Types and methods of obstetric examination of pregnant women. What examinations does a pregnant woman undergo?
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 a burdened 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 a 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.
A study of the clinical significance of additional ultrasound methods 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:
- 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 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 different methods have been proposed, 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 of 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.
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);
sexual 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.
Examination of a pregnant woman 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 serves to determine the presenting part of the fetus (head, pelvic end) - To perform it, the obstetrician needs to take the thumb of the right hand as far as possible away from the other four, grasp the presenting part of the fetus and determine its mobility relative 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.
-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 onset, disease duration, treatment and outcome
-The course of this pregnancy (by trimester):
- 1 trimester (up to 12 weeks) - common diseases, pregnancy complications (toxicoses, threat of miscarriage, etc.), the date of the first visit to the antenatal clinic and the gestational age established at the first visit.
2nd trimester (13-28 weeks) - general diseases and complications during pregnancy, weight gain, blood pressure numbers, test results, date of the first fetal movement.
3 trimester (29 - 40 weeks) - total weight gain during pregnancy, its uniformity, results of blood pressure measurements and blood and urine tests, diseases and complications of pregnancy. reasons for hospitalization.
Determining due dates or gestational age
GENERAL OBJECTIVE EXAMINATION
A general objective study is carried out in order to identify diseases of the most important organs and systems that can complicate the course of pregnancy and childbirth. In turn, pregnancy can cause 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.
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 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, 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. With a normal pelvis, the rhombus corresponds to the shape of a square. Its dimensions: horizontal diagonal rhombus is 10-11 cm, vertical- 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 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 one. 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. 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. 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 a 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; the inner surfaces of the bone identification points are difficult to access for examination.
Attachment 1
medical and diagnostic
discipline manipulation
gynecology, obstetrics
by specialty
2-79 01 31 "Nursing"
2-79 01 01 "Medicine".
Examination of a pregnant woman and a woman in labor.
External examination of a pregnant woman.
Inspection often provides very valuable data for the diagnosis. On examination, attention is paid to the growth of the pregnant woman, physique, body weight, the condition of the skin, hairiness, the condition of the visible mucous membranes, mammary glands, the size and shape of the abdomen.
Indications: 1) examination of a pregnant woman, a woman in labor.
1. Remove outer clothing.
Pay attention to the growth of the pregnant woman. With a low height of 150 cm and below, women often show signs of infantilism (narrowing of the pelvis, underdevelopment of the uterus). In tall women, other features of the pelvis are observed (wide, male-type pelvis).
Pay attention to the physique of the pregnant woman, the development of subcutaneous fat, the presence of deformation of the spine, lower extremities, joints. Severe emaciation or obesity is often a sign of metabolic disorders, endocrine diseases.
Determine the color and purity of the skin and visible mucous membranes.
Paleness of the skin and visible mucous membranes, cyanosis of the lips, yellowness of the skin and sclera, swelling are signs of a number of serious diseases.
Examine the mammary glands, determine the shape of the nipples (convex, flat, retracted), the presence of discharge (colostrum) from the nipples.
Examine the abdomen, determine the shape, with the correct position of the fetus - an ovoid (ovoid) shape. With polyhydramnios, the spherical shape and size of the abdomen is greater than the corresponding gestational age. With the transverse position of the fetus, the abdomen takes the form of a transverse oval. The shape of the abdomen can change with a narrow pelvis (pendulous, pointed).
Examine the growth of hair on the genitals, the anatomical structure of the labia, the clitoris. Determine the type of hair growth: female or male.
Examine the Michaels rhombus. Determine its shape.
Determine the presence of edema on the lower extremities and other parts of the body.
The final stage.
10. Record the obtained data in medical documentation.
Weighing a pregnant woman.
A pregnant woman is weighed at each visit to the antenatal clinic. The normal weight gain of a pregnant woman is 300-350 grams per week.When controlling body weight, the pregnant woman is weighed in the same clothes on the same scales.
Indications: 1) determination of the body weight of a pregnant woman, control over weight gain.
Workplace equipment: 1) medical scales;
2) an individual card of a pregnant woman and a puerperal; 3) exchange card.
