Pregnancy: who are at risk? High-risk pregnant women
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 with antenatal clinics can be attributed to the following risk groups:
With perinatal pathology
With obstetric pathology
With extragenital pathology.
At 32 and 38 weeks of pregnancy, point screening is performed, since new risk factors appear during these periods. Recent research data indicate that by the end of pregnancy there is an increase in the number of pregnant women with a high degree of perinatal risk (from 20 to 70%). 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 is mandatory for women at risk, the length of hospitalization, the estimated management plan for the last weeks of pregnancy and childbirth should be worked out 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 and 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 perinatal mortality occurs in women from the high-risk group, accounting for no more than 1/3 of the total number of pregnant women. Based on the literature data, his own clinical experience, as well as the multifaceted development of birth histories in the study of perinatal mortality, O.G. Frolova and E.N. Nikolaeva (1979) identified individual risk factors. These include only those factors that led to a higher level of perinatal mortality 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).
9.2. Prenatal factors:
Socio-biological:
Mother's age (under 18, over 35)
Father's age (over 40)
Occupational hazards for parents
Tobacco smoking, alcoholism, drug addiction
Mass growth indicators (growth less than 153 cm, weight 25% higher or lower than normal).
Obstetric and gynecological history:
Number of births 4 or more
Repeated or complicated abortions
Surgical interventions on the uterus or appendages
Malformations of the uterus
Infertility
Miscarriage
Non-developing pregnancy
Premature birth
Stillbirth
Death in the neonatal period
The birth of children with genetic diseases, developmental abnormalities
Low or high birth weight babies
Complicated previous pregnancy
Bacterial and viral gynecological diseases (genital herpes, chlamydia, cytomegalovirus, syphilis, gonorrhea, etc.)
Extragenital pathology:
Diseases of the urinary system
Endocrinopathy
Diseases of the blood
Liver disease
Diseases of the lungs
Connective tissue diseases
Acute and chronic infections
Violation of hemostasis
Alcoholism, drug addiction.
Complications of a real pregnancy:
Vomiting of a pregnant woman
The threat of termination of pregnancy
Bleeding in the I and II half of pregnancy
Polyhydramnios
Malnutrition
Multiple pregnancies
Placental insufficiency
Rh and ABO isosensitization
Exacerbation of viral infection
Anatomically narrow pelvis
Wrong fetal position
Postterm pregnancy
Induced pregnancy
Assessment of the state of the intrauterine fetus.
The total number of prenatal factors was 52.
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.
The course of pregnancy can be complicated by the development of toxicosis of pregnant women, its premature termination or prolongation, premature detachment of the normally located placenta. Possible violation of the development of the fetus, its death. A certain danger to the mother and the fetus is represented by the incorrect position of the fetus (oblique, transverse position), breech presentation of the fetus, anomalies in the location of the placenta, poly- and oligohydramnios, and multiple pregnancies. Severe complications (uterine bleeding, premature interruption of B., fetal death) can be the result of a cystic drift. With immunological incompatibility between the mother and the fetus, spontaneous miscarriage, toxicosis of pregnant women, hypoxia and fetal death are possible; as a result of sensitization of the pregnant woman with erythrocyte antigens of the fetus, hemolytic disease of the fetus and newborn develops. The pathological course of pregnancy and fetal developmental disorders can be observed if a pregnant woman has some extragenital and gynecological diseases.
To determine the degree of risk of perinatal pathology, an indicative scale for assessing prenatal risk factors is proposed, in points; the scale is used taking into account the individual characteristics of the anamnesis, the course of pregnancy and childbirth (Table 3).
Assessment of prenatal risk factors (O. G. Frolova, E. I. Nikolaeva, 1980)
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
With a total of 10 points or more, the risk of perinatal pathology is high, with a total of 5-9 points - medium, with a total of 4 points or less - low. Depending on the degree of risk, the obstetrician-gynecologist of the antenatal clinic draws up an individual plan for dispensary observation, taking into account the specifics of the existing or possible pathology, including conducting special studies to determine the condition of the fetus: electrocardiography, ultrasound, amnioscopy, etc. on the advisability of maintaining pregnancy. Risk assessment is carried out at the beginning of pregnancy and at 35-36 weeks. to resolve the issue of the timing of hospitalization. Pregnant women with a high risk of perinatal pathology should be hospitalized for childbirth in a specialized hospital.
A high-risk pregnancy is one in which the risk of illness or death of the mother or newborn before or after childbirth is greater than usual. There are a number of risk factors for pregnancy.
