Download (LDH) in serum and amniotic fluid. When prolonged pregnancy

MINISTRY OF PUBLIC HEALTH OF THE REPUBLIC OF UZBEKISTAN
DEVELOPMENT CENTRE OF MEDICAL EDUCATION
TASHKENT MEDICAL ACADEMY
«Affirms»
Prorector for educational work
Tashkent medical Akademy
Prof. Teshayev O.R.
THE MANUAL
ON THE PRACTICAL TRAINING OF PHYSIOLOGICAL OBSTETRICS
FORMED BY INTEGRATED METHODOLOGICAL SYSTEM
The manual
for teachers and students of the medical universities
Tashkent-2012
1
Edited by Head of the Department of Obstetrics and Gynecology, Professor TMA
Ayupova F.M and associate professor Shukurova FI
Compiled by:
Zhabbarova JK Professor of Obstetrics and Gynecology, TMA
Babazhanova GS - Professor, Department of Obstetrics and Gynecology, TMA
Bekbaulieva GN - MD, assistant professor of obstetrics and gynecology TMA
Nigmatova GM - MD, assistant professor of obstetrics and gynecology TMA
Abdullayev LM - MD, assistant professor of obstetrics and gynecology TMA
Saidzhalilova DD - MD, assistant professor of obstetrics and gynecology TMA
Ayupova DA - MD-ass. Department of Obstetrics and Gynecology, TMA
Khodjaeva DN - K.m.n., Ass. Department of Obstetrics and Gynecology, TMA
Sherbaeva DB - Ass. Department of Obstetrics and Gynecology, TMA
Muminova ZA - Ass. Department of Obstetrics and Gynecology, TMA
Reviewed by:
1. Nazhmutdinova DK-zav.kaf.akusherstva and gynecology GP TMA, MD, PhD
2. Sultans SN-Director of the Center for Practical A and D MH RU, MD, PhD
The manual was approved:
at a meeting of SSC TMA Minutes № 10 of June 6, 2008
Approved at the meeting of the Academic Council of TMA
Minutes № 12 of 25 June 2008
Scientific Secretary Ph.D., Professor G.S.Rahimbaeva
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INTRODUCTION
Currently, Uzbekistan is a new system of education, focused on entry into the world educational
space. Processes that use this accompanied by significant changes in educational theory and
practice of educational work: a transition to advanced innovative educational technology, the
widespread use of interactive teaching methods. Continues to work to improve the educational
and methodological skills teachers of the university. In this regard, each HIGH SCHOOL be
science-based regulatory model of learning that will ensure the integrity of the fundamental disciplines and profiling fundamentilizatsii profile. It is such a common technical system (EMS) of
the university as a whole and each department separately. Under the EMC implied normative
model design and implementation of the educational process, theoretically justified under postavlennymee objectives, principles, functions, and special logic and didactic training sessions
parameters (both lecture and practical). EMC objectives are: unification prepodova-Niiya, decrease dependence on experience and talent of the teacher, improving the value and share of the
individual work of students, strengthening the policy of intensification and the computerization
of the educational process, the development of creative abilities of students. Teaching science a
widely established that the learning process can not be constructed scientifically and efficiently,
while psycho-educational laws have not been translated into the language of the rules and criteria for the organization of the learning process. EMC is an educational technology, directing the
activities of each a tutor for optimal achievement of goals. General principles for the development of EMC determine specific training, is a basic element of the educational and methodical
control mechanism, being dynamic, ie constantly developed and specified. Along with this, in
recent years in healthcare, in particular, the scope of the Services Maternal and Child Health to
implement national guidance on good prenatal care and care, as well as assistance for complications in pregnancy and childbirth, based on evidence and recommendations WHO. There was a
need to introduce into the learning process of new principles and guidelines for the care of the
mother and child. To this end, the department staff prepared this teaching aid.
The manual is intended for students and teachers of the copper-IV courses tsinsih universities.
CONTENTS
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Introduction ………………………………………………............................................................
Fundamentals of perinatal care. Diagnosis of early and late pregnancy. Physiological changes in
women during pregnancy. Recommended procedures planned inspection pregnant. Principles of
SVP and family health centers, the organization of medical care for pregnant women in urban
and rural areas. Foundations of a new model of prenatal care. Assessment and monitoring of fetal
growth. Screening for fetal malformations. SVP role in the prevention of obstetric complications.
Preparing for the birth partner. School……………………………………………………………..
The organization and structure of the obstetrics-hundred tsionara. Principles of safe motherhood.
Modern views on the prevention of nosocomial infection. Clinical anatomy of the female genital
organs. The birth canal, the fetus as an object of labor ....................................................................
Childbirth. Stages of labor. Partnership delivery. Keeping partograph and its importance in the
prevention of complications during childbirth. Active management of the three stage of labor.
Assessment of neonatal Apgar scores. International criteria of live birth (CIM). Biomechanism
birth at the front as the occipital presentation. Primary treatment………………………………….
Physiological postpartum. Physiological neonatal period. 10 principles of breastfeeding. Rooming-in of mother and child. Caring for baby jelly Zami ..........................................................
Breech. External cephalic fetus in breech presentation. Biomechanism birth. Lovseta techniques
and Maurice-Smale-Veit ...................................................................................................................
Nausea and vomiting of pregnancy. Etiology, classification, clinic………………………………..
Hypertensive states in pregnancy. The definition and classification, pathophysiology, signs and
symptoms, diagnostic methods. Pre-eclampsia, the problems for the mother and fetus, diagnosis,
treatment. Obstetric tactics. Emergency treatment for severe……………………………………...
During pregnancy, birth and the postnatal period with kidney disease and anemia. Asymptomatic
bacteriuria ........................................................................................................................................
The role of the Rh factor in obstetrics. Pathophysiology isoimmunization. Re-moliticheskaya
disease of the fetus and newborn. Jaundice of the newborn, diagnosis and treatment. Indications
and techniques………………………………………………………………………………………
Miscarriage, premature labor, prelabour rupture of membranes: causes, diagnosis, management
tactics perenashivanie pregnancy, induction of labor: indications, methods ....................................
Fetoplacental insufficiency syndrome, fetal growth retardation, emergency conditions and problems of the fruit .........................................................................................................................
Topic: Fundamentals of perinatal care. Diagnosis of early and late pregnancy. Physiological changes in women during pregnancy. Recommended procedures planned inspection
4
pregnant. Principles of SVP and family health centers, the organization of medical care for
pregnant women in urban and rural areas. Foundations of a new model of prenatal care.
Assessment and monitoring of fetal growth. Screening for fetal malformations. SVP role in
the prevention of obstetric complications. Preparing for the birth partner. School of motherhood
1st place of training, equipping,
 Department of Obstetrics and Gynecology, the audience;
 dummy pelvis, female pelvis, doll fetus;
 standard models of pregnancy;
 the classic model of labor;
 gynecologic simulator ZOE;
 childbirth simulator Noelle;
 simulator newborn Newborn;
 set of slides on the topics of discipline;
 practices in small groups: a method of "round table", resolution of problems, "pen in the middle of the table", "swarm", etc.;
 testing and teaching practical skills in OSKE (objective structured clinical examination).
 video, TV, TV;
 personal computer (Pentium-III-IV);
 set of slides with typical conditions for ultrasound scanning of pregnant women and gynecologic patients;
 set of video blogs "VJOG" (USA), highlighting recent advances in diagnosis and treatment of
obstetric and gynecological conditions;
 set of movies and video with a demonstration of typical obstetric and gynecological procedures;
 educational films: "Ultrasound pregnancy. Child-person number one ";
 educational software;
 multi media training and testing;
 the use of e-mail and INTERNET;
 business simulations and case studies;
 center for training in practical skills
 offices and laboratories maternity complex
 tazomera, measuring tape, stethoscope.
 kardiotokogramm options;
 ultrasound images of the uterus at different stages of pregnancy;
2. Duration of study subjects
Number of hours - 5
3. Purpose of the lesson
 teach knowledge, skills, antenatal care of pregnant to low-risk, identification (Recognition) of
pregnancy with a high risk;
 to demonstrate and teach the special methods of investigation (examination, measurement of
abdominal circumference, height of uterus, the size of the fetus and the pelvis, external obstetric
research techniques, auscultation, two-hand bryushnostenochnoe vaginal examination);
 to give an idea about the assessment of the fetus;
 Introduction to interview with the obstetric history;
 familiarization with special and additional methods
 research;
 form a notion of the principles of hygiene pregnant;
 form a concept of physiological training psychoprophylactic
 pregnant women for childbirth, based on knowledge of physiological changes
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 in the body during pregnancy;
 inform and educate the definition of pregnancy at early and late stages of pregnancy;
Tasks
The student should know:
 the importance of prenatal care, prenatal care purposes;
 the basic principles of prenatal care based on the best evidence;
 what tests should be performed during the pre-natal care;
 new schedule clinic visits a pregnant woman;
 recommended procedures planned inspection pregnant;
 on screening for fetal malformations;
 the definition of obstetric risk;
 based on what methods of fetal assessment;
 the role of prenatal care in the prevention of obstetric complications;
The student should be able to:
Diagnose pregnancy, conduct scheduled inspection pregnant, monitor fetal growth, counting fetal movements, be gravidogrammu, give advice on nutrition and care for pregnant women,
prophylactic administration of folate, iron and iodine, to prepare pregnant women for childbirth
partnerships, conduct an external examination of the pregnant uterus by Leapolda -Levitsky, vulva, fetal heart auscultation, palpation of the fruit, to determine the approximate weight of the
fruit.
4. Motivation
Teaching students the basics of obstetrics and gynecology based knowledge acquired in previous
courses, the principles of survey pregnancy and childbirth, gynecological patients, the prevention
and primary care, diagnostic, emergency conditions, the most common in obstetric and gynecologic practice.
The study of this subject is necessary in order to allow students to focus on further studying the
course in Obstetrics and Gynecology, without the knowledge of the topic, they can not master
the future course of obstetrics and gynecology.
5. Intra and interdisciplinary communication
To successfully study subjects students must have a good level of knowledge in the following
subjects: normal and topographic anatomy, physiology, pathophysiology, histology, pathology,
microbiology, epidemiology, therapy and surgery, anesthesiology and critical care medicine,
dermatology, clinical pharmacology, endocrinology, childhood illnesses. Acquired during the
course knowledge will be used during the passage of cycles in endocrinology, internal medicine,
surgery, pathological obstetrics, gynecology, health, pediatrics, etc.
6.Soderzhanie classes
6.1. The theoretical part
There are two models of perinatal care.
Traditional:
 Mother and child are seen as patients;
 Different stages of labor are held in different areas;
 Child care is carried out in a private room;
 forbidden to visit relatives;
 Fathers only inform on the progress of labor.
Family oriented:
 Mother, baby and health workers - members of a team;
 Births from beginning to end are in the same room;
 Caring for mother and child are in the same room;
 The relatives are involved in the care of mother and child;
 father was involved in labor.
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Appropriate technology in perinatal care
 The role of women in all major decisions;
 Gravidogramma used during pregnancy and partograph - childbirth;
 Partner is allowed to be in the delivery room;
 Free choice of birthing positions;
 Exception unreasonable procedures;
 Early and unlimited contact "skin to skin";
 Prevention of hypothermia newborn;
 Effective neonatal resuscitation;
 Breastfeeding on demand and being together;
 Proper hand washing medical staff as the best way to prevent infection;
 The rational use of medicines.
Principles of effective perinatal care
Pregnancy should not be considered as a disease, birth should not be a problem, and newborns ill;
More than 85% of all pregnancies do not need an intervention on the part of physicians, therefore, a simple observation, emotional and psychological support should be considered normal
care
Mother and father in nature should take care of the newborn.
Appropriate perinatal technologies
Include not only the new efficient technologies, but also avoiding unnecessary and sometimes
harmful interventions such as routine catheterization, the ice on the lower abdomen, routine antenatal examination (screening), enema, shaving crotch episiotomy unreasonable, irrational use
of antibiotics, prevention, etc.
Foundations of a new model of antenatal care, developed by WHO
 Four quality of clinic visits HN enough to ensure a good perinatal outcome. Greater number of
clinic visits did not increase the quality of care.
 Many women do not want to attend a family clinic more often than necessary.
 frequent visits of clinic lead to waste of scarce resources that could be used more efficiently.
 During pregnancy, women often lead midwife or tera-pevt, not professional, and it has no effect on perinatal outcome.
Prenatal care
The goal of prenatal care:
 health of a child;
 provide support and assistance for a pregnant woman and her partner or family, in the development of parental roles;
 This means that health care providers should not only provide care, but also to educate.
The role of health professionals in the SVP and family health centers.
 To take measures to promote health and prevent disease;
 To provide the necessary treatment;
 To act in concert with other health professionals, for example, to provide specialized care and
antenatal education;
 To teach skills woman worries about her health;
 To be a supportive person: listen to the needs of women and to discuss any anxieties that she
or her family feels about the pregnancy, childbirth or the postpartum period.
Recommended procedures planned inspection
 Measurement of blood pressure;
 Analysis of the urine;
 Dynamic measurement of standing height uterus;
 Inspection of feet to diagnose varicose veins and edema;
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 Determination of Rh factor;
 Blood tests (blood, hemoglobin);
 A one-time ultrasound (18-20 weeks) to determine the possible fetal distress;
 Identification of body mass index (BMI) during the first visit;
 Monitoring of fetal growth.
During each visit clinics for pregnant women should be offered an assessment of the size of the
fruit to reveal too little or too much fruit for gestational age. Height standing uterus should be
measured and marked on gravidogramme every visit of clinic.
Recommended survey
 blood group and Rh - accessory partners;
 for infections: HIV, syphilis, toxoplasmosis, hepatitis B and C, measles, tuberculosis;
 in detecting extragenital pathology - referral to specialized professionals;
 the presence of genetic risk factors for disease - the direction of genetic counseling and testing
parental couple.
Poll pregnant by the definite plan. Carefully and correctly collected history plays an important role in identifying the conditions threaten the health of women and their children, disease
and so-called risk factors. You must specify the social, domestic, manufacturing conditions, genetic factors (inbreeding and its consequences, stillbirths), occupational hazards and habits, etc.
1. Should pay attention to the woman's age.
In young primiparous under 18 and over 30, as well as older women often have complications of
pregnancy and childbirth than women ¬ schinami average reproductive age.
2. Past illnesses as rickets, tuberculosis ¬ les bone osteomyelitis, childhood infectious diseases ¬
tion, gynecological diseases, diseases of the internal organs and systems, as well as hereditary
illness (mental, diseases of the blood), veneriches ¬ Kieu diseases such as gonorrhea, syphilis,
AIDS, and others, bad habits (smoking), hard physical labor and harmful production factors (vibration, noise, chemicals, rays, can have an impact on treatment and research ¬ course of pregnancy and childbirth.
3. Menstrual function largely determines the health of women. Should find out the time of establishment of menarche, duration, type of menstruation, a violation of its cyclical due to sexual
life. It is important to specify the date of the last menstrual period.
4. Sex life: at what age, the use of contraceptives.
5. Obstetrical history includes data on detorod ¬ tion functions. We need to find the number of
pregnancies and births ¬ children, course and outcome of previous pregnancies ¬ children, birth,
blood transfusion, surgical vmeshatelst ¬ va childbirth, during the postpartum period, the fate of
children born (alive, stillbirths, deaths).
6. Should pay attention to during the present ¬ ing pregnancy, presence of edema, vomiting,
headache, abdominal pain, dyspnea, salivation, etc., access to a doctor, prenatal visits, treatment
of these conditions.
Objective methods of examination.
1. Inspection: skin, mucous visible, build, height, weight, muscles, especially abdominal subcutaneous fat layer, the scars of pregnancy, swelling, varicose veins, etc.
2. The study of the cardiovascular, respiratory, digestive, urinary and other systems on conventional methods, including blood tests, urine tests, and other biochemical, hardware research
methods indicated.
Special obstetric examination consists
of outer and inner midwifery research.
Measurement and palpation zhivota.Naruzhnye obstetric examination methods preg ¬ ables are:
1. Inspection
2. The measurement of the pelvis
3. Obstetric external devices
4. Listening to the heartbeat of the fetus.
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Inspection allows the doctor to get the data, which may affect the future management of pregnancy and childbirth. Thus, the small size or too large size women, flabby belly or spiky give
reason to her presence of a narrow pelvis. The change in shape of the pelvis indicates skeletal
structure, symmetry, spinal curvature ¬ nick, kyphosis, scoliosis, etc. Changing the shape of
lumbar ¬ tion of the diamond indicates the deformation of the pelvis. On examination, pay attention to the color of the skin, edema ¬ ki, form the abdomen, breasts, development, pigmentation
of the areola, nipple shape, sensitivity to, the allocation of colostrum. After the inspection is
made from ¬ measurement of abdominal circumference and height of standing uterus measuring
tape to determine the length of gestation. Then at-stepping to the definition of size ¬ ditch large
pelvis size output, the angle of inclination of the pelvis, the index Solovyov.
Palpation - the main method of external obstetric examination. It is performed in the supine
position with the legs bent at the hip and knee joints, reducing muscle tension of the abdominal
wall.
Palpation of the abdomen to begin determining the state of the elasticity of the abdominal
wall. (Divergence muscle hernia). Then determine the amount of the uterus, its functional state
(tone). Establishing the presence of pregnancy is extremely important, as op ¬ mined timely appropriate counseling and management of patients. Determined ¬ tion of pregnancy is important
not only for women of reproductive age, and menopause in women, the girls before the menarche, when irregular menstruation or in their absence does not exclude the possibility of the onset
of pregnancy.
