The risk strategy in obstetrics provides for the identification of groups of women in whom pregnancy and childbirth may be complicated by fetal disruption, obstetric or extragenital pathology. Pregnant women who are registered in the antenatal clinic can be attributed to the following risk groups: 1. with perinatal fetal pathology; 2.with obstetric pathology; 3.with extragenital pathology. At 32 and 38 weeks of pregnancy, point screening is performed, since new risk factors appear during these periods. Research data indicate an increase in the group of pregnant women with a high degree of perinatal risk (from 20 to 70%) by the end of pregnancy. After re-determining the degree of risk, the pregnancy management plan is specified. From 36 weeks of pregnancy, women from the group of medium and high risk are re-examined by the head of the antenatal clinic and the head of the obstetric department, where the pregnant woman will be hospitalized before delivery. This examination is an important point in the management of at-risk pregnant women. In those areas where there are no maternity wards, pregnant women are hospitalized according to the schedules of regional and city health departments for preventive treatment in certain obstetric hospitals. Since antenatal hospitalization for examination and comprehensive preparation for childbirth for women at risk is mandatory, the length of hospitalization, the estimated plan for the management of the last weeks of pregnancy and childbirth should be developed in conjunction with the head of the obstetric department. A group of pregnant women at risk of perinatal pathology. It was found that 2/3 of all cases of perinatal mortality occurs in women from the high-risk group, accounting for no more than 1/3 of the total number of pregnant women. The authors divide all risk factors into two large groups: prenatal (A) and intranatal (B). Prenatal factors in turn, they are subdivided into 5 subgroups: 1. socio-biological; 2. obstetric and gynecological history; 3. extragenital pathology; 4. complications of this pregnancy; 5. assessing the state of the intrauterine fetus. Intranatal factors were also divided into 3 subgroups. These are factors from the outside: 1. mother; 2. placenta and umbilical cord; 3. the fetus. For a quantitative assessment of factors, a point system was used, which makes it possible not only to assess the probability of an unfavorable outcome of childbirth under the action of each factor, but also to obtain a total expression of the probability of all factors. Based on the calculations of the assessment of each factor in points, the authors distinguish the following degrees of risk: high - 10 points and higher; average - 5-9 points; low - up to 4 points. The most common mistake in calculating points is that the doctor does not summarize the indicators that seem insignificant to him, believing that there is no need to increase the risk group. The identification of a group of pregnant women with a high degree of risk makes it possible to organize intensive monitoring of the development of the fetus from the beginning of pregnancy. Currently, there are many possibilities for determining the state of the fetus (determination of estriol, placental lactogen in the blood, amniocentesis with the study of amniotic fluid, PCG and ECG of the fetus, etc.).

Dynamics of involutive processes in the genital organs of a woman after childbirth and methods for their assessment.

The cervix looks like a thin-walled sac with a wide gaping external pharynx with torn edges hanging down into the vagina. The cervical canal freely passes the hand into the uterine cavity. The entire inner surface of the uterus is a vast wound surface with pronounced destructive changes in the area of ​​the placental site. The lumens of the vessels in the area of ​​the placental site are compressed, blood clots form in them, which helps to stop bleeding after childbirth. Every day, the height of the uterine fundus decreases by an average of 2 cm. The cytoplasm of some muscle cells undergoes fatty degeneration, and then fatty degeneration. Reverse development also occurs in the intermuscular connective tissue. The healing process of the inner surface of the uterus begins with the disintegration and rejection of scraps of the spongy layer of the decidua, blood clots, and thrombi. During the first 3-4 days, the uterine cavity remains sterile. Discharge-lochia. In the first 2-3 days after childbirth, it is bloody discharge, from 4 to 9 days - serous-bloody, from 10 days - serous. At 5-6 weeks, the discharge from the uterus stops. Lochia have an alkaline reaction and a specific (rotten) smell. The epithelialization of the inner surface of the uterus ends by the 10th day of the postpartum period (except for the placental site). The endometrium is fully restored 6-8 weeks after childbirth. The usual tone of the ligamentous apparatus of the uterus is restored by the end of 3 weeks. Immediately after childbirth, the bottom of the uterus is 15-16 cm above the pubis, the transverse size of the uterus is 12-13 cm, the weight is about 1000 g. By 1 week after childbirth, the weight of the uterus is 500 g, by the end of 2 weeks - 350 g, 3 - 250 g, by the end of the postpartum period - 50 g. Involution of the cervix is ​​somewhat slower than the body. the internal pharynx begins to form first, by the 10th day it is practically closed. the final formation of the cervix is ​​completed by the end of 3 weeks. In the ovaries in the postpartum period, the regression of the corpus luteum ends and the maturation of follicles begins. In non-lactating women, menstruation is restored 6-8 weeks after childbirth. The first menstruation after childbirth, as a rule, occurs against the background of the anovulatory cycle: the follicle grows, matures, but ovulation does not occur, and the corpus luteum does not form. Define the height of the uterine fundus, its diameter, consistency, the presence of pain. The height of the standing of the fundus of the uterus is measured in centimeters in relation to the pubic articulation. During the first 10 days, it drops by an average of 2 cm per day. Assess the nature and number of lochia. The first 3 days of lochia are bloody in nature due to the large number of red blood cells. From the 4th day until the end of the first week, the lochia become serous-sacral. They contain many leukocytes, there are epithelial cells and areas of the decidua. By the 10th day, the lochia become liquid, light, without any admixture of blood. By about 5-6 weeks, the discharge from the uterus completely stops. The external genitals and perineum are examined daily. Pay attention to the presence of edema, hyperemia, infiltration.

Task: Place the fetus in the 1st position, anterior occipital presentation. The fetal head is at the outlet of the pelvis. Confirm with appropriate vaginal examination data.

Answer: With an external examination, the head is not palpable at all. At vaginal examination: the sacral cavity is completely filled with the head, the ischial spines are not defined. Sagittal suture in the straight size of the exit of the pelvis, a small fontanelle under the bosom.

EXAMINATION TICKET 6

1. The main decreed documents that are filled in for a pregnant woman in an antenatal clinic

Registration of medical documentation for a pregnant woman. All survey and survey data of a woman, advice and appointments should be recorded in "Individual card for pregnant and postpartum women" (form 11 l / y), which are stored in the card file of each obstetrician-gynecologist by the dates of the planned visit. In order to form an obstetric hospital about the state of health of a woman and the peculiarities of the course of pregnancy, the doctor of the antenatal clinic issues the hands of each pregnant woman (at a gestational age of 28 weeks) "Exchange card of the maternity hospital, maternity ward of the hospital" (form 113 / u) and at each visit of a pregnant antenatal clinic, all information about the results of examinations and studies is entered into her.

Generic certificate

The purpose of this program- increasing the availability and quality of medical care for women during pregnancy and childbirth through the introduction of economic incentives for medical workers and the provision of additional financial opportunities to improve the material and technical base of state (municipal) obstetric care institutions.

The introduction of birth certificates implies stimulating the work of antenatal clinics and maternity hospitals in Russia, which should lead to an improvement in the situation in obstetrics, a decrease in maternal and infant mortality, and an increase in the level of pregnancy support and services. Behind each certificate is a specific amount that will be paid from the Social Insurance Fund of the Russian Federation, and, therefore, institutions will be interested in each specific pregnant woman. The certificate is a pink document with four positions: a spine, two coupons and the certificate itself. The first coupon (with a face value of 2 thousand rubles) remains in the antenatal clinic (LCD), the second (with a face value of 5 thousand rubles) - in the maternity hospital, which the woman in labor will choose on her own. Actually, the certificate itself remains with the young mother as evidence that she received medical assistance. The certificate provides columns in which the height, weight of the child at birth, time and place of birth will be noted. At the same time, the certificate does not replace the compulsory health insurance policy or any other documents. It operates in any settlement of Russia and is issued to all citizens of the Russian Federation, without exception. In accordance with clause 5 of the "Procedure and terms of payment for services to state and municipal health care institutions for medical

assistance rendered to women during pregnancy and childbirth, approved by order of the Ministry of Health and Social Development of the Russian Federation dated January 10, 2006 No. 5 ", a generic certificate is issued upon presentation of a passport or other identity document. ZhK at the 30th week of pregnancy (with multiple pregnancies - at the 28th week). The doctor will give her a certificate and immediately take the coupon number 1, intended for the consultation. At the same time, a pregnant woman has no right not to give coupon number 1, even if she is dissatisfied with the work of the doctor. Experts advise to change the doctor ahead of schedule at 30 weeks, if there are complaints against him. There is no right to refuse a request to change the doctor in consultation with a pregnant woman. If there is a refusal, you should contact the head of the consultation or the head physician of the medical institution. In addition, in order for the ZhK to receive money according to the certificate, it is required to observe a pregnant woman continuously for 12 weeks. The sooner the expectant mother decides where it is more comfortable for her to be observed, the fewer questions will arise when issuing a certificate. It should be noted that the certificate is issued for a pregnant woman, and not for a child, therefore, even with multiple pregnancies, there will be one certificate. If a pregnant woman did not register with the LCD at all , the certificate will be given to her in the maternity hospital in which she will give birth. In this case, coupon No. 1 will be redeemed, that is, no one will receive money for it. The certificate with coupon No. 2 is taken to the maternity hospital along with the rest of the documents. So that the maternity hospital can receive money for this coupon, there is only one criterion so far - until discharge, the mother and child are alive. Experts note that by the middle of 2007 these criteria will be tightened. If a woman in labor prefers the option of paid childbirth (an agreement is concluded between a doctor and an obstetrician), the maternity hospital does not receive a certificate. Paid services do not include services (for example, paid ward of increased comfort). It should be borne in mind that a pregnant woman can actively use her right to choose a maternity hospital. If a resident of Arkhangelsk decides to give birth in Chelyabinsk, the maternity hospital is obliged to accept it. There are no duplicates for the certificate in case of loss or damage. However, the issuance of the document will be recorded in the LCD (coupon number 1), thanks to Chemurodom, she will be able to receive money, proving that the delivery took place outside of us. A pregnant woman cannot exchange a certificate for money, since this is a non-financial aid to mothers, but a means of stimulating medical institutions in a competitive environment. The total amount of funds provided for the implementation of the birth certificate program in 2006 is 10.5 billion rubles. (including for the provision of medical care to women during pregnancy in primary health care - 3.0 billion rubles at the rate of 2000 rubles for the management of one pregnancy, in the maternity hospital (department) - 7.5 billion rubles at the rate of 5000 rubles per childbirth) .In 2007, it is planned to increase the volume of financing to 14.5 billion rubles. At the same time, in the antenatal clinic, the cost of the birth certificate will increase to 3,000 rubles, in the maternity hospital - up to 6,000 rubles and 2,000 rubles will be sent to the children's clinic for medical examination services for a child of the first year of life (1,000 rubles in 6 months and 1,000 rubles in 12 months).

RUSSIAN ACADEMY OF MEDICAL SCIENCES

SCIENTIFIC RESEARCH INSTITUTE OF Obstetrics and Gynecology them. D.O. OTTA

V. V. Abramchekko, A. G. Kiselev, O. O. Orlova, D. N. Abdullaev

MANAGEMENT OF PREGNANCY AND HIGH-RISK LABOR

ST. PETERSBURG

INTRODUCTION

Abramchenko V.V., Kiselev A.G., Orlova O. O., Abdullaev D. N. "Management of high-risk pregnancy and childbirth.- SPb, 1995 year

Based on the literature data and our own experience, the issues of identifying and managing high-risk pregnant women and women in labor are highlighted. Particular attention is paid to the treatment of women with complications of pregnancy and childbirth. In particular, the issues of management of pregnant women with breech presentation of the fetus, narrow pelvis, diabetes mellitus are highlighted. The second part of the monograph is devoted to a number of complications of pregnancy and childbirth: regulation of labor, prevention and treatment of mecoium aspiration syndrome, modern methods of treatment of fetal hypoxia

The book is intended for obstetricians-gynecologists, neonatologists and anesthesiologists working in obstetric institutions.

