fiziologiuri msobiarobis martva · • sawiroebisamebr mcire intervenciebis catareba, amniotomia da...
TRANSCRIPT
1
fiziologiuri mSobiarobis
marTva
klinikuri praqtikis erovnuli rekomendacia
(gaidlaini)
2
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.
4
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.
6
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.
7
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.
8
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
9
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
A
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
ÂÖËÉÓÝÄÌÀ
180
170
160
150
140
130
120
110 100
ÓÀÍÀÚÏ×Ï ÁÖÛÔÉ
ÓÀÛÅÉËÏÓÍÏÓ ÚÄËÉÓ ÂÀáÓÍÀ (ÓÌ) ÍÉÛÀÍÉ – X
ÈÀÅÉÓ ÜÀÃÂÌÀÍÉÛÀÍÉ O
10
9
8
7
6
5 4
3
ÃÒÏ
ÛÄÊÖÌÛÅÀ ÚÏÅÄË 10ßÈ
5 4 3 2 1
oqsitocini ml\unit
ÂÀÌÏÚÄÍÄÁÖËÉ ÌÄÃÉÊÀÌÄÍÔÄÁ
É
ÌÀãÀ ÃÀ
ßÍÄÅÀ
•
180 170 160 150 140
130 120
110 100
90 80 70 60
ÔÄÌÐÄÒÀÔÖÒÀ °C
37
ÛÀÒÃcila
ÒÀÏÃÄÍÏÁ
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
1. Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument. The AGREE Collaboration. 2001. www.agreecollaboration.org. Ref Type: Electronic Citation
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
12. Kantor HI, Rember R Tabio P Buchanon R. . Value of shaving the pudendal-perineal area in delivery preparation. Obstet Gynecol 25, 509-512. 1965. Ref Type: Generic
13. Basevi V, Lavender T. Routine perineal shaving on admission in labour. he Cochrane Database of Systematic Reviews (4). 2000. Ref Type: Generic
14. Taylor G, Pryse-Davies J. The prophylactic use of antacids in the prevention of the acid-pulmonary-aspiration syndrome (Mendelson's syndrome). Lancet 1, 288-291. 1966. Ref Type: Generic
15. Crawford JS. Some aspects of obstetric anaesthesia. Br J Anaesth 28, 201-208. 1956. Ref Type: Generic
16. Roberts RB, Shirley MA. The obstetrician's role in reducing the risk of aspiration pneumonitis. With particular reference to the use of oral antacids. Am J Obstet Gynaecol 124, 611-617. 1976. Ref Type: Generic
17. Mckay S, Mahan C. Modifying the stomach contents of labouring women: why, how, with what success, and at what risks? How can aspiration of vomitus in obstetrics best be prevented? Birth 15(4), 213-221. 1988. Ref Type: Generic
18. Rutter N, Spencer A Mann N Smith M. Glucose during labour. 2, 155. 1980. Ref Type: Generic
19. Lucas A, Adrian TE Aynsley-Green A Bloom SR. Iatrogenic hyperinsulinism at birth. Lancet, 144-145. 1980. Ref Type: Generic
42
20. Tarnow-Mordi WO, Shaw JCL Liu D Gardner DA Flynn FV. Iatrogenic hyponatraemia of the newborn due to maternal fluid overload; a prospective study. Br Med J 283, 639-642. 1981. Ref Type: Generic
21. Lawrence GF, Brown VA Parsons RJ Cooke ID. Feto-maternal consequences of high-dose glucose infusion during labour. Br J Obst Gynaecol 89, 27-32. 1982. Ref Type: Generic
22. Gyte GM and Richens Y. Routine prophylactic drugs in normal labour for reducing gastric aspiration and its effects. The Cochrane Database of Systematic Reviews (2). 2005. Ref Type: Generic
23. Singata M Tranmer JE. Restricting oral fluid and food intake during labour. The Cochrane Database of Systematic Reviews ( 4). 2002. Ref Type: Generic