To identify a high-risk pregnancy, a doctor examines a pregnant woman to determine if she has any medical conditions or symptoms that make her or the fetus more likely to get sick or die during pregnancy (risk factors). Risk factors can be assigned scores corresponding to the degree of risk. Identification of high-risk pregnancy is necessary only so that a woman who needs intensive medical care would receive it in a timely manner and in full.
A woman with a high-risk pregnancy may be referred to an antenatal (perinatal) care unit (the term “perinatal” refers to events that occur before, during, or after delivery). These units are usually associated with obstetric and neonatal intensive care units to provide the highest level of care for the pregnant woman and infant. The doctor often refers a woman to a perinatal observation center before childbirth, since early medical supervision very significantly reduces the likelihood of pathology or the death of the child. The woman is also sent to such a center during childbirth if unexpected complications arise. Generally, the most common reason for referral is a high likelihood of premature birth (before 37 weeks), which often occurs if the fluid-filled membranes containing the fetus rupture before it is ready for birth (i.e., a condition called premature rupture of the membranes occurs ). Treatment at a perinatal care center reduces the likelihood of preterm birth.
In Russia, maternal mortality occurs in 1 out of 2000 births. Its main causes are several diseases and disorders associated with pregnancy and childbirth: the ingress of blood clots into the vessels of the lungs, complications of anesthesia, bleeding, infections and complications arising from increased blood pressure.
In Russia, the perinatal mortality rate is 17%. Slightly over half of these cases are stillbirths; in other cases, babies die within the first 28 days after birth. The main causes of these deaths are congenital malformations and prematurity.
Several risk factors are present even before a woman becomes pregnant. Others occur during pregnancy.
I. Risk factors before pregnancy
Before a woman becomes pregnant, she may already have some medical conditions and disorders that increase her risk during pregnancy. In addition, a woman who has had complications in a previous pregnancy is more likely to develop the same complications in subsequent pregnancies.
II. Maternal risk factors
The risk of pregnancy is influenced by the woman's age. Girls aged 15 and younger are more likely to develop preeclampsia (a condition during pregnancy in which blood pressure rises, protein appears in the urine, and fluid builds up in the tissues) and eclampsia (seizures that result from preeclampsia). They are also more likely to have a baby that is underweight or premature. Women aged 35 and older are more likely to have increased blood pressure, diabetes mellitus, the presence of fibroids (benign neoplasms) in the uterus, and the development of pathology during childbirth. The risk of having a baby with a chromosomal abnormality, such as Down's syndrome, increases significantly after age 35. If an older pregnant woman is concerned about the possibility of fetal abnormalities, chorionic villus sampling or amniocentesis may be done to determine the composition of the fetal chromosomes.
A woman who had a pre-pregnancy birth weight of less than 40 kg is more likely to have a baby that is lighter than expected according to gestational age (low body weight for gestational age). If a woman gains less than 6.5 kg in weight during pregnancy, then the risk of death of a newborn increases to almost 30%. Conversely, an obese woman is more likely to have a very large baby; obesity also increases the risk of diabetes and high blood pressure during pregnancy.
A woman less than 152 cm tall often has a smaller pelvis. She is also more likely to have a premature birth and a low birth weight.
Complications during a previous pregnancy
If a woman has had three consecutive miscarriages (spontaneous abortion) in the first three months of previous pregnancies, then another miscarriage is possible with a 35% probability. Spontaneous abortion is also more likely in women who have previously delivered stillborn babies between the 4th and 8th months of pregnancy, or have had a preterm birth in previous pregnancies. Before attempting a new conception, a woman who has had a spontaneous abortion is recommended to undergo an examination to identify possible chromosomal or hormonal diseases, structural defects of the uterus or cervix, connective tissue diseases, such as systemic lupus erythematosus, or an immune response to the fetus - most often Rh incompatibility -factor. If the cause of the spontaneous abortion is established, it can be eliminated.
A stillbirth or death of a newborn may be due to chromosomal abnormalities in the fetus, diabetes, chronic kidney or blood vessel disease, high blood pressure, or a connective tissue disorder such as systemic lupus erythematosus in the mother or her drug use.
The more preterm the previous birth was, the greater the risk of preterm birth in subsequent pregnancies. If a woman has a baby weighing less than 1.3 kg, then the likelihood of premature birth in the next pregnancy is 50%. If intrauterine fetal growth retardation has been noted, this complication may recur during the next pregnancy. The woman is examined to identify abnormalities that can lead to fetal growth retardation (for example, high blood pressure, kidney disease, overweight, infections); smoking and alcohol abuse can also lead to fetal malnutrition.
