fiziologiuri mSobiarobis marTva

definiciafarTod gavrcelebuli azria, rom mSobiarobis Sefaseba SesaZlebeliamxolod retrospeqtulad mSobiarobis Semdeg. am koncefcias aqvsramodenime uaryofiTi mxare: fiziologiur movlenas aqcevs samedicinoprocedurad, zRudavs qalis Tavisuflebas, zrdis arasaWiro CarevebissixSires. aseTi midgomis ganxorcieleba saWiroebs mSobiare qalTa didiraodenobis koncentrirebas teqnikurad kargad aRWurvilsaavadmyofoebSi, Sesabamisi xarjebis gaweviT.fiziologiuri mSobiarobis koncefciis gansazRvrebisas mxedvelobaSiunda iyos miRebuli ori mniSvnelovani faqtori: orsulobisa damSobiarobis dros arsebuli risk-faqtorebi da mSobiarobismimdinareoba. mSobiarobamde SeuZlebelia imis gansazRvra, Tu romelqals Camouyalibdeba garTulebebi. sxva mxriv, mravali qali, romelicTiTqos imyofeba maRali riskis jgufSi, mSobiarobs garTulebebisgareSe. mocemul klinikur rekomendaciebSi fiziologiuri mSobiarobaganisazRvreba, rogorc, erTnayofiani mSobiaroba dabali riskisjgufis orsulebSi samSobiaro moqmedebis TviTnebiTi dawyebiT daprogresirebiT, 37 dan -42 kviris vadamde, nayofis TaviTwinamdebareobiT, dedisa da axalSobilis damakmayofilebelimdgomareobiT mSobiarobis Semdeg. 4ra Tqma unda, yovelive zemod aRniSnuli SeiZleba moxdes maRali riskisjgufis orsulebSi, romlis ganxilva ar Sedis mocemuli klinikurirekomendaciebis miznebSi. jdomiT winmdebareoba Tu 36 kviraze armoxerxda profilaqtikuri garegani mobruneba Tavze, unda CaiTvalospaTolofiur mimdinare orsulobad, romlis ganxilva agreTve ar Sedismocemuli klinikuri rekomendaciebis miznebSi.sxva da sxva monacemebiT mSobiare qalTa daaxloebiT 70-80% SeiZlebaganvixiloT, rogorc garTulebebis ganviTarebis TvalsazrisiT dabaliriskis mqone. 5 ; 6 ; 7. 2004 wlis monacemebiT 8 samSobiaro saxlebSimiRebuli 45554 mSobiarobidan 73,4 % iyo fiziologiuri, xolo 26,6%paTologiurizogadi procedurebi hospitalizaciamdemimReb ganyofilebaSi daxvedraarsebobs mravali rekomendacia, romelTa mizania samSobiaro saxlSiqalis moTavsebasTan dakavSirebiT qalis mxriv gancdili stresisa dauxerxulobis Semcireba. Zalian mniSvnelovania, rom samedicinopersonalma gamoavlinos keTilganwyoba da mxardaWera qalisa da misiTanxmlebi pirebis mimarT. Cveulebrivad, rodesac qali TavsdebasamSobiaroSi, mas sTavazoben, gamoicvalos tansacmeli. mravaliqalisaTvis ufro misaRebia, TviTon miitanos tansacmeli da TeTreulida ar Caicvas saavadmyofos xalaTi, rac mas exmareba individualobisSenarCunebaSi.bebiaqalma da eqimma orsuls unda miawodon informacia da auxsnan yvelaim procedurisa da gamokvlevis azri, romelic mas unda Cautardes.5

mSobiare qalebSi gamwmendi oynisa da boqvenis gaparsvisupiratesobis sasargeblod ar arsebobs mtkicebulebebiAkvebamSobiarobis drosmSobiaris kvebasTan dakavSirebiT arsebobs sxvadasxva mosazrebebi.kuWis SigTavsis aspiraciis (mendelsonis sindromis) saSiSroebaendotraqealuri narkozis aucileblobis SemTxvevaSi iZulebuls xdismSobiarobis dros SeizRudos sakvebisa da siTxis miReba. qalTaumravlesobisaTvis es SezRudva ar aris rTuli gadasatani, Tumca maTiumravlesoba ganicdis wyurvilis grZnobas.damtkicebulia, rom mSobiarobis dros sakvebis SezRudva ar iZlevagarantias zemoT aRniSnuli sindromis Camoyalibebisagan Tavisdasacavad. 14;14-16;17 . ramodenime kvlevam sxvadasxva farmakologiurisaSualebebis meSveobiT kuWis SigTavsis cvlilebasa da mSobiarobisdros sakvebis SezRudvaze ar gamoavlina 100%-iani garantia mendelsonissindromisgan. calkeuli meTodis gamoyenebisas pH maCvenebelTacvalebadoba sakmaod didi iyo da mkvlevarTa monacemebiT, antacidebisaucilebeli profilaqtikuri miReba ar iZleva garantias zemoTaRniSnuli sindromis Camoyalibebisagan Tavis dasacavad.mSobiaroba iTxovs energetikul danaxarjebs. imis gamo, rom winaswar arSeiZleba ganisazRvros mSobiarobis xangrZlivoba, energiis wyaromudmivad unda iyos Sevsebuli. mSobiarobis dros sakvebis mkveTrmaSezRudvam SeiZleba gamoiwvios dehidratacia da acidozi, romlisprofilaqtikisaTvisac gamoiyeneba glukozisa da sxva xsnarebisintravenuri Seyvana. dedis mdgomareobaze aseTi kvebis zegavlenaSefasebulia ramodenime randomizirebul kvlevaSi 18-20;21 . SesaZlebelia,glukozis donis momatebam gamoiwvios insulinis donis momateba dedissisxlSi, rac, Tavis mxriv iwvevs glukozis donis momatebas nayofissisxlSi, rasac moyveba pH donis daqveiTeba Wiplaris arteriaSi.hiperinsulinemias Tan sdevs hipoglikemiis ganviTareba da es aReniSnebaim axalSobilebs, romelTa dedebsac gaukeTdaT 25 gram glukozaze metimSobiarobis dros, xolo umarilo xsnarebis gadametebuli gamoyenebaiwvevs rogorc nayofis, ise dedis hiponatriemias. amis garda,intravenuri infuzia zRudavs dedis Tavisufal gadaadgilebas da xelsuSlis mSobiarobis bunebriv mimdinareobas.mSobiarobis dros dehidratacia da acidozi SeiZleba Tavidan aviciloTsiTxis da advilad mosanelebeli sakvebis miRebiT. ZiriTadad, qalebiTviTon intuiciurad Tavs izRudaven sakvebis gadametebuli miRebisagan,da iReben mxolod siTxes, namcxvarsa da Sokolads.amgvarad, unda aRiniSnos, rom mSobiaris kvebis sakiTxi aris ZalzedmniSvnelovani da amave dros, Zalzed variabeluri sakiTxi. rogorc Cans,Tanamedrve midgoma qals aZlevs arCevans samedicino personalTangasaubrebis Semdeg TviTon gadawyvitos sakiTxi dasaSvebi sakvebisa dasasmelis raodenobis miRebis Sesaxeb fiziologiuri mSobiarobisdros. 22;238

ar arsebobs safuZveli fiziologiuri mSobiarobis drosSeizRudos siTxeebis da sakvebis miReba.Afsiqologiuri mxardaWera mSobiarobis drosbebiaqalebis daxmarebiT qalTa fsiqologiuri da fizikuri mxardaWerisSesaxeb Catarebulma randomizirebulma kvlevebma aCvenes, rom damxmaresada mSobiares Soris kargi fsiqologiuri kontaqtis arseboba (mudmivigverdze yofna da mxardaWera, mSobiaris komfortis gasaumjobesebelizomebis CaTvliT zurgis masaJi, mSobiarobis meqanizmis axsna)mniSvnelovnad aumjobesebs mSobiarobis mimdinareobas: mokldebamSobiarobis dro, naklebi raodenobiT gamoiyeneba analgeziis mizniTgamosayenebeli medikamentebis raodenoba, aseve operaciulimSobiarobebis raodenoba, mcirdeba aseve bavSvTa raodenoba, romlebicibadebian apgaris SkaliT 7 balze naklebi SefasebiT 24; 25-27 .Catarda 15 rkk, romelSic monawileobda 12 791 qali, sadacSedarebuli iyo mSobiarisa da masTan mudmivad myofi zedamxedvelispraqtika mSobiarobis Cveulebriv zedamxedvelobasTan. sistemurmimoxilvaSi yvelaze didi kvlevis CarTvam damatebiT gamoavlinaSemdegi: erTi-erTze zedamxedveloba profesionalis anaraprofesionalis mier, axloblebTan erTad an maT gareSe, dadebiTzegavlenas axdens mSobiarobis dros samedicino Carevebis sixSireze dadedis emociur mdgomareobaze. kvlevam aCvena, rom qalebs, romelTacuweven mudmiv mxardaWeras, ufro iSviaTad esaWiroebaTanalgezia/anesTezia, operaciuli saSosmxrivi mSobiaroba, sakeisro kveTa(yvela gansxvaveba statistikurad sarwmunoa) da aseve mcirdebamSobiarobasTan dakavSirebuli ukmayofileba (OOR 0.73, 95%, СI ( 0.65-0.83).samwuxarod, mocemuli suraTi mkveTrad gansxvavdeba imisgan, romelicdRes SeimCneva samSobiaro saxlebSi. qalebi mSobiarobis dros TavsgrZnoben izolirebulad, garSemortymulebi arian ra rTulieleqtronuli aparaturiT saTanado megobruli mxardaWeris gareSe.garda amisa, Tu gaviTvaliswinebT mravaladgilian mSobiarobamdelpalatebs, rTulia qalisaTvis privatulobis uzrunvelyofa mSobiarobisdros.radgan arsebobs ojaxis wevrebisa da naTesavebis garemocvaSimSobiarobis garkveuli upiratesobani, amitom aucilebelia saavadmyofospirobebSi Seiqmnas garemo, romelic miaxloebulia saxlis pirobebTane.w. samSobiaro oTaxebi - sawolebiT, televizoriT, savarZelisarweveliTda fardebiT.sistemur mimoxilvaSi 29 , romelSic CarTuli iyo 8677 qali, maTi 19-77%gadayvanili mSobiarobis dros saxlis msgavs garemo pirobebidansamSobiaro blokSi. qalebi, romlebmac imSobiares saxlis msgavsgaremoSi, ufro naklebad saWiroebdnen tkivilgamayuCebeli saSualebebismiRebas, ufro naklebad aRiniSneboda maTi imobilizacia mSobiarobisdros, aseve SeiniSneboda nayofis guliscemis darRvevis naklebi sixSire,naklebi operaciuli mSobiaroba, isini ufro kmayofilni iyvnenmeTvalyureobiT. gamovlinda ufro maRali perinataluri sikvdilianobis25;289

sixSire saxlis msgavs pirobebSi mSobiarobis dros {p=0.066}. SedegebmaaCvena, rom rodesac qalebi mSobiarobdnen saxlis msgavs pirobebSi, isiniufro mets moZraobdnen mSobiarobis pirvel periodSi da ufro xSiradmSobiarobdnen swor an naxevrad dawolil pozaSi. es ori faqtorialbaT ganapirobebs mSobiarobis aRZvris, analgeziis, operaciulimSobiarobis da nayofis guliscemis anomaliebis mniSvnelovandaqveiTebas. saxlis msgavs pirobebSi mSobiarobis danergva SeiZlebaiyos xarj-efeqturi alternativa tradiciuli samSobiaro blokisa,Tumca is saWiroebs yuradRebas gansakuTrebiT gazrdili perinatalurisikvdilianobis TvalsazrisiT.samecniero-teqnikuri progresis ganviTarebasTan erTad orsulTasamedicino daxmareba xorcieldeba mxolod mean-ginekologTa mier. aseTimidgomis upiratesobani seriozuli eWvis qveS eqceva. mSobiarobis drosmean-ginekologTa da bebiaqalTa mier gaweuli daxmarebis SedarebiTmaanalizma aCvena, rom bebiaqalebs mSobiaroba miyavT ufrokonservatulad, ufro naklebi sixSiriT SeimCneva mSobiarobisstimulacia, operaciuli saSosmxrivi mSobiaroba, (maSebi da vakuumeqstraqcia), aseve klebulobs epiziotomiis sixSire da axalSobilTaraodenoba, romlebic saWiroeben reanimacias da intensiuri TerapiisganyofilebebSi gadayvanas. ar gamovlenila gansxvaveba mSobiarobisaRZvrisa da sakeisro kveTis sixSireebs Soris.naTelia, rom qalebi fiziologiurad mimdinare orsulobiT ar arisaucilebeli iyvnen mean-ginekologis meTvalyureobis qveS.specialistebma, romlebic meTvalyureoben dabali da maRali riskisjgufis orsulebs, unda gaakeTon rTuli arCevani: moaxdinonkoncentracia an mxolod maRali riskis jgufis orsulebze anfiziologiur orsulebze (rac Seadgens SemTxvevaTa umravlesobas), risdrosac isini swrafad dakargaven kvalifikacias.bebiaqalebi da ojaxis eqimebi Tavidanve orientirebulebi arian dabaliriskis jgufis orsulebisaTvis daxmarebis aRmosaCenad, urTierTobisprocesSi ufro axlos ecnobian orsulis individualur Tvisebebs,amitom maT mier gaweuli daxmarebis xasiaTi ufro pasuxobs orsulTaumravlesobis moTxovnebs, vidre mean-ginekologis mier aRmoCenilidaxmareba.orsulebi xSirad gamoxataven survils, orsulobisa da mSobiarobisdros daxmareba miiRon erTi da imave pirisagan, visTanac isini amyarebenaxlo urTierTobas. randomizirebuli kvlevebis Sedegebma 29 aCvena, romaseT orsulebs mSobiarobisas aReniSnebaT vaginaluri gasinjvis damedikamentozuri stimulaciis mniSvnelovnad naklebi sixSire, mcirdebaaseve bavSvTa raodenoba, romlebic ibadebian apgaris SkaliT 7 qulazenaklebi SefasebiT, xolo mSobiarobis xangrZlivoba mcirdeba. Aamasgarda, aseTi qalebi ufro momzadebulebi arian mSobiarobisa daaxalSobilis movlisaTvis.mudmivi mxardaWera mSobiarobis dros, romelsac axorcielebssamedicino personali (eqimi, bebiaqali) mSobiaris axlobelTanerTad, amcirebs samedicino Carevebis ricxvs mSobiarobis drosda aseve aumjobesebs qalis mdgomareobas.A10

