1.operative Vaginal Delivery_kolkh

instrumentuli saSosmxrivi mSobiaroba

klinikuri praqtikis erovnuli rekomendacia (gaidlaini)

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klinikuri praqtikis erovnuli rekomendacia (gaidlaini) `instrumentuli saSosmxrivi mSobiaroba” miRebulia klinikuri praqtikis erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa marTvis saxelmwifo standartebis (protokolebi) SemuSavebis, Sefasebis da danergvis erovnuli sabWos 2007 wlis 21 martis sxdomaze da damtkicebulia saqarTvelos Sromis, janmrTelobisa da socialuri dacvis ministris #??????? brZanebiT.

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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. ⇒ daviT vaSakiZe _ S.p.s Mm. SaraSiZis samedicini cenris meanginekologi; ⇒ mamuka xoStaria _ mean_ginekologi, sagarejos sameano– ginekologiuri ganyofilebis gamge. eqspertebi: ⇒ merabiSvili nino (cia) samSobiaro saxli.~

mmd, profesori. S.p.s “ q. Tbilisis #2

⇒ baqraZe akaki _ saqarTvelos mean-ginekologTa asociaciis wevri, medicinis mecnierebaTa kandidati, #3 samSobiaro saxlis direqtori klinikur dargSi, saqarTvelos Sromis, janmrTelobis da socialuri dacvis saministros eqsperti mean-ginekologiis dargSi.

klinikuri rekomendaciebis zogadi mizani ⇒ meToduri rekomendaciis mizans warmoadgens dawvrilebiTi informaciis miwodeba mSobiarobis dros maSisa da vakuum-eqstraqtoris gamoyenebis Sesaxeb. ganxiluli klinikuri sakiTxebi ⇒ meToduri rekomendacia moicavs: mSobiarobis dros instrumentuli Carevis Cvenebebs, instrumentebis SerCevas da usafrTxo klinikuri praqtikis aspeqtebs. gaidlaini gankuTvnilia: ⇒ sameno stacionarSi momuSave mean-ginekologebisaTvis. informacia SeiZleba gamoyenebuli iyos bebiaqalebisaTvis da ojaxis eqimebisaTvis, romelTac exebaT fiziologiuri mSobiarobis marTva. gaidlainis gadasinjvisa da ganaxlebis vada – 3 weli

gaidlainis miRebis xerxi/wyaro 3

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) instrumentuli saSosmxrivi mSobiarobis Sesaxeb analogiuri rekomendaciebi, romlebic SemuSavebulia Sesabamisi profesionaluri jgufebis mier.

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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 Sesaferis saWiro informacias.;; am rekomendaciebis saboloo Sefasebisas gamoyenebuli iyo formaluri Sefasebis meTodi AGREE-s (Appraisal of Guidelines for Research and Evaluation ) 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) mier6. mtkicebulebaTa doneebisa da rekomendaciebis gradaciis sqema mocemul rekomendaciebSi gamoyenebulia Scottish Intercollegiate Guidelines Network (SIGN) mier mowodebuli rekomendaciebis mtkicebulebaTa doneebis modificirebuli sqema. yvela ZiriTad rekomendacias gaaCnia gradacia, romelic aRiniSneba laTinuri asoebiT А dan С mde. amave dros yovel gradacias Seesabameba monacemTa mtkicebulebis garkveuli done. rac ufro maRalia rekomendaciis gradacia, miT ufro maRalia kvlevebis sizuste, romlebzec is aris dafuZnebuli

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saWiroebs ZiriTadi literaturuli wyaros arsebobas, minimalurad erT randomizirebul sakontrolo kvlevas, romelic Catarebulia kargi xarisxiTa da SinaarsiT, rac specifiurad Seesabameba mocemul 4

mtkicebulebas an rekomendacias. saWiroebs maRali xarisxis klinikuri, magram ara randomizirebuli

