Types and methods of obstetric examination of pregnant women. Examination of a pregnant woman and a woman in labor. External examination of a pregnant woman

SURVEY OF A PREGNANT WOMAN AND WOMAN

A survey of a pregnant woman and a woman in labor is carried out according to a specific plan. The survey consists of a general and a special part. All data obtained is entered into the pregnant woman's card or into the history of childbirth.

General history

-Passport data : surname, name, patronymic, age, place of work and profession, place of birth and residence.

-The reasons that made a woman apply for medical care (complaints).

-Working and living conditions.

-Heredity and past diseases. Hereditary diseases (tuberculosis, syphilis, mental and oncological diseases, multiple pregnancies etc.) are of interest because they can have an adverse effect on the development of the fetus, as well as intoxications, in particular, alcoholism and drug addiction in parents. It is important to obtain information about all communicable and non-communicable diseases and operations carried out in early childhood, during puberty and in adulthood, their course and methods and terms of treatment. Allergy history. Transferred blood transfusions.

Special history

-menstrual function: the time of the onset of menarche and the establishment of menstruation, the type and nature of menstruation (3 or 4 week cycle, duration, amount of blood lost, pain, etc.); whether menstruation has changed after the onset of sexual activity, childbirth, abortion; date of the last, normal menstruation.

-secretory function : the nature of vaginal discharge, their quantity, color, smell.

-sexual function: at what age did you start sexual activity, what kind of marriage is in a row, the duration of marriage, the period from the beginning of sexual activity to the onset of the first pregnancy, the time of the last sexual intercourse.

- Age and health of the husband.

-Childbearing (generative) function. In this part of the history, detailed information is collected about previous pregnancies in chronological order, what is the current pregnancy, course previous pregnancies(whether there were toxicoses, gestoses, diseases of the cardiovascular system, kidneys, liver and other organs), their complications and outcome. The presence of these diseases in the past prompts you to especially carefully monitor a woman during this pregnancy. It is necessary to obtain detailed information about the course of abortions, each childbirth (duration of labor, surgical interventions, sex, weight, fetal growth, its condition at birth, length of stay in the maternity hospital) and postpartum periods, complications, methods and terms of their treatment.

-Transferred gynecological diseases :time of onset, disease duration, treatment and outcome

-The course of this pregnancy (by trimester):

- 1 trimester (up to 12 weeks) - common diseases, pregnancy complications (toxicoses, threat of miscarriage, etc.), the date of the first visit to the antenatal clinic and the gestational age established at the first visit.

2nd trimester (13-28 weeks) - general diseases and complications during pregnancy, weight gain, blood pressure numbers, test results, date of the first fetal movement.

3 trimester (29 - 40 weeks) - total weight gain during pregnancy, its uniformity, results of blood pressure measurements and blood and urine tests, diseases and complications of pregnancy. reasons for hospitalization.

Determining due dates or gestational age

GENERAL OBJECTIVE EXAMINATION

A general objective study is carried out in order to identify diseases of the most important organs and systems that can complicate the course of pregnancy and childbirth. In turn, pregnancy can cause exacerbation of existing diseases, decompensation, etc. Objective research are produced according to generally accepted rules, starting with the assessment general condition, temperature measurements, examination of the skin and visible mucous membranes. Then the organs of blood circulation, respiration, digestion, urinary, nervous and endocrine systems are examined.

SPECIAL OBSTETRIC EXAMINATION

Special obstetric examination includes three main sections: external obstetric examination, internal obstetric examination and additional research methods .

EXTERNAL OBSTETRIC EXAMINATION

External obstetric examination is carried out by inspection, measurement, palpation and auscultation.

Inspection allows you to identify the correspondence of the type of pregnant woman to her age. At the same time, attention is paid to the woman's height, physique, condition of the skin, subcutaneous tissue, mammary glands and nipples. Special attention pay attention to the size and shape of the abdomen, the presence of pregnancy scars (striae gravidarum), skin elasticity.

Pelvic examination is important in obstetrics because its structure and size have a decisive influence on the course and outcome of childbirth. A normal pelvis is one of the main conditions right flow childbirth. Deviations in the structure of the pelvis, especially a decrease in its size, complicate the course of childbirth or present insurmountable obstacles to them. The study of the pelvis is carried out by inspection, palpation and measurement of its size. On examination, pay attention to the entire pelvic area, but attach special importance to the lumbosacral rhombus (Michaelis rhombus). The rhombus of Michaelis is called the outlines in the region of the sacrum, which have the contours of a diamond-shaped area. The upper corner of the rhombus corresponds to the spinous process of the 5th lumbar vertebra, the lower one corresponds to the top of the sacrum (the place where the gluteus maximus muscles originate), the lateral corners correspond to the superior posterior iliac spines. Based on the shape and size of the rhombus, it is possible to assess the structure of the bone pelvis, to detect its narrowing or deformation, which has great importance in childbirth. At normal pelvis rhombus corresponds to the shape of a square. Its dimensions: horizontal diagonal rhombus is 10-11 cm, vertical- 11 cm. With various narrowing of the pelvis, the horizontal and vertical diagonals will different size, which will change the shape of the diamond.

In an external obstetric examination, measurements are made with a measuring tape (the circumference of the wrist joint, the dimensions of the Michaelis rhombus, the circumference of the abdomen and the height of the fundus of the uterus above the womb) and an obstetric compass (tazomer) in order to determine the size of the pelvis and its shape.

With a centimeter tape measure the largest circumference of the abdomen at the level of the navel (at the end of pregnancy it is 90-100 cm) and the height of the fundus of the uterus - the distance between the upper edge of the pubic joint and the fundus of the uterus. At the end of pregnancy, the height of the fundus of the uterus is 32-34 cm. Measuring the abdomen and the height of the fundus of the uterus above the womb allows the obstetrician to determine the gestational age, the estimated weight of the fetus, to identify disorders of fat metabolism, polyhydramnios, and multiple pregnancies.

By the external dimensions of the large pelvis, one can judge the size and shape of the small pelvis. The pelvis is measured with a tazometer. Only some measurements (exit of the pelvis and additional measurements) can be made with a centimeter tape. Usually four sizes of the pelvis are measured - three transverse and one straight. The subject is in the supine position, the obstetrician sits to the side of her and facing her.

Distantia spinarum - the distance between the most distant points of the anterior superior iliac spines (spina iliaca anterior superior) is 25-26 cm.

Distantia cristarum - the distance between the most distant points of the iliac crests (crista ossis ilei) is 28-29 cm.

Distantia trochanterica - the distance between the large trochanters of the femur (trochanter major) is 31-32 cm.

Conjugata externa (external conjugate) - the distance between the spinous process of the V lumbar vertebra and the upper edge of the pubic joint is 20-21 cm. To measure the external conjugate, the subject turns on her side, bends the underlying leg at the hip and knee joints, and stretches the overlying leg. The tazomer button is placed between the spinous process of the 5th lumbar and 1st sacral vertebrae (suprasacral fossa) behind and in the middle of the upper edge of the pubic joint in front. The size of the outer conjugate can be used to judge the size of the true conjugate. The difference between the external and true conjugate depends on the thickness of the sacrum, symphysis and soft tissues. The thickness of the bones and soft tissues in women is different, so the difference between the size of the outer and true conjugate does not always exactly correspond to 9 cm. To characterize the thickness of the bones, the measurement of the circumference of the wrist joint and the Solovyov index (1/10 of the circumference of the wrist joint) is used. Bones are considered thin if the circumference of the wrist joint is up to 14 cm and thick if the circumference of the wrist joint is more than 14 cm. Depending on the thickness of the bones, with the same external dimensions of the pelvis, its internal dimensions may be different. For example, with an outer conjugate of 20 cm and a Solovyov circumference of 12 cm (Soloviev's index is 1.2), subtract 8 cm from 20 cm and get the value of the true conjugate - 12 cm. With a Solovyov circumference of 14 cm, subtract 9 cm from 20 cm, and at 16 cm, subtract 10 cm - the true conjugate will be equal to 9 and 10 cm, respectively.