Preparatory stage of the manipulation.
1. Inform the pregnant woman about the need and essence
manipulation.
Before weighing, it is necessary to offer the pregnant woman to empty her bladder and intestines.
Check the balance of the scales by setting the weights on both scales to the zero position.
Adjust the balance, close the shutter.
The main stage of the manipulation.
5. The pregnant woman takes off her shoes and stands on the base of the scale, which
covered with oilcloth.
6. Open the shutter and, by moving the weights, balance the two
shooter.
The final stage.
7. Mark the readings of the scales, close the shutter.
8. After weighing, treat the oilcloth with a disinfectant
solution.
9. Wash your hands.
10. Write down the result in the medical documentation.
Measuring the circumference of the abdomen.
Indications: 1) determination of the gestational age and the estimated weight of the fetus.
Workplace equipment:1) measuring tape;
2) couch; 3) individual card of a pregnant woman;
4) individual diaper, 5) disinfectant.
Preparatory stage of the manipulation.
1. Inform the pregnant woman or the woman in labor of the need
2. Empty the bladder and intestines.
4. Wash your hands.
The main stage of the manipulation.
5. Apply a measuring tape around the abdomen: in front at the level
navel, behind - in the middle of the lumbar region.
The final stage.
7. Wash your hands.
8. Record the result in the individual card of the pregnant woman, history
disinfectant.
Determination of the standing height of the fundus of the uterus.
To determine the gestational age and determine the date of birth, the data of an objective examination are of great importance: determining the size of the uterus, abdominal circumference.
At 12 weeks of gestation, the fundus of the uterus reaches the upper edge of the pubic symphysis. At 16 weeks, the bottom of the uterus is located in the middle of the distance between the pubis and the navel (6-7 cm above the womb). At 20 weeks, the bottom of the uterus is 2 transverse fingers below the navel (12-13 cm above the womb). At 24 weeks, the bottom of the uterus is at the level of the navel (20-24 cm above the womb). At 28 weeks, the bottom of the uterus is two to three fingers above the navel (24-28 cm above the womb). At 32 weeks, the bottom of the uterus is in the middle of the distance between the navel and the xiphoid process (28-30 cm above the womb). At 36 weeks, the bottom of the uterus is at the level of the xiphoid process (32-34 cm above the womb). At 40 weeks, the bottom of the uterus is 28-32 cm above the womb.
Indications: 1) determination of the height of the uterine fundus.
Workplace equipment:1) measuring tape;
2) couch; 3) an individual card of the pregnant woman and the puerperal (history of childbirth); 4) individual diaper,
5) disinfectant.
Preparatory stage of the manipulation.
execution and essence of manipulation.
2. Invite the pregnant woman to empty her bladder and intestines.
3. Lay the pregnant woman on a couch covered with individual
diaper, on the back, straighten the legs.
4. Wash your hands.
The main stage of the manipulation.
5. Apply a measuring tape along the midline of the abdomen and
measure the distance between the upper edge of the symphysis and the most
protruding (upper) point of the fundus of the uterus.
The final stage.
6. Help the pregnant woman get up from the couch.
7. Wash your hands.
8. Record the result in the individual card of the pregnant woman and
puerperas (history of childbirth).
9. Put on gloves and process the centimeter tape
disinfectant.
External obstetric examination (4 appointments).
External obstetric examination refers to the main methods of examination of a pregnant woman. During palpation of the abdomen, the parts of the fetus, its size, position, position, presentation, the ratio of the presenting part of the fetus to the mother's pelvis are determined, the movement of the fetus is felt, and they also get an idea of the amount of amniotic fluid and the condition of the uterus.
Indications: 1) determination of the position of the fetus in the uterus.
Workplace equipment: 1) a couch covered with disinfected oilcloth; 2) an individual card of a pregnant woman and a puerperal (history of childbirth); 3) individual diaper.
Preparatory stage of the manipulation.
1. Inform the pregnant woman about the need to perform and
essence of manipulation.
joints.
3. Wash your hands.
4. Stand to the right of the pregnant woman facing her.
The main stage of the manipulation.
