infeqciebis sixSireze axalSobilebsa

da dedebSi.53 BB

mniSvnelovania aseve garemos sisufTavec. adre aucilebel pirobad

iTvleboda steriluri xalaTebisa da niRbebis gamoyeneba qalis

infeqciisagan dacvis TvalsazrisiT. Aam mizniT maTi gamoyeneba

usargebloa. 54 miuxedavad amisa, aiv da Sidsis, B da C hepatitebis Tavidan acilebis mizniT, gamoyenebuli unda iyos damcavi tansacmeli

personalis dainficirebuli sisxlisagan dacvis TvalsazrisiT. 4

instrumentebi, romlebic ganmeorebiTad gamoiyeneba, unda gasterildes

msoflios jandacvis organizaciis moTxovnebis Tanaxmad. 4 aucilebelia

aseve usafrTxoebis zomebis miReba qalebisa da samedicino personalis

inficirebis Tavidan asacileblad, rac moicavs sisxlsa da siTxeebTan

pirdapiri kontaqtisagan Tavis aridebas, xelTaTmanebis gamoyenebas

saSosmxrivi gasinjvisas da mSobiarobis dros, placentis Seswavlisas.

infeqciis riskis daqveiTebis TvalsazrisiT mniSvnelovania invaziuri

meTodebis minimaluri gamoyeneba, iseTebis, rogoricaa epiziotomia da

epiziorafia.

transcervikaluri amnioinfuzia aqveiTebs nayofis guliscemis

deceleraciebis sixSires da sakeisro kveTis risks. A

16

amnioinfuziis saSualebiT qveiTdeba mekoniumiT aspiraciis

sindromis riski, sakeisro kveTisa da neonataluri avadobis

sixSire. arsebuli mtkicebulebebi mxars uWers mis gamoyenebas

qalebSi, romelTac aReniSnebaT mekonialuri sanayofo siTxe. beta–mimetikebis daniSvna nayofis distresis dros warmoadgens

drois mogebis sasargeblo xerxs, romelic saSualebas iZleva

SemuSavdes mSobiarobis marTvis Semdgomi gegma.

fiziologiuri mSobiarobis dros arCevis meTodi unda iyos

wyvetili auskultacia. nayofis guliscemis eleqtronuli

monitoringis gamoyeneba asocirebulia sakeisro

kveTisa da operaciuli saSosmxrivi mSobiarobis sixSiris

momatebasTan.

saWiroa steriluri xelTaTmanebis gamoyeneba saSosmxrivi gasinjvis,

mSobiarobisa da placentis daTvalierebis dros. mSobiarobis dros

personalma unda Caicvas sufTa tansacmeli, winsafari, saTvaleebi,

steriluri xelTaTmanebi (qudi da niRabi survilisamebr,

individualuri Tavdacvis mizniT)

mSobiarobis pirveli periodis marTva

mSobiarobis dasawyisis gansazRvra

samSobiaro moqmedebis dasawyisis gansazRvra aris mSobiarobis marTvis

erT-erTi umniSvnelovanesi momenti. rogorc wesi, mSobiarobis dawyebis

dadastureba xdeba saSosmxrivi gasinjviT. Tu mSobiarobis dawyeba

arasworadaa diagnostirebuli, Sedegad amas xSirad moyveba

dausabuTebeli Carevebi, iseTebi, rogoricaa amniotomia da/an

oqsitocinis Seyvana. zogjer preliminaruli periodisa da dawyebuli

samSobiaro moqmedebis gansasxvaveblad saWiroa mocdiTi taqtika.

fiziologiuri mSobiarobis progresi fasdeba mSobiarobis saerTo

xangrZlivobiT an saSvilosnos yelis gaxsnis siCqariT (saSualod erTi

sm/sT-Si). es ukanaskneli ufro misaRebia, radganac mSobiarobis saerTo

xangrZlivobis gansazRvra SesaZlebelia mxolod retrospeqtulad.

partograma55-57 (danarTi 1) warmoadgens mSobiarobis mimdinareobis

grafikul gamosaxulebas. miTiTebulia, rom igi unda gaixsnas

saSvilosnos yelis 3 sm gaxsnisas (mSobiarobis aqtiur fazaSi) drois

erTeulSi saSvilosnos yelis gaxsnis siCqaris grafikul

gamosaxulebasTan erTad SesaZlebelia saSvilosnos SekumSvebis, aseve

nayofis guliscemis sixSiris, medikamentebis daniSvnis da sxva

mniSvnelovani parametrebis aRniSvna. partogramis gamoyenebiT

SesaZlebelia mSobiarobis Sefaseba masze mxolod erTi daxedviT:

martivia samSobiaro moqmedebis anomaliebis gamovlena. partogramis

A

A

С

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17

gamoyeneba advilia, mis mixedviT SesaZlebelia swavleba da efeqturia

informaciis gacvla. mSobiarobis dros partogramis gamoyeneba

Seswavlili iyo mravalcentrul kvlevaSi, romelSic monawileobda 35

484 qali. partogramis danergvam Seamcira rogorc gaxangrZlivebuli

mSobiarobis (6,4% 3,4% mde), aseve stimulaciis (20,7%-dan 9,1%-mde),

saswrafo sakeisro kveTis (9,9%-dan 8,3%-mde), naadrevi mSobiarobis (0,5%-

dan 0,3%) sixSirem. 58

sanayofe wylebis daRvris sakiTxma mSobiarobis dawyebamde vadamitanili

orsulobisas (= > 38 kviras) gamoiwvia diskusia saSosmxrivi gasinjvebis

riskis, 59 mSobiarobis aRZvris saWiroebisa da antibiotikebiT

profilaqtikis aucileblobis Sesaxeb. randomizirebul kvlevaSi 60 ganxiluli iyo mSobiarobis aRZvris efeqti sanayofo wylebis daRvridan

12 saaTis Semdeg mocdiT taqtikasTan SedarebiT (sanayofo siTxis

daRvridan 48 saaTis CaTvliT). Ggamovlinda, rom mSobiarobis aRZvris

jgufSi medikamenturi gautkivarebisa da sxva samedicino Carevebis

sixSire ufro maRali iyo, vidre mocdiTi taqtikis jgufSi. Aamave dros,

axalSobilebSi infeqciuri garTulebebi mocdiTi taqtikis jgufSi

gamovlinda ufro xSirad (3,2% 1,6 % winaaRmdeg). unda aRiniSnos isic,

rom zemoT aRniSnuli monacemebi miRebulia ganviTarebul qveynebSi.

sistematurma mimoxilvam am sakiTxis Sesaxeb61 gamoavlina antibiotikebis

gamoyenebis sargeblianoba da SesaZlo gverdiTi efeqtebi qalebSi

sanayofe garsebis mSobiarobamdeli darRveviT vadamitanili orsulobis

dros. orma kvlevam, romlebic moicavda 838 qals, gamoavlina dedis

infeqciebis sixSiris daqveiTeba (qorioamnionitisa da endometritis) (RR 0.43; 95% CI 0.23–0.82). ar iqna miRebuli sarwmuno mtkicebulebebi

perinataluri sikvdilianobis Sesaxeb (RR 0.98; 95% CI 0.14–6.89). kvlevebSi

gamoyenebuli iyo parenteraluri antibiotikebis sxvadasxva kombinaciebi

(ampicilini+gentamicini+cefuroqsimi), aseve aRebuli iyo sxvadasva

drois (12 saaTiani da 24 saaTiani) intervalebi samSobiaro moqmedebis

aRZvrisaTvis. meTodologiuri arasrulfasovnebis gamo antibiotikebiT

rutinuli mkurnalobis Rirebuleba vadamitanili orsulobis dros

sanayofo buStis mSobiarobamdeli darRvevis dros ucnobia da saWiroa

damatebiTi kvlevebis Catareba am sakiTxTan dakavSirebiT.

saqarTveloSi ufro miRebulia mSobiarobis marTvis aqtiuri taqtikis

gamoyeneba, imis gaTvaliswinebiT, rom sefsisi da misi garTulebebi

warmoadgenen dedis sikvdilianobis erT-erT mTavar mizezs.

sanayofe siTxis mSobiarobamdeli daRvra orsulobis adreul vadebze

(38 kviramde) warmoadgens dedisa da axalSobilis inficirebis xSir

mizezs. axlaxan gamoqveynebulma mimoxilvam, romelSic Sevida 19 kvleva,

sadac CarTuli iyo 6000 qali62 gamoavlina, rom antibiotikebis

gamoyeneba am dros dakavSirebulia qorioamnionitis sixSiris

daqveiTebasTan (RR: 0.57, 95%CI 0.37- 0.86), mSobiarobis dawyebis

gadavadebasTan 48 saaTis ganmavlobaSi (RR 0.71, 95% CI 0.58 -0.87). mcirdeba aseve neonataluri avadobis Semdegi maCveneblebi: neonataluri infeqcia

pnevmoniis CaTvliT (RR 0.68, 95% CI 0.53- 0.87), surfaqtantis gamoyenebis sixSire (RR 0.83, 95%CI 0.72 - 0.96), bavSvTa raodenoba, romlebic saWiroeben

JangbadiT mkurnalobas (RR 0.88, 95%CI 0.81-0.96) da axalSobilTa

raodenoba Tavis tvinis ultrabgeriTi kvlevis paTologiuri

monacemebiT (RR 0.82, 95% CI 0.68- 0.98). mniSvnelovnad gaizarda bavSvTa

18

raodenoba nekrozuli enterokolitiT (ori kvleva, RR 4.60, 95% CI 1.98 -10.72) im jgufSi, sadac gamoyenebuli iyo ko-amoqsiklavi an augmentini.

mSobiarobis progresis dawvrilebiTi monitoringi unda

ganxorcieldes partogramis meSveobiT

profilaqtikuri antibiotikoTerapiis faseuloba sanayofe siTxis

naadevi daRvris dros ucnobia.

sanayofe siTxis naadrevi daRvrisas orsulobis adreul

vadebze (38 kviramde) antibiotikebis gamoyeneba amcirebs

ara mxolod qorioamnionitis sixSires, aramed iwvevs

orsulobis prolongirebas da aqveiTebs seriozuli

neonataluri avadobis sixSires,…arsebuli

mtkicebulebebidan gamomdinare eriTromicini warmoadgens

saukeTeso arCevans.

mSobiaris poza mSobiarobis pirvel periodSi.

ramodenime kvlevam daadastura, rom mSobiaris zurgze mdebareoba

auaresebs saSvilosno-placentur sisxlis mimoqcevas orsuli

saSvilosnos zewolis gamo (qveda Rru venis sindromi). zurgze wola

aqveiTebs saSvilosnos kumSvadobas63;64;65.. gamokvlevebi aseve mowmoben,

rom Tu mSobiares aqvs saSualeba imoZraos da miiRos sxeulis

nebismieri mdebareoba, saSvilosnos SekumSvebi ufro efeqturi xdeba da

mSobiaroba ufro xanmoklea da naklebad mtkivneuli, aseve mcirdeba

oqsitocinis gamoyenebis sixSire. 63-67

18 rkk-is sistematiurma mimoxilvam68 aCvena, rom lateraluri da

vertikaluri pozicia mSobiarobis dros amcirebs operaciuli Carevis

aucileblobas zurgze woliT poziciasTan SedarebiT.