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kvlevis Catarebas, romelic Seesabameba rekomendaciis Sinaarss. saWiroebs mtkicebulebebis arsebobas, romlebic dafuZnebulia eqspertTa komisiis daskvnaze an maT azrze da/an dafuZnebulia

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am dargSi cnobili avtoritetuli warmomadgenlebis azrze. miuTiTebs xarisxiani kvlevebis ar arsebobaze am sakiTxTan dakavSirebiT.

epidemiologia1-3 instrumentuli saSosmxrivi mSobiarobis sixSire (maSa da vakuum-eqstraqcia) dasavleTis qveynebSi stabilurad Seadgens 10-15%. saqarTveloSi es monacemebi gacilebiT dabalia - 2002 – 2004ww – 0.4% rac miuTiTebs meanebis dabal momzadebaze am sakiTxSi. aRsaniSnavia, rom instrumentuli saSosmxrivi mSobiarobis dabali sixSire aRiniSneba sxva qveynebSic. cxadia, maSis da vakuum-eqstraqciis gamoyenebis dabali kvalifikaciis pirobebSi matulobs garTulebebi dedisa da axalSobilis mxridan, Tumca swori da frTxili gamoyeneba aqveiTebs avadobis sixSires

mSobiarobisas instrumentuli Carevis Tavidan acileba instrumentuli Careva mSobiarobis dros zrdis dedisa da nayofis avadobasa da sikvdilianobas. 14 rkk-m (n = 12 757; RR 0.89; 95% CI 0.83–0.96) gamoavlina, rom mSobiares mudmivi mxardaWera (sasurvelia ara samSobiaro saxlis TanamSromlis, aramed qalis axloblis mier) amcirebs mSobiarobisas instrumentuli Carevis aucileblobis sixSires, iseve rogorc gverdze wola da dgoma mSobiarobis dros (18 rkk) ( n = 5506; RR 0.84; 95% CI 0.73–0.98) . epiduruli analgeziis gamoyeneba zrdis mSobiarobisas instrumentuli Carevis sixSires (12 rkk, n = 3653; OR = 2.08; 95% CI 1.48–2.93). partogramis danergva amcirebs instrumentuli Carevis da oqsitocinis gamoyenebis aucileblobas.. pirvelad mSobiareebSi epiduruli analgeziiT, oqsitocinis Seyvana aqveiTebs gamosavlis maSis gamoyenebis sixSires.. Tumca am dros ganmeorebiT mSobiareebSi aucilebelia gansakuTrebuli sifrTxile meore periodSi. yvela qals unda gaewios mudmivi mxardaWera mSobiarobis dros. partogramis gamoyeneba, lateraluri da vertikaluri pozicia da epiduruli anesTeziis Tavidan acileba amcirebs mSobiarobis dros instrumentuli Carevis aucileblobas.

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klasifikacia amerikis mean-ginekologTa kolejma SeimuSava nayofis winamdebare nawilis Cadgmis axali klasifikacia da Tavidan gansazRvra maSiT mSobiarobis tipebi. (cxrili 1) winmdebare nawilis Cadgmis dadgenisaTvis ganaxlebul klasifikaciaSi gamoyenebulia winamdebare Tavis wamyvani Zvlovani wertilis dacileba xazisgan, romelic aerTebs sajdom wvetebs, gamoxatuli santimetrebSi (5sm). pirveli ricxvi aRniSnavs Tavis dgomas sajdomi wvetebis mimarT, meore ki gamoyenebul sistemas, magaliTad, Tu Tavi aris 2 sm qvemoT sajdomi wvetebisgan, misi mdgomareoba aRiniSneba rogorc (+2/5). axali klasifikaciis dasturad, mkvlevarebma aCvenes, rom rac ufro dabla ganlagdeba nayofis Tavi da rac ufro mcirea brunva, miT ufro naklebia dedisa da axalSobilis travmirebis riski. klinikuri pelvimetriis Catareba da nayofis poziciis gansazRvra mniSvnelovania winasamSobiaro Sefasebis dros.

