NASTEREA SI PROLAPSUL PELVI-PERINEAL
english version
E.Crauciuc
Clinica a-III-a Obstetrica-ginecologie
Spitalul Clinic de Obstetrica-ginecologie "Elena-Doamna" UMF "Gr.T.Popa" Iasi

"Spre deosebire de alte mamifere, nasterea la om este dureroasa. Explicatia consta in faptul ca, pe de o parte craniul sau a crescut tot mai mult in ultimele sute de mii de ani, iar pe de alta parte, mersul biped nu mai permite largirea oaselor bazinului, care marginesc canalul pelvin, pe care fatul il strabate la nastere. Cu alte cuvinte, dimensiunile craniului omenesc au atins o limita; un om cu un creier mai mare nu s-ar mai putea naste decat prin cezariana." (Michael SWORDS)
Ce putem crede despre aceasta afirmatie care ne pune pe ganduri? Sau ce sa mai credem despre craniul "omului de Mouillans" descoperit pe tarmurile algeriene a carui capacitate este cu 30-40% mai mare decat a lui Homo Sapiens Sapiens! Cum s-a nascut acel om? Toate aceste lucruri, incomode pentru stiinta actuala, ne indreapta gandurile catre trupul celei care ne-a dat viata, dupa 9 luni de suferinta, suferinta care nu s-a incheiat odata cu nasterea, deoarece aceasta, cat si alti factori, nu putini la numar, pot afecta intr-o masura mai mare sau mai mica integritatea fizica a femeii.
Prin nastere, femeia se ridica la dimensiuni psiho-sociale care depasesc `n general contributia barbatului la constructia societatii si la asigurarea fondului populational viitor. Sarcina si nasterea sunt fenomene biologice complexe, pe care numai un organism dotat cu multiple posibilitati de adaptare le poate depasi, fara ca aceasta perioada sa lase amprente fizice si psihice evidente. Daca durerea care insoteste actul parturitiei este "un blestem biblic", pe care medicina moderna incearca sa-l atenueze, o alta serie de neajunsuri sunt mai greu de prevazut, chiar daca femeia, in cursul nasterii, se bucura de ajutor competent si complex. Ea poate ramane cu invaliditati ce conduc la intunecarea activitatii intime, cat si sociale. In cadrul tributului pe care femeia il plateste gestatiei, un loc important revine prolapsului pelvi-perineal.
Cunoscut si diagosticat din timpuri stravechi, prolapsul pelvi-perineal reprezinta astazi o entitate anatomo-clinica si chirurgicala relativ bine definita, dar care include o multitudine de aspecte. Prezenta prolapsului pelvi-perineal implica modificari majore in via]a sexuala a femeii, uneori cu implicatii psihice si familiale. Modificarea conditiilor locale duce la imposibilitatea desfasurarii normale a actului sexual, la lipsa orgasmului sau diminuarea libidoului, de cele mai multe ori la ambii parteneri.
Trauma psihica a femeii care realizeaza ca nu mai poate desfasura o activitate sexuala normala nu este de neglijat. Pe langa aceste lucruri, se pune si problema de estetica feminina. Afectarea acesteia prin prezenta prolapsului duce de multe ori la traume psihice, la sentimente de neputinta si chiar de desconsideratie si abandon fata de propriul trup. Femeia suporta un sentiment invalidant, de excludere sociala. Daca femeile care au nascut raman cu multumirea actului de procreere, avand totusi un punct de sprijin in cazul unui psihic mai labil, in schimb prolapsul genital al nuliparelor si virginelor poate avea implicatii majore in viata femeii. ~n aceasta categorie se incadreaz\ prolapsul determinat de factorul constitutional, la care, daca se adauga factori traumatici obstetricali si de mediu, se poate ajunge la suferinte majore si chiar infirmitati.
Asocierea prolapsului uterin aproape intotdeauna cu prolapsul urinar si/sau rectal reprezinta un element foarte important in stabilirea conduitei si aprecierea prognosticului. Prolapsul pelvi-perineal are un caracter progresiv: cu trecerea timpului, sub influenta factorilor activi, formele clinice incipiente, de grade minore sau izolate, trec succesiv in forme din ce in ce mai avansate si mai complexe. Progresia clinica usureaza si actiunea factorilor determinanti, modificarile functionale pelvi-genitale accentuandu-se cu timpul si usurand actiunea gravitatiei si a presiunii abdominale. Se spune ca: "nu prolapsul omoara, ci complicatiile si consecintele prezentei lui".

