Organization of obstetrical and gynecological care at the feldsher-midwife point

Obstetrical and gynecological assistance to the rural population is provided by a complex of medical and preventive institutions. Depending on the degree of proximity to a rural settlement, the specialization and qualification of medical care, the level of material and technical equipment in the system of obstetric-gynecological care, it is accepted to distinguish three stages.

The first stage: the implementation of pre-medical and first medical assistance. This stage is a rural medical station. It includes a rural district hospital with an outpatient clinic and a hospital, a feldsher-midwife station( FAP), and maternity hospitals. The location of the first stage is the periphery of the district.

The second stage: the implementation of qualified medical care. It includes district( numbered) and central district hospitals, which include obstetrical and gynecological departments and women's clinics. The location of the second stage is the district center.

The third stage: provision of rural population with highly qualified( specialized) obstetric-gynecological care. It includes a regional( regional, republican) hospital, which includes obstetrics and gynecology departments and a women's consultation or an independent maternity hospital with a women's consultation. The dislocation of the third stage is the regional( regional, republican) center.

General obstetrician-gynecological care is provided by a general practitioner-the chief doctor of a rural district hospital( if there are two doctors in the district hospital, one of them).Under his direct supervision, the midwife of the district hospital works, who helps the doctor both in the hospital( takes part in childbirth) and at the outpatient clinic( takes part in the observation of pregnant women, puerperas and treatment of gynecological patients).

Despite the presence of a rural district hospital in the periphery of the district, the bulk of obstetric and gynecological care in the rural medical unit is referred to as pre-medical care, and it is performed by midwives at the feldsher-midwife point.

Feldsher-midwifery stations( FAP) are provided by the nomenclature of medical institutions. FAP is organized in a village with a population of 300 to 800 inhabitants in those cases if within a radius of 4-5 km there is no rural district hospital or dispensary.

All FAP work is provided by a midwife, midwife, nurse.

Depending on local conditions, the FAP may only conduct ambulatory care or have maternity beds. In the latter case, the FAP along with outpatient care is also stationary.

Due to the fact that the FAP provides medical assistance to the entire rural population, and not only to the female population, the premises in which it is located should consist of two halves: a paramedic and an obstetrician.

The obstetric part of the FAP should have the following set of rooms: anteroom, waiting room and midwife's office. FAPs with maternity beds, in addition to these facilities should have a viewing room, a generic and puerperal ward. Midwife FAP carries out all work on the organization and provision of obstetric and gynecological care to rural residents within a radius of the service point.

The duties of a midwife FAP include: the identification in the earliest possible time of all pregnant women in the service area, providing dispensary surveillance, including the necessary preventive measures, the patronage of pregnant women, puerperas and children under the age of 1 year;carrying out of sanitary-educational work among women;the provision of medical assistance during normal childbirth;identification of gynecological patients, referring them to a doctor and providing them with medical assistance as directed by a doctor.

Considerable assistance in the early detection of pregnant women is provided by household visits by the midwife of the FAP.All identified pregnant women from the earliest pregnancy( up to 12 weeks), and puerperas are subject to medical examination. In monitoring pregnant women, the midwife performs the entire bulk of the necessary studies. Thus, when a pregnant woman is first treated, the midwife collects a detailed anamnesis: general( heredity, transferred diseases, etc.) and special obstetric( menstrual, sexual, generative, lactational functions, gynecological diseases, etc.).From an anamnesis midwife finds out the features of the course of previous pregnancies, the presence of extragenital diseases and other suffered deviations in the state of woman's health, which can affect the course of pregnancy and childbirth.

A midwife examines each pregnant woman with a study of the internal organs: cardiac activity, blood pressure measurement( on both hands), pulse studies, urine on protein( by boiling).The midwife currently studies the health status of pregnant women based on the measurement of height, body weight( in dynamics), the presence of edema, pigmentation, mammary glands and nipples, and the condition of the abdominal press.

When conducting a special midwifery survey, the midwife measures the external dimensions of the pelvis, by means of a vaginal examination, sets the gestation period and the internal dimensions of the gas. In the second half of pregnancy measures the height of the standing of the uterus above the bosom, determines the position and presentation of the fetus, listens to his heartbeat.

For a general blood test, group membership, Rhesus factor determination, antibody titer, Wasserman reaction, an overall urinalysis of the pregnant woman is sent to the nearest laboratory. Here, bacteriological examination of the vaginal flora is carried out for the degree of purity, the separated urethra, cervix and vagina for gonococcus, the reaction of the vaginal secretion. X-ray examinations in pregnant women( X-rays of chest, fetus, pelviography, etc.) are performed only if there are strict indications.