5. With the help of the first reception, the height of the uterine fundus is determined
and that part of the fetus that is at the bottom of the uterus.
To do this, the palms of both hands are located at the level of the fundus of the uterus,
fingers approach, gently pressing down
the level of standing of the fundus of the uterus and the part of the fetus, which
located at the bottom of the uterus.
6. Using the second technique, determine the position and type of position
fetus.
Both hands from the bottom of the uterus are moved downwards, placing them on the side surfaces. Palpation of the parts of the fetus is performed alternately with the right and left hand to determine in which direction the back of the fetus and its small parts are facing. The back of the fetus is defined by touch as a wide, smooth, dense surface. Small parts of the fetus are determined from the opposite side in the form of moving small parts (legs, handles). If the back is turned to the left - the first position. If the back is turned to the right, the second position.
7. With the help of the third method, the presentation of the fetus is determined.
The study is performed as follows: the right hand is needed
put a little above the pubic joint so that a large
If the fetal head completely fills the pelvic cavity, then
it is not possible to probe it with external methods.
The final stage.
9. Wash your hands.
10. The data obtained are noted in the individual card of the pregnant woman and the puerperal (history of childbirth).
Diagnosis of malpositions of the fetus
The transverse and oblique position of the fetus are incorrect positions and occur in 0.5 - 0.7% of the total number of births. In contrast to the longitudinal position, the fetal axis forms a straight or acute angle with the longitudinal axis of the uterus, the presenting part is absent. In childbirth with a transverse and oblique position of the fetus, serious and very life-threatening complications for the mother and fetus are possible - neglected transverse position of the fetus, rupture of the uterus, death of the mother and fetus. To prevent these complications, timely diagnosis of incorrect fetal positions is needed.
Indications: examination of a pregnant woman and a woman in labor to determine the position of the fetus.
Workplace equipment: 1) couch; 2) measuring tape; 3) obstetric stethoscope; 4) ultrasonic scanning apparatus.
Preparatory stage of the manipulation.
1. Inform the pregnant woman or the woman in labor of the need
execution and essence of manipulation.
2. Lay the pregnant woman (woman in labor) on the couch.
3. Examine the shape of the abdomen (pregnant, parturient): the shape of the abdomen in
in the form of a transverse or oblique ovoid, low standing of the uterine fundus.
4. Wash your hands.
The main stage of the manipulation.
Measure the height of the fundus of the uterus. In the transverse position of the fetus, the height of the uterine fundus is less than the corresponding gestational age.
Make a palpation of the abdomen of a pregnant woman (parturient woman).
the uterus is missing a large part of the fetus. At the second admission
external obstetric examination - large parts (head,
pelvic end) are palpated in the lateral sections of the uterus.
At the third and fourth reception over the bosom, the presenting part is not
determined
The fetal heartbeat is heard at the level of the navel on the left or right, depending on the position of the fetus.
During vaginal examination, the presenting part of the fetus is not determined. During childbirth, when the cervix opens, it is possible to feel the fetal shoulder, ribs, shoulder blade, and spine.
fetal head, that is, the position of the fetus.
When the pen falls out of the genital slit, the diagnosis of the transverse position of the fetus is beyond doubt.
11. You can clarify the position of the fetus with ultrasound
research.
The final stage.
12. Record the research data in the medical documentation.
Listening to the fetal heartbeat.
Auscultation is performed with an obstetric stethoscope mainly to detect fetal heart sounds after 20 weeks, which serve as a reliable sign of pregnancy. By listening to heart tones, they also find out the condition of the fetus, which is especially important during childbirth.
Currently, electrocardiography (ECG), phonocardiography (PCG) are also used to assess fetal cardiac activity. One of the leading methods for assessing the condition of the fetus is currently cardiotocography (CTG). Normal fetal heart rate is 120-160 beats per minute.
Indications: 1) determination of fetal heart rate
Workplace equipment: 1) obstetric stethoscope;
2) stopwatch; 3) couch; 4) cardiotocograph; 5) individual diaper.
Preparatory stage of the manipulation.
