Objective examination of a pregnant woman. Methods of research of pregnant women

To diagnose pregnancy, a number of questions must be resolved. The main point is to establish the very fact of the existence of pregnancy. Next, the duration of pregnancy, the time of granting prenatal leave and the estimated date of delivery are clarified.

General methods of research of pregnant women

An important point is to find out the nature of the course of pregnancy, whether or not there are complications that require medical assistance. They find out the state of health of a woman and timely diagnose possible diseases (existing before pregnancy and arising during it), the course of which often worsens due to pregnancy.

A very important task of the study of pregnant women is to determine the condition of the fetus and the normality of its development, which has become much more accessible with the availability of modern research methods.

All these points are directly related to the selection of tactics of labor management and further prolongation of pregnancy, and also allow predicting the outcome for both the mother and the fetus. The main point that determines the final diagnosis and tactics of a doctor is the summation of all the information received and the data of an objective study of a woman.

The following methods of examination of pregnant women can be generally accepted.

survey,
inspection,
examination of internal organs by percussion, auscultation, palpation, etc.

Examination as a research method in pregnant women

The first moment when a pregnant woman is examined is an examination of a pregnant woman. Examination allows you to evaluate important data for establishing a diagnosis. On examination, attention is drawn to the growth of the pregnant woman, physique, fatness, the condition of the skin, visible mucous membranes, mammary glands, the size and shape of the abdomen.

Growth is measured as accurately as possible. With low growth (150 cm and below), signs of infantilism are quite common in women (narrowing of the pelvis, underdevelopment of the uterus, etc.). In turn, women of high stature may have their own characteristics - a wide or male-type pelvis.

In the study of pregnant women, they also attach importance to the presence of deformation of the spine and lower extremities, ankylosis of the joints and other changes in the skeletal system, which may be the causes of changes in the shape of the pelvis and its narrowing. Often, changes in the bones are the result of past diseases (rickets, poliomyelitis, tuberculosis), which also adversely affect other organs and body systems.

Signs of infantilism are often visible to the naked eye when examining a pregnant woman.

underdevelopment of the mammary glands,

insufficient development of hair in the vulva,

insufficient sexual differentiation (broad shoulders, narrow pelvis, male pattern hair growth).

Attention is drawn to the pronounced emaciation or fatness (obesity), which is a sign of metabolic disorders, endocrine and other diseases.

Such disorders are caused by irrational and malnutrition. Complications of pregnancy and childbirth in such women occur more often than usual.

The appearance of the skin may indicate the presence of pregnancy. This is due to the appearance of pigmentation of the face, white line, nipples and areola, the presence of pregnancy scars (stretch marks). It should be noted that pregnant women with pale skin and visible mucous membranes, bluish lips, yellowness of the sclera and skin, and edema cause concern, since all this can be a manifestation of serious illness.

Examination of the abdomen during the study of pregnant women

The main point of examining a pregnant woman is an examination of the abdomen, which often allows you to find out deviations from the normal course of pregnancy. With a physiologically normal course of pregnancy and the correct position of the fetus, the abdomen has an ovoid (ovoid) shape. If there is polyhydramnios, it is spherical, and the intensity of its increase does not correspond to the gestational age. The transverse position of the fetus gives a change in the shape of the abdomen - it takes the form of a transverse oval. Plus, the shape of the abdomen can change with a narrow pelvis.

When examining pregnant women, attention is also paid to the size of the sacral rhombus (Michaelis rhombus), the shape of which, together with other data, makes it possible to judge the structure of the pelvis, the presence or absence of its narrowing.

Examination of internal organs in pregnant women

The next point of the study can be called an examination of the internal organs (cardiovascular system, lungs, kidneys, and others) using auscultation, percussion, palpation, etc. This study must be carried out by a pregnant woman for the timely detection of diseases in which pregnancy is contraindicated.

Generally accepted when examining a pregnant woman are

measurement of blood pressure on both hands (with the development of preeclampsia in the second half of pregnancy, blood pressure can be not only elevated, but also different on the right and left hands),
pulse counting,
urine and blood test (ESR),
determination of blood group, rhesus,
as well as serological and other studies of latent infections (such as syphilis, toxoplasmosis, etc.).

More often and more carefully, blood and urine tests, blood pressure measurements, and weighing in women in the second half of pregnancy are performed.

In the presence of diseases of internal organs that require more accurate diagnosis, X-ray, electrophysiological, ultrasound and other instrumental examinations of organs can be used.

Special and laboratory research methods in pregnant women

Special methods of research of pregnant women:

internal (vaginal) and external-internal examination;
research using mirrors;
fetal palpation;
determination of the size and shape of the pelvis;
study of fetal cardiac activity (determine the condition of the fetus), measurement of the size of the fetus.

Laboratory and instrumental research methods to identify possible diseases, pregnancy complications and fetal developmental disorders:

hematological,
immunological (serological, etc.),
bacteriological,
histological,
cytological,
endocrinological,
mathematical,
ultrasonic.

If there are indications, it is possible to conduct fluoroscopy and radiography, amnioscopy and other instrumental research methods.

Careful examination during pregnancy allows you to detect and correct various pathologies in a timely manner, as well as prevent possible complications.

Let's talk in more detail about what research methods used for this in modern medicine.

Laboratory research

As soon as the expectant mother turns to the antenatal clinic or a private clinic at an early stage of pregnancy, the doctor must prescribe:

general blood and urine tests;
coagulogram;
analysis to determine the blood group and Rh factor. Moreover, it will need to be done not only by the woman herself, but also by her husband (this is especially true with a negative Rh factor or the first blood group in a pregnant woman);
tests for urogenital infections (by PCR);
tests to determine the level of hormones;
studies necessary to determine immunoresistance;
studies needed to assess general health.

In addition, in some cases, consultation with a geneticist may be required.

Before giving birth, you will need to take tests regularly. This is necessary in order to control the course of pregnancy and to identify possible violations at the earliest stage.

Diagnosis of infections

In early pregnancy, it is necessary to take blood tests for dangerous infections such as hepatitis B and C, syphilis, and HIV. Re-examination for HIV and syphilis should be carried out in the third trimester of pregnancy (at 30 weeks and approximately half a month before the expected date of birth).

In addition, you will need to pass smears for STIs.

ECG

Assessment of the activity of the heart is carried out when registering for pregnancy and a few weeks before childbirth. Of course, in the presence of any abnormalities, the ECG can be performed more often.

Fetal CTG

With the help of CTG, the doctor can assess the condition of the unborn baby by observing the change in the heart rate of the child at rest and during movements.

Assessment of fetal movement

This method is available to every woman and does not require special skills. During the day, the expectant mother counts the number of movements of the child and, if there are deviations from the norm, she can immediately consult a doctor for a more thorough examination.

ultrasound

Ultrasound is performed repeatedly during pregnancy, allowing you to assess the development of the unborn child, the condition of the placenta and amniotic fluid. This study combines high information content and complete safety.

Prenatal diagnosis

Prenatal diagnostics is understood as a set of methods aimed at identifying malformations of the unborn child.

"Double" test or as it is also called screening, which includes an ultrasound and a blood test, is carried out in the first trimester of pregnancy in order to exclude chromosomal abnormalities in the fetus. In particular, we are talking about such pathologies as Down syndrome, Edwards and Turner.

If the likelihood of violations is high, additional studies will be required to clarify the alleged diagnosis and decide whether to continue the pregnancy.

A modern method for diagnosing genetic disorders in an unborn child, known as a non-invasive prenatal test, makes it possible to find out for sure from the 9th week of pregnancy whether the fetus has chromosomal abnormalities.

Moreover, in this case, it is possible to exclude not only the most common diseases, but also the so-called microdeletion syndromes (pathologies caused by the loss of a very small portion of the chromosome), which provoke serious physical and mental disorders in the unborn child.

It should be noted that the probability of having a child with microdeletion syndromes (Angelman, Prader-Willi, DiGeorge and others) has nothing to do with how old the mother is. In this regard, the study is equally relevant for women of all age groups.

If earlier the only method for diagnosing these diseases was invasive procedures, now you can get an accurate answer using a routine blood test.

Rhesus conflict

If a woman with a negative Rh factor is waiting for the birth of an Rh-positive baby (and the pregnancy is not the first), a conflict may arise between the mother's body and the fetus. It is dangerous because the child develops hemolytic disease. Not so long ago, cordocentesis (fetal umbilical cord blood sampling) was the only method for diagnosing this pathology. Doppler ultrasound is now effectively used, with the help of which the doctor evaluates the speed of blood flow in the vessels of the fetal brain.

You can determine the Rh factor of the unborn baby already in the first trimester of pregnancy. To do this, a woman only needs to take a blood test.

To prevent Rh conflict, a special immunoglobulin is administered to the expectant mother at the twenty-eighth week of pregnancy, as well as a few days after childbirth.

Doppler

With the help of a special ultrasound sensor, the doctor can determine the speed of blood flow in the vessels of the uterus, umbilical cord and brain of the child. As a rule, the study is carried out at 32-33 weeks of pregnancy. With this method, the doctor will be able to understand whether the baby is receiving enough nutrients. If the parameters of the growth and weight of the fetus are below normal, dopplerometry may be prescribed at an earlier date.

Diagnosis of thrombophilia

It is necessary to carefully assess the state of the blood coagulation system if a woman has habitual miscarriage, placental abruption or some other complications were previously detected.