Thorough examination of pregnant women makes it possible to identify various pathological conditions, on the basis of which these pregnant women are allocated to high-risk groups and require the most close attention to them during pregnancy;groups of high risk for cardiac pathology, bleeding in the postpartum and early post-partum periods, inflammatory-septic complications after childbirth, endocrinopathies - diabetes, obesity, adrenal insufficiency and other types of obstetric and somatic pathology.

All individual cards of pregnant women belonging to the risk group are usually marked with the appropriate color marking, indicating a certain color for the risk of a particular pathology( red - bleeding, blue - toxicosis, green - sepsis, etc.).

The scope of studies of gynecological patients also includes the collection of general and special gynecologic history.

Special gynecological examination includes two-hand and instrumental( examination in mirrors) study. A bacterioscopic examination of the separated urethra, cervix and vagina on gonococcus is carried out using provocation methods, but indications are Borde-Zhang reactions;a vaginal smear test for atypical cells;research on tests of functional diagnostics.

If a woman needs a biochemical blood test for cholesterol, bilirubin, sugar, residual nitrogen and urine for acetone, urobilin, bile pigments, she is sent to the nearest multidisciplinary laboratory.

Women and couples who have a history of hereditary diseases or children with central nervous system deformities, Down's disease, cardiovascular malformations, are referred for screening, including the determination of sexual chromatin, to specialized medical genetic centers.

All pregnant women who show slightest deviations from normal pregnancy development should be immediately referred to a doctor.

For each subsequent visit to the FAP, pregnant women are subjected to the necessary re-examination. In the second half of pregnancy, it is especially necessary to monitor the possible development of late toxicosis, for which it is necessary to pay attention to the presence of edema, the dynamics of blood pressure and the presence of protein in the urine. It is very important to monitor the dynamics of the mass of a pregnant woman.

An obligatory part of the work of a midwife in monitoring pregnant women should be conducting classes on psycho-preventive preparation for delivery.

In the organization of monitoring pregnant women in the village, as in the city, patronage work is very important. Patronage of pregnant and gynecological patients is an element of the active dispensary method.

In addition, a child under one year of age should be examined by a pediatrician at the FAP at least once a month.

The midwife's health work is strictly planned. The plan provides for visiting days of villages and villages. In the special notebook is kept account of the patronage work, all visits of women and children are recorded. All the advice and recommendations of the midwife makes a copy of the work at the home of the visiting nurse( patronage leaf) for subsequent verification of their performance.

A paramedic and midwife are required to have a list of women on their site who are subject to preventive and periodic examinations.

Practically healthy women with a successful obstetrical anamnesis, a normal course of pregnancy between the brigade's exits are observed at the FAP midwife or district hospital, they are sent for delivery to the nearest district or district hospital.

With a group of women who are contraindicated in pregnancy, obstetrician-gynecologist and midwife talk about the dangers of pregnancy for their health, possible complications of pregnancy and childbirth, teach them to use contraceptives, recommend intrauterine contraceptives.

In normal pregnancy, a healthy woman is recommended to visit a consultation with all the analyzes and conclusions of doctors 7-10 days after the first treatment, and then visit the doctor in the first half of pregnancy 1 time per month, after 20 weeks of pregnancy - 2 times a month, after 32weeks - 3-4 times a month. With a woman's disease or a pathological pregnancy that does not require hospitalization, the frequency of the examinations is determined by the doctor individually. It is important that pregnant women carefully visit the consultation during the period of prenatal leave.

Very important in the work of a midwife FAP is the timely hospitalization of pregnant women in medical hospitals with the appearance of initial signs of a deviation from the normal course of pregnancy, as well as women with a history of obstetric anamnesis. Prenatal hospitalization in medical hospitals is subject to pregnant women with a narrow pelvis( with an external conjugate less than 19 cm), abnormal fetal position and pelvic presentation, immunological incompatibility of mother and fetus blood( including in anamnesis), extragenital diseases, with bloody discharge from the genital tract, edema, the presence of protein in the urine, increased blood pressure, excessive weight gain, with the establishment of multiple pregnancies, as well as other diseases and complications that threaten the healthAn overview of a woman or a child.