The value of the true conjugate can be judged according to the vertical dimension of the sacral rhombus And franc size. The true conjugate can be more accurately determined by diagonal conjugate .

Diagonal conjugate (conjugata diagonalis) call the distance from the lower edge of the symphysis to the most prominent point of the promontory of the sacrum (13 cm). The diagonal conjugate is determined by a vaginal examination of a woman, which is performed with one hand.

Direct pelvic outlet size - this is the distance between the middle of the lower edge of the pubic joint and the top of the coccyx. During the examination, the pregnant woman lies on her back with her legs divorced and half-bent at the hip and knee joints. The measurement is carried out with a tazometer. This size, equal to 11 cm, is 1.5 cm larger than the true one due to the thickness of the soft tissues. Therefore, it is necessary to subtract 1.5 cm from the resulting figure of 11 cm, we get the direct size of the exit from the pelvic cavity, which is 9.5 cm.

Transverse dimension of the pelvic outlet is the distance between the inner surfaces of the ischial tuberosities. The measurement is carried out with a special tazomer or centimeter tape, which are applied not directly to the ischial tuberosities, but to the tissues covering them; therefore, to the obtained dimensions of 9-9.5 cm, it is necessary to add 1.5-2 cm (soft tissue thickness). Normally, the transverse dimension is 11 cm. It is determined in the position of the pregnant woman on her back, she presses her legs to the stomach as much as possible.

Oblique dimensions of the pelvis have to be measured with oblique pelvises. To identify the asymmetry of the pelvis, the following oblique dimensions are measured: the distance from the anteroposterior spine of one side to the posterior superior spine of the other side (21 cm); from the middle of the upper edge of the symphysis to the right and left posterior superior spines (17.5 cm) and from the supracross fossa to the right and left anteroposterior spines (18 cm). The oblique dimensions of one side are compared with the corresponding oblique dimensions of the other. With a normal structure of the pelvis, the size of the paired oblique dimensions is the same. A difference greater than 1 cm indicates an asymmetric pelvis.

Lateral dimensions of the pelvis - the distance between the anteroposterior and posterior superior iliac spines of the same side (14 cm), measured with a pelvis meter. Lateral dimensions must be symmetrical and not less than 14 cm. With a lateral conjugate of 12.5 cm, childbirth is impossible.

Pelvic tilt angle - this is the angle between the plane of the entrance to the pelvis and the plane of the horizon. In the standing position of a pregnant woman, it is 45-50° . It is determined using a special device - a tazouglomer.

In the second half of pregnancy and childbirth, palpation determines the head, back and small parts (limbs) of the fetus. The longer the gestation period, the clearer the palpation of parts of the fetus. Receptions of external obstetric research (Leopold-Levitsky) is a sequentially performed palpation of the uterus, consisting of a number of specific techniques. The subject is in the supine position. The doctor sits to her right, facing her.

The first reception of external obstetric research. The first method determines the height of the uterine fundus, its shape and the part of the fetus located in the uterine fundus. To do this, the obstetrician places the palmar surfaces of both hands on the uterus so that they cover its bottom.

The second reception of external obstetric research. The second method determines the position of the fetus in the uterus, the position and type of the fetus. The obstetrician gradually lowers his hands from the bottom of the uterus to its right and left sides and, gently pressing his palms and fingers on the lateral surfaces of the uterus, on the one hand determines the back of the fetus along its wide surface, on the other - small parts of the fetus (handles, legs). This technique allows you to determine the tone of the uterus and its excitability, to feel the round ligaments of the uterus, their thickness, soreness and location.

The third reception of external obstetric research. The third technique is used to determine the presenting part of the fetus. The third method is to determine the mobility of the head. To do this, they cover the presenting part with one hand and determine whether it is the head or the pelvic end, a symptom of balloting the fetal head.

The fourth reception of external obstetric research. This technique, which is an addition and continuation of the third, allows you to determine not only the nature of the presenting part, but also the location of the head in relation to the entrance to the small pelvis. To perform this technique, the obstetrician becomes face to the feet of the subject, puts his hands on both sides of the lower part of the uterus so that the fingers of both hands seem to converge with each other above the plane of the entrance to the small pelvis, and palpates the presenting part. When examined at the end of pregnancy and during childbirth, this technique determines the ratio of the presenting part to the planes of the pelvis. During childbirth, it is important to find out in which plane of the pelvis the head is located with its largest circumference or large segment. The large segment of the head is its largest the part that passes through the entrance to the pelvis in this presentation. With an occipital presentation of the head, the border of its large segment will pass along the line of a small oblique size, with anterior head presentation - along the line of its direct size, with frontal presentation - along the line of a large oblique size, with facial presentation- along the vertical dimension line. A small segment of the head is any part of the head located below the large segment.

The degree of insertion of the head by a large or small segment is judged by palpation. With the fourth external reception, the fingers are advanced inward and slide them up the head. If at the same time the hands converge, the head stands as a large segment at the entrance to the pelvis or sank deeper, if the fingers diverge, the head is located at the entrance as a small segment. If the head is in the pelvic cavity, it is not determined by external methods.

Fetal heart sounds are heard with a stethoscope, starting from the second half of pregnancy, in the form of rhythmic, clear beats, repeated 120-160 times per minute. With head presentations, the heartbeat is best heard below the navel. With breech presentation - above the navel.

M.S. Malinovsky proposed the following rules for listening to the fetal heartbeat:

With occiput presentation - near the head below the navel on the side where the back is facing, with rear views- on the side of the abdomen along the anterior axillary line,

With facial presentation - below the navel on the side where the breast is located (in the first position - on the right, in the second - on the left),

In the transverse position - near the navel, closer to the head,

When presenting with the pelvic end - above the navel, near the head, on the side where the back of the fetus is facing.

The study of the fetal heart rate in dynamics is carried out using monitoring and ultrasound.

INTERNAL (VAGINA) EXAMINATION

Internal obstetric examination is performed with one hand (two fingers, index and middle, four - semi-hand, the whole hand). An internal study allows you to determine the presenting part, the state of the birth canal, observe the dynamics of the opening of the cervix during childbirth, the mechanism of insertion and advancement of the presenting part, etc. amniotic fluid. In the future, vaginal examination is performed only according to indications. This procedure allows you to timely identify complications of the course of childbirth and provide assistance. Vaginal examination of pregnant women and women in labor is a serious intervention that must be performed in compliance with all the rules of asepsis and antisepsis.