A coagulogram allows you to detect violations and prevent dangerous consequences associated with a tendency to thrombosis.

Specialists know how to determine the hereditary form of thrombophilia and reliably assess the likelihood of its development. If there is a high risk at the stage of pregnancy planning, it will be necessary to start a course of treatment that continues into the gestation process.

THEME #4

Methods of examination of pregnant women and women in childbirth

When examining a pregnant woman or a woman in labor, they use data from a general and special history, conduct a general objective and special obstetric examination, laboratory and additional research methods. The latter include hematological, immunological (serological, etc.), bacteriological, biochemical, histological, cytological studies; study of cardiac activity, endocrinological, mathematical research methods to identify possible diseases, pregnancy complications and fetal developmental disorders. With appropriate indications, fluoroscopy and radiography, amniocentesis, ultrasound and other modern diagnostic methods are used.

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 are palpated; the inner surfaces of the bone identification points are difficult to access for examination.

THEME #7

ANESTHESIS OF CHILDHOOD

Students are reminded of the changes in the body during pregnancy. The rapid growth of the pregnant uterus is accompanied by a high standing of the diaphragm and liver, which, in turn, leads to a displacement of the heart, pushing the lungs upward and limiting their excursion. The main changes in hemodynamics associated with an increase in the duration of pregnancy are an increase of up to 150% of the initial BCC, a moderate increase in peripheral resistance, the occurrence of uteroplacental circulation, an increase in pulmonary blood flow with a tendency to hypertension, and partial occlusion in the system of the inferior vena cava.

The syndrome of the inferior vena cava (postural hypotensive syndrome) is expressed in rapidly occurring hypotension (sometimes in combination with bradycardia, nausea, vomiting, shortness of breath) when the woman in labor is laid on her back. It is based on partial compression of the inferior vena cava by the pregnant uterus with a sharp drop in venous flow to the heart. Restoration of the initial arterial pressure occurs after the woman in labor is turned on her side (preferably on the left).

Anesthesia of childbirth is the basis of obstetric anesthesiology. Unlike surgical operations, childbirth does not require reaching deep stages III 1-2, but the stage of analgesia (I 3) is sufficient while maintaining consciousness in women in labor, contact with the doctor, and, if necessary, active participation in childbirth.

The immediate causes of labor pain are:

opening of the cervix, which has highly sensitive pain receptors;

contraction of the uterus and tension of the round uterine ligaments, parietal peritoneum, which is a particularly sensitive reflex zone;

irritation of the periosteum of the inner surface of the sacrum due to tension of the sacro-uterine ligaments and mechanical compression of this area during the passage of the fetus;

excessive contraction of the uterus as a hollow organ in the presence of relative obstacles to its emptying, resistance of the pelvic floor muscles, especially with anatomical narrowing of the pelvic inlet;

compression and stretching during uterine contractions of blood vessels, representing an extensive arterial and venous network and having highly sensitive baromechanoreceptors;

change in tissue chemistry - accumulation during prolonged contraction of the uterus of underoxidized products of tissue metabolism (lactate, pyruvate), temporarily creating uterine ischemia due to periodically recurring contractions.

NON-PHARMACOLOGICAL METHODS OF ANALGESIA

Preparation for childbirth, hypnosis, acupuncture and transcutaneous electrical nerve stimulation (TENS) are methods of influencing the psychophysiological aspect of pain. The individual patient's perception of pain depends on a number of interdependent and complicating circumstances, such as physical condition, expectation, depression, motivation, and upbringing. Pain in childbirth is exacerbated by factors such as fear of the unknown, danger, apprehensions, previous negative experiences. On the other hand, pain is relieved or better tolerated if the patient has confidence, understanding of the birth process, if expectations are realistic; breathing exercises, developed reflexes, emotional support and other distraction techniques are used. The patient's own choice is essential to the success of all physiological procedures. Among the factors associated with the success of these methods are the sincere commitment of the parturient and instructing or attending staff, higher socioeconomic and educational levels, positive previous experiences, and normal delivery.

PREPARATION FOR BIRTH

Preparation for childbearing consists of a series of conversations in which the future father is highly desirable. Teaching parents the essence of the processes that accompany pregnancy and childbirth is carried out in the form of lectures, audiovisual classes, and group discussions. The mother must be taught proper relaxation, exercises that strengthen the muscles of the abdomen and back, increase overall tone, and relax the joints (mainly the hips). She should also be taught how to use different methods of breathing during uterine contractions in the first and second stages of labor, as well as directly at the time of birth of the fetal head. Although preparation for childbirth reduces the response to pain, the need for other methods of pain relief remains approximately the same as in the control group. At the same time, the need for pain relief in prepared women during childbirth still comes later. It is advisable to discuss the possible method of pain relief during the prenatal interviews and to avoid the use of medications that are not strictly necessary or that could harm the fetus. If this is not done, the result can be a significant reduction (sometimes a complete absence) of the effect of medical pain relief, if the need for it nevertheless arose. It should be made clear that the use of epidural anesthesia or other necessary pain relief techniques, when performed correctly, is harmless to the child.

Hypnosis called a state of altered consciousness; it is not a state of sleep. The level of consciousness decreases, the concentration becomes deeper. A typical hypnotic course consists of daily sessions for 5-6 weeks, during which the woman learns how to relax, as well as how to achieve a hypnotic state easily and effectively. With the onset of childbirth, a woman herself can achieve and maintain a hypnotic state until their completion. The mechanism of hypnosis is multicomponent and, like other methods of psychological pain relief, includes a given setting, motivation, conditioned reflexes and training. The selection of patients is essential, since the technique is not effective in all cases. Preparing for hypnosis in childbirth is time-consuming and rarely used.

ACUPUNCTURE

Acupuncture It is both art and philosophy. According to Chinese culture, each organ has a certain amount of energy. Part of the energy is used locally by the organ, the rest is sent away along circular paths, returning, in the end, to the same organ. These pathways are called meridians and are located under the skin. When an organ is diseased or a source of pain, the energy produced is abnormal: either too little or too much. Inserting needles at appropriate points along the meridian can relieve pain by returning energy to normal levels. An additional element specific to acupuncture is the "gate of pain" theory. The vibration of the needle closes this gate in the central nervous system or releases endorphins that interrupt the transmission of pain impulses. It is likely that the mechanism of action also includes attitude, motivation, expectation, and environment. Theoretically, acupuncture should be the ideal way to relieve labor pain, but usually only partial pain relief occurs, and most patients require additional methods of analgesia in the second stage of labor. The method is interesting, but based on existing information, there is no reason to believe that it can take a fundamental place in obstetric analgesia and anesthesia.

TRANSCUTANEOUS ELECTRONEUROSTIMULATION (TENS)

TENS has been used for labor pain relief for many years. During childbirth, two pairs of electrodes are placed on the back of the woman in labor. The upper pair is placed on both sides of the midline, in the projection area of the dermatomes of the posterior branches from T10 to L1. The lower pair is placed on both halves of the sacrum. The electrodes are connected to the device. Women in labor can adjust the strength of the device. Usually in the first stage of labor, low-amplitude stimulation is used, causing a slight tingling sensation, with increasing stimulation during uterine contractions. The degree of stimulation will vary according to the need and pain tolerance of each individual woman. The amplitude range is mainly from 1 to 40 mA, with a frequency range of 40-150 Hz and a pulse frequency of 30-250 µs. The woman in labor activates the upper pair of electrodes during the first stage of labor and turns on the sacral electrodes at the end of the first stage or at the time when she feels pain in the lower back. This form of analgesia is safe, non-invasive, and easily accessible to the nurse or midwife. The effectiveness of TENS is variable. Some authors claim that 44% of women in labor rated pain relief as "good" or "very good" while 12% found it ineffective. However, most of the reports on the use of TENS in childbirth are anecdotal, and among them there are very few that are methodically clear. The main disadvantage of the method is the difficulty in its application of electronic monitoring of the heart rate in the fetus. Although TENS itself does not affect fetal heart rate, until filters to block electronic interference from monitoring equipment become widely available, its use in labor will be limited.

MEDICINES FOR ANESTHESIA OF CHILDHOOD

Key points to consider:

The drugs used must have a strictly selective analgesic effect, without a pronounced narcotic effect.

The use of a combination of analgesics with antispasmodics shortens the duration of labor, especially the first stage.

An increase in the duration of the analgesic effect can be achieved through the combined use of pharmacological agents capable of potentiating and mutually prolonging the action based on a combination of low doses.

The applied method of anesthesia should not inhibit labor activity and have a negative effect on the fetus and newborn.

The method should be easily manageable and accessible.

Drugs used in childbirth can be divided into three types: those administered parenterally for the relief of pain and anxiety, those used for local infiltration and regional blockades, and those used for inhalation analgesia and anesthesia. All of them pass through the placental barrier, differing in penetration rate and quantity. They include several groups: narcotics, sedatives / tranquilizers, amnestics and inhalation anesthetics, local anesthetics.