cxrili 1 sameano maSisa da vakuum-eqstraqtoris gamoyenebis klasifikacia termini

gamosavlis maSa:

gansazRvreba ACOG klasifikaciis mixedviT A Tavi moCans saSos karibWeSi sasqeso bageebis xeliT gadawevis gareSe nayofis Tavi mdebareobs menjis fskerze isriseburi nakeri imyofeba pirdapir an erT-erT irib zomaSi brunva ar aRemateba 45 graduss

gansazRvreba rusuli klasifikaciis mixedviT Tavi menjis gamosavalSia Tavi avsebs gavis Zvlis ukana zedapirs sajdomi wvetebi ar isinjeba

isrisebri nakeri menjis gamosavlis pirdapir zomaSia

Tavis dgoma (+5/5 ) wamyvani wertili (+2/5) - (+4/5) mde.

imyofeba Tavi menjis Rrus viwro nawilSia

nayofis Tavi avsebs gavis Zvlis ukana zedapiris or  brunva Seadgens 45 mesamedsa da simfizis mTel graduss an masze naklebia Sida zedapirs.

Tavi ar aRwevs menjis fskers:



brunva 45 gradusze metia

sajdomi wvetebi ar isinjeba. 6

isrisebri nakeri erT-erT irib zomaSia. Rrus maSa

Tavi mcire menjis Rrus farTo nawilSia.

nayofis Tavis 1/5 palpirdeba muclis maridan Tavis pozicia (+2/5) naklebia

nayofis Tavi ikavebs simfizis Sida zedapiris or mesameds 45 da gavis Zvlis ukana zedapiris zeda naxevars.

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brunva Seadgens graduss an mets



brunva 45 gradusze metia

Tavisuflad isinjeba gavis me4 da me-5 malebi da sajdomi wvetebi. isrisebri nakeri erT-erT irib zomaSia.

maRali maSa

ar aris CarTuli klasifikaciaSi

Cvenebebi da ukuCvenebebi instrumentuli Careva unda Catardes mSobiarobis meore periodis Semoklebis mizniT. misi gamoyeneba zogjer saWiro xdeba dedisa da nayofis gansakuTrebuli mdgomareobebis dros. retrospeqtulma kohortulma kvlevam, romelic Catarda 14759 pirveladmSobiare qalze aCvena, rom dedis avadoba mniSvnelovnad matulobs, rodesac mSobiarobis meore periodis xangrZlivoba aRemateba 3sT-s. kvlevam ar gamoavlina gansxvaveba neonataluri maCveneblebis TvalsazrisiT. sakiTxi Carevis dawyebis Sesaxeb unda gadawydes mxolod riskisa da sargeblianobis Sefasebis Semdeg. meanma unda gaiTvaliswinos, rom arcerTi Cveneba ar aris absoluturi.

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mSobiarobis dros instrumentuli Carevis Cvenebebi arcerTi Cveneba ar aris absoluturi da saWiroebs individualur midgomas

tipi nayofismxrivi dedismxrivi

Cveneba nayofis aradamakmayofilebeli mdgomareoba samedicino Cvenebebi, romelTa dros unda gaiTiSos WinTviTi aqtivoba - (III da IV klasis gulis ukmarisoba, hipertenziuli krizi, cerebrovaskularuli daavadebebi, miasTenia, zurgis tvinis dazianeba) 7

samSobiaro moqmedebis sisuste

pirvelad mSobiareebSiTavis winmsvlelobis ararseboba 3 saaTis ganmavlobaSi, regionaluri anesTeziis pirobebSi da ori saaTis ganmavlobaSi regionaluri anesTeziis gareSe. ganmeorebiT mSobiareebSiTavis winmsvlelobis ararseboba 2 saaTis ganmavlobaSi regionaluri anesTeziis pirobebSi da erTi saaTis ganmavlobaSi regionaluri anesTeziis gareSe.