V. V. Abramchenko, A. G. Kiselev, O. O. Orlova, D. N. Abdullaev.

In Russia, the main goal in the field of maternal and child health "is to develop conditions for" preserving the health and working capacity of a woman, solving issues of rational tactics - managing pregnancy 1, childbirth, the postpartum and neo-natal period, identifying ways to reduce maternal, perinatal and child morbidity and mortality ... At the same time, the creation of optimal conditions for the health of women and the development of pregnancy is the basis of "Prevention of perinatal pathology. O. G. Frolova et al. (1994) consider one of the main directions in the protection of mothers and children to reduce reproductive losses. The authors propose to consider reproductive losses. as the end result of the influence of social, medical and biological factors "on the health of pregnant women and newborns. The authors attribute the loss of embryos and fetuses to reproductive losses throughout the entire gestational period. On average, 32.3% of all pregnancies end in childbirth in the Russian Federation.

According to statistics, high-risk pregnancies in the general population are approximately 10%, and in specialized hospitals or perinatal centers, they can reach 90% (Barashnev Yu. I., 1991, etc.). WHO materials (1988) show that in Europe we are still far from defining what should be a rational delivery technique.

In the work of the World Health Organization (WHO, Geneva, 1988, 1992) "-programs of family protection, in particular, protection of mothers and children, are also given a priority task. It is emphasized that deaths in the perinatal period are responsible for most of the persistent and catastrophic It is shown that * perinatal mortality is closely related to poor health and nutritional status of the mother, complications of pregnancy and childbirth.

V. V. Chernaya, R. M. Muratova, V. N. Prilepskaya et al. (1991) recommend, depending on the complaints, about the general medical and reproductive history, the data of an objective examination, among those examined, 3 health groups should be distinguished:

- Is healthy- in the anamnesis there are no violations in the formation and subsequent, course of menstrual function, there are no pinecolotic diseases, complaints; during an objective examination (laboratory and clinical), there are no changes in the structure and function of the organs of the reproductive system.

- Practically healthy- in the anamnesis there are indications of gynecological diseases, functional abnormalities

or abortion; there are no complaints at the time of the examination, or an objective examination may be anatomical changes that do not cause dysfunctions of the reproductive system and do not reduce the working capacity of women.

__ Sick- there may be (or not) indications of

history of gynecological diseases. Complaints at the time of the examination may or may not be present. An objective examination revealed the presence of a gynecological disease. On. for the purpose of monitoring the state of health and effectiveness of each patient, * medical and health-improving measures, a “control card of a dispensary patient (study f. No. 30)” is set up.

Assessment of the health status of pregnant women should be carried out as follows:

The health of a pregnant woman can be regarded as a state of optimal physiological, mental and social functioning, in which the race of the system! of the mother's body ensure the usefulness of the health and development of the fetus.

The healthy group includes pregnant women who do not have somatic and gynecological diseases, who carry their pregnancies up to the term of physiological childbirth. These pregnant women have no risk factors for perinatal pathology.

To the group practically healthy pregnant women include women who do not have somatic and gynecological diseases, who carry their pregnancies up to the term of normal childbirth. The total assessment of the identified risk factors for perinatal pathology corresponds to a low degree of risk throughout pregnancy.

The rest of the pregnant women belong to the group sick, Assessment of the health status of the contingent of women who gave birth

should be carried out depending on ■ the state of health at the time of pregnancy, childbirth and the postpartum period, with particular attention to the restoration of reproductive function.

The postpartum observation group is established at her first visit to the antenatal clinic.

Group I includes healthy individuals with the physiological course of pregnancy, childbirth and the postpartum period, with sufficient lactation.

Group II - includes practically healthy persons with a physiological or complicated course of pregnancy, childbirth and the postpartum period, having risk factors for the onset or deterioration of extra agenital and gynecological diseases; complaints "at the time of the examination there are no

tions that cause reproductive and general health problems.

Group III includes patients with a physiological or complicated course of pregnancy, childbirth and the postpartum period, with an objective examination of which the presence of obstetric pathology, gynecological diseases, deterioration of the course of extragenital diseases was revealed.

The allocation of these groups is determined by the different nature of medical measures.

Dispensary observation of the contingent of women who have given birth is carried out within a year after childbirth. In the future, regardless of the health group, “ablation is carried out three times by actively calling the mothers to the antenatal clinic (by the 3rd, 6th and 12th months after childbirth). Three months after childbirth, a bimanual examination and examination of the cervix with the help of mirrors must be performed using the screening test "Schiller's test" (colposcop-p "s, if possible), bacterio- and pythological studies. At this stage, recreational activities and individual selection of contraceptive methods are required.

At the 6th month after childbirth, in the absence of contraindications, intrauterine contraception should be recommended. An active call of women to a consultation is carried out with the aim of controlling lactation by menstrual function and preventing unwanted pregnancy, social legal assistance. The third visit is advisable for the formation of an epicrisis for the final rehabilitation of women by the year after childbirth, for issuing recommendations on contraception, planning for subsequent pregnancy and the behavior of women in order to prevent existing complications.

At the same time, it is essential to emphasize that the analysis of domestic and foreign literature shows that the level of perinatal morbidity and mortality is especially high in a certain group of pregnant women, united in the so-called. I chew a high-risk group. The selection of such a group of pregnant women and women in labor allows you to organize a differentiated system of providing obstetric and pediatric care to this contingent of women and<их новорожденным детям. В этой связи особое значение приобретает совершенствование организации акушерско-гинекологической помощи в сельской местности.

To date, the urgency of the problem of maternal mortality has not diminished. The level of maternal mortality in the Russian Federation is still high, 6-10 times higher than the corresponding indicator of developed economic countries, and does not have a tendency to decrease (Sharapova E.I., 1992; Perfilieva G.N., 1994). The analysis shows that the high rate of maternal mortality is mainly due to abortion and such

obstetric complications such as bleeding, preeclampsia and purulent-septic complications.

Great importance is attached to the relationship and interaction of an obstetrician-gynecologist and a paramedical worker in the prevention of a number of complications of pregnancy, childbirth and perinatal morbidity and mortality.

Every year 95- 110 women, accounting for 14-16% of all maternal deaths 1. A significant influence of actratenital pathology on the formation of the most dangerous obstetric complications was also established. So, in women who died from obstetric bleeding, extragenital pathology was determined in 58% of cases, from gestosis - in 62%, from sepsis - in 68%. While in the population of pregnant women, extragital diseases are found in 25 - 30% (Serov V.N., 1990).

The proposed monograph will acquaint the reader with modern tactics of pregnancy and childbirth management in high-risk groups.

Chapter I. High-risk pregnant women

"Researchers from many countries are engaged in determining the factors and high-risk groups of pregnant women. At the same time, most of the authors, based on the clinic's data, identified risk factors, and then developed a system for their assessment. In the Russian Federation, the most detailed studies on the isolation of risk factors belong to L. S. Persianinov and The authors, based on the study of literature data, as well as the multifaceted development of childbirth histories in the study of the causes of perinatal mortality, identified individual risk factors. by this indicator in the entire group of examined pregnant women.L.S. Persianinov et al. (1976) divided all the identified risk factors into prenatal (A)

and intranatal (B).

Prenatal factors were divided into 5 subgroups: 1) socio-biological factors; 2) data of obstetric and hynecological history; 3) the presence of extragenital pathology; 4) complications of this pregnancy; 5) assessment of the condition of the fetus. The total number of prenatal factors was 52.

Intranatal factors were divided into 3 subgroups: 1) maternal risk factors, 2) placenta, and 3) fetus. This group contains 20 factors. Thus, a total of 72 risk factors were identified (see Table No. 1). A number of authors have identified ^

from 40 to 126 factors. Further, the authors point out that the analysis of literature data, assessment of the work of antenatal clinics and maternity hospitals convinced that for obstetric-gynecological practice in the present time, the most acceptable should be considered a scoring system for assessing risk factors. It makes it possible to assess not only the probability of an unfavorable outcome of childbirth in the presence of each specific factor, but also to obtain a total expression of the probability of the influence of a particular factor. An assessment scale of risk factors (in points) was developed by the authors based on an analysis of 2511 births that ended in fetal death in the perineum.

Table 1RISK FACTORS DURING PREGNANCY AND LABOR

	anka> allah		Evka Zallah
A. ANTENATAL PERIOD
1. Socio-biological		III. Extragenic diseases
1. Mother's age (years);		levania of the mother
		1. History of infections
		2. Cardiovascular diseases
		heart defects
		without breaking
2. Father's age (years):		circulation
		heart defects
		in violation
3. Occupational harm		circulation
		hypertonic disease
		I-II-III stages
		arterial hypotension
4. Bad habits: the mother:		3. Kidney disease: before pregnancy
smoking 1 pack of cigarettes		exacerbation of the disease
		during pregnancy
alcohol abuse		4. Eidocrinopathies:
		lrediabet
alcohol abuse		diabetes in relatives
		thyroid disease
5. Marital status:
lonely		adrenal diseases
6. Education:		5. Anemia:
initial		Not less than 9-10-11 g%
		6. Coagulapathy
7. Emotional loads		7. Myopia and other eye diseases

Continuation

8. Height and weight indicators of the mother:

height 150 cm and less 1

weight 25% above the norm 2 II. Obstetric and gynecological history

I. Parity:

2. Abortions before the first birth:

3 4 3. Abortions before re-birth:

4. Premature birth:

5. Stillbirth:

6. Death in the neonatal period:

7. Developmental anomalies in children 3

8. Neurological disorders 2

9. Weight of children less than 3500 2 and more than 4000 g. 1

10. Complicated course

previous rounds 1

I1. Infertility more than 2 - 5

12. Scar on the uterus after operations 4

13. Tumors of maggoi and ovaries 1 - 4

14. Isshiko-vdrvikalny failure 2

15. Malformations of Maggki 3

3 4

8. Chronic specific infections (tuberculosis, brucellosis, syphilis, current noplasmosis, etc. ______ 2-6

9. Acute infections during pregnancy 2- 7

IV Complications of pregnancy

1. Severe early toxicosis 2

2. Bleeding in the first and second half of pregnancy 3-5

3. Late toxicosis .:

dropsy 2 vephropathy I-II-III

degrees 3-5-1 (

preeclamisia 11

eclampsia 12

4. Concatenated Tokoikoya 9

5. Ph-negative blood 1

6. Ph and ABO-isooensibile-

7. Myogovodve, 3

9. Pelvic presenting zyosh

10. Multiple pregnancy m £ Ns

11. Postterm pregnancy! - SCH

12. Repeated use of medicines 1

V. Assessment of the condition of the fetus

1. Fetal hypotrophy 10-20

2. Fetal hypoxia 3-8

less than 4.9 mg / day. at 30 over. 34

less than 12.0 mg / day. at 40 weeks 15

4. The presence of meconium in amniotic fluid 3

Continuation

B. INTRANATAL PERIOD

From the side of Mia ter and			From the side of the fetus
1. Nephropathy 2. Presclampmia _ ,.			Premature birth (week of pregnancy): 28 - 30
3. Eclampsia
4. Untimely change
amniotic fluid (12 hours or more)			Heart rhythm disorder (within 30 minutes and
5. Weakness of labor
■ gelatinousness			Umbilical cord pathology:
6. Rapid labor			dropping out
7. Stimulation, sti-
imitation of the generic act			Pelvic extension:
tities
8. Clinically narrow pelvis			extraction of the fetus.
9. Threatening rupture			Operative intervention
11. From the placenta 1. "Presence of placentas:			caesarean section obstetric forceps: abdominal
partial			weekends
			vacuum extraction
2. Premature withdrawal			difficult elimination
puff normally spread			shoulders
placed placenta			General anesthesia during labor

tal period, and 8538 deliveries with a favorable outcome. In addition, the results of the study of the state of the fetus (ECG, F | KG, ultrasound examination) were used.

The total perinatal mortality in the aggregate of births in the group as a whole was conventionally taken as I point. Based on this provision, the assessment of points for each risk factor was made on the basis of calculating the level of perinatal mortality for the entire set of births and its indicators in women with the presence of one of these factors.

The principle of the risk assessment was as follows. The likelihood of the risk of an unfavorable outcome of pregnancy and childbirth for the fetus and newborn was divided into three degrees: high, medium and low. Each degree of risk was assessed based on the indicators of the Angar scale and the level of perinatal mortality. The degree of risk of perinatal pathology was considered high for children born with an Apgar score of 0 - 4 points, medium - 5 - 7 points and low - 8 - 10 points.

