Youth and beauty 

Examination of a pregnant woman. Obstetric research methods of examination of pregnant women and women in labor. Symptoms that threaten pregnancy that require special attention

When registering a pregnant woman, the doctor examines her and records the results in an individual variable card (firm IIIy).

1. Passport data: full name, series and passport number.

2. Age (young primiparous - up to 18 years old; age primiparous - 28 years and older).

4. Profession (the influence of production factors on the body of the pregnant woman and the fetus and observation of up to 30 weeks in the medical unit).

5. Medical history, general somatic and infectious diseases of the genital organs, previous pregnancies and childbirth, previous operations, blood transfusion history, epidemiological history, allergies, family history, heredity.

6. Laboratory tests: complete blood count - 1 time per month, and from 30 weeks. pregnancy - once every 2 weeks; general urine analysis - in the first rug of pregnancy monthly, and then once every 2 weeks, blood group and Rh-affiliation in both spouses, RW - three times (when registered, 28-30 weeks and 34-36 weeks), HIV and Australian antigen - when taking into account, analysis of feces for helminth eggs when taking into account: reaction of complement binding with toxoplasma antigen according to indications; coagulogram; the presence of sugar in the daily amount of urine and in the blood; analysis of vaginal discharge for microflora at registration and at 36-37 weeks; ECG - at 36-37 weeks.

7. Objective research is carried out by an obstetrician, therapist, dentist, otolaryngologist, ophthalmologist, if necessary, an endocrinologist, urologist:

a) anthropological measurements (height, weight);

b) blood pressure;

c) external obstetric examination:

  • Distantia spinarum (25-20 cm);
  • Distantia cristarum (28-29 cm);
  • Distautia trochanterica (30-31 cm);
  • Coniugata externa (20 cm).

If there is a deviation from the indicated dimensions, it is necessary to make additional measurements of the pelvis even before the internal examination:

a) lateral conjugate (between the anterior and posterior spines of the iliac bones of the same side - 14-15 cm (if this indicator is less than 12.5 cm, natural delivery is impossible);

b) oblique dimensions of the small pelvis:

  • from the middle of the upper edge of the pubic articulation to the posterior upper spine of the wings of both iliac bones - 17.5 cm each,
  • from the anterior superior spine of the wing of the ilium of one side to the posterior superior spine of the other side - 21 cm each,
  • from the spinous process of the V lumbar vertebra to the antero-superior spinous and other ilium - 18 cm each (the difference between the size of each pair is more than 1.3 cm indicates an oblique narrowing of the pelvis),

c) the size of the Michaelis rhombus:

  • vertical - between the supra-sacral fossa and the apex of the sacrum - 11 cm,
  • horizontal - between the posterior upper awns of the wings of both iliac bones - 10 cm;

d) the angle of inclination of the pelvis - the angle between the plane of the entrance to the pelvis and the plane of the horizon (measured by the pelvic angle meter in the woman's standing position) - 45-55 °;

e) dimensions of the pelvic outlet:

  • straight - between the top of the coccyx and the lower edge of the pubic symphysis - 9 cm,
  • transverse - between the inner surfaces of the ischial tubercles - 11 cm;

f) Determine the true conjugate values:

  • by external conjugate - subtract 9 cm from the size of the external conjugate,
  • by the diagonal conjugate - 1.5-2 cm is subtracted from the value of the diagonal conjugate (the figure to be subtracted is determined by the circumference in the wrist joint - with a circumference of up to 14 cm, subtract 1.5 cm, over - 2 cm),
  • according to USS data (most accurately).

At the first examination through the vagina, the size, shape, consistency, mobility of the uterus, the condition of the pelvic bones, soft tissues, and pelvic floor muscles are determined. Additionally, the bosom height (4 cm), the internal diagonal conjugate, and the pubic angle are measured.

After an increase in the size of the uterus, when its external palpation becomes possible, it is necessary to determine the tone of the uterus, the size of the fetus, the amount of amniotic fluid, the presenting part, the articulation of the fetus, its position, position and appearance, using four classical obstetric techniques (according to Leopold).

Auscultation of fetal heart sounds is performed from 20 weeks of gestation. Fetal heart sounds are heard with an obstetric stethoscope in the form of rhythmic double beats with a constant frequency of 130-140 per minute.

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

1. In the occipital presentation - near the head below the navel on the side where the back is turned. In posterior views - from the side of the abdomen along the anterior axillary line.

2 In front presentation - below the navel on the side where the breast was (in the first position - on the right, in the second - on the left).

3. In the transverse position - near the navel, closer to the head.

4. In presentation with the pelvic end - above the navel, near the head on the side where the back is turned.

In recent years, the Malysh apparatus and ultrasound devices, cardiac monitors have been widely used, which make it possible to clarify the auscultatory data in difficult cases.

Ed. K.V. Voronin

When the cherished two strips first appear on the test, a lot of questions arise. When do you need to go to a gynecologist, how to register? When and what tests will you have to take, and why? We will talk in detail about all routine examinations during pregnancy and some of the nuances of observation.

To date, a special plan of examinations and analyzes has been developed, which are required when monitoring pregnant women from the moment of registration to the very birth. The plan is based on the general recommendations for the management of uncomplicated pregnancies established by the Ministry of Health and Social Development of the Russian Federation. In the presence of complications of pregnancy or chronic pathology of the mother, the list of examinations and tests can be expanded at the discretion of the supervising physician. Visits may be more frequent, additional examination and treatment may be required, including in a hospital setting.

Dates from the fifth to the twelfth week (first trimester)

Before 12 weeks, you need at least one visit to the doctor, during which an initial examination and registration will be carried out with a card, and receiving a referral for an ultrasound scan and tests. At the first visit to the doctor, you will have a detailed conversation with him, in which the doctor will find out the details - what diseases did you have, whether you have chronic pathologies, whether there were any previous pregnancies and childbirth, how it proceeded, from what age you have menstruation, what are they in nature and much more. This is necessary to create a holistic picture of your health.

At the first visit, the doctor will give you recommendations on lifestyle and nutrition, taking vitamins and minerals, conduct an examination, measure blood pressure and pulse, height and weight, as well as a study on a gynecological chair and take smears, write out directions for tests. In addition, the doctor will give a referral for the passage of specialist doctors - therapist, dentist, ophthalmologist, ENT doctor and some others, if necessary. An ECG will need to be done.

In some cases, an ultrasound scan is prescribed within 5-8 weeks to confirm the fact of pregnancy and determine that the fetus is developing inside the uterus.

Over the next two weeks from the date of registration for pregnancy, you will need to take many tests:

  • general urine analysis, morning portion on an empty stomach to assess the work of the kidneys and bladder.

  • a vaginal swab for inflammation of the genitals and latent infections.

  • a general blood test, in the morning on an empty stomach, which will show the amount of hemoglobin and basic blood elements, will make it possible to assess the general condition of the body.

  • blood to determine the group and Rh factor. With Rh-negative blood, the blood group and the Rh factor of the spouse are determined.

  • blood for antibodies to hepatitis B and C, syphilis and HIV infection.

  • blood for antibodies to TORCH infection (toxoplasma, cytomegaly, mycoplasma and herpes). This study shows the risk of intrauterine infection of the fetus.

  • a blood test for glucose levels, which will indicate the risk of developing diabetes and changes in glucose tolerance.