dedis gadaRla winaaRmdegCvenebebi sameano maSisa da vakuum-eqstraqtoris gamoyenebisaTvis: • • • • •

nayofis sikvdili hidrocefalia an mikrocefalia, mZime xarisxis umwifroba nayofis SubliT, pirisaxiT winamdebareoba anatomiurad da klinikurad viwro menji saSvilosnos yelis arasruli gaxsna

dRevandel dRes RCOGG mogviwodebs, Tavi SevikavoT maSis gamoyenebisagan 34 kviris orsulobis vadamde, nayofis SesaZlo garTulebebis Tavidan acilebis mizniT. vakuumis gamoyeneba winaaRmdegnaCvenebia pirisaxiT winamdebareobis dros. misi gamoyenebisagan Tavi unda SevikavoT orsulobis 36 kviramde kefalohematomis da intrakranialuri sisxlCaqcevis Camoyalibebis saSiSroebis gamo. hepatiti C-s dros unda moveridoT iseT manipulaciebs, romelTa drosac xdeba nayofis kanis mTlianobis dazianeba. rogorc nebismieri instrumentuli Carevis dros, saWiroa saTanado dagegmva da momzadeba instrumentuli saSosmxrivi mSobiarobisaTvis. usafrTxo instrumentuli Careva mSobiarobis dros gulisxmobs klinikuri situaciis yuradRebiT analizs da dedasTan mWidro komunikacias.

C

8

O

instrumentuli saSosmxrivi momzadeba sruli muclismxrivi da • saSosmxrivi gamokvleva • • • • dedismxriv

momsaxure personalis mxriv M

• • • • • • •

mSobiarobis winapirobebi aucilebelia muclismxriv palpirdeba nayofis Tavis 1/5 nayofis TaviT winamdebareoba saSvilosnos yelis sruli gaxsna sanayofe garsebis ararseboba Tavisa da menjis zomebis Sesabamisoba. informirebuli Tanxmoba. adeqvaturi analgezia, Sardis buStis dacla aseptikuri pirobebi.

operatoris Sesabamisi gamocdileba. damatebiTi gegma proceduris uSedegobis SemTxvevaSi. mSobiarobaze axalSobilis reanimaciaSi daxelovnebuli personalis daswreba.

instrumentuli saSosmxrivi mSobiarobis marTva operators unda gaaCndes Sesabamisi gamocdileba da codna proceduris CasatarebisaTvis da warmoSobil garTulebaTa mkurnalobisaTvis. K sasurvelia, rezidentebma SeiZinon gamocdileba saswavlo mulaJebze, sanam daiwyeben damoukidebel muSaobas.

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instrumentuli saSosmxrivi mSobiarobis dros warumatebloba ufro xSirad dakavSirebulia Semdeg faqtorebTan: - dedis sxeulis masis indeqsi aRemateba 30-s; - nayofis didi wona an klinikurad didi nayofi; - mSobiaroba ukana saxeSi. O instrumentuli saSosmxrivi mSobiaroba saoperacios mzadyofnis pirobebSi.

unda

Catardes

C

saWiro aRWurviloba arsebobs 700 sxvadasxva saxeobis maSa. Cvens praqtikaSi farTod gamoiyeneba simfsonis (Simpson) maSa fenomenovis modifikaciiT. rodesac Catarda rkk 9