Sedegebis interpretacia unda moxdes sifrTxiliT, radganac 19 kvlevis

(5764 monawile) meTodologiuri xarisxi gansxvavebuli iyo. nebismieri

mdgomare an gverdiTi poziciis gamoyeneba zurgze an liTotomiis

poziciasTan SedarebiT dakavSirebuli iyo: mSobiarobis meore periodis

xangrZlivobis SemoklebasTan (10 kvleva, saSualo 4,29 wT. 95% CI 2.95 to 5.64 min) mSobiarobis ricxvis SemcirebasTan, romlebic moiTxovdnen

Carevas (18 kvleva, RR 0.84, 95% CI 0.73 - 0.98), epiziotomiebis sixSiris

daqveiTebasTan (12 kvleva, RR 0.84, 95% CI 0.79 - 0.91), meore xarisxis Sorisis Caxevis sixSiris gazrdasTan (11 kvleva, RR 1.23, 95% CI 1.09 - 1.39) mosalodneli sisxldenebis momatebul sixSiresTan > 500ml-ze (11 kvleva, RR 1.68, 95%CI 1.32 - 2.15), meore periodis dros mwvave tkivilis SegrZnebis

daqveiTebasTan (1 kvleva RR 0.73, 95% CI 0.60 - 0.90); nayofis guliscemis

sixSiris darRvevebis SemcirebasTan (1 kvleva RR 0.31, 95% CI 0.08 to 0.98). am mimoxilvis Sedegebma gamoavlina 500 ml-ze meti sisxlis danakargis

A

A

B

19

SesaZlo ganviTareba qalebSi, romlebic vertikalur poziciaSi

mSobiaroben. sanam ar iqneba miRebuli kvlevebis ufro dawvrilebiTi

Sedegebi am sakiTxze da ar gaumjobesdeba am kvlevebis meTodologia,

orsuls unda mieces saSualeba TviTon airCios mSobiarobis pozicia.

erTaderT gamonakliss warmoadgens sanayofe siTxis daRvra moZravi

Tavis pirobebSi. mSobiarobis marTvis dros arsebuli standartebi,

magaliTad: rogoricaa guliscemis eleqtronuli monitoringi da

oqsitocinis wveTobrivi Seyvana zRudavs qalis arCevans. mdebareobis

arCevani unda iyos nebayoflobiTi - mSobiarobisas siarulis an dgomis

daZaleba aris iseTive Tavisuflebis SezRudva, rogorc moTxovna

gaunZrevlad iwves zurgze. (danarTi 2)

orsulebs unda mivceT arCevani imSobiaron im poziciaSi,

romelsac isini yvelaze komfortulad Tvlian.

yvela qals unda gaewios mudmivi mxardaWera mSobiarobis

dros. partogramis gamoyeneba, lateraluri da vertikaluri

poza da epiduruli anesTeziis Tavidan acileba amcirebs

mSobiarobis dros operaciuli Carevis aucileblobas.

saSosmxrivi gasinjva

saSosmxrivi gasinjva warmoadgens mSobiarobis dawyebisa da progresis

Sefasebis erT-erT umniSvnelovanes saSualebas. saSosmxrivi gasinjvis

raodenoba unda SeizRudos. mSobiarobis pirveli periodis ganmavlobaSi

sruliad sakmarisia saSosmxrivi gasinjva yovel 4 saaTSi erTxel,

rogorc es mocemulia mSobiarobis partogramaSi. 69

garda amisa, saSosmxrivi gasinjva unda Catardes mxolod samedicino

CvenebebiT: samSobiaro moqmedebis sisuste, sanayofo siTxis daRvra an

WinTvebis dawyeba. es unda ganisazRvros adgilobrivi protokoliT.

klinikur bazebze, sadac mimdinareobs studentebis swavleba, xSirad

aucilebeli xdeba swavlis mizniT saSosmxrivi gasinjvebis warmoeba. Aam

dros aucilebelia qalis Tanxmoba. AaraviTar SemTxvevaSi ar unda

ganxorcieldes zewola qalze misi Tanxmobis miRebis mizniT. Aarc Tu

ise Soreul warsulSi SemoTavazebuli iyo reqtaluri gasinjva qalis

inficirebis riskis daqveiTebis TvalsazrisiT. SedarebiTma kvlevebma,

romlebic Catarebulia reqtaluri da vaginaluri gasinjvis

Sesadareblad ar gamoavlines gansxvaveba inficirebis ganviTarebis

sixSireebs Soris. 54

samSobiaro moqmedebis progresis gansazRvra

mSobiarobis progresis Sefaseba xdeba mSobiare qalze dakvirvebis

safuZvelze - misi qceviT, saSvilosnos SekumSviT, winamdebare nawilis

winmsvlelobiT, magram saSvilosnos yelis gaxsnis xarisxi mSobiarobis

progresis yvelaze zust kriteriums warmoadgens. miRebuli normebisagan

A

A

20

gadaxra unda gaxdes safuZveli mSobiarobis marTvis gegmis

gadaxedvisaTvis. Ppartogramis warmoebisas es vlindeba saSvilosnos

yelis gaxsnis SenelebiT (< 1 sm/saaTSi); bebiaqalis meTvalyureobis qveS

mimdinare mSobiarobis dros aseTi Seneleba unda iyos safuZveli

mSobiaris stacionarSi gadasayvanad.70 aucilebelia samSobiaro

moqmedebis Senelebis mizezis gansazRvra. kvlevebi gviCvenebs, rom

daaxlovebiT 20% pirveladi mSobiarebSi yelis gaxsnis siCqaris xazi

kveTavs yuradRebis xazs, xolo 10-11% ki Carevis xazs.71 mSobiarobis

neli progresi unda gaxdes ufro mizezis gamovlenis da ara aqtiuri

Carevis safuZveli. unda gamovlindes menjisa da nayofis Tavis

Seusabamobis niSnebi.

mTeli sanayofe buStis pirobebSi da gamoxatuli samSobiaro moqmedebis

dros Seusabamoba ar warmoadgens mSobiarobis Senelebis mizezs. aseT

SemTxvevebSi mizanSewonilia mocdiTi taqtika72, radganac dRevandel

dRes ar aris samecniero kvlevebi mSobiarobis aqtiuri marTvisa da

mocdiTi taqtikis SedarebasTan dakavSirebiT, Znelia zusti

rekomendaciebis gacema am sakiTxze.

daRvrili sanayofe siTxis pirobebSi da samSobiaro moqmedebis sisustis

dros ufro xSirad vlindeba meqanikuri mizezebi. aseTi mSobiarobis

marTva scildeba mocemuli rekomendaciebis farglebs.

samSobiaro moqmedebis sisustis profilaqtika

arsebobs ramodenime saSualeba samSobiaro moqmedebis sisustis

profilaqtikisaTvis. zogjer es RonisZiebebi tardeba bevrad ufro adre,

vidre partogramaze gamoCndeba samSobiaro moqmedebis Sesusteba. ufro

xSir Carevebs warmoadgens adreuli amniotomia da oqsitocinis

intravenuri Seyvana an am ori meTodis kombinacia.

adreuli amniotomia

es procedura, sanayofe garsebis qirurgiuli darRveva, SemoTavazebuli

iyo zogierTi avtoris mier, rogorc aucilebeli samSobiaro moqmedebis

dawyebidan 1 saaTis Semdeg. 73 Tumca kvlevebma gamoavlines pirveli tipis

gviani deceleraciebis sixSiris mniSvnelovani momateba adreuli

amniotomiis Semdeg. ramodenime randomizirebul kvlevaSi gamovlinda,

rom adreuli amniotomia mSobiarobis dros amoklebs mSobiarobis

xangrZlivobas saSualod 60-120 wuTamde da ar axdens zegavlenas

analgeziis da operaciuli Carevis gamoyenebis sixSireze. kvlevebma ar

gamoavlines adreuli amniotomiis raime zegavlena axalSobilTa

mdgomareobaze. 74-76

msgavsi daskvnebi miRebulia sistematuri mimoxilvaSi,77 sadac

ganixileboda rutinuli adreuli amniotomiis efeqti mSobiareebis

dabali riskis jgufSi. aRmoCnda, rom adreuli amniotomia zrdis

sakeisro kveTis albaTobas, amcirebs mSobiarobis xangrZlivobas,

oqsitocinis gamoyenebis sixSiresa da samSobiaro tkivilebs. rac

Seexeba axalSobilTa gamosavals, Semcirda apgaris SkaliT 7-ze naklebi

quliT dabadebuli bavSvebis raodenoba. statistikurad sarwmuno

21

gansxvaveba ar gamovlenila neonataluri avadobis sxva maCveneblebSi,

rogoricaa Wiplaris arteriis mJava-tutovani balansi da intensiuri

Terapiis ganyofilebaSi gadayvana.

rutinuli adreuli amniotomia saerTo jamSi ar aris sargebliani. imis

gamo, rom is zrdis sakeisro kveTis albaTobas. A fiziologiuri

mSobiarobis SemTxvevaSi amniotomiis CatarebisaTvis unda arsebobdes

mniSvnelovani Cveneba.