  • a coagulogram (blood for clotting) will show a tendency to thrombosis or bleeding.

The second visit to the doctor is planned for a period of 10 weeks of pregnancy, before visiting the doctor, you must pass a urine test. The doctor will evaluate the results of all previously passed tests and give recommendations on the further course of pregnancy.

The first scheduled ultrasound scan is prescribed at 11-12 weeks for a special prenatal screening to detect fetal malformations and genetic abnormalities. Prenatal screening also includes a blood test for special substances - chorionic gonadotropin (hCG) and plasma protein associated with pregnancy (PAPP-A), the level of which is assessed in conjunction with ultrasound data.

Second trimester studies (weeks 13 to 28)

Doctor visits will be monthly, within 16 weeks, the doctor will listen to the fetal heartbeat with a special stethoscope. In this period, the height of the fundus of the uterus and the circumference of the abdomen are measured, according to these data, the development of the fetus in the uterus and its compliance with the gestational age are assessed. These parameters will be measured at each appointment.

Within 16-20 weeks, you will have a second prenatal screening with a special blood test for hCG, alpha-fetoprotein and free estriol levels. Based on these analyzes, the risk of fetal congenital anomalies will be calculated.

At the age of 18 weeks of pregnancy, it is necessary to conduct a blood glucose test, as the growth of the fetus accelerates, and the load on the pancreas increases.

In the period of 20-24 weeks, it is necessary to undergo a second planned ultrasound scan with the exclusion of malformations and anomalies in the course of pregnancy, an assessment of the state and position of the placenta, the amount of amniotic fluid, measurement of the height and weight of the fetus. In this period, it is possible to determine the sex of the child, to carry out a Doppler ultrasonography of the fetus - an assessment of blood circulation.

A visit to the doctor is planned for a period of 22 weeks, an examination is carried out, the height of the fundus of the uterus and abdominal circumference are measured, pressure and weight are measured. The doctor evaluates the ultrasound data and screening tests, and makes recommendations.

At the 26th week, a visit to the doctor is necessary with the constant delivery of a urine test before the visit. The doctor will examine, measure the weight, pressure and circumference of the abdomen, the height of the uterine fundus, listen to the fetal heartbeat, determine its position in the uterus.

Third trimester studies (weeks 29 to 40)

A visit to the doctor is necessary in the thirtieth week of pregnancy, the doctor, in addition to the traditional examination and measurement of weight, pressure and abdomen, will refer you for tests. There will also be maternity leave before childbirth and an exchange card for the pregnant woman with the data of all analyzes and examinations, which will always be in the hands of the woman.

In this period for rent:

  • general blood analysis,

  • general urine analysis,

  • blood chemistry,

  • blood for glucose,

  • blood for screwing up (coagulogram),

  • blood for antibodies to HIV, hepatitis and syphilis,

  • smear for hidden infections.

At 33-34 weeks of pregnancy, the third ultrasound is performed to determine the development of the baby, its weight and height, the sex of the child is determined, deviations and malformations are excluded, the state of the placenta and amniotic fluid, the walls of the uterus and the cervix are analyzed. Fetal dopplerometry is also performed.

At 35 weeks, a visit to the doctor and a urine test are due. In this period, CTG of the fetus is prescribed in order to identify its motor activity and uterine tone, fetal heartbeat and its possible hypoxia.

At 37 weeks, a urinalysis and a scheduled visit to the doctor are performed.
At 38 weeks, a blood test is taken for syphilis and HIV, hepatitis for the hospital.

In the period of 39-40 weeks, an ultrasound scan of the fetus will be performed to assess the position of the fetus and its readiness for childbirth, the position of the umbilical cord, the state of the placenta and uterus, and the cervix.

At 40 weeks, you will receive a referral to the maternity hospital if you need a planned hospitalization or wait for the birth of labor at home.

Photo - photobank Lori

In this article:

Obstetric research is a set of methods and techniques for examining a woman during pregnancy and directly the childbirth itself, for an objective assessment of their condition and course. The examination of a woman consists of the following components: external obstetric examination, laboratory and clinical.

External examination

Outdoor research includes:

  • Examination of a pregnant woman. The doctor evaluates the height, body weight and body type of a woman, as well as the condition of the skin, pigmentation on the face, determines the shape of the abdomen.
  • Measurement of the abdomen. With the help of a measuring tape, the doctor measures the circumference of the abdomen at the level of the navel, and also measures the length of the standing of the fundus.
  • Palpation of the abdomen. The woman should be in a supine position. The doctor, by palpation, determines the condition of the skin, the elasticity of the skin, the thickness of the fat layer, the condition of the rectus abdominis muscles, as well as the location of the fetus.

It is especially important at the first obstetric examination to determine the direct size of the entrance to the small pelvis. In general, the study of the pelvis is extremely important, since its position and structure affects the course of pregnancy and directly on the birth itself. Narrowing of the hip joint can lead to serious complications that can lead to difficult labor.

Research on pregnant women is done in several ways:

  1. First reception. The purpose of this method of examining a woman is to determine the height of the fundus of the uterus and the part of the fetus that is at its bottom. This technique also allows you to judge the estimated timing of pregnancy, the position of the fetus and its presentation.
  2. Second trick. This method allows you to determine the position of the fetus in the uterus. By gently pressing with your fingers on the walls of the uterus, the doctor can reveal in which direction the baby is turned. In addition, this technique allows you to determine the amount of amniotic fluid and the excitability of the uterus.
  3. Third trick. The purpose of the third reception of external obstetric examination is to determine the presentation and its relation to the small pelvis, as well as the general condition of the uterus.
  4. The fourth technique allows you to determine the state of the presenting head (it is bent or unbent), as well as the level of its relationship to the small pelvis.

Obstetric research factors

During the obstetric examination of women, the doctor must determine several factors that will assess the state of pregnancy and its course.

Fetal position is the ratio of the axis of the uterus to the back of the baby. The fetal axis is an imaginary line through the back of the head and buttocks. If the axis of the fetus and the axis of the uterus coincide in direction, the position of the fetus is called longitudinal. If the axis of the fetus passes through the axis of the uterus at a right angle, this is called the transverse position of the fetus, if under an acute one, it is oblique.

Fetal position is the relationship between the position of the walls of the uterus and the back of the fetus. This factor allows you to find out in what position the baby lies in the uterus. Of course, the longitudinal position of the fetus is the most favorable, as it contributes to the good movement of the fetus through the birth canal.

The position of the fetus makes it possible to find out the ratio of the limbs of the fetus and its head to the entire body. The normal position is when the head is bent and pressed to the body, the arms are bent at the elbows, crossed between themselves and pressed to the chest, and the legs are bent at the knees and hip joints, crossed and pressed to the tummy.

Internal obstetric research: pros and cons

Some women feel that an internal obstetric examination is not necessary. Moreover, they believe that it can harm the fetus. In fact, this is not the case. This method of research in some cases allows early detection of pathologies and abnormalities in the development of pregnancy.

An internal obstetric examination should be done in the first 3 to 4 months of pregnancy. This technique allows you to identify pregnancy in the initial stages (when the abdomen is not yet visible), its estimated timing, as well as possible pathologies of the genital organs. Internal obstetric examination at a later date determines the state of the birth canal, the dynamics and degree of uterine dilatation, as well as the advancement of the presenting part of the fetus along the birth canal.