To determine the degree of influence of risk factors of the mother on the course of pregnancy and childbirth for the fetus L. S. Persianinov

et al. calculated in points all antenatal and intrapartum risk factors present in the mother of these children. At the same time, women with a total assessment of prenatal factors of 10 points or more were assigned to the high-risk group of pregnant women, 5–9 points to the medium-risk group, and up to 4 points to the low-risk group.

According to LS Persianinov et al. (1976) at the first examination of women (up to 12 weeks of pregnancy), the high-risk group is 18%, and by the end of pregnancy (32 - 38 weeks) it increases to 26.4%. According to the literature, the high-risk group of pregnant women is 16.9 - 30% (Hicks, 1992,

Zacutti et al., 1992 and others).

During childbirth, women were distributed according to the degree of risk as follows: with low risk - 42.8%, medium - 30%, high - 27.2%. Perinatal mortality was 1, 4, 20, 0, and 65.2%, respectively. Thus, the share of the group of women with low risk during childbirth decreases, while the groups of medium and high risk, respectively, increase. The data obtained by the authors show that risk factors during childbirth have a stronger effect on the level of perinatal mortality compared to those during pregnancy. The combination of high risk factors during pregnancy and childbirth is accompanied by a high perinatal mortality rate (93.2%). Since the same level of perinatal mortality occurred in pregnant women and women in labor with risk factors estimated at 4 points, this group was classified as a high-risk factor. The presence of one of these factors in a pregnant woman or woman in labor requires special attention of the obstetrician-gynecologist and other specialists who monitor her during pregnancy and childbirth. In conclusion, LS Persianinov et al. emphasize that the organization of specialized clinics, intensive monitoring high-risk pregnant women can significantly reduce perinatal mortality. Thus, intensive dynamic observation of one of the high-risk groups allowed to reduce the level of perinatal mortality by 30% compared with this indicator in a similar group of pregnant women under regular supervision.

OG Frolova, EI Nikolaeva (1976 - 1990) based on the study of the literature, as well as the development of more than 8000 birth histories, individual risk factors were identified. Evaluation of the outcomes of childbirth based on the materials of 2 basic antenatal clinics showed that the group of low-risk pregnant women lagged behind 45%, medium-risk - 28.6%, high-risk -26.4%. At the same time, perinatal mortality in the high-risk group of pregnant women was 20 times higher than in the low-risk group and 3.5 times higher than in the medium-risk group. During childbirth

the group of women with low risk was 42.8%, medium - 30%, high - 27.2%.

VA Sadauskas et al (1977) also emphasize the importance and appropriateness of identifying risk factors for the fetus during pregnancy and childbirth.

In each group, from 4 to 11 subgroups were identified, the severity of each factor was assessed using a five-point system. The classification used, according to the authors, quite accurately reflects the risk to the fetus in case of malignant pathology in pregnant women and makes it possible to organize timely and specialized intensive monitoring of the condition of the fetus. Other Russian authors also point to the expediency of identifying high-risk groups. So, A.S. Bergman et al. (1977) emphasize the role of functional diagnostic imaging in high-risk pregnant women, the role of radioimmunological determination of placental lactogen in high-risk pregnancies is indicated in the study by G. Radzuweit et al. (1977). L. S. Persiaminov et al. (1977) point out the role and importance of the use of hyperbaric oxygenation in pregnant women with high risk factors for the fetus, as a way to reduce perinatal mortality. It is also reported about the role of some extragenital diseases as a factor of increased risk (Butkevichyus S. et al., 1977; Shui-kina EP, 1976, etc.).

Some researchers (Radonov D., 1983) offer the organization of monitoring of high-risk pregnant women. Firstly, in order to improve the quality of observation of pregnant women with an increased risk of perinatal pathology, the author developed a special classification, consistent on the etiological principle, according to which 8 groups were identified:

Pregnant women with impaired uteroplacental circulation (late toxicosis, essential hypertension, xipocytic nephritis, placenta previa, abortion);

Causes that adversely affect the fetus (ionization, iso immunization, infections, chromosomal and gene abnormalities);

Adverse factors from the side of the pelvis, uterus and appendages (narrow pelvis, uterine hypoplasia, tumors);

Wrong position and presentation of the fetus, multiple pregnancies, polyhydramnios, fetal growth retardation;

Adverse factors on the part of the mother before and during pregnancy (extragenital diseases, too young or elderly primiparas, giving birth to 3 or more children, smoking);

Complicated obstetric history (infertility, dead

birth, caesarean section, bleeding, late toxicosis);

Factors related to the social environment (difficult living conditions, insufficient training, etc.);

Psycho-emotional state (unwanted or illegitimate pregnancy, poor psychoclimate iB family and at work). D. Radonov determines the degree of risk by a point system. All medium- and high-risk pregnant women are

hospital.

Secondly, after 20 weeks of pregnancy, all data are entered on a special gravidogram, which can be used to diagnose early signs of developing pathology (toxicosis, delayed fetal development, multiple pregnancy, etc.). Third, due to the rapid development in the third trimester, especially in the last month of pregnancy, various complications of the usual weekly monitoring of high-risk pregnant women are insufficient. Most of them must be hospitalized, for which it is necessary to increase the number of beds in the "intensive observation unit" - from 1/4 to 1/3 of all beds in the maternity hospital. In this department, a thorough examination of the fetus is carried out (non-stress and oxytocin tests, daily counting of the pregnant woman herself 3 times a day for 1 hour of fetal movements, ultrasound scanning, amnioscopy) with the recording of the data obtained on a special chart. Thanks to the "Carrying out of these measures, it was possible to reduce perinatal mortality to 8.9% o in undispensed pregnant women - 13.76% o) ■

Domestic scientists have made a great contribution to the development of the problem of high-risk groups of pregnant women. A number of scientists have established a number of risk factors that must be taken into account by a practicing obstetrician-gynecologist in the management of pregnancy, and this group of pregnant women often requires a comprehensive examination of the state of the fetus using modern apparatus and biochemical methods 1 of observation. V.G. Kono-nikhina (1978), when studying the risk of obstetric pathology in primiparous of various age groups, showed that the young (16-19 years) and older (30 years and older) age of primiparous women is a high risk factor for the development of obstetric pathology ... In pregnant women of a young age, compared with the optimal age (20 - 25 years), early and late toxicosis (almost in two raves), especially severe forms of toxicosis, more often occur, in two raves there is a threat of termination of pregnancy, prolonged pregnancy occurs in 3.2 times more often. In older primiparas, compared with the optimal age, early and late toxicosis are noted 3 times more often, the threat of termination of pregnancy is also 2 times more likely, and prolonged pregnancy is 6 times, premature and early rupture of amniotic fluid is 1.5 times, the weakness of labor forces 6.2 times, twice as often

childbirth takes place with a large fetus and in breech presentation, "pathological blood loss increases by 2.3 times."

In older primiparas, compared with the optimal age, delivery operations are more often used: obstetric forceps - 3.1 times, vacuum - fetal extractions - 2.9 times, cesarean section almost 5 times High frequency of complications during pregnancy and childbirth, especially in primiparas over 30 years of age, it is accompanied by a higher incidence of abnormalities in the fetus and newborn: hypoxia is 6.5 times more common, and the incidence of newborns is 4.5 times higher.

The author believes that the use of the method of intensive observation of primiparas of young and older age contributes to a more favorable course of pregnancy and childbirth, and the rates of perinatal morbidity and mortality also decrease. According to T.V. Chervyakova et al. (1981) one of the most pressing problems of modern obstetrics is the determination of the tactics of managing pregnancy and childbirth in women at high risk of perinatal pathology. Addressing these issues will be one of the main ways to improve indicators of maternal, perinatal and child morbidity and mortality. According to the authors, as a result of the studies carried out, significant progress has been achieved in the development of criteria for identifying groups and the degree of risk. perinatal pathology.

All studies were carried out in the following 6 main directions: 1) clarification of risk groups for extragenital diseases of the mother; 2) with complicated pregnancy; 3) with anomalies of the birth forces; 4) with the threat of intrauterine and postnatal infection; 5) with the threat of bleeding during childbirth and the early postpartum period. T.V. Cheriakova et al. indicate that as a result of these works, new interesting data have been obtained regarding the pathogenesis and clinic of complications of pregnancy and childbirth in women with various types of extragenital pathology, contraindications to maintaining pregnancy have been identified, indications and contraindications for the use of obstetric operations and anesthesia in childbirth have been clarified, questions have been resolved the use of various types of correlating therapy aimed at maintaining homeostasis in the body of the mother and fetus.

A number of authors propose a set of modern methods for diagnosing risk factors for the fetus during pregnancy. So, in (Research by G.M.Savelyeva et al. (1981) in order to identify the degree of risk to the fetus with a complicated course of pregnancy (nephrosis), prolonged gestation, miscarriage, Rh-sensitization), a set of modern methods was used to judge about fetal-llacental circulatory

fetal state and condition: cardiac monitoring, ultrasound scanning, study of volumetric blood flow in the intervillous space of the placenta (TC), concentration of placental lactogen and estriol in blood and amniotic fluid: biochemical parameters (ipH, O 2 voltage, concentration of basic electrolytes, glucose, urea , activity of histidase and urocania) of amniotic fluid. The authors examined more than 300 pregnant women.

The studies carried out made it possible to identify a correlative relationship between OK and the appearance of changes in the pathological nature of the studied parameters; initial and pronounced signs of fetal hypoxia according to cardiac monitoring data; the possibility of predicting the development of fetal hypoxia during labor according to some of the studied physiological and biochemical parameters. So, according to the value of OK, starting from 32 weeks, it is possible to predict the mass of newborns at the time of delivery. A decrease in TC by 30% or more indicates "intrauterine hypoxia of the fetus. An increase in TC with Rh sensitization above 200 ml / min per 100 g of placental tissue (normally, about 100 ml / min, with a placenta weight of 500 g) indicates the gigantic size of the placenta and the edematous form of hemolytic disease. ... j

An analysis of the results of cardiac monitoring made it possible to determine the value of basal changes, which were expressed in the form of rhythm monotony, basalva bradacardic, with iso- or arrhythmia. The authors cite a number of the most informative indicators that indicate fetal suffering. Therefore, according to the authors, the use of these methods in practice in combination or in isolation makes it possible to more accurately identify the degree of risk to the fetus in a complicated course of pregnancy and to determine the optimal medical tactics. Similar judgments are expressed by other authors. So, N.G. Kosheleva (1981) believes that complications of pregnancy should be considered as a risk factor for perinatal pathology. The author points out that the read-out forms of late toxicosis are especially unfavorable, while the loss of children with late toxicosis, which developed against the background of hypertension and kidney disease, is especially high.

Particular attention should be paid to the peculiarities of the course of pregnancy in diabetes mellitus. In the presence of genital infection, endocercicytes, colpitis or their combination, late toxicosis develops in every second to fourth pregnant woman, the threat of termination of pregnancy occurs in every sixth, with cavid colpitis four times more often with genital mixplasma in the genital tract. Thus, in order to reduce perinatal mortality, it is important not only to diagnose the complicated course of pregnancy, but also to clarify the “background”, “in which these complications arose. Along with

with this, it is necessary to constantly monitor the state of the intrauterine fetus using modern methods of examination and treatment of the intrauterine fetus.

Of particular importance is the study of risk factors in order to reduce perinatal mortality in a antenatal clinic (Orlean M. Ya. Et al., 1981). The authors identified four risk groups in the antenatal clinic: 1) socio-economic; 2) obstetric history; 3) obstetric pathology; 4) concomitant pathology. In this case, Rhck was determined using a point system from 5 to 45 points. 30 points in one group or 60 points in total are indicators of high risk. These measures made it possible to timely diagnose the early stages of toxicosis (shretoxicosis, watering) of pregnant women, and their timely hospitalization in hospitals made it possible to reduce the incidence of I-II degree nephropathy. S. Ye. Rub "ivchik, N. I. Turovich (1981), using a point estimate. Of risk factors in obstetrics, developed by Prof. F. Lyzikov, revealed that the first risk group for the socio-biological factor was 4% , the second group of the claim - burdened obstetric history - 17%, the third scolded the risk - complications of pregnancy - 45%, the fourth risk group - estragevital pathology - 41% - At the same time, temporary ones with a combination of two or more factors amounted to 4% - In each risk group preventive measures are taken to prevent the weakness of labor, miscarriage, treatment of subclinical forms of late toxicosis, treatment of rhesus - “conflict and pregnancy and, in the presence of astratenital pathology, the presence of pregnant women in dispensary registration with a therapist and obstetrician-gynecologist.

