What examinations does a pregnant woman undergo? Types and methods of obstetric examination of pregnant women

Carrying out a certain set of studies in a pregnant woman makes it possible to predict the course of pregnancy and childbirth, possible complications and, therefore, timely conduct a correction aimed at reducing the risk of developing diseases in her and the fetus. This complex will include: a survey, an objective study of the functions of all organs, external and internal obstetric studies, clinical and laboratory studies.

Survey of a pregnant woman

The collection of anamnesis is carried out according to the following plan.

1. Passport data.

2. Diseases suffered in childhood, adulthood, their course and treatment.

3. Heredity.

4. Working and living conditions.

5. Epidemiological history.

6. Allergological history.

7. Obstetric and gynecological history:

Menstrual function (menarche and the establishment of the menstrual cycle, the duration, pain and regularity of menstruation, the amount of blood lost during menstruation, the date of the last menstruation);

sex life(at what age, married or not);

Gynecological diseases (what, when, the duration and nature of their course, the therapy performed, the results of treatment);

Generative function - the number of previous pregnancies with a detailed clarification of their course and outcome (artificial and spontaneous abortions, childbirth);

The current pregnancy (the first and second half of pregnancy, previous diseases and for how long, outpatient, inpatient treatment).

Objective research

Examination of a pregnant woman includes: examination of a pregnant woman, special obstetric examination (external and internal), clinical and laboratory studies.

Inspectionpregnant includes:

Anthropometric studies (assessment of physique, gait, shape of the abdomen, measurement of height and body weight);

Study of the functions of organs.

Special obstetric study aims to timely assess obstetric factors and resolve the issue of the possibility of conducting labor through the natural birth canal.

External obstetric examination includes the following.

1. Measurement of the circumference of the abdomen and the height of the fundus of the uterus, It is carried out starting from the 16th week of pregnancy at each appearance in the antenatal clinic, which allows you to clarify the correspondence of the height of the fundus of the uterus to the gestational age and timely diagnose polyhydramnios, multiple pregnancy, large fetus, fetal hypotrophy. In the horizontal position of the pregnant woman, the circumference of the abdomen is measured at the level of the navel and the height of the fundus of the uterus from the upper edge of the pubic joint.

2. Measurement of the external dimensions of the large pelvis (allows you to approximately judge the size and shape of the small pelvis) is carried out with a pelvis meter in the following sequence:

Distantia spinarum - the distance between the anterior superior iliac spines (normally 25-26 cm);

Distantia cristarum - the distance between the most distant points of the iliac crests (average is 28-29 cm);

Distantia trochanterica - the distance between the large skewers of the femur (usually 31-32 cm);

Conjugata externa - the distance between the upper edge of the pubic joint and the spinous process of the V lumbar vertebra, measured in the position of the pregnant woman on her side (normally 20-21 cm);

The direct size of the exit of the pelvis (normally 9.5 cm) is the distance between the middle of the lower edge of the pubic joint and the top of the coccyx, measured in the position of the pregnant woman on her back with legs divorced and half-bent at the hip and knee joints;

The transverse size of the outlet of the pelvis (normally 11 cm) is the distance between the inner surfaces of the ischial tubercles (the position of the pregnant woman is the same as when measuring the direct size of the outlet of the pelvis);

Rhombus of Michaelis - assessment of the shape of the rhombus, measurement of the vertical (normally 11 cm) and horizontal (normally 10 cm) of its diagonals (the woman stands with her back to the doctor);

Solovyov's index (gives information about the thickness of the pelvic bones) - the circumference of the wrist joint, which is measured with a centimeter tape (normally 14 cm);

The height of the symphysis (gives an idea of ​​the thickness of the pelvic bones, the measurement is carried out during a vaginal examination).

3. Receptions of Leopold - Levitsky. First reception allows you to determine the height of the fundus of the uterus in relation to the xiphoid process (the height of the fundus of the uterus corresponds to the gestational age) and the part of the fetus that is in the fundus of the uterus. The pelvic end is defined as a large, soft and non-balloting part of the fetus, the head is defined as a large, well-defined, dense balloting part. To do this, place the palms of both hands on the bottom of the uterus and determine the distance between the bottom of the uterus and the xiphoid process or navel, specify the part of the fetus in the bottom of the uterus.