rutinul adreul amniotomias - ar gaaCnia upiratesoba, radganac

izrdeba sakeisro kveTis albaToba. fiziologiuri mSobiarobis

dros amniotomiis CatarebisaTvis unda arsebobdes mniSvnelovani

Cveneba.

oqsitocinis intravenuri Seyvana

oqsitocinis intravenuri Seyvana xSirad gamoiyeneba mSobiarobis

dasaCqareblad sanayofo garsebis TviTneburi an xelovnuri darRvevis

Semdeg. Ooqsitocinisa da adreuli amniotomiis kombinaciis gamoyenebas

xSirad mSobiarobis aqtiur marTvasac uwodeben. Ppirvelad es meTodika

mowodebuli iyo irlandiaSi78 da Seswavlili iyo mraval

randomizirebul kvlevebSi. sxva kvlevaSi73 sakontrolo jgufis qalebs

sTxovdnen ar dawoliliyvnen sawolSi, aramed sakuTari survilisamebr

damjdariyvnen an emoZravaT. am jgufSi mSobiarobis saSualo

xangrZlivoba iyo umniSvnelod ufro mokle, vidre oqsitocinis

gamoyenebis jgufSi. Aar iyo gansxvaveba axalSobilebis apgariT

SefasebaSi, aseve axalSobilebis gadayvanaSi reanimaciul

ganyofilebaSi. qalTa umravlesoba aRniSnavda, rom oqsitociniT

stimulacia iwvevda arasasiamovno SegrZnebebs. mSobiareTa 80%-ze metma

aRniSna, rom stimulaciam gaaZliera tkivili mSobiarobis dros.

sakontrolo jgufis qalTa naxevarma aRniSna, rom moZraoba mSobiarobis

dros amsubuqebda tkivils maSin, rodesac qalTa 24%-ma ver SeniSna

veranairi gansxvaveba.

aucileblobis SemTxvevaSi oqsitocinis gamoyeneba SeiZleba marto im

dawesebulebebSi, sadac SesaZlebelia saswrafo qirurgiuli daxmarebis

aRmoCena. am dros aucilebelia nayofis guliscemis eleqtronuli

monitoringi. Ddublinis kvlevis gamocdileba aseve xazs usvams Semdegs:

qalTa im jgufSi, sadac gamoyenebuli iyo auskultacia, ufro maRali

iyo nevrologiuri garTulebebis sixSire. gansakuTrebiT es aRiniSneboda

qalebSi, romelTac CautardaT oqsitociniT stimulacia. 42

igive exeba mSobiarobis aRZvris mizniT prostaglandinebis gamoyenebas.

oqsitocinis intravenuri Seyvana dasaSvebia Mmxolod infuzomatis

gamoyenebiT. Seyvanili oqsitocinis raodenoba ganisazRvreba mlerT/wm-Si

da xdeba Semdegi sqemiT: 5 erT. oqsitocini unda gaixsnas 50 ml. SpricSi.

miRebul xsnarSi oqsitocinis koncentracia Seadgens 100 mlerT/ml.

Sprici unda dayendes infuzomatSi da SeirCes Seyvanis siCqare.

A

22

3 ml/sT-5,1 mlerT/wT

4 ml/sT-6,7 mlerT/wT

5 ml/sT-8,3 mlerT/wT

6 ml/sT-10 mlerT/wT

rogorc wesi oqsitocinis infuzia unda daiwyos 3 ml/sT-iT (5,1

mlerT/wT-iT) da gaormagdes yovel 20-25 wT-Si, sanam ar iqneba miRweuli

sasurveli intensiobis samSobiaro moqmedeba (6-7 Seteva 15 wT-is

ganmavlobaSi)

oqsitocinis intravenuri Seyvana mSobiarobis dros

samSobiaro moqmedebis gasaZliereblad dasaSvebia Mmxolod

infuzomatis gamoyenebiT

oqsitocinis Seyvana kunTebSi

oqsitocinis kunTebSi Seyvana mSobiarobis stimulaciis mizniT

ganixileba, rogorc saSiSi meTodi saSvilosnos hiperstimulaciisa da

nayofze uaryofiTi zegavlenis gamo. aRsaniSnavia aseve saSvilosnos

gaskdomis momatebuli sixSirec.79 es araswori taqtika saswrafod unda

aikrZalos.

mSobiarobis meore periodis marTva

mSobiarobis meore periodSi nayofis oqsigenacia TandaTanobiT

qveiTdeba WinTvebis da saSvilosno-placentaruli sisxlis mimoqcevis

daqveiTebis gamo. xangrZlivi WinTvebi mniSvnelovnad aqveiTebs

placentarul sisxlis mimoqcevas, rasac Tan sdevs acidozis ganviTareba.

meore periodis ganmavlobaSi arsebobs individualuri gansxvavebebi,

aqedan gamomdinare, aucilebelia nayofis mdgomareobis dinamiuri

kontroli.

zogierT samSobiaroSi Cveulebriv praqtikad iTvleba mSobiares

gadayvana winasamSobiaro palatidan samSobiaro darbazSi meore

periodis dasawyisSi. Cveulebriv, samSobiaro bloki aRWurvilia

sanaTurebiT, sawolebiT, romlebsac aqvT fexebis dasadebi da sxv.

miuxedavad imisa, rom aseTi oTaxebi ufro xelsayrelia samedicino

personalisaTvis, qalisaTvis nebismieri transportireba arasasurvelia

da arasasiamovno. Nnormaluri mSobiarobis dros ar aris aucilebeli

qalis gadayvana sxva adgilze. warmatebulad SesaZlebelia qalis

momSobiareba igive oTaxSi, sadac mimdinareobda mSobiarobis pirveli

periodi.

C

23

WinTvebis dawyeba

qals sTxoven gaiWinTos saSvilosnos yelis sruli gaxsnisas rodesac

winamdebare nawili aris menJis fskerze. Ffiziologiuri midgoma

mdgomareobs imaSi, rom WinTvis SegrZneba qals TviTneburad

Camouyalibdes. Aar aris Catarebuli randomizirebuli sakontrolo

kvlevebi, romlebic Seadarebdnen WinTvebis adreul dawyebas maT gvian

dawyebasTan fiziologiuri mSobiarobis dros, Tumca ramodenime aseTi

kvleva Catarebulia epiduruli analgeziis gamoyenebisas.80 WinTvebis

daTrgunvisas gautkivarebis am meTodis gamoyenebis dros advilia

WinTvebis SeCereba SeWris momentamde. aseTi midgoma Sedarebuli iyo

WinTvebis dawyebasTan saSvilosnos yelis sruli gaxsnisas. 81-83

WinTvebis gviani dawyeba ar axdenda uaryofiT gavlenas dedisa da

nayofis mdgomareobaze. adreuli WinTvebis jgufSi aRiniSna sameano

maSebis gamoyenebis momatebuli sixSire.

zogjer WinTvebis dawyebis win xdeba Sardis buStis dacla kaTeteris

meSveobiT, magram amis aucilebloba ar aris. kaTeterizaciam

SesaZlebelia gamoiwvios saSarde gzebis dainficireba. Cadgmuli Tavis

pirobebSi kaTeterizacia gaZnelebulia da travmulic ki. sasurvelia,

mSobiares vTxovoT moSardos pirveli periodis dros, fiziologiuri

mSobiarobis dros es srulebiT sakmarisia.

WinTvis teqnika

dRevandel dRes farTod gamoiyeneba WinTvis teqnika, rodesac qali

xangrZlivad ikavebs haers da iWinTeba erTi WinTvis ganmavlobaSi 2-3-jer

20-30 wamis ganmavlobaSi (valsalvas meTodi). alternatiul meTods

warmoadgens xanmokle WinTvebi (4-6 wamis ganmavlobaSi) erTi WinTvis

ganmavlobaSi 3-5-jer.

ramodenime kvlevaSi 84;85;86;87

Catarda ori zemoT aRniSnuli meTodis

Sedareba. tradiciuli teqnikisaTvis damaxasiaTebelia meore periodis

ramdenadme Semokleba, magram mas SeuZlia nayofis guliscemis da gulis

gadmosrolis seriozuli darRvevebis gamowveva, rac sunTqviTi

teqnikiTaa ganpirobebuli. zurgze wolis gamo qveda Rru venaze zewola

auaresebs am mdgomareobas. Catarebul kvlevebSi pH saSualo maCvenebeli

ufro dabali iyo jgufSi haeris xangrZlivi SekavebiT, xolo

axalSobilebs aReniSnebodaT tendencia apgariT Sefasebis

daqveiTebisaken. Mmiuxedavad imisa, rom arsebuli monacemebi Zalian

mwiria, ufro mizanSewonilia xanmokle WinTvebi (4-6 wamis ganmavlobaSi)

erTi WinTvis ganmavlobaSi 3-5-jer

mSobiarobis meore periodis xangrZlivoba

1930 wels 628 qalSi Seswavlili iyo88 mSobiarobis meore periodis

xangrZlivoba nayofis TaviT winamdebareobis dros, romelmac saSualod

miaRwia 75 wuTs. Mmeore periodis xangrZlivoba didadaa damokidebuli

samedicino personalze, romelic marTavs mSobiarobas. Nnayofis

24

acidozisa da hipoqsiis kavSiri meore periodis xangrZlivobasTan

xSirad warmoadgens mizezs meore periodis SemoklebisaTvis Cvenebis

gareSec ki. aseTi midgoma Seswavlili iyo rig kvlevebSi 89-91. mSobiarobis meore periodis Semoklebam saTanado Cvenebebis gareSe

gamoavlina mxolod pH mniSvnelovani momateba Wiplaris arteriaSi, sxva

raime upiratesobebis gareSe dedisa da nayofis mxriv, maTi momatebuli

travmatizmis fonze, rac ar SeiZleba iyos gamarTlebuli. aqedan

gamomdinare, dedisa da nayofis damakmayofilebeli mdgomareobis dros

ar arsebobs safuZveli mSobiarobis meore periodis naadrevi

dasrulebisaTvis, pirobiTi maCveneblis gadaWarbebis SemTxvevaSic ki.

