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Outdoor obstetric study. Conducting outdoor obstetric studies. Special obstetric examination

(Leopold techniques).

Equipment:phantom, doll, pellery, couch, individual map of pregnant and herds, childbirth story.

Preparation for manipulation:

  1. The midwife asks permission from the patient to carry out manipulation.
  2. The midwife informs the patient about the progress of the upcoming manipulation, its goals, tasks.
  3. The midwife washes his hands under the crane with soap 2-fold washing, dries, clothes gloves, it becomes the right of a pregnant woman.
  4. Pregnant lies on his back with his legs bent in her knees, stomach naked.

Execution of manipulation:

(obstetrics stands in the side face to face with a pregnant woman when performing I-III receptions)

First Research Reception:

  1. The midwife has both palms on the bottom of the uterus.
  2. An approximate palm, determines the height of the bottom of the uterus and part of the fetus, which is in the bottom of the uterus.

Second Research Research: Nurse moves palms on the side surfaces of the uterus. Palpation determines the position, position and view of the position of the fetus:

a) the left hand fixes the uterus on the right, the right hand is made palpation;

b) The right hand records the uterus on the left, and the left hand produces palpation.

Third Reception Research (performed by one hand):

  1. the obstetric puts (right) hand over the Lone of pregnant in such a way that the thumb is on one side of the predicate part, and four others - to another;
  2. carefully immerses the fingers deep into, covers and determines the prerequisite part of the fetus (head, buttocks, small parts, the lack of the pre-sector part) and its attitude to the entrance to the small pelvis.

Fourth Reception:

(The midwife stands on the side of the pregnant woman, face to her feet).

Note: Indicates the ratio of the prerequisite part of the fetus to the entrance to the small pelvis: the head is pressed, the head is a small segment in the inlet in a small pelvis, the head is a large segment in the inlet in a small pelvis, the head in the cavity of the small pelvis.

  1. Palm of both hands has on the lower segment of the uterus, fingertips reaching the symphysis.
  2. Caution with the elongated fingers slides along the predatory part towards the cavity of the pelvis, specifying the ratio of the predatory part to the entrance to the small pelvis and the height of its standing (the degree of insertion of the head in a small pelvis). Reception use when the head presence in childbirth.

Completion of manipulation:

Assessment of data obtained in the study:

  1. If in the bottom of the uterus the pelvic end of the fetus (I reception of Leopold), then the prevention of the fetus head.
  2. If the back of the fetus (II receive Leopold) on the left is the first position, on the right - the second position, the back is turned forward - the front view is drawn back - the rear view.
  3. If a dense rounded part is pretended, having clear contours - then the presence of the head. If the bulk-melted part is determined - pelvic preview. If the predatory part is not determined (absent) - the position of the fetus is transverse or oblique. With the transverse position of the fetus: the head on the left - I position, the head on the right - the II position.

the pecial obstetric examination includes three main sections: an outdoor obstetric study, an internal obstetric study, additional research methods. Outdoor obstetric research is produced by inspection, measurement, palpation and auscultation. Inspection allows you to identify the correspondence of the type of pregnant age. At the same time, pay attention to the growth of women, the physique, the condition of the skin, subcutaneous tissue, the mammary glands and nipples. Special attention is paid to the magnitude and shape of the abdomen, the presence of abortion scars (Striae Gravidarum), the elasticity of the skin.

The study of the pelvis is in obstetrics because its structure and dimensions have a decisive influence on the course and outcome of labor. Normal pelvis is one of the main conditions for the right flow of childbirth. Deviations in the structure of the pelvis, especially the decrease in its size, make it difficult for labor or represent irresistible obstacles for them. The study of the pelvis is produced by inspection, palpation and measuring its size. During the inspection, pay attention to the entire area of \u200b\u200bthe pelvis, but the lumbosacral rhombus (Mikhailisa rhombus) is made of particular importance. Mikhailisa Romby call the outline in the field of the sacrum, which have contours of a diamond area. The upper corner of the rhombus corresponds to an accelerable process of V lumbar vertebra, the lower - the tip of the sacrum (the place of the fatal of large butorous muscles), the side angles - the upper-back essays of the iliac bones. With an outdoor obstetric measurement study, a centimeter ribbon (the circumference of the ray-tank joint, the dimensions of the Mikhaelis rhombus, the abdominal circle and the height of the uterus above the Lone) and the obstetric circulation (pelvomer) in order to determine the size of the pelvis and its form Distantia Spinarum - the distance between the most remote dots of the reserved food SPINA ILIACA ANTERIOR SUPERIOR) - Equally 25-26 cm. Distantia cristarum - the distance between the most remote points of the scallops of the iliac bones (Crista Ossis Ilei) is equal to 28-29 cm.

Distantia TroChanterica - the distance between large slices of femoral bones (TroChanter Major) is equal to - 31-32 cm. Conjugata Externa (outer conjugate) - the distance between the spiny void vertebrae revolution and the top edge of the Lonatic joint - equals 20-21 cm. Diagonal conjugate (Conjugata Diagonalis) call the distance from the lower edge of the Symphysia to the most outstanding point of the Cape of the sacrum (13 cm). The diagonal conjugate is determined with a vaginal study of a woman who produce with one hand. The straight size of the outlet of the pelvis is the distance between the middle of the lower edge of the Lonic articulation and the top of the tailbone. During the examination, pregnant lies on the back with divorced and semi-bent in the hip and knee joints. Measurement is carried out with a pazer. This size equal to 11 cm, more than a true 1.5 cm due to the thickness of soft tissues. Therefore, it is necessary to subtract 1.5 cm from the obtained figure of 11 cm, we obtain the direct size of the exit from the cavity of the small pelvis, which is 9.5 cm. The transverse size of the pelvis exit is the distance between the inner surfaces of the stacked bumps. The measurement is carried out by a special pazer or a centimeter tape, which are applied not directly to the collapsed grouse, but to the tissues covering them; Therefore, it is necessary to add 1.5-2 cm to the resulting dimensions of 9-9.5 cm (thickness of soft tissues). Normally, the transverse size is equal to 11 cm. It is determined in the pregnant position on his back, her legs as much as possible to the stomach. Kosy sizes of the pelvis have to be measured in space pelvis. To detect asymmetry, the pelvis is measured by the following oblique dimensions: the distance from the front axle side of one side to the rear axes of the other side (21 cm); From the middle of the top edge of the Symphysia to the right and left-fledged ostera (17.5 cm) and from the surplus fossa to the right and left reserved ostery (18 cm). The sizes of one side are compared with the corresponding sizes of the other. With the normal structure of the pelvis, the magnitude of the paired sizes is the same. The difference exceeding 1 cm indicates the asymmetry of the pelvis. The side sizes of the pelvis are the distance between the front and the ass, the axes of the iliac bones of the same side (14 cm), measured it with a pazer. Side sizes should be symmetrical and at least 14 cm. With a lateral conjugate 12.5 cm, childbirth is impossible. The angle of inclination of the pelvis is the angle between the entrance plane in the pelvis and the plane of the horizon. In the pregnant position it stands it is 45-50 °. Determine with the help of a special instrument - a pelvic. First reception of outdoor obstetric studies. The first taking of Leopold Levitsky determine the height of the bottom of the uterus, its shape and part of the fetus, located in the bottom of the uterus. For this, the obster palm surfaces of both hands has in the uterus in such a way that they cover its bottom. The second reception of the outdoor obstetric study. The second reception is determined by the position of the fetus in the uterus, position and type of fetus. The obstever gradually lowers his hands from the bottom of the uterus on the right and left side of her and, gently pressed the palms and fingers of the hands on the side surfaces of the uterus, determines the back of the fetus on one side along its wide surface, on the other - small pieces of the fetus (knobs, legs). This technique allows you to determine the tone of the uterus and its excitability, forgive the round bundles of the uterus, their thickness, soreness and location.