24. Klaus MKJ, Robertson S, Hinkley C. Psychological support during childbirth. Jordemodern. 1992;105:308-10.
25. Hodnett ED, Osborn RW. A randomized trial of the effect of monitrice support during labor: mothers' views two to four weeks postpartum. Birht 16, 177-183. 1989. Ref Type: Generic
26. Hemminki E, Saarikoski S. Ambulation and delayed amniotomy in the first stage of labor. 1983; 15:129-139. Eur J Obstet Gynecol Reprod Biol 15, 129-139. 1983. Ref Type: Generic
27. Hofmeyr GJ, Nikodem VC Wolman WL Chalmers BE Kramer T. Companionship to modify the clinical birth environment: effects on progress and perceptions of labour, and breastfeeding. Br J Obstet Gynaecol 98, 756-784. 1991. Ref Type: Generic
28. Hodnett ED, Gates S Hofmeyr G J Sakala C. Continuous support for women during childbirth . The Cochrane Database of Systematic Reviews (3). 2003. Ref Type: Generic
29. Hodnett ED. Continuity of caregivers for care during pregnancy and childbirth . The Cochrane Database of Systematic Reviews (3). 1998. Ref Type: Generic
30. Enkin M, Keirse MJNC Renfrew MJ Neilson J. A Guide to Effective care in pregnancy and childbirth, 2nd ed. Oxford, Oxford University Press . 1995. Ref Type: Generic
31. Dickersin K. Pharmacological control of pain during labour. In: Chalmers et al (eds). Effective care in pregnancy and childbirth.Oxford, Oxford University Press 1 . 1989. Ref Type: Generic
32. Dalen JE, Evans GL Banas JS Brooks HL Paraskos JA Dexter L. The hemodynamic and respiratory effects of diazepam (Valium). Anesthesiology 30, 259-263. 1969. Ref Type: Generic
33. Catchlove FH, Kafer ER. The effects of diazepam on the ventlatory response to carbon doxide and on steady-state gas exchange. Anesthesiology 34, 9-13. 1971. Ref Type: Generic
34. Flowers CE, Rudolph AJ Desmond MM. Diazepam (Valium) as an adjunct in obstetric analgesia. Obstet Gynecol 34, 6881. 1969. Ref Type: Generic
35. McAllister CB. Placental transfer and neonatal effects of diazepam when administered to women just before delivery. Br J Anaesth 52, 423-427. 1980. Ref Type: Generic
36. Anim-Somuah M, Smyth R, Howell C. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst.Rev. 2005;CD000331.
37. Thorp JA, Hu DH Albin RM McNitt J Meyer BA Cohen GR Yeast JD. The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. Am J Obstet Gynecol 169, 851-858. 1993. Ref Type: Generic
38. Matthews CD,.Martin MR. Early detection of meconium-stained liquor during labor: a contribution to fetal care. Am J Obstet Gynecol 1974;120:808-11.
43
39. Gregory GA GCPRTWH. Meconium aspiration in infants - a prospective study. J Pediatr 1974;85:848-52.
40. Fujikura T, Klionsky B. The significance of meconium staining. Am J Obstet Gynec 121, 45-50. 1975. Ref Type: Generic
41. Meis PJ, Hall M Marshall JR Hobel CJ. Meconium passage: a new classification for risk assessment during labor. Am J Obstet Gynecol 131, 509-513. 1978. Ref Type: Generic
42. MacDonald D, Grant A Sheridan-Pereira M Boylan P Chalmers I. The Dublin randomized trial of intrapartum fetal heart monitoring. Am J Obstet Gynecol 152, 524-539. 1985. Ref Type: Generic
43. Hofmeyr GJ. Amnioinfusion for meconium-stained liquor in labour. Cochrane Database of Systematic Reviews (1). 2002. Ref Type: Generic
44. R Kulier and GJ Hofmeyr. Tocolytics for suspected intrapartum fetal distress . (3). 2006. Ref Type: Generic
45. Fawole B, Hofmeyr GJ. Maternal oxygen administration for fetal distress. The Cochrane Database of Systematic Reviews (4). 2003. Ref Type: Generic
46. Nielsen PV, Stigsby B Nickelson C Nim J. Intra- and interobserver variability in the assessment of intrapartum cardiotocograms. Acta Obstet Gynecol Scand 66, 421-424. 1987. Ref Type: Generic
47. Van Geijn HP. Fetal monitoring - present and future: the evaluation of fetal heart rate patterns. Eur J Obstet Gynecol Reprod Biol 24, 117-119. 1987. Ref Type: Generic
48. Grant A. Monitoring the fetus during labour. In: Chalmers I et al (eds). Effective care in pregnancy and childbirth.Oxford, Oxford University Press. 1989. Ref Type: Generic
49. Borthen I, Lossius P Skjaerven R Bergsjш P. Changes in frequency and indications for cesarean section in Norway . Acta Obstet Gynecol Scand 68, 589-593. 1967. Ref Type: Generic
50. Curzen P, Bekir JS McLintock DG Patel M. Reliability of cardiotocography in predicting baby's condition at birth. . Br Med J 289, 1345-1347. 1984. Ref Type: Generic
51. Z Alfirevic, D Devane GML Gyte. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews (3). 2006. Ref Type: Generic
52. Nordstrom L, Ingemarsson I, Kublickas M, Persson B, Shimojo N, Westgren M. Scalp blood lactate: a new test strip method for monitoring fetal wellbeing in labour. Br J Obstet Gynaecol 1995;102:894-9.
