A complete plan of examinations during pregnancy. Obstetric research methods of examination of pregnant women and women in labor
During the clinical examination of a pregnant woman or a woman in labor, data from a general and special anamnesis are used, a general somatic and special obstetric examination is performed.
Survey
The main purpose of the survey is to identify negative factors, maternal diseases and conditions that worsen the prognosis of pregnancy and childbirth. When interviewing, find out the following information.
Surname, name, patronymic, series and passport number.
Address (according to the registration and the one where the woman actually lives).
Age. For primiparas, the age group is determined: young primiparous - up to 18 years old, primiparous - over 30 years old.
The reason for contacting an obstetrician-gynecologist.
Working and living conditions. Profession. In the presence of occupational hazards, in order to eliminate the adverse effect of production factors on the body of the pregnant woman and the fetus, the issue of rational employment of the woman should be immediately resolved.
Living conditions: the number of people living with a pregnant woman, material security, living conditions, the presence of animals in the apartment.
Postponed somatic and infectious diseases: childhood infections - chickenpox, rubella, measles, whooping cough, mumps, scarlet fever; diseases of the cardiovascular system, endocrine system, gastrointestinal tract, genitourinary, respiratory system; rickets, rheumatism, diphtheria, dysentery, viral hepatitis, typhus, tuberculosis, toxoplasmosis, genital herpes, cytomegalovirus infection, cancer.
Transfusion of blood products, allergic reactions, surgery, trauma (concussion, fractures).
Epidemiological history.
Bad habits: smoking tobacco, drinking alcohol, drugs.
Menstrual and sexual function.
Reproductive function: number of previous pregnancies, duration, course, multiple pregnancies, outcomes (childbirth and abortion), intervals between pregnancies, complications in childbirth, complications after childbirth and abortion, weight of the newborn (newborns), development and health of children in the family.
Complications of previous pregnancies and childbirth. In the case of an operated uterus (enucleation of the myomatous node with or without opening the uterine cavity, surgical access, suturing of the perforation), it is necessary to clarify the time of the surgery, the type (corporal or in the lower uterine segment), the nature of the postoperative period.
Past diseases of the genital organs: inflammation, infertility, menstrual dysfunction, surgery on the cervix, fallopian tubes, ovaries; sexually transmitted infections.
Family history: health status of family members living with the pregnant woman (tuberculosis, alcoholism, sexually transmitted diseases, smoking, etc.); heredity (multiple pregnancies, diabetes mellitus, oncological and mental illnesses, hypertension, the presence in the family of children with congenital and hereditary diseases, etc.); the age and health of the husband, the group and Rh belonging of his blood, as well as the presence of occupational hazards and bad habits.
Objective examination
Examination of a pregnant woman is carried out by an obstetrician-gynecologist, therapist, dentist, otorhinolaryngologist, ophthalmologist, and, if necessary, an endocrinologist, urologist, surgeon, cardiologist.
If indicated, medical genetic counseling is performed.
The initial examination of a pregnant woman by a therapist and other specialists without familiarization with the extract from the outpatient card is unacceptable. It is possible only in cases where the woman does not have an outpatient card at the place of residence. Objective examination of a pregnant woman includes:
- thermometry;
- anthropometry (measurement of height, determination of body weight);
- measurement of blood pressure;
- determination of physique and pelvimetry;
- examination of the skin;
- examination and palpation of the mammary glands;
- examination and palpation of the abdomen;
- palpation of the pubic articulation;
- study of the circulatory system, respiration, digestion, excretion, nervous and endocrine systems;
- routine examinations carried out by doctors of other specialties.
Determination of height and weight parameters is a prerequisite for the diagnosis of obesity and detection of latent edema.
The earlier the anthropometry is performed, the measurement of blood pressure, the more reliable the data will be for comparison as the pregnancy progresses.
Obstetric examination
The special obstetric examination includes three main sections:
- external obstetric examination;
- internal obstetric research;
- additional research methods.
External obstetric examination: examination, pelvimetry, measurement of the largest circumference of the abdomen, palpation of the abdomen and pubic symphysis, auscultation of fetal heart sounds after 20 weeks. Internal obstetric examination: examination of the external genital organs, examination of the cervix using mirrors, vaginal examination. For an indirect assessment of the internal dimensions of the small pelvis, pelvimetry is performed.
External obstetric examination
Obstetric measurements for an indirect assessment of the internal dimensions of the small pelvis are performed by pelvimetry. Values of the external dimensions of the pelvis are normal:
- distantia spinarum 25-26 cm;
- distantia cristarum 28-29 cm;
- distantia trochanterica 31-32 cm;
- conjugata externa 20-21 cm;
- conjugata diagonalis 12.5-13 cm.
It is most important already at the first examination to determine the conjugata vera (true conjugate), that is, the direct size of the entrance to the small pelvis (normally 11-12 cm). Ultrasonic measurement can give reliable data, however, due to the insufficient prevalence of this method, indirect methods for determining the true conjugates are still used:
- subtract 9 cm from the value of the conjugata externa and get the approximate size of the true conjugate;
- by the vertical size of the Michaelis rhombus (it corresponds to the value of the true conjugate);
- Frank's size (distance from the spinous process of the VII cervical vertebra to the middle of the jugular notch), which is equivalent to the true conjugate;
- by the value of the diagonal conjugate - the distance from the lower edge of the pubic symphysis to the most prominent point of the sacral promontory (12.5-13 cm) is determined during vaginal examination. With the normal size of the pelvis, the cape is not attainable. If the cape is reached, the Soloviev index is subtracted from the value of the diagonal conjugate and the size of the true conjugate is obtained.
A number of authors, based on a comparison of the measurement data of the Solovyov index (1/3 of the circumference of the hand in the area of the wrist joint) and the true conjugate, suggest subtracting 1/10 of the circumference of the hand from the value of the diagonal conjugate. For example, with a diagonal conjugate of 11 cm and a wrist circumference of 16 cm, 1.6 must be subtracted - the size of the true conjugate will be 9.4 cm (the first degree of pelvic narrowing), with a hand circumference of 21 cm, 2.1 is subtracted, in this case the size true conjugate is 8.9 cm (second degree of pelvic constriction).
If one or more sizes deviate from the indicated values, it is necessary to make additional measurements of the pelvis:
- lateral conjugate - the distance between the anterior and posterior spines of the iliac bones of the same side (14-15 cm and more); if the lateral conjugate is 12.5 cm or less, delivery is impossible;
- oblique dimensions of the small pelvis:
- from the middle of the upper edge of the pubic symphysis to the posterior superior spine of both sides (17.5 cm);
- from the front upper spine of one side to the rear upper spine of the other side (21 cm);
- from the spinous process of the V lumbar vertebra to the anterosuperior spine of each ilium (18 cm); the measured distances are compared in pairs.
The difference between the size of each pair of more than 1.5 cm indicates an oblique narrowing of the pelvis.
The angle of inclination of the pelvis is the angle between the plane of the entrance to the pelvis and the plane of the horizon (measured with a pelvic angle meter in the woman's standing position); usually it is equal to 45-55 °; deviation of its value in one direction or another can adversely affect the course of childbirth.
The pubic angle is measured - the angle between the descending branches of the pubic bone. The pubic angle is measured in the position of the pregnant woman on the gynecological chair, while the thumbs of both hands are placed along the descending branches of the pubic bone. Normally, the pubic angle is 90-100 °.
Measuring the size of the pelvic outlet is informative:
- straight size (9 cm) - between the top of the coccyx and the lower edge of the pubic symphysis. From the resulting figure, subtract 2 cm (thickness of bones and soft tissues);
- the transverse dimension (11 cm) is measured with a tazometer with crossed branches or a rigid ruler between the inner surfaces of the ischial tuberosities. To the resulting figure, add 2 cm (soft tissue thickness).
A centimeter tape measures the circumference of the abdomen at the level of the navel (at the end of a normal pregnancy it is 90-100 cm) and the height of the uterine fundus - the distance between the upper edge of the pubic joint and the bottom of the uterus. At the end of pregnancy, the height of the standing length of the uterus is on average 36 cm.Measuring the abdomen allows the obstetrician to determine the gestational age, the approximate estimated weight of the fetus (multiplying the values of the two indicated sizes), to identify a violation of fat metabolism, to suspect polyhydramnios, oligohydramnios.
Palpation of the abdomen allows you to determine the condition of the anterior abdominal wall and muscle elasticity. After an increase in the size of the uterus, when its external palpation becomes possible (13-15 weeks), it is possible to determine the tone of the uterus, the amount of OS, the presenting part, and then, as pregnancy progresses, the articulation of the fetus, its position, position and its appearance. use the so-called techniques of external obstetric research (Leopold's techniques):
- 1st reception of external obstetric examination - determination of the height of the cervix and the part of the fetus located in the bottom;
- 2nd reception of external obstetric examination - determination of the position of the fetus, which is judged by the location of the back and small parts of the fetus (arms and legs);
- 3rd reception of external obstetric research - determining the nature of the presenting part and its relationship to the small pelvis;
- 4th reception of external obstetric examination - determination of the ratio of the presenting part with the entrance to the small pelvis.
Articulation of the fetus - the ratio of the limbs of the fetus to the head and trunk. When determining the position of the fetus (the ratio of the longitudinal axis of the fetus to the longitudinal axis of the uterus), the following positions are distinguished:
- longitudinal;
- transverse;
- oblique.
Fetal position is the ratio of the fetal back to the right or left side of the uterus. Distinguish between I (the back is facing the left side of the uterus) and II (the back of the fetus is facing the right side) of the position of the fetus. Position type - the relation of the fetal back to the anterior or posterior wall of the uterus. If the back is facing anteriorly, they speak of the anterior view, posteriorly, the posterior view.
Fetal presentation is the ratio of a large part of the fetus (head and buttocks) to the entrance to the small pelvis - head or pelvic, respectively. Palpation of the symphysis pubis is performed to detect the discrepancy between the symphysis pubis and symphysitis during pregnancy. Pay attention to the width of the pubic articulation, its soreness during examination.
Listening to the fetal heartbeat is performed with an obstetric stethoscope, starting from the second half of pregnancy (less often from 18-20 weeks). An obstetric stethoscope differs from a conventional stethoscope by a wide funnel. The heart sounds of the fetus are heard from the side of the abdomen where the back is facing, closer to the head. In transverse positions, the heartbeat is determined at the level of the navel, closer to the head of the fetus. With multiple pregnancies, fetal heartbeats are usually heard clearly in different parts of the uterus. The fetal heartbeat has three main auscultatory characteristics: frequency, rhythm, and clarity. The frequency of blows is normally 120-160 per minute. The heartbeat should be rhythmic and clear. In addition to an obstetric stethoscope, fetal monitors based on the Doppler effect can be used for auscultation of fetal heart sounds. An internal obstetric examination is performed under the following conditions: the pregnant woman should lie on her back, bending her legs at the knee and hip joints and spreading them apart; the woman's pelvis should be raised; the bladder and bowels are empty; the study is carried out in compliance with all the rules of asepsis.
When examining the external genital organs, the nature of hair growth (female, male or mixed type), the development of the labia minora and majora, the state of the perineum (high and trough-shaped, low) are noted; the presence of pathological processes: inflammation, tumors, condylomas, fistulas, scars in the perineum after ruptures. When examining the area of the anus, pay attention to the presence of hemorrhoids.
Spreading the labia minora with your fingers, examine the vulva and the entrance to the vagina, the state of the external opening of the urethra, paraurethral passages and exit ducts of the large glands of the vestibule vestibule. In the study, spoon-shaped or folding mirrors are used. Determine: the color of the mucous membrane of the cervix and vagina, the nature of the secretion, the size and shape of the cervix and external uterine pharynx, the presence of pathological processes on the cervix (cicatricial deformity, ectropion, ectopia, leukoplakia, polyp of the cervical canal, condyloma) and the walls of the vagina.
Obstetric vaginal examination in the first trimester of pregnancy is two-handed (vaginal-abdominal) (see "Diagnosis of pregnancy and determining its duration"), and in the second and third trimesters - one-handed. At the beginning of the study, the state of the perineum (its rigidity, the presence of scars) and the vagina (width and length, the state of its walls, folding) are determined. Then the cervix is examined: its length, shape, consistency, the presence of scars and ruptures on it, the state of the external pharynx (closed, slightly open, misses the tip of a finger, pass for one finger, etc.) are determined. On the eve of childbirth, the degree of maturity of the cervix is determined , which is an integral indicator of the body's readiness for childbirth. When assessing 5 points, the cervix is considered immature, if the sum of points is more than 10, the cervix is mature (ready for childbirth) and labor induction can be used.
Diagnosis of pregnancy. determination of the gestational age and date of birth
With a delay in menstruation of any genesis in women of reproductive age and the absence of absolute infertility, the doctor must take into account the possibility of pregnancy. A doctor of any specialty should be proficient in diagnosing pregnancy. From an obstetric point of view, early diagnosis of pregnancy is necessary for the development of optimal patient management tactics. When pregnancy is detected early, the doctor has a number of benefits. When a pregnancy is established, the doctor should tell the patient about the signs that characterize a complicated pregnancy: pain in the lower abdomen, bleeding from the vagina.
Establishing pregnancy in the early stages according to clinical data presents certain difficulties, since endocrine diseases, stresses, and the use of pharmacological drugs can mimic the state of pregnancy. Delayed menstruation can be caused by stress, cachexia, endocrine disorders (prolactinoma, adrenal hyperandrogenism, severe hypothyroidism), taking sex hormones, psychotropic drugs.
Currently, the combination of two methods is considered the "gold standard" for diagnosing pregnancy of any localization:
- definitions of the β-subunit;
- Ultrasound using a transvaginal probe.
In addition to the early diagnosis of a normally progressive uterine pregnancy, the quantitative determination of β-hCG makes it possible to distinguish a normal pregnancy from a pathological (ectopic, intermittent) with a quantitative dynamic determination. when the delay in menstruation with a regular cycle is from one day to one week or more). In this line, the diagnosis of pregnancy is established on the basis of the determination in the uterine cavity of the ovum. The ovum is mistaken for a glandular polyp of the endometrium, a small submucous myoma node, a Nabot cyst in the isthmus or fluid accumulation in the endometrium (“false ovum” syndrome). To avoid mistakes, you need to make sure the following signs are present:
- signs of decidual changes in the endometrium (typical three-layer structure of the M-echo (endometrium), thickness 12-15 mm);
- detectable formation of a fluid structure (fluid during ultrasound is anechoic (black), gives the effect of dorsal enhancement - a lighter zone defined as a cone directly behind the fluid formation). This sign distinguishes the ovum from the polyp and submucous myomatous node, which are not fluid formations;
- fluid formation, surrounded by a hyperechoic (light) contour ("rim"). His image gives the chorion. The identification of a clear hyperechoic contour is used in the differential diagnosis of the ovum and fluid formations in the uterus.