ramodenime kvlevaSi Seswavlili iyo im axalSobilTa mdgomareoba,

romlebic dabadebuli iyvnen meore periodis sxvadasxva xangrZlivobis

Semdeg. 148 axalSobili Seswavlili iyo pH maCveneblebis da

nevrologiuri indeqsis gansazRvris Semdeg. Mmeore periodis

xangrZlivoba meryeobda, 60 wuTidan (pirvelmSobiareTa 66%) 159 wuTamde.

ar iqna gamovlenili kavSiri meore periodis xangrZlivobasa da

axalSobilTa mdgomareobas Soris.92 Catarebuli kvlevebi exeboda 6759

axalSobils, dabadebuls TaviT winamdebareobaSi, woniT >2500 gramze;

mSobiarobis meore periodis xangrZlivoba aRemateboda 3 saaTs 11%

SemTxvevaSi. Aar gamovlenila kavSiri meore periodis xangrZlivobasa da

apgariT Sefasebis dabal maCveneblebs, nevrologiur garTulebebsa an

axalSobilTa intensiuri Terapiis ganyofilebaSi gadayvanis

aucileblobas Soris. 93

amrigad, unda aRiniSnos, rom meore periodis SemoklebasTan

dakavSirebuli gadawyvetileba unda daefuZnos dedisa da nayofis

mdgomareobas. Tu dedisa da nayofis mdgomareoba damakmayofilebelia, ar

arsebobs safuZveli mSobiarobis naadrevad dasrulebisaTvis.

kategoriulad dauSvebelia WinTvebis Forsireba (saSvilosnos fuZeze

zewola)

ase rom, WinTvebis gadavadeba ufro mizanSewonilia nayofis

keTildReobisaTvis, romelic gamoixateba JangbadiT saturaciaSi94

mSobiaris pozicia mSobiarobis meore periodis dros.

rigi kvlevebiT95;96;96;97 dadasturda, rom vertikalur pozicias

mSobiarobis meore periodSi gaaCnia upiretesobani Cveulebriv

poziciasTan SedarebiT. Qqalebi am dros ganicdian ufro nakleb

diskomfortsa da sirTuleebs WinTvebisas, qveiTdeba tkivilis SegrZneba,

mcirdeba samSobiaro gzebis travmatizmi da Wrilobis inficireba.

19 kvlevis sistematurma mimoxilvam,68 romelSic CarTuli iyo 5764

monawile, aCvena, rom nebismieri mdgomare an gverdiTi poziciis

gamoyeneba zurgze an liTotomiis poziciasTan SedarebiT dakavSirebuli

iyo mSobiarobis meore periodis xangrZlivobis daqveiTebasTan (10

kvleva, saSualo 4,29 wT. 95% CI 2.95 - 5.64 wT), mSobiarobis dros

daxmarebis raodenobis daqveiTebasTan (18 kvleva, RR 0.84, 95% CI 0.73 - 0.98), epiziotomiebis sixSiris daqveiTebasTan (12 kvleva, RR 0.84 95%CI 0.79 - 0.91), Sorisis meore xarisxis Caxevisa da sisxldenebis momatebul sixSiresTan

25

(11 kvleva RR 1.68 95% CI 1.32 -o 2.15); meore periodis dros mwvave tkivilis

SegrZnebis daqveiTebasTan (1 kvleva RR 0.73, 95% CI 0.60 - 0.90); nayofis

guliscemis sixSiris darRvevebis nakleb raodenobasTan ( 1 kvleva RR 0.31 95% CI 0.08 -0.98). am mimoxilvis sacdelma Sedegebma aCvenes vertikaluri poziciis dros

500 ml-ze meti sisxlis danakargis ganviTarebis SesaZlebloba.

kvlevebSi, romlebic Seiswavlida qalebis damokidebulebas mSobiarobis

poziciis arCevisadmi, gamovlinda, rom vertikaluri pozicia ufro

misaRebi iyo qalebisaTvis naklebad gamoxatuli tkivilisa da xerxemlis

diskomfortis gamo. tradiciuli pozicia maT mier ganixileboda,

rogorc ufro xelsayreli, magram moZraobis TvalsazrisiT ufro

SemzRudavi. Qqalebma, romelTac hqondaT vertikaluri mSobiarobis

gamocdileba, gamoTqves survili SemdgomSic aseTi saxiT emSobiaraT. 98; 7

da bolos unda aRvniSnoT, rom es daskvna misaRebia mSobiarobis

rogorc pirveli, aseve meore periodisaTvis. qals SeuZlia Tavisuflad

amoirCios is pozicia, romelic mas ufro moswons da yvelaze ufro

metad aris misTvis xelsayreli. qalebs unda gaewioT mxardaWera im

poziciis arCevisas, romelic maTTvis yvelaze xelsayrelia. samedicino

personali gawvrTnili unda iyos mSobiarobis misaRebad nebismier

poziciaSi ise, rom qalis survilebi ar SeizRudos.

Catarda kvlevebi,99 romlebSic Sedarda mSobiarobis gamosavali

mSobiarobis meore periodis Catarebisas sameano savarZelSi da mis

gareSe. winaswar informirebuli pirveladi mSobiareebi gaurTulebeli

mSobiarobiT da epiduruli analgeziis gareSe randomizirebulni iyvnen

samSobiarod savarZelSi (n=163) da savarZlis gareSe jgufSi (n=157). mSobiarobis meore periodis xangrZlivobam savarZlis gareSe

mSobiarobisas 13 wT-iT gadaaWarba meore periodis xanglZlivobas

pirveli jgufis qalebSi (sameano savarZelSi). ar gamovlenila raime sxva

klinikuri gansxvaveba dedisa da axalSobilis mxriv mocemul or jgufs

Soris. miuxedavad imisa, rom savarZelSi WinTva dakavSirebulia meore

periodis mcired SemoklebasTan, raime sxva upiratesoba mas ar gaaCnia.

Sorisis dacva da movla mSobiarobis dros

Sorisis dacvis mizniT mSobiarobis dros gamoiyeneba ramodenime xerxi.

meanobisMmraval saxelmZRvaneloSi aRwerilia Sorisis dacva Tavis

gamoWris dros: erTi xelis, ZiriTadad marjvenas TiTebiT afiqsireben

Soriss, maSin, rodesac meore xeli akontrolebs Tavis gamoWris siCqares

raTa Tavidan aicilon Sorisis travma. SesaZlebelia, rom aseTi meTodi

Tavidan gvacilebs saSosa da Sorisis Caxevebis ganviTarebas, magram

winmsvlel Tavze zewola arRvevs gaSliT meqanizms Tavis dabadebisas,

aSorebs ra mas Sexebis wertilisagan simfizis rkalTan da amiT zrdis

Sorisis Caxevis albaTobas.

„HOOP“ kvlevaSi100 Sedarebuli iqna meTodi “xeldaxmarebiT” (rodesac

erTi xeli moTavsebulia bavSvis Tavze masze zewolis da mSobiarobis

kontrolis mizniT, xolo meore xeli moTavsebulia Sorisze da

gamoiyeneba gverdiTi moxra mxrebis ganTavisuflebis gasaadvileblad)

meTodTan “xeldaxmarebis gareSe” (qalis instruqtaJi da xelSeuxebloba

26

bavSvis Tavsa da Sorisze, saWiroebis SemTxvevaSi zewolis

ganxorcielebis mzadyofniT).

kvlevaSi randomizirebuli iyo 5471 qali. pirveli jgufis qalebi

aRniSnavdnen nakleb mtkivneulobas mSobiarobis Semdgom 10 dRis

ganmavlobaSi meore jgufTan SedarebiT. (34.1% vs. 31.1%; RR 1.10, 95% CI 1.01-1.18) damatebiT, epiziotomiis sixSire ufro maRali iyo xeldaxmarebis

jgufSi (12.9% vs. 10.2%; RR 0.79, 99% CI 0.65-0.96) xolo placentis xeliT

mocileba ufro dabali (1.5% vs. 2.6%; RR 1.69, 99% CI 1.02-2.78). ar

gamovlenila sxva raime statistikurad mniSvnelovani gansxvaveba

jgufebs Soris.

unda aRvniSnoT, rom Sorisis tradiciuli dacva SesaZlebelia mxolod

qalis zurgze mSobiarobisas. orsulTa vertikaluri an jdomiTi pozis

dros Sorisis dacva xdeba masTan Sexebis gareSe.

masaJi

Sorisis dacvis sxva teqnika mdgomareobs mSobiarobis meore periodSi

Sorisis mudmivi masaJiT misi gawelvis mizniT qsovilebis maqsimaluri

elastiurobis misaRwevad.

Catarda randomizirebuli kvleva101 mSobiarobis meore periodSi Sorisis

masaJis efeqtis dasadgenad specialuri wyalSi xsnadi lubrikantis

gamoyenebiT. kvlevaSi randomizebuli iyo 1340 mSobiare. dauzianebeli

Sorisis, aseve pirveli da meore xarisxis Caxevebis sixSire Tanabari iyo

masaJisa da sakontrolo jgufs Soris. aRiniSna meti mesame xarisxis

Caxeva masaJis jgufSi (12 (1.7%) v 23 (3.6%); AR 2.11, RR 0.45; 95% CI 0.23 to 0.93, P<0.04), aqedan gamomdinare, Sorisis masaJi mSobiarobis meore periodSi ar aqveiTebs Sorisis travmis, tkivilis, dispareuniis, aseve Sardisa da

ganavlis Seukaveblobis problemebs.

sxva monacemebi miRebulia masaJis sargrblianobaze antenatalur

periodSi. sistematiurma mimoxilvam – 3 rkk (2434 qali) aCvena rom

Sorisis masaJi am dros dakavSirebulia travmebis saerTo sixSiris

daqveiTebasTan, romlebic saWiroeben aRdgenas. (RR 0.91 95% CI 0.86 0.96),

travmis sixSiris daqveiTeba statistikurad sarwmuno iyo mxolod

pirvlmSobiareebSi (RR 0.90 95% CI 0.84 to 0.96) qalebs, romlebsac

ukeTdebodaT Sorisis masaJi, ufro iSviaTad esaWiroebodaT epiziotomia RR 0.85 (95% CI 0.75 to 0.97).

ar aRiniSneboda gansxvaveba pirveli, meore, mesame da meoTxe xarisxis

Sorisis travmebs Soris. ganmeorebiT mSobiareebSi aRiniSneboda

tkivilis intensiobis mniSvnelovani daqveiTeba mSobiarobidan 3 Tvis

Semdeg. RR 0.68 (95% CI 0.50 to 0.91) ar iyo nanaxi mniSvnelovani gansxvaveba

instrumentuli mSobiarobis, sqesobrivi dakmayofilebis, Sardis,

ganavlis an airebis Seukaveblobis sixSireebs Soris qalebSi Sorisis

masaJisa da sakontrolo jgufs Soris.

amis gamo, qalebs unda miewodoT informacia Sorisis masaJis

SesaZlebeli sargeblianobisa da misi teqnikis Sesaxeb perinataluri

dakvirvebis dros

27

Sorisis masaJi mSobiarobis meore periodSi ar aqveiTebs

Sorisis travmis, tkivilis, dispareuniis, aseve Sardisa da

ganavlis Seukaveblobis problemebs.