samSobiaro tkivilebimiuxedavad imisa, rom yvela qali ganicdis tkivilebs mSobiarobis dros,maTi reaqcia tkivilze meryeobs farTo sazRvrebSi. Kklinikuri kvlevebismonacemebiT, garTulebuli mSobiaroba, romelic mimdinareobssamSobiaro moqmedebis diskoordinaciiT, mSobiarobis aRZvriT,mSobiarobis stimulaciiT da operaciuli gziT ufro mtkivneulia.bebiaqalisa da mean-ginekologisaTvis, romelsac miyavs mSobiaroba,mniSvnelovania qalisaTvis daxmarebis aRmoCena tkivilebis SemsubuqebismizniT. miuxedavad imisa, rom amis miRweva SesaZlebelia medikamentebissaSualebiT, ufro mniSvnelovania aramedikamentozuri gautkivareba,romelic iwyeba qalisa da misi partnioris antenataluri momzadebisprocesSi. gamovlenilia, rom mSobiarobisaTvis mosamzadebelprogramebSi monawileoba mniSvnelovnad aqveiTebs mSobiarobisgautkivarebisaTvis medikamentozuri saSualebebis gamoyenebis sixSires 30 .samwuxarod, antenataluri momzadebis sxva dadebiTi efeqtis gamovlenaver moxerxda.mSobiarobis dros fsiqologiur daxmarebasTan erTad, romelicgansakuTrebiT mniSvnelovania, arsebobs ramodenime sxva midgoma. pirvelrigSi qals unda mivceT saSualeba mSobiarobis dros TviTon amoirCiosnebismieri poza, mas SeuZlia idges, ijdes an iaros gansakuTrebiTmSobiarobis pirveli periodis ganmavlobaSi. zogierTi qali SvebasgrZnobs Tbili abazanisa an Sxapis miRebis, masaJisa an zurgze xelismosmis Semdeg. aseTive Sedegs iZleva sunTqviTi varjiSebi da relaqsacia,romelTa saSualebiTac xdeba qalis yuradRebis gadatana. aseTimoqmedebebi usafrTxoa da SesaZlebelia maTi farTo gamoyeneba.mSobiarobis gautkivarebis medikamenturi meTodebimSobiarobis medikamenturi gautkivareba farTod gamoiyeneba da misidadebiTi efeqti damtkicebulia mravali gamokvlevebiT. samwuxarod,medikamenturi gautkivarebis negatiuri efeqti ar aris kargadSeswavlili. zogierTi dawesebulebebis monacemebiT medikamenturigautkivareba gamoiyeneba fiziologiuri mSobiarobis dros 20-80%-Si 31 .sainhalacio anesTetikebis gamoyenebis sixSire bolo xanebSi Semcirda(sul ufro xSirad is icvleba periduruli analgeziiT); gansakuTrebiTxSirad am dros gamoiyeneba azotis qveJangi JangbadTan erTadproporciiT 50%:50%-ze. Yyvela medikamenti, romelic gamoiyenebagautkivarebis mizniT, gaivlis placentur bariers da SesaZlebeliagamoiwvios nayofis sunTqviTi depresia da tvinis funqciebis moSla,aseve ZuZuTi kvebis survilis gaqroba. mag.: seduqseni iwvevs neonatalurdepresias, saSvilosnos hipotoniasa da hipoTermias 32;33;34; 35 .periduruli anesTeziis sxavdasxva variantebi (epiduruli, kaudaluri,kombinirebuli epidurul-spinaluri) farTod gamoiyeneba mSobiarobisdros. am tipis anesTeziis upiratesobani kargad aris dadasturebuli.periduruli anesTeziis gamoyenebisaTvis aucilebelia 24 saaTianianesTeziologiuri meTvalyureoba, aRWurviloba da momzadebulipersonali. Ddamtkicebul upiratesobebTan erTad mSobiarobis drosperiduruli anesTeziis gamoyeneba dakavSirebulia rig arasasurvel11

momentebTan: xangrZlivdeba mSobiarobis pirveli periodi, ufro xSiradgamoiyeneba oqsitocini, mSobiarobis meore periodSi WinTviTi refleqsisdaqveiTebis gamo matulobs Rrusa da gamosavlis maSebisgamoyenebis 36 sixSire.gamovlinda sakeisro kveTis sixSiris momateba periduruli anesTeziisgamoyenebisas 37 , gansakuTrebiT, Tu misi gamoyeneba iwyeboda saSvilosnosyelis 5 sm-ze naklebi gaxsnis dros.eWvgareSea, rom periduruli anesTezia Zalzed efeqturia paTologiurimSobiarobis dros, magram Tu is gamoiyeneba fiziologiurimSobiarobisas, ibadeba kiTxva - SeiZleba Tu ara aseT mSobiarobasvuwodoT fiziologiuri? periduruli anesTeziis gamoyeneba aris naTelimagaliTi normaluri mSobiarobis “medikalizaciisa,, rac normalurfiziologiur process gadaaqcevs samedicino procedurad. aseTitransformacia gamowveulia kulturuli faqtorebiTa da adaT-wesebiT.ase, magaliTad, aSS-Si da did britaneTSi qalTa umravlesobamSobiarobs periduruli anesTeziis gamoyenebiT. amave dros, holandiaSiqalTa 30%-ze meti mSobiarobs saxlSi medikamenturi gautkivarebisgareSe, xolo saavadmyofoSi mSobiarobis SemTxvevaSi maTi mxolodmcire raodenoba iRebs medikamentur gautkivarebas.normaluri mSobiarobis marTvisas ufro mizanSewonilad iTvlebagautkivarebis aramedikamenturi meTodebis gamoyeneba, farmakologiurmameTodebma ar unda Seicvalon mSobiarisaTvis gaweuli personaluriyuradReba da saTuTi mopyroba.fiziologiuri mSobiarobis dros sasurvelia gautkivarebisarafarmakologiuri meTodebis gamoyeneba. gamtareblobiTianalgeziis gamoyeneba axangrZlivebs mSobiarobas, zrdisoqsitocinis gamoyenebisa da operaciuli saSosmxrivimSobiarobis sixSires.Anayofis mdgomareobis Sefasebanayofis mdgomareobis Sefaseba warmoadgens mSobiarobis marTvisganuyofel nawils. Nnayofis distresis ganviTareba - guliscemissixSiris cvalebadoba 160-is zeviT da100-120 qveviT an gulicemis ritmisdarRveva, romelic ZiriTadad hipoqsiiTaa gamowveuli, SeimCnevafiziologiuri mSobiarobis drosac ki.sanayofe siTxis Sefasebasanayofe siTxeSi mekoniumis aRmoCena SesaZlebelia miuTiTebdes nayofisdistresze, aseve mkvdradSobadobis, neonataluri avadobisa dasikvdilianobis sixSiris momatebaze 38-42sanayofe garsebis darRvevis Semdeg mekoniumis aRmoCena dakavSirebuliaperinataluri avadobisa da sikvdilianobis riskis momatebasTan.sanayofe wylebis xasiaTi sanayofo buStis spontanuri darRvevisasmSobiarobis dawyebisas maSinve unda iyos Sefasebuli da mekoniumisarseboba unda gaxdes nayofze intensiuri dakvirvebis safuZveli.12

amnioinfuzia warmoadgens Wiplaris miWyletis simptomebis Tavidanacilebis efeqtur meTods mSobiarobis procesSi oligohidramnionisarsebobisas.sistematurma mimoxilvam 43 , romelic exeboda amnioinfuziasmSobiarobisas mekonialuri sanayofo siTxis arsebobisas Seamcira:mekoniumiT sanayofo siTxis SeRebva (RR 0.03, 95%, CI 0.01-0.15), nayofisguliscemis 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). perinatalurisikvdilianobis arc erTi SemTxveva ar iqna gamovlenili.profilaqtikuri amnioinfuzia oligohidramnionis dros dakavSirebuliaperinataluri gamosavlis gaumjobesebasTan, magram Wiplaris kompresiisniSnebis ar arsebobisas amnioinfuzia ar unda iyos gamoyenebuli.beta-mimetikebis daniSvna Seswavlili iyo nayofis mosalodnelidistresis dros da SesaZloa is warmoadgendes sasargeblo meTodsdrois mogebis mizniT mSobiaobis marTvis Semdgomi taqtikisgansazRvrisaTvis, Tumca sistematurma mimoxilvam 44 gvaCvena, romjgufSi, sadac gamoiyeneboda tokolitikebi, Semcirda nayofisguliscemis anomaliebi (RR- 0.26, 95% CI 0.13 CI 0.53).beta-mimetikebiTmkurnalobam magniumis sulfatTan SedarebiT Seamcira saSvilosnoskumSvadoba (RR-0.07, CI-0.00-1.10)nayofis distresis ganviTarebisas sasurvelia mSobiarobis swrafidamTavreba. magram zogjer nayofis guliscemis mravali darRveva qrebaubralo konservatuli RonisZiebebis Catarebis Semdeg, magaliTadiseTebis, rogorebicaa: dedis sxeulis mdebareobis Secvla (marcxenagverdze moTavseba), oqsitocinis Seyvanis Sewyveta saSvilosnoplacenturisisxlis mimoqcevis gasaumjobeseblad.Jangbadis moklevadiani daniSvnis efeqturoba Sefasda sistematurmimoxilvaSi 45 , romelic mimarTuli iyo Jangbadis profilaqtikuridaniSvnis efeqturobis Sesafaseblad mSobiarobis dros. Wiplarissisxlis pH-is paTologiuri maCveneblebi (7,2-ze naklebi) bevrad ufroxSirad gamovlinda oqsigenaciis jgufSi, vidre sakontrolo jgufSi. (RR3,51, 95%, CI 1,34-9.19) sxva statistikurad mniSvnelovani gansxvavebajgufebs Soris ar gamovlenila. miRebuli iyo urTierTsawinaaRmdegomonacemebi Jangbadis miwodebis xangrZlivobasa da Wiplaris arteriis pHismaCveneblebs Soris. Mamgvarad, mSobiarobis dros jangbadisprofilaqtikuri gamoyenebisaTvis ar arsebobs sakmarisi mtkicebulebebi,iseve rogorc nayofis distresis samkurnalod.nayofis guliscemanayofis gulicemis auskultaciuri da eleqtronuli dakvirvebismeTodebis Sedarebanayofis guliscemasa da mis mdgomareobas Soris kavSiri kargad arisdadasturebuli. arsebobs nayofis guliscemis gamokvlevis ori meTodi:uwyveti eleqtronuli monitoringi da garegani auskultacia sameanostetoskopiT. A auskultacia ZiriTadad tardeba 15-30 wT-Si erTxelmSobiarobis pirveli periodis ganmavlobaSi da yoveli WinTvis Semdegmeore periodSi. Aam meTodis upiratesobas warmoadgens misi simartive -13