Early diagnosis of pregnancy is very important not only for midwives and gynecologists-ditch,
but also for doctors of various specialties, as mountain monalnye, physiological and anatomical
changes that accompany-ing pregnancy can significantly affect the course of extragenital diseases
Diagnosis of pregnancy, especially in the early stages, sometimes representing ¬ it possible difficulties. Some endocrine disorders, stress ¬ raw, as well as receiving pharmacological agents can
mimic with ¬ standing of pregnancy, deceiving, and being a woman, and the doctor.
In connection with the pregnancy there is a reorganization of functions of all organs and systems
of women, which affects the well-being (subjective) and is accompanied by objectively determinable changes.
The most typical symptoms of pregnancy can be znachimos ¬ ty to diagnose divided into three
groups: questionable, probable and credible.
The most reliable and widely used method for diagnosis of pregnancy is rapid laboratory diagnosis or the presence of human chorionic gonadotropin (hCG) in the urine of women.
Suspected (doubtful) signs of pregnancy. These signs are in ¬ various subjective experiences.
Nausea, vomiting, especially in the morning, change in appetite (averted ¬ tion to meat, fish,
etc.).
Changing the olfactory sensations (aversion to perfume, tobacco smoke ¬ th, etc.).
Dysfunction of the nervous system: malaise, irritability, drowsiness, mood instability, dizziness,
etc.
Pigmentation of the skin on the face, the white line of the abdomen, in the area
nipples, streaking pregnancy frequent urination.
The increase in the abdomen, a feeling of breast engorgement.
Possible signs of pregnancy. This group includes objects against ¬ WIDE attributes defined in
the genitals, breasts, sex ¬ positively biological immunological tests for pregnancy.
Cessation of menstruation (amenorrhea) in healthy women of reproductive age.
Breast enlargement, their intensity, the appearance of colostrum
of the opening on the nipple breast stroke with pressure on
breasts (in primiparous).
Blueness (cyanosis) of the vaginal mucosa and cervical
uterus.
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Change in size, shape and consistency of the uterus.
Of signs indicating the change of form and consistency of the uterus due to pregnancy, the most
important are:
1. Uterine enlargement. Determined from the 5-6th week of pregnancy: the uterus increases in
size, the anteroposterior (sharoob is different), and later - in the cross-section. By the end of the
2nd month of pregnancy, uterine size correspond with the size gu ¬ sinogo eggs at the end of the
third - the bottom of the uterus is at or slightly above the symphysis.
2. Symptom Horwitz - Gegara. Pregnant uterus in the study of mild softening especially pronounced in the Isthmus. Pal ¬ particles of both hands in contact with two-handed study of the
neck with almost no resistance. Feature is characteristic for early pregnancy and clearly defined
in 6-8 weeks from the start of the last menstrual period.
3. Sign Snegirev. For the pregnant uterus is characteristic variability consistency. Soft pregnant
uterus under the influence of mechanical ¬ whom irritation during the two-hand research compacted and shortened. After the cessation of stimulation of the uterus again pur ¬ PETA soft consistency.
4. Sign Piskacheka. For early pregnancy characterized by asymmetry of the uterus due to a
domed protrusion of the right or left of its angle, which corresponds to the site of implantation of
the ovum. As the gestational sac, this asymmetry gradually disappears post ¬
5. Sign Gubareva and Gause. Indicates the ease of mobility of the cervix in early pregnancy,
which is associated with a significant softening of the isthmus.
6. Sign Gentera. Due to the softening of the isthmus in the early stages of pregnancy the uterus
occur bend forward and comb thickening on the anterior surface of the uterus in the midline. ¬
one however is not always determined by the thickening
Possible signs of pregnancy reveals the following:
a) by palpation of the breast and squeezing colostrum;
b) when viewed from the external genital organs and mucosal entry
the vagina;
c) the study of the use of mirrors;
d) by vaginal and abdominal-vaginal-handed
¬ used route.
Inspection of the external genitalia produce a degree ¬ sterile rubber gloves on a gynecological
chair or couch, the woman lies on her back, legs bent at the hip and knee sus ¬ tavah and divorced; enclose roller under the sacrum. Vulva is treated with one of the antiseptic solutions.
Large and small labia and I bred II fingers of his left hand and examine mucosa entrance to the
vagina.
Studies using mirrors.
After the inspection of external genitals and mucous membrane entrance to the vagina begin to
study with vaginal mirrors. This method of research reveals cyanosis of the cervix and vaginal
mucosa, as well as diseases of the cervix and vagina. We can use ¬ vatsya sash and spoonshaped mirrors. Bucket-mirror administered ¬ DYT to the vaginal vault in the closed form, and
then open doors, and the cervix is made available for inspection. Vaginal wall osmate ¬ Riva at
phasing out the mirror from the vagina. After inspection of the cervix and vaginal walls mirrors
removed and proceed to vaginal examination.
Vaginal (digital) research pregnant. Pal ¬ particles left hand pushing the large and small labia,
fingers of the right hand (II and III) inserted into the vagina, I play finger upward, IV and V - are
pressed against the palm, resting in the crotch. Investigate the condition of the muscles of the
pelvic floor, the walls of the vagina (folding, elongation, loosening), vaginal vault, cervix
(length, shape, texture) and the external cervical os (closed, open, round or slit-like shape).
Two-handed (bimanual) study pregnant.
After palpation of the cervix begin to Handed study. Fingers of his left hand gently presses down
on the abdominal wall in the direction of the pelvic cavity towards his right hand, being in the
front vaginal vault. Bringing together the fingers of both the investigated ¬ ing hands, palpate the
10
body of the uterus and determine its position, shape, size and texture, and then proceed to the
study of the fallopian tubes and ovaries. To do this, the fingers of both hands gradually moved
from the corner of the uterus to the side walls of the pelvis. To determine the capacity and shape
of the pelvis examine the inside of the pelvis, sacral dimples, side and pelvic symphysis.
Valid, or unmistakable, signs of pregnancy - are signs that appear in the second half of pregnancy and indicating the presence of the fetus in the uterus.
1.Palpiruyuschiesya the fruit. In the second half of pregnancy with abdominal palpation determined the head, back, and small pieces (finite ¬ sion) of the fetus, the more the pregnancy, the
more palpable the fruit.
2.Yasno audible fetal heart tones. With obstetric
stethoscope fetal heart tones are heard from the beginning of the second
half of pregnancy in the form of rhythmic beats, repetitive 120-140
once a minute. Sometimes it is possible to detect the fetal heartbeat 18-19 weeks of pregnancy.
Register fetal heart rate is possible in
earlier date by echocardiography (48 days after the last menstrual period), and ultrasound (with
5-6 weeks of pregnancy).
3.Dvizheniya fetus felt by a doctor during the examination pregnant.
Fetal movement is usually determined in the second half of pregnancy.
(Sami pregnant women feel fetal movement - primigravida with 20 weeks, and multiparous with
the 18th week, but these feelings to be a reliable sign of pregnancy are not relevant because they
might be wrong - the woman can take for fetal movement bowel movements.)
The most reliable information in the diagnosis of pregnancy produced by ultrasound (U.S.). During transabdominal scans pregnancy can be set from 4-5 weeks, and at transvaginal sonography 1-1.5 weeks. before. in the early diagnosis of pregnancy period is set based on the definition in
the uterus gestational sac, yolk sac, and fetal heart rate, at a later date, by visualization of the fetus (or fetuses in multiple pregnancies).
Pregnancy testing requires a comprehensive examination of the patient: only carefully collected
history, subjective complaints of hearing, making the inspection and palpation of the abdomen,
breasts, a study of external and internal genital organs, the doctor may, by the total amount of
suspected and probable signs of pregnancy diagnosis. In addition, in cases of doubt, specify the
presence of pregnancy with ultrasound (an authentic sign).
Pregnancy diagnosis is accurate even in the presence of only one significant feature.
After the establishment of the existence of pregnancy is necessary to conduct a thorough examination of the patient.
Measurement. In a study of pregnant women, in addition to determining its growth, the structure
of the pelvis (size and shape), it is necessary to measure the circumference ¬ sion abdomen and
uterus height standing. In this case, use tazomera and measuring tape.
Measuring the stomach.
Determine the measuring tape greatest ¬ Shui its circumference at the navel (late pregnancy, it is
typically 90-100 cm). Abdominal circumference greater than 100 cm is usually observed at polyhydramnios, multiple pregnancy, large fruit, transverse fetal position and obesity.
Then measure the height of standing on the bottom of the uterus with a pubic-articulation. In the
last 2-3 weeks of pregnancy, this height is 36-37 cm}, and the beginning of labor, when the bottom of the uterus drops - 34-35 cm
Fundal height standing over symphysis pubis can be determined and taeomerom with which can
also be defined and the size of the fetal head.
Palpation of the abdomen is one of the main methods of obstetric research. It is produced in the
pregnant position on back with legs bent n hip and knee joints. This eliminates the tension of the
abdominal wall and facilitates proshupyvanie abdominal organs, especially the uterus and placed
in her fetus. The doctor sits to the right of the pregnant face her.
Palpation of the abdomen to determine the start and elasticity of the abdominal wall-STI, state
recti (whether their differences hernial protrusion, etc.). Anatomical and functional status espe11
cially abdominal wall plays an important role in the normal course of labor.
Then proceed to the definition of the uterus, its function: the state (tone, the tension in the study,
etc.) and position of the fetus in the uterus.
Figuring position of the fetus in the uterus is critical to the management of pregnancy and childbirth. In the study of pregnant women and mothers chlenoraspolozhenie define, position, position, type, fetal presentation.
Chlenoraspolozhenie fetus (habitus) - the ratio of its extremities to the head and torso. In a typical normal chlenoraspolozhenii body bent, head tilted to the chest, legs bent at the hip and knee
joints and pressed to his stomach, hands crossed on his chest. In normal flexor type chlenoraspolozheniya ovoid shaped fruit with a length at term at an average of 25-26 cm wide part of
the ovoid (pelvic end of the fruit) is located in the bottom of the uterus, the narrow part (neck) is
facing the entrance to the pelvis. Fetal movement lead to a transient change in the position of
limbs, but do not violate the typical chlenoraspolozheniya. Violation of a typical chlenoraspolozheniya (head extension, etc.) occurs in 1-2% of births and complicates their course.
Fetal position (citus) - the ratio of the longitudinal axis of the fetus to the longitudinal axis (dlinniku) of the uterus.
There are the following provisions:
Longitudinal (citus longitudinalis) - longitudinal axis of the fetus and the long axis of the uterus
are the same, the axis of the fruit - the line pro ¬ walking from the neck to the buttocks;
cross (citus transverses) - longitudinal axis of the fetus re ¬ intersects the longitudinal axis of the
uterus at the right angle;
A bundle (citus obliquus) - forms the longitudinal axis of the fetus with the longitudinal axis of
the uterus an acute angle.
The longitudinal position of the fetus is normal, it happens in 99.5% of all births. Transverse and
oblique position pathological, found in 0.5% of deliveries. In transverse and oblique positions
arise mye ¬ insurmountable obstacles for the birth of the fetus.
The position of the fetus (positio) - the ratio of the back, the fetus to the right or left side of the
uterus. There are two positions: first and second. At the first position of the fetus back towards
the left side of the uterus, in the second - to the right. The first position is more common than the
second. What explains the uterus turns left one hundred ¬ Rhone front. The back of the fetus is
not always turned to the right or to the left, it is usually more anteriorly or posteriorly rotated, so
differ ¬ chayut item type.
Item type (visus) - relations ¬ back of the fetus to the front or rear wall of the uterus. If the back
is facing front, govoit ¬ ryat front of a position, if backward - back on form.
Fetal presentation (praesentatio) - the ratio of the larger fetus (head or buttocks) to the entrance
of the pelvis. If the entrance to the pelvis of the mother is the head of the fetus - previa head
when pelvic end - breech presentation. Cephalic presentation meets 96% of births, breech - by
3.5%. In transverse and oblique positions fetal position is not determined on the back and on the
head: the head to the left - the first position to the right - the second position.
Presenting part (pars praevia) the name of that part of the fruit, which is located at the entrance
of paradise in a small basin and the first pass through the birth path.
Cephalic presentation at the entrance of the pelvis can be formed been left out back of the head
(occipital previa), crown (prefrontal), forehead (frontal). face (facial presentation) of the fetus. A
typical presentation occipital (flexion type). When perednegolovnom, frontal and facial previa
head is in varying degrees of extension. Extensor type previa occurs in 1% of the longitudinal
position of the fetus.
Breech the entrance of the mother's pelvis can be turned breech fetus (clear breech presentation),
the legs of the fetus (foot previa), buttocks with legs (mixed-foot Breech presentation).
On palpation the abdomen using the so-called outer with ¬ emami midwifery studies (Leopold
receptions). Leopold (1891) introduced, palpation of the abdomen and offered typical methods
palpation, is universally recognized.
The first reception of external obstetric studies Its purpose - to determine the height of standing
12
uterus and part of the fruit, which is in the bottom. Methodology of the study. Palmar surface of
both hands placed on the uterus so that they are tightly covered bottom with adjacent cross ¬
schimi corner region of the uterus, and the fingers are facing nail Falana ¬ gami together. Most
often at the end of pregnancy (96%) and the bottom of the uterus defined buttocks. Usually distinguish them from the head is easy for a less pronounced roundness and sphericity, less dense
and less smooth surface.
First external appointment midwifery research makes it possible to judge about the pregnancy
(height standing uterus), the position of the fetus (if one of the major parts in the bottom of the
uterus - so a longitudinal position) and the previa (when the uterine fundus buttocks - means the
presenting part is the head).
The second method of external obstetric research ¬ tion Its purpose - to determine the position of
the fetus, which is judged by the location of the back and small fetal parts (handles, legs). Methodology of the study. Hands descend from the bottom of the uterus on the right and left side of
her to the level of the navel and below. Gently pressing his palms and fingers of both hands to
the side walls of the uterus, determine which side is facing the back and small parts of the fruit.
Backrest with recognizable by its wide and curved surfaces. When pressed for a large part of
which is in the bottom of the uterus, in the direction of the womb fetal trunk bends after ¬ result
of which the back becomes more accessible for research. Small parts of the fetus are determined
from the opposite side in the form of small, moving mounds. In multiparous women due to sagging abdominal wall ¬ tion and small muscles of the uterus of the fruit is easily palpated. Sometimes they can be seen by eye movement. Palpable detectable fluctuation in the uterus at large
time steps ¬ abdomen shows polyhydramnios.
By the direction in which the fetus is turned back, recognizes his position: the back of the left the first position, the back of the right - the second position. If this study could feel the movement of small parts of the fruit, it can be assumed that the fetus is alive.
The third receiving external obstetric research. Its purpose - to determine the nature of the presenting part and its rela ¬ solution to the small pelvis. Methodology of the study. One, custom,
hand cover pre-lying part, then carefully make the movement of the hand to the right and the left.
This method allows to determine the nature of the presenting part (head or buttocks), the ratio of
the presenting part to the entrance of the pelvis (if it is mobile, it is located above the entrance to
the pelvis, if at rest, then the entrance to the pelvis or in the deeper parts of the pelvis )
Fourth, receiving external obstetric research ¬ tion. Its purpose - to determine the presenting part
(head or buttocks), finding a place-tion of the presenting part (above the entrance to the pelvis, at
the entrance or deeper, where), what situation predlezhit ¬ schaya head (or to straighten a bent).
Methodology of the study. Researching becomes the face to the feet of preg ¬ variable or mother
and puts her hands flat on either side of the lower part of the uterus. Fingers of both hands facing
the entrance of the basin, it is cautious ¬ pricks slowly penetrates between the presenting part
and sides of the entrance to the pelvis and palpates accessible areas of the presenting part. If the
presenting part is movable over the entrance to the pelvis, the fingers of both hands almost entirely can be subsumed under it, especially with a lot of ¬ parous women. Here is defined as the
presence or absence of symptoms balloting typical of the head. For this brush both hands firmly
pressed against investigating the palmar surface of the lateral parts of the head, then the right
hand make a push in the right half of the head. In this case, the head is pushed to the left and
sends a push opposite - the left hand (simple balloting). After that, be ¬ strictly back to the starting position, the head says sometimes push the right arm (double balloting). With cephalic
presentation should try to get an idea of the size and density of the head of the skull bones, the
location of the neck, forehead and chin, as well as their relationship to each other (the character
prep-tent). With four reception can determine the presence or absence of the angle between the
back and the back of the fetus (the higher the chin with a fixed head at the entrance, the more
pronounced bend and the more flattened the angle between the neck and the back, and vice versa,
the lower jaw is, the stronger straighten head), the position and form of the fruit - by the way
whither the head, forehead, chin. With cephalic presentation, you must also determine how the
13
pelvis is a large segment of his head.
The degree of insertion of the fetal head in the pelvis is recommended gauging follows. Infiltrating outdoor reception at the fourth midwifery studies fingers of both hands in a basin to a deeper
m pushing the head, producing a sliding movement along it toward you, in a high standing of the
fetal head when it is mobile over the entrance, you can bring in external study carried under the
fingers of both hands, and even push it from the entrance. If in this case the fingers apart, the
head is at the entrance to a small segment of the pelvis.
Auscultation.