sxvadasxva saxeobis maSis Sesadareblad, aRmoCnda, rom maTi amorCeva xdeboda subieqturad. rotaciuli (kilandis) maSis (Kielland) dadeba asocirebulia riskTan da saWiroebs Sesabamis gamocdilebas. kilandis maSis alternatiul variants warmoadgens manualuri rotacia, romelic mTavrdeba gamosavlis maSis dadebiT an rotaciuli vakuum-eqstraqciiT. vakuum-eqstraqciisa da maSis Sedareba moxda 9 rkk-Si romelSic monawileobda 2849 mSobiare. gamovlinda, rom vakuum eqstraqtoris gamoyeneba maSebTan SedarebiT ufro xSirad uSedegoa (OR 1.7; 95% CI 1.3–2.2), dakavSirebulia nayofis kefalohematomis ganviTarebasTan (OR 2.4; 95% CI 1.7–3.4), baduris sisxlCaqcevasTan (OR 2.0; 95% CI 1.3–3.0), naklebad aris dakavSirebuli dedis saSosa da Sorisis mniSvnelovan travmasTan (OR 0.4; 95% CI 0.3–0.5), sakeisro kveTis sixSiris momatebasTan (OR 0.6; 95% CI 0.3–1.0), 5 wuTze apgariT dabal SefasebasTan (OR 1.7; 95% CI 1.0–2.8), fotoTerapiis aucileblobasTan (OR 1.1; 95% CI 0.7–1.8.). dedis naklebi travmirebis gamo vakuum-eqstraqtori rekomedirebulia, rogorc pirveli rigis instrumenti erTma rkk aCvena, rom ganavlis Seukavebloba ufro xSiria maSis gamoyenebisas vakuum-eqstraqtorTan SedarebiT. miuxedavad amisa, 5 wlianma Semdgomma dakvirvebam aCvena, rom vakuum-eqstraqciisa da maSis gamoyenebis Semdgom ar aRiniSneba mniSvnelovani gansxvavebebi dedisa da bavSvis Soreul gamosavalSi. meanma unda SearCios instrumenti, romelic yvelaze ukeTesi iqneba konkretul klinikur situaciaSi da Seesabameba mis gamocdilebas. maSebs da vakuums gaaCniaT sxvadasxva upiratesobebi da naklovanebebi

A

instrumentuli saSosmxrivi mSobiarobis garTulebebi randomizirebul kvlevaSi, romelSic moxda dabali maSis gegmiuri gamoyenebisa da spontanuri mSobiarobis Sedareba vadamde mitanili orsulobis 50 SemTxvevaSi, ar gamovlinda mniSvnelovani gansxvavebebi dedis an axalSobilisaTvis uaxloesi gamosavalis mxriv. sameano maSis jgufSi aRiniSna mSobiarobis II periodis saSualo xangrZlivobis Semcireba (10,2 wuTi nacvlad 18 wuTisa) da Wiplaris sisxlis SedarebiT maRali pH (7,27 nacvlad 7,23-isa) meta-analizma, romlis drosac moxda vakuum-eqstraqciisa da maSis gamoyenebis Sedareba, aCvena, rom pirvel SemTxvevaSi mniSvnelovnad naklebia dedis travmatizmi da zogadi Tu regionuli anesTeziis saWiroeba. vakuum-eqstraqciis jgufSi ufro naklebi iyo sakeisro kveTis warmoebis sixSire. sxva kvlevebis dros maSisa da vakuum-eqstraqciis SedarebiT aRiniSna maSis gamoyenebisas dedis avadobis (rbili qsovilebis dazianeba, diskomforti) maCveneblebis zrda. rogorc maSis, ise vakuum-eqstraqtoris gamoyenebas ukavSirdeba dedebSi hematomis ganviTareba, da savaraudod, menjis fskeris dazianeba. Tumca, faqtorebi, romlebic iwveven menjis fskeris dazianebas mravalgvaria, maT Soris normaluri spontanuri saSosmxrivi mSobiaroba, epiziotomia, mSobiarobis meore periodis gaxangrZliveba da nayofis didi zoma. didi wonis nayofze eWvis dros instrumentuli saSosmxrivi mSobiarobis riskis Sesafaseblad Catarebuli erT-erTi kvlevisas ganxorcielda >4000g meti wonis 2924 axalSobilTa da 3000-3999g wonis axalSobilTa Sedareba. nayofis didi wonis dros maSiT mSobiarobisas mniSvnelovani dazianebebis sixSire 6-jer izrdeboda (RR-6,7, 10