es aris Sesaferisi ubralo teqnologiis magaliTi, romelic martiviagamoyenebaSi.eleqtronuli monitoris gamoyeneba nayofis guliscemis Sesafasebladaucilebelia maRali riskis orsulobisa da mSobiarobis dros. Tumca amdros miRebuli informacia ufro zustia, misi interpretaciakardiotaqogramebis monacemebiT ufro rTulia. 46;47am meTodis mgrZnobeloba distresis gamovlenis TvalsazrisiT maRalia,magram specifiuroba - dabali 48 . Ees imas niSnavs, rom meTodi iZleva didiraodenobiT cru-dadebiT Sedegebs da Sesabamisad, ufro didiraodenobiT iwvevs aramizanmimarTul Carevebs mSobiarobis procesSi,gansakuTrebiT, Tu monitoringi gamoiyeneba dabali risk-jgufisorsulebSi. 49;50 rigma prospeqtulma sakontrolo kvlevebma argamoavlina gansxvaveba ubralo auskultaciasa da nayofis guliscemiseleqtronul kontrols Soris, aRiniSna sakeisro kveTis ufro maRalimaCvenebeli eleqtronuli kontrolis gamoyenebis jgufSi. sistematiurmimoxilvaSi 51 sadac Sedioda 12 rkk 37 000 qalis monawileobiT datardeboda auskultaciis da mudmivi kardiotokografiis Sedareba argamovlinda mniSvnelovani gansxvaveba perinataluri sikvdilianobissaerTo sixSireSi (RR 0.85, 95% CI 0.59-1,23, n=33 513, 11 kvleva), magram 2-jerSemcirda neonataluri cerebraruli damblis ganviTarebis sixSire. (RR0.50, 95% CI 0.31-0,80, n=32 386, 2 kvleva), Tumca aranairi gansxvaveba ar iqnagamovlenili cerebrul damblis sixSireebs Soris (RR 1,74, 95%, CI 0,97-3,11, n=13 252, 2 kvleva). mniSvnelovnad (66%-iT) gaizarda sakeisro kveTissixSire mudmivi kardiotokografiis gamoyenebisas (RR 1,66, 95%, CI 1,30-2,13,n=18 761, 10 kvleva), ramdenadme gaizarda operaciuli saSosmxrivimSobiarobis ricxvi (RR 1,16, 95%, CI 1,01-1,32, n=18 151, 9 kvleva).eWvgareSea, rom nayofis guliscemis uwyveti eleqtronuli monitoringisCatareba sakeisro kveTisa da operaciuli saSosmxrivi mSobiarobisgazrdili ricxvis fonze, sadavos xdis mis gamoyenebis fiziologiuradmimdinare mSobiarobis dros.am monacemebs gaaCniaT Zalian mniSvnelovani zegavlena dakvirvebismeTodis amorCevis sakiTxSi fiziologiuri mSobiarobis dros. amorCevismeTodi nayofis guliscemis dakvirvebis mizniT fiziologiurimSobiarobis dros unda iyos wyvetili auskultaciis meTodi. Tumca,iqac ki, sadac aris eleqtronuli kontrolis saSualeba, auskultaciurimeTodi unda iyos arCevanis meTodi fiziologiuri mSobiarobis dros.mxolod im mSobiarobis dros, rodesac saWiro xdeba mSobiarobis aRZvraan stimulacia, an mekoniumis aRmoCenis dros, eWvgareSea eleqtronulimeTodis upiratesobani. Ffiziologiuri mSobiarobis dros eleqtronulimonitoringi mniSvnelovnad zrdis mSobiarobis procesSi Carevebisraodenobas mis gamosavalze dadasturebuli dadebiTi efeqtis gareSe,garda amisa, is warmoadgens qalisaTvis damatebiTi diskomfortiswyaros. Nnayofis winamdebare Tavidan aRebuli sisxlis gamokvlevaes gamokvleva, romlis mizania mSobiarobaSi nayofis hipoqsiis SefasebaSeiswavlis nayofis mJava-tutovan wonasworobas pH-is maCvenebelis saxiT.14

arsebobs garkveuli eWvebi am meTodis sizustesTan dakavSirebiT,gansakuTrebiT winamdebare nayofis Tavze samSobiaro simsivnisCamoyalibebisas, Tumca, nayofis guliscemis eleqtronul kontrolTanerTad meTodma daadastura Tavisi klinikuri efeqturoba. is SeiZlebagamoyenebuli iyos mxolod nayofis guliscemis cvlilebis SemTxvevaSi .meTodi saWiroebs rTul aRWurvilobas, trenirebuli personalisarsebobas da sakmaod arakomfortulia mSobiarisaTvis. EeleqtrodisSeyvanisas zogjer SesaZlebelia warmoiqmnas iseTi garTulebebi,rogoricaa infeqcia da sisxldena nayofis Tavidan. da bolos, ismoiTxovs 24 saaTiani laboratoriuli samsaxuris arsebobas.axlaxan Catarebulma kvlevebma aCvenes, rom Tavis kanSi laqtatisdadgena aris pH-is kargi ganmsazRvreli, im upiratesobiT, rom is ufroadvilad Casatarebelia, ufro iafia da ufro iSviaTadaa dakavSirebuliteqnikur siZneleebTan. laqtatis gansazRvrisaTvis saWiroa mxolod 5mikrolitri sisxli 52 .am meTodebis gamoyeneba ZiriTadad SemoisazRvreba dawesebulebebiT,romlebic gankuTvnilia maRali riskis orsulebisaTvis. meTodis rolifiziologiuri mSobiarobis marTvisas SezRudulia.sanitarul-epidemiologiuri reJimisadac ar unda Catardes mSobiaroba, sisufTave warmoadgensumniSvnelovanes da aucilebel pirobas. Tumca ar aris sterilobisdacvis aucilebloba, unda moxdes xelebis saguldagulod dabana sapniTda wyliT.Uunda mieqces yuradReba mSobiare qalis da mSobiarobismarTvaSi CarTuli personalis higienasac. kvlevebma aCvenes, romregularuli baqteriologiuri kontroli da mtareblobis eradikacia araxdens zegavlenas nozokomialuri infeqciebis sixSireze axalSobilebsada dedebSi. 53 BBmniSvnelovania aseve garemos sisufTavec. adre aucilebel pirobadiTvleboda steriluri xalaTebisa da niRbebis gamoyeneba qalisinfeqciisagan dacvis TvalsazrisiT. Aam mizniT maTi gamoyenebausargebloa. 54 miuxedavad amisa, aiv da Sidsis, B da C hepatitebisTavidan acilebis mizniT, gamoyenebuli unda iyos damcavi tansacmelipersonalis dainficirebuli sisxlisagan dacvis TvalsazrisiT. 4instrumentebi, romlebic ganmeorebiTad gamoiyeneba, unda gasterildesmsoflios jandacvis organizaciis moTxovnebis Tanaxmad. 4 aucilebeliaaseve usafrTxoebis zomebis miReba qalebisa da samedicino personalisinficirebis Tavidan asacileblad, rac moicavs sisxlsa da siTxeebTanpirdapiri kontaqtisagan Tavis aridebas, xelTaTmanebis gamoyenebassaSosmxrivi gasinjvisas da mSobiarobis dros, placentis Seswavlisas.infeqciis riskis daqveiTebis TvalsazrisiT mniSvnelovania invaziurimeTodebis minimaluri gamoyeneba, iseTebis, rogoricaa epiziotomia daepiziorafia.transcervikaluri amnioinfuzia aqveiTebs nayofis guliscemisdeceleraciebis sixSires da sakeisro kveTis risks.A15

amnioinfuziis saSualebiT qveiTdeba mekoniumiT aspiraciissindromis riski, sakeisro kveTisa da neonataluri avadobissixSire. arsebuli mtkicebulebebi mxars uWers mis gamoyenebasqalebSi, romelTac aReniSnebaT mekonialuri sanayofo siTxe.beta–mimetikebis daniSvna nayofis distresis dros warmoadgensdrois mogebis sasargeblo xerxs, romelic saSualebas iZlevaSemuSavdes mSobiarobis marTvis Semdgomi gegma.fiziologiuri mSobiarobis dros arCevis meTodi unda iyoswyvetili auskultacia. nayofis guliscemis eleqtronulimonitoringis gamoyeneba asocirebulia sakeisrokveTisa da operaciuli saSosmxrivi mSobiarobis sixSirismomatebasTan.saWiroa steriluri xelTaTmanebis gamoyeneba saSosmxrivi gasinjvis,mSobiarobisa da placentis daTvalierebis dros. mSobiarobis drospersonalma unda Caicvas sufTa tansacmeli, winsafari, saTvaleebi,steriluri xelTaTmanebi (qudi da niRabi survilisamebr,individualuri Tavdacvis mizniT)AAAСmSobiarobis pirveli periodis marTvamSobiarobis dasawyisis gansazRvrasamSobiaro moqmedebis dasawyisis gansazRvra aris mSobiarobis marTviserT-erTi umniSvnelovanesi momenti. rogorc wesi, mSobiarobis dawyebisdadastureba xdeba saSosmxrivi gasinjviT. Tu mSobiarobis dawyebaarasworadaa diagnostirebuli, Sedegad amas xSirad moyvebadausabuTebeli Carevebi, iseTebi, rogoricaa amniotomia da/anoqsitocinis Seyvana. zogjer preliminaruli periodisa da dawyebulisamSobiaro moqmedebis gansasxvaveblad saWiroa mocdiTi taqtika.fiziologiuri mSobiarobis progresi fasdeba mSobiarobis saerToxangrZlivobiT an saSvilosnos yelis gaxsnis siCqariT (saSualod erTism/sT-Si). es ukanaskneli ufro misaRebia, radganac mSobiarobis saerToxangrZlivobis gansazRvra SesaZlebelia mxolod retrospeqtulad.partograma 55-57 (danarTi 1) warmoadgens mSobiarobis mimdinareobisgrafikul gamosaxulebas. miTiTebulia, rom igi unda gaixsnassaSvilosnos yelis 3 sm gaxsnisas (mSobiarobis aqtiur fazaSi) droiserTeulSi saSvilosnos yelis gaxsnis siCqaris grafikulgamosaxulebasTan erTad SesaZlebelia saSvilosnos SekumSvebis, asevenayofis guliscemis sixSiris, medikamentebis daniSvnis da sxvamniSvnelovani parametrebis aRniSvna. partogramis gamoyenebiTSesaZlebelia mSobiarobis Sefaseba masze mxolod erTi daxedviT:martivia samSobiaro moqmedebis anomaliebis gamovlena. partogramis16

gamoyeneba advilia, mis mixedviT SesaZlebelia swavleba da efeqturiainformaciis gacvla. mSobiarobis dros partogramis gamoyenebaSeswavlili iyo mravalcentrul kvlevaSi, romelSic monawileobda 35484 qali. partogramis danergvam Seamcira rogorc gaxangrZlivebulimSobiarobis (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. 58sanayofe wylebis daRvris sakiTxma mSobiarobis dawyebamde vadamitaniliorsulobisas (= > 38 kviras) gamoiwvia diskusia saSosmxrivi gasinjvebisriskis, 59 mSobiarobis aRZvris saWiroebisa da antibiotikebiTprofilaqtikis aucileblobis Sesaxeb. randomizirebul kvlevaSi 60ganxiluli iyo mSobiarobis aRZvris efeqti sanayofo wylebis daRvridan12 saaTis Semdeg mocdiT taqtikasTan SedarebiT (sanayofo siTxisdaRvridan 48 saaTis CaTvliT). Ggamovlinda, rom mSobiarobis aRZvrisjgufSi medikamenturi gautkivarebisa da sxva samedicino CarevebissixSire ufro maRali iyo, vidre mocdiTi taqtikis jgufSi. Aamave dros,axalSobilebSi infeqciuri garTulebebi mocdiTi taqtikis jgufSigamovlinda ufro xSirad (3,2% 1,6 % winaaRmdeg). unda aRiniSnos isic,rom zemoT aRniSnuli monacemebi miRebulia ganviTarebul qveynebSi.sistematurma mimoxilvam am sakiTxis Sesaxeb 61 gamoavlina antibiotikebisgamoyenebis sargeblianoba da SesaZlo gverdiTi efeqtebi qalebSisanayofe garsebis mSobiarobamdeli darRveviT vadamitanili orsulobisdros. orma kvlevam, romlebic moicavda 838 qals, gamoavlina dedisinfeqciebis sixSiris daqveiTeba (qorioamnionitisa da endometritis) (RR0.43; 95% CI 0.23–0.82). ar iqna miRebuli sarwmuno mtkicebulebebiperinataluri sikvdilianobis Sesaxeb (RR 0.98; 95% CI 0.14–6.89). kvlevebSigamoyenebuli iyo parenteraluri antibiotikebis sxvadasxva kombinaciebi(ampicilini+gentamicini+cefuroqsimi), aseve aRebuli iyo sxvadasvadrois (12 saaTiani da 24 saaTiani) intervalebi samSobiaro moqmedebisaRZvrisaTvis. meTodologiuri arasrulfasovnebis gamo antibiotikebiTrutinuli mkurnalobis Rirebuleba vadamitanili orsulobis drossanayofo buStis mSobiarobamdeli darRvevis dros ucnobia da saWiroadamatebiTi kvlevebis Catareba am sakiTxTan dakavSirebiT.saqarTveloSi ufro miRebulia mSobiarobis marTvis aqtiuri taqtikisgamoyeneba, imis gaTvaliswinebiT, rom sefsisi da misi garTulebebiwarmoadgenen dedis sikvdilianobis erT-erT mTavar mizezs.sanayofe siTxis mSobiarobamdeli daRvra orsulobis adreul vadebze(38 kviramde) warmoadgens dedisa da axalSobilis inficirebis xSirmizezs. axlaxan gamoqveynebulma mimoxilvam, romelSic Sevida 19 kvleva,sadac CarTuli iyo 6000 qali 62 gamoavlina, rom antibiotikebisgamoyeneba am dros dakavSirebulia qorioamnionitis sixSirisdaqveiTebasTan (RR: 0.57, 95%CI 0.37- 0.86), mSobiarobis dawyebisgadavadebasTan 48 saaTis ganmavlobaSi (RR 0.71, 95% CI 0.58 -0.87). mcirdebaaseve neonataluri avadobis Semdegi maCveneblebi: neonataluri infeqciapnevmoniis CaTvliT (RR 0.68, 95% CI 0.53- 0.87), surfaqtantis gamoyenebissixSire (RR 0.83, 95%CI 0.72 - 0.96), bavSvTa raodenoba, romlebic saWiroebenJangbadiT mkurnalobas (RR 0.88, 95%CI 0.81-0.96) da axalSobilTaraodenoba Tavis tvinis ultrabgeriTi kvlevis paTologiurimonacemebiT (RR 0.82, 95% CI 0.68- 0.98). mniSvnelovnad gaizarda bavSvTa17