The third reception of the outdoor obstetric study. The third reception is used to determine the prerequisite part of the fetus. Third reception you can determine the mobility of the head. For this, one hand covers the predatory part and determine the head is or a pelvic end, the symptom of running the fetus head.

The fourth reception of the outdoor obstetric study. This technique, which is a supplement and continuation of the third, allows you to determine not only the nature of the predatory part, but also the location of the head in relation to the entrance to the small pelvis. To perform this reception, the obstever becomes face to the legs of the surveyed, puts hands on both sides of the lower part of the uterus in such a way that the fingers of both hands seems to be with each other over the plane of the entrance to the small pelvis, and palprates the predatory part. In the study at the end of pregnancy and during childbirth, this technique determine the ratio of the predatory part to the planes of the pelvis. An internal obstetric study is performed by one hand (two fingers, index and middle, four-semi-head, with the whole hand). Internal study allows you to determine the predatory part, the state of the generic pathways, observe the dynamics of the cervixation of the uterus during childbirth, the mechanism of inserting and promoting the predatory part, etc. The internal study starts with an inspection of external genital organs (exhaust, development, edema of vulva, varicose veins), The perineum (its height, rigidity, the presence of scars) and the legitimacy of the vagina. The vagina is introduced phalanxes of medium and index fingers and produce its survey (width of the lumen and length, folding and extensibility of the walls of the vagina, the presence of scars, tumors, partitions and other pathological conditions). The uterine must then find and determine its shape, value, consistency, the degree of maturity, shortening, softening, the location along the longitudinal axis of the pelvis, the patency of the throat for a finger. In the study in childbirth, the degree of smoothing of the neck (preserved, shortened, smoothed), the degree of disclosure of the oz in centimeters, the state of the edges of the zea (soft or dense, thick or thin) is determined. In the guinea in the vaginal study, the state of the fetal bubble (integrity, integrity disorders, the degree of voltage, the amount of the water) is found out. Determine the predatory part (buttocks, head, legs), where they are located (above the entrance to a small pelvis, in the entrance of a small or large segment, in the cavity, at the output of the pelvis). Summary points on the head are the seams, spring, on the pelvic end - the crushes and the tailbone. Palpation of the inner surface of the pelvis walls allows you to identify the deformation of its bones, exotic and judge the pelvic capacity. At the end of the study, if the predatory part is high, measure the diagonal conjugate (Conjugata Diagonalis), the distance between the cape (Promontorium) and the lower edge of the symphysis (normally 13cm). For this, the fingers entered into the vagina are trying to reach the cape and the end of the middle finger relate to it, the index finger of the free hand is fed to the lower edge of the symphysis and mark on the hand the place that directly comes into contact with the lower edge of the lane arc. Then remove the fingers from the vagina, wash them. The assistant measures the marked distance with a centimeter ribbon or a pazer. In terms of diagonal conjugates, you can judge the size of the true conjugate

Survey of pregnant and girlfriend

The survey of pregnant and feminine is carried out by a specific plan. The survey consists of a common and special part. All data obtained is in a map of pregnant or in the history of childbirth.

General anamnesis

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

- The reasons forcing the woman to seek medical help(complaints).

- Working conditions and life.

- Heredity and transferred 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 intoxication, in particular, alcoholism and drug addiction in parents. It is important to obtain information about all infectious and noncommunicable diseases and operations transferred in early childhood during puberty and in adulthood, their flow and methods and treatment time. Allergic. Transferred hemotransphus.

Special anamnesis

- Menstrual function:the occurrence of menarche and the establishment of menstruation, the type and nature of menstruation (3 or 4-week cycles, duration, the amount of lost blood, the presence of pain, etc.); whether menstruation changed after the start of sexual life, childbirth, abortion; Date of the latter, normal menstruation.

- Secretor function: character of the discharge from the vagina, their number, color, smell.

- Sexual function:from what age is the beginning of a sex life, what a marriage in the account, the duration of marriage, the period from the beginning of sexual life before the first pregnancy, the time of the last sexual intercourse.

- Age and health husband.

- Children's (generative) function.In this part of the history collect detailed information about previous pregnancies in the chronological sequence, which is a real pregnancy, the course of previous pregnancies (there was no toxicosis, gestosis, diseases of the cardiovascular system, kidneys, liver and other organs), their complications and an outcome. The presence of these diseases in the past encourages especially carefully to watch the woman in real pregnancy. It is necessary to obtain detailed information on the flow of transferred abortions, each childbirth (duration of childbirth, operational interventions, floor, mass, the growth of the fetus, its condition at birth, the time of stay in the maternity hospital) and postpartum periods, complications, methods and timing of their treatment.

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

- The course of real pregnancy (in trimesters):

1Trimetter (up to 12) - common diseases, complications of pregnancy (toxicosis, threat of interrupts, etc.), the date of the first appearance in the female consultation and the period of pregnancy, established during the first appeal.

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

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

Determination of childbirth or pregnancy terms

General objective examination

A general objective study is carried out in order to identify diseases of the most important organs and systems that may complicate the course of pregnancy and childbirth. In turn, pregnancy may cause aggravation of existing diseases, decompensation, etc. An objective study is carried out according to the generally accepted rules, starting with the assessment of the overall state, temperature measurements, inspection of the skin and visible mucous membranes. Then they examine the blood circulation, respiration, digestion, urinary, nervous and endocrine systems.

Special obstetric examination

A special obstetric examination includes three main sections: outdoor obstetric study, internal obstetric study and additional research methods.

Outdoor obstetric study

Outdoor obstetric research is produced by inspection, measurement, palpation and auscultation.

Inspection allows you to identify the correspondence of the type of pregnant age. At the same time, pay attention to the growth of women, the physique, the condition of the skin, subcutaneous tissue, the mammary glands and nipples. Special attention is paid to the magnitude and shape of the abdomen, the presence of abortion scars (Striae Gravidarum), the elasticity of the skin.