Second reception external obstetric examination is aimed at determining the position, position and type of the fetus.

The position of the fetus is the ratio of the longitudinal axis of the fetus to the longitudinal axis of the uterus. The following positions are distinguished: a) longitudinal - the longitudinal axis of the fetus and the longitudinal axis of the uterus coincide; b) transverse - the longitudinal axis of the fetus crosses the longitudinal axis of the uterus at a right angle; c) oblique - the longitudinal axis of the fetus forms an acute angle with the longitudinal axis of the uterus.

The position of the fetus is the ratio of the back of the fetus to the right and left side of the uterus. In the first position, the back of the fetus (dense and wide surface) faces the left side of the uterus, in the second position, to the right.

View of the fetus - the ratio of the back of the fetus to the anterior (front view) or posterior (posterior view) of the uterine wall.

To perform the second Leopold-Levitsky technique, the palms of both hands of the obstetrician palpate the lateral sections of the uterus, determining the position of the fetus and the location of its back.

Third reception external obstetric examination is used to determine the presenting part of the fetus (head, pelvic end) - To perform it, the obstetrician needs thumb take the right hand as far as possible away from the other four, grasp the presenting part of the fetus and determine its mobility in relation to the plane of entry into the small pelvis.

Fourth reception allows you to determine the level of standing of the presenting part. During pregnancy, the fetal head may be mobile or pressed against the entrance to the small pelvis. This technique is especially important for assessing the progress of the fetal head through the birth canal during childbirth.

4. Auscultation. Fetal heart sounds are heard from the gestational age of 20 weeks in the primiparous and from the 18th week in the multiparous. Auscultation is carried out at each appearance of the pregnant woman in the antenatal clinic, the frequency, rhythm and sonority of the fetal heart tones are assessed (normally, the heartbeat is 120-160 beats / min, clear, rhythmic).

Internal obstetric research carried out when taking a dispensary registration for pregnancy and during hospitalization in the antenatal department with a complicated course of pregnancy or to prepare for childbirth. It is performed in order to assess the condition of the soft birth canal, structural features of the bone pelvis, the nature of the presenting part, as well as to resolve the issue of the method and timing of delivery. The research includes:

Examination and evaluation of the external genital organs (type of pubic hair growth - male or female, correct development of the labia majora and minor, the presence of pathological changes, scars in the vulva and perineum);

Examination using mirrors (valve and spoon-shaped) with an assessment of the shape of the external os of the cervix, the color of the mucous membrane of the vagina and cervix, pathological changes and the nature of the discharge;

Vaginal examination (finger) (according to indications at any stage of pregnancy).

A vaginal examination in the early stages of pregnancy allows you to set the gestational age and identify the pathology of the internal genital organs. In this case, the state is sequentially evaluated:

Vaginas - narrow (in a woman who has not given birth) or capacious (in a woman who has given birth);

Cervix - length, consistency, shape (conical in primiparous and cylindrical in multiparous), the state of the external pharynx (the external pharynx is closed in primiparous and passes the fingertip in multiparous);

Uterus - position, gestational age in weeks, consistency (soft), its mobility and pain on palpation; in the early stages of pregnancy, a ridge-like protrusion on the anterior surface of the uterus along the midline (Genter's sign), asymmetry of the uterus due to the protrusion of one of its corners (Piskachek's sign), contraction and compaction of the uterus on palpation (Snegirev's sign) can be detected;

Adnexa of the uterus (size, consistency, soreness);

Vaults of the vagina (high, free);

bone pelvis (reachability of the cape, pelvic deformities, exostoses).

Vaginal examination during full-term pregnancy makes it possible to establish the degree of readiness of the soft birth canal for childbirth. When performing the study, the state is consistently assessed:

Vagina (narrow or capacious, the presence of pathological changes);

The cervix with the determination of the degree of its "maturity" (Table 1);

The fetal bladder (its presence or absence); presenting part and its relation to the planes of the pelvis;

the oblique pelvis - the height of the symphysis, the presence of bony protrusions and deformities, the shape and depth of the sacral cavity, the reachability of the cape and the measurement of the diagonal conjugate (normally the cape is not reached).

SURVEY OF A PREGNANT WOMAN AND WOMAN

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

General history

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

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

-Working and living conditions.