aodenoba 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 undaganxorcieldes partogramis meSveobiTBprofilaqtikuri antibiotikoTerapiis faseuloba sanayofe siTxisnaadevi daRvris dros ucnobia.Asanayofe siTxis naadrevi daRvrisas orsulobis adreulvadebze (38 kviramde) antibiotikebis gamoyeneba amcirebsara mxolod qorioamnionitis sixSires, aramed iwvevsorsulobis prolongirebas da aqveiTebs seriozulineonataluri avadobis sixSires,…arsebulimtkicebulebebidan gamomdinare eriTromicini warmoadgenssaukeTeso arCevans.AmSobiaris poza mSobiarobis pirvel periodSi.ramodenime kvlevam daadastura, rom mSobiaris zurgze mdebareobaauaresebs saSvilosno-placentur sisxlis mimoqcevas orsulisaSvilosnos zewolis gamo (qveda Rru venis sindromi). zurgze wolaaqveiTebs saSvilosnos kumSvadobas 63;64;65. . gamokvlevebi aseve mowmoben,rom Tu mSobiares aqvs saSualeba imoZraos da miiRos sxeulisnebismieri mdebareoba, saSvilosnos SekumSvebi ufro efeqturi xdeba damSobiaroba ufro xanmoklea da naklebad mtkivneuli, aseve mcirdebaoqsitocinis gamoyenebis sixSire. 63-6718 rkk-is sistematiurma mimoxilvam 68 aCvena, rom lateraluri davertikaluri pozicia mSobiarobis dros amcirebs operaciuli Carevisaucileblobas zurgze woliT poziciasTan SedarebiT.Sedegebis interpretacia unda moxdes sifrTxiliT, radganac 19 kvlevis(5764 monawile) meTodologiuri xarisxi gansxvavebuli iyo. nebismierimdgomare an gverdiTi poziciis gamoyeneba zurgze an liTotomiispoziciasTan SedarebiT dakavSirebuli iyo: mSobiarobis meore periodisxangrZlivobis SemoklebasTan (10 kvleva, saSualo 4,29 wT. 95% CI 2.95 to5.64 min) mSobiarobis ricxvis SemcirebasTan, romlebic moiTxovdnenCarevas (18 kvleva, RR 0.84, 95% CI 0.73 - 0.98), epiziotomiebis sixSirisdaqveiTebasTan (12 kvleva, RR 0.84, 95% CI 0.79 - 0.91), meore xarisxis SorisisCaxevis 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 SegrZnebisdaqveiTebasTan (1 kvleva RR 0.73, 95% CI 0.60 - 0.90); nayofis guliscemissixSiris darRvevebis SemcirebasTan (1 kvleva RR 0.31, 95% CI 0.08 to 0.98). ammimoxilvis Sedegebma gamoavlina 500 ml-ze meti sisxlis danakargis18

SesaZlo ganviTareba qalebSi, romlebic vertikalur poziciaSimSobiaroben. sanam ar iqneba miRebuli kvlevebis ufro dawvrilebiTiSedegebi am sakiTxze da ar gaumjobesdeba am kvlevebis meTodologia,orsuls unda mieces saSualeba TviTon airCios mSobiarobis pozicia.erTaderT gamonakliss warmoadgens sanayofe siTxis daRvra moZraviTavis pirobebSi. mSobiarobis marTvis dros arsebuli standartebi,magaliTad: rogoricaa guliscemis eleqtronuli monitoringi daoqsitocinis wveTobrivi Seyvana zRudavs qalis arCevans. mdebareobisarCevani unda iyos nebayoflobiTi - mSobiarobisas siarulis an dgomisdaZaleba aris iseTive Tavisuflebis SezRudva, rogorc moTxovnagaunZrevlad iwves zurgze. (danarTi 2)orsulebs unda mivceT arCevani imSobiaron im poziciaSi,romelsac isini yvelaze komfortulad Tvlian.Ayvela qals unda gaewios mudmivi mxardaWera mSobiarobisdros. partogramis gamoyeneba, lateraluri da vertikaluripoza da epiduruli anesTeziis Tavidan acileba amcirebsmSobiarobis dros operaciuli Carevis aucileblobas.AsaSosmxrivi gasinjvasaSosmxrivi gasinjva warmoadgens mSobiarobis dawyebisa da progresisSefasebis erT-erT umniSvnelovanes saSualebas. saSosmxrivi gasinjvisraodenoba unda SeizRudos. mSobiarobis pirveli periodis ganmavlobaSisruliad sakmarisia saSosmxrivi gasinjva yovel 4 saaTSi erTxel,rogorc es mocemulia mSobiarobis partogramaSi. 69garda amisa, saSosmxrivi gasinjva unda Catardes mxolod samedicinoCvenebebiT: samSobiaro moqmedebis sisuste, sanayofo siTxis daRvra anWinTvebis dawyeba. es unda ganisazRvros adgilobrivi protokoliT.klinikur bazebze, sadac mimdinareobs studentebis swavleba, xSiradaucilebeli xdeba swavlis mizniT saSosmxrivi gasinjvebis warmoeba. Aamdros aucilebelia qalis Tanxmoba. AaraviTar SemTxvevaSi ar undaganxorcieldes zewola qalze misi Tanxmobis miRebis mizniT. Aarc Tuise Soreul warsulSi SemoTavazebuli iyo reqtaluri gasinjva qalisinficirebis riskis daqveiTebis TvalsazrisiT. SedarebiTma kvlevebma,romlebic Catarebulia reqtaluri da vaginaluri gasinjvisSesadareblad ar gamoavlines gansxvaveba inficirebis ganviTarebissixSireebs Soris. 54samSobiaro moqmedebis progresis gansazRvramSobiarobis progresis Sefaseba xdeba mSobiare qalze dakvirvebissafuZvelze - misi qceviT, saSvilosnos SekumSviT, winamdebare nawiliswinmsvlelobiT, magram saSvilosnos yelis gaxsnis xarisxi mSobiarobisprogresis yvelaze zust kriteriums warmoadgens. miRebuli normebisagan19

gadaxra unda gaxdes safuZveli mSobiarobis marTvis gegmisgadaxedvisaTvis. Ppartogramis warmoebisas es vlindeba saSvilosnosyelis gaxsnis SenelebiT (< 1 sm/saaTSi); bebiaqalis meTvalyureobis qveSmimdinare mSobiarobis dros aseTi Seneleba unda iyos safuZvelimSobiaris stacionarSi gadasayvanad. 70 aucilebelia samSobiaromoqmedebis Senelebis mizezis gansazRvra. kvlevebi gviCvenebs, romdaaxlovebiT 20% pirveladi mSobiarebSi yelis gaxsnis siCqaris xazikveTavs yuradRebis xazs, xolo 10-11% ki Carevis xazs. 71 mSobiarobisneli progresi unda gaxdes ufro mizezis gamovlenis da ara aqtiuriCarevis safuZveli. unda gamovlindes menjisa da nayofis TavisSeusabamobis niSnebi.mTeli sanayofe buStis pirobebSi da gamoxatuli samSobiaro moqmedebisdros Seusabamoba ar warmoadgens mSobiarobis Senelebis mizezs. aseTSemTxvevebSi mizanSewonilia mocdiTi taqtika 72 , radganac dRevandeldRes ar aris samecniero kvlevebi mSobiarobis aqtiuri marTvisa damocdiTi taqtikis SedarebasTan dakavSirebiT, Znelia zustirekomendaciebis gacema am sakiTxze.daRvrili sanayofe siTxis pirobebSi da samSobiaro moqmedebis sisustisdros ufro xSirad vlindeba meqanikuri mizezebi. aseTi mSobiarobismarTva scildeba mocemuli rekomendaciebis farglebs.samSobiaro moqmedebis sisustis profilaqtikaarsebobs ramodenime saSualeba samSobiaro moqmedebis sisustisprofilaqtikisaTvis. zogjer es RonisZiebebi tardeba bevrad ufro adre,vidre partogramaze gamoCndeba samSobiaro moqmedebis Sesusteba. ufroxSir Carevebs warmoadgens adreuli amniotomia da oqsitocinisintravenuri Seyvana an am ori meTodis kombinacia.adreuli amniotomiaes procedura, sanayofe garsebis qirurgiuli darRveva, SemoTavazebuliiyo zogierTi avtoris mier, rogorc aucilebeli samSobiaro moqmedebisdawyebidan 1 saaTis Semdeg. 73 Tumca kvlevebma gamoavlines pirveli tipisgviani deceleraciebis sixSiris mniSvnelovani momateba adreuliamniotomiis Semdeg. ramodenime randomizirebul kvlevaSi gamovlinda,rom adreuli amniotomia mSobiarobis dros amoklebs mSobiarobisxangrZlivobas saSualod 60-120 wuTamde da ar axdens zegavlenasanalgeziis da operaciuli Carevis gamoyenebis sixSireze. kvlevebma argamoavlines adreuli amniotomiis raime zegavlena axalSobilTamdgomareobaze. 74-76msgavsi daskvnebi miRebulia sistematuri mimoxilvaSi, 77 sadacganixileboda rutinuli adreuli amniotomiis efeqti mSobiareebisdabali riskis jgufSi. aRmoCnda, rom adreuli amniotomia zrdissakeisro kveTis albaTobas, amcirebs mSobiarobis xangrZlivobas,oqsitocinis gamoyenebis sixSiresa da samSobiaro tkivilebs. racSeexeba axalSobilTa gamosavals, Semcirda apgaris SkaliT 7-ze naklebiquliT dabadebuli bavSvebis raodenoba. statistikurad sarwmuno20

gansxvaveba ar gamovlenila neonataluri avadobis sxva maCveneblebSi,rogoricaa Wiplaris arteriis mJava-tutovani balansi da intensiuriTerapiis ganyofilebaSi gadayvana.rutinuli adreuli amniotomia saerTo jamSi ar aris sargebliani. imisgamo, rom is zrdis sakeisro kveTis albaTobas. A fiziologiurimSobiarobis SemTxvevaSi amniotomiis CatarebisaTvis unda arsebobdesmniSvnelovani Cveneba.rutinul adreul amniotomias - ar gaaCnia upiratesoba, radganacizrdeba sakeisro kveTis albaToba. fiziologiuri mSobiarobisdros amniotomiis CatarebisaTvis unda arsebobdes mniSvnelovaniCveneba.Aoqsitocinis intravenuri Seyvanaoqsitocinis intravenuri Seyvana xSirad gamoiyeneba mSobiarobisdasaCqareblad sanayofo garsebis TviTneburi an xelovnuri darRvevisSemdeg. Ooqsitocinisa da adreuli amniotomiis kombinaciis gamoyenebasxSirad mSobiarobis aqtiur marTvasac uwodeben. Ppirvelad es meTodikamowodebuli iyo irlandiaSi 78 da Seswavlili iyo mravalrandomizirebul kvlevebSi. sxva kvlevaSi 73 sakontrolo jgufis qalebssTxovdnen ar dawoliliyvnen sawolSi, aramed sakuTari survilisamebrdamjdariyvnen an emoZravaT. am jgufSi mSobiarobis saSualoxangrZlivoba iyo umniSvnelod ufro mokle, vidre oqsitocinisgamoyenebis jgufSi. Aar iyo gansxvaveba axalSobilebis apgariTSefasebaSi, aseve axalSobilebis gadayvanaSi reanimaciulganyofilebaSi. qalTa umravlesoba aRniSnavda, rom oqsitociniTstimulacia iwvevda arasasiamovno SegrZnebebs. mSobiareTa 80%-ze metmaaRniSna, rom stimulaciam gaaZliera tkivili mSobiarobis dros.sakontrolo jgufis qalTa naxevarma aRniSna, rom moZraoba mSobiarobisdros amsubuqebda tkivils maSin, rodesac qalTa 24%-ma ver SeniSnaveranairi gansxvaveba.aucileblobis SemTxvevaSi oqsitocinis gamoyeneba SeiZleba marto imdawesebulebebSi, sadac SesaZlebelia saswrafo qirurgiuli daxmarebisaRmoCena. am dros aucilebelia nayofis guliscemis eleqtronulimonitoringi. Ddublinis kvlevis gamocdileba aseve xazs usvams Semdegs:qalTa im jgufSi, sadac gamoyenebuli iyo auskultacia, ufro maRaliiyo nevrologiuri garTulebebis sixSire. gansakuTrebiT es aRiniSnebodaqalebSi, romelTac CautardaT oqsitociniT stimulacia. 42igive exeba mSobiarobis aRZvris mizniT prostaglandinebis gamoyenebas.oqsitocinis intravenuri Seyvana dasaSvebia Mmxolod infuzomatisgamoyenebiT. Seyvanili oqsitocinis raodenoba ganisazRvreba mlerT/wm-Sida 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.21