95%- 6,5-6,9). agreTve gamovlinda nevrologiuri darRvevebis riskis oTxjeradi zrda spontanur mSobiarobasTan an sakeisro kveTasTan SedarebiT. maSisa da vakuumeqstraqciis damatebiTma randomizebulma kvlevam gamoavlina sami faqtori, romelic asocirebulia mxris distociasTan: vakuum-eqstraqciis gamoyeneba (P=0,04), gaxangrZlivebuli mSobiaroba (P=0,03) da didi nayofi (P=0,001) aqedan gamomdinare, didi nayofis dros SesaZlebelia rogorc spontanuri mSobiarobis mcdeloba, aseve instrumentuli saSosmxrivi mSobiarobis gamoyeneba, Tumca saWiroa sifrTxilis gamoCena mxris distociis Tavidan asacileblad. vakuum-eqstraqciis potenciuri garTulebebi axalSobilebSi sameano maSiT SesaZlebelia praqtikulad SeuzRudavi Zalis kompresiisa da traqciebis ganxorcieleba. vakuum-eqstraqtoris konstruqcia iTvaliswinebs traqciebis Zalis SezRudvas, vinaidan SesaZlebelia misi mosxleta.. amis miuxedavad, vakuum-eqstraqtoriT ganxorcielebuli traqciebis Zala sakmaod mniSvnelovania da, amdenad, misi araswori gamoyenebisas SesaZlebelia nayofis mZime travmireba. vakuum-eqstraqtoris xufma SesaZloa gamoiwvios Tavis kanis dazianeba. damatebiT, Tavis kanis qvemdebare struqturebisagan aSrevebis gamo SesaZloa kefalohematomis Camoyalibeba, rac ufro xSirad gvxvdeba vakuumeqstraqciiT dabadebul axalSobilebSi (14-16%), vidre sameano maSiT dabadebulebSi (2%). subgaleuli hematomis (sisxlCaqceva Tavis qalas periosteumsa da myesovan abjars Soris sivrceSi) SedarebiTi sixSire meryeobs 26dan 45-mde yovel 1000 vakuum-eqstraqciiT dabadebulze . vakuum-eqstraqciis sxva potenciur neonatalur garTulebebs miekuTvneba intrakranialuri hematoma, hiperbilirubinemia da baduraSi sisxlCaqceva. axalSobilTa siyviTlis sixSiris momateba SesaZloa ganpirobebuli iyos vakuumeqstraqciisas kefalohematomis ganviTarebiT. vakuum-eqstraqciisas sameano maSis operaciasTan SedarebiT ufro maRalia baduraSi sisxlCaqcevis maCvenebeli, Sesabamisad 38% da 17% amasTanave, rqovanas meqanikuri dazianeba da Tvalis garegani travma ufro xSirad aRiniSneba maSis gamoyenebisas, spontanur mSobiarobasTan SedarebiT. vakuum-eqstraqciis dros aseTi dazianeba Zalzed iSviaTia, Tu vakuum-eqstraqtoris xufi SemTxveviT Tvalis areze ar iqna ganTavsebuli. arasasurveli Soreuli Sedegebis iSviaTad ganviTarebis gamo ofTalmologiuri skriningi naCvenebia mxolod gansakuTrebul SemTxvevebSi. vakuum-eqstraqciis seriozuli garTulebebis saerTo sixSire daaxloebiT 5%-mde aRwevs. aRniSnulidan gamomdinare, pacienti winaswar unda iyos gafrTxilebuli operaciul saSosmxriv mSobiarobasTan dakavSirebuli potenciuri riskis Sesaxeb. aSS sakvebisa da samkurnalwamlo saSualebaTa administraciiis (sssa) mier 1998w gamoqveynebul publikaciSi xazgasmulia, rom vakuum-eqstraqcias SesaZloa mohyves seriozuli an fataluri garTulebebi, maT Soris, subgaleuri (subaponevrozuli) da intrakranialuri sisxlCaqceva. sssa-s monacemebiT 1994-1998 wlebSi aRiniSna vakuum-eqstraqciasTan dakavSirebuli axalSobilTa sikvdilis 12 da seriozuli dazianebis 9 SemTxveva. es maCvenebeli 5-jer aRemateboda manamde 11 wliani periodis ganmavlobaSi arsebul maCvenebels. am meTodis xmarebasTan dakavSirebiT sssa-s mier SemuSavebuli rekomendaciebidan gansakuTrebiT mniSvnelovania 2 Semdegi:

1. dauSvebelia ryeviTi da brunviTi moZraobebis warmoeba. gamoyenebuli unda iqnas mxolod Tanabarzomieri traqciebi samSobiaro arxis RerZis mimarTulebiT

2. mSobiarobis dros vakuum-eqstraqciis gamoyenebisas pediatri unda imyofebodes, raTa awarmoos instrumentiT niSnebisa da simptomebis adeqvaturi monitoringi.

mzadyofnaSi gamowveuli dazianebis 11

instrumentuli saSosmxrivi mSobiarobis Sedegad ganviTarebuli mZime samSobiaro travmis sixSiris Sesafaseblad erT-erTi axlaxan Catarebuli kvlevisas Seswavlili iqna erTnayofiani orsulobis Sedegad 83340 axalSobilis gamosavali . axalSobilTa dazianebis yvelaze dabali riski gamovlinda spontanuri mSobiarobis SemTxvevaSi. saSualo riskis jgufi Seadgines vakuum-eqstraqciiT, maSiT an sakeisro kveTis gziT dabadebulebma. yvelaze maRali riski aRiniSna maSisa da vakuumeqstraqciis kombinirebis an saSosmxrivi mSobiarobis warumatebeli mcdelobis Semdeg Catarebuli sakeisro kveTis SemTxvevaSi. gamosavalis TvalsazrisiT gansxvaveba gamovlenili ar iqna, erTis mxriv, vakuum-eqstraqciasa da maSiT mSobiarobas da, meores mxriv, mSobiarobaSi Catarebul sakeisro kveTas Soris. (cxrili 2.) cxrili 2. momSobiarebis meTodis zegavlena neonatalur dazianebaze momSobiarebis meTodi

sikvdili

intrakranialuri sisxlCaqceva

sxva*

spontanuri saSosmxrivi 1/5000 mSobiaroba

1/1900

1/216

sakeisro mSobiarobaSi

1/952

1/71

sakeisro kveTa vakuumiseqstraqciis an maSis gamoyenebis Semdeg

1/333

1/38

sakeisro kveTa 1/1250 mSobiarobamde

1/2040

1/105

mxolod vakuueqstraqcia

1/3333

1/860

1/122

mxolod maSa

1/2000

1/664

1/76

da 1/1666

1/280

1/58

kveTa 1/1250

vakuum-eqstraqcia maSa

* saxis nervisa da mxris wnulis dazianeba, cns depresia, meqanikuri ventilacia 393 qalze Catarebulma prospeqtulma kohortulma kvlevam gamoavlina, rom instrumentuli saSosmxrivi mSobiarobis dros travmis sixSire matulobs im SemTxvevebSi, rodesac traqciaTa raodenoba aRemateba 3-s, aseve instrumentebis monacvleobiT gamoyenebisas. riski aseve mniSvnelovnad matulobda instrumentuli saSosmxrivi mSobiarobis Semdeg sakeisro kveTis Catarebis SemTxvevaSi. operaciul saSosmxriv mSobiarobaze uari unda iTqvas, rodesac ar aris Tavis winmsvleloba yoveli traqciis Semdeg an rodesac gamocdili specialistis mier Catarebuli 3 swored gakeTebuli traqcia uSedegoa. B

B

instrumentebis monacvleobiT gamoyeneba mizanSewonilia gamosavlis maSis dadeba uSedego vakuum-eqstraqciis Semdeg, radganac aman SeiZleba Tavidan agvacilos sakeisro kveTa, romlis 12

Catarebac mSobiarobis meore periodSi dakavSirebulia sisxldenis momatebul riskTan da nayofis momatebul travmirebasTan. instrumentebis monacvleobiT gamoyeneba dakavSirebulia nayofis travmis momatebul riskTan. operatorma yovel konkretul SemTxvevaSi unda Seafasos uSedego vakuumeqstraqciis Semdeg maSisa an sakeisro kveTis riski da sargeblianoba.