Starting from 6-7 obstetric weeks, the embryo and yolk sac are detected in the amniotic cavity, the heartbeat of the embryo is visualized, which facilitates the diagnosis. Therefore, in difficult diagnostic cases, when it is impossible to confirm or deny the presence of a uterine pregnancy by ultrasound in 4-5 obstetric weeks, or if a frozen pregnancy is suspected, a repeated examination is necessary with an interval of 7-10 days. / fruit, its motor activity. Screening ultrasound is performed three times: at 1114 weeks of gestation, 18-21 weeks and 30-34 weeks.
At the second screening ultrasound examination, it is recommended to perform transvaginal ultrasound of the cervix in the group of pregnant women at high risk of miscarriage (history of premature birth). At the same time, the state of the internal os is assessed, the length of the preserved part of the cervical canal is measured (the critical value is 25 mm).
If an ectopic pregnancy is suspected, laparoscopy is performed. In modern conditions, the determination of the characteristic clinical signs of pregnancy is auxiliary, but if they are present, it is necessary to suspect pregnancy:
- doubtful (presumptive) - associated with the subjective sensations of the pregnant woman and somatic changes in her body;
- probable - signs determined by an objective examination of the organs of the reproductive system, and positive immunological tests for pregnancy;
- reliable (undoubted) - objective signs associated with the presence of the fetus itself (determined in the second half of pregnancy).
Doubtful signs:
- changes in appetite (aversion to meat, fish, etc.), whims (attraction to spicy dishes, to unusual substances - chalk, clay, etc.), nausea, vomiting in the morning;
- changes in olfactory sensations (aversion to perfume, tobacco smoke, etc.);
- changes in the nervous system: irritability, drowsiness, instability of mood, etc.;
- pigmentation of the skin on the face, along the white line of the abdomen, nipples and areola;
- a feeling of engorgement of the mammary glands;
- increased frequency of urination;
- an increase in the volume of the abdomen.
Likely signs:
- cessation of menstruation;
- the appearance of colostrum from the milk ducts opening on the nipple when pressing on the mammary glands;
- cyanosis (cyanosis) of the vaginal mucosa and cervix;
- change in the size, shape and consistency of the uterus;
- laboratory tests (determination of chorionic hormone in urine and blood).
Reliable signs:
- imaging of the embryo / fetus by ultrasound;
- determination (palpation) of parts of the fetus. In the second half of pregnancy, palpation of the abdomen reveals the head, back and small parts (limbs) of the fetus;
- clearly audible fetal heart sounds. With simple auscultation (with an obstetric stethoscope), fetal heartbeats can be heard after 18-20 weeks;
- fetal movements felt by the doctor when examining a pregnant woman.
Determination of the gestational age is carried out on the basis of anamnestic data, according to the results of an objective examination.
By the date of the last menstrual period. The gestational age can be judged by taking into account the time elapsed from the first day of the last menstrual period until the time when the period is determined (assuming a regular menstrual cycle). To calculate the due date, you need to subtract 3 months from the date of the last menstruation and add 7 days (Negele's rule).
By ovulation. With a known date of conception, to calculate the due date, you need to subtract 3 months and subtract 7 days (modification of the Negele rule) or add 266 days (38 weeks). In addition, conventionally, the date of conception can be determined by the rise in basal temperature, by the date of in vitro fertilization or artificial insemination, according to the data of ultrasound monitoring of ovulation.
On the first visit to the antenatal clinic. Take into account the data of anamnesis and examination at the first examination of a pregnant woman. By the date of the first stir. When determining the duration of pregnancy and childbirth, the time of the first fetal movement is taken into account, which is felt by primiparous from the 20th week of pregnancy, multiparous - approximately 2 weeks earlier. However, this sensation is subjective and its meaning is limited. To determine the term of labor in primiparas, 20 weeks are added to the date of the first fetal movement (20 weeks), in multiparous women - 22 weeks are added to the date of the first movement (18 weeks). To quickly calculate the gestational age and childbirth by the date of the last menstruation and by the first movement of the fetus, special obstetric calendars are produced - gravidometers.
According to ultrasound data, carried out at different stages of pregnancy. Before imaging the embryo, gestational age is determined by the average inner diameter of the ovum, calculating the average value from its longitudinal, anteroposterior and transverse dimensions (the ultrasonic sensor is positioned in the same way as when determining the size of the uterus). With the appearance of the embryo and fetal heartbeat, its coccygeal-parietal size becomes the determining criterion; the transducer is positioned so that the ultrasound wave travels sagittally through the embryo's spinal column. After taking measurements, the data is checked against the average values from special obstetric tables and it is determined to which gestational age the sizes of the ovum and embryo correspond. By the end of the first trimester, the diagnostic value is obtained by determining the circumference of the head and abdomen of the fetus, measuring the distance between the parietal bones (biparietal diameter). In the II trimester of pregnancy, detailed fetometry is performed - the indicated parameters of the fetus are measured, as well as the length of the tubular bones (thighs, bones of the lower leg, shoulder, forearm bones), feet, and the size of the cerebellum. By comparing the obtained values with fetometric tables, a conclusion is made about what period of pregnancy the size of the fetus corresponds to. Most accurately reflects the duration of pregnancy, ultrasound performed in the first trimester in the presence of the coccygeal-parietal size. With an increase in gestational age, the size of the fetus more and more reflects the condition of the fetus and its hereditary characteristics (especially when the period exceeds 27 weeks). An approximate gestational age can be determined, starting from 15-16 weeks, by palpation of the uterine fundus and measuring the height of the structure of the length of the uterus ... It is important to remember that the height of the structure of the length of the uterus can be influenced by the size of the fetus, excess quantity, multiple pregnancy, abnormal position of the fetus and other features of the course of pregnancy. Therefore, the height of the structure of the length of the uterus, when determining the duration of pregnancy, is taken into account in conjunction with other signs (the last menstruation, the first movement, etc.). The height of the structure of the length of the uterus above the bosom is measured with a centimeter tape.
Survey. The first meeting with a pregnant woman, as a rule, takes place in an outpatient setting (women's consultation, perinatal centers), but it also happens in a hospital. At the first visit of the patient, the doctor should conduct a survey with a thorough collection of anamnesis (general and obstetric-gynecological), assess the general condition, genitals and, if necessary, use additional examination methods. All the information received is entered into the outpatient card of the pregnant woman or in the history of childbirth in the hospital.
Passport data... Pay attention to the age of the pregnant woman, especially primiparous. The complicated course of pregnancy and childbirth is more often observed in the "elderly" (over 30 years old) and "young" (up to 18 years old) primiparous. The age of the pregnant woman 35 years and older requires prenatal diagnosis due to the higher risk of having a child with congenital and hereditary pathology.
Complaints... First of all, they find out the reasons that prompted a woman to seek medical help. A visit to a doctor in the first trimester of pregnancy is usually associated with the cessation of menstruation and the assumption of pregnancy. Often during this period of pregnancy, patients complain of nausea, vomiting and other disorders of health. With a complicated course of pregnancy (miscarriage that has begun, ectopic pregnancy, concomitant gynecological diseases), there may be bleeding from the genital tract. Complaints about dysfunctions of internal organs can be caused by extragenital diseases (cardiovascular, respiratory, kidney, digestive system diseases, etc.).
Complaints of pregnant women should be treated very carefully and recorded in a medical document.
Working and living conditions. Carefully find out professional, household and environmental harmful factors that can adversely affect the course of pregnancy and fetal development (living in ecologically unfavorable regions, hard physical labor, work associated with vibration, chemicals, computers, prolonged static loads, etc.). Be sure to ask questions about smoking (including passive), alcoholism, drug addiction.
Heredity and past diseases. Find out if the family of the pregnant woman and / or her husband had multiple pregnancies, hereditary diseases (mental illness, blood diseases, metabolic disorders), as well as congenital and hereditary developmental anomalies in the next of kin.
It is necessary to obtain information about all previously transferred diseases, starting from childhood. So, for example, rickets suffered in childhood can be the cause of pelvic deformity, which will complicate the course of rolls. Indirect signs of previous rickets are late teething and the beginning of walking, skeletal deformities, etc. Poliomyelitis, tuberculosis in childhood can also lead to disorders of the pelvic structure. Measles, rubella, rheumatism, tonsillitis, recurrent tonsillitis and other infectious diseases often lead to girls lagging behind in physical and sexual development. Diphtheria of the vulva and vagina can be accompanied by the formation of cicatricial narrowing.
They also find out non-infectious and infectious diseases transferred in adulthood. Diseases of the cardiovascular system, liver, lungs, kidneys and other organs can complicate the course of pregnancy and childbirth, and pregnancy and childbirth can, in turn, exacerbate chronic diseases or cause relapses.
If there were surgical interventions in the anamnesis, then it is better to obtain medical documents about them with recommendations from specialists on the tactics of managing this pregnancy and childbirth. Of great importance are information about the injuries suffered (skull, pelvis, spine, etc.).
Menstrual function. Find out at what age the first menstruation appeared (menarche), after what period of time regular menstruation was established; the duration of the menstrual cycle, the duration of menstruation, the amount of blood lost, soreness; whether the nature of menstruation has changed after the onset of sexual activity, childbirth, abortion; the first day of the last menstrual period.
Sexual function. They collect information about the beginning of sexual activity, find out what kind of marriage is in order, whether there are pains and bleeding during intercourse, what methods of contraception were used before pregnancy, as well as the interval from the beginning of regular sexual activity to the onset of pregnancy. The absence of pregnancy within 1 year of regular sexual activity without the use of contraceptives may indicate infertility and indicate certain disorders of the reproductive system.
Information about the husband (partner) of the pregnant woman is also required: his health status, age, profession, smoking, alcoholism, drug addiction.
Gynecological history... It is necessary to obtain information about past gynecological diseases that may affect the course of pregnancy, childbirth and the postpartum period (uterine fibroids, tumors and tumor-like formations of the ovaries, diseases of the cervix, etc.). Particular attention should be paid to the transferred surgical interventions on the genitals, primarily on the uterus, leading to the formation of a scar (myomectomy). An extract from the hospital is required with a detailed description of the operation performed. For example, during myomectomy, it is necessary to obtain information about the access of surgical intervention (laparotomy or laparoscopic), with or without opening the uterine cavity, etc.
Find out the complaints of a pregnant woman about pathological discharge from the genital tract (abundant, purulent, mucous, blood, etc.), which may indicate a gynecological disease.
It is important to obtain information about past sexually transmitted diseases (HIV infection, syphilis, gonorrhea, chlamydia, etc.).
Obstetric history... First of all, it is necessary to clarify what kind of a real pregnancy is (first, repeated) and what kind of childbirth is coming up.
In foreign literature, the following concepts are distinguished.
- Nulligravida - a woman who is not currently pregnant and has no history of pregnancy.
- Gravida - a woman who is currently pregnant or has had a pregnancy before, regardless of their outcome. At the first pregnancy, a woman is considered to be primary pregnant. (primigravida), and with subsequent pregnancies - re-pregnant (multigravida).
- Nullipara - a woman who has never had a pregnancy, has reached the term of a viable fetus; earlier she may or may not have had pregnancies that ended with an abortion at an earlier date.
- Primipara - a woman who delivered one pregnancy (single or multiple) before the birth of a viable fetus.
- Multipara - a woman with a history of several full-term pregnancies before the term of a viable fetus (22 weeks of gestation, fetal weight 500 g, height 32-34 cm).
The number of induced or spontaneous abortions (miscarriages) is noted. If there were abortions, then at what stage of pregnancy, were they accompanied by complications (endometritis, inflammatory diseases of the uterus, uterine perforation, etc.). If possible, clarify the cause of the spontaneous abortion. Abortions preceding pregnancy can lead to miscarriage, pathological course of childbirth.
Multiparous people receive detailed information about their previous pregnancies and childbirth. If there were complications of pregnancy (gestosis, miscarriage, etc.), then detailed information is needed about this, since they are important in predicting the course and outcome of this pregnancy and the upcoming birth. Find out whether the delivery was timely, premature or late, spontaneous or operative (cesarean section, obstetric forceps, vacuum extraction of the fetus).
When delivering by cesarean section, the indications for it should be clarified, if possible, whether it was performed routinely or urgently, how the postoperative period proceeded, and on what day after the operation the patient was discharged.
When collecting an obstetric anamnesis, special attention should be paid to the condition of the child at birth (weight, length, Apgar score, whether the child was discharged from the maternity hospital home or transferred to the 2nd stage of nursing and in this connection), as well as the psychophysical development of the child on present day. In case of an unfavorable outcome, it is necessary to find out at what stage the death of the fetus / newborn occurred: during pregnancy (antenatal death), during childbirth (intrapartum death), in the early neonatal period (postnatal death). It is also necessary to clarify the possible cause of death (asphyxia, birth trauma, hemolytic disease, malformations, etc.).
Detailed information about the course and outcomes of previous pregnancies and childbirth allows us to identify high-risk patients who need special attention and more careful monitoring.
Objective examination. After getting acquainted with the anamnesis, the patient proceeds to an objective study, which begins with an examination.
At inspection pay attention to the growth of a pregnant woman, physique, fatness, condition of the skin, visible mucous membranes, mammary glands, the size and shape of the abdomen.
The skin during pregnancy can have certain features: pigmentation of the face, nipple area, white line of the abdomen. In the second half of pregnancy, so-called pregnancy stripes often appear. Scratches, abscesses on the skin require a special examination. Pallor of the skin and visible mucous membranes, blueness of the lips, yellowness of the skin and sclera, edema are signs of a number of serious diseases.
The objective signs of a former pregnancy and childbirth include a decrease in the tone of the muscles of the anterior abdominal wall, the presence striae gravidarum.
Pay attention to the physique, possible deformations of the skeleton, as they can affect the structure of the pelvis.
Violations of the hormonal regulation of the reproductive system can lead to underdevelopment of the mammary glands, insufficient severity of hair growth in the axillary region and on the pubis, or, conversely, excessive hair growth on the face, lower extremities, along the midline of the abdomen. In women, masculinization features are possible - broad shoulders, a male pelvis.