All these factors of examination at a later date make it possible to make predictions about the course of labor. Why else is it necessary to conduct internal obstetric research?

Thus, the gynecologist examines the external genital organs for pathologies, infections, or other abnormalities. After that, with the help of mirrors, the internal genital organs are examined. In this case, the state of the mucous membrane is assessed for the presence of infections, the vagina and cervix, as well as the state and nature of the discharge.

With the help of this study, it is possible in the early stages of pregnancy to identify pathologies that can lead to complications and even termination of pregnancy. So, for example, some infections can cause serious complications not only for the entire cycle, but also for the fetus.

Other research methods

Of course, external and internal obstetric studies largely determine the nature of the course of pregnancy, and also allow predicting how the process of childbirth itself will take place. However, these surveys are often insufficient to paint the full picture.

In order to most accurately determine the duration of pregnancy, the position of the fetus, the state of the uterus, as well as many other factors, gynecologists use additional research methods.
Auscultation of the fetus is performed using an obstetric stethoscope. This method allows you to hear fetal heartbeats, determine their frequency in the early stages, as well as during attempts and fetal hypoxia. In addition, the heart rate can be heard with the help of the "Kid" apparatus, whose work is based on the principle of the Doppler effect.

Of no small importance is the obstetric examination of pregnant women using an ultrasound machine, which allows you to fully assess the condition of the fetus, identify the exact timing of pregnancy, and also identify possible pathologies in the early stages.

In addition to the above methods of obstetric research, the following techniques take place in medical practice: the study of amniotic fluid, which is obtained using amniocentesis, the study of the uteroplacental blood flow, as well as amnioscopy, fetoscopy and much more. In addition, do not forget about the numerous analyzes and measurements that show the complete picture of pregnancy.

Any woman in this exciting period of her life should be extremely attentive to her health. After all, the health of her baby depends on this.

Useful video about research during pregnancy

Any expectant mother wants her baby to be born on time and healthy. Previously, you had to rely only on the wisdom of nature and anxiously await the birth of a child.

But now almost all the changes occurring with the baby in the womb can be tracked with the help of mandatory tests and studies that are prescribed in the antenatal clinic.

Why is this necessary?

Getting up early and taking tests on an empty stomach, sitting in queues, ultrasound examinations, examinations and measurements seem to many women to be useless procedures that take too much time and effort. If the state of health is normal, some expectant mothers try to avoid even planned research.

But all the data that is collected during pregnancy is needed by the doctor for one purpose only - so that your pregnancy goes well and you give birth to a healthy baby. Including without genetic abnormalities.

Think of your visits to the antenatal clinic not as a harsh necessity, but as a manifestation of your concern about the future baby, which begins even before his birth. After all, many hidden problems with your or his health can only be detected by test results.

First trimester

The first visit to the antenatal clinic takes place at 7-8 weeks pregnancy. It is around this time that most expectant mothers find out that they are pregnant.

The obstetrician-gynecologist will measure your weight, height, pressure and pelvic size. You can also consult with your doctor about taking vitamin and mineral preparations. But you will leave the antenatal clinic for a reason, but with a whole heap of referrals for tests and specialist consultations.

In two weeks you will have to pass:

— Analysis of urine... The morning portion of urine is collected on an empty stomach. Based on the results of this analysis, kidney function and the bacterial population of the bladder are evaluated.

— Vaginal swab for microscopic examination. It will show if there are inflammatory processes in the genitals, overt and latent infections.

— General blood analysis... For rent in the morning and on an empty stomach. It shows the composition of blood and allows you to track its change in dynamics. For example, such an important factor as the level of hemoglobin in the blood. This substance is the only oxygen transporter in the blood, and oxygen supply to the fetus depends on its amount.

- Analysis on blood group and Rh factor... Even if these indicators are tattooed on your forearm, the doctor leading your pregnancy is obliged to check them. Moreover, if you have a negative Rh factor, the father of the unborn child will also go for analysis to find out if you will have a Rh conflict (incompatibility for the Rh factor).

- Blood test for HIV, hepatitis B and C and syphilis... Even if you are completely confident in yourself and your partner, it is worth treating the need to check again as an additional guarantee that everything is in order.

- Blood test for TORCH infections... These include toxoplasma, mycoplasma, cytomegalovirus and herpes virus. They can be in a woman's body for years and not cause any inconvenience to her, but they lead to developmental defects in the unborn child. If the test is positive, the doctor selects a special treatment for the woman.

- Blood test for sugar... Pregnancy puts an increased strain on all organs of a woman. Including the pancreas. This analysis allows you to determine how effectively it works and to anticipate all the risks associated with the risk of developing diabetes during pregnancy.

- Blood test for clotting, or coagulogram. This study allows you to determine how the blood clots - whether there is a tendency to blood clots or bleeding.

During the same two weeks, it is necessary to visit a therapist, endocrinologist, ophthalmologist and otolaryngologist and make an electrocardiogram.

The second visit to the doctor is expected at 10 weeks... You again take a urine test and prepare for the fact that before each visit to the doctor until the very birth, you will begin to come with a characteristic jar. At this meeting, the doctor will review the results of your tests and the appointments of other specialists and make a conclusion about your state of health.

On the term 12 weeks you must definitely go through the so-called first screening... It consists of a blood test that detects abnormalities in the development of a child, and an ultrasound scan (ultrasound), which, according to certain parameters, shows the degree of risk of genetic abnormalities in a baby, for example, Down's syndrome.

Second trimester

FROM 16 weeks the doctor can already clearly hear the fetal heartbeat using an obstetric stethoscope. At this time, the height of the position of the fundus of the uterus and the volume of the abdomen will be measured to determine whether the child is developing correctly. Now these parameters will be measured at each visit.

IN 18 weeks passes second screening, which identifies the risks of chromosomal abnormalities and congenital malformations of the fetus by examining the level of certain blood proteins: alpha-fetoprotein and chorionic gonadotropin. This research is possible only for a month - from 16 to 20 weeks.

In other periods, the level of these proteins is not informative. In addition, at 18 weeks surrender blood sugar test - the work of the pancreas is checked again.

The next visit to the doctor is only a month later - for 22 week pregnancy. In addition to the traditional examination, you will find a mandatory ultrasound scan, which will show how the baby's organs, the placenta, and how much amniotic fluid is contained in the uterus.

At this time, it is already possible to determine gender of the unborn child... In addition to an ultrasound scan, you do a Doppler study of your blood flow, uterus, placenta and umbilical cord to see how well your baby is supplied with oxygen and nutrients.

On 26 week meeting with a doctor leading a pregnancy will not take much time - you will only have an examination.

Third trimester

TO 30 week pregnancy, a detailed blood test that you did at the very beginning of pregnancy must be repeated. Its results are required to fill exchange card - the main document of a pregnant woman, without which, in case of sudden childbirth, she can only get into a specialized maternity hospital.

At the same time, the position of the child in the uterus is determined, and the long-awaited maternity leave.

IN 33 weeks the doctor conducts third screening - with the help of an ultrasound examination, it determines the peculiarities of the baby's development, reveals some malformations that are visible only at a later date.

The next visit to the doctor is at 35 week... At this time, cardiotocography is performed - a study of the child's heart and his motor activity. With this method, the doctor can determine how well the baby is doing.