Thus, the identification of pregnant women with a risk of pregnancy pathology, timely preventive measures help to reduce complications in childbirth and perinatal mortality. Some authors (Mikhailenko E.T., Chernena M.Ya., 1982) have developed an original method of prenatal preparation of pregnant high-risk groups w> development of weakness in labor by increasing endogenous synthesis of prostaglandins, which allowed the authors to reduce the incidence of weakness by 3.5 times labor activity and halve the frequency of newborn asphyxia. L. G. Si-chinav; a et al. (1981) propose to use ultrasound scanning data to determine the degree of risk to the fetus in a rhesusconflict pregnancy.

At the same time, the optimal scanning time in pregnant women with isoserological incompatibility of the blood of the mother and the fetus should be considered 20 - 22 weeks, 30 - 32 weeks and immediately before delivery, which makes it possible to diagnose the initial form of hemolytic disease of the fetus, to determine

the degree of risk For the latter, which is important for the development of individual tactics for the management of pregnancy and childbirth. Other researchers also propose to use more widely the office of prenatal diagnostics to assess the condition of the fetus (Shmorgun FB, 1981; Tsupping E.E. et al., 1981).

At the same time, it is recommended, in addition to cardiac monitoring, "to use biochemical methods - to determine the activity of thermojutabilic alkaline phosphatase in the blood serum at a risk of pregnancy (Liivrand V.E. et al., 1981;), the coefficient of estrogen creaginine - as one of the indicators of the state of the intrauterine fetus ( Oinimäe H. V. et al., 1981), the content of steroidal hormones and cortisone. (Ttamer-mane L.P. et al., 1981); Daupaviete D.O. et al., 1981), determine the dynamics of the placental lactogen in the blood plasma of pregnant pears at risk (Reischer N.A. et al., 1981), as well as those consisting of the simindo-adrenal system (Paiu A. Yu. et al., 1981), sex determination as a risk factor based on -nii analysis of X and Y-chromatin in tissue cells of fetal membranes (Novikov Yu. I. et al., 1981).

N. V. Strizhova et al. (1981) to determine risk groups for late toxicosis of pregnant women, a complex immunodiffusion test is used using standard monospecific test systems for trophoblastic beta-globulin, placental lactogen, placentarial alpha in the amniotic fluid! - microglobulin, alfag - globulin of the "pregnancy zone", C-reactive protein, fibrinogen, alpha and beta-lipoproteins, as well as tissue antigens of the kidney. EP Zaitseva, GA Gvozdeva (1981) for the purpose of timely diagnosis of the true severity of toxicosis suggest using the immunological reaction of suppression of adhesion of leukocytes according to Holliday (Halliday., 1972). Postpartum complications in women with an increased risk of developing infections are also being studied (Zak I.R., 1981).

There are sporadic reports on the peculiarities of the mental development of children born from mothers of high-risk groups. So, M.G. Vyaskova et al. (1981) on the basis of a deep and qualified examination of 40 children of sick mothers (with the involvement of a specialist in psychology and defectology) found that children of sick mothers differ in the specifics of the development of mental activity, especially speech. The number of children with speech and intellectual pathology in the risk group turned out to be significant (28 out of 40), that is, 70%. All children with speech and intellectual pathology need special assistance of a different nature - from counseling to education in special schools.

A few works are devoted to modern methods of diagnosis and especially treatment of pregnant women with a high risk of perinatal pathology. So, I. P. Ivanov, T. A. Aksenova

i (1981) note that with a complicated course of pregnancy (toxicosis, anemia, threat of termination), the presence of extragenic - ["mental pathology) heart defects, vegetative-vascular dystonil, hypertension, diseases of the kidneys, endocrine system, etc. (often observed its npl and central insufficiency, accompanied by hypoxia or fetal malnutrition.

The degree of fetal suffering depends both on the severity and duration of the underlying disease, and on the severity of pathological changes in the placenta - a violation of its respiratory, transport, hormonal functions. The success of antenatal disease prevention and treatment of intrauterine fetal suffering is largely determined by the informativeness of methods for diagnosing the state of the fetus and the timeliness of targeted, highly effective therapy. I.P. Ivanov et al. in terms of dynamic monitoring of the state of the fetus, it is proposed to use phonoelectrocardiography in combination with functional tests and ultrasound scanning, as well as indicators of estriol, placental lactogen, activity of a thermostable isoenzyme, alkaline phosphatase, which reflect the functional activity of the placenta and indirectly allow judging the state of the fetus, as well as determining the rate of uterine-placental blood flow by the radioisotope method, indicators of the acid-base state and activity about the visitor are all new technologies.

The complex of the obtained data makes it possible to carry out pathogenetically justified therapy of fetal hypoxia and prevention of fetal hypotrophy in a timely and adequate volume.

From modern methods of treatment of hypoxia I.P. Ivanov et al. indicate the widespread use of hyperbaric oxygenation in combination with medications (cocarbocoylase, ATP, sygetin, compliamin, vitamins, etc.) against the background of treatment of the underlying disease, taking into account the maternal-fetal relationship. As a result of such therapy, the disturbed indices of the acid-base state and blood gases, hemodynamics, uterine-placental blood flow, indices of the function of the placenta and the state of the fetus are normalized.

Foreign researchers also widely use monitoring methods for determining the state of the fetus in high-risk pregnant women (Bampson., 1980, Harris et al, 1981, etc.). Studies by Teramo (1984) show that 2/3 of women whose children die in the perinatal period or suffer from asphyxia at birth or diseases in the neonatal period ™ can be identified in advance during pregnancy. Such women at high risk., Make up 1/3 of the total number of pregnant women. Careful monitoring of a pregnant woman in a antenatal clinic is essential for identifying high-risk pregnant women.

A detailed medical history, including social, medical and obstetric information, as well as clinical signs and symptoms, is the basis for identifying a high-risk pregnant woman. The author emphasizes that, along with clinical methods, an instrumental examination of the fetus in perinatal centers is necessary.

Tegato (1984) out of a total of 1695 pregnant women, identified 1 high-risk pregnant women in 480: a history of caesarean section 1 (60), a history of premature birth (birth of a child weighing less than 2500 g) in anamnesis (46), childbirth with congenital | disease (malformations - 20, neurological * defects - 3, miscellaneous - 12) in history (35), stillbirth (17), chronic diseases (63), chronic urinary tract infections (34), diabetes mellitus ( 10), the presence of diabetes mellitus in the family (185), pathological changes in glucose tolerance (21), hypertension (66), uterine bleeding in early pregnancy (IU), the first birth at the age of over 35 years (9).

The author proposes to use cardiotocragraphy with a decrease in motor activity. It has been shown that the number of movements less than 10 in 12 hours is associated with an increased frequency of fetal asphyxia (Pearson, Weaver, 1976). Next, you need to monitor the growth of the fetus, determine estriol in blood plasma, urine, while it is important to take into account what medications a woman is taking during this period, since, for example, taking glucocorticoids reduces the production of estriol, it is advisable to analyze estriol every 2 to 3 days, and also determine placental lactosgen, functional tests (oxytocin test).

It is important to note that when using a stress-free test, the author recommends performing cardiotocography (CTG) every 1 to 3 days for preeclampsia, with chronic hypertension 1-3 times a week, with intrauterine growth retardation every 1 to 3 days, with prenatal effusion. - amniotic fluid 1-2 times a day, three hepatosis of pregnant women - daily, with diabetes mellitus, class A according to White's classification weekly at a gestational age of 34 to 36 weeks, and at a gestational age of 37 weeks - 2 to 3 times a week, diabetes mellitus, classes A. B, C, D and gestational age 32 - 34 weeks. - every 2nd day., at 35 weeks. - daily, diabetes mellitus, classes F, R at a gestational age of 28 - 34 weeks. - every 2nd day, at 35 weeks. - daily. With changes in the fetal heart rate curve and 26 weeks of gestation 1 - 3 times a day.

In a comprehensive monograph by Babson et al. (1979) on the management of pregnant women with an increased risk and intensive care of the newborn, when determining the degree of risk in the perinatal period, the authors define that such a risk in the perinatal period is the risk of death or

changes in disability during the period of growth and development of a person from the moment of origin of life to 28 days after birth. At the same time, the authors distinguish between the risk associated with intrauterine development of the fetus and the risk associated with the development of the child after birth. This division makes it possible to better represent the factors associated with risk in the perinatal period.

Risk factors related to intrauterine fetal development

It is necessary to identify women who have a high probability of death or damage to the fetus during pregnancy. Completely unexpected complications rarely occur in women who underwent a comprehensive examination and long-term observation, during which significant deviations from the norm were detected in a timely manner, appropriate therapy was carried out during pregnancy and the prognosis of the "course of labor" was carried out.

Here is a list of increased risk factors that contribute to perinatal mortality or morbidity in children. Approximately 10 - 20% of women belong to these groups, and in more than half of the cases, the death of fetuses and newborns is explained by the influence of these factors.

1. A history of serious hereditary or family abnormalities, such as defective osteogenesis, Down's disease.

2. The birth of the mother herself is premature or very small for the period of pregnancy at which the birth occurred or the cases when the previous birth of the mother ended in the birth of a child with the same deviations.

3. Serious congenital anomalies affecting the central nervous system, heart, skeletal system, lung abnormalities, as well as general blood diseases, including anemia (hematocrit below 32%).

4. Serious social problems, such as teenage pregnancy, drug addiction, or the absence of a father.

5. Absence or late start of medical supervision in the perinatal period.

6. Age under 18 or over 35.

7. Height less than 152.4 cm and pre-pregnancy weight 20% lower or higher than the standard weight for this height.

8. Fifth or subsequent pregnancy, especially if the pregnant woman is over 35 years old.

" 9. Another pregnancy that occurred within 3 months. after the previous I Shchey.

| 10. A history of prolonged infertility or serious drug or hormonal treatment.

11. Teratogenic viral disease in the first 3 months of pregnancy.

12. Stressful conditions, for example, severe emotional stress, indomitable vomiting of pregnant women, anesthesia, shock, critical situations or a high dose of radiation.

13. Smoking abuse.

14. Complications of pregnancy or childbirth in the past or present, such as pregnancy toxicosis, premature placental abruption, isoimmunization, polyhydramnios or amniotic fluid discharge.

15. Multiple pregnancy.

16. Retardation of normal growth of the fetus or fetus in size sharply different from normal.

17. No weight gain or minimal gain.

18. Wrong position of the fetus, for example, breech presentation, transverse position, unidentified presentation of the fetus at the time of delivery.

19. The gestation period is more than 42 weeks.

Further, the author cites demographic studies on specific complications and the percentage of perinatal mortality in each of the complications, while in more than 60% of cases, fetal death and in 50% of cases, the death of a newborn is associated with complications such as breech presentation, premature detachment, placenta, pregnancy toxicosis , giving birth to twins and a urinary tract infection.

Factors contributing to the increased risk to the newborn

Postpartum, additional environmental factors can increase or decrease the infant's viability. Babson et al. (1979) point to the following pre- or post-delivery factors that place the infant at increased risk and therefore require special treatment and monitoring:

1. The mother has a history of the above risk factors during pregnancy, especially:

a) belated rupture of the fetal bladder;

b) incorrect presentation of the fetus and childbirth;

c) prolonged, difficult labor or very rapid labor;

d) prolapse of the umbilical cord;

2. Asphyxia of the newborn, suspected on the basis of:

a) fluctuations in the number of fetal heart beats;

b) staining of amniotic fluid with meconium, especially its withdrawal;

c) fetal acidosis (pH below 7.2);

d) the number of points according to the Apgar system is less than 7, especially if the assessment is given 5 minutes after birth.