The severity of subcutaneous adipose tissue should be assessed. Both alimentary and endocrine obesity of the II-III degree adversely affects the course of pregnancy and childbirth.
Measure the height and determine the weight of the pregnant woman. When determining body weight, one should take into account not its absolute values, but the body mass index, which is calculated taking into account the patient's height [body weight in kilograms / (height in meters) 2], which is normally 18-25 kg / m2. With low stature (150 cm and below), a narrowing of the pelvis of varying degrees is often observed; women of tall stature often have a male-type pelvis.
Examination of the abdomen in the third trimester of pregnancy allows you to find out deviations from its normal course. With normal pregnancy and the correct position of the fetus, the belly has an ovoid (ovoid) shape; with polyhydramnios, the abdomen is spherical, its dimensions exceed the norm for the expected duration of pregnancy; with the transverse position of the fetus, the abdomen acquires the shape of a transverse oval. With overstretching or divergence of the muscles of the anterior abdominal wall (more often in multiparous), the abdomen may be saggy. The shape of the abdomen also changes with a narrow pelvis.
Examination of internal organs(cardiovascular system, lungs, digestive organs, kidneys), as well as the nervous system is carried out according to the system generally accepted in therapy.
Obstetric examination includes determining the size of the uterus, examining the pelvis, assessing the position of the fetus in the uterus based on special obstetric techniques. The obstetric examination methods depend on the gestational age.
In the first trimester of pregnancy, the size of the uterus is determined with a two-handed vaginal-abdominal examination, which begins with an examination of the external genital organs. The study is carried out in sterile rubber gloves on a gynecological chair. The woman lies on her back, legs bent at the hip and knee joints and divorced; when examining on a bed, a roller is placed under the sacrum.
The external genitals are treated with an antiseptic solution. The labia majora and labia minora are parted with fingers I and II of the left hand and examine the external genital organs (vulva), the mucous membrane of the vaginal opening, the external opening of the urethra, the excretory ducts of the large glands of the vestibule and the perineum.
For the purpose of examining the walls of the vagina and cervix, research using mirrors. In this case, cyanosis due to pregnancy and various pathological changes in diseases of the vagina and cervix are determined. Vaginal mirrors (Fig. 6.1) are folding, spoon-shaped, metal or plastic. The flap mirror is inserted up to the fornix of the vagina in a closed form, then the flaps are opened, and the cervix becomes accessible for examination. The walls of the vagina are examined with the gradual removal of the speculum from the vagina.
Rice. 6.1. Vaginal mirrors (A - folding, B - spoon-shaped, B - elevator)With vaginal (digital) examination with the fingers of the left hand, the large and small labia are separated; fingers of the right hand (II and III) are inserted into the vagina, I finger is retracted upward, IV and V are pressed to the palm and rest against the perineum. In this case, the condition of the muscles of the pelvic floor, the walls of the vagina (folding, extensibility, loosening), the fornices of the vagina, the cervix (length, shape, consistency) and the external os of the cervix (closed, open, round or slit-like) is determined.
An important criterion for the former childbirth is the shape of the external cervical os, which in those who have given birth has the shape of a longitudinal slit, and in those who have not given birth, it is rounded or punctate (Fig. 6.2). Women who have given birth may have scarring after ruptures of the cervix, vagina, and perineum.
After palpation of the cervix, proceed to two-handed vaginal-abdominal examination(fig. 6.3). With the fingers of the left hand, gently press on the abdominal wall towards the pelvic cavity towards the fingers of the right hand located in the anterior fornix of the vagina. Bringing the fingers of both examining hands together, palpate the body of the uterus and determine its position, shape, size and consistency. After that, they begin to study the fallopian tubes and ovaries, gradually moving the fingers of both hands from the corner of the uterus to the lateral walls of the pelvis. To determine the capacity and shape of the pelvis, examine the inner surface of the pelvic bones, sacral cavity, lateral walls of the pelvis and symphysis.
When examining a pregnant woman in the II-III trimesters, it is necessary to measure the abdominal circumference at the level of the navel (Fig. 6.4) and the height of the uterine fundus (Fig. 6.5) with a centimeter tape when the woman is lying on her back. The height of the standing of the fundus of the uterus above the pubic articulation can be determined by the pelvic meter. These measurements are taken at each visit to the pregnant woman and compare the data obtained with gestational standards.
Normally, by the end of pregnancy, the abdominal circumference does not exceed 100 cm, and the height of the uterine fundus is 35-36 cm. The abdominal circumference of more than 100 cm is usually observed with polyhydramnios, multiple pregnancies, large fetuses, lateral position of the fetus and obesity.
Determination of the size of the pelvis seems to be extremely important, since their decrease or increase can lead to a significant disruption in the course of labor. Of greatest importance during childbirth are the sizes of the small pelvis, which are judged by measuring certain sizes of the large pelvis using a special instrument - a pelvis meter (Fig. 6.6).
Tazometer has the shape of a compass, equipped with a scale on which centimeter and half-centimeter divisions are applied. At the ends of the branches of the pelvis there are buttons that are applied to the protruding points of the large pelvis, somewhat squeezing the subcutaneous fatty tissue. To measure the transverse dimension of the pelvic outlet, a cross-branch pelvis meter was designed.
The measurement of the pelvis is carried out with the woman on her back with a naked stomach and shifted legs. The doctor stands to the right of the pregnant woman, facing her. The branches of the pelvis are taken in such a way that fingers I and II hold the buttons. The scale with divisions is facing up. The index fingers grope for the points, the distance between which is to be measured, pressing the buttons of the spread branches of the pelvis to them. On the scale, the value of the corresponding size is noted.
Determine the transverse dimensions of the pelvis - distantia spinarum, distantia cristarun, distantia trochanterica and straight size - conjugata externa.
Distantia spinarum - the distance between the anterosuperior spines of the iliac bones. The buttons of the pelvis are pressed against the outer edges of the anterosuperior spines. This size is usually 25-26 cm (Fig. 6.7, a).
Distantia cristarum - the distance between the most distant points of the iliac crests. After measurement distantia spinarum the buttons of the pelvis are moved from the spine to the outer edge of the iliac crests until the greatest distance is determined. On average, this size is 28-29 cm (Fig. 6.7, b).
Distantia trochanterica - the distance between the greater trochanters of the femur. The most protruding points of the greater trochanters are determined and the buttons of the pelvis are pressed against them. This size is 31-32 cm (Fig. 6.7, c).
The ratio of the transverse dimensions is also important. Normally, the difference between them is 3 cm; a difference of less than 3 cm indicates a deviation from the norm in the structure of the pelvis.
Conjugata externa- external conjugate, allowing you to indirectly judge the direct size of the small pelvis. To measure it, a woman should lie on her left side, bending her left leg at the hip and knee joints, and keeping her right leg extended. The button of one branch of the pelvis is set in the middle of the upper outer edge of the symphysis, the other end is pressed against the supracacral fossa, which is located under the spinous process of the V lumbar vertebra, corresponding to the upper corner of the sacral rhombus. You can determine this point by sliding your fingers down the spinous processes of the lumbar vertebrae. The fossa is easily identified under the prominence of the spinous process of the last lumbar vertebra. The external conjugate is normally 20-21 cm (Figure 6.7, d).
The external conjugate is important - its size can be used to judge the size of the true conjugate (direct size of the entrance to the small pelvis). To determine the true conjugate from the length of the outer conjugate, subtract9 cm... For example, if the external conjugate is20 cm, then the true conjugate is11 cm; if the outer conjugate has a length18 cm, then the true one is9 cmetc.
The difference between the outer and the true conjugate depends on the thickness of the sacrum, symphysis, and soft tissues. The thickness of bones and soft tissues in women is different, so the difference between the size of the outer and true conjugates does not always correspond exactly to 9 cm. The true conjugate can be more accurately determined by the diagonal conjugate.
Diagonal conjugate ( conjuigata diagonalis) represents the distance between the lower edge of the symphysis and the most protruding part of the promontory of the sacrum. This distance can be measured only with a vaginal examination, if the middle finger reaches the sacral promontory (Fig. 6.8). If it is not possible to reach this point, then the distance exceeds 12.5-13 cm and, therefore, the direct size of the entrance to the pelvis is within the normal range: equal to or exceeds 11 cm.If the sacral promontory is reached, then the point of contact with the lower edge is fixed on the arm symphysis, and then measure this distance in centimeters.
To determine the true conjugate, 1.5-2 cm is subtracted from the size of the diagonal conjugate.
If, when examining a woman, there is a suspicion of a narrowing of the pelvic outlet, then the dimensions of the exit plane are determined.
The dimensions of the pelvic outlet are determined as follows. The woman lies on her back, legs are bent at the hip and knee joints, divorced and pulled up to the stomach.
Straight size pelvic outlet is measured with a conventional pelvis meter. One button of the pelvis is pressed to the middle of the lower edge of the symphysis, the other to the apex of the coccyx (Fig. 6.9, a). The resulting size (11 cm) is larger than the true one. To determine the direct size of the pelvic outlet, subtract 1.5 cm (tissue thickness) from this value. In a normal pelvis, the straight plane size is 9.5 cm.
Transverse dimension exit - the distance between the inner surfaces of the ischial bones - is difficult to measure. This size is measured with a centimeter or a hip-meter with crossed branches in the position of a woman on her back with her legs brought to her stomach. In this area there is subcutaneous fatty tissue, therefore 1-1.5 cm is added to the resulting size. Normally, the transverse size of the pelvic outlet is 11 cm (Fig. 6.9, b).
In the same position, women are measured to assess the features of the small pelvis pubic angle applying I fingers to the pubic arches. With normal size and normal shape of the pelvis, the angle is 90 °.
In case of deformation of the pelvic bones, the oblique dimensions of the pelvis are measured. These include:
Distance from the anterior superior iliac spine of one side to the posterior superior spine of the other side and vice versa;
Distance from the upper edge of the symphysis to the right and left posterosuperior awns;
Distance from the suprasacral fossa to the right or left anterosuperior spines.
The oblique dimensions of one side are compared with the corresponding oblique dimensions of the other. With a normal structure of the pelvis, the value of the paired oblique sizes is the same. A difference greater than 1 cm indicates pelvic asymmetry.
If it is necessary to obtain additional data on the size of the pelvis, its compliance with the size of the fetal head, deformities of the bones and their joints, an X-ray examination of the pelvis is performed - X-ray pelviometry (according to indications).
In order to objectively assess the thickness of the pelvic bones, measure the circumference of the wrist joint of the pregnant woman with a measuring tape (Soloviev index; Fig. 6.10). The average size of this circumference is 14 cm. If the index is greater, it can be assumed that the pelvic bones are massive and the size of its cavity is smaller than would be expected from the results of measuring the large pelvis.
Indirect signs of a correct physique and normal size of the pelvis are the shape and size of the sacral rhombus (Michaelis rhombus). The upper border of the Michaelis rhombus is the last lumbar vertebra, the lower one is
the sacrococcygeal joint, and the lateral angles correspond to the posterior superior spines of the iliac bones (the sacral rhombus of the classical form can be seen at the statue of Venus de Milo). Normally, pits are visible in all four corners (Fig. 6.11). The dimensions of the rhombus are measured with a centimeter tape, normally the longitudinal size is 11 cm, the transverse one is 10 cm.
External obstetric examination. Obstetric terminology. The abdomen is palpated in the position of the pregnant woman on her back with the legs bent at the hip and knee joints. The doctor is to the right of the pregnant woman, facing her.
Palpation of the abdomen determines the state of the abdominal wall, rectus abdominis muscles (whether there are any discrepancies, hernial protrusions, etc.). The tone of the muscles of the abdominal wall is of great importance for the course of labor.
Then they move on to determining the size of the uterus, its functional state (tone, tension during examination, etc.) and the position of the fetus in the uterine cavity.
Determining the position of the fetus in the uterus is of great importance. In the third trimester of pregnancy, especially before childbirth and during childbirth, the articulation, position, position, type, presentation of the fetus are determined (Fig. 6.12).
When palpating the abdomen, they use the so-called external methods of obstetric research (Leopold's methods). Leopold (1891) proposed a system of abdominal palpation and typical palpation techniques that have received universal recognition.
The first reception of an external obstetric examination(Fig. 6.13, a). The goal is to determine the height of the uterine fundus and the part of the fetus located in its fundus.
The palms of both hands are placed on the uterus in such a way that they tightly cover its bottom, and the fingers are turned by the nail phalanges to each other. Most often, at the end of pregnancy, the buttocks are determined in the bottom of the uterus. Usually it is not difficult to distinguish them from the head, since the pelvic end is less dense and does not have a clear sphericity.
The first external reception of obstetric examination makes it possible to judge the duration of pregnancy (by the height of the uterine fundus), the position of the fetus (if one of its large parts is determined in the bottom of the uterus, then there is a longitudinal position) and presentation (if the buttocks are determined in the bottom of the uterus , then the presenting part is the head).
Second reception of external obstetric examination(Fig. 6.13, b). The goal is to determine the position of the fetus, which is judged by the location of the back and small parts of the fetus (arms, legs).
Hands are moved from the bottom of the uterus to its right and left sides to the level of the navel and below. Gently pressing with the palms and fingers of both hands on the side walls of the uterus, they determine which side the back and small parts of the fetus are facing. The backrest is recognized as a wide and curved surface. Small parts of the fruit are defined on the opposite side in the form of small movable tubercles. In multiparous women, due to the flabbiness of the abdominal wall and the muscles of the uterus, small parts of the fetus are more easily felt.
By the way the fetal back is facing, its position is recognized: the back to the left is the first position, the back to the right is the second position.
In the process of carrying out the second reception of an external obstetric examination, it is possible to determine the excitability of the uterus. Excitability is increased if, in response to palpation, the uterus tenses. You can determine the increased amount of amniotic fluid by the symptom of fluctuation -
one hand receives a push from the opposite.
The third reception of an external obstetric examination(Fig. 6.13, c). Target -
determine the presenting part and its relation to the small pelvis.
One, usually the right, hand covers the presenting part, after which they carefully move this hand to the right and to the left. This technique allows you to determine the presenting part (head or buttocks), the ratio of the presenting part to the entrance to the small pelvis (if it is mobile, then it is located above the entrance to the pelvis, if motionless, then it stands at the entrance to the pelvis or in the deeper parts of the small pelvis).
The fourth reception of an external obstetric examination(Figure 6.13, d). Target -
determine the presenting part (head or buttocks), the location of the presenting part (above the entrance to the small pelvis, at the entrance or deeper, where exactly), in what position the presenting head is located (in bent or unbent).