FROM 37 weeks, which is a routine check-up only, you will see your pregnancy doctor every week.

On 38 week you will additionally take a blood test for syphilis again - you need a fresh one at the maternity hospital. And on 39-40 weeks undergo another ultrasound scan to determine the position of the baby, the umbilical cord, and the condition of the placenta.

During the entire pregnancy, the doctor may prescribe additional tests or send you for a consultation with other specialists - it all depends on the characteristics of the course of pregnancy.

Interview

When contacting the antenatal clinic, a pregnant woman's card is started, which reflects the survey data, an objective and instrumental and laboratory examination of the pregnant woman according to a specific plan (upon admission to the maternity hospital, a birth history is started).

1. Passport data(surname, name, patronymic, age, place of work
and profession, place of residence). Great attention is paid to age
pregnant, especially primiparous. In the "elderly" (over 30 years old) and
"young" (up to 18 years old) primiparous complications are more often observed during
pregnancy and childbirth. Regardless of the parity, the age of the pregnant woman
over 35 years old indicates the likelihood of congenital and hereditary
pathology in children.

2. Reasons that led a woman to seek medical help
cabbage (complaints).Pregnant women usually come for the first time about pregnancy.
schenia of menstruation and suspicion of pregnancy; often they celebrate
changes in taste, nausea, vomiting and other disorders found in
early pregnancy. There are complaints of bleeding from
vagina, which is a symptom of many complications (spontaneous
miscarriage, ectopic pregnancy, trophoblastic disease, ano
malias of the location of the placenta, diseases of the cervix, etc.). Sometimes


there are signs indicating the presence of gestosis, diseases of the cardiovascular system, respiratory system, digestion, etc. All complaints of a pregnant woman should be carefully listened to and taken into account when making an obstetric diagnosis.

3. Working and living conditions.Find out in great detail, since harmful
factors of industry and agriculture can negatively
to be involved in the course of pregnancy and fetal development. Sometimes a profession
a pregnant woman is associated with vibration, working on a computer, a long hundred
lesions, etc., which is also unfavorable for pregnancy. Obligations
It should be noted that there are bad habits: alcoholism, smoking,
addiction. It is necessary to take measures to create a good for the pregnant woman
pleasant working and living conditions.

4. Heredity and past diseases.Hereditary slaughter
levania are of interest because they can be detrimental
positive influence on the development of the fetus. It is necessary to find out if the family was
a pregnant woman and her husband hereditarily transmitted mental
diseases, blood diseases, metabolic disorders, genetically
detected developmental anomalies, etc.

It is important to get information about all previous illnesses. Children's diseases are of great interest. For example, rickets suffered in childhood leads to deformity of the pelvis, which complicates the course of childbirth. Therefore, they always find out whether rickets has taken place (teeth erupted late, started walking late, the presence of skeletal deformities, etc.). Measles, rubella, tuberculosis, as well as rheumatism, tonsillitis, recurrent tonsillitis and other infectious diseases often cause a lag in physical and sexual development and can cause the development of general and genital infantilism. Diphtheria of the vulva and vagina can be accompanied by the formation of cicatricial narrowing. Kidney diseases, often occurring after scarlet fever, frequent tonsillitis, aggravate the course of pregnancy and often serve as an indication for its termination. Non-infectious, infectious, including gynecological, diseases transferred in adulthood are also clarified.

Previously transferred diseases of the cardiovascular system, liver, lungs, kidneys and other organs can affect the course of pregnancy and childbirth. In addition, pregnancy and childbirth can cause new outbreaks of quiescent diseases of the heart, kidneys and other organs.

5. Menstrual function.When interviewing, they find out: a) at what age
the first menstruation (menarche) appeared, after what period of time
established regular menstruation; b) the type and nature of menstruation (length
the duration of the menstrual cycle, the duration of menstruation, the number
loss of blood, soreness, etc.); c) has the character of me changed
structions after the onset of sexual activity, childbirth, abortion; d) when there was a pic
icy menstruation.

Menstrual function characterizes the condition of the genitals and the whole body of a woman. The appearance of the first menstruation at the age of 14-15 years and older, a long period from the first menstruation to the establishment of a normal cycle (more than 6 months), soreness of menstruation is characteristic of genital infantilism. Violation of menstrual function after the onset of sexual activity, abortion, childbirth is most often a sign of an inflammatory disease of the internal genital organs or a violation


the function of the ovaries and other endocrine glands; other gynecological diseases are also possible, which can affect the course of pregnancy, childbirth and the postpartum period (uterine fibroids, ovarian tumors, etc.).

6. Secretory function.Find out if there is discharge from the genital tract.
Pathological discharge (profuse, purulent, mucous or watery
with an admixture of pus, etc.) indicate the presence of an inflammatory
cessa; the causes of its occurrence can be polyp, erosion, cervical cancer
uterus, etc.

7. Sexual function.Find out at what age sexual intercourse began
life, what kind of marriage is there, is there any pain and bleeding during
sexual intercourse. The period from the beginning of regular sexual activity is also important.
before the first pregnancy. You need to find out if you are using
whether contraceptives were available and which ones. Intrauterine contraceptive media
things can remain in the uterus during pregnancy. Not pregnant
within 1 year after the onset of regular sex life without use
use of contraceptives may indicate certain
diseases of the genital organs. Sexual life in the first weeks of pregnancy
nosity, as well as at the end of it can be the cause of infection of the genital
ways, spontaneous abortion or premature
childbirth.

8. Information about the husband.The husband's health status, his age, profession,
possible bad habits (alcoholism, drug addiction), hereditary
diseases should be reflected in the card of the pregnant woman and in the history of childbirth.

9. Childbearing function.In this important part of the survey, the following questions are asked:
other.

▲ What a real pregnancy is. The number of previous pregnancies reaching fetal viability (and not just the number of children born) is important.

In foreign literature, the following concepts are distinguished.

1. Nulligravida -a woman who is not currently pregnant or having
history of pregnancy.

2. Gravida -a woman who is currently pregnant or has
pregnancy earlier, regardless of their outcome. At the first pregnancy
a woman is characterized as a primary pregnant (primigravida), and at
following pregnancies - as re-pregnant (multigravida).

3. Nullipara -a woman who has never had a pregnancy reaching
term of a viable fetus; she may or may not have had
Menses that ended in abortion at an earlier date.

4. Primipara- a woman who has reported one pregnancy (one- or
multiple) until the term of a viable fetus.

5. Multipara- a woman with a history of several pregnancies,
full-term to the term of a viable fetus (22 weeks of gestation, weight
fruit 500 g, height 32-34 cm).

Parity(from Lat. pario) - a history of childbirth, or the number of births in the past.


The course of previous pregnancies: were there any early toxicosis and preeclampsia (salivation, vomiting, edema, etc.), diseases of the cardiovascular system, kidneys and other organs. In the case of the presence of these diseases in the past, it is necessary to especially carefully monitor the woman during this pregnancy. It is necessary to obtain detailed information about the course of each pregnancy, childbirth and postpartum periods. If a woman had miscarriages, then their nature should be established: spontaneous or artificial, in what month the miscarriage occurred, diseases after it and their nature. Premature birth and spontaneous abortions indicate genital infantilism or the presence of diseases that adversely affect the course of pregnancy (endocrine disorders, infectious diseases, damage to the cervix and isthmus of the uterus, etc.). With spontaneous and artificial miscarriages, inflammatory diseases of the genital organs often develop, there is a tendency to premature termination of pregnancy, improper labor and bleeding during childbirth are observed.