53. B.Mead. Prevention and control of nosocomial infection in obstetrics and gynecology. Prevention and Control of Nosocomial Infections, 2nd ed., R.P.Wenzel, ed.(Baltimore,Williams &Wilkins . 1993. Ref Type: Generic
54. Crowther C, Enkin M Keirse MJNC Brown I. Monitoring the progress of labour. In: Chalmers I et al (eds). Effective care in pregnancy and childbirth.Oxford, Oxford University Press. 1989. Ref Type: Generic
55. World Health Organization Maternal Health and Safe Motherhood Programme. World Health Organization partograph in management of labour. Lancet 1994;343:1399-404.
56. Hall R,.Krins A. The partograph in obstetrics. Aust.Fam.Physician 1981;10:107-10. 57. Rajhvajn B, Kurjak A, Latin V, Barsic E. Construction and use of a partograph in the
management of labour. Z.Geburtshilfe Perinatol. 1974;178:58-62. 58. World Health Organization Maternal Health and Safe Motherhood Programme. World
Health Organization partograph in management of labour. Lancet 1994;343:1399-404.
44
59. Schutte MF TPKGSS. Management of premature rupture of the membranes: the risk of vaginal examination to the infant. Am J Obstet Gynecol 1983;146:395-400.
60. Ottervanger HP, Keirse MJNC Smit W Holm JP. Controlled comparison of induction versus expectant care for prelabor rupture of the membranes at term. J.Perinat Med . 1966. Ref Type: In Press
61. Gulmezoglu A. Antibiotics for prelabour rupture of membranes at or near term: RHL commentary (last revised: 23 January 2006). The WHO Reproductive Health Library, 9. 2006. Update Software Ltd, Oxford, 2006. Ref Type: Generic
62. Festin and M. Antibiotics for preterm prelabour rupture of membranes: RHL commentary (last revised: 14 June 2003). The WHO Reproductive Health Library (9). 2006. Ref Type: Audiovisual Material
63. Flynn AM, Kelly J Hollins G Lynch PF. Ambulation in labour. Br Med J 2, 591-593. 1978. Ref Type: Generic
64. McManus TJ, Calder AA. Upright posture and the efficiency of labour. Lancet 1, 72-74. 1978. Ref Type: Generic
65. Williams RM, Thorn MH Studd JWW. A study of the benefits and acceptability of ambulation in spontaneous labour. Br J Obstet Gynaecol ; 87, 122-126. 1980. Ref Type: Generic
66. Chan DPC. Positions during labour. Br Med J , 100-102. 1963. Ref Type: Generic 67. Melzack R, Belanger E Lacroix R. Labor pain, effect of maternal position on front
and back pain. J Pain symptom Manegem 6, 476-480. 1991. Ref Type: Generic 68. Gupta JK, Hofmeyr GJ. Position in the second stage of labour for women without
epidural anaesthesia. The Cochrane Database of Systematic Reviews . The Cochrane Database of Systematic Reviews (3). 2003. Ref Type: Generic
69. Walraven GE. WHO partograph. Lancet 1994;344:617. 70. Lennox CE,.Kwast BE. The partograph in community obstetrics. Trop.Doct.
1995;25:56-63. 71. Rajhvajn B, Kurjak A, Latin V, Barsic E. Construction and use of a partograph in the
management of labour. Z.Geburtshilfe Perinatol. 1974;178:58-62. 72. Albers LL, Schiff M Gorwoda JG. . The Length of Active Labor in Normal
Pregnancies. 1996; 87:355-9. Obstet Gynecol 87, 355-359. 1996. Ref Type: Generic
73. O'Driscoll K, Stronge JM Minogue M. Active management of labour. Br Med J 3, 135-137. 1973. Ref Type: Generic
74. Fraser WD, Marcoux S Moutquin JM Christen A. Effect of early amniotomy on the risk of dystocia in nulliparous women. N Engl J Med . 328, 1145-1149. 1993. Ref Type: Generic