The doctor stands facing the legs of a pregnant woman or woman in labor and places his palms on either side of the lower part of the uterus. With the fingers of both hands facing the entrance to the pelvis, gently and slowly penetrate between the presenting part and the lateral parts of the entrance to the pelvis and palpate the accessible areas of the presenting part.
If the presenting part is mobile above the entrance to the pelvis, the fingers of both hands can be brought almost entirely under it, especially in women who have multiparous. In this case, the presence or absence of symptom of running, characteristic of the head. To do this, the palms of both hands are pressed tightly to the lateral parts of the fetal head, then the right hand is pushed in the area of the right half of the head. In this case, the head is pushed to the left and transfers the push to the left hand .
With a cephalic presentation, one should strive to get an idea of the size of the head and the density of the bones of the skull, the location of the occiput, forehead and chin, as well as their relationship to each other.
With the help of the fourth technique, it is possible to determine the presence or absence of an angle between the back of the head and the back of the fetus (the higher the chin with the head fixed at the entrance, the more pronounced the flexion and the more smoothed the angle between the back of the head and the back, and vice versa, the lower the chin is located, the more extended head), position and appearance of the fetus according to where the back of the head, forehead, chin are directed. For example, the back of the head is facing left and anteriorly - first position, front view; chin facing left and forward - second position, rear view, etc.
With a cephalic presentation, it is also necessary to determine the depth of the head. At the fourth external reception of obstetric examination, the fingers of both hands produce a sliding movement along the head towards you. With a high standing of the fetal head, when it is mobile above the entrance, you can bring the fingers of both hands under it and even move it away from the entrance (Fig. 6.14, a). If at the same time the fingers diverge, the head is at the entrance to the small pelvis in a small segment (Fig. 6.14, b). If the hands sliding along the head converge, then the head is either located in a large segment at the entrance, or passed through the entrance and sank into deeper parts (planes) of the pelvis (Fig. 6.14, c). If the fetal head is located so low in the pelvic cavity that it completely fulfills it, then usually it is not possible to probe the head with external methods.
Auscultation. The fetal heartbeat in a pregnant woman and a woman in labor is usually listened to with an obstetric stethoscope. Its wide funnel is applied to the woman's belly.
On auscultation, fetal heart sounds are determined. In addition, you can catch other sounds emanating from the mother's body: the beating of the abdominal aorta, which coincides with the woman's pulse; "blowing" uterine murmurs that occur in large blood vessels passing along the lateral walls of the uterus (coincide with the woman's pulse); irregular bowel sounds. Fetal heart sounds give an indication of the condition of the fetus.
The heart sounds of the fetus are heard from the beginning of the second half of pregnancy and become clearer every month. They are heard from the back of the fetus, and only with a facial presentation is the fetal heartbeat more clearly heard from the side of its chest. This is due to the fact that in the facial presentation, the head is maximally unbent and the breast is closer to the wall of the uterus than the back.
With an occipital presentation, the heartbeat is well heard below the navel on the left in the first position, on the right in the second (Fig. 6.16). With breech presentation, the heartbeat is heard at or above the navel.
In transverse positions, the heartbeat is heard at the level of the navel, closer to the head of the fetus.
With multiple pregnancies, the fetal heartbeat is usually clearly heard in different parts of the uterus.
During childbirth, with the lowering of the fetal head into the pelvic cavity and its birth, the heartbeat is better heard closer to the symphysis, almost along the midline of the abdomen.
ADDITIONAL EXAMINATION METHODS IN OBSTETRACT AND PERINATOLOGY
Assessment of fetal cardiac activity. Cardiac activity is the most accurate and objective indicator of the state of the fetus in the ante- and intranatal periods. To evaluate it, use auscultation with an obstetric stethoscope, electrocardiography (direct and indirect), phonocardiography and cardiotocography.
Indirect electrocardiography performed by placing electrodes on the anterior abdominal wall of the pregnant woman (the neutral electrode is located on the thigh). Normally, the ventricular complex is clearly visible on the electrocardiogram (ECG) QRS, sometimes prong R... Maternal complexes are easy to differentiate with the simultaneous registration of the mother's ECG. The fetal ECG can be recorded from the 11-12th week of pregnancy, but it can be recorded in 100% of cases only by the end of the third trimester. As a rule, indirect electrocardiography is used after 32 weeks of pregnancy.
Direct electrocardiography is performed when electrodes are applied to the fetal head during childbirth when the cervix is opened by 3 cm or more. On a straight ECG, an atrial tooth is noted R, ventricular complex QRS and prong T.
When analyzing the antenatal ECG, the heart rate, rhythm, size and duration of the ventricular complex, as well as its shape, are determined. Normally, the rhythm of the heartbeat is correct, the heart rate ranges from 120 to 160 minutes, the tooth R pointed, the duration of the ventricular complex 0.03-0.07 s, voltage 9-65 μV. With increasing gestational age, the voltage gradually rises.
Phonocardiogram(PCG) of the fetus is recorded when the microphone is placed at the point where the stethoscope can best listen to its heart sounds. It is usually represented by two groups of oscillations that reflect I and II heart sounds. Sometimes III and IV tones are recorded. The duration and amplitude of heart sounds fluctuate noticeably in the III trimester of pregnancy, on average, the duration of the I tone is 0.09 s (0.06-0.13 s), the II tone is 0.07 s (0.05-0.09 s) ...
With the simultaneous recording of the ECG and PCG of the fetus, it is possible to calculate the duration of the phases of the cardiac cycle: phases of asynchronous contraction (AC), mechanical systole (Si), total systole (So), diastole (D). The phase of asynchronous contraction is detected between the onset of the wave Q and I tone, its duration is 0.02-0.05 s. Mechanical systole is the distance between the onset of I and II tones and lasts from 0.15 to 0.22 s.
General systole includes mechanical systole and an asynchronous contraction phase. Its duration is 0.17-0.26 s. Diastole is calculated as the distance between the beginning of II and I tone, its duration is 0.15-0.25 s. The ratio of the duration of total systole to the duration of diastole at the end of an uncomplicated pregnancy averages 1.23.
Despite the high information content, the methods of fetal electrocardiography and phonocardiography are laborious, and the analysis of the data obtained takes a long time, which limits their use for a quick assessment of the state of the fetus. In this regard, at present, cardiotocography is widely used in obstetric practice (from the 28-30th week of pregnancy).
Cardiotocography. Distinguish between indirect (external) and direct (internal) cardiotocography. During pregnancy, only indirect cardiotocography is used; at present, it is also used in childbirth, since the use of external sensors has practically no contraindications and does not cause any complications (Fig. 6.17).
An external ultrasound transducer is placed on the anterior abdominal wall of the mother in the place where the fetal heart sounds are best heard, an external strain gauge transducer is placed in the fundus of the uterus. When using the internal registration method during childbirth, a special spiral electrode is attached to the skin of the fetal head.
The study of the cardiotocogram (CTG) begins with the determination of the basal rhythm (Fig. 6.18). Basal rhythm is understood as the average value between the instantaneous values of the fetal heart rate, which remains unchanged for 10 minutes or more; this does not take into account the acceleration and deceleration.
When characterizing the basal rhythm, it is necessary to take into account its variability, i.e. the frequency and amplitude of instantaneous changes in the fetal heart rate (instantaneous oscillations). The frequency and amplitude of instantaneous oscillations are determined during each subsequent 10 minutes. The amplitude of the oscillations is determined by the magnitude of the deviation from the basal rhythm, the frequency is determined by the number of oscillations in 1 min.
In clinical practice, the following classification of types of basal rhythm variability is most widespread:
Silent (monotonous) rhythm with low amplitude (0.5 per minute);
Slightly undulating (5-10 per minute);
Undulating (10-15 per minute);
Saltatory (25-30 per minute).
The variability of the amplitude of instantaneous oscillations can be combined with a change in their frequency.
The recording is carried out in the position of the woman on the left side for 40-60 minutes.
To unify and simplify the interpretation of antenatal CTG data, a scoring system is proposed (Table 6.1).
Table 6.1. The scale for assessing the cardiac activity of the intrauterine fetus
A score of 8-10 points indicates the normal state of the fetus, 5-7 points - indicates the initial signs of a violation of its vital functions, 4 points or less - on serious changes in the state of the fetus.
In addition to analyzing the fetal cardiac activity at rest, using cardiotocography, it is possible to assess the reactivity of the fetus during pregnancy by changing its cardiac activity in response to spontaneous movements. This is a non-stress test (NST) or stress test for the mother's administration of oxytocin, holding the breath briefly during inhalation or exhalation, thermal irritation of the abdominal skin, exercise, nipple stimulation, or acoustic stimulation.
It is advisable to start the study of fetal cardiac activity with the use of NBT.
Nestreccotest... The essence of the test is to study the reaction of the fetal cardiovascular system to its movements. NBT is called reactive if, within 20 minutes, there are two or more fetal heart rate increases by at least 15 per minute and lasting at least 15 seconds, associated with fetal movements (Fig. 6.19). NBT is considered to be non-reactive with less than two fetal heart rates of less than 15 per minute for a duration of less than 15 seconds for 40 minutes.
Oxytocin test(contractile stress test). The test is based on the reaction of the fetal cardiovascular system to the induced contractions of the uterus. A woman is injected intravenously with a solution of oxytocin containing 0.01 U in 1 ml of isotonic sodium chloride solution or 5% glucose solution. The test can be evaluated if at least three contractions of the uterus are observed within 10 minutes at an injection rate of 1 ml / min. With sufficient compensatory capabilities of the fetoplacental system, in response to uterine contraction, a mildly expressed short-term acceleration or early short-term deceleration is observed.
Contraindications to the oxytocin test: pathology of attachment of the placenta and its partial premature detachment, threat of termination of pregnancy, scar on the uterus.
When determining the state of the fetus in childbirth on CTG, the basal rhythm of the heart rate, the variability of the curve, as well as the nature of slow accelerations (accelerations) and decelerations (decelerations) of the heart rate are assessed, comparing them with data reflecting the contractile activity of the uterus.
Depending on the time of occurrence relative to the contractions of the uterus, four types of decelerations are distinguished: dip 0, dip I, dip II, dip III. The most important parameters of deceleration are the duration and amplitude of the time from the onset of the contraction to the onset of the decrease. When examining the time ratios of CTG and histograms, there are early (the beginning of a decrease in the heartbeat coincides with the onset of a contraction), late (30-60 s after the start of contraction of the uterus), and a decrease outside a contraction (after 60 s or more).
Dip 0 usually occurs in response to uterine contractions, rarely sporadically, lasts 20-30 seconds and has an amplitude of 30 per minute or more. In the second stage of labor, it has no diagnostic value.
Dip 1 (early deceleration) is a reflex reaction of the fetal cardiovascular system to compression of the head or umbilical cord during contractions. Early deceleration begins simultaneously with the contraction or with a delay of up to 30 s and has a gradual beginning and end (Fig. 6.20). The duration and amplitude of decelerations correspond to the duration and intensity of the contraction. Dip 1 is equally common in physiological and complicated labor.
Dip II (late deceleration) is a sign of impaired uteroplacental circulation and progressive fetal hypoxia. Late deceleration occurs in connection with the contraction, but it is significantly delayed - up to 30-60 s from its beginning. The total duration of decelerations is usually more than 1 min. There are three degrees of severity of decelerations: mild (amplitude of reduction up to 15 per minute), medium (16-45 per minute) and severe (more than 45 per minute). In addition to the amplitude and total duration of late deceleration, the severity of the pathological process reflects the recovery time of the basal rhythm. By shape, V-, U- and W-shaped decelerations are distinguished.
Dip III is called variable deceleration. Its appearance is usually associated with the pathology of the umbilical cord and is explained by stimulation of the vagus nerve and secondary hypoxia. The amplitude of variable decelerations ranges from 30 to 90 per minute, and the total duration is 30-80 s or more. Decelerations are very diverse in form, which makes their classification much more difficult. The severity of variable decelerations depends on the amplitude: light - up to 60 per minute, moderate - from 61 to 80 per minute, and severe - more than 80 per minute.
In practice, the most convenient assessment of the state of the fetus is the time of delivery according to the scale proposed by G.M. Savelyeva (1981) (Table 6.2).
Table 6.2. Scale for assessing fetal cardiac activity in childbirth (Savelyeva G.M., 1981)
Period childbirth | Options hearty activities | Norm | Initial signs hypoxia | Expressed signs hypoxia |
Basal heart rate | Bradycardia (up to 100) Tachycardia (no more than 180) | Bradycardia (less than 100) |
||
Instantaneous heart rate fluctuations (MHR) | Periodic monotony (0-2) | Persistent monotony (0-2) |
||
Reaction to the fight | Absent; an increase in the amplitude of the MCCHR; early cuts | Short-term late cuts | Long late cuts |
|
Bradycardia | Bradycardia (less than 100 with a progressive drop in frequency); tachycardia (more than 180) |
|||
Periodic monotony | monotone; severe arrhythmia |
|||
Push response | Early cuts (up to 80 per minute); W-shaped variable reduction (up to 75-85 per minute); short-term frequency (up to 180 per minute) | Late cuts (up to 60 per minute); W-shaped variable reduction (up to 60 per minute) | Long late cuts (up to 50 per minute); long W-shaped variable reduction (up to 40 per minute) |
When using cardiotocography during childbirth, a constant assessment of the fetal cardiac activity is necessary throughout their entire course.
Ultrasound scanning (echography). Ultrasound examination (ultrasound) is currently the only highly informative, harmless and non-invasive method that allows you to objectively monitor the development of the embryo from the earliest stages and to conduct dynamic monitoring of the state of the fetus. The method does not require special preparation of the pregnant woman. In obstetric practice, transabdominal and transvaginal scanning is used.
Establishing pregnancy and assessing its development in the early stages are the most important tasks of ultrasound diagnostics in obstetrics (Fig. 6.21).
Diagnosis of uterine pregnancy with ultrasound is possible from the earliest possible date. From the 3rd week in the uterine cavity, the ovum begins to be visualized in the form of an echo-negative formation of a round or ovoid shape with a diameter of 5-6 mm. At 4-5 weeks, it is possible to identify an embryo - an echo-positive strip 6-7 mm in size. The head of the embryo is identified from 8-9 weeks in the form of a separate rounded anatomical formation with an average diameter of 10-11 mm.
The most accurate indicator of gestational age in the first trimester is the coccygeal-parietal size (CTE) (Fig. 6.22). When the embryo is not yet visible or is difficult to identify, it is advisable to use the average inner diameter of the ovum to determine the gestational age.