DRUGS

drugs- the most effective systemically acting agents used for labor pain relief. However, none of the currently used drugs in this group can provide effective analgesia, not accompanied by side effects for the mother and / or young. In addition, these drugs are used to reduce rather than completely stop pain. The most serious side effect of the use of narcotic drugs is respiratory depression for both the mother and the fetus. There is a distinct difference in the manifestation of this effect depending on the route of administration; respiratory depression is most pronounced 2-3 hours after intramuscular (IM) administration, but most often within 1 hour after intravenous (IV) administration of equivalent doses. Another side effect of all drugs is orthostatic hypotension due to peripheral vasodilation. In a horizontal position, blood pressure, heart rate and rhythm remain unchanged, but when you try to sit or stand up, blood pressure can drop sharply, often even accompanied by arrhythmia. Nausea and vomiting may occur, probably due to direct stimulation of chemoreceptor trigger zones in the medulla oblongata. The severity of the emetic effect depends on the dose and is usually similar in intensity for doses of different drugs equal in analgesic activity. Some women, however, are more sensitive to certain drugs than others. Drugs usually stimulate smooth muscle, but they decrease gastric motility and may impair uterine contractions when administered during the latent or early active phase of labor. However, once labor has stabilized, they can correct uncoordinated uterine contractions due to decreased adrenaline secretion in response to analgesia.

In practice, several options for narcotic drugs are available. With the right dosage, they have a similar analgesic effect; the choice is usually based on the degree of potential side effects and the desired duration of action. Basically, intravenous administration is preferable to intramuscular administration, since the effective dose is reduced by 1/3 -1/2 and the effect begins much sooner (5-10 minutes versus 40-50).

Morphine, the cheapest of the narcotic drugs, has recently fallen out of favor due to its many side effects on the parturient woman and a pronounced tendency to fetal respiratory depression.

Meperidine (pethidine, promedol, demerol, omnopon, dipidolor, dolantine) has become the standard for comparison with newer drugs. It is administered intramuscularly at a dose of 50-100 mg, intravenously - 25-50 mg. In childbirth, the most successful scheme is considered in which the first dose of 50 mg is administered intravenously, followed by the addition of 25 mg at intervals of at least 1 hour. The primary side effect for the mother is respiratory depression, the delayed effect for the fetus is depression at birth and a decrease in neurobehavioral assessment on the first and second days of life.

Fentanyl (sublimase) is 750-1000 times stronger than meperidine. The usual dose is 50-100 micrograms IM or 25-50 micrograms IV. The main side effect is a potentially high risk of respiratory depression. Although the drug has a short duration of action, the duration of respiratory depression may exceed this period.

Alfentanil (Alfenta) and sufentanil (Sufenta) act immediately after IV administration. Alfentanil is 1.3 times more powerful than fentanyl, sufentanil is 7-10 times more powerful. They do not have any advantages over fentanyl, but are more expensive.

Butorphanol (stodol, moradol) and pentazocine (talvin, lexir, fortral) are opioid agonist-antagonists, that is, they have a dual effect. They were obtained in the process of searching for an analgesic with minimal or no risk of addiction. It is believed that they have a "ceiling" of respiratory depression, i.e. large repeated doses cause less depressive effect than the initial one. The usual dose of bugorphanol is 1–2 mg IM or 1 mg IV. The main side effect is drowsiness. Pentazocine is prescribed at a dose of 20-30 mg / m or 10-20 / in.

Nalorphine, naloxone (narcan) is the most preferred of the currently existing narcotic antagonists. The initial dose for adults is 0.4 mg IV. The dose for the newborn is 0.01 mg / kg both intravenously and, with normal perfusion, intramuscularly. The effect develops within a few minutes and lasts 1-2 hours. Since naloxone has a relatively short duration of action, when it is used in case of an overdose of drugs in the mother or newborn, they must be carefully monitored and re-administered if necessary. Naloxone is not recommended for both drug-abusing mothers and their children due to the risk of acute withdrawal.

SEDATIVES / TRANQUILIZERS

They are used in childbirth to relieve arousal and reduce nausea and vomiting. Phenothiazines, promethazine (Phenergan) 15–25 mg IV or 50 mg IM, promazine (Sparin) 15–25 mg IV or 50 mg IM, and propiomazine (Largon) 10 mg IM often combined with the first dose of meperidine. The resulting sedation may lead to a reduction in the subsequent required dose of drugs. Hydroxyzine (Vistaril) - 50 mg IM also reduces the need for drugs. Despite the rapid penetration through the placental barrier and a decrease in the heart rate of the fetus, recommended doses do not cause neonatal depression.

Ketamine (ketalar, calypsol) is a dissociative drug that is not only a powerful amnestic, but also an excellent analgesic. Due to its amnestic effect, it is unlikely to be used in routine childbirth. However, it is a good adjunct to local and regional blockades in vaginal delivery or minor obstetric procedures; an IV dose of 0.2-0.4 mg/kg causes satisfactory anesthesia in an awake woman in labor without adversely affecting her hemodynamics, uterine contractility, or fetal condition. The appointment of such low doses can be repeated every 2-5 minutes, but not more than 100 mg in 30 minutes.

INHALATION ANESTHESIA

Inhalation analgesia caused by the appointment of low concentrations of substances with analgesic properties, providing pain relief without oppression of consciousness and protective reflexes. The ability to execute commands remains. During childbirth, the pregnant woman should begin inhaling the gas or inhalate as soon as she feels the onset of uterine contraction. A doctor or nurse may use continuous inhalation. Currently, nitrous oxide and isoflurane, trichlorethylene (trilene, narcogen), methoxyflurane (pentran), and halothane (halothane) are most often used for inhalation anesthesia. Both have a short onset time and provide a quick awakening. Of the other halogenated anesthetics, halothane has a weak analgesic activity, and enflurane is characterized by a higher degree of biotransformation and more pronounced myocardial depression than isoflurane. During childbirth, a mixture of 50% nitrous oxide and 50% oxygen can be used by the mother herself as an autoanalgesia. In childbirth, a range of concentrations from 30% nitrous oxide - 70% oxygen for women in labor who received parenteral analgesics, to 40% nitrous oxide - 60% oxygen for those who did not receive other analgesia, can also be recommended.

REGIONAL ANESTHESIA

Epidural analgesia

Caudal analgesia

Subarachnoid administration of opioids

Prolonged spinal analgesia

Paracervical block

Pudendal nerve block

Local infiltration of the perineum

Bupivacaine - 0.25% solution, lidocaine - 1-1.5-5% solution, novocaine - 0.25-0.5% solution.

ANESTHESIA OF COMPLICATED DELIVERY

With weakness of labor activity and with discoordinated labor activity: Premedication + g-hydroxybutyric acid-GHB (sodium hydroxybutyrate).

For caesarean section:

General anesthesia

Advantages:

occurs quickly;

a small number of failures;

allows quick access to all parts of the body for surgical or anesthetic intervention;

allows you to switch off, protect and control respiratory functions;

provides the ability to change and control the functions of the cardiovascular system;

quickly relieves convulsions.

Flaws:

the possibility of failure during intubation or the introduction of an endotracheal tube into the esophagus;

risk of aspiration of stomach contents;

risk of unexpected awakening;

unforeseen relaxation of the muscles of the uterus may occur;

the risk of CNS depression in the fetus and newborn;

the occurrence of an abnormal reaction to medicinal agents.

Regional anesthesia

Advantages:

there is no risk of aspiration of gastric contents;

there is no danger of failure during intubation (however, it is necessary to pay attention to the fact that the complications indicated in paragraphs 1 and 2 may occur if a general spinal block or systemic toxicosis develops);

lower blood pressure less often;

there is no decrease in the tone of the uterus;

there is no risk of an unintended exit from the state of anesthesia;

the mother may come into contact with the baby early and start breastfeeding.

Flaws:

cases of complete lack of effect;

anesthesia may be insufficient, for example, some segments fall out and it is monolateral;

unexpectedly high or complete blockade;

headache after lumbar puncture;

subsequent neurological complications;

systemic toxicity of local anesthetics (administered epidurally).

The choice of method of anesthesia for caesarean section is largely determined by the experience of the anesthetist and surgeon and the desire of the patient. Other things being equal, regional anesthesia is probably safer than general anesthesia. In addition to the advantages and disadvantages listed above, there are some special indications and contraindications for the use of methods of both general and local anesthesia.

Indications for general anesthesia:

the requirement of the woman in labor;

physiological characteristics of the patient, preventing the implementation of a regional blockade;

significant blood loss / hypovolemia;

eclamptic convulsions or an altered level of consciousness of the woman in labor;

the need for immediate surgery if a spinal block is not possible.

Contraindications for general anesthesia:

the presence of circumstances that make it difficult or impossible to intubate the trachea;

allergy or pathological reaction to general anesthesia in history;

diseases of the mother that can complicate the administration of general anesthesia, such as those listed below;

sickle cell anemia; myasthenia gravis; dystrophic myotonia;

malignant hyperthermia; diabetes.

Indications for regional anesthesia:

mother's request

premature birth;

improved communication between mother and fetus;

greater safety compared to general anesthesia;

history of deep vein thrombosis.

Contraindications for regional anesthesia:

refusal of the woman in labor;

increased bleeding, disorders of the blood coagulation system;

local sepsis;

septicemia;

Allergy of the patient to local anesthetics.

For minor obstetric operations.