The study of the pelvis is in obstetrics because its structure and dimensions have a decisive influence on the course and outcome of labor. Normal pelvis is one of the main conditions for the right flow of childbirth. Deviations in the structure of the pelvis, especially the decrease in its size, make it difficult for labor or represent irresistible obstacles for them. The study of the pelvis is produced by inspection, palpation and measuring its size. During the inspection, pay attention to the entire area of \u200b\u200bthe pelvis, but the lumbosacral rhombus (Mikhailisa rhombus) is made of particular importance. Mikhailisa Romby call the outline in the field of the sacrum, which have contours of a diamond area. The upper corner of the rhombus corresponds to an accelerable process of V lumbar vertebra, the lower - the tip of the sacrum (the place of the fatal of large butorous muscles), the side angles - the upper-back essays of the iliac bones. Based on the shape and size of Rhomb, the structure of the bone poles can be estimated, detecting its narrowing or deformation, which is of great importance in conducting birth. With a normal basin, the rhombus corresponds to the form of a square. Its dimensions: the horizontal diagonal of the rhombus is equal to 10-11 cm, vertical - 11 cm. With different thase narrowes, the horizontal and vertical diagonal will be of different sizes, as a result of which the rhombus shape will be changed.

In the outdoor obstetric measurement study, the measurement is made by a centimeter ribbon (the circumference of the ray-tank joint, the dimensions of the Mihaelis rhombus, the circumference of the abdomen and the height of the bottom of the uterus above the Lone) and the obstetric circulation (pyaseomer) in order to determine the size of the pelvis and its shape.

Santimeter tape measure the greatest circumference of the abdomen at the navel level (at the end of the pregnancy it is 90-100 cm) and the height of the uterine bottom is the distance between the upper edge of the Lonnoye and the bottom of the uterus. At the end of the pregnancy, the standing height of the uterus is 32-34 cm. Measuring the abdomen and standing height of the bottom of the uterus over Lone allows Akuster to determine the term of pregnancy, alleged weight of the fetus, identify violations of fat metabolism, multiplodes.

According to the outer sizes of a large pelvis, one can judge the magnitude and shape of a small pelvis. Measuring the pelvis is produced by a pazer. Only some sizes (pelvis output and additional measurements) can be made of centimeter tape. Typically measure four pelvis size - three transverse and one straight. The surveyed is in the position on the back, the obster sits on the side of her and face to her.

Distantia Spinarum- The distance between the most remote points of the front axles of the iliac bones (Spina Iliaca Anterior Superior) is 25-26 cm.

Distantia cristarum- The distance between the most remote spheres of iliac bones (Crista Ossis Ilei) is equal to 28-29 cm.

Distantia TroChanterica.- The distance between large skewers of the femoral bones (TroChanter Major) is equal to - 31-32 cm.

Conjugata Externa.(outer conjugate) - The distance between the spiny void vertebra and the top edge of the Lonic articulation is equal to 20-21 cm. To measure the outer conjugate, the surveyed turns on the side, the underlying leg bends in the hip and knee joints, and the overly pulling pulls out. The thazomer button is put between an awesome thoroughfone V of the lumbar and I sacrive vertebra (surplus yam) and in the middle of the top edge of the Lonnoy Jimmer in front. The exterior conjugate can be judged by the size of true conjugates. The difference between the outer and true conjugate depends on the thickness of the sacrum, symphiz 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, measure the circle of the ray-tank joint and the Soloves index (1/10 from the circle of the ray-tank joint). Thin are considered to be bones if the cooling joint is up to 14 cm and thick if the cooling joint is more than 14 cm. Depending on the thickness of the bones with the same outer sizes of the pelvis, its internal dimensions can be different. For example, with an outer conjugate, 20 cm and the Solovyov circle 12 cm (Solovyov - 1,2 index) should be obtained from 20 cm. Subscribe 8 cm and we obtain the value of the true conjugate - 12 cm. At the Solovyov circle 14 cm, it is necessary to 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 magnitude of the true conjugate can be judged by the vertical size of the sacratling rhombus and the size of the franc. True conjugate can be more accurately determined by a diagonal conjugate.

Diagonal conjugate (Conjugata Diagonalis)call the distance from the lower edge of the Symphysia to the most outstanding point of the Cape of the sacrum (13 cm). The diagonal conjugate is determined with a vaginal study of a woman who produce with one hand.

Straight output size pelvis- It is the distance between the middle of the lower edge of the Lonnoye and the top of the tailbone. During the examination, pregnant lies on the back with divorced and semi-bent in the hip and knee joints. Measurement is carried out with a pazer. This size equal to 11 cm, more than a true 1.5 cm due to the thickness of soft tissues. Therefore, it is necessary to subtract 1.5 cm from the figures obtained 11 cm, we obtain the direct size of the exit from the cavity of a small pelvic, which is 9.5 cm.

Transverse pelvis exit- It is the distance between the inner surfaces of the stacked bumps. The measurement is carried out by a special pazer or a centimeter tape, which are applied not directly to the collapsed grouse, but to the tissues covering them; Therefore, it is necessary to add 1.5-2 cm to the resulting dimensions of 9-9.5 cm (thickness of soft tissues). Normally, the transverse size is equal to 11 cm. It is determined in the pregnant position on his back, her legs as much as possible to the stomach.

Oblique sizes of the pelvisit is necessary to measure inquosic pelvis. To detect asymmetry, the pelvis is measured by the following oblique dimensions: the distance from the front axle side of one side to the rear axes of the other side (21 cm); From the middle of the top edge of the Symphysia to the right and left-fledged ostera (17.5 cm) and from the surplus fossa to the right and left reserved ostery (18 cm). The sizes of one side are compared with the corresponding sizes of the other. With the normal structure of the pelvis, the magnitude of the paired sizes is the same. The difference exceeding 1 cm indicates the asymmetry of the pelvis.

Side sizes of the pelvis- The distance between the reserved and the asses of the iliac bones of the same side (14 cm) is measured by its pazer. Side sizes should be symmetrical and at least 14 cm. With a lateral conjugate 12.5 cm, childbirth is impossible.

Taste angle- It is the angle between the entrance plane in the pelvis and the plane of the horizon. In the pregnant position, is it equal to 45-50? . Determine with the help of a special instrument - a pelvic.

In the second half of pregnancy and in childbirth, the head, the back and small parts (limbs) of the fetus are determined during palpation. The larger the term of pregnancy, the more clear palpation of the parts of the fetus. Tests of outdoor obstetric study (Leopold-Levitsky) is a consistently conductive uterine palpation, consisting of a number of certain techniques. The survey is in the back position. The doctor sits to the right of her face to her.

First reception of outdoor obstetric studies.The first taking determine the height of the bottom of the uterus, its shape and part of the fetus, located in the bottom of the uterus. For this, the obster palm surfaces of both hands has in the uterus in such a way that they cover its bottom.

The second reception of the outdoor obstetric study.The second reception is determined by the position of the fetus in the uterus, position and type of fetus. The obstever gradually lowers his hands from the bottom of the uterus on the right and left side of her and, gently pressed the palms and fingers of the hands on the side surfaces of the uterus, determines the back of the fetus on one side along its wide surface, on the other - small pieces of the fetus (knobs, legs). This technique allows you to determine the tone of the uterus and its excitability, forgive the round bundles of the uterus, their thickness, soreness and location.

The third reception of the outdoor obstetric study.The third reception is used to determine the prerequisite part of the fetus. Third reception you can determine the mobility of the head. For this, one hand covers the predatory part and determine the head is or a pelvic end, the symptom of running the fetus head.