An internal examination begins with an examination of the external genitalia (hair growth, development, swelling of the vulva, varicose veins), the perineum (its height, rigidity, scarring) and the vestibule of the vagina. The phalanges of the middle and index fingers are inserted into the vagina and it is examined (lumen width and length, folding and extensibility of the vaginal walls, the presence of scars, tumors, partitions and other pathological conditions). Then the cervix is found and its shape, size, consistency, degree of maturity, shortening, softening, location along the longitudinal axis of the pelvis, patency of the pharynx for the finger are determined. In the study during childbirth, the degree of smoothness of the neck is determined (saved, shortened, smoothed), the degree of opening of the pharynx in centimeters, the condition of the edges of the pharynx (soft or dense, thick or thin). In parturient women, a vaginal examination reveals the condition amniotic sac(integrity, violation of integrity, degree of tension, amount of front waters). The presenting part (buttocks, head, legs) is determined, where they are located (above the entrance to the small pelvis, at the entrance by a small or large segment, in the cavity, at the exit of the pelvis). Identification points on the head are sutures, fontanelles, at the pelvic end - the sacrum and coccyx. Palpation of the inner surface of the walls of the pelvis allows you to identify the deformation of its bones, exostoses and judge the capacity of the pelvis. At the end of the study, if the presenting part is high, measure the diagonal conjugate (conjugata diagonalis), the distance between the cape (promontorium) and bottom edge symphysis (normal - 13 cm). To do this, they try to reach the cape with the fingers inserted into the vagina and touch it with the end of the middle finger, bring the index finger of the free hand under the lower edge of the symphysis and mark on the hand the place that is directly in contact with the lower edge of the pubic arch. Then the fingers are removed from the vagina and washed. The assistant measures the marked distance on the hand with a centimeter tape or a pelvis meter. By the size of the diagonal conjugate, one can judge the size of the true conjugate. If Solovyov index(0.1 from Solovyov's circumference) to 1.4 cm, then 1.5 cm is subtracted from the size of the diagonal conjugate, and if more than 1.4 cm, then 2 cm is subtracted.

Determination of the position of the fetal head during childbirth

At first degree head extension (anterior-head insertion) the circle with which the head will pass through the cavity of the small pelvis corresponds to its direct size. This circumference is a large segment in anterior insertion.

At second degree extension (frontal insertion) the largest circumference of the head corresponds to a large oblique size. This circle is a large segment of the head when it is inserted frontally.

At third degree head extension (front insertion) the largest is the circle corresponding to the "vertical" size. This circle corresponds to a large segment of the head when it is inserted facially.

Determination of the degree of insertion of the fetal head during childbirth

The basis for determining the height of the head during vaginal examination is the possibility of determining the ratio of the lower pole of the head to the linea interspinalis.

Head above the entrance to the small pelvis: when gently pressing your finger up, the head moves away and returns to its original position again. The entire anterior surface of the sacrum and the posterior surface of the pubic symphysis are accessible to palpation.

Head small segment at the entrance to the small pelvis: the lower pole of the head is determined 3-4 cm above the linea interspinalis or at its level, the sacral cavity is 2/3 free. The posterior surface of the pubic symphysis is palpated in the lower and middle sections.

Head in the pelvic cavity: the lower pole of the head is 4-6 cm below the linea interspinalis, the ischial spines are not defined, almost the entire sacral cavity is filled with the head. The posterior surface of the pubic symphysis is not accessible for palpation.

Head on the pelvic floor: the head fills the entire sacral cavity, including the coccyx area, only soft tissues; the inner surfaces of the bone identification points are difficult to access for examination.

When registering a pregnant woman, the doctor examines her and records the results in an individual variable card (firm IIIy).

1. Passport data: full name, series and number of the passport.

2. Age (young primipara - up to 18 years; age primipara - 28 years and older).

4. Profession (influence of production factors on the body of a pregnant woman and fetus and observation up to 30 weeks in the medical unit).

5. Anamnesis, previous general somatic and infectious diseases, diseases of the genital organs, previous pregnancies and childbirth, surgeries, blood transfusion history, epidemiological history, allergies, family history, heredity.

6. Laboratory studies: complete blood count - 1 time per month, and from 30 weeks. pregnancy - 1 time in 2 weeks; general urine test - in the first mat of pregnancy monthly, and then 1 time in 2 weeks, blood type and Rh affiliation in both spouses, RW - three times (when registering 28-30 weeks and 34-36 weeks), HIV and Australian antigen - when registering, fecal analysis for helminth eggs when registering: complement fixation reaction with toxoplasmic antigen according to indications; coagulogram; the presence of sugar in the daily amount of urine and blood; analysis of vaginal discharge for microflora at registration and at 36-37 weeks; ECG - at 36-37 weeks.

7. An objective examination is carried out by an obstetrician, therapist, dentist, otolaryngologist, ophthalmologist, if necessary, endocrinologist, urologist:

a) anthropological measurements (height, weight);

b) blood pressure;

c) external obstetric examination:

Distantia spinarum (25-20 cm);
Distantia cristarum (28-29 cm);
Distautia trochanterica (30-31 cm);
Coniugata externa (20 cm).

If there is a deviation from the indicated dimensions, it is necessary to make additional measurements of the pelvis even before the internal examination:

a) lateral conjugate (between the anterior and posterior iliac spines of the same side - 14-15 cm (if this figure is less than 12.5 cm, natural delivery is impossible);

b) oblique dimensions of the small pelvis:

from the middle of the upper edge of the pubic articulation to the posterior superior awn of the wings of both iliac bones - 17.5 cm each,
from the anterior superior spine of the iliac wing of one side to the posterior superior spine of the other side - 21 cm each,
from the spinous process of the V lumbar vertebra to the anterior superior spinous and other ilium - 18 cm each (the difference between the sizes of each pair is more than 1.3 cm indicates an oblique narrowing of the pelvis),

c) dimensions of the Michaelis rhombus:

vertical - between the supra-sacral fossa and the top of the sacrum - 11 cm,
horizontal - between the posterior upper awns of the wings of both iliac bones - 10 cm;

d) the angle of inclination of the pelvis - the angle between the plane of the entrance to the pelvis and the plane of the horizon (measured with a pelvis in the position of a woman standing) - 45-55 °;

e) dimensions of the outlet of the pelvis:

straight - between the top of the coccyx and the lower edge of the pubic symphysis - 9 cm,
transverse - between the inner surfaces of the ischial tubercles - 11 cm;

f) determine the values of the true conjugate:

according to the outer conjugate - 9 cm is subtracted from the size of the outer conjugate,
according to the diagonal conjugate - 1.5-2 cm is subtracted from the size of the diagonal conjugate (the figure to be subtracted is determined by the circumference in the area of the wrist joint - with a circumference of up to 14 cm, subtract 1.5 cm, over - 2 cm),
according to USS (most accurately).

At the first examination through the vagina, the size, shape, consistency, mobility of the uterus, the condition of the pelvic bones, soft tissues, and pelvic floor muscles are determined. Additionally, the height of the womb (4 cm), the internal diagonal conjugate, and the pubic angle are measured.

After an increase in the size of the uterus, when its external palpation becomes possible, it is necessary to determine the tone of the uterus, the size of the fetus, the amount of amniotic fluid, the presenting part, the articulation of the fetus, its position, position and appearance, using four classic obstetric techniques (according to Leopold).

Auscultation of fetal heart sounds is carried out from 20 weeks of pregnancy. Fetal heart sounds are heard with an obstetric stethoscope in the form of rhythmic double beats with a constant frequency of 130-140 per minute.

M. S. Malinovsky proposed the following rules for listening to the fetal heartbeat:

1. With occiput presentation - near the head below the navel on the side where the back is facing. With rear views - on the side of the abdomen along the anterior axillary line.

2 With facial presentation - below the navel on the side where the breast was (in the first position - on the right, in the second - on the left).

3. In the transverse position - near the navel, closer to the head.

4. When presenting with the pelvic end - above the navel, near the head on the side where the back is facing.

IN last years widely used apparatus "Kid" and ultrasound devices, cardiac monitors, which allow you to clarify auscultatory data in difficult cases.