MODERN PERINATAL TECHNOLOGIES

(physiological adaptation and formation of health of newborns)

The physiological, immunobiological and psycho-emotional connection between mother and child is not interrupted until 1.5 years of its postnatal development. The physiological formation of adaptation reactions of the newborn and the subsequent development of the infant is possible only if the mother and child stay together in the maternity hospital. Constant contact between mother and child, which begins at birth: after the primary cutting off of the umbilical cord. The child is laid out on the mother's stomach and applied to the breast. The formation of the protective forces of the child's body is extremely negatively affected by the treatment of the breast with disinfectants or washing with running water and soap. On the areola of the nipples, a huge amount of biologically active and protective factors (lysozyme, immunoglobulins, bifidobacteria, etc.) are produced (especially before feeding, when the mother hears the voice of her child), which are necessary for the physiological formation of the local and general immune system, microbiocenosis and digestive functions. A woman should carry out hygiene measures only after feeding a child, breastfeeding from the first minutes of life and later at the request of the child without a certain time interval, including at night, excluding drinking solutions and prescribing adapted mixtures. It is necessary (if possible) to feed the child only with the milk of his mother. The direct and reverse immunobiological relationship that persists after childbirth is mediated through lactation by the universal composition of mother's milk, ideally suited only to her baby. The composition changes according to the hours and days of a newborn's life and ideally ensures the adaptation of nutritional processes and the formation of the child's own ecological system. Violation of the adaptation of the newborn, as well as his disease, affects changes in the qualitative composition of milk and increases its immunological activity. Despite the small volume of colostrum, in the first 3 days after birth, when creating conditions for frequent attachment of the newborn to the breast (at his request), at least 10-12 times a day during the adaptation period, provides him with the necessary calories and protective factors. Frequent attachment of a newborn to the breast is reflected in the increase in the product of oxytocin and prolactin in the mother's body, reduces the risk of postpartum purulent-septic diseases and bleeding, and is a necessary condition for the formation of lactational function.

Early discharge from the maternity hospital (on day 3-4) is possible under the condition of surgical cutting off of the umbilical cord residue (after 12 hours of life). By the 3rd day of the stay of the puerperal woman and the newborn in the maternity hospital, there is an increased colonization of their hospital strains of bacteria that are highly resistant to antibacterial drugs and disinfectants, virulence and toxigenicity. By day 6, almost all mothers and children are colonized. This significantly disrupts the formation of the normal endomicroecological system of the newborn and weakens the mother's defenses.

Paraphysiological conditions of newborns:

initial loss of body weight, not exceeding 6-8% of body weight at birth;

expansion of sweat glands;

toxic erythema;

sexual crisis;

physiological hyperbilirubinemia;

transient diarrhea.

The risk factors for the development of the syndrome of impaired adaptation of a healthy newborn (in a healthy mother with a physiological course of pregnancy) often include conditions that separate mother and child in the early neonatal period and violate proper breastfeeding. In all other cases, changes in the functional state of the newborn are due to risk factors from the mother and fetus.

Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
1. 1. Antenatal care: routine care for the healthy pregnant woman. National Collaborating 2. Center for Women’s and Children’s Health Commissioned by the National Institute for 3. Clinical Excellence. 2nd edition © 2008 National Collaborating Center for Women's and Children's Health. 1st edition published in 2003 4. Clinical protocol “Management of normal pregnancy (low-risk pregnancy, uncomplicated pregnancy)”, Mother and Child Project, Russia, 2007 5. Routine Prenatal Care ICSI Management of Labor Guidelines for hospital-based care. August 2005, $80 6. Guidelines for effective care during pregnancy and childbirth. Enkin M, Keirs M, Neilson D et al. . 2009. 8. Cochrane guidelines. Pregnancy childbirth. 2010 9. Orders of the MZRK No. 452 of 03.07.12 “On measures to improve medical care for pregnant women, women in childbirth, puerperas and women of childbearing age” 10. Order No. 593 of 08.27.12. "On approval of the regulation of the activities of health organizations providing obstetric and gynecological care"

Information

ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION:

List of protocol developers with qualification data: Mishina M.Sh. - obstetrician-gynecologist of the highest category, senior resident of obstetrics department 2 of JSC "NSCMD".

Reviewers: Kudaibergenov T.K. - Chief freelance obstetrician-gynecologist of the Ministry of Health of the Republic of Kazakhstan, director of the Republican State Enterprise "National Center for Obstetrics, Gynecology and Perinatology".
Kobzar N. N. - candidate of medical sciences, doctor of the highest category in obstetrics and gynecology, social hygiene and healthcare organization, head. Department of Obstetrics and Gynecology, KRMU.

Indication of the conditions for revising the protocol: The protocol is reviewed at least once every 5 years, or upon receipt of new data related to the application of this protocol.

ApplicationA

Rubella

the disease does not pose a danger to the mother;
there is a risk of fetal defects if the mother develops symptoms of infection before the 16th week of pregnancy;
· for prevention, the most effective state program of universal universal vaccination of children of the first year of life and adolescent girls, as well as women in the postpartum period;
· screening should be offered to all pregnant women at the first visit who do not have documentary evidence of vaccination (2a);
· accidental vaccination of women who subsequently become pregnant is not an indication for termination of pregnancy due to the safety of the live vaccine for the fetus;
women who are suspected of developing rubella infection should be isolated from other pregnant (or potentially pregnant) women, but after the disappearance of clinical signs of infection, they do not pose a danger to others
If the woman is not vaccinated against rubella or, recommend the introduction of the vaccine after delivery

ApplicationIN

Vaginal candidiasis -

infection that does not affect pregnancy.
· Diagnosis of vaginal candidiasis is based on microscopy of vaginal discharge. Culture is used to confirm the diagnosis.
Screening for vaginal candidiasis is not recommended.
Treatment of infection is indicated only in the presence of clinical manifestations: butoconazole, clotrimazole, econazole, terconazole or nystatin. However, it is very important to remember that the effect of drugs taken orally by the mother on the child is unknown.
· There is no need for hospitalization or isolation of women with vaginal candidiasis from other women.
· The newborn must be co-habitat with his mother, and can also be breastfed.

Asymptomatic bacteriuria
prevalence - 2-5% of pregnancies;
· increases the risk of preterm birth, the birth of small children, acute pyelonephritis in pregnant women (on average, develop in 28-30% of those who have not received treatment for asymptomatic bacteriuria);
definition - the presence of bacterial colonies -> 10 5 in 1 ml of an average portion of urine, determined by the cultural method (gold standard) without clinical symptoms of acute cystitis or pyelonephritis;
· diagnostic testing - midstream urine culture - should be offered to all pregnant women at least once at registration (1a);
For treatment, ampicillin, 1st generation cephalosporins, which have shown the same effectiveness in studies, can be used;
• treatment should be continuous during pregnancy with positive culture results, the criterion for successful treatment is the absence of bacteria in the urine;
• a single dose of antibacterial agents is also effective as a 4-day and 7-day course, but due to fewer side effects, single doses should be used;
It is logical to use drugs for which sensitivity has been established;
Treatment of severe forms of MVS infection (pyelonephritis) should be carried out in a specialized hospital (urological)

Hepatitis B
during pregnancy, the course and treatment of acute hepatitis does not differ from treatment outside of pregnancy;
Infection of a child most often occurs intranatally (90%);
· a blood test for hepatitis B (2 times per pregnancy) should be offered to all pregnant women to identify women carriers of HBsAg, for effective prevention of children born to such mothers - human anti-D immunoglobulin + vaccination on the first day of life (1b);
· Patients - carriers of HBsAg do not pose a danger in everyday life for staff and other women, as well as for their children, therefore, they should not be isolated in the antenatal and postpartum periods.

Hepatitis C
is one of the main causes of liver cirrhosis, hepatocellular carcinoma, liver failure;
There are no effective methods of prevention and treatment - therefore it is logical to suggest not to conduct routine screening for hepatitis C (3a), it may be more appropriate to study only the risk group (users of intravenous drugs with a history of transfusion of blood and its components, asocial, etc.). d.);
· but with a high prevalence of hepatitis C in the population and the financial capacity of the region, routine screening can be carried out by decision of local authorities;
· Patients - carriers of the hepatitis C virus do not pose a danger in everyday life for staff and other women, as well as for their children, therefore, they should not be isolated in the antenatal and postpartum periods.

Bacterial vaginosis
Asymptomatic course is observed in 50% of pregnant women;
· RCTs show that screening and treating otherwise healthy pregnant women (not complaining) for vaginal dysbiosis does not reduce the risk of preterm birth or other complications such as preterm rupture of membranes (1a);
in pregnant women with a history of preterm birth
indications for the appointment of treatment is the presence of clinical symptoms, especially the woman's complaints of itching, burning, redness in the vulva, profuse discharge with an unpleasant odor;
treatment - metronidazole for 7 days (per os or locally), but safety for the fetus has not been proven for up to 13 weeks of pregnancy.

Human Immunodeficiency Virus (HIV)
· the risk of vertical transmission depends on the level of the viral load of the pregnant woman and the state of immunity;
· the risk of vertical transmission without prevention in developed countries is 15-25%;
3-stage prevention:
- chemoprophylaxis during pregnancy and childbirth;
- elective caesarean section before the onset of labor, with an anhydrous period<4 часов;
· - refusal of breastfeeding reduces the risk of vertical transmission of HIV infection to 1%;
· HIV testing should be offered to all pregnant women twice during pregnancy (at registration and at 30-32 weeks of gestation) (1a);
· obstetric facilities should have rapid tests for examination of pregnant women with unknown HIV status;
· healthcare professionals who monitor a pregnant woman are required to actively help build adherence to treatment;
· some patients with HIV (+) status belong to the group of socially maladjusted, so they should be given increased attention in matters of possible domestic violence, smoking, alcoholism, drug addiction;
· Patients-carriers do not pose a danger in everyday life for staff and other women, as well as for their children, therefore, they should not be isolated in the antenatal and postpartum periods.