B

epiziotomiis roli instrumentuli saSosmxrivi mSobiarobis dros E aSS-Si 323 operaciul saSosmxriv mSobiarobaze Catarebuli kvlevis mizans warmoadgenda epiziotomiisa da III-IV xarisxis Sorisis dazianebas Soris kavSiris gamovlena. dadginda, rom epiziotomiis gamoyeneba ar zrdis Sorisis III-IV xarisxis dazianebis risks maSiT momSobiarebis SemTxvevaSi da dakavSirebulia Sorisis dazianebis riskTan vakuum-eqstraqciis dros. Ees monacemebi ar emTxveva britaneTis monacemebs, radganac iq upiratesobas aniWeben mediolateralur epiziotomias. Semdgomma kvlevam gamoavlina maSis gamoyenebisas epiziotomiis dadebiTi zegavlena Sorisis travmebis simZimesa da sixSireze, gansakuTrebiT mediolateraluri epiziotomiis dros.

C

epiziotomiis roli instrumentuli saSosmxrivi mSobiarobis dros sabolood gansazRvruli ar aris da saWiroebs Semdgom kvlevebs. profilaqtikuri antibiotikoTerapia A Catarda erTi rkk, romelic moicavda 393 qals. jgufSi, romelSic ar iyo Catarebuli antibiotikoTerapia gamovlinda 7 qali endomiometritiT. antibiotikoTerapiis jgufSi ar gamovlinda endomiometritis arcerTi SemTxveva. Mam monacemebma ver miaRwies statistikur gansxvavebas.

A

ar aris sakmarisi mtkicebulebebi instrumentuli saSosmxrivi mSobiarobis dros profilaqtikuri antibiotikoTerapiis CatarebisaTvis. A

Tromboprofilaqtika instrumentuli saSosmxrivi mSobiarobis dros prolongirebuli mSobiaroba da imobilizacia warmoadgenen risk-faqtors venuri Tromboemboliis warmoqmnisaTvis. am faqtorebis gadaxedva Uunda moxdes mSobiarobis Semdeg da momatebuli riskis jgufSi dainiSnos Tromboprofilaqtika. instrumentuli saSosmxrivi mSobiarobis Semdeg unda moxdes venuri Trombozis riskis Sefaseba P

C 13

A analgeziis meTodebi instrumentuli saSosmxrivi mSobiarobis Semdeg winaaRmdeg Cvenebebis ararsebobis dros saWiroa paracetamolis da diklofenakis regularuli gamoyeneba, rac dadebiT efeqts iZleva instrumentuli mSobiarobisa da sakeisro kveTis Semdeg.

C

profilaqtikuri RonisZiebebi Sardis buStis disfunqciis Tavidan acilebis mizniT instrumentuli mSobiarobis Semdeg instrumentuli saSosmxrivi mSobiaroba, regionaluri anesTezia da mSobiarobis prolongireba dakavSirebulia Sardis buStis disfunqciis momatebul riskTan. unda ganxorcieldes Sardis gamoyofis droisa da raodenobis monitoringi. A

C

unda ganxorcieldes siTxis balansis monitoringi specialuri grafebis meSveobiT, minimum 24 sT-is ganmavlobaSi, raTa Tavidan aviciloT mSobiarobis Semdgomi Sardis Sekaveba.

C

qalebs, romelTac gaukeTdaT spinaluri an epiduruli anesTezia, Sardis Sekavebis Tavidan acilebis mizniT unda CaeudgaT mudmivi kaTeteri. Sardis Seukaveblobis Tavidan acilebis mizniT qalebs unda vurCioT fizioTerapia.

C A

gamoyenebuli literatura

14