75. Fraser WD SRPIFTSRPD. A randomized controlled trial of early amniotomy. Br J Obstet Gynaecol 1991;98:84-91.
76. Barrett JFR, Savage J Phillips K Lilford RJ. Randomized trial of amniotomy in labour vs the intention to leave membranes intact until the second stage. Br J Obstet Gynaecol 99, 5-10. 1992. Ref Type: Generic
77. Khalid S.Khan. Amniotomy to shorten spontaneous labour: RHL commentary (last revised: 6 January 2000). (9). 2006. The WHO Reproductive Health Library, Update Software Ltd, Oxford. Ref Type: Audiovisual Material
78. O'Driscoll K MD. . Active management of labour: the Dublin experience. 1986. 79. Zheng Qiao-ling ZX. Analysis of 39 cases of maternal deaths caused by incorrect
use of oxytocin. Chin J Obstet Gynecol. 1994;29:317.
45
80. Simpson KR,.James DC. Effects of immediate versus delayed pushing during second-stage labor on fetal well-being: a randomized clinical trial. Nurs.Res 2005;54:149-57.
81. Byrom A,.Downe S. Second stage of labour: challenging the use of directed pushing. RCM.Midwives. 2005;8:168-9.
82. Menez-Orieux C, Linet T, Philippe HJ, Boog G. [Delayed versus immediate pushing in the second stage of labor for nulliparous parturients with epidural analgesia: a meta-analysis of randomized trials]. J Gynecol Obstet Biol Reprod (Paris) 2005;34:440-7.
83. Plunkett BA, Lin A, Wong CA, Grobman WA, Peaceman AM. Management of the second stage of labor in nulliparas with continuous epidural analgesia. Obstet Gynecol 2003;102:109-14.
84. Barnett MM HSS. Infant outcome in relation to second stage labor pushing method. Birth 1982; 9:221-228. Birth 1982;9:221-8.
85. Knauth DG HEP. Effect of pushing techniques in birthing chair on length of second stage of labor. Nurs Res 1986;35:49-51.
86. Parnell JC, Langhoff-Roos J, Iversen R, Damgaard P. [Pushing technique in the expulsive phase of labor. A randomized study]. Ugeskr.Laeger 1993;155:2259-62.
87. Cruttenden J. To push or not to push? Mod.Midwife. 1995;5:31-2. 88. De Snoo K. Leerboek der Verloskunde (Textbook of Obstetrics). 1930. 89. Wood C NKHDBH. Time - an important variable in normal delivery. J Obstet
Gynaecol Br Commnwlth 1973;80:295-300. 90. Katz Z LMDRB-HHZY. The beneficial effect of vacuum extraction on the fetus.
Acta Obstet Gynecol Scand 1982;61:337-40. 91. Yancey MK HAJGBWBK. Maternal and neonatal effects of outlet forceps
delivery compared with spontaneous vaginal delivery in term pregnancies. Obstet Gynecol 1991;78:646-50.
92. Knuist M EMVAD. Uitdrijvingsduur en toestand van de pasgeborene bij door vroedvrouwen geleide bevallingen (Duration of the second stage and condition of the neonate in deliveries attended by midwives). Ned Tijdschr Geneeskd 1989;133:932-6.
93. Menticoglou SM MFHCMI. Perinatal outcome in relation to second-stage duration. A 1995;173:906-12.
94. Simpson KR,.James DC. Effects of immediate versus delayed pushing during second-stage labor on fetal well-being: a randomized clinical trial. Nurs.Res 2005;54:149-57.
95. Chen SZ, Aisaka K Mori H Kigawa T. Effects of sitting position on uterine activity during labor. Obstet Gynecol 79, 67-73. 1987. Ref Type: Generic
96. Gardosi J, Hutson N, and B-Lynch C. Randomised control trial of squatting in the second stage of labour. Lancet 1, 74-77. 1989. Ref Type: Generic
97. Liddell HS FPR. The birthing chair in the second stage of labour. 1985; 25:65-68. Aus NZ J Obstet Gynaecol 1985;25:65-8.
98. Stewart P SH. A randomized study of the sitting position for delivery using a newly designed obstetric chair. 989; 96:327-333. Br J Obstet Gynaecol 1989;96:327-33.
99. Bloom SL, Casey BM, Schaffer JI, McIntire DD, Leveno KJ. A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. Am J Obstet Gynecol 2006;194:10-3.