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

Special history

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

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

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

- Age and health of the husband.

-Childbearing (generative) function. In this part of the 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 birth (duration of labor, surgical interventions, gender, weight, fetal growth, its condition at birth, length of stay in maternity hospital) And postpartum periods, complications, methods and terms of their treatment.

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

-The course of this pregnancy (by trimester):

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

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

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

Determining due dates or gestational age

GENERAL OBJECTIVE EXAMINATION

General objective examination is carried out in order to identify diseases 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 skin and visible mucous membranes. Then the organs of blood circulation, respiration, digestion, urinary, nervous and endocrine systems are examined.

SPECIAL OBSTETRIC EXAMINATION

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

EXTERNAL OBSTETRIC EXAMINATION

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

INTERNAL (VAGINA) EXAMINATION

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

An internal examination begins with an examination of the external genitalia (hair growth, development, swelling of the vulva, varicose veins veins), perineum (its height, rigidity, the presence of scars) and the vestibule of the vagina. The middle and middle phalanges are inserted into the vagina. index finger and examine it (lumen width and length, folding and extensibility of the vaginal walls, the presence of scars, tumors, partitions and other pathological conditions). Then the cervix is ​​found and its shape, size, consistency, degree of maturity, shortening, softening, location along the longitudinal axis of the pelvis, patency of the pharynx for the finger are determined. In the study during childbirth, the degree of smoothness of the neck is determined (saved, shortened, smoothed), the degree of opening of the pharynx in centimeters, the condition of the edges of the pharynx (soft or dense, thick or thin). In parturient women, a vaginal examination 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 Solovyov index(0.1 from Solovyov's circumference) to 1.4 cm, then 1.5 cm is subtracted from the size of the diagonal conjugate, and if more than 1.4 cm, then 2 cm is subtracted.

Determination of the position of the fetal head during childbirth

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

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

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

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

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

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

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

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

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

I The trimester of pregnancy is decisive in predicting its outcome for the mother and fetus, therefore, an in-depth examination of the woman's health status and identification of prenatal risk factors is necessary.

The first examination is carried out at 8-14 weeks of pregnancy. Further, the schedule of mandatory examinations includes the terms of gestation: 20-24 weeks, 36-38 weeks, 40-41 weeks.

The main tasks of the survey in I trimester the following:

Establishing the presence of pregnancy, determining its duration, the date of the expected birth. If necessary, the question of the duration of pregnancy is decided taking into account the ultrasound data.

Examination of the health status of a pregnant woman to identify risk factors for the development of maternal and fetal complications. After the first examination by an obstetrician-gynecologist, the pregnant woman is sent for examination to a therapist who examines her twice during pregnancy (in the early stages and at 30 weeks of pregnancy). The pregnant woman is also consulted by other specialists (dentist, ophthalmologist, otorhinolaryngologist and, if indicated, by other specialists).

Deciding on the possibility of maintaining or recommending termination of pregnancy if it threatens life or poses a danger of the birth of a sick handicapped child.

Drawing up an individual examination plan and conducting an algorithm for prenatal monitoring.

Prevention and treatment of complications during pregnancy.

At the first communication between a doctor and a pregnant woman, the following is necessary:

1. Reveal:

Features of the anamnesis (family, gynecological, obstetric). When reviewing the family history, one should highlight the presence of relatives diabetes, hypertension, tuberculosis, mental, oncological diseases, multiple pregnancy, the presence in the family of children with congenital and hereditary diseases. Obstetric and gynecological history includes information about the features menstrual cycle, the number of pregnancies, the intervals between them, the outcomes of childbirth, the weight of newborns, the development and health of children. We also need data on abortions and their complications, surgeries, gynecological diseases, and infertility. It is important to identify whether there were any laparoscopic operations, including the removal of myomatous nodes.

Past and concomitant diseases taken medications, the presence of allergies. It is necessary to obtain information about past diseases such as rubella, toxoplasmosis, genital herpes, cytomegalovirus infection, chronic tonsillitis, diseases of the kidneys, lungs, liver, cardiovascular, endocrine systems, oncological pathology, increased bleeding, operations, blood transfusion, allergic reactions.

The nature of work, lifestyle, bad habits, occupational hazards.