The fourth reception of the outdoor obstetric study.This technique, which is a supplement and continuation of the third, allows you to determine not only the nature of the predatory part, but also the location of the head in relation to the entrance to the small pelvis. To perform this reception, the obstever becomes face to the legs of the surveyed, puts hands on both sides of the lower part of the uterus in such a way that the fingers of both hands seems to be with each other over the plane of the entrance to the small pelvis, and palprates the predatory part. In the study at the end of pregnancy and during childbirth, this technique determine the ratio of the predatory part to the planes of the pelvis. During childbirth, it is important to find out in which plane the head pelvis is its largest circumference or a large segment. The large segment of the head is the greatest part of it, which passes through the entrance to the pelvis with this preview. When the head of the largest segment, the border of its large segment will be held along the line of small oblique size, with the front-head preview - along the line of its right size, with a frontal presence - along the line of a large sized size, with a facial preview - along the vertical size line. A small head segment is called any part of the head below the large segment.

The degree of head insertion is a large or small segment judged by Palpation. With the fourth outer taking, the fingers are promoted deep into and slide on the head up. If the hands of the hands converge, the head is worth a large segment in the entrance to the pelvis or sank deeper if the fingers diverge - the head is in the inlet of a small segment. If the head in the pelvis cavity, it is not defined by outer techniques.

The cordial tones of the fetus are listened to the stethoscope, starting with the second half of pregnancy, in the form of rhythmic, clear blows, repeated 120-160 times per minute. With headsets, the heartbeat is best listened below the navel. With pelvic previews - above the navel.

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

With a tight preview - near the head below the navel on the side where the back is turned, with rear species - the abdomen from the front axillary line,

With a facial preview - below the navel from the other side where the breast is located (at the first position - to the right, with the second - left),

With cross position - near the navel, closer to the head,

When prepaying the puzzle end is the above navel, near the head, on the side where the back of the fetus is turned.

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

Internal (vaginal) study

An internal obstetric study is performed by one hand (two fingers, index and middle, four-semi-head, with the whole hand). Internal study allows you to determine the predatory part, the state of the generic pathways, observe the dynamics of the cervical disclosure during childbirth, the mechanism of inserting and promoting the predatory part, etc. In the manufacture of a vaginal study is produced upon admission to a rowing room, and after influencing the accumulative waters. In the future, the vaginal research is carried out only by testimony. Such an order allows you to promptly identify the complications of childbirth and assist. Vaginal research of pregnant and feminine is a serious intervention, which must be carried out in compliance with all the rules of asepsis and antiseptics.

Internal research is beginning with an inspection of external genital organs (exhaust, development, edema of the vulva, varicose veins), perineum (its height, rigidity, the presence of scars) and the defects of the vagina. The vagina is introduced phalanxes of medium and index fingers and produce its survey (width of the lumen and length, folding and extensibility of the walls of the vagina, the presence of scars, tumors, partitions and other pathological conditions). The uterine must then find and determine its shape, value, consistency, the degree of maturity, shortening, softening, the location along the longitudinal axis of the pelvis, the patency of the throat for a finger. In the study in childbirth, the degree of smoothing of the neck (preserved, shortened, smoothed), the degree of disclosure of the oz in centimeters, the state of the edges of the zea (soft or dense, thick or thin) is determined. In the guinea in the vaginal study, the state of the fetal bubble (integrity, integrity disorders, the degree of voltage, the amount of the water) is found out. Determine the predatory part (buttocks, head, legs), where they are located (above the entrance to a small pelvis, in the entrance of a small or large segment, in the cavity, at the output of the pelvis). Summary points on the head are the seams, spring, on the pelvic end - the crushes and the tailbone. Palpation of the inner surface of the pelvis walls allows you to identify the deformation of its bones, exotic and judge the pelvic capacity. At the end of the study, if the predatory part is high, measure the diagonal conjugate (Conjugata Diagonalis), the distance between the cape (Promontorium) and the lower edge of the symphysis (normally 13cm). For this, the fingers entered into the vagina are trying to reach the cape and the end of the middle finger relate to it, the index finger of the free hand is fed to the lower edge of the symphysis and mark on the hand the place that directly comes into contact with the lower edge of the lane arc. Then remove the fingers from the vagina, wash them. The assistant measures the marked distance with a centimeter ribbon or a pazer. In terms of diagonal conjugates, you can judge the sizes of true conjugates. If the Solovyov index (0.1 on the Solovyov circle) is 1.4 cm, 1.5 cm is subtracted from the size of the diagonal conjugate, and if more than 1.4 cm, then 2 cm are subtracted.

Determination of the position of the fetus head during childbirth

With the first degree of extension of the head (front-head inlet) circle, which head will pass through the cavity of the small pelvis, corresponds to its direct size. This circle is a large segment with an optional insertion.

With a second degree of extension (frontal insert) of the greatest circumference of the head corresponds to a large oblique size. This circle is a large head segment with its frontal insertion.

For the third degree of extension of the head (facial inlet), the circumference corresponding to the "vertical" size is greatest. This circle corresponds to the large segment of the head in the face of its insertion.

Determining the degree of insertion of the fetus head during childbirth

The basis of determining the height of the head of the head during a vaginal study is the ability to determine the ratio of the lower pole of the head to Linea Interspinalis.

Head over the entrance to a small pelvis: with careful pressing finger, the head moves and returns again to the original position. Palpation is available all the front surface of the sacrum and the rear surface of the pubic alphabet.

Head with a small segment in the inlet in a small pelvis: the lower pole of the head is determined by 3-4 cm above the Linea Interspinalis or at its level, the sacral inlet is free on 2/3. The rear surface of the pubic symphiz is palpable in the lower and middle departments.

The head in the cavity of the small pelvis: the lower pole of the head for 4-6 cm below Linea Interspinalis, sedanistic astests are not determined, almost the entire sacrats in the head. The rear surface of the pubic symphima of palpation is not available.

Head on the pelvic day: the head performs all the sacrivettage, including the area of \u200b\u200bthe tailbone, only soft fabrics are forgiven; The inner surfaces of bone identification points are difficult to access.

The main obstetric concepts include: position, prediction, position, view, insert, fetal location.

Fetal position (Situs) - The ratio of the longitudinal axis of the fetus to the longitudinal axis of the mother. Normal is the longitudinal position of the fetus. The oblique and transverse position of the fetus makes a delivery through the natural generic paths impossible.

View of the Fetal (Visus) - The ratio of the backrest of the fetus to the front or rear wall of the uterus. Optimal is the front view. At the injection, complications are possible.

POSITION OF THE FLIG (POSITIO) - The ratio of the back of the fetus to the right and left side of the uterus. When you turn the back to the left, the position is called the first, right - the second. Knowledge of the position is necessary to select the right actions and recommendations (for example, the palpitations of the fetus is better listened by the position, in childbirth, it is recommended to lie on the side of the position). In the case of the transverse position of the fetus, the position is determined by the fetus head.

PRAESENTATIO PREEDITION - The ratio of the large part of the fetus (head or buttocks) to the entrance to the small pelvis.
Right is the head preview. Birth through natural labor pathways is possible and with a pelvic preview, but there are more complications for the fetus. Pelvic preview are purely berical, foot and mixed (when the butters and legs are also preserved).