Auscultation stomach determined fetal heart tones. You can also catch the other sounds coming
from the mother, the beating of the abdominal aorta, which coincide with the pulse of a woman,
"following" uterine noises that occur in the large blood vessels passing in the side walls of the
uterus (the same as the pulse of women); spasmodic bowel sounds .
To audio phenomena emanating from the fruit are heart-HN that fetal umbilical vessels noise,
deaf spasmodic jerky movements of the fetus. Auscultation produce mainly for the determination
of fetal heart tones, which serve as a reliable sign of pregnancy. By listening to the heart sounds
and ascertain the state of the fetus, which is particularly important during labor.
Fetal heart tones stethoscope listening first of the second half of pregnancy (at least from 18-20
weeks), and with each month are distinct. Fetal heart tones are heard in the side of the abdomen,
where the fruit is turned back, closer to the head. Only when previa clearly auscultated fetal heart
from his chest. This is due to the fact that the head is the most personal previa straighten breast
and adjacent to the wall of the uterus closer than back
When the occipital previa heartbeat good listening on the left - at the first position to the right in the second. Breech heart auscultated at or above the belly button. In transverse positions
heartbeat heard at the navel closer to the head of the fetus. A multiple pregnancy fetal heartbeat
usually vyslu ¬ clearly permanently damaged in different parts of the uterus.
During labor, when lowering the fetal head in the pelvis and birth heartbeat better listening closer to the symphysis, almost in the middle line of the abdomen.
The most reliable method to determine the life and death of the fetus is an ultrasound. assessment
of life of the embryo in the earlier period is based on the registration of his heart and motor activity, determination of fetal cardiac activity (heart beating) is possible with 3-4 weeks.
The fetal heart rate in early pregnancy can listen in 100% - after 8 weeks of gestation.
Use other methods to determine the nature of fetal heart tones: phonocardiography and cardiotocography to determine the due date, the first day of your last period was added 280 days, ie 10
obstetric or 9 calendar months. Payment due date, usually easier to produce, from the date of last
menstrual period is counted back three calendar months and add 7 days. For example, if the last
period began on October 2, then count back 3 months (September 2, August 2, and 2 June) and
add 7 days, determine the expected date of birth, July 9, and if your last period started on May
20, the expected delivery date 27 February, etc.
The proposed delivery date can be calculated by ovulation: the first day of the expected, but not
advancing menstruation is counted 14-16 days ago and found to date is added 273-274 days.
In determining the date of birth recorded in the same time of the first fetal movements to the date
of the first stirring of obstetric add 5 months in multiparous and get the expected delivery date.
However, remember that this feature is only of secondary importance.
Preparation for childbirth
Confidentiality and partner support in labor is possible only in the individual delivery room.
Private rooms for labor prevents cross infection.
With the onset of labor, every woman goes to the House, where the baby is born. Therefore
there is no need to use prenatal ward.
Room for labor must be clean, and do not necessarily sterile. After each delivery bed and the
floor should be washed with soap or other suitable detergent.
Room for labor must be well lit to make it convenient to watch the child.
14
Room for labor must be prepared for the partnership delivery. The environment should as
much as possible to resemble the home and provide a sense of comfort (eg, curtains, posters or
decorations on the walls, music, plastic flowers, etc.).
You must also have chairs for relatives.
At every birth must be present qualified medical staff, who owns the necessary skills in particular midwife.
Equipment required for each delivery.
In every room for the birth should be available basic equipment and essential drugs.
Watch with a second hand, are necessary in order to accurately observe the time of birth and
time of the intensive care unit, if it is carried out. The room for the birth should be as devices that
allow mothers to choose the most-zitsiyu for delivery (eg, a beach ball for a relaxing Swedish
wall or horizontal bar, where she can hang, etc.)
Clean the table with a radiant warmer is a must to help the child in warm conditions. Also
required for children hat, socks, warm diapers, blankets, and electronic or mercury thermometer
to measure the temperature of the child.
Warm towels obsushivaniya child warm diapers (in the absence of a cap can cover a baby's
head), equipment for suctioning mucus (catheter or pear), a set of compression / intersection cord
necessary drugs (drugs for resuscitation, vitamin K, an ointment for the treatment eyes), and
equipment for resuscitation (bag and mask sizes) should be prepared in advance and be available
for every birth. Some equipment, such as an incubator or cot heater, optional in every delivery
room, but it will be close.
The use of new educational technologies:
METHOD "hot potato"
The steps are:
1.Predvaritelno teacher prepares questions on the subject (at least 2-3 questions for each student.)
2. Participants sit in a circle.
3. The teacher turns away, and participants begin to quickly communicate to each other by one to
dramatize the "hot potato", so she could not burn your hands.
4. At this time the teacher turns around and says: "STOP."
5. After that, who turns out to be a "hot potato", answers the question of the teacher, and the other participants can add.
6. After the party answers the question, the teacher turns away again and members continue to
quickly communicate to each other down the line had staged a "hot potato", as long as the teacher does not turn and say, "Stop!".
7. Thus, the game lasts as long as the participants did not answer all questions.
6.2. The analytical part of
Case studies:
1. In the clinic turned female 23 years with complaints of nausea. Last period of 5 weeks ago.
The diagnosis? Additional methods of diagnosis?
A: Pregnancy. Analysis for HCG, ultrasound of the uterus
2. In antenatal turned primigravida complained of poor fetal movements. Bottom of the uterus
between the navel and the xiphoid process. Fetal heartbeat muffled rhythmic, feet swelling. The
gestational age 35-36 weeks. Weight gain of 10 kg.
What is the most informative method of investigation in this situation, the?
A: Ultrasound - research.
3. For external obstetric study of pregnant uterine fundus is located midway between the navel
and the xiphoid otrost-com. OJ - 95 cm, WMM - 34 cm longitudinal position of the fetus, II position predlezhat fetal buttocks above the entrance to the pelvis.
Where auscultated fetal heart?
Answer: Right above the navel.
4. For external obstetric study of pregnant uterine fundus is located midway between the navel
and the xiphoid otrost-com. OJ - 92 cm, VDM - 31 cm longitudinal position of the fetus, I posi15
tion predlezhit fetal head above the entrance to the pelvis. Fetal heartbeat clarity tion, rhythmic,
140 beats a minute left below the navel.
What is the expected timing of pregnancy? The estimated weight of the fetus?
A: 32 weeks. 2800,0 ± 200,0
5. New mother is in labor 12 hours. Vaginal examination:
Opening uterine mouth full, no membranes. Predlezhit head occupies the top half of the sacral
cavity and heart. Sagittal suture in the left oblique pelvis, a small soft spot on the right front, a
large - left posteriorly.
What is the position, type, position?
A: longitudinal position, I position, front view.
6.3. Graphic organizer: Making graphic organizer
"Clusters" on "Diagnosis of early and late pregnancy"
(Cluster - beam bunch) way to map the information - gathering ideas around a main factor for
determining the meaning and focus of the assembly. Encourages mainstreaming knowledge
helps freely and openly engage in the thought process of the new association presentation on the
topic.
6.4.Prakticheskaya part
Outside obstetrical examination method Leopold-Levitsky
Purpose: External obstetrical examination method Leopold-Levitsky
Performs step (steps):
Events number does not hold nil
(0 points) Fully
correctly
performed
(20 points)
1. The doctor explains the pregnant woman, it would be delatUkladyvaem pregnant Ku-tice, the
doctor comes back to the right to a pregnant 0 20
2. 1 point - puts both hands palms flat on the pregnant belly and determines the height of standing uterus, as well as part of the fruit of the subject there 0 20
3. 2 reception - both palms hands puts on bo-kam abdomen and determine the type and position
of the fetus 0 20
4. 3 reception - the doctor puts his right hand on the lower segment of the uterus, producing
"balotatsiyu", thereby defining the presenting part of the fetus 0 20
5. 4 Reception - Doctor stands face to the feet of pregnancy, the palms puts on proposed ac-cess
of the fruit, and determines the extent of insertion of the fetal head in the pelvic cavity. If your
fingers between the presenting part of the fetus and the entrance to the basin are not touching
each other, then she went into the pelvic cavity. And if you come in contact, the presenting part
is not yet part of the pelvic cavity. 0 20
Total 0100
7.Formy control of knowledge, skills and abilities
-Oral;
-Written;
Testing;
Solution situational problems;
And demonstration of skills mastered.
8.Kriterii assessment monitoring
№ Progress
Score in% level of students' knowledge
1 96-100% Excellent
"5" full correct answer to the question of the etiology, pathogenesis, classification, clinic, diagnostics, treatment and prevention of this disease. To sum up and make decisions, creative thinking cally, self-analyzes, case studies resolves correctly, with a creative approach, with full justi16
fication of the answer. Actively and creatively involved in interactive games, take the right decisions and summarizes and analyzes. Medical history, partograph fills correctly.
2 91-95% Excellent
"5" full correct answer to the question of the etiology, pathogenesis, classification, clinic, diagnostics, treatment and prevention of this disease. Think creatively, independently is analyzed,
case studies decides correctly, with a creative approach, with full justification of the answer. Actively and creatively involved in interactive games, take the right decision. History of diseases,
partograph fills with 1 grammatical mistake.
3 86-90% Excellent
"5" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis, treatment and prevention of diseases of the covered completely, but have 1-2 errors in the
response. Own analyzes, inaccuracies in the solution B-ation problems, but with the right approach. Actively involved in interactive games, make the right decisions. Medical history, partograph fills with 2-3 grammatical errors.
4 81-85% Good
"4" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis,
treatment and prevention of diseases of the covered completely, but there are 2-3 inaccuracies,
errors. Into practice, understands the essence of the question, says confidently, is a faithful representation. Situational problems solved correctly, but the justification answer sufficiently. Actively involved in interactive games, take the right decision. History of diseases, partograph fills with
2-3 grammatical errors, inaccuracies in the description.
5 76-80% Good
"4" correct but incomplete lighting-set questions. The student knows the etiology, pathogenesis,
classification, clinic of the disease, but not completely disassembled diagnosis, treatment and
prevention of this disease. Understands the issue, says confidently. There is an exact representation. Actively involved in the interactive-tion games. On case studies gives partial solutions.
Medical history, partograph fills with 3-4 grammatical errors, inaccuracies in the description.
6 71-75% Good
"4" correct but incomplete lighting-set questions. The student knows the etiology and pathogenesis of the disease, but not completely disassembled diagnosis, treatment and prevention of this
disease. Understands the issue, says confidently, is a faithful representation. On case studies
gives partial solutions. History of diseases, partograph fills with 3-4 grammatical errors, 3-4 errors in the description.
7 66-70% Satisfactory
"3" right answer half the questions. Student knows the etiology of the disease, but do not pay out
the classification, clinic-tion of the disease, the treatment and fumbles of prevention. Understands the issues ca, says confidently, has the only views on certain issues topic. Situa-tional
problems are solved correctly, but there is no justification of the answer. Medical history, partograph fills with 3-4 grammatical errors, 3-4 errors in the description.
8 61-65% Satisfactory
"3" right answer half the questions. Errors in the etiology, pathogenesis, poorly versed and confused in the treatment and prevention of this disease. Says uncertainly, has the only views on certain issues topic. Making mistakes in solving situational problems. History of diseases and partograph fills with errors.
9 55-60% Satisfactory
"3" error response to half the questions. Student makes an error in the etiology of the diseasedanno, confused and poorly versed in other matters related to the disease. Says uncertainly has a
partial view on the subject. Situational problems solved incorrectly. Medical history and partograph fills with errors.
10 50-54% unsatisfactory-liminary "2" The correct answer to third-represented supplied questions. Student does not know the etiology of the disease, and poorly versed entangled in other
issues related to the disease. C-ation problems are solved with the right approach is wrong. Med17
ical history and partograph fills with errors.
46-49 11% unsatisfactory-liminary "2" right answer quarter supplied-represented issues. Student
does not know the etiology of the disease, and poorly versed entangled in other issues related to
the disease. C-ation problems are solved with the right approach is wrong. Medical history and
partograph fills with errors.
12 41-45% unsatisfactory-liminary "2" Lighting fifth set of issues with bugs. Student does not
know the etiology of this disease, little versed in other matters related to the disease. Gives an
incomplete and partially incorrect answers to questions on the classification of the clinical disease. Situa-tional problems are solved with the right approach is wrong. More than half of the
patient's history and the partograph filled with errors.
13 36-40% unsatisfactory-liminary "2" Lighting 1/10 of the questions at the wrong approach.
Does not know the etiology of the disease, and poorly versed entangled in other issues related to
data-tion of the disease. Gives incomplete and partially incorrect responses to questions on the
classification, climate-ship of the disease. Situa-tional problems are solved with the right approach is wrong. Bole half medical history and partograph fills with gross errors.
14 31-35% unsatisfactory-liminary "2" to the questions not answers. Does not know and does not
understand the other issues relating to this of diseases. Does not know how to fill out and describe the clinical history and the Party of the program.
9. Typical flow chart of lesson
Stages of work, time-name The content of the
Teachers Students
1etap. Introduction to the training session
(5min) 1.1.Soobschaet topic, purpose, and planned training results. Familiar with the plan,
features of the training session.
1.2.Nazyvaet: key categories and concepts from the data subject tion, a list of books for selfstudy
1.3.Soobschaet indicators and criteria of educational work in class
Listen, record,
specify, ask the question.
Stage 2.
Primary
(235 min) 2.1.Provodit updating knowledge through блиц-опроса/вопросно-ответной
forms / brainstorming, etc.
2.2. Consistently describes the steps
on the organization of the educational process according to the structure of practical training.
Meet
Abstracts with ethyl.
Working in groups, will present the results of the group work
Stage 3.
The Final-Resultant-regulating (60 min)
3.1.Delaet opinion on the subject, attention was concentrated on the main students, according
to the importance of the work done for future careers.
3.2. Commends the work of groups (some of students) summarizes vzaimootsenki. Analyzes
and evaluates the degree of achievement of lesson.
3.3. Gives the task for independent work, informing schaet and criteria evaluation. Selfevaluation,
interaction assessment.
Ask the question.
18
Write down the job.
10. Checklists.
1. What are the signs of pregnancy are suspect, probable and reliable?
2. Specify the symptoms associated with changes in the gastrointestinal tract.
3. Which areas are most pronounced when the pigmentation of pregnancy?
4. List the symptoms suggestive of functional disorders of the central nervous system.
5. What is a "band pregnant" or stretch marks?
6. Which group is the termination of pregnancy symptoms Me-syachnyh?
7. What accounts for the softening of the uterus during pregnancy?
8. At what stage of pregnancy the uterus becomes noticeable increase in bimanual study?
9. How does the shape of the uterus when a pregnancy?
10. What is the size of the uterus at eight weeks of pregnancy?
11. What is the sign of Gegara?
12. What is the sign of Piskacheka?
13. What is the sign of Snegireva?
14. To describe the symptom, is to determine when bimanual study comb ridge on the front
of the uterus in the midline?
15. What is the second sign Gentera?
16. What is the value of suspected and probable signs of pregnancy?
17. Which hormone identify biological and immunological responses to pregnancy?
18. Specify methods for the detection of fetal heartbeat.
19. At what stages of pregnancy feel fetal movement?
20. What is the lack of reliable signs of pregnancy?
21. How credible evidence must reveal to diagnose pregnancy?
11. Recommended Reading
Summary:
1. Abramchenko, VV Epidural anesthesia in obstetrics: a guide for physicians / 2006. - 229 p.
2. Abramchenko, VV Pregnancy and delivery of high risk: a guide for physicians / - M. Med.
Inform, 2004. - 400 p.
3. Abramchenko, VV Cesarean section in perinatal medicine: a guide for physicians / 2005. 126.
4. Abramchenko, VV Postoperative intensive care in obstetrics / Literature, 2000. - 88.
5. Abramchenko, VV Pharmacotherapy of preterm labor / 2006. - 448.
6. Abramchenko, VV Purulent-septic infection in obstetrics and gynecological
logii.rukovodstvo / 2005. - 459
7. Abramchenko, VV Postoperative intensive care in obstetrics / - St. Petersburg: Spec. Literature, 2000. - 88.
8. Abramchenko, VV Clinical perinatology / IntelTek, 2004. - 424 p.
9. Ailamazyan, EK Midwifery: a textbook for honey. Universities / 2003 - 528.
10. Topical issues of Obstetrics, Gynecology and Reproductive / Ed. EV KOKHANEVICH.
- Moscow: Triad-X, 2006. - 480.
11. Obstetrics. Ed. GM Savelyeva. - M.: Medicine, 2000. - 816 p.
12. Obstetric and gynecological care: Hands-on. for doctors / Ed. VI Kulakov. - Moscow:
MEDpress, 2000. - 512 p.
13. Obstetrics. Clinical lectures: a manual for schools with a CD / Ed. OV Makarova. - Moscow: GEOTAR Media, 2007. - 640.
14. Obstetrics. Directory of the University of California / Ed. Nisvandera K., A. Evans: Lane.
from English. - M.: Practice, 1999. - 704 p.
15. Barashnev, YI Perinatal neurology / Y. Barashnev. - M.: "Triad - X", 2005. - 670 p.
19
16. Bodyazhina, VI Akushersvo. The manual for the media. prof. Education / VI Bodyazhina. - Rostov-on-Don: Phoenix, 2003. - 480.
17. Resurrection, SL Fetal assessment. CTG. Doplerometriya. Biophysical profile: a manual
for the system of postgraduate medical. Education / SL Resurrection. - Minsk: The Book
House, 2004. - 304.