At the feldsher-midwife point, only normal( uncomplicated) births are provided. In those cases when a complication arises in childbirth( which can not always be foreseen), the FAP midwife should immediately call the doctor or, if possible, deliver the woman in the hospital to the hospital. In this case, it is very important to decide on the means of transportation. It must be remembered that women with permanent seizure, preeclampsia and eclampsia, and with a threatening rupture of the uterus can not be transported. If a woman with an unseparated afterbirth needs to be transported in connection with any complications of pregnancy, the midwife of the FAP must first of all make a manual separation of the afterbirth and, with a contracted uterus, transport the woman. If it is not possible to provide the woman with the necessary assistance to such an extent that she is able to be transportable, she should be called to see a doctor and plan a plan for further action.

Midwife FAP is obliged to carry out patronage of children, especially the first three years of life. At the same time, it is necessary to observe the multiplicity of observations of children of the first year of life by the midwife( paramedic) of the FAP:

• 1 st month of life - supervision at home only 5 times;

• 2nd month of life - home surveillance 3 times;

• 3-5th months of life - supervision at home 2 times a month;

• 6-12th months of life - supervision at home once a month.

Providing emergency first aid to a pregnant woman and giving birth to a woman, the FAP midwife has the right to perform the following obstetric surgeries and benefits: turning the fetus to a pedicle with full opening of the uterine throat and whole or freshly drained water, extraction of the fetus behind the pelvic end, manual detachment, manual examination of the cavityuterus, restoration of the integrity of the perineum( after rupture of the perineum or perineotomy).When bleeding in the early postpartum period, the midwife should exclude the rupture of the tissues of the birth canal. The complications that arise during the delivery, require midwives, in addition to an urgent call of a doctor, clear actions of an organizational nature, on which the outcome of birth largely depends. The midwife must fully master the primary methods of resuscitation of newborns born in asphyxia.

It is very important in the work of the midwife FAP to carry out careful documentation. For each pregnant woman applying to the FAP, the "Individual card of the pregnant woman"( f-111 / y) is filled. When identifying obstetric complications or extragenital diseases, a duplicate of this card is filled, which is transmitted to the district obstetrician-gynecologist.

For each woman in labor, the "History of Childbirth" is filled( f-099 / y).All women who gave birth in the FAP are registered in the birth register( f-098 / y).In addition to these documents, a diary-notebook of pregnant women's records( f-075 / y) and a diary( f-039-l / y) are kept at the FAP.

When you send a pregnant woman( after 28 weeks of pregnancy) or a puerperum to a doctor's midwifery hospital, she receives an "Exchange card"( registration form No. 113).

If a pregnant woman is hospitalized before 28 weeks, she is given an extract from her medical history( registration form No. 27).When she is discharged from the hospital, she receives an extract from the medical history that she receives from the FAP midwife.

An important part in the work of midwife feldshersko-obstetric point is the organization and conduct of preventive examinations of women. Preventive examinations of rural women are desirable to be carried out in the autumn-winter period, so that before the beginning of spring field work, finish the treatment of the identified patients.

All the work on the organization of preventive examinations is supervised by the district obstetrician-gynecologist and the chief midwife of the district. Preliminary the plan of carrying out of examinations in which the place where inspection will be carried out, calendar terms of inspections on each settlement is specified. Preventive examinations are carried out by midwives of FAP who have undergone special training and instruction. For the successful carrying out of a preventive examination, the midwife must first make a household detour, the tasks of which are to explain to women the purpose of the examination, the method of carrying it out, the place of examination, etc.

The purpose of preventive examinations is early detection of pre-tumor, tumor, inflammatory and so-called functional diseases of sexual organs in womenspheres and the appointment, if necessary, of appropriate treatment. Preventive examinations also provide an opportunity to identify among the organized part of the female population the manifestations of occupational hazards that affect the organs of the sexual sphere, and work out measures for their elimination.

Immediate examination of women consists of two sequential procedures: first, examination of the external genitalia, vagina and vaginal part of the cervix( using mirrors), and secondly, two-hand studies to determine the state of internal genitalia.

During preventive examinations, objective diagnostic methods are used: cytological examination of the vaginal discharge, "prints" from the cervix, colposcopic examination.

For carrying out laboratory tests, the material is taken from various parts of the urogenital apparatus of the woman:

• smears from the urethra and cervical canal for bacteriological examination on the gonococci of Neisser and the flora. The material obtained from the urethra is applied to the slide in the form of a circle, and from the cervical canal - in the form of a stroke in the longitudinal direction;

• A smear from the posterior vaginal fornix to determine the degree of purity of the vaginal contents is taken after the insertion of the mirrors and using a stick with a wound cotton wool. The smear is applied to the slide in the longitudinal direction in the form of a stroke;

• Smear from the side wall of the vagina for hormonal cytodiagnostics is also taken after the introduction of mirrors and with the help of a stick with a wound wool wrapped on its end. The smear is applied in the form of a stroke along the glass;

• a smear-scraping from the surface of erosion of the cervix is ​​obtained with a spatula and streaked across the slide;

• a smear-scraping from the cervical canal is taken with a Volkmann spoon and applied to the glass in the form of a circle( or several circles).