3 ml/sT-5,1 mlerT/wT4 ml/sT-6,7 mlerT/wT5 ml/sT-8,3 mlerT/wT6 ml/sT-10 mlerT/wTrogorc wesi oqsitocinis infuzia unda daiwyos 3 ml/sT-iT (5,1mlerT/wT-iT) da gaormagdes yovel 20-25 wT-Si, sanam ar iqneba miRweulisasurveli intensiobis samSobiaro moqmedeba (6-7 Seteva 15 wT-isganmavlobaSi)oqsitocinis intravenuri Seyvana mSobiarobis drossamSobiaro moqmedebis gasaZliereblad dasaSvebia Mmxolodinfuzomatis gamoyenebiTCoqsitocinis Seyvana kunTebSioqsitocinis kunTebSi Seyvana mSobiarobis stimulaciis mizniTganixileba, rogorc saSiSi meTodi saSvilosnos hiperstimulaciisa danayofze uaryofiTi zegavlenis gamo. aRsaniSnavia aseve saSvilosnosgaskdomis momatebuli sixSirec. 79 es araswori taqtika saswrafod undaaikrZalos.mSobiarobis meore periodis marTvamSobiarobis meore periodSi nayofis oqsigenacia TandaTanobiTqveiTdeba WinTvebis da saSvilosno-placentaruli sisxlis mimoqcevisdaqveiTebis gamo. xangrZlivi WinTvebi mniSvnelovnad aqveiTebsplacentarul sisxlis mimoqcevas, rasac Tan sdevs acidozis ganviTareba.meore periodis ganmavlobaSi arsebobs individualuri gansxvavebebi,aqedan gamomdinare, aucilebelia nayofis mdgomareobis dinamiurikontroli.zogierT samSobiaroSi Cveulebriv praqtikad iTvleba mSobiaresgadayvana winasamSobiaro palatidan samSobiaro darbazSi meoreperiodis dasawyisSi. Cveulebriv, samSobiaro bloki aRWurviliasanaTurebiT, sawolebiT, romlebsac aqvT fexebis dasadebi da sxv.miuxedavad imisa, rom aseTi oTaxebi ufro xelsayrelia samedicinopersonalisaTvis, qalisaTvis nebismieri transportireba arasasurveliada arasasiamovno. Nnormaluri mSobiarobis dros ar aris aucilebeliqalis gadayvana sxva adgilze. warmatebulad SesaZlebelia qalismomSobiareba igive oTaxSi, sadac mimdinareobda mSobiarobis pirveliperiodi.22

WinTvebis dawyebaqals sTxoven gaiWinTos saSvilosnos yelis sruli gaxsnisas rodesacwinamdebare nawili aris menJis fskerze. Ffiziologiuri midgomamdgomareobs imaSi, rom WinTvis SegrZneba qals TviTneburadCamouyalibdes. Aar aris Catarebuli randomizirebuli sakontrolokvlevebi, romlebic Seadarebdnen WinTvebis adreul dawyebas maT gviandawyebasTan fiziologiuri mSobiarobis dros, Tumca ramodenime aseTikvleva Catarebulia epiduruli analgeziis gamoyenebisas. 80 WinTvebisdaTrgunvisas gautkivarebis am meTodis gamoyenebis dros adviliaWinTvebis SeCereba SeWris momentamde. aseTi midgoma Sedarebuli iyoWinTvebis dawyebasTan saSvilosnos yelis sruli gaxsnisas. 81-83WinTvebis gviani dawyeba ar axdenda uaryofiT gavlenas dedisa danayofis mdgomareobaze. adreuli WinTvebis jgufSi aRiniSna sameanomaSebis gamoyenebis momatebuli sixSire.zogjer WinTvebis dawyebis win xdeba Sardis buStis dacla kaTeterismeSveobiT, magram amis aucilebloba ar aris. kaTeterizaciamSesaZlebelia gamoiwvios saSarde gzebis dainficireba. Cadgmuli TavispirobebSi kaTeterizacia gaZnelebulia da travmulic ki. sasurvelia,mSobiares vTxovoT moSardos pirveli periodis dros, fiziologiurimSobiarobis dros es srulebiT sakmarisia.WinTvis teqnikadRevandel dRes farTod gamoiyeneba WinTvis teqnika, rodesac qalixangrZlivad ikavebs haers da iWinTeba erTi WinTvis ganmavlobaSi 2-3-jer20-30 wamis ganmavlobaSi (valsalvas meTodi). alternatiul meTodswarmoadgens xanmokle WinTvebi (4-6 wamis ganmavlobaSi) erTi WinTvisganmavlobaSi 3-5-jer.84;85;86;87ramodenime kvlevaSiCatarda ori zemoT aRniSnuli meTodisSedareba. tradiciuli teqnikisaTvis damaxasiaTebelia meore periodisramdenadme Semokleba, magram mas SeuZlia nayofis guliscemis da gulisgadmosrolis seriozuli darRvevebis gamowveva, rac sunTqviTiteqnikiTaa ganpirobebuli. zurgze wolis gamo qveda Rru venaze zewolaauaresebs am mdgomareobas. Catarebul kvlevebSi pH saSualo maCvenebeliufro dabali iyo jgufSi haeris xangrZlivi SekavebiT, xoloaxalSobilebs aReniSnebodaT tendencia apgariT SefasebisdaqveiTebisaken. Mmiuxedavad imisa, rom arsebuli monacemebi Zalianmwiria, ufro mizanSewonilia xanmokle WinTvebi (4-6 wamis ganmavlobaSi)erTi WinTvis ganmavlobaSi 3-5-jermSobiarobis meore periodis xangrZlivoba1930 wels 628 qalSi Seswavlili iyo 88 mSobiarobis meore periodisxangrZlivoba nayofis TaviT winamdebareobis dros, romelmac saSualodmiaRwia 75 wuTs. Mmeore periodis xangrZlivoba didadaa damokidebulisamedicino personalze, romelic marTavs mSobiarobas. Nnayofis23

acidozisa da hipoqsiis kavSiri meore periodis xangrZlivobasTanxSirad warmoadgens mizezs meore periodis SemoklebisaTvis CvenebisgareSec ki. aseTi midgoma Seswavlili iyo rig kvlevebSi89-91 .mSobiarobis meore periodis Semoklebam saTanado Cvenebebis gareSegamoavlina mxolod pH mniSvnelovani momateba Wiplaris arteriaSi, sxvaraime upiratesobebis gareSe dedisa da nayofis mxriv, maTi momatebulitravmatizmis fonze, rac ar SeiZleba iyos gamarTlebuli. aqedangamomdinare, dedisa da nayofis damakmayofilebeli mdgomareobis drosar arsebobs safuZveli mSobiarobis meore periodis naadrevidasrulebisaTvis, pirobiTi maCveneblis gadaWarbebis SemTxvevaSic ki.ramodenime kvlevaSi Seswavlili iyo im axalSobilTa mdgomareoba,romlebic dabadebuli iyvnen meore periodis sxvadasxva xangrZlivobisSemdeg. 148 axalSobili Seswavlili iyo pH maCveneblebis danevrologiuri indeqsis gansazRvris Semdeg. Mmeore periodisxangrZlivoba meryeobda, 60 wuTidan (pirvelmSobiareTa 66%) 159 wuTamde.ar iqna gamovlenili kavSiri meore periodis xangrZlivobasa daaxalSobilTa mdgomareobas Soris. 92 Catarebuli kvlevebi exeboda 6759axalSobils, dabadebuls TaviT winamdebareobaSi, woniT >2500 gramze;mSobiarobis meore periodis xangrZlivoba aRemateboda 3 saaTs 11%SemTxvevaSi. Aar gamovlenila kavSiri meore periodis xangrZlivobasa daapgariT Sefasebis dabal maCveneblebs, nevrologiur garTulebebsa anaxalSobilTa intensiuri Terapiis ganyofilebaSi gadayvanisaucileblobas Soris. 93amrigad, unda aRiniSnos, rom meore periodis SemoklebasTandakavSirebuli gadawyvetileba unda daefuZnos dedisa da nayofismdgomareobas. Tu dedisa da nayofis mdgomareoba damakmayofilebelia, ararsebobs safuZveli mSobiarobis naadrevad dasrulebisaTvis.kategoriulad dauSvebelia WinTvebis Forsireba (saSvilosnos fuZezezewola)ase rom, WinTvebis gadavadeba ufro mizanSewonilia nayofiskeTildReobisaTvis, romelic gamoixateba JangbadiT saturaciaSi 94mSobiaris pozicia mSobiarobis meore periodis dros.rigi kvlevebiT 95;96;96;97 dadasturda, rom vertikalur poziciasmSobiarobis meore periodSi gaaCnia upiretesobani CveulebrivpoziciasTan SedarebiT. Qqalebi am dros ganicdian ufro naklebdiskomfortsa da sirTuleebs WinTvebisas, qveiTdeba tkivilis SegrZneba,mcirdeba samSobiaro gzebis travmatizmi da Wrilobis inficireba.19 kvlevis sistematurma mimoxilvam, 68 romelSic CarTuli iyo 5764monawile, aCvena, rom nebismieri mdgomare an gverdiTi poziciisgamoyeneba zurgze an liTotomiis poziciasTan SedarebiT dakavSirebuliiyo mSobiarobis meore periodis xangrZlivobis daqveiTebasTan (10kvleva, saSualo 4,29 wT. 95% CI 2.95 - 5.64 wT), mSobiarobis drosdaxmarebis 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 sixSiresTan24

(11 kvleva RR 1.68 95% CI 1.32 -o 2.15); meore periodis dros mwvave tkivilisSegrZnebis daqveiTebasTan (1 kvleva RR 0.73, 95% CI 0.60 - 0.90); nayofisguliscemis sixSiris darRvevebis nakleb raodenobasTan ( 1 kvleva RR 0.3195% CI 0.08 -0.98).am mimoxilvis sacdelma Sedegebma aCvenes vertikaluri poziciis dros500 ml-ze meti sisxlis danakargis ganviTarebis SesaZlebloba.kvlevebSi, romlebic Seiswavlida qalebis damokidebulebas mSobiarobispoziciis arCevisadmi, gamovlinda, rom vertikaluri pozicia ufromisaRebi iyo qalebisaTvis naklebad gamoxatuli tkivilisa da xerxemlisdiskomfortis gamo. tradiciuli pozicia maT mier ganixileboda,rogorc ufro xelsayreli, magram moZraobis TvalsazrisiT ufroSemzRudavi. Qqalebma, romelTac hqondaT vertikaluri mSobiarobisgamocdileba, gamoTqves survili SemdgomSic aseTi saxiT emSobiaraT. 98; 7da bolos unda aRvniSnoT, rom es daskvna misaRebia mSobiarobisrogorc pirveli, aseve meore periodisaTvis. qals SeuZlia TavisufladamoirCios is pozicia, romelic mas ufro moswons da yvelaze ufrometad aris misTvis xelsayreli. qalebs unda gaewioT mxardaWera impoziciis arCevisas, romelic maTTvis yvelaze xelsayrelia. samedicinopersonali gawvrTnili unda iyos mSobiarobis misaRebad nebismierpoziciaSi ise, rom qalis survilebi ar SeizRudos.Catarda kvlevebi, 99 romlebSic Sedarda mSobiarobis gamosavalimSobiarobis meore periodis Catarebisas sameano savarZelSi da misgareSe. winaswar informirebuli pirveladi mSobiareebi gaurTulebelimSobiarobiT da epiduruli analgeziis gareSe randomizirebulni iyvnensamSobiarod savarZelSi (n=163) da savarZlis gareSe jgufSi (n=157).mSobiarobis meore periodis xangrZlivobam savarZlis gareSemSobiarobisas 13 wT-iT gadaaWarba meore periodis xanglZlivobaspirveli jgufis qalebSi (sameano savarZelSi). ar gamovlenila raime sxvaklinikuri gansxvaveba dedisa da axalSobilis mxriv mocemul or jgufsSoris. miuxedavad imisa, rom savarZelSi WinTva dakavSirebulia meoreperiodis mcired SemoklebasTan, raime sxva upiratesoba mas ar gaaCnia.Sorisis dacva da movla mSobiarobis drosSorisis dacvis mizniT mSobiarobis dros gamoiyeneba ramodenime xerxi.meanobisMmraval saxelmZRvaneloSi aRwerilia Sorisis dacva TavisgamoWris dros: erTi xelis, ZiriTadad marjvenas TiTebiT afiqsirebenSoriss, maSin, rodesac meore xeli akontrolebs Tavis gamoWris siCqaresraTa Tavidan aicilon Sorisis travma. SesaZlebelia, rom aseTi meTodiTavidan gvacilebs saSosa da Sorisis Caxevebis ganviTarebas, magramwinmsvlel Tavze zewola arRvevs gaSliT meqanizms Tavis dabadebisas,aSorebs ra mas Sexebis wertilisagan simfizis rkalTan da amiT zrdisSorisis Caxevis albaTobas.„HOOP“ kvlevaSi 100 Sedarebuli iqna meTodi “xeldaxmarebiT” (rodesacerTi xeli moTavsebulia bavSvis Tavze masze zewolis da mSobiarobiskontrolis mizniT, xolo meore xeli moTavsebulia Sorisze dagamoiyeneba gverdiTi moxra mxrebis ganTavisuflebis gasaadvileblad)meTodTan “xeldaxmarebis gareSe” (qalis instruqtaJi da xelSeuxebloba25