If a woman has a baby weighing more than 4.2 kg at birth, she may have diabetes. The likelihood of a spontaneous abortion or death of a woman or baby is increased if the woman suffers from such diabetes during pregnancy. Pregnant women are tested for its presence by measuring blood sugar (glucose) between the 20th and 28th weeks of pregnancy.
A woman who has had six or more pregnancies is more likely to have weak labor (contractions) during labor and bleeding after delivery due to weakening of the muscles in the uterus. Rapid labor is also possible, which increases the risk of severe uterine bleeding. In addition, such a pregnant woman is more likely to have a placenta previa (the location of the placenta in the lower part of the uterus). This condition can cause bleeding and may be an indication for a caesarean section because the placenta often obstructs the cervix.
If a woman has a child with a hemolytic disease, then the next newborn has an increased likelihood of the same disease, and the severity of the disease in the previous child determines its severity in the next one. This disease develops when a pregnant woman with Rh-negative blood develops a fetus whose blood is Rh-positive (that is, there is an incompatibility with the Rh factor), and the mother develops antibodies against the blood of the fetus (sensitization to the Rh factor occurs); these antibodies destroy the fetal red blood cells. In such cases, the blood of both parents is tested. If a father has two genes for Rh-positive blood, then all his children will have Rh-positive blood; if he has only one such gene, then the probability of Rh-positive blood in the child is approximately 50%. This information helps doctors to properly care for the mother and baby in subsequent pregnancies. Usually, during the first pregnancy with a fetus with Rh-positive blood, no complications develop, but contact between the blood of the mother and the baby during childbirth causes the mother to develop antibodies against the Rh factor. As a result, there is a danger to subsequent newborns. If, however, Rh0- (D) -immunoglobulin is administered after the birth of a child with Rh-positive blood of a mother whose blood is Rh-negative, then the antibodies against Rh factor will be destroyed. Due to this, hemolytic diseases of newborns are rare.
A woman who has had preeclampsia or eclampsia is more likely to recur, especially if the woman has chronically high blood pressure.
If a woman has a child with a genetic disease or congenital defect, then a genetic examination of the child is usually carried out before a new pregnancy, and in case of stillbirth, both parents. When a new pregnancy occurs, ultrasound (ultrasound), chorionic villus sampling and amniocentesis are done to look for abnormalities that are likely to recur.
Developmental defects
Defects in the development of a woman's genitals (for example, doubling of the uterus, weakness or insufficiency of the cervix that cannot hold the developing fetus) increases the risk of miscarriage. To detect these defects, diagnostic operations, ultrasound or X-ray examination are necessary; if a woman has had repeated spontaneous abortions, these studies are carried out even before the onset of a new pregnancy.
Fibroids (benign neoplasms) of the uterus, which are more common in older age, can increase the likelihood of premature birth, complications during childbirth, abnormal presentation of the fetus or placenta, and repeated miscarriages.
Diseases of a pregnant woman
Some diseases of a pregnant woman can be dangerous for both her and the fetus. The most important of these are chronic high blood pressure, kidney disease, diabetes mellitus, severe heart disease, sickle cell disease, thyroid disease, systemic lupus erythematosus, and blood coagulation disorders.
Diseases in family members
The presence of relatives with mental retardation or other hereditary diseases in the family of the mother or father increases the likelihood of such diseases in the newborn. The tendency to have twins is also common among members of the same family.
III. Risk factors during pregnancy
Even a healthy pregnant woman can be exposed to adverse factors that increase the likelihood of impairment to the fetus or her own health. For example, she may come into contact with teratogenic factors (exposures that cause birth defects) such as radiation, certain chemicals, drugs, and infections, or she may develop a disease or complication associated with pregnancy.
Exposure to drugs and infection
Substances that can cause congenital malformations of the fetus when taken by a woman during pregnancy include alcohol, phenytoin, drugs that counteract the effect of folic acid (lithium preparations, streptomycin, tetracycline, thalidomide). Infections that can lead to birth defects include herpes simplex, viral hepatitis, influenza, paratitis (mumps), rubella, chickenpox, syphilis, listeriosis, toxoplasmosis, Coxsackie and cytomegalovirus diseases. At the beginning of pregnancy, a woman is asked if she has taken any of these medications or if she has suffered any of these infectious inflammations after conception. Of particular concern is smoking, alcohol and drug use during pregnancy.