100. Jo Garcia. Care in normal labour. (HOOP trial group) Social Scientist National Perinatal Epidemiology Unit . 1999. Ref Type: Internet Communication
101. Stamp G, Kruzins G, Crowther C. Perineal massage in labour and prevention of perineal trauma: randomised controlled trial. BMJ 2001;322:1277-80.
46
102. Woolley RJ. Benefits and risks of episiotomy: a review of the English-language literature since 1980. Obstet Gynecol Surv 1995;50:806-35.
103. Goldberg J, Holtz D, Hyslop T, Tolosa JE. Has the use of routine episiotomy decreased? Examination of episiotomy rates from 1983 to 2000. Obstet Gynecol 2002;99:395-400.
104. Webb DA CJ. Hospital variation in episiotomy use and the risk of perineal trauma during childbirth. Birth 2002;29:132-6.
105. Pel M HMHAVdVFTPE. Provider-associated factors in obstetric interventions. Eur J Obstet Gynecol Reprod Biol 1995;61:129-34.
106. Carroli G, Belizan J. Episiotomy for vaginal birth. The Cochrane Database of Systematic Reviews (2). 2006. Ref Type: Generic
107. Sleep J GAM. West Berkshire perineal management trial: three year follow up. Br Med J 1987;295:749-51.
108. Fleming EM HSNC. Does perineal suturing make a difference? The SUNS trial. BJOG 2003;110:684-9.
109. Lundquist M OANENM. Is it necessary to suture all lacerations after a vaginal delivery? Birth 2000;27:79-85.
110. Head M. Dropping stitches. Do unsutured tears to the perineum heal better than sutured ones? Nursing Times 1993;89:64-5.
111. Clement S RB. To stitch or not to stitch? A long term study of women with unsutured perineal tears. Practising Midwife 1998;2:20-8.
112. Kwast BE. Maternity care in developing countries. In: Health matters. Public health in North-South perspective. 1995.
113. Gilbert L PWBVA. Postpartum haemorrhage - a continuing problem. Brit J Obstet Gynaecol 1987;94:67-71.
114. Elbourne DR, Prendiville WJ Carroli G Wood J McDonald S. Prophylactic use of oxytocin in the third stage of labour. The Cochrane Database of Systematic Reviews (2). 2006. Ref Type: Generic
115. McDonald S, Abbott JM Higgins SP. Prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour. he Cochrane Database of Systematic Reviews (2). 2006. Ref Type: Generic
116. Gulmezoglu AM, Forna F Villar J Hofmeyr GJ. Prostaglandins for prevention of postpartum haemorrhage. The Cochrane Database of Systematic Reviews (2). 2006. Ref Type: Generic
117. Prendiville W ED. Care during the third stage of labour. In: Chalmers I et al (eds). Effective care in pregnancy and childbirth. 2006.
118. Harding JE EDPWJ. Views of mothers and midwives participating in the Bristol randomized, controlled trial of active management of the third stage of labor. Birth 1989;16:1-6.
119. Begley CM. A comparison of "active" and "physiological" management of the third stage of labour. Midwifery 1990;6:3-17.
120. Thilaganathan B CALJBR. Management of the third stage of labour in women at low risk of postpartum haemorrhage. Eur J Obstet Gynecol Reprod Biol 1993;48:19-22.
121. Pritchard JA BRDJWKM. Blood volume changes in pregnancy and the puerperium . Am J Obstet Gynecol 1962;84:1271.
122. Newton M. Postpartum hemorrhage. Am J Obstet Gynecol 1966;94:711-7. 123. De Leeuw NKM LLTEDS. Correlation of red cell loss at delivery with changes in
red cell mass. Am J Obstet Gynecol 1968;100:1092-101. 124. Letsky E. The haematological system. In In: Hytten F CGe, ed. Clinical physiology
in obstetrics, 2nd edition. Oxford, Blackwell , 1991. 125. Prendiville WJ HJEDSGM. The Bristol third stage trial: active vs physiological
management of third stage of labour. Br Med J 1988;297:1295-300.
47
126. Prendiville WJ, Elbourne D McDonald S. Active versus expectant management in the third stage of labour. The Cochrane Database of Systematic Reviews, Issue 2 . 2006. Ref Type: Data File
127. Edgardo Abalos. Management of the third stage of labour: RHL commentary (last revised: 7 July 2004). The WHO Reproductive Health Library, No 9 Update Software Ltd Oxford 2006. 2006. Ref Type: Data File
128. International Confederation of Midwives (ICM) and International Federation of Gynaecologists and Obstetricians (FIGO. Joint statement: management of the third stage of labour to prevent post-partum haemorrhage . Journal of Midwifery & Women's Health 2006;49:76-7.