The nature of the previous birth (timely, late or premature), their course. The correct course of the previous birth indicates the good health of the pregnant woman and the absence of abnormalities in the birth canal. Complications and surgical interventions in previous childbirth, stillbirth or death of a child after birth indicate possible anomalies of the birth canal, complications of pregnancy, diseases of a pregnant woman. Pathological childbirth in the past (burdened obstetric history) gives reason to expect the development of complications during this pregnancy and childbirth. It should be determined whether postpartum diseases were previously observed, since they can cause serious complications in subsequent births (labor anomalies, placental accreta, bleeding, rupture of the uterus, including in the scar, if the previous birth ended with a cesarean section, and the postoperative period was with complications).

4.2.2. Objective examination

After getting acquainted with the anamnesis, the patient proceeds to an objective study, which begins with an examination.

Examination of a pregnant woman.Examination often provides very valuable data for the diagnosis. On examination, attention is paid to the growth of the pregnant woman, physique, fatness, the condition of the skin, visible mucous membranes, mammary glands, the size and shape of the abdomen.

Growth. The height of the pregnant woman must be measured accurately. With low growth (150 cm and below), women often show signs of infantilism (narrowing of the pelvis, underdevelopment of the uterus, etc.). In women of tall stature, other features of the pelvis (wide, male type) are observed.

Body type. Deformation of the spine and lower extremities, ankylosis of the joints and other changes in the skeletal system indicate a possible change in the shape of the pelvis and its narrowing. Bone changes and


joints often appear as a result of rickets, poliomyelitis, tuberculosis, which could have a negative effect on other organs and systems. Examination reveals additional visible signs of infantilism (underdevelopment of the mammary glands, insufficient development of hair in the external genital area), insufficient sexual differentiation (broad shoulders, narrow pelvis, male hair growth) and other developmental features in which pregnancy often proceeds with complications ... Severe exhaustion or obesity is often a sign of metabolic disorders, endocrine and other diseases. The occurrence of these disorders may be due to inappropriate diet and regime. Complications of pregnancy and childbirth occur in these women more often than usual.

Skin. Pigmentation of the face, white line, nipples and areola, pregnancy stripes suggests pregnancy. Pallor of the skin and visible mucous membranes, cyanosis of the lips, yellowness of the skin and sclera, edema are signs of a number of serious diseases.

Milk glands. Their development, the condition of the nipples (normal, flat, inverted), the presence of discharge (colostrum) from the nipples are assessed.

Examination of the abdomen. In the second half of pregnancy, examination sometimes reveals deviations from its normal course. With normal pregnancy and the correct position of the fetus, the belly has an ovoid (ovoid) shape; with polyhydramnios, it is spherical, increases very sharply, not according to the gestational age; with the transverse position of the fetus, the abdomen acquires the shape of a transverse oval. The shape of the abdomen can change with a narrow pelvis.

Examination of internal organs.After the examination, a study of the cardiovascular system, lungs, digestive organs, nervous, urinary and other systems is carried out according to the generally accepted technique (auscultation, percussion, palpation, etc.). Examination of the heart, lungs, kidneys and other organs in pregnant women is necessary for the timely detection of diseases in which pregnancy is contraindicated.

A pregnant woman is required to measure blood pressure, body weight and height, examine urine and blood (morphological picture, ESR), determine the blood group, Rh affiliation, perform serological and other studies of latent infections (syphilis, HIV, viral hepatitis, toxoplasmosis, etc. etc.). In all pregnant women, discharge from the cervix, cervical canal, vagina is examined to detect trichomoniasis, gonorrhea, chlamydia, mycoplasmosis, and bacterial flora. In the second half of pregnancy, blood pressure measurement, body weight, blood and urine tests are carried out systematically. After applying all these research methods, they begin a special obstetric examination.

Measurement.When examining a pregnant woman, in addition to determining her growth, the structure of the pelvis (its size and shape), it is necessary to measure the circumference of the abdomen and the height of the uterine fundus. In this case, a pelvimeter and a centimeter tape are used.

Measurement of the abdomen. Determine with a centimeter tape its largest circumference at the level of the navel (at the end of pregnancy, it is usually 90-100 cm) (Figure 4.8). Abdominal circumference greater than 100 cm usually



Fig. 4.8. Measurement of the abdominal circumference with a centimeter tape.


Fig. 4.9. Measurement of the height of the fundus of the uterus above the pubic articulation with a centimeter tape.


observed with polyhydramnios, multiple pregnancies, large fetuses, transverse position of the fetus and obesity.

Then measure the height of the fundus of the uterus above the pubic articulation (Fig. 4.9). In the last 2-3 weeks of pregnancy, this height is 36-37 cm, and by the beginning of labor, when the bottom of the uterus drops, it is 34-35 cm.

The height of the standing of the fundus of the uterus above the pubic articulation can be determined by the pelvic meter, with which the size of the fetal head can also be determined.

Examination of the pelvis. In obstetrics, the study of the pelvis is very important, since the structure and size of the pelvis are critical for the course and outcome of labor. The presence of a normal pelvis is one of the main conditions for the correct course of labor. Deviations in the structure of the pelvis, especially a decrease in its size, complicate the course of labor or present insurmountable obstacles for them.

Examination of the pelvis is performed by inspection, feeling and measurement. When examining, they pay attention to the entire pelvic area, but they attach particular importance to the sacral rhombus (Michaelis rhombus), the shape of which, together with other data, makes it possible to judge the structure of the pelvis (Fig. 4.10).

The sacral rhombus is a platform on the posterior surface of the sacrum: the upper corner of the rhombus is the depression between the spinous process of the V lumbar vertebra and the beginning of the middle sacral ridge; bo-


Measurement of the pelvis is performed with a special instrument - a pelvis meter. Tazometer has the shape of a compass, equipped with a scale on which centimeter and half-centimeter divisions are applied. There are buttons at the ends of the branches of the pelvis; they are applied to the places, the distance between which is to be measured. To measure the transverse dimension of the pelvic outlet, a cross-branch pelvis meter was designed.

When measuring the pelvis, the woman lies on her back with a bare stomach, legs extended and pushed together. The doctor stands to the right of the pregnant woman, facing her. The branches of the pelvis are taken in such a way that the thumbs and forefingers hold the buttons. The scale with divisions is facing up. The index fingers probe the points, the distance between which is measured by pressing the buttons of the separated branches of the pelvis to them, and the value of the desired size is marked on the scale.

Usually, four sizes of the pelvis are measured: three transverse and one straight.

1. Distantia spinarum- the distance between the anterior-superior awns under
sacral bones. The buttons of the pelvis are pressed to the outer edges of the front
non-upper awns. This size is usually 25-26 cm (Fig. 4.11, a).

2. Distantia cristarum- the distance between the most distant points
crests of the ilium. After measuring distantia spinarum buttons
the pelvis is moved from the awns along the outer edge of the iliac crest
bones until the greatest distance is determined; this distance
and there is distantia cristarum; it is on average 28-29 cm (Fig. 4.11, b).