Ed. K.V. Voronin

Every expectant mother who is observed during pregnancy must undergo mandatory examinations of a pregnant woman, which are provided for by the Orders of the Ministry of Health of the Russian Federation and the Standards for the provision of medical care.

If the woman is somatically healthy, the doctor determines basic examinations for her. If a pregnant woman has a concomitant somatic pathology or the disease was identified during pregnancy, the range of diagnostics is expanded. Dispensary examination of a pregnant woman in her work time paid by the state.

Pregnancy Diagnosis

The first and main symptom of pregnancy is the delay in menstruation. In case of delayed menstruation, it is recommended to take a pregnancy test. This test is a cardboard strip that must be dipped into morning urine for a few seconds (it has the highest content of the “pregnancy hormone”).

According to the number of strips that appeared after a certain period of time, a woman will know whether she is pregnant or not. Two stripes mean that pregnancy is present, one stripe - no. In the case when the test demonstrates the absence of pregnancy, and there are no periods, blood should be taken from a vein for the presence of chorionic gonadotropin.

In addition, an ultrasound (ultrasound examination) of a pregnant woman is often performed. Its purpose is to determine the presence and duration of pregnancy, and exclude the diagnosis of "ectopic pregnancy".

Examinations of a pregnant woman in the first trimester (0-12 weeks)

After the detection of pregnancy, the woman becomes registered in her antenatal clinic. Although, observed in given period You can also visit a paid medical clinic that specializes in this.

During registration, the gynecologist issues a list of tests that should be passed. Usually this is: a blood test for the Rh factor, a group, syphilis, AIDS, hepatitis, a general and biochemical blood test, a blood test for sugar levels, a general urine test, a swab taken from the vagina.

In addition, according to indications, tests for the presence of urogenital infections, as well as an analysis for hormones, are possible. If there is a possibility of a Rh conflict (the wife has a negative Rh factor, and the man has a positive one), the pregnant woman’s blood is examined several more times during the pregnancy for the presence of specific antibodies to the erythrocytes of the embryo and their number is detected. Up to the thirty-second week, this study is carried out once a month, and in the period from 32-35 weeks - twice a month, and then until childbirth - every week.

In addition, a pregnant woman needs to go through the following doctors:

therapist;
otolaryngologist;
ophthalmologist;
dentist
undergo an ECG (electrocardiogram).

A pregnant woman should visit a gynecologist once a month. Before each visit to the doctor, it is necessary to do a general urine test, according to its results, the gynecologist will evaluate the work of the woman's kidneys. During each visit, the pregnant woman is weighed, blood pressure is measured on both arms, the height of the uterine fundus is measured, and the fetal heartbeat is heard.

Examination of a pregnant woman in the second trimester (13-24 weeks)

When a woman is in her second trimester, she is sent for an ultrasound. Ultrasound examination of a pregnant woman at this time allows:

determine the number of fruits;
determine the duration of pregnancy;
identify possible malformations of limbs, organs abdominal cavity, fetal nervous system.

From 16 to 18 weeks expectant mother offer to take a "triple test", which is designed to determine the "genetic health" of the baby. The levels of chorionic gonadotropin (CG), alpha-fetoprotein (AFP), unconjugated estriol (NE) are determined in the blood. If there is a deviation of the level of these substances from normal one may suspect certain chromosomal abnormalities in the fetus (Down syndrome, including). It is recommended to do this study twice, with an interval of a couple of weeks at 15-20 weeks of pregnancy.

There is no need to panic if the result of the "triple test" shows a deviation from the norm. Sometimes the test gives erroneous results - about 9.3% of the time. To clarify the results, the woman is sent for an additional study - amniocentesis. Amniocentesis is a study of amniotic fluid to confirm the absence or presence of a chromosomal abnormality in the fetus. It is performed under the control of an ultrasound examination of a pregnant woman. Before this study, the doctor should warn the patient that in a small percentage of cases (1 percent), amniocentesis provokes a miscarriage.

During the second half of pregnancy, a woman needs to visit her gynecologist a little more often: once every two weeks (in the case of a normal pregnancy).

Examinations of a pregnant woman in the third trimester (from 24 weeks until childbirth)

At a period of 24 to 26 weeks of pregnancy, a woman is prescribed the next scheduled ultrasound. During this ultrasound examination of a pregnant woman, the doctor examines the structure of the baby's body, the doctor reveals congenital malformations internal systems and organs, sees the sex of the child, the quality and quantity of amniotic fluid in the pregnant woman, the place of attachment of the placenta, as well as its condition.

A woman at this time also needs to pass a clinical blood test, which demonstrates the level of hemoglobin in the blood, and, therefore, the absence or presence of anemia.

After the thirtieth week, the pregnant woman begins to go to the gynecologist every two weeks. At the same time, the doctor issues an exchange card to the pregnant woman, in which the results of all examinations and analyzes are entered. Now, with this card, she needs to go everywhere, since childbirth can begin at any moment, and without an exchange card, doctors can only take a woman in labor to a specialized maternity hospital, where pregnant women without a fixed place of residence, without a local residence permit, from other cities, without tests, etc. .

After 32 weeks, the gynecologist issues maternity leave if the woman works. Until this date, the state must pay for all dispensary examinations of a pregnant woman during working hours.

Within 33-34 weeks, Dopplerography is performed - an examination that allows you to evaluate the placenta, blood flow in the vessels of the uterus, as well as the main vessels of the baby. Modern technologies make it possible to find the studied vessel with high accuracy, assess the nature of the blood flow and perform dopplerometry - a quantitative assessment of blood flow in the area of interest. The study provides an opportunity to find out if the baby is getting enough nutrients and oxygen. If the blood flow rate is reduced, then cardiotocography (CTG) may be prescribed by the gynecologist.

With the help of CTG, the tone of the uterus, the presence of its contractions, and the motor activity of the baby are revealed. By motor activity possible intrauterine hypoxia fetus. To conduct the study, the pregnant woman is placed on the couch, tapes with sensors are fixed in the abdomen. For 30 - 40 minutes, the readings of the device are printed on a paper tape or they can be seen on the display monitor.

For a period from 35 to 36 weeks, a biochemical blood test, a blood test for syphilis, AIDS, a vaginal swab is taken. At the same time, the last ultrasound examination of a pregnant woman is done, with the help of which the doctor evaluates the condition of the placenta, the weight and height of the baby, its position in the uterus (breech presentation or head presentation), the quality and quantity of female amniotic fluid (oligohydramnios, polyhydramnios , their transparency).

If the results of the examinations are normal, then the pregnant woman needs to go to the gynecologist weekly and take urine tests, waiting for the onset of labor.

If the results of tests or studies demonstrate some kind of trouble in the state of the baby or the pregnant woman, the patient is taken under special control. Namely, medications are prescribed that improve blood flow through the placenta, additional ultrasound examinations and dopplerometry. The last two studies are also carried out when the expected day of birth has come, but at the same time generic activity does not start.

However, there is no need to panic and be nervous due to the fact that the birth is delayed. At each consultation, the doctor will evaluate your condition and, if necessary, give you a referral to the maternity hospital.

A convincing two lines on a pregnancy test showed that yes, it happened. You are pregnant. And, the world for you, immediately, has changed dramatically in two stages - before pregnancy and after. You began to listen to yourself, to identify additional evidence of pregnancy. But, along with the pleasant and joyful news, comes the realization that now you will have to spend a significant part of your personal time not in your favorite activities and hobbies, but in medical institutions to visit numerous medical offices there.