3. Premature birth (up to 38 weeks).

4. Delayed labor (after 42 weeks) with signs of fetal malnutrition.

5. Babies are too small for the given pregnancy rate (below 5% of the curve).

6. Babies that are too big for the given gestational age (below 95% of the curve) especially large babies born prematurely.

7. Any breathing disorder or stoppage.

8. Obvious birth defects.

9. Cramping, lameness, or difficulty sucking or swallowing.

10. Bloating and / or vomiting.

11. Anemia (hemoglobin content less than 45%) or hemorrhagic diathesis.

12. Jaundice in the first 24 hours after birth or the level of bilirubin above 15 mg / 100 ml of blood.

1. Initial selection.

2. Selection during a visit to a pregnant antenatal clinic.

3. Selection during childbirth: upon admission to the obstetric facility and upon admission to the maternity ward.

4. Assessment during labor:

a) a newborn,

b) mothers.

5. Postpartum assessment:

a) newborn

b) mothers.

Pregnant women with identified risk factors are classified as follows: according to the criteria below at each stage:

I. Initial selection Biological and marital factors.

a) high risk:

1. The mother is 15 years old or younger.

2. The mother is 35 years of age or older.

3. Excessive obesity.

b) Moderate risk:

1. The mother's age is from 15 to 19 years old.

2. The mother's age is from 30 to 34 years.

3. Unmarried.

4. Obesity (weight 20% above the standard weight for a given height).

5. Exhaustion (weight less than 45.4 kg.).

6. Small in stature (152.4 cm or less).

Obstetric history

A. High risk:

1. Pre-diagnosed anomalies of the birth canal:

a) inferiority of the cervix; "

b) abnormal development of the cervix;

c) abnormal development of the uterus.

2. Two or more previous abortions.

3. Intrauterine fetal death or death of a newborn during a previous pregnancy.

4. Two previous premature births or the birth of babies at term, but underweight (less than 2500 g).

5. Two previous children are oversized (weighing more than 4000 g).

6. Malignant tumor in the mother.

7. Uterine fibroids (5 cm or more or submucosal localization).

8. Cystic ovaries.

9. Eight or more children.

10. Presence of isoimmunization in a previous child.

11. A history of enlampsia.

12. The presence of the previous child:

a) known or suspected genetic or family abnormalities;

b) congenital malformations.

13. A history of complications that required special therapy in the neonatal period, or the birth of a child with a trauma during childbirth.

14. Medical indications for termination of a previous pregnancy. B. Moderate risk:

1. Previous premature birth or delivery of a child at term, but with a low weight (less than 2500 g), or abortion.

2. One oversized child (over 4000 g). m> "p ^ u

3. Previous childbirth ended with surgery: SC

a. caesarean section, b. the imposition of forceps, c. extraction at the pelvic end.

4. Previous prolonged labor or significantly obstructed labor.

5. Narrowed pelvis.

6. Serious emotional problems associated with a previous pregnancy or childbirth.

7. Previous operations on the uterus or cervix.

8. First pregnancy.

9. The number of children from 5 to 8.

10. Primary infertility. , |

P. Incompatibility in the ABO system in history.

12. Incorrect presentation of the fetus in previous births.

13. A history of endometriosis.

14. Pregnancy after 3 months. or sooner after the last birth.

Medical and surgical history

A. High risk:

1. The average degree of hypertension.

2. Kidney disease of moderate severity.

3. Severe heart disease (II - IV degree of heart failure) or congestion caused by heart failure.

4. Diabetes.

5. Removal of endocrine glands in history.

6. Cytological changes in the cervix.

7. Cardiac anemia.

8. Drug addiction or alcoholism.

9.Presence of a history of tuberculosis or PPD test (diameter more than 1 cm)

10. Pulmonary disease. ;

11. Malignant tumor.

12. Gastrointestinal disease or liver disease.

13. Previous surgery on the heart or blood vessels.

B. Moderate risk.

1. The initial stage of hypertension.

2. Mild kidney disease.

3. Mild heart disease (I degree).

4. Presence of mild hypertensive in the anamnesis during! ■ pregnancy.

5. Postponed pyelonephritis.

6. Diabetes (mild).

7. Family diabetes.

8. Disease of the thyroid gland.

9. Positive results of a serological test.

10. Excessive use of drugs.

11. Emotional problems.

12. The presence of sickle-shaped erythrocytes in the blood.

13. Epilepsy.

II. Selection during a visit to a pregnant antenatal clinic "in the prenatal period. ,

Early pregnancy I

A. High risk: : ";" ■; : I

1. Lack of enlargement of the uterus or disproportionate enlargement. I

2, Action of teratogenic factors :: I

a. radiation; !■:■, ■. ..... - ..... \|

b. infections;

v. chemical agents.

3. Pregnancy complicated by immunization.

4. The need for genetic diagnosis in the antenatal period. 5. Severe anemia (hemoglobin content 9 g% or less).

B. Moderate risk:

1. Refractory urinary tract infection.

2. Suspected ectopic pregnancy.

3. Suspicion of a failed abortion.

4. Severe, indomitable vomiting of a pregnant woman.

5. Positive serological reaction for gonorrhea.

6. Anemia, not amenable to treatment with iron preparations.

7. Viral disease.

8. Vaginal bleeding.

9. Mild anemia (hemoglobin content from 9 to 10; 9 g%).

Late pregnancy

A. High risk:

1. Lack of enlargement of the uterus or disproportionate enlargement.

2. Severe anemia (hemoglobin content less than 9 g%).

3. The gestation period is more than 42 1/2 units.

4. Severe preeclampsia.

5. Eclampsia.

6. Breech presentation if normal labor is planned.

7. Isoimmuyaization of moderate severity (necessary intrauterine blood flow or complete exchange transfusion of blood to the fetus).

8. Placenta previa.

9. Polyhydramnios or multiple pregnancy.

10. Intrauterine fetal death.

11. Thromboembolic disease.

12. Premature birth (less than 37 weeks gestation).

13. Premature rupture of the amniotic fluid (less than 38 weeks of gestation).

14. Obstruction of the birth canal caused by a tumor or other reasons.

15. Premature placental abruption.

16. Chronic or acute pyelonephritis.

17. Multiple pregnancy.

18. Abnormal reaction to oxytocin test.

19. A drop in the level of estriol in the urine of a pregnant woman. B. Moderate risk:

1. Hypertensive conditions during pregnancy (mild).

2. Breech presentation if a cesarean section is planned.

3. Unidentified presentation of the fetus.

4. The need to determine the degree of maturity of the fetus.

5. Postterm pregnancy (41-42.5 weeks).

6. Premature rupture of membranes (childbirth does not occur more than 12 hours if the gestation period is more than 38 weeks).

7. Excitement of labor.

8. Estimated imbalance between the size of the fetus and the pelvis at the time of delivery.

9. Non-fixed presentation for 2 weeks. or less before the estimated due date.

Risk stratification in obstetrics provides for the identification of groups of women in whom pregnancy and childbirth may be complicated by fetal disruption, obstetric or extragenital pathology. Based on the history, physical examination and laboratory tests, the following unfavorable prognostic factors are identified.

I. Socio-biological:
- mother's age (up to 18 years old; over 35 years old);
- the father's age is over 40;
- professional harm from parents;
- smoking, alcoholism, drug addiction, substance abuse;
- weight growth indicators of the mother (height 150 cm or less, weight 25% higher or lower than normal).

II. Obstetric and gynecological history:
- the number of births is 4 or more;
- repeated or complicated abortions;
- surgical interventions on the uterus and appendages;
- malformations of the uterus;
- infertility;
- miscarriage;
- undeveloped pregnancy (NB);
- premature birth;
- stillbirth;
- death in the neonatal period;
- the birth of children with genetic diseases and developmental anomalies;
- the birth of children with low or large body weight;
- complicated course of a previous pregnancy;
- bacterial-viral gynecological diseases (genital herpes, chlamydia, cytomegaly, syphilis,
gonorrhea, etc.).

III. Extragenital diseases:
- cardiovascular: heart defects, hyper and hypotensive disorders;
- diseases of the urinary tract;
- endocrinopathy;
- blood diseases;
- liver disease;
- lung disease;
- connective tissue diseases;
- acute and chronic infections;
- violation of hemostasis;
- alcoholism, drug addiction.

IV. Complications of pregnancy:
- vomiting of pregnant women;
- the threat of termination of pregnancy;
- bleeding in the first and second half of pregnancy;
- gestosis;
- polyhydramnios;
- lack of water;
- placental insufficiency;
- multiple pregnancy;
- anemia;
- Rh and AB0 isosensitization;
- exacerbation of a viral infection (genital herpes, cytomegaly, etc.).
- anatomically narrow pelvis;
- wrong position of the fetus;
- post-term pregnancy;
- induced pregnancy.

For a quantitative assessment of factors, a scoring system is used, making it possible not only to assess the probability of an unfavorable outcome of childbirth under the action of each factor, but also to obtain a total expression of the probability of all factors.

Based on the calculations of the assessment of each factor in points, the authors distinguish the following degrees of risk: low - up to 15 points; average - 15-25 points; high - more than 25 points.

9.1. Isolation and clinical examination of pregnant women in high-risk groups

The most common mistake in calculating points is that the doctor does not summarize the indicators that seem insignificant to him.

The first point screening is carried out at the first visit of the pregnant woman to the antenatal clinic. The second - at 28–32 weeks, the third - before childbirth. After each screening, the pregnancy management plan is specified. The identification of a group of pregnant women with a high degree of risk makes it possible to organize intensive monitoring of the development of the fetus from the beginning of pregnancy.

From 36 weeks of pregnancy, women from the group of medium and high risk are re-examined by the head of the antenatal clinic and the head of the obstetric department, where the pregnant woman will be hospitalized before delivery.

This examination is an important point in the management of at-risk pregnant women. In areas where there are no maternity wards, pregnant women are hospitalized for preventive treatment in certain obstetric hospitals.

Since antenatal hospitalization for examination and comprehensive preparation for childbirth for women at risk is mandatory, the length of hospitalization, the estimated plan for the management of the last weeks of pregnancy and childbirth should be developed in conjunction with the head of the obstetric department. Antenatal hospitalization at the time determined jointly by the doctors of the consultation and the hospital is the last, but very important task of the antenatal clinic. Having timely hospitalized a pregnant woman from medium or high risk groups, the doctor of the antenatal clinic can consider his function fulfilled.

A group of pregnant women at risk of perinatal pathology. It was found that 2/3 of all cases of PS occurs in women from the high-risk group, accounting for no more than 1/3 of the total number of pregnant women.

On the basis of literature data, own clinical experience, as well as the multifaceted development of birth histories in the study of PS, O. G. Frolova and E. N. Nikolaeva (1979) identified individual risk factors. These include only those factors that led to a higher level of PS in relation to this indicator in the entire group of surveyed pregnant women. The authors divide all risk factors into two large groups: prenatal (A) and intranatal (B).

Prenatal factors, in turn, are divided into 5 subgroups:

- social and biological;
- obstetric gynecological history;
- extragenital pathology;
- complications of this pregnancy;
- assessment of the state of the intrauterine fetus.

Intranatal factors were also divided into 3 subgroups. These are factors from the outside:

- mothers;
- placenta and umbilical cord;
- the fetus.

Among the prenatal factors, 52 factors are distinguished, among the intranatal ones - 20. Thus, a total of 72 factors have been identified.
risk.

DAY STATIONARY

Day hospitals are organized at outpatient polyclinic institutions (women's consultation), maternity hospitals, gynecological departments of multidisciplinary hospitals in order to improve the quality of medical care for pregnant and gynecological patients who do not require round-the-clock observation and treatment.

· The hospital carries out continuity in the examination, treatment and rehabilitation of patients with other health care institutions: when the condition of sick women worsens, they are transferred to the appropriate departments of the hospital.

· The recommended capacity of the day hospital is at least 5-10 beds. To ensure a full-fledged diagnostic and treatment process, the duration of the patient's stay in the day hospital should be at least 6-8 hours a day.

· The management of the day hospital is carried out by the chief physician (head) of the institution on the basis of which this structural unit is organized.

· The staff of the medical staff and the working hours of the day hospital of the antenatal clinic depend on the amount of care provided. For each patient of the day hospital, a "Card of a patient of a day hospital at a polyclinic, a hospital at home, a day hospital in a hospital" is entered.