3. Distantia trochanterica -the distance between the great skewers of troubles
broken bones. Find the most prominent points of the large skewers
and press the buttons of the pelvis to them. This size is 31-32 cm (Fig.
4.11, c).

The ratio between the transverse dimensions is also important. For example, normally the difference between them is 3 cm; a difference of less than 3 cm indicates a deviation from the norm in the structure of the pelvis.

4. Conjugata externa- external conjugate,those. straight size of the pelvis.
The woman is laid on her side, the underlying leg is bent at the hip
and knee joints, the overlying one is pulled. A button of one branch is



Figure 4.12. Measurement of the external conjugate (conjugata ex-terna).


the zomer is placed in the middle of the upper outer edge of the symphysis, the other end is pressed against the supra-sacral fossa, which is located between the spinous process of the V lumbar vertebra and the beginning of the middle sacral ridge (the supra-sacral fossa coincides with the upper corner of the sacral rhombus).

The upper outer edge of the symphysis is easily identified; to clarify the location of the supra-sacral fossa, slide your fingers along the spinous processes of the lumbar vertebrae towards the sacrum; the fossa is easily identified by touching under the protrusion of the spinous process of the last lumbar vertebra. The external conjugate is normally 20-21 cm (Figure 4.12).

▲ The outer conjugate is important - its size can be used to judge the size of the true conjugate. To determine the true conjugate, 9 cm is subtracted from the length of the outer conjugate. For example, if the outer conjugate is 20 cm, then the true conjugate is 11 cm; if the outer conjugate is 18 cm long, then the true one is 9 cm, etc.


The difference between external and true conjugates depends on the thickness of the sacrum, symphysis and soft tissues. The thickness of bones and soft tissues in women is different, so the difference between the size of the outer and the true conjugate does not always correspond exactly to 9 cm. The true conjugate can be more accurately determined by the diagonal conjugate.

Conjugata diagonaliscalled the distance from the lower edge of the symphysis to the most prominent point of the promontory of the sacrum. The diagonal conjugate is determined during the vaginal examination of a woman, which is performed in compliance with all the rules of asepsis and antiseptics. II and III fingers are inserted into the vagina, IV and V are bent, their rear rests against the perineum. The fingers inserted into the vagina are fixed at the apex of the cape, and the edge of the palm rests against the lower edge of the symphysis (Fig. 4.13, a, b). After that, the second finger of the other hand marks the place of contact of the examining hand with the lower edge of the symphysis. Without taking the second finger away from the intended point, the hand in the vagina is removed, and the assistant measures the distance from the apex of the third finger to the point in contact with the lower edge of the symphysis with a pelvimeter or a measuring tape.

AND The diagonal conjugate with a normal pelvis is on average 12.5-13 cm.To determine the true conjugate, 1.5-2 cm is subtracted from the size of the diagonal conjugate.

It is not always possible to measure the diagonal conjugate, because with normal sizes of the pelvis, the cape is not reached or is palpable with difficulty.


Fig. 4.13. Measurement of the diagonal conjugate (a, b).

If the tip of the extended toe cannot reach the cape, the volume of this pelvis can be considered normal or close to normal. The transverse dimensions of the pelvis and the external conjugate are measured in all pregnant women and parturient women without exception.

If, when examining a woman, there is a suspicion of a narrowing of the pelvic outlet, then the size of this cavity is determined.

The dimensions of the pelvic outlet are determined as follows. The woman lies on her back, legs bent at the hip and knee joints, pulled apart and pulled up to the stomach.

Straight sizepelvic outlet is measured with a conventional pelvis meter. One button of the pelvis is pressed to the middle of the lower edge of the symphysis, the other to the apex of the coccyx. The resulting size (11 cm) is larger than the true one. To determine the direct size of the pelvic outlet, subtract 1.5 cm from this value (taking into account the thickness of the tissues). In a normal pelvis, the straight size is 9.5 cm.


Of known clinical significance is the definition the shape of the pubic angle.Whennormal size of the pelvis, it is equal

90-100 °. The shape of the pubic angle is determined by the following method. The woman lies on her back, legs bent and pulled up to her stomach. With the palm side, the thumbs are applied close to the lower edge of the symphysis. The location of the fingers allows you to judge the magnitude of the angle of the pubic arch.

Oblique pelvishave to be measured with a slanting pelvis. To identify the asymmetry of the pelvis, the following oblique dimensions are measured:

1) the distance from the anterosuperior spine of the ilium on one side
us to the posterior superior spine of the other side and vice versa;

2) the distance from the upper edge of the symphysis to the right and left posterior superior
awns;

3) the distance from the supra-sacral fossa to the right or left anteroposterior
keep them.

The oblique dimensions of one side are compared with the corresponding oblique dimensions of the other. With a normal structure of the pelvis, the value of the paired oblique sizes is the same. A difference greater than 1 cm indicates pelvic asymmetry.

If it is necessary to obtain additional data on the size of the pelvis, its compliance with the size of the fetal head, deformities of the bones and their joints, an X-ray examination of the pelvis is performed (according to strict indications). Radiopelviometry is performed with a woman lying on her back and on her side, which makes it possible to establish the shape of the sacrum, pubic and other bones; a special ruler determines the transverse and straight dimensions of the pelvis. The head of the fetus is also measured and on this basis it is judged that its size corresponds to the size of the pelvis. The size of the pelvis and its correspondence to the size of the head can be judged by the results of ultrasound examination.

With external pelvic measurement, it is difficult to take into account the thickness of the pelvic bones. Of known importance is the measurement of the circumference of the wrist joint of a pregnant woman with a centimeter tape (Solovyov index; Fig. 4.14). The average size of this circle is 14 cm.If the index is greater, it can be assumed that


that the pelvic bones are massive and the size of its cavity is smaller than one would expect from the measurement of the large pelvis.

Palpation of the abdomenis one of the main methods of obstetric research. It is performed in the position of the pregnant woman on her back with the legs bent at the hip and knee joints. This eliminates the tension of the abdominal wall and facilitates the probing of the abdominal organs, especially the uterus and the fetus located in it. The doctor sits to the right of the pregnant woman, facing her.

Palpation of the abdomen begins with determining the state and elasticity of the abdominal wall, the state of the rectus abdominis muscles (whether there are any discrepancies, hernial protrusions, etc.). The anatomical and especially the functional state of the abdominal wall plays an important role in the normal course of labor.

Then they move on to determining the size of the uterus, its functional state (tone, tension during examination, etc.) and the position of the fetus in the uterine cavity.

Finding out the position of the fetus in the uterine cavity is of exceptional importance for the management of pregnancy and childbirth. When examining pregnant women and women in labor, the articulation, position, position, type, presentation of the fetus are determined.

Articulation of the fetus (habitus) - the ratio of its limbs to the head and body. With a typical normal articulation, the torso is bent, the head is tilted towards the chest, the legs are bent at the hip and knee joints and pressed to the stomach, the arms are crossed on the chest. With a normal flexion type of articulation, the fetus has the shape of an ovoid, the length of which at full-term pregnancy is on average 25-26 cm.The wide part of the ovoid (the pelvic end of the fetus) is located in the bottom of the uterus, the narrow part (the back of the head) faces the entrance to the small pelvis. Fetal movements lead to a short-term change in the position of the limbs, but do not violate the characteristic articulation. Violation of the typical articulation (head extension, etc.) occurs in 1-2% of labor and complicates their course.