Sorisis Caxeva, perineotomia da epiziotomia

epiziotomiis sixSire gansxvavdeba sxvadasxva qveynebSi.102 magram

aRiniSneba statistikurad sarwmuno epiziotomiebis ricxvis Semcireba

1983 -2000 wlebis SualedSi .103

ase magaliTad, aSS-is saavadmyofoebSi epiziotomiis sixSire aRwevs 20-

73%-s, rac am proceduras yvelaze gavrcelebuls xdis. Sorisis mesame da

meoTxe xarisxis dazianebis sixSire varirebs 4-13%-mde sxvadasxva

saavadmyofoebSi. 104 holandiaSi ki, sadac mSobiaroba mihyavT ZiriTadad

bebiaqalebs, epiziotomiis sixSire Sedagens 24,5%-s. 105

ZiriTadad, gamoiyeneba CaWris ori saxe. Pperineotomiisas Wriloba ufro

advilad ikereba da aRiniSneba ufro kargi kosmetikuri efeqti, maSin,

rodesac Sua-lateraluri epiziotomia ufro efeqturad icavs

dazianebisagan swor nawlavs.

Sorisis CaWris ZiriTad Cvenebebs fiziologiuri mSobiarobisas

warmoadgens nayofis asfiqsiis niSnebi, Tavis winmsvlelobis Seneleba,

Sorisis mosalodneli Caxeva. Sorisis CaWris farTo gamoyenebis

mxardaWerisaTvis literaturaSi moyvanilia damatebiTi argumentebi: am

dros Wriloba ufro advilad aRdgeba da ufro Cqara xorcdeba,

nawarmoebi Wriloba icavs Soriss da menjis Rrus kunTebs Semdgomi

travmisagan, riTac xdeba Sardis Seukaveblobis simptomebis

Camoyalibebis Tavidan acileba.

Catarebulma gamokvlevebma ar daadastures zemoT aRniSnuli

mosazrebebi Sorisis CaWris aucilebeli damcvelobiTi Catarebis

sasargeblod.

eqvsi rkk-is monacemebis meta-analizma106

aCvena, rom SezRuduli

epiziotomia rutinulTan SedarebiT dakavSirebulia Sorisis ukana

nawilis nakleb dazianebasTan (RR 0.88, 95% CI 0.84 - 0.92), kervis nakleb

aucileblobasTan (RR 0.74, 95% CI 0.71 - 0.77) da Sexorcebisas nakleb

garTulebebTan (RR 0.69, 95% CI 0.56 - 0.85). SezRuduli epiziotomia

dakavSirebuli iyo Sorisis wina nawilis ufro xSir dazianebasTan. (RR 1.79, 95% 1.55-2.07). ar inaxa gansxvaveba saSos da Sorisis mZime dazianebebs

Soris (RR 1.11, 95% CI 0.83-1.50); dispareuniis sixSires Soris, (RR 1.02, 95%

CI 0.90 - 1.16); Sardis Seukaveblobis sixSireebs Soris, (RR 0.98, 95% CI 0.79 - 1.20) da mwvave tkivilis gancdas Soris. igive Sedegebi iyo miRebuli

SezRuduli epiziotomiis Sedarebisas mediolateralur an Suaxazis

epiziotomiasTan.

aqedan gamomdinare, fiziologiuri mSobiarobis dros epiziotomia unda

Catardes mkacri Cvenebebis mixedviT. karg magaliTs warmoadgens

monacemebi, romelic inglisSi Catarebuli kvleviT aris miRebuli, sadac

A

28

dedisa da nayofisaTvis zianis miyenebis gareSe epiziotomiis sixSire

daqveiTebulia 10%-mde. 107

zogierTi avtoris mier SemoTavazebulia, ar gaikeros Sorisis

umniSvnelo (I da II xarisxis travmebi).

Catarda ori mcire rkk da ori mcire retrospeqtuli kvleva Sorisis

pirveli da meore xarisxis travmebis gakervisa da maTi gakervis gareSe

datovebis Sesadareblad. SotlandiaSi Catarebulma kvlevam108 (74

pirveladi mSobiare) ar gamoavlina mniSvnelovani gansxvaveba jgufebs

Soris tkivilis TvalsazrisiT, magram gakervis jgufSi gamovlinda

Wrilobis ufro kargi mdgomareoba mSobiarobidan 6 kviris Semdeg.

SveciaSi Catarebulma rkk-m109 (78 pirveladi mSobiare) aCvena tkivilis

umniSvnelo momateba gakervis gareSe datovebul jgufSi, magram ar

gamoavlina gansxvaveba Wrilobis SexorcebaSi jgufebs Soris. orma

mcire retrospeqtulma kvlevam110;111 ar gamoavlina gansxvaveba adreul

avadobaSi da Wrilobis SexorcebaSi jgufebs Soris. SemdgomSi

Catarebuli sami kvleva meTodologiurad arasrulfasovani iyo. saWiroa

ufro meti mtkicebulebebis mopoveba gakerili da gakervis gareSe

datovebuli Sorisis I da II xarisxis travmebis axlo da Soreuli

efeqtebis Sesaxeb.

epiziotomiis warmoeba fiziologiuri mSobiarobis dros

dasaSvebia mxolod mkacri CvenebebiT. Mmisi rutinuli

gamoyeneba dauSvebelia.

Sorisis travmis aRsadgenad gamwovi sinTetikuri masalis

(deqsonis da vikrilis) gamoyeneba, ketgutTan SedarebiT,

mniSvnelovnad amcirebs tkivils, analgeziis gamoyenebis,

Wrilobis gaxsnis da xelmeored gakervis sixSires.

mSobiarobis mesame periodis marTva

mSobiarobis mesame periodi xasiaTdeba momyolis (placentis)

mocilebiTa da gamoyofiT. Aam dros dawyebuli sisxldena (placentis

nawilebis CarCenis gamo) SeiZleba sicocxlisaTvis saSiSi aRmoCndes.

sisxlis dena mSobiarobis Semdgom Aadreul periodSi warmoadgens dedis

sikvdilianobis erT-erT ZiriTad mizezs ganviTarebad qveynebSi. 112

mSobiarobis Semdgomi sisxlis denis sixSire matulobs risk-faqtorebis

arsebobisas: mravalnayofiani orsulobis, mravalwylianobis,

mSobiarobis stimulaciisa da saSosmxrivi operaciuli mSobiarobis

dros. 113 fiziologiuri mSobiarobis drosac SesaZlebelia mesame

periodi garTuldes sisxldeniT. am garTulebis Tavidan acilebis

mizniT Casatarebeli ramodenime RonisZieba SemoTavazebuli da

A

A

29

Seswavlili iyo randomizirebuli kontrolirebadi kvlevebis

saSualebiT da warmodgenilia qvemoT.

saSvilosnos SesakumSi preparatebis profilaqtikuri gamoyeneba.

SesakumSi nivTierebebis Seyvana xdeba mesame periodis sxvadasxva

etapebze, ufro xSirad intravenurad da kunTebSi, nayofis wina mxaris an

axalSobilis dabadebis Semdeg.

ZiriTadad Seswavlilia da gamoiyeneba oqsitocini da ergotaminis

derivatebi - meTilergometrini an am ori preparatis kombinacia-

sintometrini

7 kvlevis (3000 qalze meti) sistemurma mimoxilvam,114 romelic Catarda

ganviTarebul qveynebSi, aCvena oqsitocinis profilaqtikuri gamoyenebis

efeqturoba (naklebi sisxlis danakargi, RR sisxlis danakargisaTvis >

500 ml-ze 0.50; 95%, CI 0.43,- 0.69) da oqsitocinis Terapiuli mizniT

gamoyenebis naklebi sixSire (RR 0.50; 95% CI 0.39, 0.64); im jgufTan

SedarebiT, sadac SesakumSi saSualebebi ar iyo gamoyenebuli,

gamovlenili iyo umniSvnelod gazrdili tendencia placentis xeliT

mocilebisa (RR 1.17; 95% CI 0.79, 1.73) da amave dros momatebuli iyo

sisxlis transfuziis saWiroeba (RR 1.30; 95% CI 0.50, 3.39)

oqsitocinisa da ergometrinis Sedareba moxda 6 kvlevaSi,115 romelic

moicavda 9332 qals, oqsitocinTan SedarebiT, ergometrinisa da

oqsitocinis kombinacia asocirebuli iyo mSobiarobis Semdgomi

sisxldenis sixSiris daqveiTebasTan (sisxlis danakargi minimum 500 ml),

(OR 0.82, 95% CI 0.71 - 0.95). es dadebiTi efeqti aRiniSna oqsitocinis

rogorc 5 ise 10 erTeulis gamoyenebisas, magram efeqti ufro

gamoxatuli iyo dabali dozis (5 erT) Seyvanisas. ar gamovlenila

gansxvaveba sisxlis danakargis 1000ml da meti danakargis TvalsazrisiT.

iseTi gverdiTi efeqtebi, rogoricaa gulisreva, Rebineba da hipertenzia

ufro damaxasiaTebeli iyo ergometrinisa da oqsitocinis

kombinaciisaTvis. rodesac mxedvelobaSi iyo miRebuli jgufebis

heterogenuloba, ar gamovlenila statistikurad sarwmuno gansxvaveba

dedisa da axalSobilis gamosavalis mxriv. ergometrin-oqsitocinis

rutinuli gamoyeneba, rogorc mesame periodis aqtiuri marTvis nawilisa

asocirebulia mSobiarobis Semdgomi sisxlis denis mcire, magram

statistikurad sarwmuno daqveiTebasTan im SemTxvevaSi, rodesac sisxlis

danakargi udris an aRemateba 500 ml-s. ar gamovlenila statistikurad

sarwmuno gansxvaveba 1000 ml–is toli an meti sisxlis denis SemTxvevaSi.

statistikurad sarwmuno gansxvaveba aRiniSna dedis mxriv Semdegi

gverdiTi efeqtebis ganviTarebaSi: diastoluri arteriuli wnevis

momateba, gulisreva da Rebineba oqsitocin-ergometrinis jgufSi. ase

rom, Semcirebuli sisxlis danakargi mSobiarobis Semdgom unda

Sewonili iyos oqsitocin-ergometrinis gamoyenebis SesaZlo gverdiT

efeqtebTan.