avSvis Tavsa da Sorisze, saWiroebis SemTxvevaSi zewolisganxorcielebis mzadyofniT).kvlevaSi randomizirebuli iyo 5471 qali. pirveli jgufis qalebiaRniSnavdnen nakleb mtkivneulobas mSobiarobis Semdgom 10 dRisganmavlobaSi meore jgufTan SedarebiT. (34.1% vs. 31.1%; RR 1.10, 95% CI 1.01-1.18) damatebiT, epiziotomiis sixSire ufro maRali iyo xeldaxmarebisjgufSi (12.9% vs. 10.2%; RR 0.79, 99% CI 0.65-0.96) xolo placentis xeliTmocileba ufro dabali (1.5% vs. 2.6%; RR 1.69, 99% CI 1.02-2.78). argamovlenila sxva raime statistikurad mniSvnelovani gansxvavebajgufebs Soris.unda aRvniSnoT, rom Sorisis tradiciuli dacva SesaZlebelia mxolodqalis zurgze mSobiarobisas. orsulTa vertikaluri an jdomiTi pozisdros Sorisis dacva xdeba masTan Sexebis gareSe.masaJiSorisis dacvis sxva teqnika mdgomareobs mSobiarobis meore periodSiSorisis mudmivi masaJiT misi gawelvis mizniT qsovilebis maqsimalurielastiurobis misaRwevad.Catarda randomizirebuli kvleva 101 mSobiarobis meore periodSi SorisismasaJis efeqtis dasadgenad specialuri wyalSi xsnadi lubrikantisgamoyenebiT. kvlevaSi randomizebuli iyo 1340 mSobiare. dauzianebeliSorisis, aseve pirveli da meore xarisxis Caxevebis sixSire Tanabari iyomasaJisa da sakontrolo jgufs Soris. aRiniSna meti mesame xarisxisCaxeva masaJis jgufSi (12 (1.7%) v 23 (3.6%); AR 2.11, RR 0.45; 95% CI 0.23 to 0.93,P

Sorisis masaJi mSobiarobis meore periodSi ar aqveiTebsSorisis travmis, tkivilis, dispareuniis, aseve Sardisa daganavlis Seukaveblobis problemebs.ASorisis Caxeva, perineotomia da epiziotomiaepiziotomiis sixSire gansxvavdeba sxvadasxva qveynebSi. 102 magramaRiniSneba statistikurad sarwmuno epiziotomiebis ricxvis Semcireba1983 -2000 wlebis SualedSi . 103ase magaliTad, aSS-is saavadmyofoebSi epiziotomiis sixSire aRwevs 20-73%-s, rac am proceduras yvelaze gavrcelebuls xdis. Sorisis mesame dameoTxe xarisxis dazianebis sixSire varirebs 4-13%-mde sxvadasxvasaavadmyofoebSi. 104 holandiaSi ki, sadac mSobiaroba mihyavT ZiriTadadbebiaqalebs, epiziotomiis sixSire Sedagens 24,5%-s. 105ZiriTadad, gamoiyeneba CaWris ori saxe. Pperineotomiisas Wriloba ufroadvilad ikereba da aRiniSneba ufro kargi kosmetikuri efeqti, maSin,rodesac Sua-lateraluri epiziotomia ufro efeqturad icavsdazianebisagan swor nawlavs.Sorisis CaWris ZiriTad Cvenebebs fiziologiuri mSobiarobisaswarmoadgens nayofis asfiqsiis niSnebi, Tavis winmsvlelobis Seneleba,Sorisis mosalodneli Caxeva. Sorisis CaWris farTo gamoyenebismxardaWerisaTvis literaturaSi moyvanilia damatebiTi argumentebi: amdros Wriloba ufro advilad aRdgeba da ufro Cqara xorcdeba,nawarmoebi Wriloba icavs Soriss da menjis Rrus kunTebs Semdgomitravmisagan, riTac xdeba Sardis Seukaveblobis simptomebisCamoyalibebis Tavidan acileba.Catarebulma gamokvlevebma ar daadastures zemoT aRniSnulimosazrebebi Sorisis CaWris aucilebeli damcvelobiTi Catarebissasargeblod.eqvsi rkk-is monacemebis meta-analizma 106 aCvena, rom SezRuduliepiziotomia rutinulTan SedarebiT dakavSirebulia Sorisis ukananawilis nakleb dazianebasTan (RR 0.88, 95% CI 0.84 - 0.92), kervis naklebaucileblobasTan (RR 0.74, 95% CI 0.71 - 0.77) da Sexorcebisas naklebgarTulebebTan (RR 0.69, 95% CI 0.56 - 0.85). SezRuduli epiziotomiadakavSirebuli iyo Sorisis wina nawilis ufro xSir dazianebasTan. (RR1.79, 95% 1.55-2.07). ar inaxa gansxvaveba saSos da Sorisis mZime dazianebebsSoris (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 miRebuliSezRuduli epiziotomiis Sedarebisas mediolateralur an SuaxazisepiziotomiasTan.aqedan gamomdinare, fiziologiuri mSobiarobis dros epiziotomia undaCatardes mkacri Cvenebebis mixedviT. karg magaliTs warmoadgensmonacemebi, romelic inglisSi Catarebuli kvleviT aris miRebuli, sadac27

dedisa da nayofisaTvis zianis miyenebis gareSe epiziotomiis sixSiredaqveiTebulia 10%-mde. 107zogierTi avtoris mier SemoTavazebulia, ar gaikeros SorisisumniSvnelo (I da II xarisxis travmebi).Catarda ori mcire rkk da ori mcire retrospeqtuli kvleva Sorisispirveli da meore xarisxis travmebis gakervisa da maTi gakervis gareSedatovebis Sesadareblad. SotlandiaSi Catarebulma kvlevam 108 (74pirveladi mSobiare) ar gamoavlina mniSvnelovani gansxvaveba jgufebsSoris tkivilis TvalsazrisiT, magram gakervis jgufSi gamovlindaWrilobis ufro kargi mdgomareoba mSobiarobidan 6 kviris Semdeg.SveciaSi Catarebulma rkk-m 109 (78 pirveladi mSobiare) aCvena tkivilisumniSvnelo momateba gakervis gareSe datovebul jgufSi, magram argamoavlina gansxvaveba Wrilobis SexorcebaSi jgufebs Soris. ormamcire retrospeqtulma kvlevam 110;111 ar gamoavlina gansxvaveba adreulavadobaSi da Wrilobis SexorcebaSi jgufebs Soris. SemdgomSiCatarebuli sami kvleva meTodologiurad arasrulfasovani iyo. saWiroaufro meti mtkicebulebebis mopoveba gakerili da gakervis gareSedatovebuli Sorisis I da II xarisxis travmebis axlo da Soreuliefeqtebis Sesaxeb.epiziotomiis warmoeba fiziologiuri mSobiarobis drosdasaSvebia mxolod mkacri CvenebebiT. Mmisi rutinuligamoyeneba dauSvebelia.ASorisis travmis aRsadgenad gamwovi sinTetikuri masalis(deqsonis da vikrilis) gamoyeneba, ketgutTan SedarebiT,mniSvnelovnad amcirebs tkivils, analgeziis gamoyenebis,Wrilobis gaxsnis da xelmeored gakervis sixSires.AmSobiarobis mesame periodis marTvamSobiarobis mesame periodi xasiaTdeba momyolis (placentis)mocilebiTa da gamoyofiT. Aam dros dawyebuli sisxldena (placentisnawilebis CarCenis gamo) SeiZleba sicocxlisaTvis saSiSi aRmoCndes.sisxlis dena mSobiarobis Semdgom Aadreul periodSi warmoadgens dedissikvdilianobis erT-erT ZiriTad mizezs ganviTarebad qveynebSi. 112mSobiarobis Semdgomi sisxlis denis sixSire matulobs risk-faqtorebisarsebobisas: mravalnayofiani orsulobis, mravalwylianobis,mSobiarobis stimulaciisa da saSosmxrivi operaciuli mSobiarobisdros. 113 fiziologiuri mSobiarobis drosac SesaZlebelia mesameperiodi garTuldes sisxldeniT. am garTulebis Tavidan acilebismizniT Casatarebeli ramodenime RonisZieba SemoTavazebuli da28

Seswavlili iyo randomizirebuli kontrolirebadi kvlevebissaSualebiT da warmodgenilia qvemoT.saSvilosnos SesakumSi preparatebis profilaqtikuri gamoyeneba.SesakumSi nivTierebebis Seyvana xdeba mesame periodis sxvadasxvaetapebze, ufro xSirad intravenurad da kunTebSi, nayofis wina mxaris anaxalSobilis dabadebis Semdeg.ZiriTadad Seswavlilia da gamoiyeneba oqsitocini da ergotaminisderivatebi - meTilergometrini an am ori preparatis kombinaciasintometrini7 kvlevis (3000 qalze meti) sistemurma mimoxilvam, 114 romelic CatardaganviTarebul qveynebSi, aCvena oqsitocinis profilaqtikuri gamoyenebisefeqturoba (naklebi sisxlis danakargi, RR sisxlis danakargisaTvis >500 ml-ze 0.50; 95%, CI 0.43,- 0.69) da oqsitocinis Terapiuli mizniTgamoyenebis naklebi sixSire (RR 0.50; 95% CI 0.39, 0.64); im jgufTanSedarebiT, sadac SesakumSi saSualebebi ar iyo gamoyenebuli,gamovlenili iyo umniSvnelod gazrdili tendencia placentis xeliTmocilebisa (RR 1.17; 95% CI 0.79, 1.73) da amave dros momatebuli iyosisxlis transfuziis saWiroeba (RR 1.30; 95% CI 0.50, 3.39)oqsitocinisa da ergometrinis Sedareba moxda 6 kvlevaSi, 115 romelicmoicavda 9332 qals, oqsitocinTan SedarebiT, ergometrinisa daoqsitocinis kombinacia asocirebuli iyo mSobiarobis Semdgomisisxldenis sixSiris daqveiTebasTan (sisxlis danakargi minimum 500 ml),(OR 0.82, 95% CI 0.71 - 0.95). es dadebiTi efeqti aRiniSna oqsitocinisrogorc 5 ise 10 erTeulis gamoyenebisas, magram efeqti ufrogamoxatuli iyo dabali dozis (5 erT) Seyvanisas. ar gamovlenilagansxvaveba sisxlis danakargis 1000ml da meti danakargis TvalsazrisiT.iseTi gverdiTi efeqtebi, rogoricaa gulisreva, Rebineba da hipertenziaufro damaxasiaTebeli iyo ergometrinisa da oqsitociniskombinaciisaTvis. rodesac mxedvelobaSi iyo miRebuli jgufebisheterogenuloba, ar gamovlenila statistikurad sarwmuno gansxvavebadedisa da axalSobilis gamosavalis mxriv. ergometrin-oqsitocinisrutinuli gamoyeneba, rogorc mesame periodis aqtiuri marTvis nawilisaasocirebulia mSobiarobis Semdgomi sisxlis denis mcire, magramstatistikurad sarwmuno daqveiTebasTan im SemTxvevaSi, rodesac sisxlisdanakargi udris an aRemateba 500 ml-s. ar gamovlenila statistikuradsarwmuno gansxvaveba 1000 ml–is toli an meti sisxlis denis SemTxvevaSi.statistikurad sarwmuno gansxvaveba aRiniSna dedis mxriv SemdegigverdiTi efeqtebis ganviTarebaSi: diastoluri arteriuli wnevismomateba, gulisreva da Rebineba oqsitocin-ergometrinis jgufSi. aserom, Semcirebuli sisxlis danakargi mSobiarobis Semdgom undaSewonili iyos oqsitocin-ergometrinis gamoyenebis SesaZlo gverdiTefeqtebTan.SesakumSi preparatebis gamoyenebis gverdiT efeqtebs miekuTvnebagulisreva, Rebineba, Tavis tkivili, hipertenzia. Ees garTulebebi ufrogamoxatulia ergotaminis gamoyenebisas. Ggarda amisa, ergotaminisgamoyenebisaTvis damaxasiaTebelia ufro iSviaTi, magram bevrad ufroseriozuli garTulebebi - gulis gaCereba, qalasSida sisxlcaqcevebi,29