18. Gazhonova, VE Ultrasound in Gynecology / VE Gazhonova. - Moscow: MEDpressinform, 2005. - 264.
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21. Demidov, VN Pelvic ultrasound in women. Adnexal cysts and benign ovarian tumors: a
practical guide / V. Demidov. - Moscow: Academy of Medical Sciences, 1999, vol. II. - 100
p.
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24. Duda VI Operative obstetrics: a manual / Minsk Interpresservis, Book House, 2002. - 512
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26. Zhilyaev, NI Operative Obstetrics: Ouch. Manual / Kiev 2004. - 468 p.
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29. Clinical recommendations. Obstetrics and Gynecology: scientific publication / Ed. VI
Kulakov. - Moscow: GEOTAR Media, 2006. - 512 p.
30. Clinical lectures on obstetrics and gynecology / Ed. AN Strizhakova etc. - M.: Medicine,
2000. - 379 p.
31. Clinical evaluation of laboratory tests in women: study guide / Moscow Medical and
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33. Kulakov, VI Intensive care in obstetrics and gynecology (efferent methods) / - M: MIA,
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36. Perinatology Basics: A tutorial / Ed. MP Shabalov. - Moscow: MEDpress-inform, 2002. 576 p.
37. Practical skills in obstetrics and gynecology: a manual / LY Suprun, TS Divakova and
others. - Minsk: New Knowledge, 2002. - 166 p.
38. Rational pharmacotherapy in obstetrics and gynecology: Hands-on. for practitioners / Ed.
VI Kulakov, VN Serov. - M.: 2005.
39. Guide Out - patient care in obstetrics and gynecology / Ed. VE Radzinsky. M: GEOTAR
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20
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TK Beam. - M.: "GEOTAR - Media", 2007. - 173 p.
50. Shmagel, KV Immune pregnant women / KV Shmagel, VA Cherries. - Moscow: Medical
Book, 2003. - 226 p.
51. Tskhai, VB Perinatal obstetrics: a manual for honey. Universities / VB Tskhai. - Atlanta:
Med. Academy of RAMS, Moscow, Honey. book, 2003.
52. Amniotic and extraembryonic structures in normal and complicated pregnancy / Ed. VE
Radzinsky. 2004. - 393 p.
53. Congenital, perinatal and neonatal infections: Per. from English. / Ed. A.Grinou, J. Osborne, S. Sutherland. - M.: Medicine, 2000. - 287.
54. Kulakov VI, Murashko LE Premature birth. M. Medicine, 2002.
55. Serov VN etc. Eclampsia: A Guide for Physicians / V.N.Serov etc. - M.: MIA, 2002. 463
- with
56. VM Sidelnikov Habitual loss beremennosti.-M.: Triad-X, 2002.
57. Disseminated intravascular coagulation in obstetrics AD Makatsaria etc. - M.: Triad-X,
2002. - 496.
58. Schechtman, MM, GM Burduli Diseases of the respiratory system and blood circulation
in beremennyh.-M.: Triad-X, 2002. - 230C.
59. Shifman EM Pre-eclampsia, eclampsia, NELLP syndrome / Inteltek, 2002.
More:
60.Uchebnoe grant for the development of practical skills surgical / Edited by prof. Atalieva
AE, prof. Babadjanova BD Tashkent 2003. C102-115
61.Algoritmy diagnosis and treatment of surgical / Edited by Academician Karimov
Sh.I.Tashkent 2003. From 39-64
62.Uchebnoe benefit surgical subjects for medical students / Edited by Academician Karimov Sh.I.Tashkent -2003 Part II Obstetrics and ginekologiya.S 64-19013. Practical skills in
obstetrics and gynecology / Metod.posobie / / Tashkent 2008.
63.Akushersky soft tissue injuries of the birth canal, Kulakov VI, Butova E.A.2004.
64.Akusherstvo. National rukovodstvo._2004.
65.Infektsii in Obstetrics and Gynecology How VK Seagull 2006
66.Hirurgicheskaya technique cesarean secheniya_Strizhakov A.N._2007.
67.Ratsionalnaya pharmacotherapy in obstetrics and ginekologii.2007
Chan_Gynecology_and_obstetrics.2004
68.Rukovodstvo for outpatient care in obstetrics and gynecology, Kulakov V.I.2005.
70.Sidorova_I.S._Rukovodstvo_po_akusherstvu_ (Medicina, 2006) (ru) (1033s
71.Posobie for practical development of Obstetrics Voronin (KV) 2007.
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72.Kirienko AI, Matyushenko AA, Andriyashkin VV Ostryi tromboflebit/2005
AN 73.Ivanyan - Intrauterine growth ploda/2007
74.DVS_sinrom _v_akusherstve.2004
75.Neonatologiya (Bazhanov NP). - T. I. - 2004
76.Prikaz MZ № 500 "On the reorganization of maternity hospitals to improve the efficiency
of perinatal care and the prevention of nosocomial infections."
77.Internet sites:
http://www.studmedic.narod.ru/, http://med.siteedit.ru/,
http://www.rukovodstvo-po-akusherstvu.-uchebnoe-posobie.html,
http://www.materinstvo.ru, http://mama.ru.http://www.art-med.ru,, http://www.doctor.ru,
http://www.rodim.ru, http://mamka.ru
http://medagent.ru, http://www.art-med.ru, http://www.medsan.ru,
http://mediki.spb.ru, http://medinstitut.e2e.ru, http://www.medstudy.narod.ru
http://www.obgyn.ru, http://www.medsno.ru, http://medrusnet.euro.ru
www.medtext.ru, www.medpoisk.ru, www.medicum.nnov.ru/student/
http://6years.net/, http://preryvanie-beremennosti.pharmabort.ru/
http://med4net.ru/, http://www.med-life.ru/, http://www.pregnant.ru/
http://www.roddom.ru, http://www.medpoisk.ru/, http://www.medlinks.ru
Topic: The organization and structure of the obstetric and gynecological clinic. Principles
of safe motherhood. Modern views on the prevention of nosocomial infection. Clinical
anatomy of the female genital organs. The birth canal, the fetus as an object of labor
1st place of training, equipping,
 Department of Obstetrics and Gynecology, the audience;
 dummy pelvis, fetal doll, female pelvis:
22
 standard models of pregnancy;
 the classic model of labor;
 gynecologic simulator ZOE;
 childbirth simulator Noelle;
 simulator newborn Newborn;
 set of slides on the topics of discipline;
 methods work in small groups: the method of the incident, "a round table" problem solving,
"pen in the middle of the table", "swarm", etc.;
 testing and teaching practical skills in OSKE (objective structured clinical examination).
 video, TV, TV;
 personal computer (Pentium-III);
 set of slides with typical conditions for ultrasound scanning of pregnant women and gynecologic patients;
 set of video blogs "VJOG" (USA), highlighting recent advances in diagnosis and treatment of
obstetric and gynecological conditions;
 set of videos and films demonstrating the typical obstetrician-cal and gynecological procedures, and operations;
 educational films: "The principles of respect for epidemiological regime in the maternity hospital. Principles of Safe Motherhood ";
 educational software;
 multi media training and testing;
 the use of e-mail and INTERNET;
 business simulations and case studies;
 slides (structure obstetric complex anatomy of the female genital organs);
 set of test items.
 list obstetric departments of the hospital;
 structure of work in the offices of obstetric care (functional importance of each department);
 anatomy illustration of female genital organs (ligaments and muscles of the pelvic floor, blood
supply, innervation, etc.);
 schematic planes pelvis showing oblique, straight and transverse dimensions;
 size head and torso of the fetus;
 form image lumbosacral diamond in a woman with a normal pelvis.
 center for training in practical skills
 maternity department and laboratory complex.
2. Duration of study subjects
Hours - 5.
3. Purpose of the lesson
 consider the principles of organization of obstetric hospital;
 examine the sanitary and epidemiological conditions in maternity hospitals (maternity complex
structure, especially the work);
 to introduce the work of the Office;
 to submit the medical records (birth history, partograph, exchange card);
 consider the principles of safe motherhood;
 explore modern concepts of prevention vnutribolnich-tion of infection;
 examine the scheme of history-taking during pregnancy, childbirth and postpartum women;
 discuss the clinical anatomy of the female genital organs with obstetric point of view (anatomical units form the birth canal, pelvic bone sections, planes and dimensions of the pelvic planes,
angle and wire axis of the pelvis, unlike the female from the male pelvis);
 to study the characteristics of the fruit with obstetrical point of view (the size of the head of the
23
fetus, shoulder and full-term fetus yagodichek);
 examine obstetric terminology, the nature of the location of the fetus in the uterus and options
for the various locations.
Tasks
The student should know:
 the principles of the organization of the obstetric hospital;
 basis of sanitary and epidemiological regime in maternity complexes;
 principles of receiving, I-st obstetric department, II-nd obstetric ward, intensive care and neonatal intensive care;
 prntsipe safe motherhood;
 modern ideas on the prevention of intrauterine infection and migration;
 clinical anatomy of the female genital organs;
 the structural components of the birth canal;
 features chlenoraspolozheniya normal fetus;
 size torso, the head of the fetus.
The student should be able to:
Conduct physiological psychoprophylactic preparing pregnant women for childbirth, to conduct
an external examination of the pregnant uterus by Leapolda-Levitsky, diagnose early and late
stages of pregnancy, history-taking in a pregnant woman, pregnant inspect, including external
genitalia, palpation of the fetus and to determine the approximate weight fetus.
4.Motivatsiya
Teaching students the basics of obstetrics and gynecology based knowledge acquired in
previous courses, the principles of survey pregnancy and childbirth, gynecological patients, the
prevention and primary care, diagnostic, emergency conditions, the most common in obstetric
and gynecologic practice.
The study of this subject is necessary in order to allow students to focus on further studying the
course in Obstetrics and Gynecology, without the knowledge of the topic, they can not master
the future course of obstetrics and gynecology.
5.Intra Mezhpredmetnye and communication
To successfully study subjects students must have a good level of knowledge in the following
subjects: normal and topographic anatomy, physiology, pathophysiology, histology, pathology,
microbiology, epidemiology, therapy and surgery, anesthesiology and critical care medicine,
dermatology, clinical pharmacology, endocrinology, childhood illnesses. Acquired during the
course knowledge will be used during the passage of cycles in endocrinology, internal medicine,
surgery, pathological obstetrics, gynecology, health, pediatrics, etc.
6.Soderzhanie classes
6.1. The theoretical part
Type obstetrical institutions, their main objectives. Organization of the obstetric hospital. Sanitary and epidemiological conditions in maternity hospitals (ro-Dil'nyi structure of the complex,
especially the work). Health education. Familiarity with offices.
Organization of specialized units to treat pregnant women with different diseases, perinatal centers for the care of premature infants, regional maternity hospitals, specialized sanatoriums and
rest homes for pregnant women, strengthening of health education and health education of the
population in the area of maternal and child health, the organization of rural health units prevention of disease among adolescents, girls prepare for family life and many other reproductive
health problems.
The structure of maternity facilities and organization where they work on the same principle, in
accordance with international standards on the basis of the order of Ministry of Health of Uzbekistan 500.
As part of maternity complex has the following divisions: Hospital, medical - diagnostic units
and Administrative - economic part.
24
Maternity hospital in its structure has:
 Receiving - Inspection Division;
 the department of pathology of pregnancy (30-35% of total obstetric beds);
 I obstetric department (25-30% of the total number of obstetric beds);
 II obstetric department (25-30% of the total number of obstetric co-EC);
 the emergency department and intensive care of pregnant women, mug-down and childbirth;
 the intensive care unit and neonatal intensive care;
 gynecology department (15-20% of the total number of beds obstetric complex);
 sterilization and laboratory departments.
Receiving - office is in sight of the receiving part, observation and bathing and delousing
establishment. Here obstetrician or midwife collects history, conducting physical examination.
Evaluates the status of the pregnant woman, measures the body temperature, inspection of the
skin, throat, were counted pulse, measures blood pressure in both arms and get acquainted with
the exchange of cards pregnant.
The department of pathology of pregnancy are intended to provide adequate medical care
to pregnant women, as attendants, and with extragenital pathology.
Obstetrics Department I and II are identical and are intended for the confinement and of
the postpartum period.
In the emergency department and intensive care pregnancy, labor and childbirth, and the
intensive care unit and neonatal intensive care is emergency care and intensive care.
Gynecology department are intended to provide adequate medical care for pregnant women up to 20 weeks. pregnant and nonpregnant women with inflammatory diseases of the genital
organs, infertility, etc.
Strict adherence to all the rules of aseptic and antiseptic has exceptionally important in
obstetric practice.
The "Safe Motherhood"
The initiative "Safe Motherhood" was launched in 1987 is an international program aimed at
health professionals providing health care for women during pregnancy, childbirth and postpartum. This initiative was taken in order to promote the efforts of the medical community to reduce
maternal mortality by half to 2000
It was decided to continue the initiative, but under a different name - "safe motherhood" because
there has been indicators that are planned in the program.
Safe motherhood means not only the prevention of illness and death, it also involves the care of
the mother and child. This concept includes the physical, mental and social well-being of women
before delivery, during, and after birth, which should give birth and healthy childhood, which is
consistent with the Constitution of WHO (1948), which defines health as "a state of complete
physical, mental and social well-being and not merely the absence of disease and infirmity "
The principles of "safe motherhood"
Providing prenatal care for all pregnant women is the primary responsibility of the family in
which the woman lives. Woman needs the support of his family and the community during pregnancy, childbirth, postpartum and during lactation, especially if it has problems. To ensure that
care home need information, skills and motivation to ensure the implementation and maintenance of any new practice. This approach also needs social and financial support of the society.
Moreover, he needs the support of the health care system by providing appropriate, sensitive and
friendly services that provide complete services of maternal and perinatal care, taking into account the physical-cal, emotional, and psychosocial needs of women and newborns.
Targeted interventions for mothers and children
Healthcare workers can anticipate, avoid or solve many unexpected data, and sometimes dangerous problems that can occur during labor, thus reducing the maternal mortality rate to very low
levels. However, health care providers also need the support that can be provided only in the
hospital when they see that their expertise and available equipment is not enough to deal with
25
complications during childbirth. All women need care the primary level, and special care is required only in certain cases. At the same time, the two types of care (primary and specialized
care) need to work together, while providing effective integrated services. In many countries,
postpartum care is provided even less than care during childbirth. This is an extremely important
area where there are many opportunities to improve the situa-tion.
MODERN CONCEPTS OF PREVENTION OF INFECTION VNUTRIBOLNICH-NOY
Nosocomial infections can also be classified as endemic or epidemic. More common endemic
infections. For epidemic outbreaks of infection are characteristic, which are defined as an unusual increase in the incidence of infection.
Nosocomial infections are common throughout the world, both in developed countries and in
countries with limited resources. Infection in hospitals - this is one of the major causes of death
and increased morbidity in patients who are in hospital. This is a serious problem, both for the
patient and for the health system as a whole.
Hospital infections: sources and transmission
The bacteria that cause hospital infections can be transmitted in various ways:
1. Permanent or transit flora patients (endogenous infection-tion). Bacteria present in the normal
flora to cause in-infection, because beyond the natural environment (eg, urinary tract) due to tissue damage (injury), or improper use of antibiotics, provoking an overgrowth of bacteria. For
example, Gram-negative bacteria from the digestive tract are often the cause of infection of surgical wounds after surgical operations performed on the abdomen, urinary tract infection, or a
cat-terizirovannyh patients.
2. Flora received from another patient or health care provider (the exogenous cross-infection).
The bacteria are transmitted from patient to patient:
 by direct contact (hands, spraying saliva or other bodily fluids)
 droplets (droplets of moisture or dust-carrying bacteria from an infected patient)
 After medical personnel living in working processes of patient care (hands, nose, throat, and
clothing), which are temporary or permanent vehicle of infection, subsequently transferring the
bacteria to other patients in the course of the direct contact of the care,
 In subjects infected patients (including equipment), the hands of staff, visitors and other objects of the environment (ie, water, other liquids or food).
3. Flora received from the environment hospital (endemic or epidemic heteroinfection environment).
Several types of micro-organisms survive well in the environment of medical institutions:
 In the water, humid and sometimes sterile products or disinfectants (Pseudomonas, Acinetobacter, Mycobacterium)
 On linen, equipment and maintenance. Proper cleaning is usually limits the risk of bacterial
survival, as for the life of most organisms need moisture or high temperature, and nutrients
 In the food
 In the fine dust and droplets of sputum, released during the speech, and cough (if the bacteria
is less than 10 mu.m in diameter, it is kept in the air for several hours and can enter the respiratory tract like fine dust)
Hospital infections: sources and transmission
People are the main source, the main carrier and recipient organisms, becoming a new source of
infection.
Nosocomial infections: prevention
Prevention of nosocomial infections requires an integrated program and monitoring, which includes the following key components:
 limit transmission of microorganisms from patient to patient in the care of them:
 Hand washing and use of gloves;
 aseptic technique;
 insulation measures;
26
 sterilization and disinfection;
 Laundry
 Monitoring of infection in the environment
 Protecting patients: the rational use of antimicrobial drugs, nutrition, vaccination
Nosocomial infections: prevention
Responsible for infection control, all health workers - doctors, nurses, therapists, pharmacists,
technicians and other
Hand hygiene: the importance of
All bacteria that can be found on the hands, can be divided into two categories: transient and
resident.
Resident flora, one that inhabits the deeper layers of the skin are more difficult to remove. In
addition, there is less likelihood that the resident flora (eg, staphylococcal infection and
coryneform bacteria) will cause nosocomial infections.