2. Conduct a general clinical and special (gynecological and obstetric) examination.

At the first examination of a pregnant woman, height, body type, body weight, and pelvic dimensions are assessed. Measure arterial pressure on both hands, examine the condition of the heart, respiratory organs, thyroid and mammary glands, liver, abdominal organs. A vaginal examination is mandatory (examination of the cervix and vagina with the help of mirrors, the size of the uterus, its consistency, tone, the area of ​​\u200b\u200bthe appendages).

At 10 weeks of gestation, blood pressure should be recorded. With the normal development of pregnancy, it should be in the range of 120/80-115/70 mm Hg. Art. The presence of hypertension during this period is the basis for an in-depth examination for renal pathology or the presence of hypertension, as well as the possibility of reduced production of PGE 2 (primary placental insufficiency). It is important at this time to identify the peak of CG secretion, confirming the function of the trophoblast.

3. Research: blood tests with the definition of the group, Rh affiliation, coagulogram, hematocrit, acetone level, ketone bodies (according to indications); as well as blood tests for HIV, RW , Hbs , HCV . A general urine test allows you to roughly judge the condition of the kidneys.

4. Conduct a study on the most common infections, which are leading in the formation of complications of pregnancy and the occurrence of congenital malformations. This group TORCH - infections (toxoplasmosis, rubella, cytomegalovirus, herpes, etc.). If antibodies to the rubella virus, CMV, toxoplasma are not detected, the patient is at risk for primary infection during pregnancy, which is especially dangerous for the fetus.

Based on the data obtained, there may be grounds for testing for diabetes, tuberculosis, syphilis, etc.

It is necessary to conduct bacteriological and virological examination of the vaginal contents. It is necessary to investigate not the translucent, but the parietal flora (scraping of the mucous membrane).

A screening ultrasound scan should be performed to clarify the gestational age, size assessment gestational sac, embryo, fetus, determining the number of embryos, as well as the length of the cervix and the size of the internal os if a threatened miscarriage is suspected.

Primary laboratory studies:

1. Clinical blood test.

2. General analysis of urine.

3. Coagulogram, antibodies to hCG, antibodies to lupus antigen.

4. Determination of glucose content in the blood.

5. Blood type, Rh -factor, determination of anti-Rhesus antibodies.

6. Serodiagnosis of syphilis, HIV infection, hepatitis.

7. Determination of antibody titer to rubella virus, toxoplasmosis.

8. Determination of the level of 17-KS (according to indications).

9. Examination for urogenital infection.

Determination of hemoglobin and hematocrit. According to WHO definition, anemia of pregnant women is considered to be a decrease in hemoglobin levels below 100 g / l, hematocrit - below 30%. In such cases, it is necessary to examine the pregnant woman to determine the cause of the disease.

The study of the middle portion of urine for the presence of protein, glucose, bacteria, leukocytes. If a pregnant woman has kidney disease, it is necessary to determine the prognosis of pregnancy for the mother and fetus, to prevent the occurrence possible complications with the development of pregnancy, prescribe appropriate therapy and, if necessary, hospitalize in a specialized hospital.

Coagulogram and determination of antibodies. The risk group for the presence of autoantibodies to phospholipids is the following category of women with a history of:

Habitual miscarriage of unknown origin;

intrauterine fetal death II and III trimesters of pregnancy;

Arterial and venous thromboses, cerebrovascular diseases;

Thrombocytopenia of unknown origin;

False positive reactions to syphilis;

Early toxicosis, preeclampsia;

Retardation of intrauterine development of the fetus;

Autoimmune diseases.

In the presence of antiphospholipid antibodies in I trimester of pregnancy is determined by hyperfunction of platelets. The degree of hypercoagulability of the plasma link of hemostasis increases. As a result of platelet hyperfunction and hypercoagulation of the plasma link of hemostasis, thrombosis and heart attacks occur in the placenta, markers of activation of intravascular coagulation - PDF and soluble complexes of fibrin monomers are determined. All these disorders can lead to thrombosis of the vessels of the placenta and death of the fetus.