Indications for the selection of pregnant women for hospitalization in a day hospital:

- vegetative-vascular dystonia and hypertension in the first and second trimesters of pregnancy;
- exacerbation of chronic gastritis;
- anemia (Hb not lower than 90 g / l);
- early toxicosis in the absence or presence of transient ketonuria;
- the threat of termination of pregnancy in the first and second trimesters in the absence of a history of habitual miscarriages and a preserved cervix;
- critical periods of pregnancy with a history of miscarriage without clinical signs of threat of termination;
- medical genetic examination, including invasive methods (amniocentesis, chorionic biopsy, etc.) in the pregnant group of high perinatal risk in the absence of signs of threatened abortion;
- non-drug therapy (acupuncture, psycho and hypnotherapy, etc.);
- Resuscitation in the I and II trimesters of pregnancy (for examination, nonspecific desensitizing therapy);
- suspicion of PN;
- suspicion of heart disease, pathology of the urinary system, etc.;
- carrying out special therapy for alcoholism and drug addiction;
- upon discharge from the hospital after suturing the cervix for ICI;
- continuation of observation and treatment after a long hospital stay.

Some mothers-to-be are at risk of pregnancy. This term scares many women, becomes the cause of their excitement, which is very contraindicated during the period of expectation of a child. Identification of high-risk pregnancy is necessary in order for a woman to receive the necessary medical care on time and in full. Let's consider what are the risk factors during pregnancy, and how doctors act in the case of such pathologies.

Who is at risk for pregnancy?

High-risk pregnancies are characterized by an increased likelihood of fetal death, miscarriage, premature birth, intrauterine growth retardation, intrauterine or neonatal illness and other disorders.

Determining the risks during pregnancy is extremely important, as it allows you to start the necessary therapy in a timely manner or carefully monitor the course of pregnancy.

Who is at risk for pregnancy? Experts conditionally divide all risk factors into those that are present in a woman even before the moment of conception and those that arise already during pregnancy.

Risk factors that a woman has before pregnancy and can affect its course:

• The age of the woman is under 15 and over 40. An expectant mother under 15 years of age has a high probability of preeclampsia and eclampsia - severe pathologies of pregnancy. They also often have premature or underweight babies. Women over 40 have a high risk of having a baby with a genetic disorder, most often Down syndrome. In addition, they often suffer from high blood pressure during gestation.
• Body weight less than 40 kg. Such expectant mothers have the likelihood of having a baby with a low weight.
• Obesity. Obese women are also at high risk of pregnancies. In addition to the fact that they are more likely than others to have high blood pressure and the development of diabetes mellitus, there is a high probability of having a baby with a large weight.
• Growth less than 152 cm. Such pregnant women often have reduced pelvic sizes, a high risk of premature birth and low birth weight.
• The risk during pregnancy exists in those women who have had multiple consecutive miscarriages, premature births or stillbirths.
• A large number of pregnancies. Experts note that already the 6-7th pregnancies often have many complications, including placenta previa, weakness of labor, postpartum hemorrhage.
• Defects in the development of the genital organs (insufficiency or weakness of the cervix, doubling of the uterus) increase the risk of miscarriage.
• Diseases of a woman are often dangerous both for her and for the unborn child. Such diseases include: kidney disease, chronic hypertension, diabetes mellitus, thyroid disease, severe heart disease, systemic lupus erythematosus, sickle cell anemia, disorders of the blood coagulation system.
• Diseases of family members. If there are people with mental retardation or other hereditary diseases in the family or among close relatives, the risk of having a baby with the same pathologies significantly increases.

Risk factors that arise already during pregnancy include the following conditions and diseases:

• Multiple pregnancy. About 40% of multiple pregnancies end in miscarriage or premature birth. In addition, expectant mothers carrying two or more babies are more prone to high blood pressure than others.
• Infectious diseases that have arisen during pregnancy. Rubella, viral hepatitis, infections of the genitourinary system, herpes are especially dangerous during this period.
• Alcohol and nicotine abuse. Probably everyone already knows that these addictions can cause miscarriages, premature birth, intrauterine pathologies of a child, premature or low birth weight.
• Pathology of pregnancy. The most common are oligohydramnios and polyhydramnios, which can lead to premature termination of pregnancy and many of its complications.

Management of high-risk pregnancies

If a woman has risks during pregnancy, there is a need for strict medical supervision.

Potential risk factors for pregnancy

In addition, additional examinations are prescribed for pregnant women from this group, depending on the indications. The most commonly used are ultrasound, umbilical cord puncture, amnioscopy, determination of the level of GT21, determination of alpha-fetoprotein content, fetal endoscopy, Doppler apparatus, embryoscopy, trophoblast biopsy, pelvic x-ray.

If necessary, a pregnant woman is taken to a day or round-the-clock hospital. If there are risks to the course of pregnancy or fetal development, the doctor prescribes special therapy.

Do not despair for a woman who is at risk of pregnancy. Under the competent supervision of doctors, in most cases, the possibility of developing pathologies is minimized. The main thing is to follow all the doctor's recommendations and believe that a miracle will happen at a certain time - the birth of a healthy child.

Highlight the risk groups of pregnant women in the antenatal clinic for obstetric and perinatal pathology.

The risk strategy in obstetrics provides for the identification of groups of women in whom pregnancy and childbirth may be complicated by fetal disruption, obstetric or extragenital pathology. Pregnant women who are registered in the antenatal clinic can be attributed to the following risk groups: 1. with perinatal fetal pathology; 2.with obstetric pathology; 3.with extragenital pathology. At 32 and 38 weeks of pregnancy, point screening is performed, since new risk factors appear during these periods. Research data indicate an increase in the group of pregnant women with a high degree of perinatal risk (from 20 to 70%) by the end of pregnancy. After re-determining the degree of risk, the pregnancy management plan is specified. From 36 weeks of pregnancy, women from the group of medium and high risk are re-examined by the head of the antenatal clinic and the head of the obstetric department, where the pregnant woman will be hospitalized before delivery. This examination is an important point in the management of at-risk pregnant women. In those areas where there are no maternity wards, pregnant women are hospitalized according to the schedules of regional and city health departments for preventive treatment in certain obstetric hospitals. Since antenatal hospitalization for examination and comprehensive preparation for childbirth for women at risk is mandatory, the length of hospitalization, the estimated plan for the management of the last weeks of pregnancy and childbirth should be developed in conjunction with the head of the obstetric department. A group of pregnant women at risk of perinatal pathology. It was found that 2/3 of all cases of perinatal mortality occurs in women from the high-risk group, accounting for no more than 1/3 of the total number of pregnant women. The authors divide all risk factors into two large groups: prenatal (A) and intranatal (B). Prenatal factors in turn, they are subdivided into 5 subgroups: 1. socio-biological; 2. obstetric and gynecological history; 3. extragenital pathology; 4. complications of this pregnancy; 5. assessing the state of the intrauterine fetus. Intranatal factors were also divided into 3 subgroups. These are factors from the outside: 1. mother; 2. placenta and umbilical cord; 3. the fetus. For a quantitative assessment of factors, a point system was used, which makes it possible not only to assess the probability of an unfavorable outcome of childbirth under the action of each factor, but also to obtain a total expression of the probability of all factors. Based on the calculations of the assessment of each factor in points, the authors distinguish the following degrees of risk: high - 10 points and higher; average - 5-9 points; low - up to 4 points. The most common mistake in calculating points is that the doctor does not summarize the indicators that seem insignificant to him, believing that there is no need to increase the risk group. The identification of a group of pregnant women with a high degree of risk makes it possible to organize intensive monitoring of the development of the fetus from the beginning of pregnancy. Currently, there are many possibilities for determining the state of the fetus (determination of estriol, placental lactogen in the blood, amniocentesis with the study of amniotic fluid, PCG and ECG of the fetus, etc.).

Dynamics of involutive processes in the genital organs of a woman after childbirth and methods for their assessment.

The cervix looks like a thin-walled sac with a wide gaping external pharynx with torn edges hanging down into the vagina. The cervical canal freely passes the hand into the uterine cavity. The entire inner surface of the uterus is a vast wound surface with pronounced destructive changes in the area of ​​the placental site. The lumens of the vessels in the area of ​​the placental site are compressed, blood clots form in them, which helps to stop bleeding after childbirth. Every day, the height of the uterine fundus decreases by an average of 2 cm. The cytoplasm of some muscle cells undergoes fatty degeneration, and then fatty degeneration. Reverse development also occurs in the intermuscular connective tissue. The healing process of the inner surface of the uterus begins with the disintegration and rejection of scraps of the spongy layer of the decidua, blood clots, and thrombi. During the first 3-4 days, the uterine cavity remains sterile. Discharge-lochia. In the first 2-3 days after childbirth, it is bloody discharge, from 4 to 9 days - serous-bloody, from 10 days - serous. At 5-6 weeks, the discharge from the uterus stops. Lochia have an alkaline reaction and a specific (rotten) smell. The epithelialization of the inner surface of the uterus ends by the 10th day of the postpartum period (except for the placental site). The endometrium is fully restored 6-8 weeks after childbirth. The usual tone of the ligamentous apparatus of the uterus is restored by the end of 3 weeks. Immediately after childbirth, the bottom of the uterus is 15-16 cm above the pubis, the transverse size of the uterus is 12-13 cm, the weight is about 1000 g. By 1 week after childbirth, the weight of the uterus is 500 g, by the end of 2 weeks - 350 g, 3 - 250 g, by the end of the postpartum period - 50 g.

Allocation of pregnant women into risk groups

The involution of the cervix is ​​somewhat slower than that of the body. the internal pharynx begins to form first, by the 10th day it is practically closed. the final formation of the cervix is ​​completed by the end of 3 weeks. In the ovaries in the postpartum period, the regression of the corpus luteum ends and the maturation of follicles begins. In non-lactating women, menstruation is restored 6-8 weeks after childbirth. The first menstruation after childbirth, as a rule, occurs against the background of the anovulatory cycle: the follicle grows, matures, but ovulation does not occur, and the corpus luteum does not form. Define the height of the uterine fundus, its diameter, consistency, the presence of pain. The height of the standing of the fundus of the uterus is measured in centimeters in relation to the pubic articulation. During the first 10 days, it drops by an average of 2 cm per day. Assess the nature and number of lochia. The first 3 days of lochia are bloody in nature due to the large number of red blood cells. From the 4th day until the end of the first week, the lochia become serous-sacral. They contain many leukocytes, there are epithelial cells and areas of the decidua. By the 10th day, the lochia become liquid, light, without any admixture of blood. By about 5-6 weeks, the discharge from the uterus completely stops. The external genitals and perineum are examined daily. Pay attention to the presence of edema, hyperemia, infiltration.

Task: Place the fetus in the 1st position, anterior occipital presentation. The fetal head is at the outlet of the pelvis. Confirm with appropriate vaginal examination data.

Answer: With an external examination, the head is not palpable at all. At vaginal examination: the sacral cavity is completely filled with the head, the ischial spines are not defined. Sagittal suture in the straight size of the exit of the pelvis, a small fontanelle under the bosom.

EXAMINATION TICKET 6

1. The main decreed documents that are filled in for a pregnant woman in an antenatal clinic

Registration of medical documentation for a pregnant woman. All survey and survey data of a woman, advice and appointments should be recorded in "Individual card for pregnant and postpartum women" (form 11 l / y), which are stored in the card file of each obstetrician-gynecologist by the dates of the planned visit. In order to form an obstetric hospital about the state of health of a woman and the peculiarities of the course of pregnancy, the doctor of the antenatal clinic issues the hands of each pregnant woman (at a gestational age of 28 weeks) "Exchange card of the maternity hospital, maternity ward of the hospital" (form 113 / u) and at each visit of a pregnant antenatal clinic, all information about the results of examinations and studies is entered into her.

Generic certificate

The purpose of this program- increasing the availability and quality of medical care for women during pregnancy and childbirth through the introduction of economic incentives for medical workers and the provision of additional financial opportunities to improve the material and technical base of state (municipal) obstetric care institutions.