Chlamydia
the most common STI in the European region;
· increases the risk of preterm birth, IUGR, neonatal mortality;
· transmission from mother to child leads to neonatal conjunctivitis and pneumonia in 30-40% of cases;
· it is necessary to provide information about the methods of prevention of conjunctivitis during childbirth - laying tetracycline or erythromycin ointment in the conjunctiva of the newborn by the end of the first hour after childbirth;
screening for asymptomatic chlamydia should not be offered because there is no good evidence of their effectiveness and cost-effectiveness (3a);
The "gold standard" for diagnosing chlamydia is PCR;
treatment of uncomplicated genital chlamydial infection during pregnancy (outpatient):
- erythromycin 500 mg four times a day for 7 days, or
- amoxicillin 500 mg three times a day for 7 days, or
- azithromycin or clindamycin.

Cytomegalovirus infection (CMV)
· CMV remains the most important cause of congenital viral infections in the population;
· the risk of transmission of CMV infection is almost exclusively associated with primary infection (1-4% of all women);
Two possible courses of CMV infection among newborns infected from mothers before birth:
- generalized infection (10-15% of infected fetuses) - from moderate enlargement of the liver and spleen (with jaundice) to death. With supportive care, most newborns with CMV disease survive. Despite this, 80% to 90% of these newborns have complications in the first years of life, which may include hearing loss, visual impairment, and varying degrees of mental retardation;
- asymptomatic form (90% of all infected fetuses) - in 5-10% of cases, auditory, mental or coordination problems of varying degrees may develop;
· the risk of complications in women who were infected at least 6 months before fertilization does not exceed 1%;
· Routine screening should not be offered to all pregnant women due to the impossibility of practically proving the presence of a primary infection, the lack of an effective treatment for CMV infection, the difficulty in diagnosing infection and fetal involvement (2a);
Termination of pregnancy before 22 weeks is possible in extremely rare cases with:
- confirmed primary infection of the mother;
- positive results of amniocentesis;
- non-specific ultrasound findings (fetal anomalies, developmental delay).

Toxoplasmosis
· prevalence in Kazakhstan is generally low, so routine screening is not offered (2a);
• the route of transmission from mother to child is transplacental, can cause intrauterine death, IUGR, mental retardation, hearing impairment and blindness;
· the risk of transmission is mainly related to the primary infection;
The risk of fetal infection depends on the gestational age:
- the lowest (10-25%) when the mother becomes infected in the first trimester - severe lesions are observed in up to 14% of cases;
- the highest (60-90%) when the mother becomes infected in the third trimester - severe lesions are almost never encountered;
treatment - Spiramycin (not recommended before the 18th week of pregnancy), while there is no reliable evidence of the effectiveness of treatment in preventing congenital infections and fetal lesions;
information on the prevention of toxoplasmosis (and other foodborne infections) should be provided at the first visit to a healthcare professional:
- do not eat raw and undercooked meat;
- thoroughly clean and wash vegetables and fruits before eating;
- wash hands and kitchen surfaces, dishes, after contact with raw meat, vegetables and fruits, seafood, poultry;
- wear gloves during gardening or contact with the ground, which can be contaminated with cat feces. After work, wash your hands thoroughly;
- if possible, avoid touching the cat's bowl or litter box, if there is no helper, always wear gloves;
- do not let cats out of the house, do not take homeless cats into the house during pregnancy, it is not recommended to give cats raw or insufficiently processed meat;
· Patients who have had toxoplasmosis do not pose a danger to staff and other women, as well as to their children, so they should not be isolated in the antenatal and postpartum periods.

Genital herpes
· the prevalence of carriage in Kazakhstan in most regions is high;
Screening is not recommended as results do not change management (2a);
Fetal damage varies widely - from an asymptomatic course to damage only to the skin, in severe cases - damage to the eyes, nervous system, generalized forms;
• the risk of infection of the newborn is high in case of primary infection of the mother immediately before delivery (up to 2 weeks) (risk up to 30-50%) - it is necessary to offer delivery by CS;
Very low risk for recurrent infection<1-3%) - рекомендовано родоразрешение через естественные родовые пути;
· herpetic infection is not an indication for hospitalization of women. Women who are found to have the active form during childbirth should practice personal hygiene when in contact with the baby, and should not pick up another baby. No insulation required.

Syphilis
· prevalence in the population varies considerably in different regions, but remains relatively high;
· screening is offered to all women twice during pregnancy (at registration and at 30 weeks) (2a);
· Patients with syphilis are at high risk of other STIs, so they should be offered additional testing;
treatment - penicillin, can be done on an outpatient basis;
a woman who has received an adequate course of treatment for syphilis does not need to be isolated from other women and does not pose a risk to her child;
· consultation, treatment and control - at the venereologist.

Tuberculosis
When infected in the neonatal period - a high risk of mortality;
active form of tuberculosis - an indication for treatment (isoniazid, rifampicin, pyrazinamide and ethambutal). These drugs are safe for pregnant women and for the fetus;
streptomycin, ethionamide and protionamide should be excluded because of their danger;
It is necessary to inform the expectant mother about the management of the postpartum period:
- isolation from the child is not required;
- breastfeeding is possible, the use of all anti-tuberculosis drugs during breastfeeding is not dangerous;
- it is necessary to continue the full course of treatment of the mother;
- the child will have to receive preventive treatment;
· it is necessary to have information about the living conditions of the unborn child, the presence of people living in the same apartment or house with an active form of tuberculosis for timely measures when a newborn is discharged from the maternity ward.

Appendix C

Woman's weight. Measuring weight gain at each visit is unreasonable, and it is not necessary to advise women to make dietary restrictions to limit weight gain.

Pelvimetry. Routine pelvimetry is not recommended. Neither clinical nor radiographic pelvimetry data has been shown to be of sufficient predictive value to determine mismatch between the size of the fetal head and maternal pelvis, which is best detected by careful observation of the course of labor (2a).

Routine auscultation of the fetal heart has no predictive value, since it can only answer the question: is the child alive? But in some cases, it can give confidence to the patient that everything is fine with the child.

Counting fetal movements. Routine scoring results in more frequent detection of decreased fetal activity, more frequent use of additional methods for assessing the condition of the fetus, more frequent hospitalizations of pregnant women and an increase in the number of induced births. Of greater importance is not the quantitative, but the qualitative characteristics of fetal movements (1b).

Preeclampsia.
- The risk of developing pre-eclampsia should be assessed at the first visit to determine an appropriate schedule for antenatal visits. Risk factors for more frequent visits after 20 weeks include: first upcoming first birth, age over 40; history of preeclampsia in close relatives (mother or sister), BMI >35 at first visit, multiple pregnancies, or existing vascular disease (hypertension or diabetes)
- Whenever blood pressure is measured during pregnancy, a urine sample should be taken to determine proteinuria
- Pregnant women should be informed about the symptoms of severe preeclampsia, as their presence may be associated with worse outcomes for mother and child (headache, blurred vision or flickering in the eyes; moderate or severe pain under the ribs; vomiting; rapid onset of swelling of the face, hands and feet)

Routine ultrasound in the second half of pregnancy. A study of the clinical relevance of routine ultrasound examinations in late pregnancy found an increase in antenatal hospitalization and induced labor without any improvement in perinatal outcomes (1b). However, the feasibility of ultrasound in special clinical situations has been proven:
- in determining the exact signs of vital activity or death of the fetus;
- when assessing the development of a fetus with suspected IUGR;
- when determining the localization of the placenta;
- confirmation of the alleged multiple pregnancy;
- assessment of the volume of amniotic fluid in case of suspicion of poly- or oligohydramnios;
- clarification of the position of the fetus;
- in procedures such as the imposition of a circular suture on the cervix or external rotation of the fetus on the head.

Doppler ultrasound of the umbilical and uterine arteries. Routine Doppler ultrasonography of the umbilical artery should not be offered.

Stress and non-stress CTG. There is no evidence for the use of antenatal CTG as an additional check for fetal well-being in even high-risk pregnancies (1a). In 4 studies evaluating the impact of routine CTG, identical results were obtained - an increase in perinatal mortality in the CTG group (3 times!), with no effect on the frequency of caesarean sections, the birth of children with a low Apgar score, neurological disorders in newborns and hospitalization in the neonatal ICU. The use of this method is indicated only with a sudden decrease in fetal movements or with prenatal bleeding.

APPENDIX E
GRAVIDOGRAM

Maintaining a gravidogram is mandatory at each visit in the second and third trimester. The gravidogram shows the height of the uterine fundus (VDM) in cm (on the vertical axis) corresponding to the gestational age (on the horizontal axis). A graph of changes in VDM during pregnancy is being built. It is important not to find the measured height of the bottom of the uterus between the lines, but to parallel them.