It is necessary to emphasize the importance early start therapy of patients with APS due to the damaging effect of lupus antigens on the vessels of the placental site. The detected disorders of the hemostasis system are an indication for the use of antiplatelet agents and anticoagulants against the background of glucocorticosteroid therapy. For the relief of hemostatic disorders, it is prescribed from 9-10 weeks of pregnancy and later:

Prednisolone or metipred 2.5-5 mg / day;

Curantyl 75.0 mg/day one hour before meals;

Trental 300.0 mg/day;

Fraxiparine 0.3 ml 2 times subcutaneously or small doses of heparin from 10,000 to 30,000 IU / day (the duration of heparin therapy is determined by the severity of hemostasiological disorders).

This treatment regimen is optimal for gestation periods up to 20 weeks and can be used repeatedly until delivery.

Control of the hemostasis system is carried out 1 time in 2 weeks.

With autosensitization to hCG or pregnancy proteins associated with hCG, hemostasis disorders in I trimester are also expressed, which is an indication for heparin therapy.

Determination of glucose content in the blood. All pregnant women undergo a scanning study to detect diabetes by determining the concentration of glucose on an empty stomach and 1 hour after taking 50 g of glucose. If the fasting blood glucose level is above 5.00 mmol / l, one hour after taking 50 g of glucose - more than 7.77 mmol / l, as well as in the presence of risk factors (glucosuria, a family history of aggravated diabetes), a test for glucose tolerance.

Determination of the blood group, Rh -factor and anti-Rhesus antibodies. All pregnant women should undergo a blood test in order to timely identify Rh -isoimmunization, which is especially often the cause of the most severe forms hemolytic disease fetus. Other isoantibodies can also cause serious complications.

Serodiagnosis of syphilis, HIV infection, hepatitis. Seropositive women may be advised to terminate the pregnancy. The risk of vertical transmission of infection is at least 24%. The fetus becomes infected with syphilis II trimester.

Hepatitis B screening results may indicate that a newborn needs immunoglobulin and hepatitis B vaccine immediately after birth. The risk of transmission early in pregnancy is low.

Determination of antibodies to rubella virus and toxoplasmosis. Positive rubella serological test results due to primary infection during I trimester of pregnancy indicate a high degree risk congenital anomalies therefore, it is advisable to recommend termination of pregnancy.

Screening for rubella appears to be useful because negative tests it is possible to warn the patient that contact with an infected person is dangerous for her infant, and offer active immunization after delivery.

If a pregnant woman is diagnosed with acute toxoplasmosis, there may be a question of terminating the pregnancy for medical reasons. It should be noted that most of these women give birth to an infected child.

Determination of the level of 17-KS in daily urine, the level of GDEA to determine the source of hyperandrogenism. 17-CS is determined every 2-3 weeks to adjust the dose of dexamethasone. Monitoring the course of pregnancy in women with hyperandrogenism should be carried out taking into account the critical periods of pregnancy characteristic of this pathology: 13 weeks (testosterone release by the ovaries of the male fetus), 20-24 weeks (the beginning of hormonal production of the adrenal cortex), 28 weeks (ACTH release by the pituitary gland fetus).

In addition to dexamethasone, with the threat of termination of pregnancy in I trimester, it is advisable to use hCG at 1500 IU intramuscularly once a week. With combined and ovarian hyperandrogenism, severe hyperestrogenism, it is advisable to prescribe natural (but not synthetic) gestagen preparations. With adrenal hyperandrogenism, the appointment of gestagens is not justified, since in most cases there is an increased content of progesterone.

Examination for urogenital infection. Given the widespread prevalence of urogenital infection among the population in terms of preconception preparation and during pregnancy, it is necessary to conduct a laboratory examination for the presence of a sexually transmitted infection:

Examination of scrapings from the cervical canal and urethra by the method PCR for the presence of bacteriaChlamydia, Mycoplasma, Ureaplasma, family virusesherpesviridae - BUT and CMV;

Determination in blood serum by ELISA of antibodies of class M and G to C. Trachomatis, M. Hominis, HSV-1, HSV-2, CMV;

Microscopic examination of vaginal, cervical and urethral discharge.

Pregnant women with urogenital infection should be allocated to the group increased risk if possible, the birth of a child with intrauterine infection, morphofunctional immaturity and malnutrition.

echographic scan. Sonography is the most important tool for examining a pregnant woman and can be used according to clinical indications at any stage of pregnancy.