Transient flora, one that inhabits the upper layers of the skin are more easily removed by routine hand washing. Health workers often acquire it during direct contact with patients or contaminated surfaces in the immediate vicinity of the patient.
Hands of medical personnel is a major component in the transmission of nosocomial infections. Transmission of nosocomial infections can be minimized by following proper hand hygiene.
Hand washing technique
Hands should be disinfected before direct contact with the patient and after any activity or contact that can infect your hands, including after removing gloves. At the same time, detergents and
alcohol based gels are a practical alternative to soap and water, alcohol itself is not a cleaning
agent.
Or potentially dirty container
nirovannye microorganisms hands should be washed thoroughly with soap and warm water, then
wipe dry. Preparing hand improves disinfection.
Inadequate drying can lead to re-infection of hands that have just been washed. Wet surfaces are
more effective in the transfer of microorganisms than dry, in addition, if you do not wipe your
hands dry, the skin is more susceptible to damage. For wiping hands to use disposable paper
towels quality. Towels should be near the sinks in wall containers.
Restricting visiting relatives
Effectiveness of the practice is not restricted visits dokazana.Mnogie hospitals justify the prohibition or restriction of visits to the possibility of infection, despite the fact that research in concurrent and historical control groups demonstrated no adverse effect on the level of visits to bacterial contamination of newborns.
Masks and hats
From wearing hats and masks should be discarded, and the aprons and gowns worn only by those
who do not want to dirty their own clothing in contact with the child.
Staff should use special or sterile medical gown as far as possible discharge of blood or other
body fluids, as well as in the case of manipulation or invasive procedures
 Protecting patients: Medical personnel wearing a mask in the operating room, when in contact
with patients with depressed immune response or procedures related to the penetration of the
body cavity. In these cases it is sufficient to use a surgical mask.
 Protection of medical personnel: health workers should wear masks during contact with patients with infections transmitted by airborne droplets, or during bronchoscopy or other similar
examinations. In this case, high-performance mask.
 Patients with infections transmitted by airborne droplets, should wear a surgical mask when
you are outside the insulator.
Ultraviolet radiation
As an additional air purification, ultraviolet radiation (UV) is effective in reducing the transmis27
sion of airborne bacterial and viral infections in hospitals (wards and corridors), military barracks, the school environment, but it has minimal effect on inactivating fungal spores. Health
care facilities are used UV lamps of two types - with directional and omni-directional radiation.
Regular maintenance of the UV radiation is very important. Usually, such a service is to
purify the lamps from dust and replace the old bulbs as needed. UV tubes should be replaced and
cleaned according to the manufacturer's instructions.
Staff medical institutions operating UV disinfection of premises, should be trained on the following:
1. basic principles of the UV system (mechanism and restrictions).
2. potential danger of excessive UV exposure.
3. potential sensitivity associated with certain medical conditions or the use of certain medications.
4. the importance of maintenance and record-keeping.
Patients and visitors to medical facilities that use UV system should be informed about the
purpose of their use and warn of potential hazards and precautions.
The use of disinfectants.
The effectiveness of routine use of disinfectants is not proven.
Demonstrated that bacterial contamination of the floor back to its original level in 2 hours after
washing, regardless of whether it was carried out with the use of a disinfectant or not.
Instead of spraying disinfectants recommended a thorough cleaning and mechanical cleaning.
The structure of the female pelvis. Gender and age differences in the pelvis. Taz with obstetrical
point of view (size, plane inclination). External genitalia, structure, and functions. Internal sex
organs (uterus, tubes, ovaries), the structure and function. Topography of the pelvic organs of
women. Muscles, ligaments, tissue, peritoneum, blood, lymphatic system, innervation genitals.
Female reproductive system consists of internal reproductive organs located in the pelvic cavity,
and external genitalia that are outside of the bone of the pelvis. The internal genitalia include: the
uterus, ovaries, fallopian tubes and vagina. External genitalia include the crotch, large and small
labia, vestibule and clitoris.
Vagina - vagina, colpos, tubular, muscular - elastic body is folding, its walls formed ¬
form a arches - front, rear, left, right. Uterus - uterus is pear-shaped, consisting of three parts
(body, isthmus, neck), weight 50-100,0 length 8 cm, has three layers: mucous - endometrium,
muscular - myometrium, serous - perimetrium. On the sides of the uterus are the fallopian tubes
(tubae uterinae). Ovaries - ovaria paired female sexual as ¬ iron, measuring 4X2X2 cm, weight
6-8 g, consists of cortical (located follicles) and medullary layers. II. Taz - pelvis bone canal,
sealed joint-mi, within which the sexual and neighbor ¬ tion in their bodies. Pelvis in obstetrics
is of great importance, since it is the birth canal and not mu ¬ moving fetus.
The pelvis consists of four bones: two nameless, sacrum and coccyx. Hip bone consists of three
bones: the iliac (os ileum), seat-of-tion (os ischii), pubic (os pubis), which are connected in
vertlozhnoy depression (acetabulum). Ilium is the upper section of the nameless braid ¬ ty - ends
flank bone crest (crista iliaca). It is the front and rear ends with two Dwell ¬ Memo - peredneverhnyaya iliac spine-spina iliaca nor superior, anteroinferior - spina itlaca anrerior posterior,
caudineural iliac spine-spina iliaca inferior superior iliac spine and lowback - spina iliaca posterior inferior. Ha inner surface of iliac bone, in the transition region of the wing to the body relies
pectiniform races ¬ ledge, curved, Beza ¬ myannaya line - llnia innominata, idushaya to the sacrum and the upper edge of the pubic arch.
Ischium has a body, which forms the acetabulum and the two branches: the upper and the
lower, the upper branch of the body goes down and ends buttocks - tuber ischii. On the back of
the lower branch of this bone has a projection - spina ischii, the lower branch is forward and upward and connects to the lower branch of the pubic bone. Pubic bone, has a triangular shape ¬
mu and consists of a body and two branches: the top and bottom. The body is part of the acetabulum, vet ¬ integer fit together symphysis pubis symphysis (symphisis). Sacrum consists of 5-6
vertebrae are connected into one. The front surface is concave, back arched. At the junction of I
28
and V sacral vertebra forms ledge - sacral promontory (promontorium). Verhushka connected to
the coccyx through the joints.
Female pelvis of the male has different depth, subtlety, capacity. The pelvis is important in
labor and is wired the way in which advances in childbirth fetus. Distinguish between large and
small basin boundary between the two is the front - the top of the symphysis, laterally - unnamed
line
promontorium.
Big basin bordered in front - the abdominal wall, back, spine, sides wings flank bone ..
Large size of the pelvis.
1.distantio spinarum 25-26 cm distance between distant points of the spina iliaca anterior superior.
2.distantio cristarum 28 - 29 cm, long-term point of iliac crest bone.
3. distant about trochanterica - 31 -32 cm distant points trochanter major.
4. Conjugata externa 20-21 cm from the top corner of the diamond of the lumbar and upper outer
edge of the symphysis.
5. Conjugata lateralis - Conjugate lateral - from the spina iliaca anterior superior to the spina iliaca posterior superior - the same side - is 14 - 15 cm
6. Conjugata obliqva - from the spina iliaca anterior superior to the spina iliaca poste-rior superior - the other side is 17 - 18 cm
In the pelvis are 4 plane.
1. The plane of the entrance to the pelvis.
Boundaries: front - top of the pubic articulation ¬ tion, sides linea innominata, back - cape promontorium.
Dimensions: direct conjugates called true-conjugata vera - the distance from the edge of the pubic arch verhnevnutrennego to Cape = 11 cm, transverse - distant points linea innominata 13 cm,
oblique right and left are equal to 12 cm, the distance from the sacroiliac joint to povzdoshnolonnogo hill.
2. The plane of the widest part.
Boundaries: front - mid symphysis pubis, rear joint of the 2nd and 3rd sacral vertebrae, laterally
inner plate ¬ ka - fossa acetabulum Dimensions: straight from the middle of the symphysis pubis
to the junction of the 2nd and 3rd sacral vertebra - 12, 5 cm, cross ¬ WIDE remote centers acetabular -12.5 cm
3. The plane of the narrow part.
Boundaries: front - the edge of the pubic arch, the sides - the seat-awn-tion of bone, behind - the
sacrococcygeal joint.
Dimensions: straight - from the bottom of the pubic arch to the sacrococcygeal junction - 11.5
cm
cross-distant points ¬ her inner surface buttocks tuber ischia - 11,0 cm
4. Plane out of the pelvis.
Boundaries: front - the edge of pubic articulation ¬ of, behind - the coccyx, laterally - the seat of
¬ WIDE mounds. Dimensions: a straight line from the bottom of the SIM fiza to ver ¬ Huschke
tailbone -9.5 cm transverse - distant points buttocks - 11 cm In conducting the line through the
centers of all sizes formed direct wire axis of the pelvis-shaped fish hook.
In a study of women should perform the following measurements:
 size of a large basin.
 size of exits the pelvis.
 Wrist circumference - An index ¬ Soloviev 14 - 16 cm
 womb height = 4 - 5 cm
 Diagonal conjugates = 13 cm,
 Outdoor conjugates = 20 - 21 cm
 Diamond Michaelis - longitudinal size-11cm, cross-10 ,5-11 cm
29
 pubic angle - is 90 - 100 °.
 pelvis circumference = 80 - 90 cm
 10. The angle of inclination of the pelvis - the ratio of the plane WMO ¬ yes the pelvis to the
horizontal plane.
Pelvic floor.
The output from the bone of the pelvis is closed tight muscle-fascial the plate, called Pelvic
Floor. The system of muscles and fascia called diaphragma pelvis. Anterior diaphragm fixed to
the pubic bone, back to the coccyx with the lig. sacrotuberosita, on the side-to fascia obturatoria.
The pelvic floor consists of three layers.
1. The outer layer of the following muscles.
a) m. sphincter ani externus
b) m. bulbocaver nosus (constrictor cunni)
a) m transversus perinei superficialis
d) m. ischio - cavernosus
2. Layer forming the pelvic diaphragm is composed mainly of the fascial tissue, which lie deep
in the m. transversus perinei profundus
3. Deep muscle layer, which covers the reduction ¬ storage basin. This m. levator ani, consisting
of m. pubococcygeus, so ileiococcygeus, so ischiococcygeus. Edge that pubococcugens both
sides embrace the rectum and form a hiatus genitalia, except rectum through which passes in
front of the vagina and the urinary ¬ emissive channel. During labor, the pelvic floor is undergoing major changes involved in ¬ Ø Work nanii fetus, forming the channel, sometimes damaged.
Fruit of the object of labor
In the study of the fruit, as the object of labor, should first pay attention to his head, as the largest
part on the seams and fontanelles on their value in labor. You should know the basic acoustic ¬
sherskie notions chlenoraspolozhenie, position, type, presenting part, wired point insertion. The
head of the mature fruit consists of 2 unequal hour ¬ children - the skull and face. The skull is
formed from the forehead ¬ GOVERNMENTAL - os frontalis, parietal-os parietalis, temporal-os
temporalis and neck - os occipitalis bones, which are joined together by sutures and fontanelles.
On the head are the following joints: frontal suture-sutura frontalis between the frontal bones,
sagittal or sagittal-sutura sagitalis-between parietal bones; coronal - sutura coronaria between the
parietal and frontal bones; lyambdovidny (sutura lambdoi-dea) - between the parietal and occipital bones. Fontanels on the head of the following:
a) large fontanelle - fonticulus major is
between the back of the frontal and anterior
parts of both parietal bones, is
connective plate diamond shape.
b) small fontanelle - fonticulus minor has a triangular shape, is located between the rear of
both parietal and occipital bones. Fontanelles connect strelovid-tion seam.
a) lateral fontanelles-fonticulus lateralia
Sutures and fontanels during labor shift and for ¬ go at each other, cowering in the same direction, increasing in another, which is called the configuration ¬ her. According to him the doctor
recognizes the position of the head in the pelvis and follows the mechanism of delivery. On the
head are following dimensions and the corresponding circle.
1. Direct-d. frontoocclpitalls: from the nose to the outermost point of the neck, 12 cm, circumference-circumferentia frontooccipitalis 34cm.
2. Great scythe - d. mentooccipitalis - from the chin to the neck-13cm circumference - circ. mentooccipltalis - 42 cm
3. Small oblique - d. suboccipito-bregmaticus of suboccipital fossa to the middle of the large fontanelle-9, 5 cm, the circle-circ. suboccipito-bregmaticus - 32 cm
4. Vertical - d. sublingva bregmaticus from mid ¬ HN large fontanelle to the suboccipital bone =
9.5 cm, the circle circ. sublingva-bregmaticus 32 - 33 cm
5. Large cross - d. biparietalis distant points parietal tuber = 9.5 cm
30
6. Small cross - d. bifemporalis between temples = 8 cm
To determine the transverse size of the fruit shoulder area = 12 cm, circles 35-36 cm transverse
dimension ¬ measures yagodichek - 9-9.5 cm, circumference 27-18 cm, measure the growth of
the newborn, on average 50-53 cm, weight - an average of 3500.0.
The use of new educational technologies:
METHOD "web"
The steps are:
1.Predvaritelno students are given time to prepare questions on the passed occupation.
2.Uchastniki sit in a circle.
3.Odnomu participant is given a skein of yarn and he asks his prepared by the question (which
itself needs to know the full answer), hold the thread end and throwing the ball of any student.
4.Student, received a skein, answers the question (the participant, who gave-it says the answer),
and passes the baton to the issue further. Participants continue to ask questions and to answer
them, until everything will be in the web.
5.What Once all the students have finished asking questions, the student, holding coil, returns to
a participant, from whom he received the question, while asking the question, and so on, until the
"unwinding" of the coil.
Note: To prevent the students that should be attentive to each answer, because they do not know
who to throw coils.
6.2. The analytical part of
Case studies:
1. For external obstetric study of pregnant uterine fundus is located midway between the navel
and the xiphoid otrost-com. OJ - 92 cm, VDM - 31 cm longitudinal position of the fetus, I position predlezhit fetal head above the entrance to the pelvis. Fetal heart clear, rhythmic, 140 beats a
minute left below the navel.
What is the expected timing of pregnancy?
What is the estimated weight of the fetus?
A: 32 weeks. The estimated fetal weight 2800,0 ± 200,0.
2. Primigravida 30 years of full-term pregnancy. Fetal heart rate 136 beats clear. in min. Skirmishes continued for 3 hours. Prenatal rupture of water (dry period was 12 hours). Temperature
of 37,8 º C. Purulent vaginal discharge.
In what branch hospitalized woman?
Answer: In the maternity ward.
3. Multigravida. The gestational age of 12 weeks. Against the background of aching pain in the
abdomen and in the lumbar region appeared spotting.
In what branch hospitalized woman?
Answer: In the gynecological ward.
4. To the doctor asked prenatal primigravida at 37 weeks gestation. Registered on pregnancy was
not. Complaints about the heaviness in the epigastric region, vomiting single, headache. BP 150/100 mm Hg. column.
Tactics prenatal doctor?
Answer: Magnesian therapy and urgent hospitalization in a maternity center.
5. Received a woman 32 years old with 40 weeks of pregnancy. On examination: the stomach is
increased by the pregnant uterus. OJ-100cm, height-33cm uterus. At the bottom of the uterus
palpable volumetric soft part of the fetus, in the right side - a vast area is uniform, the left - small
parts in the lower segment of the uterus - rounded, dense part of the fetus with sharp edges, moving the entrance to the pelvis. Fetal heart is clear, rhythmic, 140 beats / min, listen to the right
below the navel.
The estimated weight of the fetus? Reply: 3300,0 ± 200,0.
6.Beremennaya 16 years admitted to the maternity ward to decide on the method of delivery.
Pregnancy first, uneventful. Gestational age 41 - 42 weeks. An objective study is the estimated
fetal weight 4200 g, the size of the pelvis 23-26-29-18 cm, head presentation. At vaginal exami31
nation: cervix 2.5 cm long, dense, rejected posteriorly, the outer jaws closed.
The diagnosis? In what branch hospitalized woman?
A: Pregnancy I. 41 42ned. V16let. Large fruit. Obscheravnomernosuzhen HYDRATED pelvis II
degree. Hospitalized in the maternity ward.
6.3. Graphic organizer: Making graphic organizer
"Categorical table" on "the birth canal and the fruit of the object of labor"
CATEGORIZATION TABLE
Category - a sign of (general), reflecting the essential properties and relations. Brings together
the information obtained on the basis of the selected features. Develops systems thinking, the
ability to structure, organize information.
6.4.Prakticheskaya part
Determination of intrauterine fetal weight.
Objective: To determine the intrauterine fetal weight.
Performs step (steps):
Events number does not hold nil
(0 points) Fully
correctly
performed
(20 points)
1. The doctor explains the pregnant woman, that will do 0 20
2. Pregnant laid on the couch, on the back 0 20
3. The doctor gets to face her 0 20
4. With a tape measure physician abdominal circumference and height of standing uterus 0 20
5. Received two values are multiplied with each other.
100h32 = 3200 g. 0 20
Total 0100
7.Formy control of knowledge, skills and abilities
-Oral;
-Written;
Testing;
Solution situational problems;
And demonstration of skills mastered.