Inclinatio - The ratio of the sweep seam relative to the pelvis axis.
There are axial, or synclithic, inserting the head and outstanding, or asinclitic, head insert, i.e., the deviation of the seam from the axis of the Kepeda (to the Symphybean) or the for the Cape). The physiological is considered the deviation of the sweep seam from the pelvic axis to any side by 1 cm.

Fruit Locality (Habitus) - The ratio of the limbs to the head and torso. The flexing type of location (optimal) is distinguished when the head is tilted to the chest, the torso is bent, the limb is bent and are shown to the body. With a normal bent melligence, the fruit fits into the loop of the ovoid, when the head of the head is turned to the entrance to the small pelvis. The movements of the fetus take place, but do not violate the general principle of location, it is preserved in childbirth. Birth in this case pass normally. In the case of an extensive location, especially the heads, complications are possible.

Methods of examination of pregnant women:

General examination methods include - collection of anamnesis, general inspection, outdoor obstetric examination, inspection of external genital organs, inspection on mirrors, bimanual research (the last three methods also refer to gynecological research methods and are considered in detail in the course of gynecology).

In addition, laboratory methods of research and surveys from specialists are pregnant. Additional obstetric methods of surveys include: ultrasound examination, cardiotocography, amniocentesis, etc.

When you first handle a pregnant woman in a female consultation (usually a woman is already suspecting that she has a pregnancy) it is necessary to confirm the diagnosis, to establish a period. It is very important that the woman apply as soon as possible so that it is possible to begin work on the prevention of harmful effects, give recommendations. It is necessary to incline a woman to preserve pregnancy, convince her in the correctness and responsibility of this act, even if pregnancy was not planned. The exceptions are cases where pregnancy is contraindicated in medical testimony. In this case, the early turnout will allow you to identify the testimony and prepare a woman to interrupt pregnancy.

With the desired pregnancy during the first appearance, there are examinations, they reveal complaints, problems, risk factors, carry out inspection, taking smears. If there is an opportunity, then immediately take a woman into accounting for pregnancy, 2 individual cards fill in 2, give it recommendations, make up a plan for further observation. But it may happen that there is no time for such detailed communication (a lot of urgent patients, the woman itself does not have time). If there are no significant risk factors, the next meeting for detailed communication with a pregnant woman is scheduled for another day, which will be more convenient.

Examination scheme for pregnant women in women's advice:

Clarification of basic passport data:

Passport number and insurance certificate are recorded. The surname, name, patronymic of a woman (it is necessary to find out how a woman wants to be called, the midwife must introduce a woman herself, as well as to submit a doctor who will lead it, or this does a doctor). Age (risk factors include young age up to 18 years, after 30 for primary and more than 35 for repeated). Home address and telephone (registration and accommodation, preferably, the woman is observed at the place of residence, it is convenient for patronage, but in modern conditions, given the availability of convenient means of communication, and option for registration is possible. The housing conditions are specified, with whom a woman living together, what are the convenience. Place of work and profession (working conditions are immediately clarified, the availability of professional harm, in this case, is provided with exemption from harmful work).

Money data:

(F. I. O., Age, Place of work and profession, the presence of industrial evidence). It is necessary to ask: with whom you can contact some of the relatives to whom the woman most trusts if it is necessary. All this information should be on the first page. Also, the first page is made in a natural or encoded form the most important information about risk factors.

Complaints:

A healthy pregnant woman may not be complaints. Nevertheless, it is necessary to find out if it does not have any unpleasant feelings, pain. When studying the following topics, those complaints that need to be identified will be studied.

Collecting anamnesis:

Information about working conditions and life. It is necessary to find out the nature of the work, what is the harmfulness of production, as well as to clarify what work a woman performs a woman, to prevent the exception of excessive load, household harm, and also find out whether the animals (probability of infection) are found. Learn about the formation of a woman and its interests, which will help improve contact with her.

Heredity:

To identify in a pregnant woman's hereditary predisposition: there was no diabetes, hypertensive diseases, other endocrine, genetic diseases. It is important to know the heredity of her husband. It is necessary to get information about the bad habits of the pregnant and her husband, give recommendations.

Information about the suffering diseases:

Children's infections, colds, diseases of the cardiovascular system, diseases of the urinary system, liver, initial ad, etc. First of all ask about tuberculosis, rubella and infectious hepatitis. To identify: Whether the woman did not enter into contacts with tuberculosis and infectious patients, if she had such patients at home, learn about her trips to epidemiologically unfavorable areas lately.

Separately ask about surgical interventions, whether blood transfusion was. Ask the features of the menstrual function (from what age menstruates, duration, regularity, frequency, soreness of monthly, abundance of discharge). From what age is sex life out of marriage, in marriage, which means protected from pregnancy. List transferred gynecological diseases, venereal diseases (the health of her sexual partner is the child's father).

In order of priority, list all pregnancies, their outcome and complications. Separately tell about the course of this pregnancy before taking into account. Next, a general inspection is carried out, in which they draw attention to growth, weight, posture, physique, nutrition, skin condition, subcutaneous fiber, vessels, lymph nodes, the presence of edema. Explore the pulse and blood pressure, the tones of the heart. Measure the temperature and inspection of the nasopharynx, listened to the lungs. Conduct palpation of the abdomen, liver, check the symptom of the harness by the lower back, are interested in physiological shipments.

Outdoor obstetric examination:

In the early period of pregnancy, it consists of measuring the circumference of the abdomen and delvimetry. In the late period of pregnancy, in addition, the base height of the uterus, the palpation of the uterus, the techniques of the outdoor obstetric study of Leopold-Levitsky and listen to the fetal heartbeat are carried out. Next, inspection of external genital organs, inspection on mirrors, vaginal and bimanual research.

The study on the mirrors is carried out when a woman lies on a gynecological chair, which puts the oilcloth or lining (in modern conditions, a disposable lining is provided). Also accurately prepare a woman to vaginal and bimanual research. After each woman, the chair must be treated with a disinfectant solution. The midwife or the doctor handles his hands by the express method, puts on sterile gloves, takes a sterile mirror. Preparation of a woman: the emptying of the bladder, the treatment of external genital organs with a weak disinfectant solution (0.02% P-p permanganate potassium or furacin).

The technique of manipulation: after examining the external genital organs with his left hand, there are sex lips, the right hand is introduced with a furnace mirror with closer sash in one of the oblique sizes, the mirror is adjusted to the arches, translated into the transverse size and disclose. After inspecting the neck and taking of smears, the mirror is removed in the opposite way. The flag-like mirror (rear) is also administered in one of the oblique sizes, after administration, it is installed in a transverse size, after which the Ot lift is introduced. After inspecting the neck and vagina, the tools are removed in the opposite way and plunge into the drive. The color of the mucous, the nature of the discharge is noted, the presence of erosion is detected.