In early pregnancy, ultrasound is performed for:

Confirmation of pregnancy;

Clarification of the gestational age;

Clarification of the location of the fetal egg;

Detection of multiple pregnancy;

Exceptions of hydatidiform mole;

Exclusion of formations in the small pelvis or hormonally active ovarian tumors;

Diagnosis of uterine fibroids or ovarian formations that could interfere with the normal course of childbirth.

Ultrasound can detect:

Hypoplasia of the embryo;

Non-immune dropsy;

Cystic hygroma of the neck;

anencephaly;

spina bifida;

Cephalocele;

Choroid plexus cysts of the lateral ventricles of the brain;

Splitting of the hard palate;

polydactyly;

Diaphragmatic hernia;

sacrococcygeal teratomas;

agenesis of the kidneys;

Polycystic kidney disease;

Consolidated twins.

Ultrasound diagnostics are available:

Most of the defects of the limbs;

Hydronephrosis;

Polycystic kidney disease;

Gastroschisis (splitting of the anterior abdominal wall of the fetus);

Facial clefts;

Defects of the nervous system.

Generally accepted indications for medical genetic counseling and in-depth prenatal examination:

1. Late age parents (mothers aged 35 and over).

2. The presence in the anamnesis of a child with intrauterine malformations.

3. Hereditary diseases in the family.

4. Consanguineous marriage.

5. Occupational hazards (chemical production, radiation exposure and UVI).

6. Bad habits (alcohol, drugs).

7. Taking teratogenic drugs (antidepressants, tetracycline, codeine, antithyroid drugs, etc.).

8. Acute viral diseases during pregnancy.

9. The threat of termination of pregnancy from an early date.

10. Spontaneous miscarriages in history.

Invasive diagnostics. Indications for invasive methods of prenatal diagnosis in Itrimester (chorionic biopsy, amniocentesis, cordocentesis, placentocentesis):

The age of the pregnant woman is over 35;

Chromosomal aberrations in one of the spouses;

A history of a child with intrauterine malformations or chromosomal abnormalities;

The presence of congenital malformations or echomarkers of fetal developmental disorders;

Change in the level of AFP and HCG;

X-linked diseases in the family.

Invasive interventions are carried out with the consent of the pregnant woman under ultrasound control by a trained medical specialist in order to obtain fetal cells and determine the genetic state of the fetus based on them.

When terminating a pregnancy within 12 weeks, direct methods of genetic diagnosis are used, which are used during the prenatal examination of a pregnant woman.

A selected sample of fetal tissue after termination of pregnancy should be identified on the basis of cytomorphological examination.

Additional research methods (according to indications):

Hormonal;

Biochemical;

Immunological;

Hematological:

lupus anticoagulant,

API;

Invasive methods of prenatal diagnosis (amniocentesis, chorionic biopsy).

The volume of examination of pregnant women is presented in Table. 1 .

Table 1 . Standard for clinical and laboratory examination of pregnant women in I trimester Initial treatment (up to 12 weeks)

Physical examination: measurement of body weight, height, blood pressure (on both arms), palpation thyroid gland, mammary glands, auscultation of the heart and lungs, examination of the abdomen and extremities, examination by a dentist cervix in mirrors

Physical examination

See the chapter "Clinical methods of examination of pregnant women".

Laboratory research

When registering a pregnant woman, a general blood and urine test, determination of the group and Rh-affiliation of the blood, and determination of the level of glucose in the blood are mandatory.

If you have a history of stillbirth, miscarriage, extragenital diseases, you should:

Determine the content of hemolysins in the blood of a pregnant woman;
- to establish the blood type and Rh affiliation of the husband's blood, especially when determining the negative Rh; factor or blood group 0 (I) in a pregnant woman;
- conduct research on the presence of pathogens of urogenital infection by the method of quantitative PCR diagnostics;

To determine the excretion of hormones, indicators of immunoresistance, as well as all necessary research to judge the presence and nature of the course of extragenital diseases;
- for pregnant women with aggravated obstetric, family and gynecological history conduct medical genetic counseling.