8.Kriterii assessment monitoring
Number suc-BAE-bridge
Score in% level of students' knowledge
1 96-100% Excellent
"5" full correct answer to the questions on the etiology, pathogenesis, classification, clinical
manifestations, diagnosis, treatment and prevention of this disease. To sum up and make decisions, creative thinking, self-analyzes, case studies resolves correctly, with a creative approach,
with full justification of the answer. Actively and creatively involved in interactive games, take
the right decisions and summarizes and analyzes. Medical history, partograph fills correctly.
2 91-95% Excellent
"5" full correct answer to the questions on the etiology, pathogenesis, classification, clinical
manifestations, diagnosis, treatment and prevention of this disease. Creative thinking, selfanalyzes, case studies resolves correctly, with a creative approach, with full justification of the
answer. Actively and creatively involved in interactive games, take the right decision. Medical
history, filled with partograph one grammatical error.
3 86-90% Excellent
"5" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis, treatment and prevention of this disease is completely covered, but have 1-2 errors in the response. Own analyzes, inaccuracies in solving situational problems, but with the right approach.
Actively involved in interactive games, make the right decisions. Medical history, partograph
32
fills with 2-3 grammatical errors.
4 81-85% Good
"4" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis,
treatment and prevention of this disease is completely covered, but there are 2-3 inaccuracies,
errors. Into practice, understands the essence of the question, says confidently, is a faithful representation. Situational problems solved correctly, but the justification answer sufficiently. Actively involved in interactive games, take the right decision. Medical history, partograph fills with 23 grammatical errors, inaccuracies in the description.
5 76-80% Good
"4" Correct, but incomplete coverage of the issue. The student knows the etiology, pathogenesis,
classification, clinic of the disease, but not completely disassembled diagnosis, treatment and
prevention of this disease. Understands the issue, says confidently. There is an exact representation. Actively participate in the games. On case studies gives partial solutions. Medical history,
partograph fills with 3-4 grammatical errors, inaccuracies in the description.
6 71-75% Good
"4" Correct, but incomplete coverage of the issue. The student knows the etiology and pathogenesis of the disease, but not completely disassembled diagnosis, treatment and prevention of this
disease. Understands the issue, says confidently, is a faithful representation. On case studies
gives partial solutions. Medical history, partograph fills with 3-4 grammatical errors, 3-4 errors
in the description.
7 66-70% satisfactory solution is without foundation
"3" right answer half the questions. The student knows the etiology of the disease, but not all
lists of the classification, a clinic of the disease, is confused in the treatment and prevention. Understands the issue, said confidently, has accurate representations only on specific issues topic.
Situational problems solved correctly, but there is no justification of the answer. Medical history,
partograph fills with 3-4 grammatical errors, 3-4 errors in the description.
8 61-65% satisfactory solution is without foundation
"3" right answer half the questions. Errors in the etiology, pathogenesis, poorly versed and confused in the treatment and prevention of this disease. Says uncertainly, has the only views on certain issues topic. Making mistakes in solving situational problems. Medical history and partnership gram fills with errors.
9 55-60% satisfactory solution is without foundation
"3" error response to half the questions. Student makes an error in the etiology of this disease,
poorly versed and confused in other matters relating to the disease. Says uncertainly has a partial
view on the subject. Situational problems solved incorrectly. Medical history and partograph fills
with errors.
10 50-54% Unsatisfactory-vletvori-state "2" The correct answer is 1/3 set questions owls. Student does not know the etiology of the disease, poorly versed and entangled in other issues related to the disease. Situational problems solved correctly if the right approach. Medical history and
partograph fills with errors.
11 46-49% Unsatisfactory-vletvori-state "2" The correct answer to fourth questions posed owls.
Student does not know the etiology of the disease, poorly versed and entangled in other issues
related to the disease. Situational problems solved correctly if the right approach. Medical history and partograph fills with errors.
12 41-45% Unsatisfactory-vletvori-state "2" Lighting fifth of the questions with errors. Student
does not know the etiology of this disease, little versed in other matters related to the disease.
Gives an incomplete and partially incorrect answers to questions on the classification of the clinical disease. Situational problems solved correctly if the right approach. More than half the history of the disease and the partograph filled with errors.
13 36-40% Unsatisfactory-vletvori-state "2" Lighting 1/10 of the questions at the wrong approach. Does not know the etiology of the disease, and poorly versed entangled in other issues
related to the disease. Gives an incomplete and partially incorrect answers to questions on the
33
classification of the clinical disease. Situational problems solved correctly if the right approach.
Bole half medical history and partograph fills with gross errors.
14 31-35% Unsatisfactory-vletvori-state "2" to the questions not answers. Knows and time is
chosen in other matters related to the disease. Does not know how to fill out and describe the history of the disease and the partograph.
9. Typical flow chart of lesson
Stages of work, time-name The content of the
Teachers Students
1etap. Introduction to the training session
(5min) 1.1.Soobschaet topic, purpose, and planned training results. Familiar with the plan,
features of the training session.
1.2.Nazyvaet: key categories and concepts from the data subject tion, a list of books for selfstudy
1.3.Soobschaet indicators and criteria of educational work in class
Listen, record,
specify, ask the question.
Stage 2.
Primary
(235 min) 2.1.Provodit updating knowledge through блиц-опроса/вопросно-ответной
forms / brainstorming, etc.
2.2. Consistently describes the steps
on the organization of the educational process according to the structure of practical training.
Meet
Abstracts with ethyl.
Working in groups, will present the results of the group work
Stage 3.
The Final-Resultant-regulating (60 min)
3.1.Delaet opinion on the subject, attention was concentrated on the main students, according
to the importance of the work done for future careers.
3.2. Commends the work of groups (some of students) summarizes vzaimootsenki. Analyzes
and evaluates the degree of achievement of lesson.
3.3. Gives the task for independent work, informing schaet and criteria evaluation. Selfevaluation,
interaction assessment.
Ask the question.
Write down the job.
10. Test questions
1.How offices exist in obstetric complexes?
2.Po what criteria decide on hospitalization?
3.What role does the department of pathology of pregnancy?
4.Perechen work performed in the emergency department.
5.What features Obstetrics dictate strict observance of sanitary-epidemiological regime?
34
6.Nazovite 4 factors that determine the outcome of labor in the correct position of the fetus.
7.What is the concept of "birth canal"?
8.Chto constitutes "soft birth canal?"
9.Kosti and joints of the pelvis.
10.On what the department is divided into two bowl?
11.Razmery normal pelvis.
12.Kostnye border lumbosacral diamond.
13.Formy lumbosacral diamond in women with a normal pelvis.
14.Chemu is the inclination of the pelvis?
15.Chto conjugate is real?
16.Ukazat boundary plane broad, narrow part of the pelvis.
17.Ukazat size plane broad, narrow part of the cavity and exit the pelvis.
18.Chto called wire axis of the pelvis?
19. What are the bones of the head is a brain of the fetus?
20. What distinguishes the seams on the head of the fetus?
21. List the fontanelles of the fetal head?
22. Between which points is measured in the following sizes of head: a small amount of
skew, a large amount of skew, straight size, vertical?
23. What is called the configuration heads?
24. List the muscles of the pelvic floor.
11. Recommended Reading
Summary:
1. Abramchenko, VV Epidural anesthesia in obstetrics: a guide for physicians / 2006. - 229 p.
2. Abramchenko, VV Pregnancy and delivery of high risk: a guide for physicians / - M. Med.
Inform, 2004. - 400 p.
3. Abramchenko, VV Cesarean section in perinatal medicine: a guide for physicians / 2005. 126.
4. Abramchenko, VV Postoperative intensive care in obstetrics / Literature, 2000. - 88.
5. Abramchenko, VV Pharmacotherapy of preterm labor / 2006. - 448.
6. Abramchenko, VV Purulent-septic infection in obstetrics and gynecological
logii.rukovodstvo / 2005. - 459
7. Abramchenko, VV Postoperative intensive care in obstetrics / - St. Petersburg: Spec. Literature, 2000. - 88.
8. Abramchenko, VV Clinical perinatology / IntelTek, 2004. - 424 p.
9. Ailamazyan, EK Midwifery: a textbook for honey. Universities / 2003 - 528.
10. Topical issues of Obstetrics, Gynecology and Reproductive / Ed. EV KOKHANEVICH.
- Moscow: Triad-X, 2006. - 480.
11. Obstetrics. Ed. GM Savelyeva. - M.: Medicine, 2000. - 816 p.
12. Obstetric and gynecological care: Hands-on. for doctors / Ed. VI Kulakov. - Moscow:
MEDpress, 2000. - 512 p.
13. Obstetrics. Clinical lectures: a manual for schools with a CD / Ed. OV Makarova. - Moscow: GEOTAR Media, 2007. - 640.
14. Obstetrics. Directory of the University of California / Ed. Nisvandera K., A. Evans: Lane.
from English. - M.: Practice, 1999. - 704 p.
15. Barashnev, YI Perinatal neurology / Y. Barashnev. - M.: "Triad - X", 2005. - 670 p.
16. Bodyazhina, VI Akushersvo. The manual for the media. prof. Education / VI Bodyazhina. - Rostov-on-Don: Phoenix, 2003. - 480.
17. Resurrection, SL Fetal assessment. CTG. Doplerometriya. Biophysical profile: a manual
for the system of postgraduate medical. Education / SL Resurrection. - Minsk: The Book
House, 2004. - 304.
18. Gazhonova, VE Ultrasound in Gynecology / VE Gazhonova. - Moscow: MEDpressinform, 2005. - 264.
35
19. Gluhovets, BI Ascending infection of placental / BI Gluhovets. - Moscow: MEDpressinform, 2006. - 240.
20. Humeniuk, EG Obstetrics: Physiology of pregnancy: a training ben-beats / EG Humeniuk. - Petrozavodsk: IntelTek, 2004. - 170 p.
21. Demidov, VN Pelvic ultrasound in women. Adnexal cysts and benign ovarian tumors: a
practical guide / V. Demidov. - Moscow: Academy of Medical Sciences, 1999, vol. II. - 100
p.
22. Duda VI Obstetrics: a textbook for high schools in the specialty "General Medicine" / Minsk: High School, 2004. - 639 p.
23. Duda VI Physiological OB / - Minsk: 2000. - 447 p.
24. Duda VI Operative obstetrics: a manual / Minsk Interpresservis, Book House, 2002. - 512
p.
25. Zhilyaev, NI Obstetrics: phantom course / - Kiev, 2002. - 239 p.
26. Zhilyaev, NI Operative Obstetrics: Ouch. Manual / Kiev 2004. - 468 p.
27. Zhilyaev, NI Operative surgery in obstetrics and gynecology / 2004.
28. Selected lectures on obstetrics and gynecology / Ed. AK Strizhakova etc. - Rostov-onDon: Phoenix, 2000. - 512 p.
29. Clinical recommendations. Obstetrics and Gynecology: scientific publication / Ed. VI
Kulakov. - Moscow: GEOTAR Media, 2006. - 512 p.
30. Clinical lectures on obstetrics and gynecology / Ed. AN Strizhakova etc. - M.: Medicine,
2000. - 379 p.
31. Clinical evaluation of laboratory tests in women: study guide / Moscow Medical and
Dental. University. NA Semashko. - M: 2005. - 96 p.
32. Kulakov, VI Preterm birth / VI Kulakov, LE Ants. - M.: Medicine, 2002. - 176.
33. Kulakov, VI Intensive care in obstetrics and gynecology (efferent methods) / - M: MIA,
1998. - 206 p.
34. Drugs used in obstetrics and gynecology / Ed. Acad. RAMS VI Kulakov, Acad. RAMS
VN Serov. 2006. - 375 p.
35. Emergency care in obstetrics and gynecology. Quick Guide - M. GEOTAR - Media,
2007. - 52.
36. Perinatology Basics: A tutorial / Ed. MP Shabalov. - Moscow: MEDpress-inform, 2002. 576 p.
37. Practical skills in obstetrics and gynecology: a manual / LY Suprun, TS Divakova and
others. - Minsk: New Knowledge, 2002. - 166 p.
38. Rational pharmacotherapy in obstetrics and gynecology: Hands-on. for practitioners / Ed.
VI Kulakov, VN Serov. - M.: 2005.
39. Guide Out - patient care in obstetrics and gynecology / Ed. VE Radzinsky. M: GEOTAR
- Media, 2007.
40. Guide to practical training in obstetrics / Ed. VE Radzinsky. - M.: MIA, 2004. - 576 p.
41. Saveliev, GM Obstetrics: a textbook for schools / GM Savelyev, RI Shalina. - Moscow:
GEOTAR Media, 2008. - 656 p.
42. Sidelnikov, VM AG Antonov Premature birth. A premature baby / VM Sidelnikov, AG
Antonov. -M. "GEOTAR" 2006.
43. Smirnov, A. Pregnancy without problems / AN Smirnov. - Moscow: Atris Press, 2002. 208.
44. Smirnov, LM Obstetrics and Gynecology: Textbook / LM Smirnov. - M.: Medicine,
1999. - 368 p.
45. Handbook of obstetrics, gynecology and perinatology: uch.posobie for doctors / Ed. GM
Savelevoy.2006. - 720.
46. Trifonov, E. Obstetrics and gynecology: a manual for med._vuzov / EV Trifonov. - Moscow: VLADOS, 2005. - 175 p.
47. Filippova, GG Psychology of motherhood: a manual / GG Filippov. - Moscow: Publish36
ing House of the Institute of Psychiatry, 2002. - 240.
48. Chernukha, EA Prolonged and prolonged pregnancy. Guide for Physicians / EA Chernukha. - M.: "GEOTAR - Media", 2007. - 207.
49. Chernukha, EA TK Puchko breech presentation. Guide for Physicians / EA Chernukha,
TK Beam. - M.: "GEOTAR - Media", 2007. - 173 p.
50. Shmagel, KV Immune pregnant women / KV Shmagel, VA Cherries. - Moscow: Medical
Book, 2003. - 226 p.
51. Tskhai, VB Perinatal obstetrics: a manual for honey. Universities / VB Tskhai. - Atlanta:
Med. Academy of RAMS, Moscow, Honey. book, 2003.
52. Amniotic and extraembryonic structures in normal and complicated pregnancy / Ed. VE
Radzinsky. 2004. - 393 p.
53. Congenital, perinatal and neonatal infections: Per. from English. / Ed. A.Grinou, J. Osborne, S. Sutherland. - M.: Medicine, 2000. - 287.
54. Kulakov VI, Murashko LE Premature birth. M. Medicine, 2002.
55. Serov VN etc. Eclampsia: A Guide for Physicians / V.N.Serov etc. - M.: MIA, 2002. 463
- with
56. VM Sidelnikov Habitual loss beremennosti.-M.: Triad-X, 2002.
57. Disseminated intravascular coagulation in obstetrics AD Makatsaria etc. - M.: Triad-X,
2002. - 496.
58. Schechtman, MM, GM Burduli Diseases of the respiratory system and blood circulation
in beremennyh.-M.: Triad-X, 2002. - 230C.
59. Shifman EM Pre-eclampsia, eclampsia, NELLP syndrome / Inteltek, 2002.
More:
60.Uchebnoe grant for the development of practical skills surgical / Edited by prof. Atalieva
AE, prof. Babadjanova BD Tashkent 2003. C102-115
61.Algoritmy diagnosis and treatment of surgical / Edited by Academician Karimov
Sh.I.Tashkent 2003. From 39-64
62.Uchebnoe benefit surgical subjects for medical students / Edited by Academician Karimov Sh.I.Tashkent -2003 Part II Obstetrics and ginekologiya.S 64-19013. Practical skills in
obstetrics and gynecology / Metod.posobie / / Tashkent 2008.
63.Akushersky soft tissue injuries of the birth canal, Kulakov VI, Butova E.A.2004.
64.Akusherstvo. National rukovodstvo._2004.
65.Infektsii in Obstetrics and Gynecology How VK Seagull 2006
66.Hirurgicheskaya technique cesarean secheniya_Strizhakov A.N._2007.
67.Ratsionalnaya pharmacotherapy in obstetrics and ginekologii.2007
Chan_Gynecology_and_obstetrics.2004
68.Rukovodstvo for outpatient care in obstetrics and gynecology, Kulakov V.I.2005.
70.Sidorova_I.S._Rukovodstvo_po_akusherstvu_ (Medicina, 2006) (ru) (1033s
71.Posobie for practical development of Obstetrics Voronin (KV) 2007.
72.Kirienko AI, Matyushenko AA, Andriyashkin VV Ostryi tromboflebit/2005
AN 73.Ivanyan - Intrauterine growth ploda/2007
74.DVS_sinrom _v_akusherstve.2004
75.Neonatologiya (Bazhanov NP). - T. I. - 2004
76.Prikaz MZ № 500 "On the reorganization of maternity hospitals to improve the efficiency
of perinatal care and the prevention of nosocomial infections."
77.Internet sites:
http://www.studmedic.narod.ru/, http://med.siteedit.ru/,
http://www.rukovodstvo-po-akusherstvu.-uchebnoe-posobie.html,
http://www.materinstvo.ru, http://mama.ru.http://www.art-med.ru,, http://www.doctor.ru,
http://www.rodim.ru, http://mamka.ru
http://medagent.ru, http://www.art-med.ru, http://www.medsan.ru,
37
http://mediki.spb.ru, http://medinstitut.e2e.ru, http://www.medstudy.narod.ru
http://www.obgyn.ru, http://www.medsno.ru, http://medrusnet.euro.ru
www.medtext.ru, www.medpoisk.ru, www.medicum.nnov.ru/student/
http://6years.net/, http://preryvanie-beremennosti.pharmabort.ru/
http://med4net.ru/, http://www.med-life.ru/, http://www.pregnant.ru/
http://www.roddom.ru, http://www.medpoisk.ru/, http://www.medlinks.ru
Topic: Childbirth. Stages of labor. Partnership delivery. Keeping partons program and its
importance in the prevention of complications during childbirth. Active management of the
three stage of labor. Assessment of neonatal Apgar scores. International criteria of live
birth (CIM). Biomechanism birth at the front as the occipital presentation. Primary treatment of the newborn.