1. Inform the pregnant woman or the woman in labor of the need
execution and essence of manipulation.
2. Lay the pregnant woman on a couch covered with individual
3. Wash your hands.
4. Conduct an external obstetric examination to determine
position and presentation of the fetus.
The main stage of the manipulation.
5. Apply an obstetric stethoscope with a wide funnel to a bare
pregnant belly.
6. With occipital presentation, the fetal heartbeat is heard
below the navel: on the left - in the first position, on the right - in the second
positions. With breech presentation, the most pronounced
fetal heartbeat is audible above the umbilicus
fetal position on the left or right. With the transverse position of the fetus
- at the level of the navel, closer to the head.
7. When listening to the fetal heartbeat, you can catch the beat
abdominal aorta, large vessels of the uterus. They match the pulse
9. Monitoring the fetal heart activity using
cardiotocography. The pregnant woman is laid on the couch and carried out
external obstetric examination. to the ultrasonic receiver
contact gel is applied and placed on the mother's abdomen in
the best place to hear heart sounds. Fasten
belt and record for 40 minutes in the position of the patient
on the left side.
The final stage.
10. After the end of the examination, wipe the stethoscope with a rag,
moistened with a disinfectant solution.
11. Wash your hands.
12. Record the received data in the individual card of the pregnant woman
and puerperas (history of childbirth).
Measurement of the external dimensions of the pelvis. Solovyov index.
Measurement of the size of the large pelvis allows us to indirectly judge the size of the small pelvis, allows us to establish the degree of narrowing of the pelvis. Solovyov's index makes it possible to get an idea of the thickness of the bones of a pregnant woman. Normally, the Solovyov index is 14-16 cm. To determine the true conjugate, 9 cm is subtracted from the outer one. If the Solovyov index is more than 16 cm, the pelvic bones are thick, 10 cm is subtracted from the outer conjugate. If the Solovyov index is less than 14 cm, the bones the pelvis is thin, 8 cm is subtracted from the outer conjugate.
Indications: 1) measurement of the external dimensions of the pelvis;
2) measurement of the Solovyov index.
Workplace equipment: 1) couch; 2) tazomer;
3) measuring tape; 4) individual diaper;
5) disinfectant.
Preparatory stage of the manipulation.
1. Inform the pregnant woman or the woman in labor of the need
execution and essence of manipulation.
2. Place the patient on a couch covered with an individual
diaper, on the back, legs straightened.
3. Wash your hands.
4. Stand to the right of the woman, facing her.
5. Take the tazomer so that the scale is facing up, and large and
index fingers lay on the buttons of the tazomer.
6. With your index fingers, feel the points between which
measure the distance by pressing the buttons of the tazomer to them and mark
on the scale the value of the resulting size.
The main stage of the manipulation.
7. Distancia spinarum - the distance between the anterior superior spines
iliac bones. The buttons of the tazomer are pressed against the outer
edges of the anterior superior spines. Normally 25-26 cm.
8. Distancia cristarum - the distance between the most distant points
iliac crests. I move the buttons from the awns along
outer edge of the iliac crests until
determine the greatest distance, this will be
distance Cristarum. Normally 28-29 cm.
9. Distancia trachanterica - distance between large skewers
thigh bones. The most prominent points of the large trochanters are found (the patient is offered to turn the feet inward and outward) and the buttons of the pelvis are pressed. Normally 30-31 cm.
10. For measuring the longitudinal dimension (outer conjugate)
the pregnant woman should be laid on her side, the lower leg bent in
hip and knee joints, overlying - straighten.
11. The buttons of the tazomer are installed in the middle of the upper outer
edges of the symphysis and to the supracacral fossa on the back, which is located
under the spinous process of the fifth lumbar vertebra, which
corresponds to the upper corner of the Michaels rhombus - the size is equal to
The Solovyov-circumference index in the area of the wrist joint is measured with a centimeter tape. Normally, the Solovyov index is 14 cm.
The final stage.
13. Record the data obtained in the individual card of the pregnant woman
and childbirth.
14. Wash your hands,
15. Treat the tazometer with a ball dipped in a disinfectant
means.