Assessment of the vital activity of the embryo in the early stages of gestation is based on the registration of its cardiac activity and motor activity. With ultrasound, the cardiac activity of the embryo can be recorded from 4-5 weeks. The heart rate gradually increases from 150-160 per minute at 5-6 weeks. up to 175-185 per minute at 7-8 weeks, followed by a decrease to 150-160 per minute by 12 weeks. Motor activity is detected from 7-8 weeks.
When studying the development of the fetus in the II and III trimesters of pregnancy, the biparietal size and circumference of the head, the average diameter of the chest, diameters or circumference of the abdomen, as well as the length of the femur are measured, while determining the estimated weight of the fetus (Fig.6.23).
With the use of modern ultrasound equipment, it became possible to assess the activity of various organs and systems of the fetus. Most congenital malformations can be diagnosed antenatally. For their detailed assessment, three-dimensional echography is used, which gives a three-dimensional image.
Ultrasound makes it possible to accurately establish the localization, thickness and structure of the placenta. With real-time scanning, especially with transvaginal examination, a clear image of the chorion can be obtained from 5-6 weeks of gestation.
An important indicator of the condition of the placenta is its thickness, with typical growth as pregnancy progresses. By 36-37 weeks, the growth of the placenta stops. In the future, during the physiological course of pregnancy, the thickness of the placenta decreases or remains at the same level, amounting to 3.3-3.6 cm.
Ultrasound signs of changes in the placenta as pregnancy progresses are determined by the degree of maturity according to P. Grannum (Table 6.3, Fig. 6.24).
Table 6.3. Ultrasound signs of the degree of maturity of the placenta
Degree maturity of the placenta | Chorial membrane | Parenchyma | Basal layer |
Straight, smooth | Homogeneous | Not identified |
|
Slightly wavy | Few echogenic zones | Not identified |
|
With grooves | Linear echogenic seals | Linear arrangement of small echogenic zones (basal dotted line) |
|
With depressions reaching the basal layer | Rounded seals with central vacuum | Large and partly confluent echogenic zones, giving an acoustic shadow |
Doppler study of blood flow in the mother-placenta-fetus system. There are quantitative and qualitative methods for assessing Doppler blood flow in the studied vessel. In obstetric practice, qualitative analysis is widely used. In this case, it is not the absolute value of the blood velocity that is of primary importance, but the ratio of blood flow velocities in systole (C) and diastole (D). The most commonly used systolic-diastolic ratio (SDR), pulsation index (PI), to calculate which additionally take into account the average blood flow velocity (MCV), as well as the index of resistance (IR) (Fig. 6.25).
The greatest practical value during pregnancy is the study of the uteroplacental blood flow: in the uterine arteries, their branches (spiral, arcuate, radial) and umbilical cord arteries, as well as fetal hemodynamics: in the aorta and cerebral vessels of the fetus. Currently, the study of venous blood flow in the fetus in ductus venosus.
During uncomplicated pregnancy, the indicators of peripheral vascular resistance gradually decrease, which is expressed by a decrease in blood flow indices (Table 6.4).
Table 6.4. Doppler measurements in the fetal aorta, umbilical cord artery and uterine artery in the third trimester of uncomplicated pregnancy, M ± m
An increase in vascular resistance, manifested primarily by a decrease in the diastolic component of blood flow, leads to an increase in these indices.
In obstetric practice, fetal Doppler echocardiography is also used. It has the greatest practical value in the diagnosis of congenital heart defects.
Color Doppler mapping (CDM) is a combination of two-dimensional echo pulse information and color information about the blood flow rates in the organs under study. The high resolution of the devices makes it possible to visualize and identify the smallest vessels of the microvasculature. This makes the method indispensable in the diagnosis of vascular pathology, in particular, for the detection of retroplacental bleeding; vascular changes in the placenta (angioma), their anastomoses, leading to reverse arterial perfusion in twins, entanglement of the umbilical cord. In addition, the method allows one to assess malformations of the heart and intracardiac shunts (from the right ventricle to the left through an interventricular septal defect or regurgitation through a valve), to identify the anatomical features of fetal vessels, especially of small caliber (renal arteries, circle of Willis in the fetal brain). The CDC provides the ability to study blood flow in the branches of the uterine artery (up to the spiral arteries), terminal branches of the umbilical artery, and the intervillous space.
Determination of the biophysical profile of the fetus. Real-time ultrasound devices make it possible not only to assess the anatomical features of the fetus, but also to obtain fairly complete information about its functional state. Currently, the so-called fetal biophysical profile (BFPP) is used to assess the intrauterine state of the fetus. Most authors include non-stress test data and indicators determined by real-time ultrasound scanning in this concept: respiratory movements, motor activity, fetal tone, amniotic fluid volume, placenta maturity (Table 6.5).
Options | 2 points | 1 point | 0 points |
Non-stress test | 5 or more accelerations with an amplitude of at least 15 per minute and a duration of at least 15 s, associated with fetal movements in 20 minutes | From 2 to 4 accelerations with an amplitude of at least 15 per minute and a duration of at least 15 s, associated with fetal movements in 20 minutes | 1 acceleration and less in 20 minutes |
Fetal motor activity | At least 3 generalized movements within 30 minutes | 1 or 2 generalized fetal movements within 30 minutes | Absence of generalized fetal movements within 30 minutes |
Respiratory movements of the fetus | At least 1 episode of respiratory movements lasting at least 60 s in 30 minutes | At least 1 episode of respiratory movements lasting from 30 to 60 seconds in 30 minutes | Lack of breathing or breathing lasting less than 30 seconds in 30 minutes |
Muscle tone | 1 episode of return of fetal limbs from extended to flexed position or more | At least 1 episode of the return of the fetal limbs from extended to flexed position | Extremities in an extended position |
Amniotic fluid | Vertical pocket of a free area of water 2-8 cm | 2 pockets or more amniotic fluid 1-2 cm in size | Amniotic fluid pocket less than 1 cm |
maturity placenta | Corresponds to gestational age | III degree of maturity up to 37 weeks |
The high sensitivity and specificity of BFPP are explained by a combination of markers of acute (non-stress test, respiratory movements, motor activity and fetal tone) and chronic (amniotic fluid volume, degree of maturity of the placenta) fetal disorders. Reactive NBT, even without additional data, indicates a satisfactory condition of the fetus, with non-reactive NBT, ultrasound of the remaining biophysical parameters of the fetus is shown.
Determination of BFPP is possible already from the beginning of the third trimester of pregnancy.
Ultrasound examination of the brain (neurosonography) of the newborn. Indications for neurosonography in the early neonatal period are chronic oxygen deficiency in the intrauterine period of development, birth in breech presentation, operative delivery, rapid and rapid labor, asphyxia, as well as high or low birth weight, neurological symptoms.
The study is carried out using sectoral sensors (3.5-7.5 MHz). No special drug preparation is required. The duration of the study is on average 10 minutes.
With an echographic examination of the brain, standard sections are successively obtained in the coronary and sagittal planes through the large fontanelle (Fig. 6.26). Scanning through the temporal bone of the child's head allows for a better assessment of the state of the extracerebral spaces. Cerebral blood flow in children is determined mainly in the anterior and middle cerebral arteries. Arteries appear on the screen as pulsating structures. Visualization is greatly facilitated by the use of color Doppler imaging. When analyzing the curves of blood flow velocities in the cerebral vessels, the systolic-diastolic ratio and the resistance index are determined.
With neurosonography, it is possible to diagnose ischemia and cerebral edema, changes in the ventricular system of the brain, intracranial hemorrhages of various localization and severity, malformations of the central nervous system.
Study of amniotic fluid includes the determination of the amount, color, transparency, biochemical, cytological and hormonal composition.
Determination of the amount of amniotic fluid... Determination of the volume of amniotic fluid by ultrasound can be subjective or objective. An experienced specialist can assess the amount of amniotic fluid with a careful longitudinal scan (a large amount of fluid between the fetus and the anterior abdominal wall of a pregnant woman with polyhydramnios, a sharp decrease in the number of spaces free from echo structures, with oligohydramnios).
There are objective semi-quantitative echographic criteria for non-invasive assessment of the amount of amniotic fluid. To do this, measure the depth of the free area of the amniotic fluid (vertical pocket), the value of which is normally from 2 to 8 cm.A more accurate method for determining the volume of amniotic fluid is to calculate the amniotic fluid index (AFI) by ultrasound - the sum of the maximum pocket sizes in the four quadrants of the cavity uterus. With a normal pregnancy, the AFI is 8.1-18 cm.
Amnioscopy- transcervical examination of the lower pole of the fetal bladder. During amnioscopy, attention is paid to the color and consistency of amniotic fluid, an admixture of meconium or blood, the presence and mobility of flakes of caseous grease. Indications for amnioscopy are suspicion of chronic fetal hypoxia, prolonged pregnancy, isoserological incompatibility of the blood of the mother and the fetus. For amnioscopy, the pregnant woman is placed in a gynecological chair and a vaginal examination is performed to determine the patency of the cervical canal. Under aseptic conditions, on the finger or after exposing the neck with mirrors, a tube with a mandrel is led into the cervical canal by the internal pharynx. The diameter of the tube is selected depending on the opening of the neck (12-20 mm). After removing the mandrel and turning on the illuminator, the tube is positioned so that the presenting part of the fetus is visible, from which the light beam is reflected. If a mucous plug interferes with inspection, it is carefully removed using a swab. With a low location of the placenta on the membranes, the vascular pattern is clearly visible. Contraindications to amnioscopy: inflammation in the vagina and cervix, placenta previa.
Amniocentesis- an operation, the purpose of which is to obtain amniotic fluid for biochemical, hormonal, immunological, cytological and genetic research. The results provide an indication of the condition of the fetus.
Indications for amniocentesis are isoserological incompatibility of the blood of the mother and the fetus, chronic fetal hypoxia (prolonged pregnancy, gestosis, extragenital diseases of the mother, etc.), establishing the degree of maturity of the fetus, antenatal diagnosis of its sex, the need for karyotyping in case of suspected congenital or hereditary fetal pathology , microbiological research.
Depending on the puncture site, a distinction is made between transvaginal and transabdominal amniocentesis. The operation is performed under ultrasound guidance, choosing the most convenient puncture site depending on the location of the placenta and small parts of the fetus (Fig. 6.27).
In transabdominal amniocentesis, after treatment of the anterior abdominal wall with an antiseptic, anesthesia of the skin, subcutaneous tissue and subaponeurotic space is done with 0.5% novocaine solution. For research, take 10-15 ml of amniotic fluid. In pregnant women with Rh sensitization, when a study of the optical density of bilirubin (OPB) is necessary, a sample of amniotic fluid should be quickly transferred to a dark vessel to avoid changes in the properties of bilirubin under the influence of light. Samples contaminated with blood or meconium are unsuitable for testing.
Transvaginal amniocentesis is performed through the anterior vaginal fornix, cervical canal, or posterior vaginal fornix. The choice of the place of insertion of the puncture needle depends on the location of the placenta. After sanitation of the vagina, the cervix is fixed with bullet forceps, shifted up or down, depending on the chosen method, and a puncture of the vaginal wall is made at an angle to the wall of the uterus. When the puncture needle enters the uterine cavity, amniotic fluid begins to emerge from its lumen.
Complications possible with amniocentesis: premature rupture of amniotic fluid (more often with transcervical access), injury of fetal vessels, injury of the urinary bladder and intestines of the mother, chorioamnionitis. Complications of amniocentesis can also include premature rupture of the membranes, premature birth, placental abruption, fetal injury, and cord injury. However, due to the widespread introduction of ultrasound control during this operation, complications are extremely rare. In this regard, the contraindications to amniocentesis have also changed: almost the only contraindication to it is the threat of termination of pregnancy. Amniocentesis, like all invasive interventions, is performed only with the consent of the pregnant woman.
Determination of the degree of maturity of the fetus... For this purpose, a cytological study of amniotic fluid is carried out. To obtain and study the sediment, amniotic fluid is centrifuged at 3000 rpm for 5 minutes, smears are fixed with a mixture of ether and alcohol, then stained using the Garras-Shore, Papanicolaou method or, more often, 0.1% Nile blue sulfate solution. Nuclear-free lipid-containing cells (a product of the sebaceous glands of the fetal skin) are colored orange (the so-called orange cells). Their content in the smear corresponds to the maturity of the fetus: before 38 weeks of gestation, the number of these cells does not exceed 10%, and after
38 weeks reaches 50%.
To assess the maturity of the fetal lungs, the concentration of phospholipids in the amniotic fluid is also determined, primarily the lecithin / sphingomyelin (L / C) ratio. Lecithin, saturated with phosphatidylcholine, is the main active principle of the surfactant. Interpretation of the value of the ratio L / C:
L / S = 2: 1 or more - mature lungs. Only 1% of newborns are at risk of developing respiratory distress syndrome;
L / S = 1.5-1.9: 1 - development of respiratory distress syndrome is possible in 50% of cases;
L / S = less than 1.5: 1 - the development of respiratory distress syndrome is possible in 73% of cases.
The method of qualitative assessment of the ratio of lecithin and sphingomyelin (foam test) has also found practical application. For this purpose, 3 ml of ethyl alcohol is added to a test tube with 1 ml of amniotic fluid and within
Shake the tube for 3 minutes. The formed ring of foam indicates the maturity of the fetus (positive test), the absence of foam (negative test) indicates the immaturity of the lung tissue.
Diagnostics of the rupture of amniotic fluid... One of the methods for diagnosing rupture of amniotic fluid during pregnancy is a cytological examination of freshly colored preparations. A drop of vaginal contents is applied to a glass slide, a drop of 1% eosin solution is added and covered with a cover glass. Under a microscope on a pink background, brightly colored epithelial cells of the vagina with nuclei, erythrocytes, leukocytes are visible. When the waters have receded, large accumulations of uncolored "scales" of the skin of the fetus are visible.
In recent years, in order to diagnose prenatal rupture of amniotic fluid, the amnio test is widely used - special tampons soaked in a reagent, which change color when in contact with amniotic fluid.
X-ray examination. Due to the negative effect of ionizing radiation on the embryo and fetus, X-ray examination is rarely used. At the end of pregnancy, the radiosensitivity of the fetus decreases, X-ray examinations at this time are less dangerous. In obstetric practice, to clarify changes in the bone pelvis, sometimes they resort to X-ray pelvimetry, which allows you to determine the shape and true dimensions of the small pelvis.