129. Dunn PM FIRA. Influence of early cord ligation on the transplacental passage of foetal cells. Obstet Gynaecol Br Commwealth 1966;73:757-60.
130. Botha MC. The management of the umbilical cord in labour. S Afr J Obstet Gynaecol 1968;6:30-3.
131. Buckels LJ UR. Cardiopulmonary effects of placental transfusion. J Pediatr 1965;67:239-46.
132. Spears RL AGBSFJKJMAPLSR. The effect of early versus late cord clamping on signs of respiratory distress. Am J Obstet Gynecol 1966;95:564-8.
133. Yao AC LJVV. Expiratory grunting in the late cord clamped normal infant. Pediatrics 1971;48:865-70.
134. Nelson NM EMSSBKMRSDL. A randomized clinical trial of the Leboyer approach to childbirth. New Engl J Med 1980;302:655-60.
135. Yao AC LJ. Placental transfusion. Am J Dis Child 1974;127:128-41. 136. Dunn PM. The third stage and fetal adaptation. In: Clinch J, Matthews T eds.
1985. Perinatal medicine. Proceedings of the IX European Congress of perinatal medicine held in Dublin, Ireland, 1984. Lancaster, MTP Press. Ref Type: Conference Proceeding
137. Michaelsen KF MNSG. A longitudinal study of iron status in healthy Danish infants: effects of early iron status, growth velocityand dietary factors. Acta Paediatr 1995;84:1035-44.
138. Pisacane A. Neonatal prevention of iron deficiency. Placental transfusion is a cheap and physiological solution. Br Med J 1996;312:136-7.
139. Rabe H, Reynolds G Diaz-Rossello J. Early versus delayed umbilical cord clamping in preterm infants. The Cochrane Database of Systematic Reviews , Issue 3. 2004. Ref Type: Electronic Citation
140. Soltani H, Dickinson F Symonds. Placental cord drainage after spontaneous vaginal delivery as part of the management of the third stage of labourI. The Cochrane Database of Systematic Reviews, Issue 3 . 2006. Ref Type: Electronic Citation
141. Report of the Technical Working Group on Essential Care of the Newborn . World Health Organization . 1996. Ref Type: In Press
142. Brown S, Small R Faber B Krastev A Davis P. Early postnatal discharge from hospital for healthy mothers and term infants. The Cochrane Database of Systematic Reviews 2002, Issue 3. 2002. Ref Type: Audiovisual Material
143. Marianne Weiss DRPRPRLLMRaMNBR. Length of Stay after Vaginal Birth:Sociodemographic and Readiness-for-Discharge Factors. Birth 2004;31:93-101.
48
avtorTa jgufi: saqarTvelos mean-ginekologTa asociacia
⇒ Tengiz AasaTiani _ mean-ginekologi, Tssu postdiplomuri
samedicino ganaTlebis da uwyveti profesionaluri ganviTarebis
institutis reproduqciuli janmrTelobis departamentis
xelmZRvaneli, asocirebuli profesori, saqarTvelos mean-
ginekologTa asociaciis prezidenti.
⇒ petre lomaia – mean-ginekologi, mmk, m.SaraSiZis samedicino
centris sameano ganyofilebis gamge.
eqspertebi:
⇒ paliko kintraia - mean-ginekologi, akad. CaCavas mean-
ginekologiis da perinataluri medicinis samecniero kvleviTi
institutis direqtori, profesori
⇒ gia TevdoraSvili – mean-ginekologi, #2 samSobiaro saxlis
generaluri direqtori, medicinis mecnierebaTa doqtori,
asocirebuli profesori;
⇒ mamuka xoStaria – mean-ginekologi, sagarejos S.p.s.£#5 saavadmyofo-poliklinikuri gerTianrbis qalTa konsultaciis
gamge;
⇒ akaki baqraZe – #2 samSobiaro saxlis mean-ginekologi, mmk,
saqarTvelos Sromis, janmrTelobis da socialuri dacvis
saministros eqsperti meanoba-ginekologiaSi;
⇒ nukri manjgalaZe - £mean-ginekologi, # 4 samSobiaro saxlis
generaluri direqtori;
⇒ nino abulaZe – mean-ginekologi, Tssu reproduqciuli
janmrTelobis departamentis aspiranti;
⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros janmrTelobis dacvis
departamenti;
⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros janmrTelobis dacvis
departamenti.