APPENDIX E

Birth plan

(To be completed with the health worker)
My name _______________________________________________
Expected due date __________________________________________
Name of my doctor _______________________________
My child's doctor will be _________________________
The support person during childbirth will be ________________

These people will be present at the birth of ______________________

__ Antenatal education in PHC

Activities for dads
__ Maternity hospital

__ Antenatal courses beyond PHC

Do you want to tell anything additional about yourself (important points, fear, concern) _____________________________________________________________

My goal:
__ So that only people close to me and a nurse support and reassure me
__ To provide medical pain relief in addition to support and comfort
__ Other, explain ___________________________________

__ First stage of labor (contractions)
Please check which comforting measures you would like your midwife to offer you during labour:
__ Put on your own clothes
__ Walk
__ Hot/cold compress
__ Lots of pillows
__ Generic Orb Usage
__ Listen to my favorite music
__ Focus on your favorite subject
__ Massage
__ Epidural anesthesia

Birth of a child

Your midwife will help you find various comfortable positions in the second stage of labor. Which of the following would you like to try:
__ Upright position during childbirth
__ On the side
__ Don't want to use the obstetric chair

After the birth of my child, I would like:
__ For _______________ to cut the umbilical cord
__ Put the baby on my stomach right after birth
__ Wrapped in a blanket before handing it to me
__ Have your child wear their own hat and socks
__ To get my baby swaddled for the first time
__ To film or take photos during childbirth

Unexpected events during childbirth

If you need more information on the following, ask your doctor or midwife:
Forceps/vacuum extraction
__ Amniotomy
__ Episiotomy
__ Fetal monitoring
__ Labor induction
__ Rhodostimulation
__ Birth by caesarean section

From birth to discharge

Our obstetric department considers it necessary for mother and child to stay together for 24 hours. Health workers will support you and help you care for your child when he or she is in the same room as you.

I'm going to:
__ Breastfeed your baby
__ Give extra food or supplements to my baby

During my stay in the department, I would like to:
__ Be with your child at all times
__ To be present during my child's examination by a neonatologist
__ Be present during procedures for my child
__ To have a nurse show me how to bathe my baby
__ Bathe my baby by myself
__ Have my child circumcised
__ Have your child vaccinated with BCG and hepatitis B
__ Other_____________________________________________________________________________

The following people will help me at home

________________________________________________________

Your suggestions and comments

I would like to be visited after discharge from the hospital:
__ Yes. Who?________________________________
__ No
__ Not decided

Signature ___________________________ date _________________________________

Signature of the specialist who collected the information _________________________________

APPENDIX G

How to take care of yourself during pregnancy

· Taking good care of yourself during pregnancy will help you to maintain not only your own health, but also the health of your unborn child. As soon as you think that you are pregnant, immediately contact the antenatal clinic. If the pregnancy is confirmed and you are registered, see your doctor regularly according to the established schedule.
· Eat healthy foods (see below for more information). You will gain about 8-16 kg in weight, depending on how much you weighed before pregnancy. Pregnancy is not the time to lose weight.
· Sleep or rest when you need it. Don't exhaust yourself, but don't relax completely either. Each person's need for sleep is individual, but for most, eight hours a day is enough.
Do not smoke and avoid being around smokers. If you smoke, quit ASAP!
· Do not drink any alcoholic beverages (beer, wine, spirits, etc.). Of course, drugs are out of the question!
· Do not take any pills or other medicines other than those prescribed by your doctor. Remember that herbs and herbal tinctures/teas are also medicines.
· During pregnancy, you should also avoid strong and pungent odors (such as the smell of paint or varnish). Precautions should also be taken when handling household cleaners and detergents: read label instructions carefully and follow them, wear gloves and do not work in a poorly ventilated area.
· If you have a cat, ask someone in the family to clean her toilet, or be sure to use rubber gloves (there is a disease - toxoplasmosis, transmitted through cat feces and dangerous for pregnant women). In all other respects, your pets do not pose a danger to you and your child.
Physical exercise is good for both you and your child. If there are no problems (see below for a detailed list of problems), you can continue to do the same exercises as before pregnancy. Hiking and swimming are especially good and convenient ways to stay active, stimulate circulation, and control weight gain.
· Sexual relations during pregnancy are normal and safe for your health. They will not harm your child either. Don't worry if sexual desire has increased or decreased due to hormonal changes - this is also normal for each woman individually. There are several precautions you must take. As your belly will gradually increase in size, you may need to try different positions to find the most comfortable one. It is not recommended to lie on your back. If you have had a miscarriage or a premature birth in the past, your doctor may advise you to abstain from sexual intercourse. And if you have vaginal bleeding, pain or amniotic fluid begins to leak, exclude sexual contact and consult a doctor as soon as possible.
· Do not hesitate to ask your doctor or midwife for information and let them know if you feel unwell. Now is the time to get information about the benefits of breastfeeding and family planning methods for breastfeeding women.

Healthy food for you and your child
· Of course, good nutrition is important both for your health and for your child's growth and development. Healthy eating during pregnancy is just as important as healthy eating at any other time in a woman's life. There are no "magic" products that are especially necessary for the normal course of pregnancy. There are very few "forbidden" products. Of course, you should avoid foods that you are allergic to; try also to eat as little as possible sweets, fatty foods.
· In terms of structure, your meals should resemble a pyramid: the widest part, the "basis", consists of bread, cereals, cereals and pasta. You should eat these foods more than any other. Fruits and vegetables form the second largest essential food group. A third, even smaller group is made up of dairy products, as well as meat, bean eggs, and nuts. At the top of the pyramid are fats, oils and sweets, which are recommended to be eaten in minimal quantities. If you have any questions about a healthy diet, ask your doctor for help.
· Pregnant women need more iron and folic acid. Eat foods rich in iron (legumes, leafy green vegetables, milk, eggs, meat, fish, poultry) and folic acid (legumes, eggs, liver, beets, cabbage, peas, tomatoes). Also take vitamins and iron tablets if your doctor recommends them.
· If you do not have a very good appetite, eat small meals 5-6 times a day instead of 3 large meals.
· Drink eight glasses of liquid, preferably water, daily. Do not drink more than three glasses a day of caffeinated drinks (tea, coffee, cola) or drinks that are high in sugar. It is especially not recommended to consume tea and coffee with food (caffeine interferes with the absorption of iron).

Discomfort associated with pregnancy

Pregnancy is a time of physical and emotional changes. During certain periods of pregnancy, many women experience some discomfort. Don't worry. These are common problems that will go away after the baby is born. The most common inconveniences are:
Frequent urination, especially in the first three and last three months.
Increased fatigue, especially in the first three months. Get plenty of rest, eat healthy foods, and do light exercise. This will help you feel less tired.
Nausea in the morning or at other times of the day often resolves after the first three months. Try to eat dry cookies or a piece of bread early in the morning. Avoid spicy and fatty foods. Eat little but often.
Heartburn may appear in the fifth month of pregnancy. To avoid it, don't drink caffeinated coffee or soda; do not lie down or bend over immediately after eating; sleep with a pillow under your head. If heartburn persists, seek advice from your doctor.
· You may experience constipation during pregnancy. Drink at least 8 glasses of water and other fluids a day and eat fiber-rich foods such as green vegetables and bran cereals. This amount of water will also help you avoid urinary tract infections.
The ankles or feet may swell. Raise your legs several times a day; sleep on your side to reduce swelling.
In the last 3-4 months of pregnancy, lower back pain may occur. Wear flat shoes, try not to lift heavy things; if you still have to lift weights, bend your knees, not your back.

Alarms

Call your healthcare provider right away if you have any of the following symptoms:
bloody discharge from the genital tract;
Abundant liquid discharge from the vagina;
constant headache, blurred vision with spots or flashes in the eyes;
sudden swelling of the hands or face;
temperature rise to 38º C or more;
severe itching and burning in the vagina or increased vaginal discharge;
Burning and pain during urination;
· severe abdominal pain that does not subside even when you lie down and relax;
more than 4-5 contractions within an hour;
· if you hurt your stomach during a fall, a car accident, or if someone hit you;
· after six months of pregnancy - if your baby makes less than 10 movements within 12 hours.

obstetric research. Methods of examination of pregnant women and women in childbirth

obstetrical research

METHODS OF EXAMINATION OF PREGNANT WOMEN AND WOMEN IN BIRTH

Purpose of the lesson: to study and practically master the methods of diagnosing pregnancy, examining pregnant women, various methods for determining the duration of pregnancy and childbirth.

The student must know: signs of pregnancy (doubtful, probable, reliable), changes in the size of the uterus depending on the duration of pregnancy, the size of the large pelvis, four external obstetric examinations, the concepts of "small segment", "large segment" of the fetal head, rules for listening to fetal heart sounds, rating scale maturity of the cervix, additional research methods: determination of chorionic gonadotropin, ultrasound diagnostics, cardiomonitoring.

The student must be able to: collect an anamnesis in a pregnant woman, conduct a general objective and special obstetric examination, including measuring the circumference of the abdomen, the height of the fundus of the uterus, the size of the large pelvis, the size of the pelvic outlet, determine the value of the true conjugate (4 ways to determine it), measure the circumference of the wrist joint, Frank size , dimensions of the lumbosacral rhombus (20 measurements), using four methods of external obstetric examination, determine the position, position and type, the presenting part of the fetus, the ratio of the presenting part of the fetus to the plane of the entrance to the small pelvis, listen to the fetal heart sounds and their frequency, conduct an internal obstetric examination, assess the degree of maturity of the cervix, determine the presenting part of the fetus, evaluate additional research methods (CG, ultrasound), determine the gestational age, the expected date of birth.