Not all visits are pleasant for a woman, but one cannot do without them. Sometimes you unwittingly become a witness various conversations in the circle of women giving birth and pregnant women. Some are glad that there were few procedures during pregnancy, while others complain that they were tortured to follow all the instructions of their doctor. Is there a golden mean?

Getting ready for the first visit

Your first pregnancy examination will take place using a gynecological chair. Few women like this procedure, but there is nowhere to go, and therefore, in order to reduce the percentage discomfort you should prepare for it in advance. It is necessary to draw up a calendar with notes on when you would have had your period if you had not become pregnant.

Agree, this is easy to do, especially with a regular cycle. Therefore, do not plan a visit to the doctor directly on these days, as they are considered critical periods and therefore dangerous for the development of pregnancy. Also postpone ultrasounds and physical examinations, unless, of course, nothing bothers you, until the eighth week, counting from the first day of your last period.

Before visiting a medical institution, you should take a bath or shower, put on fresh underwear. There is no need to wash especially, and even more so to douche. The doctor should examine the condition of your vagina in a normal state. The use of perfumes and intimate deodorants is not recommended. They are often the cause allergic reaction regarded by the doctor as inflammation.

Most women shave their perineum before visiting the doctor. But, is it really worth it? No, not necessarily. Of course, it is not always convenient for a doctor to examine a woman with excessive hair on the external genital organs, but if you do not do this regularly, then you should not, because this intimate process can lead to severe irritation skin.

Be sure to empty your bladder. During the examination, the doctor should assess the condition of the internal genital organs, and not an overfilled bladder. In addition, the intestines must also be empty. Sexual contacts should be excluded a day before the visit to the doctor. This is due to the fact that a small amount of seminal fluid remains in the vagina after intercourse, which distorts the results of the analysis. Of course, sometimes there is a long queue to the gynecologist, therefore, it will not be superfluous to visit the toilet before your appointment.

What you wear also plays an important role. You should be comfortable, but you should also quickly undress or empty your chest at the gynecologist's appointment. Socks or slippers will not be superfluous so that you do not walk barefoot on the cold floor to the gynecological chair. Take your towel as well, despite the fact that the gynecologist will offer you a paper one.

It will also be desirable to purchase a disposable gynecological kit so that you are not tormented by thoughts about the conscientiousness of the sterilization of examination instruments by the medical staff. By the way, they are inexpensive and, as a rule, are sold in most pharmacies. In the set: a plastic mirror designed to examine the cervix, sterile gloves, special brushes or sticks for taking material for analysis, always a disposable film that replaces a towel.

Before the examination itself, a preliminary conversation between the doctor and the patient, measurement of pressure, then examination on the couch and weighing is preceded. Let's leave some recommendations for women. Leave your shoes in front of a separate examination room, if available. Ask the midwife or doctor where it is possible to undress, so as not to accidentally put clothes on a radiator or a sterile table.

Undress slowly, during this time the medical staff will fill out the necessary documents.

Put on slippers or put on socks, put a towel or a film on the chair so that it lines up with the edges, but does not hang from it. Climb onto the chair slowly up the stairs and take a position so that the buttocks are on the very edge of it. Next, on the stands on the chair, place your legs, while the slingshots should be fixed in the popliteal fossa.

If the design of the chair is not familiar to you, ask your gynecologist about it without hesitation. Try to relax and calm down, while placing your hands on your chest. Consider what the doctor does should not be. This exacerbates discomfort and makes inspection difficult. About everything that interests you, you can ask the doctor after the examination.

What does 1 examination during pregnancy mean?

The examination begins, as a rule, with an examination of the woman's external genital organs. At the same time, the doctor professionally evaluates the condition of the skin and mucous membranes of the perineum, clitoris, labia majora and labia minora, and necessarily the external opening of the urethra.

The doctor also examines the inner thighs, allowing you to predict varicose veins, areas of rash elements or pigmentation in advance. viewed in without fail and area anus for the presence of cracks and hemorrhoids, other pathologies.

The second stage is the examination in the mirrors. An examination is directed mainly to identify certain diseases of the vagina or the condition of the cervix is determined. There are two types of mirrors: spoon-shaped and folding. The introduction of a mirror is the most unpleasant procedure during the examination.

The nature of the discharge from the cervix is given special attention. Allocations with streaks of blood indicate the risk of abortion. talking about infection unusual smell secretions and if they are cloudy.

Required tests

A smear on the flora is the first analysis when registering during pregnancy. The doctor, with a special spoon, "scoops" the substance from the cervical canal, urethra, vagina and puts it on the glass. The material is examined in the laboratory under a microscope.

With this analysis, the presence of an inflammatory process is revealed, and some types of infection are also detected, namely: gonorrhea, candidiasis, fungal, bacterial vaginosis, trichomoniasis.

A smear on the flora, during the entire bearing of the child, is repeated 3-4 times, even in the case of its positive results.

This frequency is explained by the fact that during pregnancy, long-forgotten and not making themselves felt infections “wake up”. An example is candidiasis, which occurs in women during pregnancy, 2-3 times more often. The body of a woman is rebuilt, which leads to an increase in the level of female sex hormones. The vaginal environment becomes more acidic, in which the candida feels great.

It should be noted that hormonal changes reduce cellular immunity and the activity of leukocytes, which leads to increased reproduction in the genital tract of a pregnant woman of this fungus. The number of microorganisms is higher, the longer the gestational age. Therefore, candidiasis strongly worries expectant mothers in the last trimester.

A cytological examination is the second mandatory analysis, in which the structural features of the surface cells and the cervical canal are examined. A smear is taken with a special tool - a brush or spatula. The analysis is important for the detection of oncological diseases on early stages. During pregnancy, it is extremely necessary, because pregnancy itself only aggravates the course similar diseases. For analysis, a cytological smear directly taken from the vaginal fornix is also important.

It allows you to correctly assess a woman's hormonal status, determine abnormalities in the uteroplacental blood flow, or predict the risk of abortion.

In recent years, many antenatal clinics have been examining pregnant women for sexually transmitted infections. At the first visit, such an analysis is not taken, usually during a second examination on a chair.

Also, the doctor will prescribe without fail and urine. By the way, rented during the first visit antenatal clinic, and the analysis itself turns out to be the most frequent due to the fact that the kidneys may not be able to cope with the increased load during pregnancy. Blood is taken from a vein to determine the blood type and Rh factor. Also, with the help of this analysis, malignant changes are detected.

Determined by blood test and hemoglobin level. Its low level, in addition to the woman's poor health, also leads to a violation of the course of pregnancy. To increase the level of hemoglobin, iron preparations are indicated. But, women in the early stages, these drugs are poorly tolerated due to toxicosis. Therefore, as a substitute, it is recommended proper nutrition. It is also necessary to detect the presence of antibodies to rubella and other infections: herpes, cytomegalovirus.

At the first examination, the doctor will also take an interest in your husband's health. Find out his age, the presence of hereditary diseases, blood type and. An anamnesis of relatives will also be collected, and on both sides. In case of hormonal, metabolic and hereditary diseases, other additional examinations will naturally be prescribed.

Inspection by hand

After examination with a mirror, a two-handed vaginal examination is performed. In this regard, the doctor determines the position, size and condition of the uterus, ovaries, fallopian tubes. To do this, the doctor spreads his arms large labia and gently inserts the middle and index fingers right hand. The left hand rests on the stomach. In this case, the condition of the vagina is assessed: the extensibility of the walls, the width of the lumen, the presence of partitions, tumors, scars and other pathological conditions that affect the course of pregnancy and subsequent childbirth.