Indications for roentgenopelviometry: suspicion of a discrepancy between the size of the mother's pelvis and the fetal head, anomalies in the development of the pelvis, spinal trauma.
Direct and lateral images of the pelvis are made. On the radiograph, taken in frontal projection, measure the transverse size of the pelvis and the frontal-occipital size of the head. On the lateral radiograph, the true conjugate and the large transverse size of the head are determined. The shape and size of the sacrum on the roentgenogram are characterized by the length of its chord, the angle of the sacral curvature and the size of its radius. To assess the sacrum, the sacral index is used, which is calculated as the ratio of the length of the sacral chord to the radius of the sacral curvature. The sacral index reflects the length of the sacrum and the severity of its curvature. Determination of flattening of the sacrum is an important sign for predicting the nature of the birth act.
Radiopelviometry data allow you to clarify the shape of the narrow pelvis and accurately determine the degree of narrowing.
Determination of tissue pO 2at the fetus... The oxygen tension (pO2) in the tissues of the fetus can be determined by the polarographic method during childbirth in the absence of the fetal bladder. This provides early diagnosis of intrauterine fetal hypoxia. Intra- and percutaneous polarographic method can be used. For the intradermal determination of pO2, open microelectrodes are used, which are easily and without complications inserted into the tissues. Intra-tissue polarographic determination has a known advantage, since the electrodes respond more quickly to changes in pO_ and are less inert than electrodes for percutaneous measurement.
A working needle electrode is inserted under the skin of the fetal head to a depth of 0.5-0.6 mm after the amniotic fluid has flowed out and the cervix is opened to
4 cm or more, the reference electrode is inserted into the posterior fornix of the vagina.
Study of the blood of the fetus and newborn. The most important information about the condition of the fetus can be obtained from the results of a direct examination of its blood obtained from the umbilical cord or head.
Cordocentesis... Blood is obtained from the umbilical cord vein by intrauterine puncture under ultrasound guidance (Fig. 6.28).
The method is indicated for the diagnosis of congenital and hereditary pathology (karyotyping of the fetus), intrauterine infection, fetal hypoxia, its anemia in immunoconflict pregnancy. In addition to a wide range of diagnostic tasks, cordocentesis can also solve some important problems of intrauterine therapy in fetal hemolytic disease.
Cordocentesis is performed after 18 weeks of pregnancy. Before taking fetal blood, the localization of the placenta and the place of umbilical cord discharge are established. When the placenta is located on the anterior wall of the uterus, the needle for aspiration of blood is carried out transplacentally; in the case of localization of the placenta on the posterior wall, the needle is inserted transamnionally. The umbilical cord is punctured near the place of its discharge from the placenta. With high motor activity of the fetus, which interferes with the puncture, intramuscular or intravenous administration of drugs to the fetus is recommended to ensure its short-term complete immobilization. For this, the muscular neuroblocker pipcuronium (arduan) is used at a dose of 0.025-0.25 mg / kg. The volume of the blood sample depends on the indication for cordocentesis; usually no more than 2 ml is required.
The risk of developing complications during cordocentesis for a pregnant woman is low. Complications for the fetus include premature effusion of water (0.5%), bleeding from a punctured vessel (5-10%), as a rule, not prolonged and not life-threatening to the fetus. Perinatal losses do not exceed 1-3%. Contraindications to cordocentesis are the same as to amniocentesis.
Determination of the acid-base state (CBS) of blood... During childbirth, fetal capillary blood is obtained from the presenting part by the Zaling method. For this purpose, after the discharge of amniotic fluid, a metal tube of an amnioscope with fiber optics is introduced into the birth canal. At the same time, a section of the presenting part of the head or buttocks is clearly visible, the skin of which is wiped with a gauze swab in order to create hyperemia. A special scarifier is used to puncture the skin to a depth of 2 mm, after which blood is collected (except for the first drop) into a sterile heparinized polyethylene capillary without air layers and impurities of amniotic fluid. The study of microdoses of blood allows you to quickly obtain information about the condition of the fetus, but the method is very laborious and not always feasible.
To determine the CBS of blood in a newborn, blood is taken from the vessels of the umbilical cord immediately after birth, or capillary blood is used from the child's heel.
When examining blood oxygen concentration, the values of pH, BE (deficiency of bases or excess of acids), pCO2 (partial tension of carbon dioxide), and pO2 (partial tension of oxygen) are taken into account.
Chorionic villus sampling (aspiration) - an operation, the purpose of which is to obtain chorionic villous cells for karyotyping the fetus and determining chromosomal and gene abnormalities (including the determination of hereditary metabolic disorders), as well as to determine the sex of the fetus. Samples are taken transcervically or transabdominally at 8-12 weeks of pregnancy under ultrasound control. A sterile polyethylene flexible catheter with a length of 26 cm and an external diameter of 1.5 mm is inserted into the uterine cavity and carefully, under visual control, it is advanced to the placenta localization and further between the uterine wall and the placental tissue. Then, with a syringe with a capacity of up to 20 ml, containing 3-4 ml of culture medium and heparin, the chorionic tissue is aspirated, which is then examined (Fig. 6.29). Chorionic tissue samples can also be taken in multiple pregnancies.
Complications of chorionic villus sampling are intrauterine infection, bleeding, spontaneous miscarriage, and hematoma formation. Later complications include premature birth, low birth weight (less than 2500 g), fetal malformations. Perinatal mortality reaches 0.2-0.9%. Contraindications to a chorionic biopsy may be an infection of the genital tract and symptoms of a threatening miscarriage. In the later stages of pregnancy, placentocentesis is possible.
Fetoscopy(direct examination of the fetus) is used to identify congenital and hereditary pathology. The method allows you to examine parts of the fetus through a thin endoscope inserted into the amniotic cavity, and through a special channel to take samples of blood and epidermis for examination. Fetoscopy is carried out as one of the final stages of the examination if there is a suspicion of congenital fetal anomalies.
Method of inserting a fetoscope: after appropriate skin treatment under local anesthesia under sterile conditions, a small skin incision is made and a trocar located in the cannula is inserted into the uterine cavity. Then it is removed, a sample of amniotic fluid is obtained for research, an endoscope is inserted into the cannula and a targeted examination of the fetus is carried out. If necessary, take a blood sample or biopsy of the fetal skin. At the end of the operation, cardiac monitoring of the fetus is carried out; the pregnant woman remains under observation for 24 hours.
Complications of fetoscopy include rupture of amniotic fluid, termination of pregnancy. Complications such as bleeding and the development of infection, the formation of small superficial hematomas on the limbs of the fetus are extremely rare. Due to the possibility of abortion, fetoscopy is rarely used.
Study of the hormonal profile. Biological methods for diagnosing pregnancy, based on the reaction of animals to the administration of the patient's urine, whether or not containing XE, have now lost their leading role. Preference is given to immunological methods.
Immunological methods for diagnosing pregnancy... Immunological methods include various methods for determining chorionic gonadotropin (CG) or its b-subunit (b-CG) in blood serum and urine. Preference is given to the radioimmunoassay method for the quantitative determination of b-hCG in blood serum, since it has a high specificity and sensitivity. The enzyme-linked immunosorbent assays for detecting hCG in urine, as well as other variants of immunological tests (capillary, plate), deserved a positive assessment. Such well-known serological methods for the determination of hCG in urine, such as the reaction of inhibition of agglutination of erythrocytes or sedimentation of latex particles, have a right to exist.
Agglutination, or latex particle fixation test, is a method for determining the level of CG in the urine, which is excreted in the urine 8 days after fertilization. A few drops of the patient's urine are mixed with antibodies to HCG, then latex particles coated with HCG are added. If hCG is present in urine, it binds to antibodies; if hCG is absent, then antibodies bind to latex particles. This rapid test is positive in 95% of cases from the 28th day after fertilization.
Radioimmunoassay test. Determine the content of the b-subunit of hCG in the blood plasma.
In this article:
Obstetric research is a set of methods and techniques for examining a woman during pregnancy and directly during childbirth, for an objective assessment of their condition and course. The examination of a woman consists of the following components: external obstetric examination, laboratory and clinical.
External examination
Outdoor research includes:
- Examination of a pregnant woman. The doctor evaluates the height, body weight and body type of a woman, as well as the condition of the skin, pigmentation on the face, and determines the shape of the abdomen.
- Measurement of the abdomen. With the help of a measuring tape, the doctor measures the circumference of the abdomen at the level of the navel, and also measures the length of the standing of the fundus of the uterus.
- Palpation of the abdomen. The woman should be in a supine position. The doctor, by palpation, determines the condition of the skin, the elasticity of the skin, the thickness of the fat layer, the condition of the rectus abdominis muscles, as well as the location of the fetus.
It is especially important at the first obstetric examination to determine the direct size of the entrance to the small pelvis. In general, the study of the pelvis is extremely important, since its position and structure affects the course of pregnancy and directly on the birth itself. Narrowing of the hip joint can lead to serious complications that can lead to difficult labor.
Research on pregnant women is done in several ways.:
- First reception. The purpose of this method of examining a woman is to determine the height of the fundus of the uterus and the part of the fetus that is at its bottom. This technique also allows you to judge the estimated timing of pregnancy, the position of the fetus and its presentation.
- Second trick. This method allows you to determine the position of the fetus in the uterus. By gently pressing with your fingers on the walls of the uterus, the doctor can reveal in which direction the baby is turned. In addition, this technique allows you to determine the amount of amniotic fluid and the excitability of the uterus.
- Third trick. The purpose of the third reception of external obstetric examination is to determine the presentation and its relation to the small pelvis, as well as the general condition of the uterus.
- The fourth technique allows you to determine the state of the presenting head (it is bent or unbent), as well as the level of its relationship to the small pelvis.
Obstetric research factors
During the obstetric examination of women, the doctor must determine several factors that will assess the state of pregnancy and its course.
Fetal position is the ratio of the axis of the uterus to the back of the baby. The fetal axis is an imaginary line through the back of the head and buttocks. If the axis of the fetus and the axis of the uterus coincide in direction, the position of the fetus is called longitudinal. If the axis of the fetus passes through the axis of the uterus at a right angle, this is called the transverse position of the fetus, if under an acute one, it is oblique.
Fetal position is the relationship between the position of the walls of the uterus and the back of the fetus. This factor allows you to find out in what position the baby lies in the uterus. Of course, the longitudinal position of the fetus is the most favorable, as it contributes to the good movement of the fetus through the birth canal.
The position of the fetus makes it possible to find out the ratio of the limbs of the fetus and its head to the entire body. The normal position is when the head is bent and pressed to the body, the arms are bent at the elbows, crossed between themselves and pressed to the chest, and the legs are bent at the knees and hip joints, crossed and pressed to the tummy.
Internal obstetric research: pros and cons
Some women feel that an internal obstetric examination is not necessary. Moreover, they believe that it can harm the fetus. In fact, this is not the case. This method of research in some cases allows early detection of pathologies and abnormalities in the development of pregnancy.
An internal obstetric examination should be done during the first 3 to 4 months of pregnancy. This technique allows you to identify pregnancy in the initial stages (when the abdomen is not yet visible), its estimated timing, as well as possible pathologies of the genital organs. Internal obstetric examination at a later stage determines the state of the birth canal, the dynamics and degree of uterine dilatation, as well as the advancement of the presenting part of the fetus along the birth canal.
All these factors of examination at a later date make it possible to make predictions about the course of labor. Why else do you need to do internal obstetric research?
Thus, the gynecologist examines the external genital organs for the presence of pathologies, infections or other abnormalities. After that, with the help of mirrors, the internal genital organs are examined. In this case, the condition of the mucous membrane is assessed for the presence of infections, the vagina and cervix, as well as the condition and nature of the discharge.
With the help of this study, it is possible in the early stages of pregnancy to identify pathologies that can lead to complications and even termination of pregnancy. So, for example, some infections can cause serious complications not only for the entire cycle, but also for the fetus.
Other research methods
Of course, external and internal obstetric studies largely determine the nature of the course of pregnancy, and also make it possible to predict how the process of childbirth itself will take place. However, these surveys are often insufficient to paint the full picture.
In order to most accurately determine the duration of pregnancy, the position of the fetus, the state of the uterus, as well as many other factors, gynecologists use additional research methods.
Auscultation of the fetus is performed using an obstetric stethoscope. This method allows you to hear fetal heartbeats, determine their frequency in the early stages, as well as during attempts and fetal hypoxia. In addition, the heart rate can be heard with the help of the "Kid" apparatus, whose work is based on the principle of the Doppler effect.
Of no small importance is obstetric examination of pregnant women using an ultrasound machine, which allows you to fully assess the condition of the fetus, identify the exact timing of pregnancy, and also identify possible pathologies in the early stages.
In addition to the above methods of obstetric research, the following techniques take place in medical practice: the study of amniotic fluid, which is obtained using amniocentesis, the study of the uteroplacental blood flow, as well as amnioscopy, fetoscopy and much more. In addition, do not forget about the numerous analyzes and measurements that show the complete picture of pregnancy.
Any woman in this exciting period of her life should be extremely attentive to her health. After all, the health of her baby depends on this.
Useful video about research during pregnancy
An objective examination of a pregnant woman (woman in labor) consists of a general examination of the body and a special obstetric examination.
General examination produced by organs and systems. Laboratory tests are also carried out: urine analysis, clinical blood test, determination of blood group and Rh-affiliation. It is of great importance to clarify the state of mind of a pregnant woman, her attitude to the upcoming childbirth, since the effect of psycho-preventive preparation for childbirth depends on this.
During a general examination, attention should also be paid to hypotension and anemia in a pregnant woman, since in these conditions, threatening termination of pregnancy, premature birth, abnormalities of labor forces, threatening fetal asphyxia, bleeding in the follow-up and early postpartum periods are more often observed.
Special obstetric examination includes external and internal obstetric examination.
1. External obstetric examination performed by examining the pregnant woman, palpating (palpation), listening to the abdomen (auscultation) and measuring the size of the pelvis, abdomen, and the Soloviev index. At inspection the pregnant woman notes the features of her physique (correct, incorrect), the condition of the abdominal muscles, tissue turgor; reveal pigmentation and scars of pregnancy (fresh, old), defects in the structure of the spine (kyphosis, scoliosis, lordosis), skull and chest (signs of rickets); determine the size and shape of the abdomen (pointed, saggy belly with a narrow pelvis), the state of the mammary glands. Examine and measure the sacral rhombus to identify possible deviations in the structure of the pelvis, its shape and size.