miokardiumis infarqti, mSobiarobis Semdgomi eklamfsia da filtvebisSeSupeba.arsebuli monacemebis mixedviT, ergometrinTan SedarebiT upiratesobaeniWeba oqsitocinis gamoyenebas. Ggarda amisa, cxeli klimatis qveynebSioqsitocini ufro stabiluria, vidre ergometrini an meTilergometrini. 115kvlevebi, romlebic Seiswavlidnen prostaglandinebis (misoprostolisda intramuskularuli prostaglandinis) gamoyenebas (43 203 monawile) 116ar aCvenes sisxlis denis sixSiris daqveiTeba.oraluri misoprostoli doziT 600 mkg iwvevs klinikurad dastatistikurad sarwmuno 1000 ml-ze meti sisxlis danakargis gazrdassainieqcio uterotonul nivTierebebTan SedarebiT (7 kvleva, 22 749 qali,3.6% vs 2.7%; (RR) 1.34, 95% (CI) 1.16 - 1.55). Semcivneba da sxeulistemperaturis momateba (>38ºC) damaxasiaTebelia misoprostolisaTvis dadozirebazea damokidebuli (600 mcg vs 400 mcg: ori kvleva Semcivnebaze, RR:1.33; 95% CI: 1.07 - 1.64). oqsitocinTan SedarebiT, Semcivnebis SedarebiTiriski 600 mkg oraluri misoprostolis miRebisas Seadgens 3.29-s (7kvleva, 22 746 qali,19.7% vs 6.0%, 95% CI 3.03 - 3.56), xolo 38 graduscelsiusze maRali temperaturis SedarebiTma riskma Seadgina 6,78 (7kvleva, 2 209 qali; 6.3% vs 2.8% 95% CI 5.55 - 8.30).sainieqcio prostaglandinebis gamoyeneba asocirebulia sisxlis saerTodanakargis raodenobis daqveiTebasTan mSobiarobis mesame periodSi(saerTo sxvaoba - 70 ml, 95% CI -73 to -67 ml) uterotonur saSualebebTanSedarebiT, magram gaaCniaT ufro meti gverdiTi efeqti. mwiria amSedarebis Sesaxeb monacemebi MmSobiarobis Semdgomi mZime sisxldenisSemTxvevaSi, iseve rogorc damatebiTi uterotonuli xsnarebisgamoyenebis Taobaze.arc intramuskularul prostaglandinebs da arc misoprostols argaaCniaT upiratesoba uterotonul saSualebebTan SedarebiTmSobiarobis mesame periodis marTvisas gansakuTrebiT, dabali riskisjgufis qalebSi.mSobiarobis mesame periodis marTva (aqtiuri da mocdiTi taqtikisSedareba)saSvilosnos SesakumSi saSualebebis kombinirebuli gamoyeneba Wiplarissakontrolo daqaCvasTan erTad xSirad moixseneba, rogorc mSobiarobisaqtiuri marTva mocdiTi taqtikis sapirispirod. zogjer amas daerTvebaWiplaris adreuli gadakvanZvac, rac aucilebeli xdeba Wiplarissakontrolo daWimvisas.vinaidan Wiplaris adreuli gadakvanZva aisaxeba bavSvis mdgomareobaze,es aspeqti calke unda iyos ganxiluli.literaturuli monacemebiT, mesame periodis aqtiuri marTva ufromizanSewonilia, ZiriTadad imis gamo, rom sisxlis dena mSobiarobis30

Semdgom periodSi aRiniSneba ufro iSviaTad da am dros ufro maRaliahemoglobinis maCveneblebi. 117;118;119;119;120sisxlis gadasxmasTan da momyolis xeliT mocilebasTan dakavSirebulimonacemebi sxvadasxva iyo or did (bristolisa da dublinis) kvlevaSi.orive kvlevaSi aqtiuri marTva dakavSirebuli iyo garTulebebismomatebul sixSiresTan gulisrevis, Rebinebisa da hipertenziis saxiT,rac SesaZloa ergometrinis gamoyenebiT iyo ganpirobebuli.jandacvis msoflio organizaciis 4 ganmartebiT mSobiarobis Semdgomisisxlis dena ewodeba sisxlis danakargs ≥ 500 ml-ze. SesaZlebelia, romes ganmarteba aixsnas imiT, rom msoflios mraval kuTxeSi 500 ml-ze metisisxlis danakargi warmoadgens sicocxlisaTvis realur safrTxesanemiis maRali sixSiris gamo. mravali monacemebiT sisxlis saSualodanakargi 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 gamoyenebisasaReniSneboda sisxlis danakargi ≥500ml-ze da mxolod 3%-s >1000ml-ze.sisxlis gadasxma gamoiyeneba mxolod qalis sasicocxlo funqciebisdarRvevis dros. aseTi gadaxarisxeba gansakuTrebiT mniSvnelovaniagaumarTlebeli sisxlis gadasxmisagan Tavis asarideblad, iseTigarTulebebis Tavidan acilebis mizniT, rogoricaa Sidsi da inficireba.rogorc zemoT iyo aRniSnuli, SemoTavazebulia mSobiarobis mesameperiodis marTvis ramodenime varianti. aqtiuri marTva moicavsintervenciebis jgufs: profilaqtikuri uterotonuri saSualebis SeyvanaaxalSobilis dabadebis Semdeg, Wiplaris adreuli klemireba da gadaWrada Wiplaris kontrolirebadi daWimva. mocdiTi taqtika ki gulisxmobsimas, rom davelodoT placentis mocilebis niSnebs da WiplarigadaikvanZoT maSin, rodesac gaqreba misi pulsacia (xelSeuxeblobismidgoma). mesame periodis aqtiuri marTvis es ori midgoma Sedarebuliiyo mimoxilvaSi sadac CarTuli iyo 5 kvleva. 126 aqtiuri marTva mocdiTtaqtikasTan SedarebiT (samSobiaros pirobebSi) asocirebuli iyo riskisdaqveiTebasTan, kerZod: sisxlis danakargis saerTo gansxvaveba – 79.33 ml(95% CI - 94.29-64.37); mSobiarobis Semdgomi 500 ml-ze meti sisxlisdanakargi (RR 0.38, 95% CI 0.32-046) da mSobiarobis mesame periodisgaxangrZliveba (saerTo gansxvaveba - 9.77 wT. 95% CI 10.0 -9.53-mde). aqtiurmarTvasTan 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 gverdiTiefeqtebi axalSobilis gamosavlis mxriv. rutinul “aqtiur marTvas”gaaCnia upiratesoba sisxlis danakargis, mSobiarobis Semdgomis sisxlisdenisa da mesame periodis sxva seriozuli garTulebebis Tavidanacilebis TvalsazrisiT. magram aqtiuri marTva dakavSirebulia gverdiTiefeqtebis momatebul riskTan (gulisreva, Rebineba da hipertenzia)ergometrinis gamoyenebis pirobebSi. aqtiuri midgoma unda gaxdesrutinuli mSobiarobis mesame periodis marTvisas. aqtiuri marTvadakavSirebulia sisxlis dakargvis nakleb albaTobasTan, mSobiarobisSemdgomi sisxlis denisa da hemotransfuziis nakleb aucileblobasTan.gverdiT efeqtebSi Sedis: mSobiarobis mesame periodis gaxangrZliveba,31

dedis anemia, gulisrevisa da pirRebinebis momatebuli albaToba damomatebuli arteriuli wneva (ergotaminis gamoyenebisas) 127mocemuli sakiTxis mniSvnelobis gaTvaliswinebiT bebiaqalTasaerTaSioriso konfederaciam da mean-ginekologTa saerTaSorisofederaciam gaavrceles saerTo gancxadeba 128 mSobiarobis mesame periodismarTvis Sesaxeb mSobiarobis Semdgomi sisxlis denis prevenciis mizniT.qals unda SevTavazoT mesame periodis aqtiuri marTva, radganac isaqveiTebs atoniuri sisxlis denis albaTobas.mSobiarobis mesame periodis aqtiuri marTva moicavs Carevebs, romlebicgamiznulia placentis gamoZevebis gasaadvileblad saSvilosnoskumSvadobis gaZlierebiT da mSobiarobis Semdgomi sisxlis denisprofilaqtikiT. 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 marTvisgansaxorcieleblad.uterotonuli saSualebebis gamoyeneba• bavSvis dabadebidan erTi wuTis Semdeg, unda moxdes muclispalpacia meore bavSvis arsebobis gamosaricxad da gakeTdes10 erT. oqsitocini kunTSi. oqsitocins gaaCnia upiratesobasxva uterotonul saSualebebTan SedarebiT, radganac isefeqturia Seyvanidan 2-3 wT-is Semdeg, gaaCnia minimalurigverdiTi efeqtebi da SeiZleba gamoyenebuli iyos yvelaqalSi.• Tu oqsitocini ar aris xelmisawvdomi, SeiZleba Semdegiuterotonuli nivTierebebis gamoyeneba: ergometrini 0,2 mg.kunTSi, sintometrini 1 amp. kunTSi an misoprostoli 400-600mkg oralurad. misoprostolis oraluri daniSvna undamoxdes im SemTxvevaSi, rodesac ar aris xelmisawvdomi/an araris Sesaferisi oqsitocinisa da ergotaminis jgufisalkaloidebis Senaxvis pirobebi.• uterotonul xsnarebs esaWiroeba Sesabamisi Senaxvispirobebi: ergometrini: 2-8 gradusi celsiusiT, mzissxivebisagan da gayinvisagan dacva; misoprostoli: oTaxistemperatura, daxurul konteinerSi; oqsitocini: 15-30 gradusicelsiusiT, dacva gayinvisagan;• mocemuli unda iyos informacia am preparatebis gverdiTiefeqtebis Sesaxeb.• ergometrinisa da sintometrinis (radganac is Seicavsergometrins) micema ar SeiZleba preeklamfsiis, eklamfsiisada momatebuli arteriuli wnevis dros.32

Wiplaris kontrolirebadi traqcia• gaakeTeT Wiplaris klemireba SorisTan axlos (rodesac janmrTelaxalSobilTan Sewydeba pulsacia) da daiWireT is xelSi;• moaTavseT meore xeli qalis boqvenze da daafiqsireT saSvilosnosaSualo intensiobis zewoliT Wiplaris kontrolirebadi traqciisdros;• moaxdineT Wiplaris susti daqaCva da daelodeT saSvilosnos kargSekumSvas (2-3 wT) sTxoveT dedas, gaiWinTos da Zalian nazadCamoqaCeT Wiplari placentis gamosaZeveblad ise, rom ar SewyvitoTzewola saSvilosnoze;• Tu placenta ar gamoZevda 30-40 wm-is ganmavlobaSi, Wiplariskontrolirebadi daWimvisas, ar gaagrZeloT Wiplaris daqaCva;• frTxilad daiWireT EWiplari da daelodeT saSvilosnos xelaxalSekumSvas;• Semdegi SekumSvisas gaimeoreT Wiplaris kontrolirebadi traqciasaSvilosnoze zewoliT.arasodes ar ganaxorcieloT Wiplaris traqcia saSvilosnoze zewolisada misi kargi SekumSvis gareSe.• rodesac placenta daibadeba, daiWireT is ori xeliT dafrTxilad daatrialeT imisaTvis, rom garsebi daixves. frTxiladgamoqaCeT sruli gamoZevebisaTvis.• Tu garsebi gaixa, frTxilad daaTvaliereT saSos zeda mesamedi dasaSvilosnos yeli steriluri xelTaTmanebiT da gamoiyeneTfanjriani momWeri garsebis CarCenili nawilebis mosacileblad.• yuradRebiT daaTvaliereT placenta misi nawilebis CarCenisTavidan asacileblad. Tu CarCenilia dedis zedapiris nawilebi, anaris mogleJili garsebi sisxlZarRvebiT, unda vifiqroT placentisnawilebis CarCenaze da miviRoT Sesabamisi zomebi.saSvilosnos masaJi• dauyovnebliv daiwyeT saSvilosnos fuZis masaJi manamde, sanamsaSvilosno SeikumSeba;• ganaxorcieleT SekumSuli saSvilosnos palpacia yovel 15 wT-SierTxel da gaimeoreT palpacia saWiroebisamebr pirveli 2 saaTisganmavlobaSi;• darwmundiT, rom saSvilosno ar dundeba masaJis damTavrebisSemdeg.yvela zemoT aRniSnuli moqmedebis Catarebis arsi auxseniT mSobiaresada mis axloblebs. ganaxorcieleT mudmivi meTvalyureoba da mxardaWera.mSobiarobis mesame periodis aqtiuri marTva amcirebs sisxlisraodenobis danakargs, mSobiarobis Semdgom sisxlidenas dasisxlis gadasxmis aucileblobas. GgverdiT movlenebsA33