Next, the doctor examines the cervix and determines its size, shape, location, consistency. The cervix in the normal course of pregnancy is tilted back, its length is over 2 cm, dense to the touch, the finger channel is not passable. In the event of an abortion, the cervix softens, shortens, shifts to the center, and the canal opens. An experienced gynecologist needs only to touch it to assess the condition of the cervix.

Next, the doctor feels the uterus, the size of which, most often, corresponds to the gestational age. But, if a woman is diagnosed with uterine fibroids, she is expecting twins, she is pregnant for the third or fourth time in a row, with some gynecological diseases, then the size of the uterus may be larger. The doctor also pays attention to the shape and consistency of the uterus. During pregnancy, the uterus is softer than normal. The softening of the part of the uterus, which is closer to the cervix, is especially observed.

Various irregularities on the uterus are often a sign of various anomalies in the development of the uterus or fibroids. Uterus on not long term mobile and in the pelvis occupies a middle position. In case of restriction of its mobility or deviation to the side, this indicates an inflammatory disease of the uterine appendages or an adhesive process. The next to be examined by a doctor are the ovaries and the fallopian tubes to exclude ectopic pregnancy in which the examination is painful. At the end of the examination, the doctor feels the inner surface of the symphysis, sacrum, side walls of the pelvis.

As you can see, there is nothing wrong with the first visit to the doctor, so feel free to go - this is important for your future pregnancy.

The main obstetric concepts include: position, presentation, position, view, insertion, articulation of the fetus.

Fetal position (situs)- the ratio of the longitudinal axis of the fetus to the longitudinal axis of the mother. The longitudinal position of the fetus is normal. The oblique and transverse position of the fetus makes delivery through the natural birth canal impossible.

Type of fruit (visus)- the ratio of the back of the fetus to the anterior or posterior wall of the uterus. The front view is the best. Complications are possible with the rear view.

Fetal position (positio)- the ratio of the back of the fetus to the right and left side of the uterus. When the backrest is turned to the left, the position is called the first, to the right - the second. Knowledge of the position is necessary to select the correct actions and recommendations (for example, the fetal heartbeat is better heard from the side of the position, it is recommended for the woman to lie on the side of the position during childbirth).
When transverse position Fetal position is determined by the fetal head.

Fetal presentation (praesentatio)- the ratio of a large part of the fetus (head or buttocks) to the entrance to the small pelvis. The right one is cephalic presentation. Childbirth through the natural birth canal is also possible with breech presentation, but there is more complications for the fetus. Breech presentation there are purely gluteal, foot and mixed (when both buttocks and legs are presented).

Head insertion (inclinatio)- the ratio of the swept seam relative to the axis of the pelvis.
There are axial, or synclitic, insertion of the head and off-axis, or asynclitic, insertion of the head, i.e., deviation of the seam from the axis anteriorly (to the symphysis) or backwards (to the promontory). The deviation of the swept suture from the axis of the pelvis in any direction by 1 cm is considered physiological.

The articulation of the fetus (habitus)- the ratio of the limbs to the head and torso.
There is a flexion type of articulation (optimal), when the head is tilted towards chest, the body is bent, the limbs are bent and brought to the body. In a normal flexion articulation, the fetus fits into the contour of the ovoid; in cephalic presentation, the back of the head faces the entrance to the small pelvis. Fetal movements take place, but do not violate the general principle of location, it is preserved during childbirth. Childbirth in this case proceeds normally. In the case of an extensor articulation, especially of the head, complications are possible.

Methods of examination of pregnant women:

TO common methods examinations include - history taking, general examination, external obstetric examination, examination of the external genital organs, examination on mirrors, bimanual examination (the last three methods also apply to gynecological research methods and are discussed in detail in the course of gynecology).

In addition, laboratory methods of research and examination by specialists are carried out for pregnant women.
To additional obstetric methods examinations include: ultrasound examination, cardiotocography, amniocentesis, etc.

When a pregnant woman first visits a antenatal clinic (usually a woman herself suspects that she is pregnant), it is necessary to confirm the diagnosis and set a deadline. It is very important that a woman apply as early as possible so that work can be started on the prevention of harmful effects and recommendations can be made. It is necessary to persuade a woman to maintain pregnancy, to convince her of the correctness and responsibility of this act, even if the pregnancy was not planned. The exception is cases where pregnancy is contraindicated due to medical indications. In this case, an early turnout will allow timely identification of indications and prepare the woman for termination of pregnancy.

At desired pregnancy during the first visit, examinations are prescribed, complaints, problems, risk factors are identified, they are examined, swabs are taken. If possible, they immediately register the woman for pregnancy, fill out 2 individual cards, give her recommendations, and draw up a plan for further observation. But it may happen that there is no time for such detailed communication (many emergency patients, the woman herself does not have time). If there are no significant risk factors, then the next meeting for detailed communication with the pregnant woman is scheduled for another day, on which it will be more convenient.

The scheme of examination of a pregnant woman in a antenatal clinic:

Clarification of basic passport data:

The number of the passport and insurance certificate are recorded. The surname, name, patronymic of the woman is found out (it is necessary to find out how the woman wants to be called, the midwife must introduce herself to the woman, and also introduce the doctor who will lead her, or the doctor will do it). Age (risk factors include young age up to 18 years, after 30 for nulliparous and over 35 for multiparous). Home address and telephone (registration and residence, it is preferable that a woman be observed at the place of residence, this is convenient for patronage, however, in modern conditions, given the availability of convenient means of communication, the option of registration is also possible). Clarified living conditions with whom the woman lives together, what are the amenities. Place of work and profession (working conditions, the presence of occupational hazards are immediately specified, in this case, exemption from hazardous work is provided).

Husband details:

(Full name, age, place of work and profession, the presence of occupational hazards). It is necessary to ask: which of the relatives can be contacted, whom the woman trusts most of all, if necessary. All of this information should be on the first page. Also, on the first page, in natural or encoded form, the most important information about risk factors.

Collection of complaints:

A healthy pregnant woman may not have complaints. Nevertheless, it is necessary to find out if she has any discomfort, pain. In the study of subsequent topics, those complaints that need to be identified will be studied.

Collection of anamnesis:

Information about the conditions of work and life. It is necessary to find out the nature of the work, what is the harmfulness of the workplace, and also to clarify what kind of work the woman does at home, to warn about the exclusion of excessive workload, household hazards, and also to find out if there are animals at home (probability of infection). Find out about the woman's education and interests, which will help improve contact with her.

Heredity:

To identify a hereditary predisposition in a pregnant woman: did the parents have diabetes, hypertension, other endocrine, genetic diseases. It is important to know the heredity of the husband. Need to get information about bad habits pregnant woman and her husband, to give recommendations.

Information about past illnesses:

Childhood infections, colds, diseases of the cardiovascular system, diseases of the urinary system, liver, initial blood pressure, etc. First of all, ask about tuberculosis, rubella and infectious hepatitis. To find out whether the woman has recently come into contact with tuberculosis and infectious patients, whether she has such patients at home, to find out about her recent trips to epidemiologically disadvantaged areas.

Separately ask about surgical interventions, whether there was a blood transfusion. Ask about the features of the menstrual function (from what age menstruates, duration, regularity, frequency, painful menstruation, profusion of discharge). From what age sex life outside of marriage, in marriage, by what means she was protected from pregnancy. List the transferred gynecological diseases, sexually transmitted diseases (the health of her sexual partner - the father of the child).