Measurement of the dimensions of the pelvic outlet plane.
If during examination of a pregnant woman there is a suspicion of a narrowing of the pelvic exit, then the dimensions of this plane are determined. up to 11.5 cm.
The transverse size of the pelvic outlet is determined between the inner surfaces of the ischial tuberosities: it is 11 cm.
Indications: 1) measuring the dimensions of the pelvic outlet plane
Workplace equipment: 1) tazomer; 2) measuring tape; 3) gynecological chair; 4) medical couch;
5) individual diaper; 6) individual card of the pregnant woman and the puerperal; 7) history of childbirth.
Preparatory stage of the manipulation.
1. Inform the pregnant woman or the woman in labor of the need
execution and essence of manipulation.
2. Lay the pregnant woman on a gynecological chair covered with
disinfected oilcloth and individual diaper, on the back,
legs are bent at the hip and knee joints, divorced in
sides and as close to the stomach as possible.
3. Wash your hands.
The main stage of the manipulation.
To measure the direct size of the pelvic outlet, one button of the pelvis
coccyx. From the resulting size subtract 1.5cm (fabric thickness)
- we get the true distance.
The transverse dimension is measured with a centimeter tape or a pelvis with crossed branches. Feel the inner surfaces of the ischial tuberosities and measure the distance between them. To the obtained value, you need to add 1-1.5 cm, taking into account the thickness of the tissues located between the buttons and the buttocks.
The final stage.
Record the received data in the individual card of the pregnant woman,
Examination of the cervix with the help of mirrors.
This research method allows you to determine the shape of the cervix, the shape of the external pharynx, identify cyanosis of the cervix and vaginal mucosa (a likely sign of pregnancy), diseases of the cervix and vagina (inflammation, erosion, polyp, cancer), assess the nature of the discharge, examine the walls of the vagina.
Indications: 1) examination of gynecological patients;
2) examination of pregnant women and puerperas; 3) carrying out preventive examination.
Workplace equipment: 1) gynecological chair;
2) sterile gloves; 3) mirrors spoon-shaped Sims or folding Cuzco are sterile; 4) sterile diapers; 5) containers with a disinfectant; 6) an individual card of a pregnant woman and a puerperal (outpatient medical card), 7) rags.
Preparatory stage of the manipulation.
1. Inform the pregnant woman, the puerperal and the gynecological
patient about the need to fulfill and the essence of this
manipulation.
2. Invite the patient to empty her bladder.
3. Place the patient on the gynecological chair in the “on
back, legs bent at the hip and knee joints and
pulled apart."
4. Wash your hands and put on sterile gloves.
The main stage of the manipulation.
5. With the thumb and forefinger of the left hand, spread the large and
small labia.
6. Insert the Cusco speculum in a closed form longitudinally into the vagina
length of the genital slit along the back wall of the vagina halfway.
7. Then turn so that one sash is in front, the other is behind,
mirror handle - facing down.
8. Then press on the lock, move the mirror open
to the vaults so that the cervix is visible, and fix it.
9. Examine the cervix, determine the shape of the cervix, condition
external pharynx, position, size, color of the mucous membrane,
the presence of pathological processes. The walls of the vagina are examined
when removing mirrors
10. Spoon-shaped mirrors are first introduced with an edge along the back wall
means.
12. Wash your hands.
13. Record the data obtained in the history of childbirth or in
an individual pregnancy card.
14. Put on gloves and process the pelvis and gynecological chair
disinfectant.
Preparing a pregnant woman and a puerperal for an ultrasound scan.
Ultrasound scanning is a highly informative, harmless research method and allows for dynamic monitoring of the fetal condition.
In the first trimester of pregnancy:
1) early diagnosis of pregnancy (3-3.5 weeks);
2) monitor the growth and development of the fetus;
3) establish the symptoms of a threatened abortion
(hypertonicity); the state of the internal os and the length of the cervix;
4) determine the area of chorion detachment, determine
non-developing pregnancy;
5) determine multiple pregnancy;
6) determine hydatidiform mole and ectopic pregnancy.