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.

-Reasons that forced a woman to seek medical help(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 anamnesis, detailed information is collected about previous pregnancies in chronological order, what is the current pregnancy, the course of previous pregnancies (whether there were any toxicosis, gestosis, 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 timing of their treatment.

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

-The course of this pregnancy (by trimester):

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

3rd 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 an exacerbation of existing diseases, decompensation, etc. An objective examination is carried out according to generally accepted rules, starting with an assessment of the general condition, temperature measurement, 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

A 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. Particular attention is paid to the size and shape of the abdomen, the presence of pregnancy scars (striae gravidarum), skin elasticity.

The study of the pelvis 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 for the correct course of 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, attention is paid to the entire pelvic area, but the lumbosacral rhombus (Michaelis rhombus) is of particular importance. 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 is of great importance in the management of childbirth. With a normal pelvis, the rhombus corresponds to the shape of a square. Its dimensions: the horizontal diagonal of the rhombus is 10-11 cm, the vertical one is 11 cm. With different narrowing of the pelvis, the horizontal and vertical diagonals will be of different sizes, as a result of which the shape of the rhombus will change.

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 articulation 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 size of the true conjugate can be judged by the vertical size of the sacral rhombus and the size of Frank. The true conjugate can be more accurately determined by the 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, is it 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. In the study 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 the largest part of it that passes through the entrance to the pelvis.

with this presentation. With an occipital presentation of the head, the border of its large segment will pass along the line of small oblique size, with anterior head presentation - along the line of its direct size, with frontal presentation - along the line of large oblique size, with facial presentation - along the line of vertical size. 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. In parturient women, a vaginal examination is performed upon admission to the obstetric institution, and after the outflow of 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 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. When examining childbirth, the degree of cervical smoothness (preserved, 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) are determined. In parturient women, a vaginal examination determines the condition of the fetal bladder (integrity, violation of integrity, degree of tension, amount of anterior 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 the lower edge of the symphysis (normally 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 the Solovyov index (0.1 from the Solovyov circumference) is up 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 the first degree of extension of the head (anterocephalic 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.

With the second degree of 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 the third degree of extension of the head (facial 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.

The head above the entrance to the small pelvis: with gentle pressure upwards with a finger, the head moves back and returns to its original position. The entire anterior surface of the sacrum and the posterior surface of the pubic symphysis are accessible to palpation.

The head is a 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.

The head in the cavity of the small pelvis: 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 made by the head. The posterior surface of the pubic symphysis is not accessible for palpation.

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

Matrikul - "Curation of a woman in labor.

1. Collect complaints. - Say hello and name yourself; - Have a friendly facial expression, soft tone of conversation. - Clarify how to contact the patient, establish contact; -Use correct questioning, especially regarding intimate details of the anamnesis; 2. Collect anamnesis (pay attention to menstrual, generative, sexual, secretory functions, the course of this and previous pregnancies, childbirth, somatic diseases). 3. -Explain the need for the survey, its purpose. - Explain the details of the examination, their safety, possible sensations at the same time. - Wash your hands, put on gloves. Before an external obstetric examination - warm your hands. Examination of a woman in labor (measuring body temperature, pulse, blood pressure, standing height of the fundus of the uterus, assessing the nature of lochia). 4. Examination of the mammary glands. 5. Determine the day of the postpartum period, possible postpartum complications. Planning and predicting the results of conservative treatment After establishing the diagnosis, when planning treatment, the doctor must: - With words, facial expressions, create an atmosphere of trust. - Communicate the need for each specific appointment. - Communicate expected results from each assignment. - Inform that the treatment will not bring unnecessary suffering to the patient, will not negatively affect one of the functions of the female body. - Assure the patient that all appointments will be completed in a timely manner, and she is required to carefully follow the recommendations. - Obtain informed consent from the patient for treatment. When reporting a treatment prognosis. - Follow the intonation of the voice, it should correspond to what you want to say. - With a favorable prognosis, express satisfaction, verbally and with a pleasant facial expression, intonation to convince the patient of this. - In case of an unfavorable prognosis, verbally encourage the patient to fight the disease, note each positive symptom. Intonations and facial expressions should not be emphasized optimistic, as this may cause distrust. - In case of aggressive behavior, behave calmly, verbally support every step of the patient, aimed at combating the disease. - Make sure that the patient does not have unclear questions. At the end of the conversation, re-emphasize the positive changes. Matrikul - "Curation of the pregnant." 1. -Say hello and name yourself; - Have a friendly facial expression, soft tone of conversation. - Clarify how to contact the patient, establish contact; -Use correct questioning, especially regarding intimate details of the anamnesis;

Collect complaints. 2. Collect anamnesis (pay attention to menstrual, generative, sexual, secretory functions, the course of this and previous pregnancies, childbirth, somatic diseases). 3. Examination of a pregnant woman. Explain the need for the survey, its purpose. - Explain the details of the examination, their safety, possible sensations at the same time. - Wash your hands, put on gloves. Before an external obstetric examination - warm your hands. - Conduct an examination of the pregnant woman (obstetric examination, measurement of the size of the pelvis, abdominal circumference, height of the uterine fundus, listening and assessing the fetal heartbeat, detecting edema). 4. Evaluation of additional laboratory and instrumental methods for examining a pregnant woman. 5. Define a birth plan. Planning and predicting the results of conservative treatment After establishing a diagnosis, planning treatment, the doctor must: - With words, facial expressions create an atmosphere of trust. - Communicate the need for each specific appointment. - Communicate expected results from each appointment. - Inform that the treatment will not bring unnecessary suffering to the patient, will not negatively affect one of the functions of the female body. - Assure the patient that all appointments will be completed in a timely manner, and she is required to carefully follow the recommendations. - Obtain informed consent from the patient for treatment. When reporting a treatment prognosis. - Follow the intonation of the voice, it should correspond to what you want to say. - With a favorable prognosis, express satisfaction, verbally and with a pleasant facial expression, intonation to convince the patient of this. - In case of an unfavorable prognosis, verbally encourage the patient to fight the disease, note each positive symptom. Intonations and facial expressions should not be emphasized optimistic, as this may cause distrust. - In case of aggressive behavior, behave calmly, verbally support every step of the patient, aimed at combating the disease. - Make sure that the patient does not have any unclear questions. At the end of the conversation, re-emphasize the positive changes. Matrikul - "Curation of a gynecological patient" 1. Collect complaints. - Say hello and name yourself; - Have a friendly facial expression, soft tone of conversation. - Clarify how to contact the patient, establish contact; -Use correct questioning, especially regarding intimate details of the anamnesis;

2. Collect anamnesis (pay attention to menstrual, generative, sexual, secretory functions, pregnancy, childbirth, somatic diseases). 3. -Explain the need for the survey, its purpose. - Explain the details of the examination, their safety, possible sensations at the same time. - Wash your hands, put on gloves. Conduct an examination of the skin, subcutaneous fat and mucous membranes, palpation of the lymph nodes, thyroid gland, abdomen, mammary glands). 4. Evaluation of the results of examination in the mirrors, bimanual examination, ultrasound data, bacteriological and bacterioscopic examination of secretions from the genital organs, the results of a smear on the "hormonal mirror", methods of functional diagnostics. 5. Diagnose a gynecological disease, draw up a treatment plan. Planning and predicting the results of conservative treatment After establishing the diagnosis, when planning treatment, the doctor must: - With words, facial expressions, create an atmosphere of trust. - Communicate the need for each specific appointment. - Communicate the expected outcome from each appointment. - Inform that the treatment will not bring unnecessary suffering to the patient, will not negatively affect one of the functions of the female body. - Assure the patient that all appointments will be completed in a timely manner, and she is required to carefully follow the recommendations. - Obtain informed consent from the patient for treatment. When reporting a treatment prognosis.

Follow the intonation of the voice, it should correspond to what you want to say. - With a favorable prognosis, express satisfaction, verbally and with a pleasant facial expression, intonation to convince the patient of this. - In case of an unfavorable prognosis, verbally encourage the patient to fight the disease, note each positive symptom. Intonations and facial expressions should not be emphasized optimistic, as this may cause distrust. - In case of aggressive behavior, behave calmly, verbally support every step of the patient, aimed at combating the disease. - Make sure that the patient does not have unclear questions. At the end of the conversation, re-emphasize the positive changes.

Childbirth rarely occurs unexpectedly. Usually, before their onset, a pregnant woman develops symptoms that are considered as harbingers of childbirth. These include the descent of the bottom of the uterus, the presenting part, the appearance of facilitated breathing, the discharge of thick viscous mucus from the vagina, the protrusion of the navel, the appearance of irregular pulling pains in the lower abdomen and in the lumbosacral region, turning into a feeling of a cramping nature.

The onset of labor is characterized by two signs: the secretion of mucus from the cervical canal and the appearance of pains of a cramping nature, which are called preparatory contractions and occur due to contraction of the muscles of the uterus. The onset of labor is evidenced by the appearance of strong, regular and prolonged contractions.

A pregnant woman is called a woman in labor during the entire time of childbirth.

Contractions are contractions of the uterus. They are involuntary, periodic and often painful. The intervals between them are called pauses.