In the future, laboratory studies are carried out in the following terms:

Complete blood count - 1 time per month, and from 30 weeks of pregnancy - 1 time per
2 weeks;
- general urinalysis - at each visit;
- blood test for AFP, hCG - at 16–20 weeks;
- blood glucose level - at 22–24 and 36–37 weeks;
- coagulogram - at 36–37 weeks;
- bacteriological (desirable) and bacterioscopic (required) examination of vaginal discharge - at 30 weeks

Infection screening (see chapter "Infection screening"). Most infections diagnosed during pregnancy, do not deserve special concern, since in most cases they do not affect the course pregnancy, the risk of intrauterine or intranatal infection. Therefore, those who lead pregnant woman, it is important not to impose unnecessary restrictions on pregnancy and not to waste the available resources.

When registering a pregnant woman, they are examined for syphilis (Wasserman reaction), hepatitis B and C, HIV infection. In addition, microscopic, microbiological and cytological examination is necessary. smears and scrapings from the vagina and cervix to detect STIs (gonorrhea, trichomoniasis, chlamydia).
- Retest for syphilis and HIV at 30 weeks and 2–3 weeks before delivery.

Additional research methods

An ECG is performed for all pregnant women at the first appearance and at 36–37 weeks, if there are special indications, if necessary.

Ultrasound during pregnancy is performed three times: the first, to exclude the pathology of the development of the fetal egg - on up to 12 weeks; the second, for the purpose of diagnosing fetal CM - for a period of 18–20 weeks; the third - for a period of 32-34 weeks.

Investigation of clinical significance additional methods Ultrasound in late pregnancy revealed an increase in antenatal hospitalizations and induced labor without any improvement outcomes.

The feasibility of ultrasound in special clinical situations has been proven:
- when determining exact signs life or death of the fetus;
- when assessing the development of a fetus with suspected IUGR;
- when determining the localization of the placenta;
– confirmation multiple pregnancy;
- assessment of the volume of AF in case of suspicion of a lot or oligohydramnios;
- clarification of the position of the fetus;
- with some invasive interventions.

· KTG. There is no evidence for the routine use of CTG in the antenatal period as a additional verification of the well-being of the fetus during pregnancy. This method is only shown for a sudden decrease in fetal movements or prenatal bleeding.

Assessment of fetal movement - a simple diagnostic method that can be used in a comprehensive assessment fetal status in high-risk pregnant women.

Subjective assessment of fetal movement. Pregnant women should be offered informal supervision of fetal movements for self-control. Deterioration of fetal movement during the day is an alarming symptom during pregnancy, which must be reported to the expectant mother at one of the first appointments (no later than the 20th weeks) so that she could orient herself in time and seek medical help.

Counting the number of fetal movements. Two various methods, but there is no data on advantages of one over the other.

– Cardiff Method: Starting at 9 am, the woman, lying or sitting, should concentrate on the movements of the fetus and record how long it takes for the fetus to make 10 movements. If the fetus has not made 10 movements to 9 evening, the woman should consult a specialist to assess the condition of the fetus.

– Sadowski method: within one hour after eating a woman should, if possible, lying down, focus on fetal movements. If the patient does not feel 4 movements within an hour, she should fix them within the second hour. If after two hours the patient has not felt 4 movements, she should contact a specialist.

Routine counting of fetal movements leads to more frequent detection of decreased fetal activity, more frequent use additional methods for assessing the condition of the fetus, to more frequent hospitalizations pregnant women and to an increase in the number of induced births. However, there is no data on the effectiveness of counting fetal movements to prevent late antenatal fetal death.

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

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

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

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

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

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

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

Methods of examination of pregnant women:

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

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

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

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

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

Clarification of basic passport data:

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

Husband details:

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

Collection of complaints:

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

Collection of anamnesis:

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

Heredity:

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

Information about past illnesses:

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

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

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

External obstetric examination:

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

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

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

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

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

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

Measuring the circumference of the abdomen:

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

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

Measurement of the standing height of the uterine fundus:

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

Receptions of external obstetric research of Leopold-Levitsky:

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

First take:

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

Second take:

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

Third take:

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

Fourth take:

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

Listening to the fetal heartbeat:

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

Observation of a pregnant woman in a antenatal clinic:

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

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

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

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

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

During pregnancy, the following laboratory tests are prescribed:

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

Twice during pregnancy, the examination is carried out:

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

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

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

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

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

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

Medical documentation:

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

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

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

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

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

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

Obligations of a midwife in a antenatal clinic:

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

Equipment of the gynecological office:

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

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

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

Patronage:

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

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