Vaginal (finger) study. The sex lips are moved to the 1st and 2nd fingers of the left hand, the 3rd finger of the right hand is introduced into the vagina, they take it towards the back wall, after which the 2nd finger is introduced. Together, the 2nd and 3rd fingers are introduced as deep as possible, the 1st finger of the right hand is set up and rests on the puberty, the 4th and 5th fingers of the right hand bent and pressed against the palm and rest in the crotch. Thus, the condition of the muscles of the pelvic bottom, the walls of the vagina, while noting the width, the state of the arches, neck (length, form, consistency), the state of the outer zea (its shape, is closed or passes the finger tip).

A two-year (bimanual) study of a pregnant woman is a continuation of the vaginal research. The fingers entered into the vagina are located in the front edge, shifting the neck of the stop. The fingers of the left hand through the abdominal wall palprate the bottom of the uterus. Bridging hands, palpate the uterus and determine its shape, magnitude, position, consistency, mobility, pain. Reveal signs of pregnancy. After that, the area of \u200b\u200bappendages from one and on the other hand, the fingers entered into the vagina are mixed into the appropriate arch. After that, the co-standing pelvis bones is palpable. Trying to reach a cape through the back arch.

As a result, the survey and inspection establishes the period of pregnancy, the risk or complications, physical, psychological and social problems are revealed, physical, psychological and social problems. Make up a pregnancy plan, prescribe surveys. Give recommendations.

Measurement of the circumference of the abdomen:

The dynamics of measuring the circumference of the abdomen in pregnant women makes it possible to identify deviations from the normal course of pregnancy. The absence of speakers or negative dynamics is observed at low colors, hypotrophy or fetal death. Too rapid increase in the uterus is observed with multi-way, multipleness and large fruit. The measurement is carried out at each visit to the pregnant women's consultation (i.e. every two weeks). Before studying the bladder should be emptied.

A woman is placed on the couch (on the subplated individual diaper). The circle is measured by a centimeter tape at the navel level. The length of the circle is individual and cannot afford to judge the term of pregnancy. After measuring the tape, 1% chlorine solution is treated twice with an interval (better if each pregnant will have its own individual centimeter tape). Before and after manipulation, the midwife conducts hygienic handling of hands. Hands should be warm. The couch after each woman is treated with chloramine.

Measuring the standing height of the bottom of the uterus:

It is indicated as f (from lat. Fundus - the bottom of the uterus). It is carried out from 13-14 weeks, since before that time the bottom of the uterus is hidden behind the pubic. Measurement is carried out with the same purpose as the measurement of the circle, but allows you to determine the term of pregnancy. Preparation of a woman is the same (see above). The beginning of the centimeter tape is applied to the upper edge of the symphysis and stick to the left hand. The right hand stretch the centimeter tape on the front line of the abdomen to the bottom of the uterus and applied with his right hand to the point of maximum standing. For each period of pregnancy, it is characterized by the bottom of the uterus at a certain level in relation to the pubic, navel and the rib arc. With a dead pregnancy, moving the length of the circumference and the height of the bottom of the uterus, the value of the alleged mass of the fetus is obtained (Jordania method).

Receptions of outdoor obstetric research Leopold-Levitsky:

Preparation of a woman and midwife is the same as when measuring the circumference of the abdomen.

First reception:

The palms of both hands are reduced together, and the bottoms of the uterus are contour, determining the level of standing of the bottom (and thus the term of pregnancy), as well as the form of the uterus. Catching over the fingers in the bottom area, determine the large part in the day. You can apply the reception of the balloting (periodically tapping with the fingers of one and the other hand in the bottom area, it feels the movement of a large part, especially the heads).

Second reception:

Hands are parallel to the midline on the side surfaces of the uterus. First, it is carried out from top to bottom with a relaxed hand, and then the hand is rounded and crossed with your fingers, feeling the fruit, smooth and convex contours. This technique is determined by the position, position and type of fetus. From the extremities, there are more convexities, and the more manifests the movement. From the side of the back of the uterus of more cardiac activity of the fetus smooth. In this case, the tone of the uterus is also determined, its excitability.

Third reception:

The widespread 1st and 3rd fingers of the right hand are immersed as deeper into the area of \u200b\u200bthe lower segment (above the publs parallel to him). The head is more rounded and dense. With a movable head, it is easily shifted, located above the lane arc. With a complete bladder, a study is painfully and robust. The third reception is revealed by the predatory part and its standing level of relatively small pelvis. At the first three receptions, the midwife stands or sits on the right of a pregnant face to her.

Fourth reception:

Specify the predatory part and the level of its standing. At the same time, the midwife stands, turning to the feet of the woman. The palms of hands have in the field of the lower segment, contouring the prevailing part, trying to connect the fingers between the head and the pubic. If the hands converge, the predatory part is above the entrance to the small pelvis and mobile. If the hands diverge, the head is lowered into the cavity of the small pelvis.

Listening to the fetal heartbeat:

The fetal heartbeat is listened to with each appearance of a pregnant woman in female consultation since the second half of pregnancy, with the help of an obstetric stethoscope (which is processed by chlorine after inspection). Tones listened to the best from the position of the fetus. With a head preview - below the navel, with pelvis - above the navel. The normal rhythm of heartbeat with the dead pregnancy iso-ISO beats per minute. Fetal heartbeat can be heard or written with additional research methods: ultrasound, KTG, ECG, FKG.

Watching pregnant women in women's advice:

Pregnant should attend female consultation on average every 2 weeks. Before the very kind, it is rational to inspect and consult every week. Strictly prescribed multiplicity and methods of examination. If a woman does not attend the LCD, patronage is carried out. Such a surveillance system is called dispensary. A detailed examination with the examination of all systems and organs is carried out only when taking into account.

In subsequent visits, a pregnant inspection is carried out according to the following scheme:

Survey complaints.
Weighing (calculating weight gain).
Measurement of pulse and blood pressure.
Palpation of belly and uterus.
Measurement of the circumference of the abdomen and the height of the bottom of the uterus.
Conductings of outdoor obstetric research.
Listening to the fetal heartbeat.
Detection of edema.
Find out the nature of the discharge, urination and defecation.

Only the studies that can be performed under this gestation period are performed, for example, the use of leopold-levitsky techniques and listening to the fetal heartbeat is carried out with the second half of pregnancy.

Each time you specify the term of pregnancy, identify problems, give recommendations, prescribe surveys and the following appearance. Total urine analysis is prescribed every 2 weeks. Inspection of external genital organs and inspection on the mirrors together with the taking of smears is carried out 3 times during pregnancy. Vaginal research is carried out only on special indications.

During pregnancy, the following laboratory studies are appointed:

Three times (1 time in each trimester):
strokes from the cervical canal and the outer opening of the urethra to detect gonorrhea;
blood from veins on the detection of syphilis (Vasserman reaction - RW);
Blood from the finger on clinical analysis (hemoglobin, leukocytosis, SE, etc.).

Twice during pregnancy, a survey is conducted:

Blood from Vienna on the detection of HIV infection (form 50);
Blood from Vienna to identify hepatitis B and p.

Blood on a group and a rhesus is observed once. It is recommended to explore the blood of her husband. With the difference of the group and the resume, the antibody titer is being studied approximately 1 time per month.