Attempts are a contraction of the muscles of the uterus and at the same time rhythmic contractions of the abdominal muscles and diaphragm joining them.

Childbirth is divided into periods. The opening period is the time from the onset of regular contractions to the full opening of the uterine os. Contractions at the beginning of labor can last 6-10 seconds, at the end of labor their duration increases to 40-50 seconds or more, and the pauses between them are sharply reduced.

With head presentation of the fetus, normal pelvis size and good functional state of the uterus, part of the lower segment tightly covers the presenting part of the fetus, which leads to the separation of amniotic fluid into anterior and posterior.

Smoothing of the cervix and opening of the uterine os in primiparous and multiparous proceed differently. In primiparas, by the beginning of labor, the external and internal os are closed, and the cervical canal is preserved throughout its entire length. The process of opening the neck starts from the top. First, the internal os opens to the side, and the neck is somewhat shortened. After straightening the cervical canal, the neck is finally smoothed out, and only then does the external pharynx begin to open. Before the external pharynx opens, its edges gradually become thinner. Due to contractions, the uterine os opens completely and can be determined during vaginal examination in the form of a thin border.

In multiparous women, during the entire period of opening, the processes of smoothing and opening of the cervical canal occur simultaneously. At the height of one of the contractions, with full or almost complete opening of the uterine pharynx, the fetal membranes are torn and light (anterior) waters are poured out in an amount of 100-200 ml. If the fetal bladder opens before the full disclosure of the uterine pharynx, then it is customary to talk about the early outflow of amniotic fluid. The fetal bladder can burst even before the onset of labor - in this case, the outflow of water is called premature. Excessively dense membranes of the fetal bladder can lead to its belated opening.

Untimely discharge of amniotic fluid often entails a violation of the physiological course of childbirth and complications from the fetus. The duration of the opening period in primiparous is 12–18 hours (average 15 hours), in multiparous it is almost half as much, and sometimes it is only a few hours.

The period of exile begins with the onset of full disclosure of the uterine os and ends with the birth of the fetus. Contractions after the outflow of water usually weaken, the uterine cavity decreases somewhat in volume, its walls more tightly cover the fetus. Soon, contractions resume, and rhythmic contractions of the abdominal wall, diaphragm, and pelvic floor muscles (pulls) join them. Attempts, following one after another, increase intrauterine pressure, and the fetus, making a series of rotational and translational movements, gradually approaches the pelvic floor. The force of the attempts is aimed at expelling the fetus from the birth canal. Attempts are repeated after 5-4-3 minutes and even more often. There is a change on the part of the perineum, which, during attempts, begins to protrude. At the height of one of the attempts, the lower part of the head is shown from the genital slit. In the pause between attempts, the head hides behind the genital slit, and when the next attempt appears, it is shown again. This phenomenon is called head insertion and usually coincides with the end of the second moment of the labor mechanism - the internal rotation of the head. After some time, the head, moving towards the exit from the small pelvis, is even more shown from the genital gap during attempts. In the intervals between attempts, the head does not go back into the birth canal. This condition is called eruption of the head and coincides with the third moment of the mechanism of childbirth - extension of the head. The birth canal at this time is so dilated that the presenting part (most often the head) is born from the genital slit, and then the shoulders and trunk of the fetus. With the fetus, the back waters are poured out, mixed with a small amount of blood and a cheese-like lubricant.

The duration of the exile period in primiparous is 1-2 hours, in multiparous - from several to 30-45 minutes.

The afterbirth period covers the period of time from the moment of expulsion of the fetus to the birth of the placenta. The duration of the afterbirth period in both primiparous and multiparous is approximately the same (20–40 min). The succession period is characterized by the appearance of successive contractions, which lead to the gradual separation of the placenta from the walls of the uterus. The subsequent period is accompanied by physiological blood loss, which usually does not exceed 250 ml.

In some cases, in the pathological course of pregnancy and childbirth in the afterbirth period, severe bleeding, life-threatening, may occur. The nurse should know that active interventions are performed if the blood loss exceeds 400 ml, or the afterbirth period continues if there is no bleeding for more than 2 hours. It should be remembered that the woman in labor in the afterbirth period is not transportable.

A woman after the birth of the placenta is called a puerperal. The afterbirth period is replaced by the postpartum period.

In the first 2-4 hours after childbirth, dangerous complications can occur: hypotonic bleeding due to insufficient or poor uterine contraction, birth shock, etc. In this regard, the nurse carefully monitors the condition of the puerperal in the early postpartum period, especially in the next 2 hours after childbirth .

In some cases, the placenta may separate from the wall of the uterus, but not be separated from the birth canal. The separated placenta continues to remain in the uterus, thereby preventing its contraction. Therefore, without waiting for the expiration of the two-hour period, the separated placenta doctor removes with the help of external techniques, and the nurse provides the doctor with appropriate assistance (holds a sterile tray near the external genital organs of the woman in labor, shows the placenta if it is isolated, determines blood loss, etc.). Then they examine the external genital organs, including the vestibule of the vagina, the perineum, the walls of the vagina, and in primiparas, the cervix.

If tears are found, the nurse delivers the puerperal on a gurney to the dressing room for stitching.

The medical staff working in the postpartum department provides careful care for the puerperal, strictly observing the rules of asepsis and antisepsis. Only healthy women should be in the ward. Women in childbirth with fever, open seams, fetid postpartum discharge are transferred to a special obstetric department, where women in childbirth are under continuous medical supervision.

In the first 4 days, the room is cleaned up to 3-4 times a day, in the following days - in the morning and in the evening. The sister makes sure that the external genitalia of the puerperal are kept clean.

When washing, pay attention to the anus, where hemorrhoids often appear after childbirth. If the nodes are painful, an ice pack wrapped in a sterile diaper is applied to them, a candle with belladonna is injected into the rectum once a day. Large hemorrhoids, if they do not soon decrease and disappear, have to be set inward. They do this in a rubber glove with 1-2 fingers lubricated with petroleum jelly, in the position of the puerperal on her side.

To avoid infection of the newborn, do not allow it to come into contact with the mother's bed. For this, the child is placed on an oilcloth or a sterile diaper. The mother must prepare for feeding the child, her hands must be washed clean.

Particular attention should be paid to the care of the mammary glands. It is recommended to wash them with a solution of ammonia or warm water and soap in the morning and evening after feeding. The nipples are washed with a 1% solution of boric acid and dried with absorbent cotton, preferably sterile.

For small cracks in the nipples, sterile fish oil is used, the nipple and areola are lubricated with it, and the nipple is covered with cotton wool. Fish oil can be replaced with calendula ointment. It is recommended to powder the nipples with streptocide powder.

Parents must strictly observe the rules of personal hygiene. Especially important is the cleanliness of the body, underwear and bed linen, which must be changed every 4-5 days. If the mother sweats a lot, the underwear should be changed more often, especially shirts and sheets. It is also necessary to change bedding frequently, especially in the first days after childbirth. The strictest cleanliness of the ward, bed and all care items must be observed.

The sister makes sure that the sleep of the puerperal is sufficient, and that it is quiet in the ward. Particular attention is paid to the diet of puerperas. Nutrition should be varied, high-calorie, with a sufficient amount of vegetables and fruits. During the day, the puerperal should drink 0.5–1 l of milk.

If a woman complains of chills, headache, pain in the lower abdomen, etc., it is necessary to measure the temperature, count the pulse and inform the doctor about this.

A specially trained nurse or methodologist conducts physiotherapy exercises with puerperas in order to strengthen the abdominal muscles and pelvic floor.

If in the first days after childbirth a woman has impaired urination, then before catheterization of the bladder, one should try to cause independent urination: a warm bedpan is placed under the pelvis of the puerperal and waters the external genital organs with warm water.

With swelling of the external genital organs, they are covered with a sterile gauze pad, and an ice pack is placed on top.

In the first 3 days, bowel function may be difficult. In the absence of contraindications, you can put a cleansing enema.

The nurse is obliged to monitor the air temperature in the wards, which should not be higher than 18–20 °C.

Towels, pillowcases, linen sheets, etc. should be changed regularly. bed linen produced before wet cleaning of the room and at least an hour before feeding newborns. Tanks with an oilcloth bag with a tight-fitting lid are brought directly to the place of collection of dirty linen. It is strictly forbidden to throw laundry on the floor or into open laundry bins.

Every day, at least 3 times a day, it is necessary to carry out a wet cleaning of the floor, panels, hard inventory of the mother's wards, corridors and all utility rooms using a 0.15% solution of chloramine. For current disinfection, it is recommended to use not only chloramine, bleach, but also hydrogen peroxide with detergents for processing hard equipment, floors, panels. After wet cleaning, the wards are ventilated for at least 30 minutes, then irradiated with a bactericidal lamp.

The care of the puerperal woman in the presence of stitches on the perineum has its own characteristics. The toilet of the external genital organs of puerperas is carried out in the ward for 4–5 days of the postpartum period. Washing is done very carefully, since the area of \u200b\u200bthe seams cannot be wiped with cotton wool. The inner thighs and external genitalia are washed with a weak solution of potassium permanganate. The seams are treated with 5% tincture of iodine or sprinkled with streptocide, if raids appear on the seams, they should be washed with hydrogen peroxide and lubricated with 5% tincture of iodine once a day.