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A MODERN VIEW OF THE PROBLEM OF BIRTH TRAUMA
Shavkatillayeva Dilrukh Gafurjonovna
Khurramova Nafosat Ramzovna
Clinical residents of the Department of Obstetrics and Gynecology No.
2 of Samarkand State Medical University
Nasimova N.R.
Scientific supervisor: DcS
https://doi.org/10.5281/zenodo.14842404
Annotation.
Birth trauma is a set of pathological conditions arising under the influence
of mechanical factors during the labor process. This type of traumatism is an interdisciplinary
problem covering such areas of medicine as obstetrics, pediatrics, pediatric neurology, and
related sciences.
Birth injuries occupy a significant place in the structure of perinatal morbidity and
mortality. The frequency of birth injuries in natural childbirth reaches 3.6%, whereas in
cesarean section this figure is about 1.2%. Despite progress in the study of this problem, the
level of traumatism among newborns remains at a relatively high level.
Keywords:
birth trauma, episiotomy, pelvic floor muscle insufficiency, prevention of
soft tissue tears, vaginal microflora.
Introduction.
In modern obstetric practice, the problem of ruptures and various
methods of dissection of the perineum during childbirth, as well as their impact on the
function of the pelvic floor, remains relevant. Despite the introduction of modern methods of
labor management, the level of birth trauma remains high. According to M.V. Kazhina, its
frequency varies from 10.2% to 39.0%, while L.R. Toktar and co-authors indicate that this
figure can reach 85%. Foreign studies also confirm the significant prevalence of this problem:
about 30% of births are accompanied by traumatic injuries. To reduce the risk of spontaneous
perineal ruptures and reduce the frequency of neonatal injuries, an episiotomy technique was
developed, which is widely used in obstetric practice throughout the world. The frequency of
its use varies from 15% to 80%, which means that every third or fourth woman undergoes
this surgical intervention [5]. In a number of clinical situations (e.g., fetal distress, risk of
perineal rupture, breech presentation), episiotomy can actually prevent serious injuries.
However, practice shows that the frequency of surgical dissection of the perineum
significantly exceeds the frequency of spontaneous ruptures, which calls into question the
validity and appropriateness of the widespread use of this procedure. Birth trauma, both
natural and iatrogenic, can lead to the development of serious complications. Ruptures and
surgical dissection of the perineum create conditions for infection, and despite modern
advances in the treatment of soft birth canal injuries, infectious complications are recorded in
19.3% of women in labor. Violation of the healing process can lead to suture divergence,
suppuration, healing by secondary intention, weakening of the vulvar ring and pelvic floor
muscles, as well as cicatricial deformation of the vulva, causing a gaping of the genital slit.
The formation of secondary intention predisposes to functional insufficiency of the
pelvic floor muscles, which over time can lead to pelvic organ prolapse [6]. In the long term,
complications such as ectropion and leukoplakia of the cervix, dyspareunia, urinary
incontinence, and decreased libido are possible. According to studies, the risk of prolapse and
prolapse of the internal genital organs in women who have suffered perineal injuries with
subsequent wound healing by secondary intention reaches 47.3%. The issues of pathogenesis,
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causes and mechanisms of injury, as well as the effect of surgical dissection of the perineum
on pelvic floor function remain a subject of debate. Given the significant impact of these
complications on the quality of life of women, further clinical studies are needed to find
optimal solutions to this problem. According to the biomechanics of the birth process,
throughout the entire period of labor, the fetus is exposed to various mechanical factors:
contractions, the head overcoming obstacles when passing through the entrance to the pelvis
during its adaptation, the forward movement of the head, as well as the influence of the pelvic
floor muscles [10]. However, a number of researchers distinguish between these mechanical
effects and true birth trauma, classifying the former as birth injuries. They are pathological
processes characterized mainly by local reactive changes that do not cause systemic
responses from the div of the fetus and the newborn [11] [12]. In contrast, birth trauma is
understood as a systemic reaction of the newborn's div, which leads to destabilization of
compensatory-adaptive mechanisms and the development of serious damage to the central
nervous system. In classical obstetrics, considerable attention is paid to the issue of the
correspondence between the sizes of the fetal head and the pelvic ring of the mother, since
this factor plays a key role in the development of trauma in both the mother and the child
[19,20]. It is interesting to note that over the past fifty years, the number of narrow pelvises
with a diagonal conjugate of 17.5 cm or less has decreased significantly: if in 1950–1952 this
figure was 4.8%, then by 1965–1967 it had dropped to 0.9%. Currently, the frequency of
diagnosis of anatomically narrow pelvis varies within 1–7.7%, while clinically narrow pelvis
occurs with a constant frequency – from 0.6% to 1.7%. It is important to emphasize that the
presence of an anatomically narrow pelvis does not always mean clinical failure of the labor
process: if the fetus is small, the discrepancy may not manifest itself.
In recent years, there has been an increase in cases of fetal macrosomia, which is due, in
particular, to an increase in the incidence of diabetes mellitus in pregnant women. Gestational
diabetes mellitus is increasingly being diagnosed, as well as manifest forms of diabetes
mellitus, first detected during pregnancy. The increase in the number of large newborns is one
of the reasons for the persistence of the incidence of clinically narrow pelvises during
childbirth, despite the general decrease in the proportion of anatomically narrow pelvises in
the population. This process is largely due to a decrease in the number of flat rachitic and
osteomalacic pelvises.
Thus, the problem of discrepancy between the sizes of the fetus and the pelvis remains
relevant in the context of risk factors for birth trauma. Currently, the incidence of birth
injuries in newborns is 2-7 cases per 1000 births. In the structure of causes of intranatal
mortality, birth trauma does not exceed 3.2%, and in cases of death of newborns in the early
neonatal period - 2.5%. The incidence of newborn morbidity due to birth trauma ranges from
7% to 8%. Most fractures resulting from birth trauma are caused by difficulties in extracting
the fetus or its abnormal presentation. The most common type of bone injury during
childbirth is a clavicle fracture, which can be observed with a frequency of up to 15 cases per
1000 live births [13-17]. The humerus is usually fractured immediately at the moment of
birth, which is often accompanied by a brachial plexus injury. Femur and rib fractures are less
common, but such injuries are recorded much less frequently compared to other types of
birth injuries.
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Conclusion
. To develop effective preventive measures aimed at reducing the incidence
of birth injuries in newborns, it is important to systematize the factors that increase the risk
of such injuries.
The first group of factors includes causes unrelated to the use of obstetric benefits
during childbirth. The first subgroup of this category consists of the characteristics of the
course of labor, such as the duration of the first and second stages of labor. Additionally, this
group includes factors related to the time of rupture of the fetal membranes: premature,
timely rupture, as well as the duration of the anhydrous interval. On the part of the fetus, this
category includes macrosomia, as well as possible genetic predispositions to pathologies of
various organs and systems that reduce resistance to traumatic effects. These factors
contribute to the development of spontaneous birth injuries.
In recent years, due to the active study of molecular genetic mechanisms involved in the
development of various pathological conditions, more and more attention has been paid to
the study of genetic and epigenetic factors that affect the risk of birth injuries in newborns. Of
particular interest is the individual predisposition to the effects of physical factors during the
birth process.
Various coagulopathies can play a certain role in the formation of birth injuries to the
skull, contributing to the development of thrombohemorrhagic syndrome, which, in turn,
manifests itself in intracerebral hemorrhages. The severity of these hemorrhages largely
depends on the state of the hemocoagulation system. Violation of key hemostasis parameters
can be caused by genetically determined disorders of the blood coagulation system.
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