In order of priority, list all pregnancies, their outcome and complications. Tell separately about the course of this pregnancy before registration. Next, a general examination is carried out, during which attention is paid to height, weight, posture, physique, nutrition, condition of the skin, subcutaneous tissue, blood vessels, lymph nodes, and the presence of edema. Examine the pulse and blood pressure, heart sounds. They measure the temperature and conduct an examination of the nasopharynx, listen to the lungs. They palpate the abdomen, liver, check the symptom of tapping on the lower back, are interested in physiological functions.

External obstetric examination:

IN early dates pregnancy, it consists of measuring the circumference of the abdomen and pelvimetry. In late pregnancy, in addition, they measure the height of the uterine fundus, palpate the uterus, use Leopold-Levitsky's external obstetric examination, and listen to the fetal heartbeat. Next, an examination of the external genitalia, an examination on the mirrors, a vaginal and bimanual examination is carried out.

A study on mirrors is carried out when a woman lies on a gynecological chair, on which an oilcloth or lining is placed (in modern conditions, a disposable lining is provided). Similarly, a woman is prepared for vaginal and bimanual examination. After each woman, the chair must be treated with a disinfectant solution. The midwife or doctor treats her hands with the express method, puts on sterile gloves, takes a sterile mirror. Preparing a woman: emptying the bladder, treating the external genitalia with a weak disinfectant solution (0.02% solution of potassium permanganate or furacilin).

Manipulation technique: after examining the external genitalia, the labia is parted with the left hand, a folding mirror with closed shutters in one of the oblique dimensions is inserted with the right hand, the mirror is brought to the vaults, transferred to the transverse dimension and opened. After examining the cervix and taking smears, the mirror is removed in the opposite way. A spoon-shaped mirror (rear) is also introduced in one of the oblique dimensions, after the introduction it is set in a transverse dimension, after which the Ott lift is also inserted from above. After examining the cervix and vagina, the instruments are removed in the opposite way and immersed in the drive. The color of the mucosa, the nature of the discharge are noted, and the presence of erosion is detected.

Vaginal (finger) examination. The labia is pushed apart with the 1st and 2nd fingers of the left hand, the 3rd finger of the right hand is first inserted into the vagina, taken to the side rear wall followed by insertion of the 2nd finger. Together, the 2nd and 3rd fingers are inserted as deeply as possible, the 1st finger of the right hand is pulled up and rests against the pubis, the 4th and 5th fingers of the right hand are bent and pressed against the palm and rest against the perineum. Thus, the state of the muscles of the pelvic floor, the walls of the vagina are examined, while noting the width, the state of the vaults, the neck (length, shape, consistency), the state of the external pharynx (its shape, closed or misses the fingertip).

A bimanual (bimanual) examination of a pregnant woman is a continuation of a vaginal examination. The fingers inserted into the vagina are placed in the anterior fornix, shifting the neck backwards. The fingers of the left hand through the abdominal wall palpate the fundus of the uterus. Bringing the hands together, palpate the uterus and determine its shape, size, position, texture, mobility, pain. Look for signs of pregnancy. After that, the area of \u200b\u200bthe appendages is palpated from one side and the other, while the fingers inserted into the vagina are mixed into the corresponding fornix. After that, the condition of the pelvic bones is palpated. Try to reach the cape through the rear vault.

As a result of the survey and examination, the gestational age is established, risk factors or complications, physical, psychological and social problems pregnant. Make up a pregnancy management plan, prescribe examinations. They give recommendations.

Measuring the circumference of the abdomen:

The dynamics of measuring the circumference of the abdomen in a pregnant woman allows you to identify deviations from the normal course of pregnancy. The absence of dynamics or negative dynamics is observed with oligohydramnios, malnutrition or fetal death. Too rapid increase in the uterus is observed with polyhydramnios, multiple pregnancy and a large fetus. The measurement is carried out at each visit to the pregnant antenatal clinic (i.e. every two weeks). Before the study, the bladder must be emptied.

The woman is laid on a couch (on a padded individual diaper). The circumference is measured with a centimeter tape at the level of the navel. The circumference is individual and cannot be used to judge the gestational age. After measuring, the tape is treated twice with an interval with a 1% solution of chloramine (it is better if each pregnant woman has her own individual centimeter tape). Before and after the manipulation, the midwife performs hygienic treatment of the hands. Hands must be warm. The couch after each woman is treated with chloramine.

Measurement of the standing height of the uterine fundus:

It is designated as F (from lat. Fundus - the bottom of the uterus). It is carried out starting from 13-14 weeks, since before this period the bottom of the uterus is hidden behind the pubis. The measurement is carried out for the same purpose as the measurement of the circumference, but also allows you to determine the gestational age. The preparation of the woman is the same (see above). The beginning of the centimeter tape is applied to the upper edge of the symphysis and held with the left hand. With the right hand, a centimeter tape is pulled along the anterior line of the abdomen to the bottom of the uterus and applied with the right hand to the point of maximum standing. Each period of pregnancy is characterized by finding the bottom of the uterus at a certain level in relation to the pubis, navel and costal arch. In full-term pregnancy, by multiplying the circumference and the height of the uterine fundus, the value of the estimated fetal weight is obtained (Jordania method).

Receptions of external obstetric research of Leopold-Levitsky:

The preparation of the woman and the midwife is the same as for measuring the circumference of the abdomen.

First take:

The palms of both hands are brought together, and the fundus of the uterus is contoured with the outer ribs, determining the level of standing of the bottom (and thus the duration of pregnancy), as well as the shape of the uterus. Fingering in the bottom area, determine the large part located in the bottom. You can apply the technique of balloting (they periodically tap the fingers of one and the other hand in the bottom area, while moving a large part, especially the head, is felt).

Second take:

Place hands parallel middle line on the lateral surfaces of the uterus. First, it is carried out from top to bottom with a relaxed hand, and then the hand is rounded and fingered, feeling parts of the fetus, smooth and convex contours. This technique determines the position, position and type of the fetus. From the side of the limbs there are more bulges, and more movement is manifested. From the back of the uterus, more cardiac activity of the fetus is smoother. With this technique, the tone of the uterus, its excitability are also determined.

Third take:

The widely spaced 1st and 3rd fingers of the right hand are immersed as deep as possible into the region of the lower segment (above the pubis parallel to it). The head appears more rounded and dense. With a movable head, it is easily displaced, located above the pubic arch. With a full bladder, the study is painful and ineffective. The third method reveals the presenting part and its level of standing relative to the small pelvis. At the first three appointments, the midwife stands or sits to the right of the pregnant woman facing her.

Fourth take:

Clarify the presenting part and the level of its standing. At the same time, the midwife stands facing the woman's legs. The palms of the hands are located in the area of the lower segment, contouring the presenting part, trying to connect the fingers between the head and the pubis. If the hands converge, the presenting part is located above the entrance to the small pelvis and is mobile. If the arms diverge, then the head is lowered into the cavity of the small pelvis.

Listening to the fetal heartbeat:

The fetal heartbeat is heard at each visit of the pregnant woman to the antenatal clinic, starting from the second half of pregnancy, using an obstetric stethoscope (which, after examination, is treated with chloramine). Tones are heard best from the position of the fetus. With head presentation - below the navel, with pelvic - above the navel. normal rhythm heart rate at full-term pregnancy ISO-ISO beats per minute. The fetal heartbeat can be heard or recorded using additional methods research: ultrasound, CTG, ECG, FCG.