1st place of training, equipping,
 Department of Obstetrics and Gynecology, the audience;
 dummy pelvis, fetal doll, female pelvis.
38
 standard models of pregnancy;
 the classic model of labor;
 gynecologic simulator ZOE;
 childbirth simulator Noelle;
 simulator newborn Newborn;
 set of slides on the topics of discipline;
 practices in small groups: a method of "round table", resolution of problems, "pen in the middle of the table", "swarm", etc.;
 testing and teaching practical skills in OSKI (objective structured clinical examination).
 video, TV, TV;
 personal computer (Pentium-III);
 set of slides with typical conditions for ultrasound scanning of pregnant women and gynecologic patients;
 set of video blogs "VJOG" (USA), highlighting recent advances in diagnosis and treatment of
obstetric and gynecological conditions;
 set of movies and video with a demonstration of typical obstetrician-cal and gynecological
procedures and operations.
 training videos;
 educational software;
 multi media training and testing;
 the use of e-mail and INTERNET;
 business simulations and case studies;
 center for skills training;
 offices and laboratories maternity complex;
 delivery room;
 set of tests;
 set of slides on "fiziologichekih childbirth" slaydoskop;
 tools used during delivery-test tasks;
 step-research: the definition of readiness of the cervix for delivery, registration of labor, determine the ratio of the fetal head to the planes of the pelvis, determining the integrity of the placenta, the placenta separation methods;
 medical history partograph;
2.Prodolzhitelnost study subjects
The number of hours-5
3.Tsel classes
 examine the criteria the onset of labor, the harbingers of birth;
 to study in detail the characteristics of the three stages of labor;
 to explain the concept of battles and attempts;
 to explain the concept of the lower uterine segment, the contraction ring, the inner belt fit;
 learn to identify the cervix;
 to analyze the role of membranes in labor;
 consider the methods for determining the condition of the fetus during labor (CTG, ultrasound,
doplerometriya, etc.);
 discuss the specifics of labor (each period separately);
 explore options occipital previa;
 consider moments biomechanism birthing occipital fetal presentation;
Tasks
The student should know:
 the normal anatomy of the female genital oraganov;
39
 causes the onset of labor;
 neurohumoral regulation of labor;
 dominant genera;
 role in the development of the fruit of labor;
 signs of labor;
 triple descending gradient;
 stages of labor and their characteristics;
 moments biomechanisms birth at the front as the occipital presentation.
The student should be able to:
Demonstrate on a doll and pelvis all moments biomechanisms birth at the anterior and posterior
occipital previa types, determined by methods of Leopold-Levitsky position, position, type and
fetal presentation, to determine the readiness of the cervix for labor, to determine the integrity of
membranes, defined on the phantom in what plane of the pelvis is the head of the fetus, to show
the active management of the third stage of labor.
4.Motivatsiya
Management of labor in modern conditions is subject to governance generic act with your prediction of possible complications to the mother and fetus in order to reduce maternal and perinatal smertnosti.Krome addition, you should pay attention to rodorazreschenie differentiated according to the degree of risk of labor and select the optimal timing, methods and levels obstetric
facilities.
Intra 5.Mezhpredmetnye and communication
In preparation for the lesson, students will need to know the anatomy of the female genital organs, the structure and size of the fetal head, the structure and size of the female pelvis, biochemical processes in the body of a woman in preparation for childbirth.
Checking the basic knowledge of anatomy and topographic anatomy. The knowledge gained student can use the lessons of gynecology, intensive care, surgery and hygiene, therapy ..
6.Soderzhanie classes
6.1.Teoreticheskaya part
Delivery is called a complex biological process, which aims to expulsion from the uterus
through the birth canal after the fruit maturity. Theory and causes birth until now not fully
known. Different substances affect the development of labor
Oxytocin causes birth, so endogenous oxytocin may cause labor, but its level is fixed during
pregnancy and increases in the II stage of labor.
Cortisol - in adrenalectomized and hypophysectomized animals, as well as dressing the pituitary
portal system in fetuses are lengthened pregnancy. Introduction cortisol pregnant sheep causes
birth, administration of ACTH in fetal sheep - causes premature birth. In humans, there is elongation (prolon-doping) to 42-45 weeks of pregnancy when fetal anencephaly - no pituitary and
hypothalamus and labor does not occur. Lack of progesterone (P) (decrease) facilitates removal
of the uterus in pregnant rabbits. The man is not decreased progesterone in preterm labor. Likely
decline in the placenta P observed just before the birth, which promotes the synthesis of prostaglandins.
Prostaglandins - triggers birth vaginally appointment prostaglandins cause contraction of the
uterus. Prostaglandins are released during manipulation of the cervix and rupture of membranes,
the absolute precursor of prostaglandin - decidua vera. There is an increase of arachidonic acid in
the amniotic fluid. Esterified form of arachidonic acid is released from fetal membranes activates
phospholipase (by reducing progesterone), the release of arachidonic acid under the influence of
prostaglandin synthetase is converted to prostaglandins.
Under the action of prostaglandins is preparation of the cervix for childbirth: - softening - shortening - patency of the cervical canal,
- The location of the neck in the center of the pelvis, - thinning of the lower segment of the uterus up to 0.5 cm.
40
Pregnancy is considered full-term and fixed-term labor from 38 to 42 weeks gestation (266-280294 days) there is no evidence of post-term fetus (at 41-42 weeks) with a minimum mass for a
full-term baby 2500 g and 47 cm. Onset of labor is preceded by the appearance of so-called precursors of birth.
Harbingers of birth - a sign near the onset of labor, appear 7-10 days before delivery and appear
prolapse uterus due to clamping of the presenting part of the fetus to the entrance of the pelvis
and reduce the volume of amniotic fluid through the physiological water scarcity, a discharge of
"mucus plug", the lack of increase pregnant body mass, increased uterine tone (proud gait pregnant). The formation of the contact zone between the presenting fetal head and the lower segment of the uterus, amniotic fluid with are divided into front and rear. 12 hours prior to delivery
(on average 6 hours) develops preliminary period immediately preceding the onset of labor. Proceeds for pregnant almost unnoticeably marked irregular painless contractions of the uterus,
which are gradually becoming stronger and more persistent, and finally go into battle.
Preliminary period corresponds to the time of formation of the dominant clan, accompanied by a
biological "maturing" of the cervix. Normally, the preliminary period does not cause disturbances in women during sleep and wakefulness, painless.
When pathological preliminary period: painful, irregular uterine contractions lead to sleep disturbances, fatigue, pregnancy and development anomalies of labor.
Confinement is divided into three periods, lasts an average of 18 hours:
I period - the period of the opening of the cervix, II period - the period of expulsion, III period the period of the sequence.
I stage of labor - is that part of childbirth, which begins with the appearance of regular contractions and ends with complete cervical dilatation.
Contractions - is involuntary rhythmic muscle contractions of the uterus. Regular labors is when
contractions lasting 10-15 minutes (min) 30-35 seconds. Contractions are characterized by duration (from a minimum of 30-35 seconds at the beginning of period I to 90 seconds in the II stage
of labor), the force F = 20-50 mm Hg. Art., frequency (the interval of 10-15 minutes to 2-3
minutes at the end of period II) and painful: the pain of contractions is due to:
1. Hypoxia Acronym endometrium.
2. Compression of the nerve ganglia of the cervix and lower uterine segment.
3. Dilatation with its dilatation.
4. Stretching of the peritoneum covering the body of the uterus.
In the period of labor contractions I have: the deceleration phase, the phase of maximum lift, relaxation phase. This results in the cervix and the promotion of the fetal head.
Reduction in the uterus extend from the right tube angle (pacemaker) on the bottom and the left
corner of the pipe, the body and the lower segment of the uterus (triple descending gradient). In
the muscle of the womb processes:
retraction, contraction, distraction: stretching the cervix and lower segment.
In addition to disclosure of the cervix caused by uterine contractions, front amniotic fluid during
the match are sent to the lower pole of the amniotic sac and embraced it as a wedge ("hydraulic")
toward the cervix, the process of smoothing the cervix and its disclosure. These processes have
their own characteristics in I-and II-Rodia Rodia women.
I-Rodia - first smoothing and then a disclosure
II-Rodia - simultaneously smoothing and disclosure.
In the period I recovered phases: latent and active phases. Pace of cervical cancer: the I-and IIRodia Rodia women.
I - 1,1-1,3 cm (1 cm / hour. Average)
II - 1,5-1,8 cm (2 cm / hour. Average)
The total duration of the period I - 8-16 hours. At I-Rodia - 12 hours., At II-Rodya to half less (7
hrs.).
WHO recommendations for labor management
 Presence at birth relatives on women's choices and freely visit the postpartum period
41
 A healthy newborn is the mother
 Routine shaving the pubic area and the use of an enema before labor is not justified
 Women should not offer the lithotomy position for birth as the only possible
 Failure to routine episiotomy
 Failure to routine use of pain medication during labor
Safe delivery, according to WHO, are:
 Net
 Ongoing trained person
 Availability of skilled obstetric care in case of high risk of complications or
Partnership delivery
In women who received continuous support partner (15 studies, 12,791 women):
 Increased likelihood of vaginal birth
 Perception of the birth process was more positive
 rarely felt they are not involved in the decision-making process
Ongoing support partner accompanied by a decrease:
 Frequency of use of pharmacological analgesia
 delivery rate
 Frequency Caesarean
Continuous support during labor has been more effective if provided:
 by other than medical personnel
 Since the onset of labor
Mother's position in the first stage of labor
Vertical position and the free movement leads to:
- Shortening of the duration of labor
- Less commonly used anesthetic
- Less is necessary to stimulate labor
Less frequent violations of fetal heart rate
Doing I stage of labor.
1. History (obstetrical, gynecological).
2. Outside obstetrical examination.
3. Vaginal examination at admission and then on the testimony by the normal course of labor
(type, position, presentation).
4. Listening to the heartbeat, blood pressure, pulse, the woman's condition, the nature of discharge from the genital tract, the nature of promoting the front of the product.
5. The height of the physiological state of the contraction of the ring, the nature of labor.
6. All this doctor performs every 4 hours (in the prenatal examination), with an entry in the partograph.
Midwife. Observation during the act of birth: the woman, the nature of labor. Every hour - pressure, pulse, every 30 minutes - the heartbeat of the fetus, the character of discharge from the genital tract. Changes in the condition of the woman and the fetus - call your doctor. Indications for
extraordinary vaginal examination:
1. Change (worsening) in the state of women in labor (increased blood pressure, seizures, blurred
vision, headache, abdominal pain).
2. Changes (disturbances) the nature of labor.
3. Deterioration of intrauterine fetal (palpitations 100 or 180), fetal distress - Booth observation.
4. Bleeding from the genital tract.
5. Narcotic analgesics should be appointed (not less than 2 hours before delivery).
During childbirth to prevent hemoconcentration recommended intravenous infusion of 0.5-1.0
liters of saline solution, provides quick access to a vein in emergency situations, it is important
during anesthesia, prevention of blood pressure reduction.
Little is recommended during labor (prevention of vomiting), the administration of antacids - at
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admission and after 3 hours of admission.
Currently, delivery conducted on partogram
Partograph - a way to graphically display the birth process:
 The progression of birth:
 the cervix
 Promotion of the fetal head
 in labor
 fetal status
 status of mother
Features and benefits
Effective monitoring standard
Early detection of poor progress in labor
Detection of pelvic disproportion-head before symptoms obstruc-tion
Timely make informed decisions about the far-necks tactics birth
The definition of the necessary interventions
Simplicity, low cost, availability, visibility
Basic principles of the partograph
Partograph is used to maintain basically the first stage of labor
- However, in the second stage of labor should continue to record indicators of mother and fetus,
and uterine contractions
Partograph begin to fill in the presence of
- One or more uterine contractions in 10 minutes lasting 20 seconds or more in the latent phase
- Two or more uterine contractions in 10 minutes lasting 20 seconds or more in the active phase
- No complications requiring urgent care and / or delivery
Partograph completed during labor, and not after their completion
Partograph during labor should be in the delivery room
Filling and interpretation of the partograph should exercise trained personnel (doctor or midwife)
Keeping partograph terminated if
- A complication requiring emergency delivery
II stage of labor.
After full disclosure of uterine os (10-12 cm) in the norm is rupture of membranes. Contraction
ring is located 10 cm above the womb (the middle between the vagina and the navel) - a signSchatz Unterberger. After the outpouring of water labors slows uterus adapt to new conditions.
The period of exile, ending the birth of the fetus. Characteristic of the II stage of labor is the appearance of any attempts - synchronous with the uterus arbitrary (reflex) contractions of the abdominal muscles, diaphragm and pelvic floor. Attempts to extend from 50 to 90 seconds with an
interval of 2-3 minutes. Duration II period at I-Rodya to 2 hours (50 minutes), at II-Rodya to 50
minutes (20 min.) Given that the width of the symphysis pubis 2 cm, the rate of advance of the
fetal head through the birth canal at I-Rodia - 1 cm / hour, II-Rodia - 2 cm / hour. During childbirth fetal gradually descends into the pelvic cavity and changes its position relative to the plane
of the pelvis, which we define 3 and 4 doses of external and vaginal examination:
1. Head over the entrance or pinned to the door of the pelvis: pv pelvis defined liberty nameless
line cape and Pubic joint, sagittal suture is in the plane of the transverse size of the entrance to a
small basin, a large and a small soft spot on one level.
2. Small segment of the head at the entrance to the pelvis - the head is stationary, its largest segment is located above the plane of the entrance. When sheath-dimensional study of the cape can
be approached, pelvis - free, sagittal suture in a slightly oblique size.
3. The head of a large segment of the entrance to the pelvis - head most of its circumference in
the plane of the entrance to a small basin, determined pr.mostoideus, cervical groove on 1 cross
pin above the vagina. Head at p.v. - The upper third of the womb, the Cape reached a bent finger,
a small Rodnichek below the large, oblique sagittal suture in the pelvis.
43
4. Head in the widest part of the pelvis, is 2/3 the womb, I, II, III sacral vertebrae, defined ischial
spine, in an oblique sagittal suture size.
5. Head in the narrow part of the pelvic cavity - top head is not defined, the head of the fetus fills
the womb, all the sacrum to the sacrococcygeal joint, in an oblique sagittal suture, but close to
the right.
6. Head to the outlet of the pelvis - all filled head, spine not achieved, sagittal suture in the forward rate. 95% of births are in the front as the occipital presentation. Multiple paths, which
makes the fruit in the process of moving through the birth canal, called Biomechanism birth.
Biomechanism birth.
1. The fruit is oblique to its small size of the suboccipital fossa up of the front corner of the large
fontanelle - d = 9,5 cm, env. - 32 cm.
2. Wired point - small fontanel.
3. I point - bending.
II the time - internal rotation of the head with the correct rotation of the occiput to the symphysis,
III time - education I commit point - suboccipital fossa (the fetus) and the lower edge of the
symphysis in women,
IV moment - extension of the head around the point of fixation and its birth,
V point - external cephalic version and internal shoulder rotation,
VI point - education second fixation point - the front shoulder of the fetus (the top third) and the
lower edge of the symphysis pubis in the mother,
VII moment - lateral flexion of the trunk around the second point of fixation, the birth of the rear
shoulders, and then the front of the torso.
Keeping II stage of labor
Expectant management of passive-phase second stage of labor appropriate for satisfactory progress in labor
-The longer the period of active attempts, the higher the risk of postpartum hemorrhage, intrauterine infection and perinatal morbidity
Keeping II stage of labor: push can be enabled only when the head is lowered into the pelvic
cavity, t. To. pressure on the head of the bone canal 10 kg (risk of injury, the head is not configured), the risk of bleeding into the brain and spinal cord. Clinical signs that head down on the
pelvic floor:
1. Head is not defined under the womb using obstetric techniques.
2. Positive symptom Piskacheka (through the labia lips one phalanx determines the presenting
head).
3. Any attempts at sexual gaping slit and anus.
With these clinical signs woman is transferred to tribal hall. In the II stage of labor: about the
state of women (blood pressure, pulse, mood), and fetal monitoring after each attempts (palpitations) or every 3 minutes, t. To. 30-50% of fetuses with fetal distress syndrome and dying during
childbirth do not show signs of previous suffering. The head of the fetus first cuts right - appears
during attempts and disappears into the vagina after its termination, then I formed the point of
fixation (Biomechanism by birth) and head erupt, ie disappears into the vagina is pushing. From
now beginning to have an obstetrical benefits. Midwife assisted delivery with cephalic presentation is a collection of serial manipulations at the end of II stage of labor to promote the physiological mechanism of labor and injury prevention of mother.
Midwife should wear sterile gown, mask, cap, hand processed for abdominal surgery and put on
sterile gloves, external genitals and inner thighs women carefully treated with a disinfectant solution, dried with a sterile cotton swab (sequence crotch, thighs, vulva, anus) treated with antiseptic (yodonat). Anus or cover cloth diaper.