In the second trimester of pregnancy:
diagnose fetal malformations and diseases: hydrocephalus, anencephaly, absence of limbs, intestinal obstruction, hernia of the anterior abdominal wall;
determination of the gestational age, hypo- and hypertrophy of the fetus when measuring the size of the head and body;
determination of the sex of the fetus.
AT third trimester of pregnancy:
determination of presentation and position, type of fetus;
by the size of the head and body of the fetus, determination of its mass.
assessment of the amount of amniotic fluid;
the condition of the scar on the uterus after a caesarean section;
the exact location of the placenta, the degree of maturity of the placenta;
measurement of the size of the pelvis, conjugates of the pelvis.
In the postpartum period:
monitoring of uterine involution;
detection of endometritis, remnants of placental tissue.
Indications:
1) examination of a pregnant woman, a woman in labor and a puerperal.
Workplace equipment: 1) ultrasonic device; 2) contact gel; 3) individual diaper; 4) couch; 5) an ultrasound examination form; 6) condom, 7) disinfectant, 8) rubber and cotton gloves.
Preparatory stage of the manipulation.
1. Inform a pregnant woman, a woman in labor or a puerperal about
the need to perform and the nature of the manipulation.
2. Lay an individual diaper on the couch.
3. Put the pregnant woman on couch on the back.
4. The anterior abdominal wall is lubricated with gel.
5. For transvaginal ultrasound, put on the vaginal probe
condom.
The main stage of the manipulation.
6. Moving the abdominal sensor along the abdomen and examine
screen image.
The final stage.
7. Help the pregnant woman get up from the couch.
8. Record the obtained data in the conclusion of the ultrasound
research
9. Treat the sensor with a disinfectant.
Determination of the expected due date and date of prenatal leave.
In accordance with the legislation in the Republic of Belarus, all working women are granted maternity leave at 30 weeks of pregnancy, lasting 126 days (70 days before childbirth and 56 days after childbirth). Women living in areas with radioactive contamination of 1 Ci / sq. km and above - from 27 weeks of pregnancy to 146 days. In case of complicated childbirth or the birth of two or more children, this allowance is paid for 140 and 160 calendar days, respectively.
Indications: 1) determination of the term of childbirth and the date of prenatal leave.
Workplace equipment: 1) medical couch;
2) measuring tape; 3) tazomer; 4) calendar;
5) an individual card of the pregnant woman and the puerperal (history of childbirth).
The main stage of the manipulation.
Determine the date of birth by menstruation. By the first day
obstetric months). Or from the first day of your last period
subtract 3 months and add 7 days.
2. Determine the date of birth by stirring. By the date of the 1st stirring
add 140 days for primiparas (20 weeks, 5 obstetric
months). In multiparous - 154 days (22 weeks, 5.5 months).
3. Determine the date of birth by the first appearance at the antenatal clinic.
This takes into account the data of an objective examination:
the size of the uterus, the volume of the abdomen, the height of the bottom
uterus, fetal length and fetal head size.
4. Determine the date of delivery according to the ultrasound data.
5. The date of maternity leave is determined by the same data.
Determination of protein in urine.
Proteinuria (the appearance of protein in the urine) is an important prognostic sign of late preeclampsia in pregnant women and kidney disease. There are qualitative and quantitative reactions to determine the protein in the urine. In the emergency room of the maternity hospital, the determination of protein in the urine is carried out by qualitative reactions to incoming pregnant women and women in childbirth.
Indications: 1) determination of protein in the urine of a pregnant woman, a woman in labor, a puerperal, a gynecological patient.
Workplace equipment: 1) 2 test tubes; 2) pipette;
3) 20% salicylic acid sulfate solution; 4) an individual card of a pregnant woman and a puerperal (history of childbirth); 5) gloves;
6) kidney-shaped tray.
Preparatory stage of the manipulation.
1. Inform the pregnant woman or the woman in labor of the need
execution and essence of manipulation.
2. Make a toilet of the external genital organs.
3. Offer a pregnant woman or a woman in labor to urinate in a tray.
4. Put on sterile gloves.
The main stage of the manipulation.
Sample with sulfosalicylic acid.