Observation of a pregnant woman in a antenatal clinic:

A pregnant woman should visit a antenatal clinic on average every 2 weeks. Before the birth itself, it is rational to conduct an examination and consultations every week. The frequency and methods of examination are strictly prescribed. If a woman does not attend the LCD, patronage is carried out. Such a system of observation is called prophylactic medical examination. A detailed examination with an examination of all systems and organs is carried out only upon registration.

In subsequent visits to the pregnant woman, the examination is carried out according to the following scheme:

Survey of complaints.
Weighing (calculation of weight gain).
Measurement of pulse and blood pressure.
Palpation of the abdomen and uterus.
Measurement of the circumference of the abdomen and the height of the fundus of the uterus.
Conducting external obstetric examinations.
Listening to the fetal heartbeat.
Detection of edema.
Find out the nature of discharge, urination and defecation.

Perform only those studies that can be performed at a given gestational age, for example, the use of Leopold-Levitsky techniques and listening to the fetal heartbeat is carried out from the second half of pregnancy.

Each time they specify the gestational age, identify problems, give recommendations, prescribe examinations and the next turnout. General analysis urine is prescribed every 2 weeks. Examination of the external genitalia and examination on the mirrors, together with the taking of smears, is carried out 3 times during pregnancy. Vaginal examination is performed only for special indications.

During pregnancy, the following laboratory tests are prescribed:

Three times (1 time in each trimester):
smears from the cervical canal and the external opening of the urethra to detect gonorrhea;
blood from a vein to detect syphilis (Wasserman reaction - RW);
blood from a finger clinical analysis(hemoglobin, leukocytosis, ESR, etc.).

Twice during pregnancy, the examination is carried out:

blood from a vein to detect HIV infection (form 50);
blood from a vein to detect hepatitis B and C.

Blood is tested once for group and Rh factor. It is recommended to examine the husband's blood. With a difference between the group and Rh, an antibody titer test is performed approximately 1 time per month.

At 17 weeks, a blood test for alpha-fetoproteins is taken to detect fetal pathology.
In the second half of pregnancy, a swab from the throat is examined for the carriage of staphylococcus aureus, feces - for worm eggs and intestinal infections. It is rational to reveal a latent infection (toxoplasmosis, mycoplasmosis, viral infections, etc.).

If there is a risk of miscarriage, a smear is taken for hormonal threat. In the presence of cervical erosion, a smear is taken for oncocytology. During pregnancy, ultrasound examinations are performed three times: at 17 weeks, at 30 weeks and at 37 weeks. Ultrasound examination reveals: the size of the fetus, the correct development for this period, whether there are any intrauterine malformations (CM), the sex of the fetus, the position and presentation of the fetus, the amount of water, the location and condition of the placenta, the condition of the uterus as a fetus-place.

Before the ultrasound examination, it is necessary to remind the woman that she needs to drink about 500 ml of liquid before the examination in order to fill the bladder. For longer periods, this is not required. During the study, abdominal access is used to lubricate the abdominal wall with a fat emulsion; when examining with a vaginal probe, a special case or condom is put on it.

Twice during pregnancy, a woman needs to consult a general practitioner, an ophthalmologist, a dentist and an otolaryngologist. These specialists should be in the antenatal clinic, at least a therapist. If necessary, a woman can consult with a antenatal clinic lawyer.

Medical documentation:

All data about the pregnant woman, the results of the examination are entered into the individual card of the pregnant woman (2 copies), one copy is kept in the office, and the other woman always carries with her.

Each exchange card of a pregnant woman must contain the following pages:

title page(passport details and address);
history data;
general inspection data;
data from obstetric external and internal examinations;
pregnancy management plan;
list of dynamic observations; - a list of laboratory examinations;
list of expert opinions.

A pregnant woman should understand the expediency of such an intensive examination and observation, she agrees to them absolutely voluntarily. It should be emphasized that it is very important to detect infections before and during pregnancy in order to treat them in time, and that infected and unexamined women are admitted to the departments for infected and unexamined women. It is necessary to explain that timely detected minimal deviations make it possible to apply preventive measures and prevent complications of pregnancy and childbirth. This will be an incentive for a woman who is interested in maintaining her health and the health of her child.

It is necessary that a woman trust the midwife, not be afraid of her, and be able to discuss her problems with her. You should use the time of communication to give the woman advice on hygiene, examination and preparation for childbirth.

The time of visiting the antenatal clinic should be convenient for the woman. At the place of work or study, they are obliged to give the opportunity to visit the antenatal clinic during the morning reception, during daylight hours, when there are fewer problems with transport. If a woman misses an appointment, the midwife should find out by phone the reason. In case of an emergency, it is recommended to call an ambulance. If a woman does not want or cannot attend a consultation, patronage is carried out.

Obligations of a midwife in a antenatal clinic:

Since pregnant women visit the antenatal clinic on the day of the planned appearance, they try to schedule their visit so that they do not come into contact with gynecological patients (more infected).

Equipment of the gynecological office:

A couch, two tables (for a doctor and a midwife), chairs for staff and visitors, a gynecological chair, a lamp, a screen (or a gynecological examination room in the next room). For the examination, you need: a tonometer, a phonendoscope, an obstetric stethoscope, a tazomer, a centimeter tape, manipulation tables for instruments and medicines. Instruments: vaginal mirrors, forceps, tweezers, Volkmann's spoons for taking smears for Neisser's gonococci. Bix for dressings, spatulas. Bix with gloves or disposable gloves. Sterile oilcloths or disposable pads, disinfectant solutions, storage containers for tools, gloves, oilcloths, etc. The office should have a sink with water, soap and disinfectant solutions for hand treatment, towels.

Cases for medical documentation and case histories. Card file of individual cards of pregnant women, which are laid out alphabetically (separately put aside the cards of those who did not appear, those who were hospitalized, those who gave birth). Journal for registration of pregnant women, preliminary entry. Forms of prescriptions, directions for analyzes and consultations. There should be calendars under the glass, necessary reference Information: addresses and telephones, opening hours of offices, institutions to which patients are sent, tests, prescriptions, norm for laboratory research and etc.

The midwife comes before the doctor, ventilates and prepares the office, instruments, cards of the appointed pregnant women, glues the tests, prepares new referrals and information for the doctor and for the pregnant woman. During the appointment, together with the doctor (or instead of the doctor in the case of the physiological course of pregnancy), he receives pregnant women, conducts examinations, gives recommendations, conducts a conversation, draws up documentation, monitors the processing of tools, cleaning the office, conducts patronage.

Patronage:

Woman skips appointment for consultation different reasons: lack of understanding of the importance of examinations, lack of contact with the doctor and midwife, burdensomeness of the visiting procedure (queue, lack of necessary amenities while waiting). It depends on the midwife that such reasons do not arise. Sometimes a woman has complaints and problems, but she does not want to tell the doctor and midwife about it, as she is afraid of hospitalization and treatment, avoids preventive hospitalization for examination or preparation for childbirth. Can be family problems(care for sick relatives, no one to leave the child with, etc.).

When visiting a woman at home, a midwife can assess living conditions, family problems, talk with relatives and convince them to encourage the woman to attend counseling. At home, the survey and examination scheme is exactly the same as in the antenatal clinic. To do this, you need to take with you a tonometer, an obstetric stethoscope, a centimeter, referral forms for examinations. At the end of the reporting period, an analysis of performance indicators is carried out: how many pregnant women were registered, the outcome of pregnancy and childbirth, the percentage of complications for the mother and fetus, the correctness of issuing maternity leave and etc.