SesakumSi preparatebis gamoyenebis gverdiT efeqtebs miekuTvneba

gulisreva, Rebineba, Tavis tkivili, hipertenzia. Ees garTulebebi ufro

gamoxatulia ergotaminis gamoyenebisas. Ggarda amisa, ergotaminis

gamoyenebisaTvis damaxasiaTebelia ufro iSviaTi, magram bevrad ufro

seriozuli garTulebebi - gulis gaCereba, qalasSida sisxlcaqcevebi,

30

miokardiumis infarqti, mSobiarobis Semdgomi eklamfsia da filtvebis

SeSupeba.

arsebuli monacemebis mixedviT, ergometrinTan SedarebiT upiratesoba

eniWeba oqsitocinis gamoyenebas. Ggarda amisa, cxeli klimatis qveynebSi

oqsitocini ufro stabiluria, vidre ergometrini an meTilergometrini.115

kvlevebi, romlebic Seiswavlidnen prostaglandinebis (misoprostolis

da intramuskularuli prostaglandinis) gamoyenebas (43 203 monawile)116

ar aCvenes sisxlis denis sixSiris daqveiTeba.

oraluri misoprostoli doziT 600 mkg iwvevs klinikurad da

statistikurad sarwmuno 1000 ml-ze meti sisxlis danakargis gazrdas

sainieqcio uterotonul nivTierebebTan SedarebiT (7 kvleva, 22 749 qali, 3.6% vs 2.7%; (RR) 1.34, 95% (CI) 1.16 - 1.55). Semcivneba da sxeulis

temperaturis momateba (>38ºC) damaxasiaTebelia misoprostolisaTvis da

dozirebazea damokidebuli (600 mcg vs 400 mcg: ori kvleva Semcivnebaze, RR: 1.33; 95% CI: 1.07 - 1.64). oqsitocinTan SedarebiT, Semcivnebis SedarebiTi

riski 600 mkg oraluri misoprostolis miRebisas Seadgens 3.29-s (7

kvleva, 22 746 qali,19.7% vs 6.0%, 95% CI 3.03 - 3.56), xolo 38 gradus

celsiusze maRali temperaturis SedarebiTma riskma Seadgina 6,78 (7

kvleva, 2 209 qali; 6.3% vs 2.8% 95% CI 5.55 - 8.30).

sainieqcio prostaglandinebis gamoyeneba asocirebulia sisxlis saerTo

danakargis raodenobis daqveiTebasTan mSobiarobis mesame periodSi

(saerTo sxvaoba - 70 ml, 95% CI -73 to -67 ml) uterotonur saSualebebTan

SedarebiT, magram gaaCniaT ufro meti gverdiTi efeqti. mwiria am

Sedarebis Sesaxeb monacemebi MmSobiarobis Semdgomi mZime sisxldenis

SemTxvevaSi, iseve rogorc damatebiTi uterotonuli xsnarebis

gamoyenebis Taobaze.

arc intramuskularul prostaglandinebs da arc misoprostols ar

gaaCniaT upiratesoba uterotonul saSualebebTan SedarebiT

mSobiarobis mesame periodis marTvisas gansakuTrebiT, dabali riskis

jgufis qalebSi.

mSobiarobis mesame periodis marTva (aqtiuri da mocdiTi taqtikis

Sedareba)

saSvilosnos SesakumSi saSualebebis kombinirebuli gamoyeneba Wiplaris

sakontrolo daqaCvasTan erTad xSirad moixseneba, rogorc mSobiarobis

aqtiuri marTva mocdiTi taqtikis sapirispirod. zogjer amas daerTveba

Wiplaris adreuli gadakvanZvac, rac aucilebeli xdeba Wiplaris

sakontrolo daWimvisas.

vinaidan Wiplaris adreuli gadakvanZva aisaxeba bavSvis mdgomareobaze,

es aspeqti calke unda iyos ganxiluli.

literaturuli monacemebiT, mesame periodis aqtiuri marTva ufro

mizanSewonilia, ZiriTadad imis gamo, rom sisxlis dena mSobiarobis

31

Semdgom periodSi aRiniSneba ufro iSviaTad da am dros ufro maRalia

hemoglobinis maCveneblebi. 117;118;119;119;120

sisxlis gadasxmasTan da momyolis xeliT mocilebasTan dakavSirebuli

monacemebi sxvadasxva iyo or did (bristolisa da dublinis) kvlevaSi.

orive kvlevaSi aqtiuri marTva dakavSirebuli iyo garTulebebis

momatebul sixSiresTan gulisrevis, Rebinebisa da hipertenziis saxiT,

rac SesaZloa ergometrinis gamoyenebiT iyo ganpirobebuli.

jandacvis msoflio organizaciis4 ganmartebiT mSobiarobis Semdgomi

sisxlis dena ewodeba sisxlis danakargs ≥ 500 ml-ze. SesaZlebelia, rom

es ganmarteba aixsnas imiT, rom msoflios mraval kuTxeSi 500 ml-ze meti

sisxlis danakargi warmoadgens sicocxlisaTvis realur safrTxes

anemiis maRali sixSiris gamo. mravali monacemebiT sisxlis saSualo

danakargi bunebrivi mSobiarobis dros Seadgens 500 ml-s, xolo 5%

SemTxvevaSi aRwevs 1000 ml-s da mets 121-124.

bristolis kvlevaSi 125 18% qals marTvis mocdiTi taqtikis gamoyenebisas

aReniSneboda sisxlis danakargi ≥500ml-ze da mxolod 3%-s >1000ml-ze.

sisxlis gadasxma gamoiyeneba mxolod qalis sasicocxlo funqciebis

darRvevis dros. aseTi gadaxarisxeba gansakuTrebiT mniSvnelovania

gaumarTlebeli sisxlis gadasxmisagan Tavis asarideblad, iseTi

garTulebebis Tavidan acilebis mizniT, rogoricaa Sidsi da inficireba.

rogorc zemoT iyo aRniSnuli, SemoTavazebulia mSobiarobis mesame

periodis marTvis ramodenime varianti. aqtiuri marTva moicavs

intervenciebis jgufs: profilaqtikuri uterotonuri saSualebis Seyvana

axalSobilis dabadebis Semdeg, Wiplaris adreuli klemireba da gadaWra

da Wiplaris kontrolirebadi daWimva. mocdiTi taqtika ki gulisxmobs

imas, rom davelodoT placentis mocilebis niSnebs da Wiplari

gadaikvanZoT maSin, rodesac gaqreba misi pulsacia (xelSeuxeblobis

midgoma). mesame periodis aqtiuri marTvis es ori midgoma Sedarebuli

iyo mimoxilvaSi sadac CarTuli iyo 5 kvleva.126 aqtiuri marTva mocdiT

taqtikasTan SedarebiT (samSobiaros pirobebSi) asocirebuli iyo riskis

daqveiTebasTan, kerZod: sisxlis danakargis saerTo gansxvaveba – 79.33 ml

(95% CI - 94.29-64.37); mSobiarobis Semdgomi 500 ml-ze meti sisxlis

danakargi (RR 0.38, 95% CI 0.32-046) da mSobiarobis mesame periodis

gaxangrZliveba (saerTo gansxvaveba - 9.77 wT. 95% CI 10.0 -9.53-mde). aqtiur marTvasTan dakavSirebuli iyo dedis gulisrevis momatebuli albaToba

(RR 1.83 95%, CI 1.51-2.23), Rebineba da arteriuli wneva (SesaZlebelia,

ergometrinis gamoyenebis gamo). ar gamovlenila dadebiTi an gverdiTi

efeqtebi axalSobilis gamosavlis mxriv. rutinul “aqtiur marTvas”

gaaCnia upiratesoba sisxlis danakargis, mSobiarobis Semdgomis sisxlis

denisa da mesame periodis sxva seriozuli garTulebebis Tavidan

acilebis TvalsazrisiT. magram aqtiuri marTva dakavSirebulia gverdiTi

efeqtebis momatebul riskTan (gulisreva, Rebineba da hipertenzia)

ergometrinis gamoyenebis pirobebSi. aqtiuri midgoma unda gaxdes

rutinuli mSobiarobis mesame periodis marTvisas. aqtiuri marTva

dakavSirebulia sisxlis dakargvis nakleb albaTobasTan, mSobiarobis

Semdgomi sisxlis denisa da hemotransfuziis nakleb aucileblobasTan.

gverdiT efeqtebSi Sedis: mSobiarobis mesame periodis gaxangrZliveba,

32

dedis anemia, gulisrevisa da pirRebinebis momatebuli albaToba da

momatebuli arteriuli wneva (ergotaminis gamoyenebisas)127

mocemuli sakiTxis mniSvnelobis gaTvaliswinebiT bebiaqalTa

saerTaSioriso konfederaciam da mean-ginekologTa saerTaSoriso

federaciam gaavrceles saerTo gancxadeba128 mSobiarobis mesame periodis

marTvis Sesaxeb mSobiarobis Semdgomi sisxlis denis prevenciis mizniT.