In 17 weeks to identify the pathology of the fetus, the blood test is taken on alpha-fetoproteins.
In the second half of pregnancy, the smear from the groove on the carriage of Staphilococcus, Cal - on the eggs of worms and intestinal infections. Rationally reveal a hidden infection (toxoplasmosis, mycoplasmosis, viral infections, etc.).

With the danger of unbearably, the smear is taken on a hormonal threat. In the presence of erosion of the cervix, a smear is taken on oncocytology. During the pregnancy, an ultrasound examination is carried out three times: at 17 weeks, 30 weeks and 37 weeks. With an ultrasound examination, it is detected: the size of the fetus, the correctness of the development for this period, is there any intrauterine defects (industrial complex, the fetus floor, the position and presence of the fetus, the amount of water, the localization and the state of the placenta, the state of the uterus as fruit chamber.

Before an ultrasound examination, it is necessary to remind a woman that you need to drink before the study of about 500 ml of fluid to fill the bladder. With a large period, this is not required. During the study, abdominal access lubricates the abdominal wall of the fatty emulsion, during the study by the vaginal sensor they put a special case or a condom.

Twice during pregnancy, a woman needs to consult with the therapist, an oculist, dentist and a otolaryngologist. These specialists should be in women's consultation, at least the therapist. If necessary, a woman can consult with a female consultation lawyer.

Medical documentation:

All data on pregnant women, the survey results are entered into an individual map of pregnant (2 copies), one instance is stored in the office, and another woman always carries with him.

In each exchange map of the pregnant woman there must be the following pages:

Title page (passport details and address);
Anamnese data;
General inspection data;
data of obstetric outdoor and internal examinations;
a pregnant plan;
a sheet of dynamic observations; - a leaf of laboratory surveys;
Lesson of experts.

A pregnant woman should understand the feasibility of such an intensive survey and observation, on them it agrees absolutely voluntary. It should be emphasized that it is very important to identify infections before and during pregnancy to cure them on time, and that infected and non-learned women come to the branches for infected and non-crushed women. It is necessary to explain that the minimum deviations identified are allowed to apply prophylactic measures and prevent complications of pregnancy and childbirth. It will be an incentive for a woman interested in preserving his health and child health.

It is necessary that the woman trust the midwives, was not afraid of her, could discuss his problems with her. You need to use the time of communication to give a woman tips on hygiene, surveys and preparation for childbirth.

The time of a female consultation should be convenient for a woman. At the place of work or study, it is obliged to give the opportunity to attend women's advice during the morning reception, in bright hours, when there are fewer problems with transport. If the woman missed the reception, the midwife should find out the cause. In the case of an emergency, an ambulance is recommended. If a woman does not want or can not visit a consultation, patronage is held.

Responsibilities of midwfing in women's advice:

Since pregnant women visit the female consultation on the day of the planned appearance, their visit is trying to appoint that they cannot be contacted with gynecological patients (more infected).

Equipment of the gynecological office:

A couch, two tables (for a doctor and for midwife), chairs for personnel and for visitors, gynecological chair, lamp, screen (or gynecological observation in the next room). For the survey, it is necessary: \u200b\u200ba tonometer, a phoneneoscope, an obstetric stethoscope, a tazometer, a centimeter tape, manipulation tables for tools and medicines. Tools: Vaginal Mirrors, Corncangs, Tweezers, Folkman Spirals for Taking Mail Takes on Summer Gonococci. Bix for dressing material, spatulas. Bix with gloves or disposable gloves. Sterile oilcloths or disposable lining, disinfecting solutions, tank capacity for tools, gloves, gloves, and dr. In the office there must be a sink with water, soap and disinfecting solutions for hand treatment, towels.

Cabinets for medical documentation and disease stories. Card file of individual maps of pregnant women who are laid down according to the alphabet (separately postpone the cards of non-appeared, hospitalized, giving birth). Magazine for registration of pregnant women, pre-recording. Forms of recipes, destinations for analyzes and consultations. Under the glass should be calendars, necessary background information: addresses and phone numbers, opening hours of cabinets, institutions that are sent to patients, analyzes, registers, norm for laboratory research, etc.

The midwife comes before the doctor, ventilats and prepares the office, tools, prescribed maternity cards, lines tests, prepares new directions and information for the doctor and for pregnant women. During the reception, together with the doctor (or instead of a physician in the case of physiological pregnancy), it leads to the reception of pregnant women, conducts a survey, gives recommendations, conducts a conversation, draws up documentation, follows the processing of tools, cleaning the cabinet, conducts patronage.

Patronage:

A woman misses consultation for various reasons: misunderstanding the importance of surveys, the lack of contact with the doctor and obstetrics, the burdensiveness of the visiting procedure (queue, lack of necessary amenities during waiting). From the midwife depends so that such reasons do not occur. Sometimes a woman has complaints and problems, but she does not want to report this to a doctor and obstetrician, as hospitalization and treatment is afraid, avoids preventive hospitalization for examination or preparation for childbirth. There may be family problems (care for sick relatives, with no one to leave the child, etc.).

Visiting a woman at home, the midwife can evaluate the living conditions, family problems, talk with relatives and convince them to help the woman visiting the consultation. At home, the survey scheme and surveys are exactly the same as in the women's consultation. To do this, take with you a tonometer, an obstetric stethoscope, centimeter, forms of directions for surveys. At the end of the reporting period, analyzes the performance indicators: how many pregnant women were registered, the outcome of pregnancy and childbirth, the percentage of complications for the mother and the fetus, the correctness of the issuance of maternity leave, etc.

Table of contents of the topic "Fetal memberstellation (Habitus).":
1. Fetal location (Habitus). Foot position (Situs). Longitudinal position. Cross position. Oblique position.
2. Position of the Fetal (Positio). View of the position (Visus). The first position of the fetus. The second position of the fetus. Front view. Back view.
3. PREVENTION OF THE FLIG (PRAEMENTATIO). Head prepay. Pelvic preview. Prepare part.
4. Outdoor techniques of obstetric studies (Leopold techniques). First reception Leopold. The purpose and methodology of the study (reception).
5. The second reception of the outdoor obstetric study. The second reception of Leopold. The purpose and methodology of the study (reception).
6. Third reception of outdoor obstetric research. The third reception of Leopold. The purpose and methodology of the study (reception).
7. Fourth reception of outdoor obstetric studies. Fourth Reception Leopold. Symptom of running. The purpose and methodology of the study (reception).
8. The degree of insertion of the fetus head into a small pelvis. Determining the degree of fetal head insertion.
9. Auscultation of the fetus. Listening to the belly of pregnant and female in labor. Cardual fetus tones. Places of best listening to the heart of the fetus.
10. Determination of the term of pregnancy. The time of the first movement of the fetus. Day of the last menstruation.

Outdoor techniques of obstetric research (Leopold techniques). First reception Leopold. The purpose and methodology of the study (reception).

When palpation belly uses the so-called outdoor receptions of obstetric research (receptions Leopold). Leopold (1891) introduced the palpation of the abdomen into the system and suggested typical palpation techniques that have received universal recognition

Fig. 4.17. First reception of outdoor obstetric studies.

First reception outdoor obstetric research (Fig. 4 17) purpose It is to determine the height of the standing of the bottom of the uterus and a part of the fetus located in her day.