miekuTvneba: mesame periodis gaxangZliveba, dedis anemia,gulisrevis da Rebinebis momatebuli riski, arteriuliwnevis Aaweva (ergometrinis preparatebis xmarebisas)Wiplaris gadakvanZvis droWiplaris gadakvanZvis dro (maSinve nayofis dabadebis Semdgom anmogvianebiT) axdens garkveul zegavlenas dedisa da nayofismdgomareobaze. 117 dedis mdgomareoba am dros Seswavlili iyoramodenime kvlevaSi. 129;130 ar iyo gamovlenili Wiplaris gadakvanZvisdrois zegavlena mSobiarobis Semdgomi sisxldenis sixSireze.nayofis mdgomareobaze zegavlena Seswavlili iyo ramodenimerandomizirebuli kvlevis meSveobiT. 131-134 gamovlinda, rom axalSobilismdebareobisas dedis doneze an cota qvemoT 3 wuTis ganmavlobaSiWiplaris gadakvanZvamde nayofTan gadadis sisxlis daaxloebiT 80 ml.133;135;136 , is damatebiT iRebs daaxloebiT 50 mg. rkinas, rac SemdgomSiamcirebs rkinadeficituri anemiis ganviTarebis sixSires. 137;138Teoriulad sisxlis aseTma gadanawilebam SeiZleba gamoiwvioshipervolemia, policitemia da hiperbilirubinemia. aseTi garTulebebisalbaToba Seswavlili iyo rig kvlevebSi117 . Tumca axalSobilebs,romelTac CautardaT Wiplaris adreuli gadakvanZva, aReniSnebodaThemoglobinis, hematoktirisa da bilirubinis ufro dabali maCveneblebi,ar aRiniSneboda gansxvaveba klinikur mimdinareobasa da neonataluravadobaSi Wiplaris gadakvanZvis warmoebis drois Sedarebisas.sistematiuri mimoxilvaSi 139 Wiplaris gviani gadakvanZva dRenaklulaxalSobilebSi dakavSirebuli iyo nakleb transfuziis sixSiresTanaxalSobilis 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 axalSobilebSiaris ufro fiziologiuri meTodi, vidre adreuli. placentarulisisxlis damatebiTi transfuzia nayofTan warmoadgens fiziologiurprocess. fiziologiuri mSobiarobisas ar aris sakmarisi mizezebibunebriv procesSi Casarevad.Wiplaris sakontrolo daWimvisas oqsitocinis winaswari SeyvaniT, rigsameano klinikebSi farTod danergili meTodis gamoyenebisas, Wiplarisadreuli gadakvanZva aucilebelia. Tumca im adgilebSi, sadac farTodgamoiyeneba gviani gadakvanZva (Wiplaris pulsaciis gaqrobis Semdeg), araris gamovlenili uaryofiTi efeqtebi.damatebiT, rogorc zemoT aRvniSneT, Wiplaris gadakvanZva agvaridebsrkinadeficituri anemiis ganviTarebas 137;138 .sistematiur mimoxilvaSi 140 Seswavlili iyo Wiplaris drenaJisspecifiuri efeqti mSobiarobis mesame periodSi oqsitocinisprofilaqtikuri gamoyenebisas an mis gareSe.Wiplaris drenaJi moicavs mis klemirebasa da gadaWras bavSvis dabadebisSemdeg, magram SemdgomSi, Wiplaris dedismxrivi klemis moxsniTa dasisxlis Tavisufali drenirebis ganaxlebiT. es SeiZleba Catardes sxva34

intervenciebTan erTad, magaliTad, oqsitocinis rutinul SeyvanasTanerTad, Wiplaris sakontrolo daWimvasTan da Ddedis WinTvasTan erTad.Wiplaris drenaJma SesaZlebelia zemoqmedeba iqonios mSobiarobis mesameperiodze, radganac Sedegebi aCveneben mSobiarobis mesame periodisxangrZlivobis 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 Sedegebisinterpretacia unda moxdes sifrTxiliT.saWiroa Semdgomi kvlevebi Wiplaris drenaJis zemoqmedebaze mSobiarobismesame periodis marTvaze.axalSobilis movlauSualod mSobiarobis Semdeg saguldagulo yuradReba unda mieqcesaxalSobilis movlas (sasunTqi gzebi, sxeulis da garemos temperaturisSenarCuneba, dedasTan adreuli kontaqti da adreuli ZuZuTi kveba). 141yvela axalSobilma unda miiRos dauyovnebeli daxmareba dabadebisasgamocdili specialistis mier, rac moicavs Termul dacvas, sisufTavesada Wiplaris movlas, daxmarebas sunTqvis dawyebaSi da ZuZuTi kvebas,awonvas, Tvalebis profilaqtikas da pirvel gamokvlevas.dedis movla mSobiarobis Semdegplacenta saguldagulod unda iyos daTvalierebuli (mTlianoba,hematomebi, placentis aranormaluri mimagreba).saSvilosnos yelis rutinuli daTvalierebis AAaucilebloba ar arismtkicebadi. saSvilosnos yelis daTvalierebis Cvenebas warmoadgenssisxlosdena, instrumentaluri mSobiaroba, swrafi mSobiaroba.saSvilosnos Rrus xeliT revizia unda Catardes mkacrad mxolodCvenebebis mixedviT.dedis mdgomareobis Sefaseba xdeba mSobiarobidan ramodenime saaTisganmavlobaSi: pulsi, arteriuli wneva, temperatura. gansakuTrebiTmniSvnelovania sisxlis danakargis da saSvilosnos fuZis dgomis zustiSefaseba.fiziologiuri mSobiarobidan ori saaTis Semdeg Tu melogine ar iyodaZinebuli rbili samSobiaro gzebis daTvalierebisaTvis, sasurvelia iswamodges, daibanos xel-piri, moawovos axalSobils da survilismixedviT, TviTon gadavides palataSi meuRlis an axloblebisTanxlebiT.meloginis gawera fiziologiuri mSobiarobis dros xdeba pediatrTanSeTanxmebiT dadgenili standartis mixedviT, magram upiratesoba undamieniWos adreul gaweras.sistematiurma mimoxilvam 142 romelSic Seswavlili iyo adreulu gawerisSedegebi (samSobiaroSi Semobrunebis TvalsazrisiT) 3600 qalSi vergamoavlina uaryofiTi gavlena dedis da bavSvis janmrTelobaze, TumcayuradReba unda mieqces dedis sociodemografiul maCveneblebs da mismzadyofnas gawerisaTvis. 14335

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ÛÀÒÃcilaÒÀÏÃÄÍÏÁTavis Cadgma: 5 - moZravi 4 –mibjenili 3 - mcire segmentiT 2- didi segmentiT 1 - menjis RruSi 0 - gamosavalSidanarTi 2 qalis SesaZlebeli poza mSobiarobis pirvel dameore periodebSi37

gaidlainis gadasinjvisa da ganaxlebis vada – 3 weligaidlainis miRebis xerxi/wyarogaidlainis SemuSavebis meTodologia• mocemuli gaidlainis Semqnis procesSi samuSao jgufisgadawyvetilebiT moZiebuli da Sefasebuli iqna ukvearsebuli praqtikuli rekomendaciebi. moxda arsebulirekomendaciebis adaptirebuli variantis SemuSaveba, romelicerTis mxriv pasuxobs saerTaSoriso moTxovnebs, xolo meoremxriv iTvaliswinebs saqarTvelos samedicino dawesebulebaTarogorc adamianur, ise teqnikur resursebs.• klinikuri rekomendaciebis, epidemiologiuri monacemebisa damtkicebeulebebis Semdgomi moZieba xorcieldeboda Yahoo,AltaVista, Google, DoctorGuide, Yandex, Rambler saZiebo operatorebismeSveobiT, aseve samedicino monacemebis eleqtronulibibliografiuli monacemTa bazis, „medlainis,, (MEDLINE)meSveobiT. pirvel rigSi moZiebuli iyo (National GuidelinesClearinhouse, TRIP, SumSearch) fiziologiuri mSobiarobis Sesaxebanalogiuri rekomendaciebi, romlebic SemuSavebuliaSesabamisi profesionaluri jgufebis mier.• calkeuli klinikuri sakiTxebis Sesaxeb mtkicebulebaTa daim sakiTxTa moZieba, romlebic arasrulad aris ganxiluli,warmoebuli iyo kohreinis monacemTa bazaSi The Cochrane Library2006, Issue 3, da jandacvis msoflio organizaciisreproduqciuli janmrTelobis biblioTekaSi #9.moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analiziCatarebuli Ziebis Sedegad miRebuli iyo ramodenime klinikurimeToduri rekomendacia, romlebic Seicavda jgufis miznis SesafebissaWiro informacias. am rekomendaciebis saboloo Sefasebisasgamoyenebuli iyo formaluri Sefasebis meTodi AGREE-s (Appraisal ofGuidelines for Research and Evaluation ) 1 meSveobiT. Sefasebis Sedegad amorCeuliiyo ramodenime rekomendacia, romlebic safuZvlad daedo Semdgomanalizsa da maT adaptacias. am rekomendaciaSi mocemuli debulebebiSejamebuli iyo cxrilebSi da warmodgenili iyo samuSao jgufiswevrebis mier Sefasebis mizniT. cxrilSi Sedioda debulebisoriginaluri versia da mtkicebulebis done wyaros mixedviT. samuSaojgufs unda Seefasebina rekomendaciebis vargisianoba saqarTvelosjandacvis pirveladi rgolis pirobebSi. rekomendacia miRebuladiTvleboda, Tu mas mxars uWerda SemqmnelTa samuSao jgufisumravlesoba.rekomendaciis SemuSavebisas Cven gamoviyeneT modificirebuli sqema,romelic mowodebulia SIGN (Scottish Intercollegiate Guideline Network) mier 2 .39

mtkicebulebaTa doneebisa da rekomendaciebis gradaciis sqemamtkicebulebis doneAB BCD DDspkvlevebis daxasiaTeba, romlebic safuZvlad daedorekomendaciasmaRali xarisxis meta-analizi, randomizirebulikontrolirebadi kvlevis meta-analizi, rkksistemuri mimoxilva an didi rkk sistematuriSecdomis Zalian dabali albaTobiT (+++), romlisSedegebic SesaZlebelia gavrceldes Sesabamispopulaciaze;kohortuli an SemTxveva-kontrolis tipiskvlevebis maRali xarisxis sistemuri mimoxilvaanmaRali xarisxis (++) kohortuli an SemTxvevakontrolistipis kvleva sistematuri SecdomisZalian dabali albaTobiT.anrkk (+) sistemuri Secdomis dabali albaTobiT,romlis Sedegebic SeiZleba gavrceldes Sesabamispopulaciaze;kohortuli an SemTxveva-kontrolis tipis kvleva ankontrolirebadi kvleva randomizaciis gareSesistematuri Secdomis dabali albaTobiT (+),romlis Sedegebic SeiZleba gavrceldes Sesabamispopulaciazeanrkk Zalian dabali (++) an dabali (+) sistematuriSecdomis albaTobiT, romlis Sedegebic arSeiZleba gavrceldes Sesabamis populaciaze;SemTxvevaTa seriebis aRweraanarakontrolirebadi kvlevaaneqspertTa azri.saukeTeso praqtika, romelic dafuZnebuliarekomendaciis SemqmnelTa gamocdilebaze.alternatiuli gaidlaini ar arsebobs40

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avtorTa jgufi:saqarTvelos mean-ginekologTa asociacia⇒ Tengiz AasaTiani _ mean-ginekologi, Tssu postdiplomurisamedicino ganaTlebis da uwyveti profesionaluri ganviTarebisinstitutis reproduqciuli janmrTelobis departamentisxelmZRvaneli, asocirebuli profesori, saqarTvelos meanginekologTaasociaciis prezidenti.⇒ petre lomaia – mean-ginekologi, mmk, m.SaraSiZis samedicinocentris sameano ganyofilebis gamge.eqspertebi:⇒ paliko kintraia - mean-ginekologi, akad. CaCavas meanginekologiisda perinataluri medicinis samecniero kvleviTiinstitutis direqtori, profesori⇒ gia TevdoraSvili – mean-ginekologi, #2 samSobiaro saxlisgeneraluri direqtori, medicinis mecnierebaTa doqtori,asocirebuli profesori;⇒ mamuka xoStaria – mean-ginekologi, sagarejos S.p.s.£#5saavadmyofo-poliklinikuri gerTianrbis qalTa konsultaciisgamge;⇒ akaki baqraZe – #2 samSobiaro saxlis mean-ginekologi, mmk,saqarTvelos Sromis, janmrTelobis da socialuri dacvissaministros eqsperti meanoba-ginekologiaSi;⇒ nukri manjgalaZe - £mean-ginekologi, # 4 samSobiaro saxlisgeneraluri direqtori;⇒ nino abulaZe – mean-ginekologi, Tssu reproduqciulijanmrTelobis departamentis aspiranti;⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa dasocialuri dacvis saministros janmrTelobis dacvisdepartamenti;⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa dasocialuri dacvis saministros janmrTelobis dacvisdepartamenti.48