The introduction of birth certificates implies stimulating the work of antenatal clinics and maternity hospitals in Russia, which should lead to an improvement in the situation in obstetrics, a decrease in maternal and infant mortality, and an increase in the level of pregnancy support and services. Behind each certificate is a specific amount that will be paid from the Social Insurance Fund of the Russian Federation, and, therefore, institutions will be interested in each specific pregnant woman. The certificate is a pink document with four positions: a spine, two coupons and the certificate itself. The first coupon (with a face value of 2 thousand rubles) remains in the antenatal clinic (LCD), the second (with a face value of 5 thousand rubles) - in the maternity hospital, which the woman in labor will choose on her own. Actually, the certificate itself remains with the young mother as evidence that she received medical assistance. The certificate provides columns in which the height, weight of the child at birth, time and place of birth will be noted. At the same time, the certificate does not replace the compulsory health insurance policy or any other documents. It operates in any settlement of Russia and is issued to all citizens of the Russian Federation, without exception. In accordance with clause 5 of the "Procedure and terms of payment for services to state and municipal health care institutions for medical

assistance rendered to women during pregnancy and childbirth, approved by order of the Ministry of Health and Social Development of the Russian Federation dated January 10, 2006 No. 5 ", a generic certificate is issued upon presentation of a passport or other identity document. ZhK at the 30th week of pregnancy (with multiple pregnancies - at the 28th week). The doctor will give her a certificate and immediately take the coupon number 1, intended for the consultation. At the same time, a pregnant woman has no right not to give coupon number 1, even if she is dissatisfied with the work of the doctor. Experts advise to change the doctor ahead of schedule at 30 weeks, if there are complaints against him. There is no right to refuse a request to change the doctor in consultation with a pregnant woman. If there is a refusal, you should contact the head of the consultation or the head physician of the medical institution. In addition, in order for the ZhK to receive money according to the certificate, it is required to observe a pregnant woman continuously for 12 weeks. The sooner the expectant mother decides where it is more comfortable for her to be observed, the fewer questions will arise when issuing a certificate. It should be noted that the certificate is issued for a pregnant woman, and not for a child, therefore, even with multiple pregnancies, there will be one certificate. If a pregnant woman did not register with the LCD at all , the certificate will be given to her in the maternity hospital in which she will give birth. In this case, coupon No. 1 will be redeemed, that is, no one will receive money for it. The certificate with coupon No. 2 is taken to the maternity hospital along with the rest of the documents. So that the maternity hospital can receive money for this coupon, there is only one criterion so far - until discharge, the mother and child are alive. Experts note that by the middle of 2007 these criteria will be tightened. If a woman in labor prefers the option of paid childbirth (an agreement is concluded between a doctor and an obstetrician), the maternity hospital does not receive a certificate. Paid services do not include services (for example, paid ward of increased comfort). It should be borne in mind that a pregnant woman can actively use her right to choose a maternity hospital. If a resident of Arkhangelsk decides to give birth in Chelyabinsk, the maternity hospital is obliged to accept it. There are no duplicates for the certificate in case of loss or damage. However, the issuance of the document will be recorded in the LCD (coupon number 1), thanks to Chemurodom, she will be able to receive money, proving that the delivery took place outside of us. A pregnant woman cannot exchange a certificate for money, since this is a non-financial aid to mothers, but a means of stimulating medical institutions in a competitive environment. The total amount of funds provided for the implementation of the birth certificate program in 2006 is 10.5 billion rubles. (including for the provision of medical care to women during pregnancy in primary health care - 3.0 billion rubles at the rate of 2000 rubles for the management of one pregnancy, in the maternity hospital (department) - 7.5 billion rubles at the rate of 5000 rubles per childbirth) .In 2007, it is planned to increase the volume of financing to 14.5 billion rubles. At the same time, in the antenatal clinic, the cost of the birth certificate will increase to 3,000 rubles, in the maternity hospital - up to 6,000 rubles and 2,000 rubles will be sent to the children's clinic for medical examination services for a child of the first year of life (1,000 rubles in 6 months and 1,000 rubles in 12 months).

At the initial visit of the patient to the doctor about the alleged presence of pregnancy, in order to establish the correct diagnosis, it is necessary to conduct a comprehensive examination, including taking anamnesis, physical examination, instrumental and laboratory studies.

How to take an anamnesis during pregnancy?

In the process of collecting anamnesis, first of all, you should pay attention to the circumstances that can serve as risk factors for various diseases and obstetric complications. It should be borne in mind:

• the age of the patients;
• living and working conditions;
• addiction to bad habits (smoking, alcohol consumption, drug use, etc.);
• heredity and transferred extragenital diseases;
• menstrual function;
• sexual function;
• transferred gynecological diseases;
• reproductive function.

Already at the stage of collecting the anamnesis of a pregnant woman and assessing complaints, it is possible to identify a number of presumptive signs of pregnancy in the early stages (dyspeptic symptoms, changes in olfactory sensations, dysfunctions of the nervous system, increased urination), as well as some probable signs of pregnancy (cessation of menstruation).

High-risk pregnancy

In addition, the information obtained allows us to prognostically determine the range of possible complications in this pregnancy.

An objective examination of a pregnant woman begins with a general examination, in which the height and weight of the patient is measured, the physique, the condition of the skin and mammary glands, and the shape of the abdomen are assessed. In this case, along with other equally important data, it is also possible in the early stages of pregnancy to detect some of its hypothetical signs (pigmentation of the skin of certain parts of the body, an increase in the size of the abdomen and engorgement of the mammary glands) and probable (enlargement of the mammary glands, the appearance of colostrum from the nipple with pressure) ...

By auscultation, percussion and palpation, the state of the cardiovascular and respiratory systems, the organs of the gastrointestinal tract, the nervous and urinary systems, and the musculoskeletal system are studied.

The study of internal organs, especially during the initial examination, allows you to timely identify diseases that are contraindications for prolonging pregnancy.

During the examination, the patient's blood pressure is measured, using laboratory methods, blood is examined (morphological structure, ESR, blood group, Rh affiliation, biochemical parameters, coagulation system, serological tests to detect infection, etc.), urine, urinary tract discharge for the presence of infections.

In this case, the circumference of the abdomen and the height of the standing of the fundus of the uterus above the pubis are measured. The results obtained are compared with the standards typical for a given gestational age.

Mandatory in the collection of an anamnesis of a pregnant woman is the study of the patient's pelvis by examination, palpation and measurement. Pay attention to the lumbosacral rhombus, the shape and size of which make it possible to judge the structure of the pelvis.

When measuring the pelvis in all patients, three external transverse dimensions must be determined (Distantia spinarum, Distantia cristarum, Distantia trochanterica), one straight line is the external conjugate (Conjugata externa). When subtracting 9 cm from the length of the outer conjugate, one can judge the size of the true conjugate.

As additional external parameters, especially if a narrowing of the pelvis is suspected, the dimensions of the pelvic outlet, the height of the pelvis and its oblique dimensions are determined. When collecting anamnesis, an additional measurement of the circumference of the wrist joint is performed, which allows you to get an idea of ​​the thickness of the bones of the skeleton, including the pelvic bones.

Palpation of the abdomen

When collecting anamnesis, palpation of the abdomen is performed using external methods of obstetric research, which makes it possible to get an idea of:

• condition and elasticity of the anterior abdominal wall and rectus abdominis muscles (discrepancies, hernial formations);
• the size and tone of the uterus;
• articulation of the fetus (the relation of its limbs to the trunk and head);
• position of the fetus (the ratio of the longitudinal axis of the fetus to the longitudinal axis of the uterus);
• position of the fetus (the ratio of the back of the fetus to the sides of the uterus) and its type (the ratio of the back of the fetus to the anterior or posterior wall of the uterus);
• presentation of the fetus (the ratio of the head or pelvic end of the fetus to the entrance to the small pelvis).

Auscultation of a pregnant woman

With auscultation with an obstetric stethoscope, fetal heart sounds are usually heard after 20 weeks of gestation. At the same time, the place of the best listening to the tones of the fetus, the frequency and rhythm of the heartbeats are determined. In addition, when taking anamnesis, the noise of the vessels of the umbilical cord, the pulsation of the abdominal part of the aorta of the pregnant woman, and intestinal noises are also determined.

Palpation and auscultation also make it possible to verify the presence of reliable or certain signs of pregnancy that appear in the second half of pregnancy and indicate the presence of a fetus in the uterine cavity:

• palpable parts of the fetus - head, back and limbs;
• clearly audible fetal heart sounds;
• fetal movements felt by the doctor during examination.

Gynecological history of a pregnant woman

Examination by a gynecologist in early pregnancy

Examination of the external genitalia is required for anamnesis. It allows you to get an idea of ​​the state of the vulva, the mucous membrane of the entrance to the vagina, excretory ducts of the large glands of the vestibule of the vagina, the surface of the perineum.

When examining with the help of mirrors, the condition of the vaginal part of the cervix and the walls of the vagina is determined. At the same time, in the early stages of pregnancy, such probable signs as cyanosis of the cervix and vaginal walls are revealed, and their diseases can also be detected or suspected. At the same time, for anamnesis, you can take material (discharge from the cervical canal, from the fornix of the vagina, from the urethra and paraurethral passages) for cytological examination and identification of causative agents of infectious diseases of the urinary tract. The cytological picture of vaginal discharge indirectly makes it possible to judge the readiness of the body for childbirth after 39 weeks of gestation based on an assessment of the number of superficial, scaphoid, intermediate and parabasal cells, eosinophilic and pyknotic index.

The results of the examination of the external genital organs and examination with the help of mirrors make it possible to reveal the signs and consequences of previous pregnancies and childbirth, which include: scars in the area of ​​old ruptures or incisions of the perineum, a wider vagina and less pronounced folding of its walls, a slit-like form of the external mouth of the canal the cervix (in some cases deformed by scars or lateral tears).

Vaginal (digital) examination allows you to determine the condition of the pelvic floor muscles, walls and fornices of the vagina, cervix (length, location in relation to the pelvic axis, shape, consistency) and its external pharynx (degree of opening, shape, deformations and defects).

With the help of a two-handed study, the position, shape, contours, size, consistency of the uterus are determined and the condition of the uterine appendages is assessed.

In the early stages of pregnancy, using these studies, for anamnesis, such probable signs as a change in the size, shape and consistency of the uterus are revealed. In addition, during vaginal examination, the diagonal conjugate (Conjugata diagonalis) is also determined, which, together with the data of external measurements, makes it possible to judge the shape and size of the pelvis. However, it is not always possible to measure the diagonal conjugate, since the promontory is not reached with normal pelvic dimensions.

The research results allow not only to establish the fact of pregnancy, to assess the nature of its course and the condition of the fetus, but also to determine the duration of pregnancy and childbirth.

Risk stratification in obstetrics provides for the identification of groups of women in whom pregnancy and childbirth can be complicated by a violation of the vital functions of the fetus, obstetric or extragenital pathology. Based history, physical examination data and laboratory tests reveal the following adverse prognostic factors.

I. Socio-biological:
- mother's age (up to 18 years old; over 35 years old);
- the father's age is over 40;
- professional harm from parents;
- smoking, alcoholism, drug addiction, substance abuse;
- weight growth indicators of the mother (height 150 cm or less, weight 25% higher or lower than normal).

II. Obstetric and gynecological history:
- the number of births is 4 or more;
- repeated or complicated abortions;
- surgical interventions on the uterus and appendages;
- malformations of the uterus;
- infertility;
- miscarriage;
- undeveloped pregnancy (NB);
- premature birth;
- stillbirth;
- death in the neonatal period;
- the birth of children with genetic diseases and developmental anomalies;
- the birth of children with low or large body weight;
- complicated course of a previous pregnancy;
- bacterial-viral gynecological diseases (genital herpes, chlamydia, cytomegaly, syphilis,
gonorrhea, etc.).

III. Extragenital diseases:
- cardiovascular: heart defects, hyper and hypotensive disorders;
- diseases of the urinary tract;
- endocrinopathy;
- blood diseases;
- liver disease;
- lung disease;
- connective tissue diseases;
- acute and chronic infections;
- violation of hemostasis;
- alcoholism, drug addiction.