qals unda SevTavazoT mesame periodis aqtiuri marTva, radganac is

aqveiTebs atoniuri sisxlis denis albaTobas.

mSobiarobis mesame periodis aqtiuri marTva moicavs Carevebs, romlebic

gamiznulia placentis gamoZevebis gasaadvileblad saSvilosnos

kumSvadobis gaZlierebiT da mSobiarobis Semdgomi sisxlis denis

profilaqtikiT. misi ZiriTadi komponentebia:

• uterotonuli saSualebebis Seyvana;

• Wiplaris kontrolirebadi traqcia;

• saSvilosnos masaJi placentis gamoZevebisaTvis, saWiroebisamebr.

mSobiarobis procesSi yvela monawile unda flobdes codnas, unar-

Cvevebsa da kritikuli Sefasebis unars mesame periodis aqtiuri marTvis

gansaxorcieleblad.

uterotonuli saSualebebis gamoyeneba

• bavSvis dabadebidan erTi wuTis Semdeg, unda moxdes muclis

palpacia meore bavSvis arsebobis gamosaricxad da gakeTdes

10 erT. oqsitocini kunTSi. oqsitocins gaaCnia upiratesoba

sxva uterotonul saSualebebTan SedarebiT, radganac is

efeqturia Seyvanidan 2-3 wT-is Semdeg, gaaCnia minimaluri

gverdiTi efeqtebi da SeiZleba gamoyenebuli iyos yvela

qalSi.

• Tu oqsitocini ar aris xelmisawvdomi, SeiZleba Semdegi

uterotonuli nivTierebebis gamoyeneba: ergometrini 0,2 mg.

kunTSi, sintometrini 1 amp. kunTSi an misoprostoli 400-600

mkg oralurad. misoprostolis oraluri daniSvna unda

moxdes im SemTxvevaSi, rodesac ar aris xelmisawvdomi/an ar

aris Sesaferisi oqsitocinisa da ergotaminis jgufis

alkaloidebis Senaxvis pirobebi.

• uterotonul xsnarebs esaWiroeba Sesabamisi Senaxvis

pirobebi: ergometrini: 2-8 gradusi celsiusiT, mzis

sxivebisagan da gayinvisagan dacva; misoprostoli: oTaxis

temperatura, daxurul konteinerSi; oqsitocini: 15-30 gradusi

celsiusiT, dacva gayinvisagan;

• mocemuli unda iyos informacia am preparatebis gverdiTi

efeqtebis Sesaxeb.

• ergometrinisa da sintometrinis (radganac is Seicavs

ergometrins) micema ar SeiZleba preeklamfsiis, eklamfsiisa

da momatebuli arteriuli wnevis dros.

33

Wiplaris kontrolirebadi traqcia

• gaakeTeT Wiplaris klemireba SorisTan axlos (rodesac janmrTel

axalSobilTan Sewydeba pulsacia) da daiWireT is xelSi;

• moaTavseT meore xeli qalis boqvenze da daafiqsireT saSvilosno

saSualo intensiobis zewoliT Wiplaris kontrolirebadi traqciis

dros;

• moaxdineT Wiplaris susti daqaCva da daelodeT saSvilosnos karg

SekumSvas (2-3 wT) sTxoveT dedas, gaiWinTos da Zalian nazad

CamoqaCeT Wiplari placentis gamosaZeveblad ise, rom ar SewyvitoT

zewola saSvilosnoze;

• Tu placenta ar gamoZevda 30-40 wm-is ganmavlobaSi, Wiplaris

kontrolirebadi daWimvisas, ar gaagrZeloT Wiplaris daqaCva;

• frTxilad daiWireT EWiplari da daelodeT saSvilosnos xelaxal

SekumSvas;

• Semdegi SekumSvisas gaimeoreT Wiplaris kontrolirebadi traqcia

saSvilosnoze zewoliT.

arasodes ar ganaxorcieloT Wiplaris traqcia saSvilosnoze zewolisa

da misi kargi SekumSvis gareSe.

• rodesac placenta daibadeba, daiWireT is ori xeliT da

frTxilad daatrialeT imisaTvis, rom garsebi daixves. frTxilad

gamoqaCeT sruli gamoZevebisaTvis.

• Tu garsebi gaixa, frTxilad daaTvaliereT saSos zeda mesamedi da

saSvilosnos yeli steriluri xelTaTmanebiT da gamoiyeneT

fanjriani momWeri garsebis CarCenili nawilebis mosacileblad.

• yuradRebiT daaTvaliereT placenta misi nawilebis CarCenis

Tavidan asacileblad. Tu CarCenilia dedis zedapiris nawilebi, an

aris mogleJili garsebi sisxlZarRvebiT, unda vifiqroT placentis

nawilebis CarCenaze da miviRoT Sesabamisi zomebi.

saSvilosnos masaJi

• dauyovnebliv daiwyeT saSvilosnos fuZis masaJi manamde, sanam

saSvilosno SeikumSeba;

• ganaxorcieleT SekumSuli saSvilosnos palpacia yovel 15 wT-Si

erTxel da gaimeoreT palpacia saWiroebisamebr pirveli 2 saaTis

ganmavlobaSi;

• darwmundiT, rom saSvilosno ar dundeba masaJis damTavrebis

Semdeg.

yvela zemoT aRniSnuli moqmedebis Catarebis arsi auxseniT mSobiaresa

da mis axloblebs. ganaxorcieleT mudmivi meTvalyureoba da mxardaWera.

mSobiarobis mesame periodis aqtiuri marTva amcirebs sisxlis

raodenobis danakargs, mSobiarobis Semdgom sisxlidenas da

sisxlis gadasxmis aucileblobas. GgverdiT movlenebs

A

34

miekuTvneba: mesame periodis gaxangZliveba, dedis anemia,

gulisrevis da Rebinebis momatebuli riski, arteriuli

wnevis Aaweva (ergometrinis preparatebis xmarebisas)

Wiplaris gadakvanZvis dro

Wiplaris gadakvanZvis dro (maSinve nayofis dabadebis Semdgom an

mogvianebiT) axdens garkveul zegavlenas dedisa da nayofis

mdgomareobaze. 117 dedis mdgomareoba am dros Seswavlili iyo

ramodenime kvlevaSi. 129;130 ar iyo gamovlenili Wiplaris gadakvanZvis

drois zegavlena mSobiarobis Semdgomi sisxldenis sixSireze.

nayofis mdgomareobaze zegavlena Seswavlili iyo ramodenime

randomizirebuli kvlevis meSveobiT. 131-134 gamovlinda, rom axalSobilis

mdebareobisas dedis doneze an cota qvemoT 3 wuTis ganmavlobaSi

Wiplaris gadakvanZvamde nayofTan gadadis sisxlis daaxloebiT 80 ml. 133;135;136, is damatebiT iRebs daaxloebiT 50 mg. rkinas, rac SemdgomSi

amcirebs rkinadeficituri anemiis ganviTarebis sixSires. 137;138 Teoriulad sisxlis aseTma gadanawilebam SeiZleba gamoiwvios

hipervolemia, policitemia da hiperbilirubinemia. aseTi garTulebebis

albaToba Seswavlili iyo rig kvlevebSi 117. Tumca axalSobilebs,

romelTac CautardaT Wiplaris adreuli gadakvanZva, aReniSnebodaT

hemoglobinis, hematoktirisa da bilirubinis ufro dabali maCveneblebi,

ar aRiniSneboda gansxvaveba klinikur mimdinareobasa da neonatalur

avadobaSi Wiplaris gadakvanZvis warmoebis drois Sedarebisas.

sistematiuri mimoxilvaSi 139 Wiplaris gviani gadakvanZva dRenaklul

axalSobilebSi dakavSirebuli iyo nakleb transfuziis sixSiresTan

axalSobilis anemiis gamo da sisxlCaqcevebTan (RR) 2.01, 95% CI 1.24 to 3.27) RR 1.74, 95% CI 1.08 to 2.81) adreul gadakvanZvasTan SedarebiT. amrigad, Wiplaris gviani gadakvanZva (30 -120 wamSi) dRenaklul axalSobilebSi

aris ufro fiziologiuri meTodi, vidre adreuli. placentaruli

sisxlis damatebiTi transfuzia nayofTan warmoadgens fiziologiur

process. fiziologiuri mSobiarobisas ar aris sakmarisi mizezebi

bunebriv procesSi Casarevad.

Wiplaris sakontrolo daWimvisas oqsitocinis winaswari SeyvaniT, rig

sameano klinikebSi farTod danergili meTodis gamoyenebisas, Wiplaris

adreuli gadakvanZva aucilebelia. Tumca im adgilebSi, sadac farTod

gamoiyeneba gviani gadakvanZva (Wiplaris pulsaciis gaqrobis Semdeg), ar

aris gamovlenili uaryofiTi efeqtebi.

damatebiT, rogorc zemoT aRvniSneT, Wiplaris gadakvanZva agvaridebs

rkinadeficituri anemiis ganviTarebas 137;138.

sistematiur mimoxilvaSi140 Seswavlili iyo Wiplaris drenaJis

specifiuri efeqti mSobiarobis mesame periodSi oqsitocinis

profilaqtikuri gamoyenebisas an mis gareSe.

Wiplaris drenaJi moicavs mis klemirebasa da gadaWras bavSvis dabadebis

Semdeg, magram SemdgomSi, Wiplaris dedismxrivi klemis moxsniTa da

sisxlis Tavisufali drenirebis ganaxlebiT. es SeiZleba Catardes sxva

35

intervenciebTan erTad, magaliTad, oqsitocinis rutinul SeyvanasTan

erTad, Wiplaris sakontrolo daWimvasTan da Ddedis WinTvasTan erTad.