5. Pour 4-5 ml of filtered urine into a test tube and add 8-10 drops of sulfosalicylic acid.
6. In the presence of protein in the urine, a flocculent sediment or turbidity is formed.
The final stage.
7. Remove gloves, place in a container with a disinfectant
means.
8. Wash your hands.
9. Record the result in medical documentation.
10. Place the test tubes and the tray in a container with a disinfectant
means.
Appendix 2
to the Instructions for the execution technique
medical and diagnostic
"Nursing in obstetrics and
gynecology, obstetrics
by specialty
2-79 01 31 "Nursing"
2-79 01 01 "Medicine".
Physiological childbirth.
Sanitary treatment of the mother.
Indications: 1) treatment of the skin in order to prevent the development of purulent-inflammatory diseases in puerperas and newborns.
Contraindications: 1) bleeding; 2) the threat of abortion; 3) the threat of uterine rupture; 4) high blood pressure; 5) upon admission in the pressing period, the question of the amount of sanitization is decided by the doctor.
Workplace equipment: 1) an individual package for a woman in labor; 2) disposable machines 2pcs; 3) a bottle of liquid soap; 4) soap in disposable packaging; 5) Esmarch's mug; 6) couch; 7) oilcloth; 8) disinfected toilet pad; 9) scissors;
10) forceps; 11) sterile washcloth; 12) enema tip; 13) antiseptic; 14) iodine (iodonate solution 1%); 15) cotton swabs; 16) gloves.
Preparatory stage of the manipulation.
Inform the woman in labor about the need to perform and the essence of the manipulation.
Cover the couch with disinfected oilcloth.
Wash the hands.
The main stage of the manipulation.
Nails are cut on the hands and feet using disinfected scissors - 2 pcs.
We treat the armpits and genitals with liquid boiled soap using a cotton swab on the forceps and shave the hair with a disposable razor as prescribed by the doctor.
The midwife puts on gloves.
The midwife puts a cleansing enema (uses a one-time plastic tip or a sterile tip), after 5-10 minutes the woman in labor empties her intestines (do not rush her). Cover the toilet before use with a disinfected gasket. The midwife is present.
Remove gloves and wash hands.
After a bowel movement, the woman in labor takes a shower using an individual piece of soap and a washcloth (sterile). Be sure to wash your hair.
The woman in labor is dried with a sterile towel, puts on sterile underwear from the kit, disinfected slippers.
The external genital organs, the perineum are treated with an antiseptic agent for the prevention of pyoderma.
The final stage:
12. A mark is made in the history of childbirth about the sanitization carried out.
Determining the duration of contractions and pauses.
To assess the contractile activity of the uterus during childbirth, palpation control and objective methods of recording the contractile activity of the uterus using external and internal hysterography (tokography) are used, computer technology can be used, which makes it possible to obtain constant information about the contractile activity of the uterus.
Indications: 1) assessment of the contractile activity of the uterus during childbirth.
Workplace equipment: 1) stopwatch;
2) cardiotocograph; 3) couch; 4) individual diaper.
Preparatory stage of the manipulation.
Lay the woman in labor on the couch, covered with an individual diaper, on her back.
Wash the hands.
The main stage of the manipulation.
The subject sits on a chair near the woman in labor and puts his hand on the area of the uterine fundus.
The time is determined by the stopwatch. During which the uterus, which was previously soft and relaxed, will be hard, this is a fight. Using a stopwatch, the time during which the uterus is relaxed is recorded - this is a pause.
When registering the contractile activity of the uterus using external hysterography, we put the uterine sensor on the bottom of the uterus in the area of the best probing of contractions, we record for 40 minutes. Position on the left side.
The final stage.
Wash the hands.
Record the data obtained in the history of childbirth.
Preparation of the necessary drugs for labor pain relief in the first period.
Childbirth is usually accompanied by pain of varying severity. The strength of the pain sensation depends on the state of the central nervous system, individual characteristics and the attitude of the woman in labor to the upcoming motherhood. Pain during contractions is due to the opening of the cervix, hypoxia of the tissues of the uterus, compression of nerve endings, tension of the uterine ligaments.