At the slightest suspicion of the presence of the disease a woman should be immediately referred to a doctor.

In the conduct of preventive examinations, it is very important to carefully register and record all examined women, for which a list of persons subject to a targeted medical examination for identification( f-048 / y) is provided. .

For registration and registration of women subject to active dispensary follow-up onthey have control cards for dispensary follow-up( f-030 / y).

In the work of the obstetrical and gynecological service in rural areas, occupational safety issues for agricultural workers occupy a large part in all its stages. Agricultural works have their own characteristics, the most important of which are seasonality, the performance of various production operations in a short time in any weather conditions, etc. This requires a lot of effort and strain from the person, which inevitably leads to violations of the working and rest regime. Workers of agricultural production experience additional adverse effects of such production factors as noise, vibration, dust, contact with pesticides( pesticides) and mineral fertilizers. The main work on implementing measures aimed at protecting the work of rural residents is performed by hygienists. However, obstetric-gynecological service should participate in this work, as unfavorable production factors have a negative impact on the specific functions of the female body.

Before midwives in rural areas, the task is to educate women about the negative attitude towards abortion as an operation that can cause trauma, which often entails gynecological and other diseases. In addition, for older women in the presence of Rh-negative blood factor, signs of uterine infantilism( a small underdeveloped uterus), it is necessary to explain especially urgently the importance of maintaining the first pregnancy.

The question of modern means of contraception, the features of their action, their effective application is of great importance in the prevention of abortions. It is necessary to explain what means are the most effective and harmless, and to warn against the use of harmful and ineffective means and methods. When conducting interviews midwife FAP should identify the following groups of women: those who want to interrupt pregnancy;who came to the consultation after the abortion;puerperas after discharge from the obstetric hospital;applied for preventive examination;who enter into marriage.

Special attention is paid to the use of oral contraceptives, since, if properly administered, they are among the most effective. Hormonal contraceptives are synthetic analogues of female sex hormones-estrogens and progesterone and their derivatives. When they are introduced into the body of a woman, a state of pregnancy is created, the so-called pseudopregnancy, which ensures sterility. The main mechanism for ensuring sterility with oral contraceptives is to suppress them by ovulation, i. E.maturation and release of a mature egg from the ovary.

However, when taking oral contraceptives, there are also undesirable phenomena in the form of breast tenderness, an increase in body weight of not more than 2 kg, headaches( migraine), vaginal discharge, menstrual irregularities, and occasional spontaneous bleeding or intermenstrual uterine bleeding. Contraindications to taking hormonal contraceptives are: breast cancer;all kinds of cancers of the reproductive organs;impaired liver function;recent liver disease or jaundice;deep vein thrombosis;pulmonary embolism;trauma of blood vessels of the brain;rheumatic heart disease;phlebeurysm;cardiovascular diseases, including hypertension and diabetes with complications( in history or in the form of clinical manifestations);undiagnosed abnormal uterine bleeding;congenital hyperlipidemia. As contraindications, age over 40 must be considered;Smoking and age over 35;in an anamnesis acute preeclampsia of pregnancy;in nulliparous women - rare, irregular menstruation, amenorrhoea, later menarche;lactation lasting less than 6 months;planned surgical operation;bouts of depression. Consider the following diseases: mild hypertension( diastolic pressure above 90, but below 105 mm Hg);chronic kidney disease,

Midwife should explain to women positive aspects when taking hormonal contraceptives:

• alleviation of premenstrual tension;

• Beneficial effect on women with irregular menstrual cycles, which becomes more regular, and menstrual bleeding often decreases;there is information about the improvement of the condition of women suffering from iron deficiency anemia;

• Reduction of the risk of pelvic inflammatory disease among women who use oral contraceptives;

• improvement of the condition in diseases of sebaceous glands - acne and acne pass;

• mid-cycle pain relief;

• protective action against rheumatoid arthritis;

• may be a decrease or increase in libido;

• protective action against the development of benign breast tumors.

not accompanied by hypertension;epilepsy;migraine;diabetes mellitus without complications from the vessels;diseases of the gallbladder.