Smoking is one of the most common bad habits among pregnant women in Russia. Despite awareness of the health risks of smoking, the number of adult women who smoke themselves or live with people who smoke has dropped slightly over the past 20 years, and the number of women who smoke has increased. Smoking among adolescent girls has become significantly more common and exceeds this figure among adolescent boys.
Although smoking harms both the mother and the fetus, only about 20% of women who smoke quit during pregnancy. The most common consequence of maternal smoking during pregnancy for the fetus is its low birth weight: the more a woman smokes during pregnancy, the less the baby's weight will be. This effect is more pronounced among older women who smoke, who are more likely to have children with lower weight and height. Women who smoke are also more likely to have placental complications, premature rupture of membranes, premature birth and postpartum infections. A pregnant woman who does not smoke should avoid exposure to tobacco smoke when smoking in others, as it can similarly harm the fetus.
Congenital malformations of the heart, brain, and face are more common in newborns born to pregnant smokers than to nonsmokers. Maternal smoking may increase the risk of sudden infant death syndrome. In addition, children of mothers who smoke have a small but noticeable delay in growth, intellectual development and behavior formation. These effects, according to experts, are caused by exposure to carbon monoxide, which reduces the delivery of oxygen to the tissues of the body, and nicotine, which stimulates the release of hormones that constrict the blood vessels of the placenta and uterus.
Alcohol consumption during pregnancy is the leading known cause of congenital malformations. Fetal alcohol syndrome, one of the main consequences of drinking during pregnancy, affects an average of 22 out of 1,000 live births. This condition includes stunted growth before or after birth, facial defects, a small head size (microcephaly), probably associated with insufficient brain development, and impaired mental development. Mental retardation is a consequence of fetal alcohol syndrome more often than any other known cause. In addition, alcohol can cause other complications, from miscarriage to severe behavioral disorders in a newborn or developing child, such as antisocial behavior and inability to concentrate. These abnormalities can occur even when the newborn does not have any obvious physical birth defects.
The likelihood of miscarriage almost doubles when a woman drinks any form of alcohol during pregnancy, especially if she drinks a lot. Often, birth weight is below normal in those newborns who were born to women who drank alcohol during pregnancy. Newborns whose mothers drank alcohol have an average birth weight of about 1.7 kg, compared with 3 kg for other newborns.
An increasing number of pregnant women are experiencing drug use and dependence. For example, in the United States, more than five million people, many of whom are women of childbearing age, regularly use marijuana or cocaine.
An inexpensive laboratory test called chromatography can be used to test a woman's urine for heroin, morphine, amphetamines, barbiturates, codeine, cocaine, marijuana, methadone, and phenothiazine. Injecting drug users, that is, drug addicts who use syringes for drug use, have a higher risk of developing anemia, infection of the blood (bacteremia) and heart valves (endocarditis), skin abscess, hepatitis, phlebitis, pneumonia, tetanus and sexually transmitted diseases (in including AIDS). Approximately 75% of newborns with AIDS had mothers who were injecting drug users or in prostitution. Other sexually transmitted diseases, hepatitis and other infections are more common in these newborns. They are also more likely to be born prematurely or have intrauterine growth retardation.
The main component of marijuana, tetrahydrocannabinol, can cross the placenta and affect the fetus. Although there is no definitive evidence that marijuana causes birth defects or slows the growth of the fetus in the uterus, some studies show that using marijuana leads to abnormalities in baby behavior.
Cocaine use during pregnancy causes dangerous complications in both the mother and the fetus; many women who use cocaine also use other drugs, which aggravates the problem. Cocaine stimulates the central nervous system, acts as a local anesthetic (pain reliever), and constricts blood vessels. The narrowing of the blood vessels leads to a decrease in blood flow and the fetus does not receive enough oxygen.
Reduced delivery of blood and oxygen to the fetus can affect the development of various organs and usually leads to skeletal deformities and narrowing of some parts of the intestine. Diseases of the nervous system and behavioral disorders in children of those women who use cocaine include hyperactivity, uncontrollable tremors and significant learning difficulties; these violations can last for 5 years or more.
If a pregnant woman suddenly has a large increase in
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: During 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 provided to women during pregnancy and childbirth, approved by order of the Ministry of Health and Social Development of the Russian Federation No. 5 dated January 10, 2006 ", 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. , 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 repaid, that is, no one will receive money for it. The certificate with coupon No. 2 is taken by the woman in labor 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 2,000 rubles for the management of one pregnancy, in the maternity hospital (department) - 7.5 billion rubles at the rate of 5,000 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 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, 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 fornices 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 the 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.