Wiplaris drenaJma SesaZlebelia zemoqmedeba iqonios mSobiarobis mesame

periodze, radganac Sedegebi aCveneben mSobiarobis mesame periodis

xangrZlivobis statistikurad mniSvnelovan Semcirebas (erTi kvleva, n = 147, sxvaoba (wuTebSi) 95% ( CI -8.02 to -2.90), mSobiarobidan 30 wT-is Semdeg

(erTi kvleva, n = 477, RR- 28, 95% CI 0.10 to 0.73), magram am Sedegebis

interpretacia unda moxdes sifrTxiliT.

saWiroa Semdgomi kvlevebi Wiplaris drenaJis zemoqmedebaze mSobiarobis

mesame periodis marTvaze.

axalSobilis movla

uSualod mSobiarobis Semdeg saguldagulo yuradReba unda mieqces

axalSobilis movlas (sasunTqi gzebi, sxeulis da garemos temperaturis

SenarCuneba, dedasTan adreuli kontaqti da adreuli ZuZuTi kveba).141

yvela axalSobilma unda miiRos dauyovnebeli daxmareba dabadebisas

gamocdili specialistis mier, rac moicavs Termul dacvas, sisufTavesa

da Wiplaris movlas, daxmarebas sunTqvis dawyebaSi da ZuZuTi kvebas,

awonvas, Tvalebis profilaqtikas da pirvel gamokvlevas.

dedis movla mSobiarobis Semdeg

placenta saguldagulod unda iyos daTvalierebuli (mTlianoba,

hematomebi, placentis aranormaluri mimagreba).

saSvilosnos yelis rutinuli daTvalierebis AAaucilebloba ar aris

mtkicebadi. saSvilosnos yelis daTvalierebis Cvenebas warmoadgens

sisxlosdena, instrumentaluri mSobiaroba, swrafi mSobiaroba.

saSvilosnos Rrus xeliT revizia unda Catardes mkacrad mxolod

Cvenebebis mixedviT.

dedis mdgomareobis Sefaseba xdeba mSobiarobidan ramodenime saaTis

ganmavlobaSi: pulsi, arteriuli wneva, temperatura. gansakuTrebiT

mniSvnelovania sisxlis danakargis da saSvilosnos fuZis dgomis zusti

Sefaseba.

fiziologiuri mSobiarobidan ori saaTis Semdeg Tu melogine ar iyo

daZinebuli rbili samSobiaro gzebis daTvalierebisaTvis, sasurvelia is

wamodges, daibanos xel-piri, moawovos axalSobils da survilis

mixedviT, TviTon gadavides palataSi meuRlis an axloblebis

TanxlebiT.

meloginis gawera fiziologiuri mSobiarobis dros xdeba pediatrTan

SeTanxmebiT dadgenili standartis mixedviT, magram upiratesoba unda

mieniWos adreul gaweras.

sistematiurma mimoxilvam142 romelSic Seswavlili iyo adreulu gaweris

Sedegebi (samSobiaroSi Semobrunebis TvalsazrisiT) 3600 qalSi ver

gamoavlina uaryofiTi gavlena dedis da bavSvis janmrTelobaze, Tumca

yuradReba unda mieqces dedis sociodemografiul maCveneblebs da mis

mzadyofnas gawerisaTvis. 143

36

danarTi 1

partograma ÂÅÀÒÉ ÓÀáÄËÉ asaki orsuloba ÌÛÏÁÉÀÒÏÁÀ ÈÀÒÉÙÉ ßÚËÄÁÉÓ ÃÀÙÅÒÉÓ ÃÒÏ eqimis xelmowera

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160

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140

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110 100

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37

ÛÀÒÃcila

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Tavis Cadgma: 5 - moZravi 4 –mibjenili 3 - mcire segmentiT 2 - didi segmentiT 1 - menjis RruSi 0 - gamosavalSi danarTi 2 qalis SesaZlebeli poza mSobiarobis pirvel da

meore periodebSi

38

39

gaidlainis gadasinjvisa da ganaxlebis vada – 3 weli

gaidlainis miRebis xerxi/wyaro

gaidlainis SemuSavebis meTodologia

• mocemuli gaidlainis Semqnis procesSi samuSao jgufis

gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve

arsebuli praqtikuli rekomendaciebi. moxda arsebuli

rekomendaciebis adaptirebuli variantis SemuSaveba, romelic

erTis mxriv pasuxobs saerTaSoriso moTxovnebs, xolo meore

mxriv iTvaliswinebs saqarTvelos samedicino dawesebulebaTa

rogorc adamianur, ise teqnikur resursebs.

• klinikuri rekomendaciebis, epidemiologiuri monacemebisa da

mtkicebeulebebis Semdgomi moZieba xorcieldeboda Yahoo, AltaVista, Google, DoctorGuide, Yandex, Rambler saZiebo operatorebis meSveobiT, aseve samedicino monacemebis eleqtronuli

bibliografiuli monacemTa bazis, „medlainis,, (MEDLINE) meSveobiT. pirvel rigSi moZiebuli iyo (National Guidelines Clearinhouse, TRIP, SumSearch) fiziologiuri mSobiarobis Sesaxeb

analogiuri rekomendaciebi, romlebic SemuSavebulia

Sesabamisi profesionaluri jgufebis mier.

• calkeuli klinikuri sakiTxebis Sesaxeb mtkicebulebaTa da

im sakiTxTa moZieba, romlebic arasrulad aris ganxiluli,

warmoebuli iyo kohreinis monacemTa bazaSi The Cochrane Library 2006, Issue 3, da jandacvis msoflio organizaciis

reproduqciuli janmrTelobis biblioTekaSi #9.

moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi

Catarebuli Ziebis Sedegad miRebuli iyo ramodenime klinikuri

meToduri rekomendacia, romlebic Seicavda jgufis miznis Sesafebis

saWiro informacias. am rekomendaciebis saboloo Sefasebisas

gamoyenebuli iyo formaluri Sefasebis meTodi AGREE-s (Appraisal of Guidelines for Research and Evaluation )1 meSveobiT. Sefasebis Sedegad amorCeuli

iyo ramodenime rekomendacia, romlebic safuZvlad daedo Semdgom

analizsa da maT adaptacias. am rekomendaciaSi mocemuli debulebebi

Sejamebuli iyo cxrilebSi da warmodgenili iyo samuSao jgufis

wevrebis mier Sefasebis mizniT. cxrilSi Sedioda debulebis

originaluri versia da mtkicebulebis done wyaros mixedviT. samuSao

jgufs unda Seefasebina rekomendaciebis vargisianoba saqarTvelos

jandacvis pirveladi rgolis pirobebSi. rekomendacia miRebulad

iTvleboda, Tu mas mxars uWerda SemqmnelTa samuSao jgufis

umravlesoba.

rekomendaciis SemuSavebisas Cven gamoviyeneT modificirebuli sqema,

romelic mowodebulia SIGN (Scottish Intercollegiate Guideline Network) mier2.

40

mtkicebulebaTa doneebisa da rekomendaciebis gradaciis sqema

mtkicebulebis done kvlevebis daxasiaTeba, romlebic safuZvlad daedo

rekomendacias

A

maRali xarisxis meta-analizi, randomizirebuli

kontrolirebadi kvlevis meta-analizi, rkk

sistemuri mimoxilva an didi rkk sistematuri

Secdomis Zalian dabali albaTobiT (+++), romlis

Sedegebic SesaZlebelia gavrceldes Sesabamis

populaciaze;

B B

kohortuli an SemTxveva-kontrolis tipis

kvlevebis maRali xarisxis sistemuri mimoxilva

an

maRali xarisxis (++) kohortuli an SemTxveva-

kontrolis tipis kvleva sistematuri Secdomis

Zalian dabali albaTobiT.

an

rkk (+) sistemuri Secdomis dabali albaTobiT,

romlis Sedegebic SeiZleba gavrceldes Sesabamis

populaciaze;

C

kohortuli an SemTxveva-kontrolis tipis kvleva an

kontrolirebadi kvleva randomizaciis gareSe

sistematuri Secdomis dabali albaTobiT (+),

romlis Sedegebic SeiZleba gavrceldes Sesabamis

populaciaze

an

rkk Zalian dabali (++) an dabali (+) sistematuri

Secdomis albaTobiT, romlis Sedegebic ar

SeiZleba gavrceldes Sesabamis populaciaze;

D DD

SemTxvevaTa seriebis aRwera

an

arakontrolirebadi kvleva

an

eqspertTa azri.

sp saukeTeso praqtika, romelic dafuZnebulia

rekomendaciis SemqmnelTa gamocdilebaze.

alternatiuli gaidlaini ar arsebobs

41

gamoyenebuli literatura

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2. Harbour R,.Miller J. A new system for grading recommendations in evidence based clinical guidlines. BJM 2001;323:334-6.

3. World Health Organization. World Health Organization. Second Meeting of Focal Points of Reproductive Health/ Health of Women and Children in the European Region. Copenhagen . 1998. Ref Type: Generic

4. World Health Organization. Care in normal birth. 1995. Ref Type: Generic 5. MacVicar J, Dobbie G Owen-Johnstone L Jagger C Hopkins M Kennedy J. Simulated

home delivery in hospital: a randomised controlled trial. Br J Obstet Gynaecol 100, 316-323. 1993. Ref Type: Generic

6. Hundley VA, Cruickshank FM Lang GD Glazener CMA Milne JM Turner M Blyth D Mollison J Donaldson C. Midwife managed delivery unit: a randomised controlled comparison with consultant care. Br Med J 309, 1400-1404. 1994. Ref Type: Generic

7. Waldenstorm U, Borg IM Olsson B Skold M Wald S. The Birth Experience. A study of 295 new mothers.. Birth . 1996. Ref Type: Generic

8. Center fo Disease Control. Health care in Georgia; Staistical Yearbook. Ministry of Labour Health and Socoal Welfare, 2004.

9. Lauzon L, Hodnett E. . Labour assessment programs to delay admission to labour wards. The Cochrane Database of Systematic Reviews 2001, Issue 3. Cochrane Database of Systematic Reviews (3). 2001. Ref Type: Generic

10. nemas during labour. Cuervo LG, Rodrнguez MN, Delgado MB. E . The Cochrane Database of Systematic Reviews .. (3). 1999. Ref Type: Generic

11. Johnston RA, Sidall RS. Is the usual method of preparing patients for delivery beneficial or necessary? Am J Obstet Gynecol 4, 645-650. 1922. Ref Type: Generic

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