THE DELIVERY AND THE PELVI-PERINEAL PROLAPSE

Eduard Crauciuc 3rd Clinic of Obstetrics and Gynecology The "Elena Doamna" Obstetrics and Gynecology Hospital The "Grigore T. Popa" University of Medicine and Pharmacy of Iasi

"Unlike other mammals, human delivery is painful. The explanation resides in the fact that, on the one hand, the human skull has grown more and more during the past hundreds of thousands of years and, on the other hand, the bipedal walking does not allow more dilatation of the pelvic bones, which enclose the pelvic channel crossed by the foetus. In other words, the dimensions of the human skull have reached a limit; a man with a bigger brain could only be born through a C-section." (Michael SWORDS)
What could we think about this troubling statement? Or what should we believe about the skull of the "Mouillans man", discovered on Algerian shores, whose volume was 30 - 40% bigger than that of the Homo Sapiens Sapiens' skull! How was that man born? All these things, so inconvenient for the present-day science, make us think about the body of the women who brought us to life. After 9 months of pregnancy, their suffering does not end with the delivery process, because this one and many other factors, as well, may affect more or less women's physical integrity.
By giving birth, women achieve certain psychological and social dimensions that surpass, generally speaking, men's contribution to building up the society and to assuring the future populational fund. Pregnancy and birth are complex biological phenomena, which only a highly adaptable organism can overcome, that is, without bearing obvious physical and psychological marks. The pain that accompanies the labour is a "Biblical curse" that modern medicine has been trying to reduce.
But apart from that, there is a lot of difficulties hard to anticipate, even though women are offered, during delivery, complex professional medical assistance. These difficulties may lead to certain infirmities, affecting therefore women's intimacy, as well as social activities. In respect to the price that women have to pay to pregnancy, one of the most important issues is the pelvi-perineal prolapse.
Known and diagnosed very long ago, the pelvi-perineal prolapse is an anatomic-clinical and surgical entity relatively well defined today, but which also includes a multitude of aspects. The presence of the pelvi-perineal prolapse entails a series of important changes in women's sexual life, occasionally bearing psychological and domestic implications. The modification of the local conditions leads to the impossibility of normally performing the coitus, to the absence of climax or to the diminution of the libido. And, most of the times, this occurs with both partners. Therefore, women's psychological trauma, as concerns the impossibility of a normal sexual life, is not to be neglected.
Moreover, there is the issue of feminine aesthetics. The physical change as a result of the prolapse leads women very often to psychological trauma, to feelings of helplessness or even of disdain and abandon towards their own body. In other words, women experience a feeling of invalidity, of social exclusion. If women who have given birth find a psychological support in having children, as far as virgins and childless women are concerned, the genital prolapse may have very serious effects. In this context, the prolapse determined by the constitutional factor, and sometimes by traumatic obstetric and environmental factors as well, can result in major suffering or even infirmities.
The usual association of the uterine prolapse with the urinary and/or rectal prolapse represents an extremely important element in estimating the prognosis and establishing an adequate medical prognosis. The pelvi-perineal prolapse has a progressive character: in time, due to active factors, the incipient clinical forms of minor or isolated degrees change successively into more and more advanced and complex forms. This clinic progression facilitates the active influence of the determinant factors; thus, the pelvi-genital functional modifications grow for the worse and favour the negative influence of gravity and abdominal pressure. Therefore, it is said that "it is not the prolapse that causes death, but the complications and the consequences of its presence".