The position of the fetus (situs) is the ratio of the longitudinal axis of the fetus to the longitudinal axis (longitudinal axis) of the uterus.

The following provisions are distinguished:

▲ longitudinal (situs longitudinalis; Fig. 4.15, a, b, c) - longitudinal axis
the fetus and the longitudinal axis of the uterus coincide, the fetal axis is a line, about
walking from occiput to buttocks;

▲ transverse (situs transversus; Fig. 4.16) - the longitudinal axis of the fetus
cuts the longitudinal axis of the uterus at a right angle;

▲ oblique (situs obliquus) - the longitudinal axis of the fetus forms with the longitudinal
the axis of the uterus is an acute angle.

The longitudinal position of the fetus is normal; it occurs in 99.5% of all deliveries. The transverse and oblique positions are pathological, occurring in 0.5% of births. In the transverse and oblique positions, there are insurmountable obstacles to the birth of the fetus.

Fetal position (positio) - the ratio of the fetal back to the right or left side of the uterus. There are two positions: first and second. When the first



Position type (visus) - the relation of the fetal back to the anterior or posterior wall of the uterus. If the back is facing forward, they speak of front view position,if backwards - oh back view.

Presentation of the fetus (pga-esentatio) - the ratio of a large

parts of the fetus (head or buttocks) to the entrance to the small pelvis. If the fetal head is located above the entrance to the mother's pelvis - head presentation,if the pelvic end is presentation is pelvic.Cephalic presentation occurs in 96% of deliveries, pelvic presentation - in 3.5%.

With transverse and oblique fetal positions, the position is determined not by the back, but by the head: the head on the left is the first position, on the right is the second position.

The presented part(pars praevia) is the name of the part of the fetus that is located at the entrance to the small pelvis and first passes through the birth canal.

With a cephalic presentation, the occiput (occipital presentation), crown (anteroposterior), forehead (frontal), face (facial presentation) of the fetus can be turned to the entrance to the small pelvis. Occipital presentation (flexion type) is typical. In the antero-cephalic, frontal and facial presentations, the head is in varying degrees of extension. The extensor presentation is found in 1% of all longitudinal fetal positions.

With a breech presentation, the buttocks of the fetus (pure breech presentation), the legs of the fetus (breech presentation), buttocks with legs (mixed breech-leg presentation) can be turned towards the entrance to the mother's pelvis.

Fig. 4.15. The position of the fetus in the uterus.

a - longitudinal position, occipital presentation, second position: 1 - anterior view, 2 - view from the side of the pelvic outlet. Sagittal suture in the left oblique size, a small fontanel on the right in front; b - longitudinal position, occipital presentation, first position: 3 - posterior view, 4 - view from the side of the pelvic outlet. Sagittal suture in the left oblique size, the small fontanelle on the left behind; c - longitudinal position, occipital presentation, second position: 5 - posterior view, 6 - view from the side of the pelvic outlet. Sagittal suture in the right oblique size, small fontanelle on the right back.


When palpating the abdomen, use the so-called external methods of obstetric research(Leopold's tricks). Leopold (1891) introduced abdominal palpation into the system and proposed typical palpation techniques that have received universal recognition.

The first reception of external obstetric research (Fig. 4.17). Its purpose is to determine the height of the uterine fundus and the part of the fetus located in its bottom.

Research methodology.The palmar surfaces of both hands are placed on the uterus in such a way that they tightly cover its bottom with the adjacent areas of the corners of the uterus, and the fingers are facing the nail phalanges to each other. Most often, at the end of pregnancy (in 96% of cases), the buttocks are determined in the bottom of the uterus. Usually, it is easy to distinguish them from the head by their less pronounced roundness and sphericity, lower density and less smooth surface (see below).

The first external reception of obstetric research makes it possible to judge the duration of pregnancy (by the height of the uterine fundus), the position of the fetus (if one of its large parts is in the bottom of the uterus, then there is a longitudinal position) and presentation (if the buttocks are in the bottom of the uterus, then the presenting part is the head).

The second method of external obstetric research (Fig. 4.18). Its purpose is to determine the position of the fetus, which is judged by the location of the back and small parts of the fetus (arms, legs).

Research methodology.Hands are lowered from the bottom of the uterus to its right and left sides to the level of the navel and below. Gently pressing with the palms and fingers of both hands on the side walls of the uterus, they determine which side the back and small parts of the fetus are facing. The backrest is recognized by its wide and curved surface. When pressing on a large part, located in the bottom of the uterus, towards the bosom of the fetus's body bends, as a result of which the back becomes more accessible for research. Small parts of the fruit are defined on the opposite side in the form of small, mobile tubercles. In multiparous women, due to the flabbiness of the abdominal wall and the muscles of the uterus, small parts of the fetus are more easily felt. Sometimes their movement is visible to the eye.

The second external method of obstetric research also allows you to determine the state of the round uterine ligaments, their soreness, thickness, tension, symmetry of the right and left ligaments, their location in relation to the uterus. Moreover, if the ligaments converge upward, the placenta is located on the back wall of the uterus, if they diverge or run parallel to each other, the placenta is located on the front wall of the uterus.

Next, the reaction of various parts of the uterus (its right and left half, body and lower segment) to physical irritation is determined: gently pressing on the uterus with the fingers of both hands, they monitor the strength of the contractions of the uterine muscles caused by this technique and its soreness. These data, allowing to judge the functional state of the muscles of the uterus, play a special role during childbirth.

A palpable fluctuation in the uterus with a large abdomen indicates polyhydramnios.

By the way the fetal back is facing, its position is recognized: the back to the left is the first position, the back to the right is the second position.

Fig. 4.17. The first reception of external obstetric research.


Fig. 4.18. The second method of external obstetric research.


If during this study it was possible to feel the movement of small parts of the fetus, we can assume that the fetus is alive.

The third method of external obstetric research (Fig. 4.19). Its purpose is to determine the nature of the presenting part and its relation to the small pelvis.

Research methodology.One, usually the right, hand covers the presenting part, after which they carefully make movements with this hand to the right and left. This technique allows you to determine the nature of the presenting part (head or buttocks), the ratio of the presenting part to the entrance to the small pelvis (if it is mobile, then it is located above the entrance to the pelvis, if it is motionless, then at the entrance to the pelvis or in the deeper parts of the small pelvis ).

The fourth method of external obstetric research (Fig. 4.20). Its purpose is to determine the presenting part (head or buttocks), the location of the presenting part (above the entrance to the small pelvis, in the entrance or deeper, where exactly), in what position the presenting head is located (in bent or unbent).

Research methodology.The examiner stands facing the legs of a pregnant woman or woman in labor and places his hands flat on both sides of the lower part of the uterus. With the fingers of both hands facing the entrance to the pelvis, he carefully and slowly penetrates between the presenting part and the lateral parts of the entrance to the pelvis and palpates the accessible areas of the presenting part.

If the presenting part is movable above the entrance to the pelvis, the fingers



Fig. 4.19. The third reception is externally Fig. 4.20. The fourth reception of an external obstetrician
th obstetric research. research.

both hands can be almost completely brought under it, especially in women who have given birth to many. In this case, the presence or absence of symptom of running,characteristic of the head. For this, the hands of both examining hands are tightly pressed with the palmar surfaces to the lateral parts of the head; then a push is made with the right hand in the area of \u200b\u200bthe right half of the head. In this case, the head is pushed to the left and transfers the push to the opposite - left hand (simple ballot).After that, quickly returning to its original position, the head sometimes gives a push to the right hand (double ballot).