IV. Complications of pregnancy:
- vomiting of pregnant women;
- the threat of termination of pregnancy;
- bleeding in the first and second half of pregnancy;
- gestosis;
- polyhydramnios;
- lack of water;
- placental insufficiency;
- multiple pregnancy;
- anemia;
- Rh and AB0 isosensitization;
- exacerbation of a viral infection (genital herpes, cytomegaly, etc.).
- anatomically narrow pelvis;
- wrong position of the fetus;
- post-term pregnancy;
- induced pregnancy.

For a quantitative assessment of factors, a scoring system is used, making it possible not only to assess the probability of an unfavorable outcome of childbirth under the action of each factor, but also to obtain a total expression of the probability of all factors.

Based on the calculations of the assessment of each factor in points, the authors distinguish the following degrees of risk: low - up to 15 points; average - 15-25 points; high - more than 25 points. The most common mistake in calculating points is that the doctor does not summarize the indicators that seem insignificant to him.

The first point screening is carried out at the first visit of the pregnant woman to the antenatal clinic. The second - at 28–32 weeks, the third - before childbirth. After each screening, the pregnancy management plan is specified. The identification of a group of pregnant women with a high degree of risk makes it possible to organize intensive monitoring of the development of the fetus from the beginning of pregnancy.

From 36 weeks of pregnancy, women from the group of medium and high risk are re-examined by the head of the antenatal clinic and the head of the obstetric department, where the pregnant woman will be hospitalized before delivery.

This examination is an important point in the management of at-risk pregnant women. In areas where there are no maternity wards, pregnant women are hospitalized for preventive treatment in certain obstetric hospitals.

Since antenatal hospitalization for examination and comprehensive preparation for childbirth for women at risk is mandatory, the length of hospitalization, the estimated plan for the management of the last weeks of pregnancy and childbirth should be developed in conjunction with the head of the obstetric department. Antenatal hospitalization at the time determined jointly by the doctors of the consultation and the hospital is the last, but very important task of the antenatal clinic. Having timely hospitalized a pregnant woman from medium or high risk groups, the doctor of the antenatal clinic can consider his function fulfilled.

A group of pregnant women at risk of perinatal pathology. It was found that 2/3 of all cases of PS occurs in women from the high-risk group, accounting for no more than 1/3 of the total number of pregnant women.

On the basis of literature data, own clinical experience, as well as the multifaceted development of birth histories in the study of PS, O. G. Frolova and E. N. Nikolaeva (1979) identified individual risk factors. These include only those factors that led to a higher level of PS in relation to this indicator in the entire group of surveyed pregnant women. The authors divide all risk factors into two large groups: prenatal (A) and intranatal (B).

Prenatal factors, in turn, are divided into 5 subgroups:

Socio-biological;
- obstetric gynecological history;
- extragenital pathology;
- complications of this pregnancy;
- assessment of the state of the intrauterine fetus.

Intranatal factors were also divided into 3 subgroups. These are factors from the outside:

Mothers;
- placenta and umbilical cord;
- the fetus.

Among the prenatal factors, 52 factors are distinguished, among the intranatal ones - 20. Thus, a total of 72 factors have been identified.
risk.

DAY STATIONARY

Day hospitals are organized at outpatient polyclinic institutions (women's consultation), maternity homes, gynecological departments of multidisciplinary hospitals in order to improve the quality of medical care pregnant and gynecological patients who do not require round-the-clock observation and treatment.

The hospital carries out continuity in the examination, treatment and rehabilitation of patients with others health care institutions: when the condition of sick women worsens, they are transferred to the appropriate departments hospitals.

· The recommended capacity of the day hospital is at least 5-10 beds. To ensure a full-fledged medical the diagnostic process, the duration of the patient's stay in the day hospital should be at least 6-8 hours day.

The day hospital is managed by the chief physician (head) of the institution, on the basis of which this structural unit was organized.

The staff of the medical staff and the working hours of the day hospital of the antenatal clinic depend on the volume assistance provided. For each patient of the day hospital, a "Card of the patient of the day hospital polyclinics, home inpatient care, day care in the hospital ”.

Indications for the selection of pregnant women for hospitalization in a day hospital:

Vegetovascular dystonia and hypertension in the first and second trimesters of pregnancy;
- exacerbation of chronic gastritis;
- anemia (Hb not lower than 90 g / l);
- early toxicosis in the absence or presence of transient ketonuria;
- the threat of termination of pregnancy in the first and second trimesters in the absence of a history of habitual miscarriages and preserved cervix;
- critical periods of pregnancy with a history of miscarriage without clinical signs of threat of termination;
- medical genetic examination, including invasive methods (amniocentesis, chorionic biopsy, etc.) in pregnant women in the high perinatal risk group in the absence of signs of threatened abortion;
- non-drug therapy (acupuncture, psycho and hypnotherapy, etc.);
- Resuscitation in the I and II trimesters of pregnancy (for examination, conducting nonspecific desensitizing therapy);
- suspicion of PN;
- suspicion of heart disease, pathology of the urinary system, etc.;
- carrying out special therapy for alcoholism and drug addiction;
- upon discharge from the hospital after suturing the cervix for ICI;
- continuation of observation and treatment after a long hospital stay.

High-risk pregnancy is characterized by an increased likelihood of spontaneous death, fetal death, premature birth, intrauterine growth retardation, disease in the prenatal or neonatal period, malformations and other disorders.

Among the risk factors are both those that cause intrauterine developmental disorders, for example, the use of teratogenic drugs in the first trimester of pregnancy, and those that are their consequence, and therefore require clarification of the cause and prevention of complications, such as polyhydramnios. Based on the history, 10-20% of pregnant women can be classified as high-risk. High-risk pregnancies are associated with nearly 50% of perinatal morbidity and mortality. Adequate risk assessment before delivery reduces them. Some of the risk factors arise in the first and second stages of labor, therefore, monitoring the condition of the fetus during childbirth is critical.

Identifying high-risk pregnancies is important because it is the first step in preventing their consequences. If aware of the potential hazard, therapeutic measures can significantly reduce the risk to the fetus and newborn.

Hereditary factors... High-risk pregnancy factors are chromosomal abnormalities, developmental defects, hereditary metabolic disorders, mental retardation and other hereditary diseases in blood relatives. It should be borne in mind that parents usually report such diseases only if their manifestations are obvious, and in the process of collecting anamnesis, ask leading questions.

Maternal-specific risk factors... The lowest neonatal mortality and morbidity during the neonatal period is observed in children from mothers aged 20-30 who were under full medical supervision during pregnancy. High-risk pregnancies are observed in adolescents and women over 40 years of age, especially the first, is more often accompanied by intrauterine growth retardation, fetal hypoxia and intrauterine death. A young mother's age also increases the risk of chromosomal abnormalities and unrelated malformations.

The risk to the fetus increases with diseases of the mother, multiple pregnancies, especially monochorionic, infections, taking certain medications. Pregnancy resulting from the successful use of modern reproductive technologies (in vitro fertilization, sperm injection into the cytoplasm of the egg) is associated with the risk of low or very low birth weight, multiple malformations, multiple pregnancies. Prematurity, low birth weight, and multiple pregnancy, in turn, increase the risk of cerebral palsy.

High-risk pregnancies often end in premature birth. Predictive factors for preterm labor include cervical flattening, genital infections, the presence of fetal fibronectin in the secretions of the cervical canal and vagina, and prenatal amniotic fluid rupture.

Factors that allow pregnancy to be classified as a high-risk group

Diseases of the mother affecting the fetus and newborn

High and low water also indicates that pregnancy is at risk. Although the exchange of amniotic fluid occurs quickly, normally it gradually (less than 10 ml / day) increases up to 34 weeks. pregnancy and then gradually decreases. The volume of amniotic fluid during normal pregnancy varies widely (500-2000 ml by the 40th week). A volume of more than 2000 ml in the III trimester is regarded as polyhydramnios, less than 500 ml - as oligohydramnios.

Polyhydramnios is observed in 1-3% of pregnancies, lack of water - in 1-5%. When the volume of amniotic fluid is assessed by the index of amniotic fluid, which is measured by the vertical diameter of its part filled with fluid, in 4 quadrants. An index of more than 24 cm indicates polyhydramnios, less than 5 cm indicates low water.

Acute polyhydramnios is rare and is usually accompanied by late spontaneous abortion up to 28 weeks. Chronic polyhydramnios in the third trimester is manifested by the discrepancy between the size of the uterus and the gestational age. Sometimes it is only diagnosed during childbirth. Polyhydramnios is often accompanied by premature birth, placental abruption, malformations, including obstruction of the gastrointestinal tract, which prevents the fetus from swallowing amniotic fluid, their subsequent absorption, congenital neuromuscular diseases. Polyuria of the fetus and its dropsy also lead to polyhydramnios. Ultrasound reveals an increase in the volume of amniotic fluid, concomitant malformations, dropsy of the fetus, ascites or hydrothorax in him. In 60% of cases, the cause of polyhydramnios cannot be established. To eliminate polyhydramnios, multiple amniocentesis is used. If it is caused by fetal polyuria, a short course of indomethacin is prescribed to the pregnant woman. Treatment of polyhydramnios is indicated if it causes acute respiratory failure in the mother, and with the threat of premature birth. In the latter case, it gives additional time, allowing for a course of corticosteroid therapy, which accelerates the maturation of the fetal lungs.

Low water accompanies intrauterine growth retardation, malformations, in particular of the kidneys, bladder, the use of certain drugs that reduce fetal urine output, therefore it becomes obvious after 20 weeks. pregnancy, when urine becomes the main component of amniotic fluid. If ultrasound reveals a normal-sized bladder in the fetus, amniotic fluid leakage should be excluded. Low water causes minor developmental anomalies caused by compression of the fetus - clubfoot, spatulate hands, deformity of the nose. The most severe complication of chronic oligohydramnios is lung hypoplasia. The risk of compression of the umbilical cord during childbirth due to lack of water is partially eliminated by intra-amnial administration of saline. Ultrasound in low water reveals a decrease in the index of amniotic fluid up to 1-2 cm, intrauterine growth retardation or malformations. Often, oligohydramnios is accompanied by an increase in the level of a-fetoprotein, intrauterine growth retardation, uterine bleeding and is associated with the risk of intrauterine fetal death.

Antenatal diagnostics: examination of the mother's blood, ultrasound, examination of amniotic fluid and cells obtained by amniocentesis, biopsy of chorionic villi or fetal tissue, fetal blood examination.

It is extremely important to timely diagnose complications of childbirth and high-risk pregnancies, since they are the leading cause of death and morbidity in the first day of life. The size of the uterus inappropriate for the gestational age should be alarming. Its increase is observed with multiple pregnancies, polyhydramnios, the size of the fetus, much more corresponding to the gestational age, a decrease - with oligohydramnios and intrauterine growth retardation. Rupture of the membranes earlier than 24 hours before the end of labor increases the likelihood of intrauterine infection. More often it occurs with premature birth. In full-term pregnancy, rupture of the fetal bladder, as a rule, entails the onset of labor in the next 48 hours, but increases the likelihood of chorioamnionitis and compression of the umbilical cord. With gestational age up to 37 weeks. the period between rupture of the fetal bladder and the onset of labor can be much longer, which increases the risk of umbilical cord prolapse, oligohydramnios, placental abruption, and abnormal fetal position. With a duration of more than 7 days, the development of hypoplasia of the lungs, fetal deformities and contractures of the extremities associated with compression of the uterus is possible. With prolonged and difficult childbirth, there is a high probability of fetal hypoxia and its mechanical injury. At the same time, the risk of hypoxia and intracranial hemorrhage is also high with rapid labor. The danger of hypoxic damage to the fetal brain is especially great with premature detachment of the placenta, anomalies of its attachment, compression of the umbilical cord. A brown or green color of amniotic fluid indicates an intrauterine discharge of meconium due to an episode of hypoxia several hours ago. The successful outcome of childbirth in high-risk pregnancies depends to a large extent on the qualifications of the obstetrician, but the methods of delivery and the circumstances dictating their use create additional risks. Thus, the risk of intracranial hemorrhage with vacuum extraction, the use of forceps and caesarean section is much higher than with spontaneous birth through natural routes. Traumatic intracranial hemorrhage is often the cause of death of a newborn removed by the application of high or abdominal forceps by the pelvic end or by turning the fetus from a transverse position.