The sacral rhombus has the shape of a square, the longitudinal and transverse dimensions of which are 11 cm. The rhombus acquires irregular outlines with sharp deformities of the pelvis. So, with a flat pelvis, the longitudinal size of the rhombus is shorter than the transverse one, with a generally evenly narrowed pelvis, the transverse size of the rhombus is shorter than the longitudinal one.
Feeling (palpation) is one of the main methods of obstetric research, which allows you to obtain the necessary information about the position of the fetus, its size. Before the examination, the pregnant woman must empty the bladder and intestines. Palpation is performed on a couch or in a gynecological chair in the position of the pregnant woman on her back with bent legs. In this position, the tension of the muscles of the abdominal wall is eliminated, which facilitates palpation. Using the so-called external manual methods of obstetric research proposed by Leopold, the height of the uterine fundus, its size, shape, mobility, position of the fetus, the presenting part and its relation to the pelvis, back and limbs of the fetus are determined.
The first external reception of obstetric research allows you to determine the height of the uterine fundus, which in turn makes it possible to judge the shape of the uterus (ovoid, saddle, two-horned), gestational age, and the part of the fetus located in the bottom of the uterus (head, buttocks). When examining, they stand to the right of the pregnant woman, facing her. The palmar surfaces of both hands are placed on the stomach above the navel in such a way that they fit snugly to the bottom of the uterus (Fig. 1). With this technique, it is relatively easy to determine the buttocks of the fetus located at the bottom of the uterus by their lower density, less smooth surface and the lack of pronounced roundness inherent in the head.
The second external technique allows you to determine the position and position of the fetus. The position of the fetus is the ratio of the axis of the fetus to the length of the uterus; it can be longitudinal (correct position), transverse and oblique (incorrect position).
Fetal position is the ratio of the fetal back to the lateral sides of the uterine wall. In the longitudinal position of the fetus, the positions are distinguished left (first), when the back is turned to the left, and right (second), when the back is turned to the right. With the transverse position of the fetus, the position is determined by the position of the head: if it is turned to the left, it is the left position, if it is right, it is right. The types of fetal position are also determined by palpation: anterior, if the back is facing anteriorly, and posterior, if the back is facing posteriorly.
During the second appointment, the doctor is to the right of the pregnant woman, facing her. The palms of both hands are placed on the sides of the abdomen and, gently pressing with palms and fingers, feel the lateral parts of the uterus (Fig. 2). The backrest is relatively easy to recognize as a wide, elongated platform of dense consistency with a wide and curved surface. The limbs and small parts of the fetus are palpated in the form of small dense tubercles that can move. The movement of the small parts indicates that the fetus is alive.
The third external method of obstetric research is used to determine the nature of the presenting part (head or buttocks), its mobility (if it is mobile, it is located above the entrance to the pelvis, motionless - at the entrance to the pelvis or in the pelvic cavity), the position of the presenting head (bent or unbent) ... The third method of obstetric research is performed with one hand, which is placed above the bosom, and the end phalanges of the thumb and middle fingers cover the presenting part (Fig. 3). The head of the fetus is recognized by its round shape and dense consistency; during pregnancy, she is mobile and runs. The buttocks have an uneven consistency, less mobile (they are not characterized by ballot), irregular shape.
The fourth external reception of obstetric research is carried out to clarify the data obtained when using the third reception, that is, to determine the location of the presenting part (especially the head). With the help of this technique, the standing height of the presenting part is established, the position of the presenting head (bent or unbent), the incorrectness of its insertion is specified. To implement this technique, they stand face to the legs of a pregnant woman (woman in labor), hands are placed on both sides of the lower part of the uterus.
With the fingertips directed to the entrance to the pelvis, they tend to penetrate between the presenting part and the lateral parts of the pubic bones (Fig. 4).
Rice. 1-4. Techniques for external obstetric research.
To determine the presenting part of the head or pelvic end, the occipital (normal childbirth) is distinguished when the head is bent, while the head is extended - anteroparietal, frontal, facial presentation; with breech presentation - gluteal and leg.
To determine the position in the longitudinal positions of the fetus, you can use the obstetric manual technique of S. D. Astrinsky, based on the swelling of the amniotic fluid. With light pushes of the finger (such as when determining ascites) to the right or left side of the pregnant uterus, the wave of amniotic fluid is directed in the opposite direction, where it is perceived by the palm tightly attached to the uterus. If shocks are made on the side of the uterus, where small parts of the fetus are presented, then the palm pressed to the uterus where the back of the fetus is located does not perceive the swelling, since the wave of amniotic fluid excited on the side of presentation of small parts fades out (Fig. 5).
On the side where the swelling of the liquid is perceived by the palm, there are small parts of the fruit (Fig. 6). Consequently, with the left (first) position, the palm perceives the wave of amniotic fluid on the right, and with the right (second) - on the left.
This research method is less traumatic than the second method according to Leopold, with the help of which the back and small parts of the fetus are also determined.
- Minutes of meetings of the Expert Commission on Healthcare Development of the Ministry of Health of the Republic of Kazakhstan, 2013
- 1. Antenatal care: routine care for the healthy pregnant woman. National Collaborating 2. Center for Women’s and Children’s Health Commissioned by the National Institute for 3. Clinical Excellence. 2nd edition © 2008 National Collaborating Center for Women’s and Children’s Health. 1st edition published in 2003 4. Clinical protocol "Management of normal pregnancy (low risk pregnancy, uncomplicated pregnancy)", Project "Mother and Child", Russia, 2007 5. Routine Prenatal Care ICSI Management of Labor Guidelines for hospital-based care. August 2005, 80 p. 6. Guidelines for effective care during pregnancy and childbirth .. Enkin M, Keirs M, Neilson D et al. Translated from English under the editorship of AV Mikhailov, SP "Petropolis", 2007 7. WHO guidelines for effective perinatal care ... 2009. 8. Cochrane Guidelines. Pregnancy childbirth. 2010 9. Orders of the MZRK No. 452 07/03/12 "on measures to improve medical care for pregnant women, women in labor, women in childbirth and women of fertile age" 10. Order No. 593 dated 08/27/12. "On approval of the regulation of the activities of health organizations providing obstetric and gynecological care"
Information
ORGANIZATIONAL ASPECTS OF THE PROTOCOL IMPLEMENTATION:
List of protocol developers with qualification data: Maishina M.Sh. - Obstetrician-gynecologist of the highest category, senior resident of the obstetrics department 2 of JSC "NSCMD".
Reviewers: Kudaibergenov T.K. - Chief freelance obstetrician-gynecologist of the Ministry of Health of the Republic of Kazakhstan, director of the RSE "National Center for Obstetrics, Gynecology and Perinatology."
Kobzar NN - candidate of medical sciences, doctor of the highest category in the specialty of obstetrics and gynecology, social hygiene and organization of health care, head. Department of Obstetrics and Gynecology KRMU.
Indication of the conditions for revision of the protocol: The protocol is revised at least once every 5 years, or upon receipt of new data related to the application of this protocol.
ApplicationA
Rubella
· The disease does not pose a danger to the mother;
There is a risk of developmental defects in the fetus if the mother develops symptoms of infection before the 16th week of pregnancy;
· For prevention, the most effective state program of universal universal vaccination of children of the first year of life and adolescent girls, as well as women in the postpartum period;
· Screening should be offered to all pregnant women at the first visit who do not have documented vaccination (2a);
· Accidental vaccination of women who subsequently find themselves pregnant is not an indication for termination of pregnancy because of the safety of the fetus with a live vaccine;
Women with suspected rubella infection should be isolated from other pregnant (or potentially pregnant) women, but after the disappearance of clinical signs of infection, they do not pose a danger to others
If the woman has not been vaccinated against rubella or, recommend vaccination after childbirth
ApplicationV
Vaginal candidiasis -an infection that does not affect pregnancy.
Vaginal candidiasis is diagnosed by microscopy of vaginal discharge. Culture is used to confirm the diagnosis.
· Screening for vaginal candidiasis is not recommended.
· Treatment of infection is indicated only in the presence of clinical manifestations: butoconazole, clotrimazole, econazole, terconazole or nystatin. However, it is very important to remember that the effect of drugs taken by the mother orally on the child is unknown.
· There is no need to hospitalize or isolate women with vaginal candidiasis from other women.
· The newborn should be in a joint stay with his mother, and can also be breastfed.
Asymptomatic bacteriuria
· Prevalence - 2-5% of pregnancies;
· Increases the risk of premature birth, low birth weight, acute pyelonephritis in pregnant women (on average, it develops in 28-30% of those who have not received treatment for asymptomatic bacteriuria);
· Determination - the presence of bacterial colonies -> 10 5 in 1 ml of the average portion of urine, determined by the culture method (gold standard) without clinical symptoms of acute cystitis or pyelonephritis;
· Diagnostic examination - culture of the middle portion of urine - should be offered to all pregnant women at least once upon registration (1a);
· For treatment, ampicillin, 1st generation cephalosporins, which in studies have shown the same effectiveness, can be used;
· Treatment should be continuous during pregnancy when positive culture results are obtained, the criterion for successful treatment is the absence of bacteria in the urine;
· A single dose of antibacterial agents is also effective as 4- and 7-day courses, but because of the smaller number of side effects, one-time ones should be used;
· It is logical to use drugs for which sensitivity has been established;
Treatment of severe forms of AIM infection (pyelonephritis) should be carried out in a specialized hospital (urological)
Hepatitis B
· During pregnancy, the course and treatment of acute hepatitis does not differ from treatment outside of pregnancy;
· Infection of a child most often occurs intrapartumly (90%);
· A blood test for hepatitis B (2 times per pregnancy) should be offered to all pregnant women in order to identify women who are carriers of HBsAg, for effective prevention of children born to such mothers - anti-D human immunoglobulin + vaccination in the first day of life (1b);
· Patients - carriers of HBsAg do not pose a danger in everyday life for staff and other women, as well as for their children, therefore they should not be isolated in the antenatal and postpartum periods.
Hepatitis C
· Is one of the main causes of liver cirrhosis, hepatocellular carcinoma, liver failure;
There are no effective methods of prevention and treatment - therefore, it is logical to suggest not to conduct routine screening for hepatitis C (3a), it may be more expedient to investigate only the risk group (intravenous drug users who have a history of blood and blood components transfusion, antisocial, etc.) etc.);
· But with a high prevalence of hepatitis C in the population and the financial capacity of the region, routine screening can be carried out at the discretion of the local authorities;
· Patients - carriers of the hepatitis C virus do not pose a danger in everyday life for staff and other women, as well as for their children, therefore they should not be isolated in the antenatal and postpartum periods.
Bacterial vaginosis
· Asymptomatic course is observed in 50% of pregnant women;
· RCT results show that screening and treating healthy (non-complaining) pregnant women for vaginal dysbiosis does not reduce the risk of premature birth or other complications, such as premature rupture of membranes (1a);
In pregnant women with a history of premature birth
· Indications for the appointment of treatment are the presence of clinical symptoms, primarily the woman's complaints of itching, burning, redness in the vulva, abundant discharge with an unpleasant odor;
· Treatment - metronidazole for 7 days (per os or topically), however, safety for the fetus has not been proven before 13 weeks of gestation.
Human Immunodeficiency Virus (HIV)
· The risk of vertical transmission depends on the viral load of the pregnant woman and the state of immunity;
· The risk of vertical transmission without prophylaxis in developed countries is 15-25%;
3-stage prophylaxis:
· - chemoprophylaxis during pregnancy and childbirth;
- elective caesarean section before the onset of labor, with an anhydrous period<4 часов;
· - refusal from breastfeeding reduces the risk of vertical transmission of HIV infection to 1%;
· HIV testing should be offered to all pregnant women 2 times during pregnancy (upon registration and at 30-32 weeks of pregnancy) (1a);
· Obstetric care facilities should have rapid tests to screen pregnant women with unknown HIV status;
· Health care providers who look after a pregnant woman have a responsibility to actively promote adherence to treatment;
· Some patients with HIV (+) status belong to the group of socially maladjusted, therefore, they should be given increased attention in matters of possible domestic violence, smoking, alcoholism, drug addiction;
· Patient-carriers do not pose a danger in everyday life for staff and other women, as well as for their children, therefore they should not be isolated in the antenatal and postpartum periods.
Chlamydia
· The most common STI in the European region;
· Increases the risk of premature birth, IUGR, neonatal mortality;
· Transmission from mother to child leads to neonatal conjunctivitis and pneumonia in 30-40% of cases;
· It is necessary to provide information on methods of prevention of conjunctivitis during childbirth - placing tetracycline or erythromycin ointment in the conjunctiva of the newborn by the end of the first hour after childbirth;
· Screening for asymptomatic chlamydia should not be offered as there is no reliable evidence of their effectiveness and cost-effectiveness (3a);
· "Gold standard" diagnostics of chlamydia - PCR;
Treatment of uncomplicated genital chlamydia infection during pregnancy (outpatient):
- erythromycin 500 mg four times a day for 7 days, or
- amoxicillin 500 mg three times a day for 7 days, or
- azithromycin or clindamycin.
Cytomegalovirus infection (CMV)
· CMV remains the most important cause of congenital viral infections in the population;
· The risk of transmission of CMV infection is almost exclusively associated with primary infection (1-4% of all women);
Two possible variants of the course of CMV infection among newborns infected from mothers before birth:
- generalized infection (10-15% of infected fetuses) - from moderate enlargement of the liver and spleen (with jaundice) to death. With supportive care, most newborns with CMV disease survive. Despite this, 80% to 90% of these newborns have complications in the first years of life, which may include hearing loss, blurred vision and varying degrees of mental retardation;
- asymptomatic form (90% of all infected fetuses) - in 5-10% of cases, hearing, mental or coordination problems of varying degrees may develop;
· The risk of complications in women who were infected at least 6 months before fertilization does not exceed 1%;
· Routine screening should not be offered to all pregnant women due to the impossibility, in practice, to prove the presence of a primary infection, the lack of an effective treatment for CMV infection, difficulties in diagnosing infection and fetal damage (2a);
Termination of pregnancy up to 22 weeks is possible in extremely rare cases with:
- confirmed primary infection of the mother;
- positive results of amniocentesis;
- nonspecific ultrasound data (fetal anomalies, developmental delay).