Another effective method of preventing pregnancy is intrauterine contraception, which is based on the introduction into the uterine cavity of an intrauterine device that prevents pregnancy.

The mechanism of contraceptive action of the IUD consists in impaired implantation of a fertilized egg, accelerated migration of the latter, as a result of which it prematurely enters the uterine cavity, when the endometrium is not yet prepared for implantation;influence of drug IUDs on the endometrium. In this case, a process of the type of chronic endometritis with the phenomena of local atrophy of the endometrium, edema of it, increased vascularization and, possibly, disturbances of hormonal secretion arises in the endometrium.

Before the introduction of the IUD, the midwife should collect tools and accessories;to instruct women and provide them with the information they need;collect anamnestic data by filling in the questionnaire;calm the woman, and also make sure that she is fully aware of the importance of the IUD, including the advantages and disadvantages of the method, understands the procedure for the introduction of the IUD and the need for dispensary follow-up while wearing the IUD.After the introduction of the IUD, a woman should be examined for the first time in 1 month, then 3 months later. In the future, a woman should attend a consultation at an interval of 6 months, being on examination during the period between menstruation.

Women before intrauterine contraception are given a bacterioscopic examination of smears from the cervical canal, vagina and urethra on the flora and the degree of purity, a clinical blood test, according to the indications - urinalysis. IUDs are administered only at normal hemogram parameters, I-II degree of purity of vaginal contents.

IUD is administered on the 5th-7th day of the menstrual cycle, immediately after uncomplicated abortion or 4-6 months after uncomplicated birth. Sometimes the administration of the IUD on the 5th-6th day after uncomplicated births is permissible provided that the postpartum period is normal.

Introduction of the IUD to women who have been treated for inflammatory diseases of the uterus and appendages is possible only after 6-10 months in the absence of aggravation of the process.

Contraindications to the introduction of the Navy

The following types of IUDs are distinguished:

• non-medicamentous( Lunneca loop, Margulis spiral, double helix);

• medicamentous( basic) - copper-containing( T-C 200, etc.) and means releasing hormones.

1. Acute, subacute and chronic with frequent exacerbations of inflammatory diseases of female genital organs, including inflammatory diseases of the cervix.

2. Presence of a pregnancy or at least a suspicion of it.

3. Infectious-septic diseases and febrile condition of any etiology.

4. Isthmic-cervical insufficiency.

5. A septic( or infected) miscarriage in an anamnesis for 3 months before the proposed introduction of IUD.

6. Postpartum infection of the pelvic organs within 3 months before the proposed introduction of the IUD.

7. Benign tumors and neoplasms of female genital organs.

8. Polyposis of the cervical canal, leukoplakia, erosion of the cervix.

9. Polyposis, endometrial hyperplasia.

10. Tuberculosis of the genitals.

11. Violations of the menstrual cycle( meno-, metrorrhagia).

12. Anemia.

13. Violations of the blood coagulation system( diathesis, thrombocytopathy, etc.).

14. Congenital or acquired abnormalities of the uterus( fibromatous submucous nodes), incompatible with the design or shape of the IUD, the size of the uterine cavity, not corresponding to the size and shape of the IUD.

15. Stenosis or obstruction of cervical canal passages( perforation hazard).

16. Dysmenorrhea or menorrhagia with loss of ability to work( in the anamnesis) - for hormone-containing IUDs.

17. Repeated expulsions of the IUD( especially large size).

18. Allergy to substances released by the IUS( copper, antifibrinolytic agents, hormones, etc.).19. Absence of a birth in the anamnesis.

Observations of women using the IUD.Immediately after the introduction of the IUD, there may be dizziness, weakness, nausea, pain in the lower abdomen. In such cases, rest is advisable, the administration of analgesics, antispasmodics, inhalation of ammonia vapors. After the introduction of the IUD, there may be minor bleeding within 3-5 days or pain in the lower abdomen of a pulling nature that does not require specific therapy. It is necessary to have sexual abstinence within the first 7-10 days after the administration of the IUD.

The maximum period of IUD stay in the uterine cavity should not exceed 4 years, as with prolonged use the property of the material from which the IUD is made changes;decreases its contraceptive ability. Indication for the removal of IUD: prolonged pain, spotting like menopause or metrorrhagia, exacerbation of the inflammatory process in the genitals, partial expulsion of the IUD, the desire of a woman to have a pregnancy, the expiration of the period of use of the IUD.

Positive aspects of the IUD are their high efficiency, duration of use, the possibility of removal at any time, the admissibility of use during the breastfeeding period, the absence of unwanted feelings during sexual intercourse.