Indications: 1) 1 stage of labor
Workplace equipment: 1) work table;
2) sterile disposable syringes; 3) tourniquet; 4) antiseptic;
5) sterile balls; 6) containers with a disinfectant;
7) medicines: diazepam (seduxen solution 0.5% -2.0), diphenidramine (dimedrol solution 1% -1.0), droperidol solution 0.25% -5.0, atropine sulfate solution 0.1% -1 -2 ml, trimeperidine (promedol solution 1% -2% -1.0), papaverine hydrochloride solution 2% -2.0, sodium hydroxybutyrate solution 20%, moradol 0.025-0.03 mg / kg, tramadol (tramal 50- 100mg/in/muscularly); no-shpa 2.0.
8) for regional and local anesthesia prepare:
2% lidocaine solution, 0.5% anecaine solution 20.0,
0.25% -0.5% solution of butevacaine, procaine (0.5% solution of novocaine - 200.0).
Preparation of everything necessary for the delivery and treatment of the newborn.
When taking delivery and processing a newborn, it is very important to comply with measures to prevent nosocomial infections in accordance with the orders of the Ministry of Health of the Republic of Belarus.
Indications: 1) childbirth.
Workplace equipment:
1) alcohol iodine 5%; 2) iodine (iodonate 1%); 3) sterile vaseline oil; 4) sodium sulfacyl solution 30%; 5) ethyl alcohol 70°;
6) sterile forceps in a kraft bag; 7) 5% potassium permanganate solution;
8) antiseptic; 9) disinfectant;
10) glasses; 11) apron; 12) delivery bed;
13) sterile oilcloth; 14) a sterile delivery kit is disposable; 15) a jug for washing women in labor;
16) obstetric stethoscope; 17) apparatus for measuring blood pressure;
18) graduated flask for measuring blood loss during childbirth;
19) ice pack; 20) disposable sterile children's catheter;
21) electric pump; 22) electronic scales;
23) filled dropper with isotonic sodium chloride solution 0.9% -400.0;
24) bix for childbirth, which should include a kit for a woman in labor (sterile shirt, mask, scarf, shoe covers), a kit for primary treatment of the umbilical cord (2 trays, 3 hemostatic clips, 2 sticks with cotton wool, scissors, 6 gauze wipes, pipette, catheter), umbilical cord secondary treatment kit (sterile cotton balls, 2 cotton swabs, silk ligature, centimeter tape, scissors), newborn swaddling kit (3 sterile diapers, blanket), midwife kit (sterile cap, mask, gown, gloves), a set with bracelets and a medallion (2 sterile bracelets, 1 medallion);
25) disposable sterile umbilical cord bracket;
26) methylergometrine solution 0.02% 1 ml, oxytocin 1 ml, isotonic sodium chloride solution 0.9% -400.0; 27) enameled basin;
28) wooden sticks with cotton.
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 a family history, one should highlight the presence of diabetes mellitus, hypertension, tuberculosis, mental and oncological diseases, multiple pregnancies in relatives, the presence of children with congenital and hereditary diseases in the family. The obstetric and gynecological history includes information about the characteristics of the 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, medications taken, 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. They measure blood pressure on both hands, examine the condition of the heart, respiratory organs, thyroid and mammary glands, liver, and 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, assess the size of the fetal egg, embryo, fetus, determine 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, prevent the occurrence of possible complications during 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 particular importance of early initiation of therapy in 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 of fetal hemolytic disease. 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 risk of congenital anomalies, so it is advisable to recommend termination of pregnancy.
Rubella screening appears to be useful because negative tests can warn the patient that contact with an infected person is dangerous for her infant and suggest 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 identified as a high-risk group for the possibility of having 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 of 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 of the thyroid gland, mammary glands, auscultation of the heart and lungs, examination of the abdomen and limbs, examination by a dentist Gynecological examination: bimanual vaginal examination, cytological analysis of vaginal discharge and smears from cervical canal (diagnosis of chlamydia), determination of the configuration and size of the uterus and the condition of the appendages, external pelvimetry, examination of the cervix in the mirrors