Toxoplasmosis
· Prevalence in Kazakhstan is generally low, therefore routine screening is not offered (2a);
· The path of transmission from mother to child - transplacental, can cause intrauterine death, IUGR, mental retardation, hearing defects and blindness;
· The risk of transmission is mainly associated with primary infection;
The risk of fetal infection depends on the gestational age:
- the lowest (10-25%), when the mother becomes infected in the first trimester - severe lesions are observed up to 14% of cases;
- the highest (60-90%), when the mother becomes infected in the third trimester - severe lesions practically do not occur;
· Treatment - Spiramycin (not recommended until the 18th week of pregnancy), while there is no reliable evidence of the effectiveness of treatment in preventing congenital infections and fetal lesions;
At the first visit to a medical specialist, information on the prevention of infection with toxoplasmosis (and other foodborne infections) should be provided:
- do not eat raw or uncooked meat;
- thoroughly clean and wash vegetables and fruits before eating;
- wash hands and kitchen surfaces, dishes, after contact with raw meat, vegetables and fruits, seafood, poultry;
- Wear gloves when gardening or contact with the ground, which can be contaminated with cat faeces. Wash your hands thoroughly after work;
- if possible, avoid touching the cat's bowl or toilet, if there is no assistant, always do it with gloves;
- do not let cats out of the house, do not take homeless cats into the house during pregnancy, it is not recommended to give cats raw or insufficiently processed meat;
· Patients who have undergone toxoplasmosis do not pose a danger to staff and other women, as well as to their children, therefore they should not be isolated in the antenatal and postpartum periods.
Genital herpes
· The prevalence of carriage in Kazakhstan in most regions is high;
· Screening is not recommended as the results do not change management (2a);
· Damage to the fetus varies widely - from asymptomatic to damage only to the skin, in severe cases - damage to the eyes, nervous system, generalized forms;
· The risk of infection of a newborn is high in case of primary infection of the mother immediately before childbirth (up to 2 weeks) (risk up to 30-50%) - delivery by KS should be offered;
If the infection recurs, the risk is very low (<1-3%) - рекомендовано родоразрешение через естественные родовые пути;
· Herpes infection is not an indication for hospitalization of women. Women who are found to have an active form during childbirth should maintain personal hygiene when in contact with the baby, and should not pick up another baby. No insulation required.
Syphilis
· The prevalence in the population varies considerably in different regions, but remains relatively high;
· Screening is offered to all women twice during pregnancy (at registration and at 30 weeks) (2a);
• patients with syphilis have a high risk of having other STIs, so they should be offered additional testing;
· Treatment - penicillin, can be performed on an outpatient basis;
· A woman who has undergone an adequate course of syphilis treatment does not need isolation from other women and does not pose a risk to her child;
· Consultation, treatment and control - at the venereologist.
Tuberculosis
· In case of infection in the neonatal period - a high risk of mortality;
· Active form of tuberculosis - an indication for treatment (isoniazid, rifampicin, pyrazinamide and ethambutal). These drugs are safe for pregnant women and the fetus;
· Streptomycin, ethionamide and prothionamide should be excluded because of their danger;
It is necessary to inform the expectant mother about the management of the postpartum period:
- isolation from the child is not required;
- breastfeeding is possible, the use of all anti-tuberculosis drugs during breastfeeding is not dangerous;
- it is necessary to continue the full course of treatment for the mother;
- the child will need to receive preventive treatment;
· It is necessary to have information about the living conditions of the unborn child, the presence of people living in the same apartment or house with an active form of tuberculosis for timely measures when the newborn is discharged from the maternity ward.
Appendix C
Woman's weight. Measuring weight gain at every visit is unreasonable, and there is no need to advise women to make dietary restrictions to limit weight gain.
Pelvimetry. Routine pelvimetry is not recommended. It has been proven that neither clinical nor X-ray pelviometry data have sufficient predictive value to determine the discrepancy between the size of the fetal head and the mother's pelvis, which is best detected with careful monitoring of the course of labor (2a).
Routine fetal heart rate auscultation has no predictive value, since it can only answer the question: is the child alive? But in some cases, it can give the patient confidence that everything is fine with the child.
Counting fetal movements. Routine counting leads to more frequent detection of decreased fetal activity, more frequent use of additional methods for assessing the condition of the fetus, more frequent hospitalizations of pregnant women and an increase in the number of induced labor. Of greater importance is not the quantitative, but the qualitative characteristics of fetal movements (1b).
Preeclampsia.
- The risk of developing preeclampsia should be assessed at the first visit to determine an appropriate schedule for antenatal visits. Risk factors that necessitate more frequent visits after 20 weeks include: the first coming first birth, age over 40; a history of preeclampsia in close relatives (mother or sister), BMI> 35 at first visit, multiple births, or pre-existing vascular disease (hypertension or diabetes)
- Whenever blood pressure is measured during pregnancy, a urine sample should be taken to determine proteinuria
- Pregnant women should be informed about the symptoms of severe preeclampsia, as their presence may be associated with more adverse outcomes for the mother and baby (headache, blurred vision or flickering in the eyes; moderate to severe pain under the ribs; vomiting; rapid onset of facial edema, arms and legs)
Routine ultrasound in the second half of pregnancy. A study of the clinical relevance of routine ultrasound imaging in late pregnancy revealed an increase in antenatal hospitalizations and induced labor without any improvement in perinatal outcomes (1b). However, the expediency of ultrasound has been proven in special clinical situations:
- when determining the exact signs of vital activity or fetal death;
- when assessing the development of a fetus with suspected IUGR;
- when determining the localization of the placenta;
- confirmation of the alleged multiple pregnancy;
- assessment of the volume of amniotic fluid in case of suspicion of high or low water;
- clarification of the position of the fetus;
- for procedures such as the imposition of a circular suture on the cervix or external rotation of the fetus on the head.
Doppler ultrasound of the umbilical and uterine arteries... Routine Doppler ultrasound of the umbilical artery should not be offered.
Stress and non-stress CTG. There is no evidence to support the use of CTG in the prenatal period as an additional check for fetal well-being in pregnancies, even at high risk (1a). In 4 studies evaluating the effect of routine CTG, identical results were obtained - an increase in perinatal mortality in the CTG group (3 times!), In the absence of an effect on the frequency of cesarean sections, the birth of children with a low Apgar score, neurological disorders in newborns and hospitalization in a neonatal ICU. The use of this method is indicated only with a sudden decrease in fetal movements or with prenatal hemorrhage.
APPENDIX E
GRAVIDOGRAM
Maintaining a gravidogram is mandatory at every visit in the second and third trimester. The gravidogram shows the height of the uterine fundus (UDM) in cm (on the vertical axis) according to the gestational age (on the horizontal axis). A graph of changes in BMR during pregnancy is plotted. It is important not to find the measured height of the fundus between the lines, but to parallel them.
APPENDIX E
Birth plan(To be completed in conjunction with a medical professional)
My name _______________________________________________
Expected due date ________________________________________
My doctor's name _______________________________
My child's doctor will be _________________________
The supportive person during labor will be ________________
These people will be present during labor ______________________
__ Antenatal education in PHC
Classes for dads
__ Maternity hospital
__ Antenatal courses other than PHC
Do you want to report something additional about yourself (important points, fear, concern) _______________________________________________________
My goal:
__ So that only people close to me and the nurse support and comfort me
__ To provide pain relief medication in addition to support and comfort
__ Other, explain ___________________________________
__ First stage of labor (contractions)
Please indicate which anti-anxiety measures you would like your midwife to offer you during labor:
__ Put on your own clothes
__ Walk
__ Hot / cold compress
__ Lots of pillows
__ Using the generic ball
__ Listen to my favorite music
__ Focus on your favorite subject
__ Massage
__ Epidural anesthesia
Birth of a child
Your midwife will help you find various comfortable positions during the second stage of labor. Which of the following points would you like to try:
__ Upright position during labor
__ On the side
__ I do not want to use the obstetric chair
After the birth of my child, I would like to:
__ For _______________ to cut the umbilical cord
__ They put the baby on my stomach right after birth
__ Wrapped in a blanket before handing it over to me
__ For the child to put on their own hat and socks
__ To swaddle my baby for the first time
__ To take a video or photograph during labor
Unexpected incidents during childbirth
If you need more information on the following questions, ask your doctor or midwife:
Forceps use / vacuum extraction
__ Amniotomy
__ Episiotomy
__ Fetal monitoring
__ Labor arousal
__ Rodostimulation
__ Delivery by caesarean section
From birth to discharge
Our obstetric department considers it necessary for a mother and child to stay together for 24 hours. Health professionals will support you and assist you in caring for your child when he is in the same room with you.
I'm going to:
__ Breastfeed your baby
__ Give complementary food or supplements to my baby
While in the department, I would like to:
__ To be with the child all the time
__ Be present when my child is examined by a neonatologist
__ Be present during the procedures for my child
__ For the nurse to show you how to bathe my child
__ Bathe my child myself
__ To circumcise my child
__ For the child to be vaccinated with BCG and hepatitis B
__ Other _______________________________________________________________________
The following people will help me at home
________________________________________________________
Your suggestions and comments
I would like to be visited after discharge from the hospital:
__ Yes. Who?________________________________
__ No
__ Not decided
Signature ___________________________ date ___________________________________
Signature of the specialist who collected the information _________________________________
APPENDIX G
· Full-fledged self-care during pregnancy will help you to maintain not only your health, but also the health of your unborn child. As soon as it seemed to you that you are pregnant, immediately contact the antenatal clinic. If the pregnancy is confirmed and you are registered, visit your doctor regularly according to the established schedule.
· Eat healthy foods (see below for more information). You will gain approximately 8-16 kg in weight, depending on how much you weighed before pregnancy. Pregnancy is not the time to lose weight.
· Sleep or rest when you need it. Don't exhaust yourself, but don't relax completely either. The need for sleep is different for each person, but most people need eight hours a day.
· Do not smoke and avoid being near smokers. If you smoke, quit ASAP!
· Do not consume any alcoholic beverages (beer, wine, spirits, etc.). Of course, drugs are out of the question!
· Do not take any pills or medicines other than those prescribed by your doctor. Remember that herbs and herbal infusions / teas are also medications.
· During pregnancy, you should also avoid strong and pungent odors (such as paint or varnish). Precautions are also required when handling household cleaners and detergents: read and follow label instructions carefully, wear gloves and do not work in poorly ventilated areas.
· If you have a cat, ask someone from the family to clean her toilet, or be sure to use rubber gloves (there is a disease - toxoplasmosis, transmitted through cat feces and dangerous for pregnant women). In all other respects, your pets are not dangerous for you or your child.
· Exercise is good for both you and your child. If there are no problems (see below for a detailed list of problems), you can continue to do the same exercises as before pregnancy. Hiking and swimming are especially good and comfortable ways to stay active, stimulate circulation, and control weight gain.
· Sexual relationships during pregnancy are normal and safe for your health. They will not harm your child either. Do not worry if, due to hormonal changes, sexual desire increases or decreases - this is also normal for each woman individually. There are several precautions you should take. As your belly will gradually enlarge, you may have to try different positions to find the most comfortable one. It is not recommended to lie on your back. If you have previously had a miscarriage or premature birth, your doctor may advise you to refrain from sexual intercourse. And if you have vaginal bleeding, pain or amniotic fluid started to leak, exclude sexual intercourse and consult a doctor as soon as possible.
· Do not hesitate to ask your doctor or midwife for information and notify them if you feel unwell. Right now, in a timely manner, get information about the benefits of breastfeeding and family planning methods for lactating women.
Healthy food for you and your child
· Of course, good nutrition is important both for your health and for your child's growth and development. Eating healthy during pregnancy is just as important as eating healthy at any other time in a woman's life. There are no "magic" foods that are especially necessary for the normal course of pregnancy. There are very few "prohibited" products. Of course, you should avoid foods that you are allergic to; also try to eat as little sweets, fatty foods as possible.
· In structure, your food should resemble a pyramid: the widest part, the "base", consists of bread, cereals, cereals and pasta. You should eat more of these foods than any other. Fruits and vegetables form the second largest group of essential foods. The third, even smaller group is made up of dairy products, as well as meat, legumes, eggs and nuts. At the top of the pyramid are fats, oils and sweets, which are recommended to be eaten in minimal quantities. If you have any questions about healthy eating, see your doctor for help.
· Pregnant women need more iron and folic acid. Eat foods rich in iron (legumes, leafy greens, milk, eggs, meat, fish, poultry) and folic acid (legumes, eggs, liver, beets, cabbage, peas, tomatoes). Also take vitamins and iron tablets if your doctor recommends them.
· If your appetite is not very good, eat small meals 5-6 times a day instead of 3 large meals.
· Drink eight glasses of liquid, preferably water, daily. Do not drink more than three glasses a day of drinks containing caffeine (tea, coffee, cola) or drinks with a high sugar content. It is especially not recommended to consume tea and coffee with food (caffeine interferes with the absorption of iron).
Discomforts associated with pregnancy
Pregnancy is a time of physical and emotional change. During certain periods of pregnancy, many women experience some discomfort. Do not worry. These are common problems that will go away after the baby is born. The most common inconveniences are:
· Frequent urination, especially in the first three and last three months.
· Increased fatigue, especially in the first three months. Get plenty of rest, eat healthy foods, and do light exercise. This will help you feel less tired.
· Nausea in the morning or at other times of the day often goes away after the first three months. Try to eat dry biscuits or a slice of bread early in the morning. Avoid spicy and oily foods. Eat small meals often.
Heartburn may occur in the fifth month of pregnancy. To avoid it, do not drink coffee or caffeinated soda; do not lie down or bend over immediately after eating; sleep with a pillow under your head. If heartburn persists, seek the advice of your doctor.
· During pregnancy, you may be concerned about constipation. Drink at least 8 glasses of water and other fluids a day and eat foods rich in fiber, such as green vegetables and bran cereals. The specified volume of water will also help you avoid urinary tract infections.
· Ankles or feet may swell. Raise your legs several times a day; sleep on your side to reduce swelling.
· In the last 3-4 months of pregnancy, lower back pain may appear. Wear shoes without heels, try not to lift weights; if you do have to lift weights, bend your knees, not your back.
Alarms
Call your healthcare professional immediately if you develop any of the following symptoms:
• bloody discharge from the genital tract;
Profuse liquid discharge from the vagina;
· Persistent headache, blurred vision with the appearance of spots or flashes in the eyes;
• sudden swelling of the hands or face;
· Temperature rise up to 38º С and more;
Severe itching and burning in the vagina or increased vaginal discharge;
Burning and pain when urinating;
· Severe abdominal pain that does not subside even when you lie down and relax;
More than 4-5 contractions per hour;
· If you hurt your stomach during a fall, car accident, or if someone hit you;
· After six months of pregnancy - if your baby performs less than 10 movements in 12 hours.