Research methodology. The palm surfaces of both hands are located in the uterus in such a way that they tightly covered its bottom with the adjacent areas of the corners of the uterus, and the fingers were turned to nail phalanges to each other. Most often at the end of pregnancy (in% of% of cases), buttocks are determined in the bottom of the uterus. Usually, it is easy to distinguish them from the head to a less pronounced roundness and sphericity, less density and less pad.

First outdoor reception of obstetric research It makes it possible to judge the term of pregnancy (in the height of the bottom of the uterus), about the position of the fetus (if one of its large parts in the bottom of the uterus means, there is a longitudinal position) and about the preview (if in the bottom of the uterus of the buttock means the preserving part is the head) .

1. Outdoor pelviometry.

With external pelviometry, the following pelvis dimensions are measured:

Distancia Spinarum, i.e. The distance between the most remote points of the front-axis is normal, this distance is 25-26 cm;

Distancia cristarum, i.e. The distance between the two most distant points of the scallops of the iliac bones, in the normal pelvis, this distance is 28-29 cm;

Distancia Intertrochanterica, is the distance between the most remote points of large skewers of the femur bone, equal to normal 31-32 cm

Coniugata Externa, i.e. The distance between the oscent overhang 5 of the lumbar vertebrae and the upper edge of the LONA joint, is normal, equal to 20-21 cm.

The size of a large pelvis allows you to make an idea of \u200b\u200bthe sizes of a small pelvic.

Measure the Solovyov index. This is a rounded joint circle, equal to 14-15 cm, which helps to make an idea of \u200b\u200bthe inner container pelvis: with narrow bones (Solovyov's index is 14-15 cm) The inner tank capacity is greater, more profitable to pass the fetal head.

2. Potion of the abdomen.It is performed in the position of the scams being examined on the back and the hip joints. The outer palpation helps determine the state of the front abdominal wall, the tone of the uterus, its size, the state of round uterine ligaments, to make an idea of \u200b\u200bthe number of accumulating waters, etc. With the help of external research methods, the position, presence, position and type of fetus position are determined.

The position of the fetus is the ratio of the longitudinal axis of the body of the fetus to the longitudinal axis of the uterus. The longitudinal, transverse and oblique position of the fetus are distinguished. The most frequent is the longitudinal position of the fetus (99.5%). If the longitudinal axis of the fetus corresponds to the longitudinal axis of the mother, such a position is called longitudinal. If the longitudinal axis of the fetus is a direct angle to the longitudinal axis of the mother's body, then such a position is called transverse. If the longitudinal axis of the fetus body is oblique angle with the longitudinal axis of the mother's body, then such a position is called oblique. The transverse and oblique position of the fetus are pathological and lead to the complications of the generic act.

Prelation is the ratio of a large part of the fetus to the entrance in a small pelvis. The prelationship of the fetus may be the head (96.5%), pelvic (3-4%). In rare cases above the entrance to a small pelvis, not one part of the fetus can be determined, for example, the head and handle, head and loops of the umbilical cord, the pelvic end of the fetus and loops of the umbilical cord. In such cases, they are talking about the complex prelations of the fetus, which are pathological and more often arise in oblique and pathological positions of the fetus.

The position of the fetus is the ratio of the backrest of the fetus to the left or right wall of the uterus. Distinguish:

the first (or left) position of the fetus,

second (right) position of the fetus.

The view of the position is the ratio of its back to the front wall of the uterus.

Front view - the back of the fetus is facing the front wall of the uterus.

Back view - The back of the fetus is addressed to the rear wall of the uterus (i.e., to the mother's spine). (Fig.195,196 pp 176-177 oBstetrics)

There are 4 reception of an outdoor examination of a pregnant woman who are called Leopold-Levitsky techniques

The first reception of Leopold-Levitsky. This is the palpation area of \u200b\u200bthe bottom of the uterus, which helps determine the presence of a large part of the fetus in the bottom of the uterus and determine which part of the fetus is located in this area.

The fetus head is felt as a large, round, dense, running part in the bottom of the uterus. A pelvic end is defined as a rather massive, a rather soft part of the fetus with fuzzy contours, which is not capable of running. Thus, 1 reception allows you to determine:

    position of the fetus: if the large part of the fetus is determined in the bottom of the uterus, it means the position of the fetus is longitudinal;

    the prevention of the fetus - if in the bottom of the uterus, the pelvic end of the fetus is located, then the presence of the head and vice versa.

The first admission allows, in addition, to make an idea of \u200b\u200bthe sizes of the uterus, whether the magnitude of the uterus corresponds to the estimated period of pregnancy, as well as determine the tone of the uterus, the excitability of it during palpation, soreness, etc.

When carrying out 1 reception, the doctor is located to the right of the patient, sits face to her. The palm of both hands of the obstetrician puts the plafhmy on the uterus in such a way that they tightly wrapped in her bottom, and the fingertips were addressed to each other (Fig.56 Jordania, page 109). Palping, the obstetricer is trying to determine the height of the bottom of the uterus, the presence of a large part of the fetus. If a wide, softly soft with fuzzy contours is painted in the bottom of the uterus, (pelvic end), then the head is located above the entrance to a small pelvis. The detection of a dense, round, smooth and running part in this area means that the fetus head is located in the bottom of the uterus., Ie above the entrance to the pelvis should be the pelvic end of the fetus. With the transverse position of the fetus in the region of the uterus, it is not possible to determine any major part.

The second reception of Leopold-Levitsky. Obster sits to the right of the surveyed, face to her. Both of the obstetricians are plagged on both sides of the uterus. Alternally pressing the palms on the right and left side of the uterus, the obstever tries to determine which way the back of the fetus is addressed. The back is recognized as a wide, and curved surface. Small pieces of the fetus are determined from the opposite side in the form of small, movable buggers. Figure 57 pp 109 Jordania

The second obstetric reception allows you to determine the position of the fetus, position and view of the position. In addition, with the help of this reception, the obstever determines the movements of the fetus, the tone and excitability of the uterus, the condition and location of round uterine ligaments. . (Figure 57 pp 109 Jordania)

The third obstetric reception makes it possible to accurately determine the nature of the prerequisite part of the fetus and its attitude towards the entrance in a small pelvis. Obster sits face to face the surveyed, to the right of it. The four fingers of the right hand are located at the lower end of the uterus so that the elbow edge of the palm is on the upper edge of the Lonatic articulation, the thumb was on the right of the middle line, the remaining fingers on the left. Thus, the fingers cover the prerequisite part of the fetus, if it does not fall into the uterine cavity. After that, they make movements to the right and left, which allows you to determine the mobility of the preliminary part of the fetus. (Fig. 58 pages 110 of Jordania)

Fourth obstetric reception. Usually it complements the third obstetric reception. The study is made by an obstetrician, which becomes facing the feet of the patient. Four fingers each hand are located at the bottom of the uterus on both sides of the middle line parallel to the ligaments. Pressing the fingers towards down and backward, the obster is trying to palpate a piece of the fetus, which occupies the lower pole of the uterus. This reception helps to determine the insertion of the preempting part of the fetus.