With a cephalic presentation, one should strive to get an idea of \u200b\u200bthe size of the head and the density of the bones of the skull, the location of the occiput, forehead and chin, as well as their relationship to each other (the nature of the proposal).

With the help of the fourth technique, it is possible to determine the presence or absence of an angle between the back of the head and the back of the fetus (the higher the chin with the head fixed at the entrance, the more pronounced the flexion and the more smoothed the angle between the back of the head and the back, and vice versa, the lower the chin is located, the more extended head), position and type of the fetus - according to where the back of the head, forehead, chin are turned. For example, the back of the head is facing left and anteriorly - first position, front view; chin facing left and forward - second position, rear view, etc.


With a cephalic presentation, it is also necessary to determine in which pelvic cavity the head is located with its large segment.

The degree of insertion of the fetal head into the small pelvis is recommended to be determined as follows. Having penetrated at the fourth external reception of obstetric examination with the fingers of both hands as deeply as possible into the pelvis and pressing on the head, they make a sliding movement along it in the direction towards themselves. With a high standing of the fetal head, when it is mobile above the entrance, it is possible, during external examination, to bring the fingers of both hands under it and even move it away from the entrance (Fig. 4.21). If at the same time the fingers diverge, the head is at the entrance to the small pelvis in a small segment (Fig. 4.22). If the hands sliding along the head converge, then the head is either located in a large segment at the entrance, or passed through the entrance and sank into deeper parts (planes) of the pelvis (Fig. 4.23). If the fetal head penetrates so deeply into the pelvic cavity that it completely fulfills it, then usually it is no longer possible to probe the head with external methods.

Auscultation.Auscultation of the abdomen of a pregnant woman and a woman in labor is usually performed with an obstetric stethoscope. An obstetric stethoscope differs from the usual one with a wide funnel, which is applied to a woman's naked belly.

With auscultation of the abdomen, fetal heart sounds are determined. In addition, you can pick up other sounds emanating from the mother's body; beating of the abdominal aorta, coinciding with the pulse of a woman; "blowing" uterine murmurs that occur in large blood vessels passing in the lateral walls of the uterus (coincide with the woman's pulse); irregular bowel sounds.

The sound phenomena emanating from the fetus include fetal heart sounds, the noise of the vessels of the umbilical cord, deaf irregular jerky movements of the fetus. Auscultation is performed mainly to determine the fetal heart sounds, which are a reliable sign of pregnancy. By listening to heart sounds, they also find out the condition of the fetus, which is especially important during childbirth.

Fetal heart sounds are heard with a stethoscope from the beginning of the second half of pregnancy (less often from 18-20 weeks) and become clearer every month. The heart sounds of the fetus are heard in the side of the abdomen where the back of the fetus is facing, closer to the head (Fig. 4.24, a). Only with facial presentations, the fetal heartbeat is heard more clearly from the side of his chest. This is due to the fact that in the facial presentation, the head is maximally unbent and the breast is adjacent to the wall of the uterus closer than the back (Fig. 4.24, b).

With an occipital presentation, the heartbeat is well heard below the navel, on the left - in the first position, on the right - in the second (Fig. 4.24, c). With breech presentation, the heartbeat is heard at or above the navel.

In transverse positions, the heartbeat is heard at the level of the navel, closer to the head of the fetus.

With multiple pregnancies, the fetal heartbeat is usually heard clearly in different parts of the uterus.

During childbirth, with the lowering of the fetal head into the pelvic cavity and its birth, the heartbeat is better heard closer to the symphysis, almost along the midline of the abdomen.



Fig. 4.24. Listening to fetal heart sounds.

a - from the back; b - from the side of the chest; c - depending on the presentation of the fetus and its position: 1 - the first position, the anterior view of the occipital presentation, 2 - the second position, the anterior view of the occipital presentation, 3 - the first position, the anterior view of the breech presentation, 4 - the second position, the anterior view of the breech presentation ...

The most reliable method for determining the life and death of the fetus is ultrasound. Evaluation of the vital activity of the embryo in the early stages is based on the registration of its cardiac activity and motor activity. Determination of the cardiac activity of the embryo (heartbeat) is possible from 3-4 weeks. The cardiac activity of the fetus in the early stages can be determined in 50% of women before 6-7 weeks of pregnancy, in 95% - at the 8th week and in 100% - after the 8th week of pregnancy.

Other methods of determining the nature of fetal heart sounds are also used: phonocardiography and cardiotocography (see section 4.5).

4.2.3. Determination of the gestational age.

Provision of a certificate of incapacity for work to pregnant women and women in childbirth

Determination of the gestational age.To determine the duration of pregnancy and childbirth, information from the anamnesis about the time of the last menstruation and the first movement of the fetus is important.

The gestational age can be judged on the basis of accounting for the time elapsed from the first day of the last menstruation to the moment,when the term is determined. To do this, determine the period of ovulation, which usually coincides with the beginning of pregnancy. In order to determine this time, the doctor needs to have information about the day of the expected, but not coming menstruation. From the first day of the expected (not come) menstruation, they count back 14-16 days and thus determine the possible time of ovulation.

When determining the duration of pregnancy and childbirth, take into account the time of the first movement of the fetus,which is felt by primiparas from the 20th week, i.e. from the middle of pregnancy, multiparous - about 2 weeks earlier. The first fetal movement is a subjective sign and much less important than the date of the last menstruation. A woman often forgets the date of the first movement of the fetus or mistakenly determines this date, taking intestinal peristalsis for the movement of the fetus. The time of fetal movement is taken into account only as an auxiliary sign.

To speed up the calculation of pregnancy by menstruation, ovulation and the first movement of the fetus, there are special obstetric calendars and rulers.

For recognizing the gestational age and finding out the date of birth, the data of an objective examination are of great importance: determining the size of the uterus, the volume of the abdomen and the height of the bottom of the uterus, the length of the fetus and the size of the head.

The size of the uterus and the height of its standing at different stages of pregnancy(fig. 4.25). At the end of the 1st obstetric month of pregnancy (4 weeks), the size of the uterus reaches approximately the size of a hen's egg.

At the end of the 2nd obstetric month of pregnancy (8 weeks), the size of the uterus approximately corresponds to the size of a goose egg.

At the end of the 3rd obstetric month (12 weeks), the size of the uterus reaches the size of the head of the newborn, its asymmetry disappears, the uterus fills the upper part of the pelvic cavity, its bottom reaches the upper edge of the pubic arch.

Starting from the 4th month of pregnancy, the bottom of the uterus is probed through the abdominal wall, and the duration of pregnancy is judged by the height of the bottom


Fig. 4.25. The height of the standing of the fundus of the uterus at various stages of pregnancy.

uterus. It should be remembered that the height of the uterine fundus can be influenced by the size of the fetus, excess amniotic fluid, multiple pregnancy, abnormal position of the fetus and other features of the course of pregnancy. Therefore, the height of the standing of the bottom of the uterus when determining the duration of pregnancy is taken into account in conjunction with other signs (the date of the last menstruation, the first movement of the fetus, etc.).