The woman lies on her back, head end elevated, legs bent, perhaps, Dena and rest on the bed, the
woman's hands are on the handrails for easy pushing. Obstetrical benefits may be provided in the
position of women on the side with divorced hips. Acceptance of delivery in the occipital previa
carries midwife. Physician during the period of exile following the heartbeat of the fetus, labor
44
and delivery. He makes use of drugs, perform surgery (episodes - and perineotomy). All pathological delivery, including breech takes a doctor, he makes forceps, vacuum ekstratsiyu fruit etc.
To provide obstetrical benefits begin after the eruption of the head, i. E. when the head is at the
end of attempts to not go back to the sex gap.
Obstetrical manual includes five points:
1. The first point of obstetric aid is to prevent premature extension of the head. This is necessary
to the head was born in the bent position, his least-necks circumference (32 cm), passing the
small oblique
size (9.5 cm). To implement one time midwife puts his left hand on the crotch so that the palmar
surface of the fingers somknutnyh placed on the head of the fetus and prevent it from straightening
2. Artificial tissue from the area of debt relief in smaller more - be-rezhno stretch fabric vulva
right hand (removed) from the head and sent tissue towards the perineum (the back wall) to reduce its stress.
3. The third point of obstetric aid - any attempts regulation - the purpose: to slow progress of the
head through the birth canal to the last time to adapt to the size of the nascent head. If it is not,
there will be a gap of tissues of the perineum.
1, 2 and 3 times to carry out benefits until the head is not close to the parietal tuber gender gap.
4. The fourth point of obstetric benefits - removal of the fetal head is pushing. The woman asked
not to push, and often offer deep breathing mouth open. With such a push can not breath. At this
point, the midwife gently removes his right hand fabric crotch with little face fetal posterior and
left hand slowly extends the head, if the need arises in attempts, a woman asked tightly. Next
midwife waiting while attempts will turn heads outside and internal rotation of shoulder and then
proceeds to provide the fifth time obstetrical benefits.
5. Fifth point obstetrical benefits - removal shoulder and torso. Fetal grab with both hands and
gently pulled backwards until the upper third of the vagina by the anterior shoulder (the fixation
point). After that, the left hand grasp the head so that his hand was on the back of the fetus's
cheek, lifting the head in front, right hand, gently shift the crotch of the back shoulder, back
shoulder is born. Then grab fruit from behind aksilyarnye pits and display body in the direction
of the axis of the birth canal to the mother's abdomen.
After birth, the fetus begins III period (sequence) genera, which ends the placenta: placenta and
the umbilical cord with a shell (secundina). The placenta does not have the ability to contract,
and placental bed with the rest of the uterus with the start sequence begins to contract labor and
greatly reduced in size. This leads to a communication failure between the placenta and the uterine wall. The placenta can be separated in two ways:
1. From the center - formed retroplacental hematoma, which contributes to the separation of the
placenta. This method is called the center (by Schulze). In central placenta no external bleeding
and hematoma retroplacental born with afterbirth, fruit shells inside-out, and the mother inside.
2. If the placenta begins with the edge (by Duncan), the retroplacental hematoma is formed, and
with each contraction increases the area of placental abruption. At the regional office from the
very beginning there bleeding from the genital tract and the last born maternal surface outside.
Successive period lasts an average of 10-15 minutes, with no bleeding can wait up to 30 minutes.
Blood loss in the third period of an average of 250 ml, the maximum allowable blood loss up to
400 ml, or 0.5% of body weight women. In some cases there may be a delay separated the placenta in the uterus. Therefore it is necessary to know the signs that indicate that the placenta separated from the uterus and is in the cervix or vagina.
Expectant management of the third stage of labor
Watchful
Without the use of uterotonic drugs
Without pulling the umbilical cord, or pressure on the uterus
Waiting independent placenta or the use of an additional load, or nipple stimulation
To date have taken the active management of the third stage of labor:
45
 Introduction of oxytocin (10 IU / m) or another drug-yuschego causing uterine contractions in
the first minute after birth;
 The birth of the placenta by controlled cord traction;
 uterine massage after delivery of the placenta.
Advantages of active management of the third stage of labor compared with expectant
 Reduced total blood loss
 Reduction of postpartum blood loss of over 500 ml
 Reduction of postpartum blood loss of over 1000 ml
 Reduce the total duration of the third stage of labor
 Reduction of cases of low hemoglobin levels in parturients, the need for blood transfusions
and postnatal therapeutic-Soviet oxytocin
Signs of the placenta:
1. Sign Schroeder - the uterus after the birth of the fetus is in the navel, is deflected to the right
and up
2. Sign Alfeld - placenta falls to the lower segment or moisture-ing School and extended umbilical cord.
3. Sign-Kyustnera Chukalova - not connected to the uterus and is not drawn into the birth canal
with pressure side of his hand above the vagina.
4. Sign Dovzhenko - retraction cord with a deep breath.
5. Sign Strassmann - oscillating movement of blood in the placenta in the uterus by pokalachivanii inseparable placenta when transferred to the umbilical cord.
6. Sign Klein - straining or pressure on the bottom of the uterus and the umbilical cord goes back
into the sex gap at the termination of the pressure.
In order to determine that the placenta detached, just use the 2.3 feature. If the placenta is separated, then immediately proceed to its selection. Before you select the latter, you need to empty
the bladder, and then offer the woman tightly. Under the effect of abdominal pressure of the placenta is usually easily born. If this method was unsuccessful, then turn to release the placenta
outdoor receptions.
Ways to the Division of the following:
1. Abuladze way - make gentle massage of the uterus so that it fell. Then with both hands grasp
the abdominal wall in the longitudinal folds and offer women more tightly. Separated with the
latter easily born thanks to a significant increase in the intraperitoneal pressure.
2. Gentera way - the bottom of the uterus lead out to the middle line, the doctor becomes the side
of the face to the pregnant woman, her foot, hands balled into fists, put the back surface to the
bottom of the main phalanx of uterine tube angles and gradually jam on the bottom of the uterus
downwards and inwards. In this method of separation of the placenta woman should not push.
3. Credit-Lazarevic way - as the most traumatic and painful, people resort to it after unsuccessfully for the first two methods. Based technique is the following: the uterus taken out into the
middle position, a light massage try to get her to fall, and then cover the bottom of the uterus by
hand so that the thumb is on the front wall of the uterus, in the bottom of the palm, the remaining
four fingers on the back of the uterus. After that, the squeezing of the placenta. The latter usually
born
whole, but sometimes delayed membrane of the uterus. In this case, who was born the placenta
taking up and slowly rotate in the same direction. Thus there is a twist wrappers, which contributes to their peeling from the walls of the uterus and removal without dropping out. There is another way (cn. Gentera) after giving birth the placenta offer lean on your feet and raise your pelvis. In this case the placenta hanging down and his weight promotes exfoliation and removal of
shells.
After birth, the placenta begins early postpartum period, which lasts 24 hours ing. After the birth
of the last inspected (integrity shells and maternal surface), carefully inspect edge of the placenta, and then inspect the shell - this last flip fruit shells, paying attention to the integrity of the
46
blood vessels, etc. To. availability of additional vessels means extra lobe, which remains in the
uterus. In this case, you must perform manual examination of the uterus, i. K. which can cause
bleeding in the early or late postpartum period. Inspection of the birth canal: cervix, perineum,
the uterus.
Initial assessment of the functional state of the newborn performed on a scale of Virginia Apgar
(USA) proposed in 1953. In Russia, the double entry Apgar score: at 1 and 5 minutes after birth,
all newborns regardless of gestational age and birth weight. Vital signs are: heart rate, breathing,
muscle tone, reflex responses activity and color of the skin, which evaluate 0, 1, 2 points. A
healthy newborn is rated 8-10. The prognostic value of scale is a group of full-term children.
Clinical symptoms listed in the Apgar score depends on many factors, primarily on the degree of
maturity, metabolic changes and the severity of asphyxia.
Maturity of the newborn is determined by the totality of clinical, functional, and biochemical parameters. In each age period, from zygote adaptation features of the fetus, newborn and infant
match his calendar age in conjunction with the environment surrounding it and interacting with
it. The central nervous system is informative characteristic of maturity. In the study of child assess posture, position, spontaneous motility face, emotional reactions, birth unconditioned reflexes and activity of sucking. For clinical signs of neonatal maturity is determined by the sum of
scorecard balls each trait.
CRITERIA live births and stillbirths, recommended that WHO.
Childbirth - the complete expulsion or extraction (extraction) dead or alive fetus from the mother
weighing more than 500 grams, regardless of gestational age, or when the term of 22 weeks or
more.
Live birth - the complete expulsion or extraction of a product of conception from the mother, regardless of the duration of pregnancy, which, after such separation, breathes or shows one of the
other signs of life, such as the heart, pulsation of the umbilical cord or explicit voluntary movement of muscles, regardless of whether the cut umbilical cord and a placenta separated.
Stillbirth (stillborn fetus) - the death of the product of conception to its complete expulsion or
extraction from its mother is a function of the duration of pregnancy, and the lack of such an office after the sign of life (heartbeat, breathing, pulsating umbilical cord or explicit voluntary
movement of muscles).
Depending on the timing of the death distinguish antenatal and intrapartum fetal death and the
postnatal death of the newborn:
1) antenatal death - occurred before the onset of labor;
2) intranatal death - which came during childbirth;
3) postnatal death - occurs after the birth of a live baby.
Perinatal period - begins with 22th full week (154 - ro day) intrauterine life (at this time in normal fetal weight is 500 g) and ends after seven completed days after birth.
Neonatal period (neonatal period) - starts at moment of birth ends after 28 completed days after
birth.
Neonatal mortality - the death rate among infants in the first full 28 days of life, distinguish the
early neonatal mortality (ie, mortality during the first 7 days of life) and late neonatal mortality
(ie, mortality, taking place in the period after 7 full days of life to 28 completed days of life).
Early neonatal deaths divided by the following categories:
- Less than an hour;
- From 1 to 23 hours;
- From 24 to 167 hours.
Depending on the duration of pregnancy distinguish genera:
1) premature (preterm) - birth gestation less than 37 completed weeks (259 days);
2) The term (full-term) - Birth of pregnancy from 37 completed weeks to less than 42 completed
weeks (259-293 days);
3) delayed (post-term) - Birth of pregnancy at 42 completed weeks or more (294 days or more).
Newborn - Primary WC: eye treatment, cutting off the umbilical cord and handling balance,
47
leather neonatal anthropometry. Conducting secondary treatment and secondary prevention of
umbilical blenorei performed in a designated area for infants on a heated changing table, and only, if changing the midwife in a sterile gown and prepare her hands under aseptic and antiseptic.
Bracket to the umbilical residue does not impose, but replace the ligature provided: thick and
juicy cord Rh-negative mother's blood supplies, low birth weight infants and children in serious
condition. Conduct initial processing of skin, weighing, measuring length, head circumference,
chest circumference and diapering.
The use of new educational technologies:
METHOD "BOOM"
Purpose: Entertainment, concentration.
Means: Chairs.
Approximate time: 10 minutes.
The steps are:
1. All participants sit in a circle They should consider aloud in turn. Everyone whose number is a
multiple of three (3-6-9-12, etc.) or ends with the number 3 (13-23-33, etc.) have to say
"BOOM" instead of a number. The next player must continue normal account. Example: The
first man says, "time", said the following "two", the player who had to say "three", but instead
says "BOOM!" Next "four", etc.
2. A player who has forgotten to say "BOOM" or a mistake in the number, followed by
"BOOM!" Out of the game.
3. The numbers should be called quickly, if a player thinks too long (more than 5 seconds), it is
also out of the game.
4. The remaining two players wins.
Note: The game can be more difficult, using the multiplicity of a large number of lamas or a
combination of the three multiplicity and multiplicity of five.
6.2.Analiticheskaya part
Case studies:
1.Pervorodyaschaya 23 years old was admitted to the maternity hospital in labor in 5 - 6 minutes
and 30 seconds in a satisfactory condition. Pulse 82 beats per minute, blood pressure - 120/80
mm Hg. Pelvic dimensions: 25 - 28 - 30 - 20, OJ - 98 cm, WMM - 35 cm. Heartbeat plaid clear,
rhythmic, 136 beats per minute.
What is the diagnosis?
How to birth?
Answer: Ber.I 40 weeks. genera I. I stage of labor, vaginal delivery
2.Rozhenitsa is in labor 12 hours. Vaginal examination:
Opening uterine mouth full, no membranes. Predlezhit head occupies the top half of the sacral
cavity and heart. Sagittal suture in the left oblique pelvis, a small soft spot on the right front, a
large - left posteriorly.
What is the position, type, position?
A: longitudinal, I position, front view
3.Povtornorodyaschaya 30 years in a labor 8 hours. Attempts after 2 - 3 minutes for 50 - 60 seconds. Fetal heart clear, rhythmic, 130 beats per minute. During any attempts cut into the buttocks
of the fetus.
The diagnosis?
What is obstetric tactics
Answer: breech presentation. II stage of labor, manual allowance Tsovyanovu
4.B 11.00 entered primigravida woman, 29 years with complaints of pain in the lower back and
abdomen, regular, 4-5 minutes. of 25 - 30 sec., average power and intensity. Amniotic fluid retreated to 10.00 - light.
Vaginally: admission - the cervix 5 cm
The diagnosis?
What period of the birth?
48
Which phase?
A: Bear I 40 weeks, birth I, I stage of labor, the active phase.
5. Received a woman 30 years old to 38 weeks of pregnancy. After seeing it you have written a
history of the following: stomach enhanced by the pregnant uterus. OJ-89cm, height 35cmuterus. At the bottom of the uterus palpable volumetric soft part of the fetus, in the right halfuniform extensive area in the left-smaller parts in the lower uterine segment rounded, dense part
of the fetus with sharp edges, moving the entrance to the pelvis. Fetal heart is clear, rhythmic,
140 beats / min, listen to the right below the navel.
The diagnosis?
Predlezhaschaya part?
Position and the position of the fetus?
Answer: I Ber 38ned, Childbirth I, I stage of labor, cephalic presentation, longitudinal, II position, rear view.
6. At 9.00 pm she received 30 to 39 weeks gestation. Complaints of pain in the lower back and
abdomen, regular, 10 to 12 minutes at 20 - 25 sec., Average power and intensity. Amniotic fluid
would not leave. After seeing it you have written a history of the following: stomach enhanced
by the pregnant uterus. OJ-89cm, height of uterus - 35cm. At the bottom of the uterus palpable
volumetric soft part of the fetus, in the right side - a vast area is uniform, the left - small parts in
the lower segment of the uterus - rounded, dense part of the fetus with sharp edges, moving the
entrance to the pelvis. Fetal heart is clear, rhythmic, 140 beats / min, listen to the right below the
navel.
Vaginally: admission - the cervix 1 cm
13.00 - cervical dilatation 3 cm
17.00 - the cervix 6 cm
20.00 - the cervix 10 cm
The diagnosis?
What period of the birth?
Presenting part, the position and the position of the fetus?
The estimated weight of the fetus?
Answer: I Ber 39ned beginning I stage of labor, longitudinal, head, II position, 3100,0 ± 200,0.
6.3. Graphic organizer: Making graphic organizer
"Table W / X / Y / Y on" What stage of labor? '
TABLE W / X / Y / Y
Know / want to know / learn.
Allows for research work on the text, topic or chapter.
Develops systems thinking, analysis skills, structuring.
6.4.Prakticheskaya part
DEFINITION OF TERMS OF LABOUR
Objective: To determine the terms of labor
Performs step (steps):
Events number does not hold nil
(0 points) Fully
correctly
performed
(20 points)
1. On the first day of the last menstrual period (by Naegeli) is counted from that date back three
calendar months and add 7 days 0 20
2. By ovulation: the first day of your last period was added 14 days (period expected ovulation
and conception) and then added 280 ± 7 days. 0 20
3. On the first fetal movements: the date of the first fetal movements in primiparous added 20
weeks, multiparous - 22-23 weeks 0 20
4. Date first appearance to the doctor in early pregnancy that date pribav-lyayut the deadline
49
missing weeks of gestation to 40 and are due date 0 20
5. For objective data: at the time of inspection set term pregnancy and, by adding the missing
week to 40, determine the date of birth 0 20
Total 0100
7.Formy control of knowledge, skills and abilities
-Oral;
-Alphabet;
Testing;
Solution situational problems;
And demonstration of skills mastered.
8.Kriterii assessment monitoring
№ Progress
Score in% level of students' knowledge
1 96-100% Excellent
"5" full correct answer to the question of the etiology, pathogenesis, classification, clinic, diagnostics, treatment and prevention of this disease. To sum up and make decisions, creative thinking cally, self-analyzes, case studies resolves correctly, with a creative approach, with full justification of the answer. Actively and creatively involved in interactive games, take the right decisions and summarizes and analyzes. Medical history, partograph fills correctly.
2 91-95% Excellent
"5" full correct answer to the question of the etiology, pathogenesis, classification, clinic, diagnostics, treatment and prevention of this disease. Think creatively, independently is analyzed,
case studies decides correctly, with a creative approach, with full justification of the answer. Actively and creatively involved in interactive games, take the right decision. History of diseases,
partograph fills with 1 grammatical mistake.
3 86-90% Excellent
"5" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis, treatment and prevention of diseases of the covered completely, but have 1-2 errors in the
response. Own analyzes, inaccuracies in the solution B-ation problems, but with the right approach. Actively involved in interactive games, make the right decisions. Medical history, partograph fills with 2-3 grammatical errors.
4 81-85% Good
"4" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis,
treatment and prevention of diseases of the covered completely, but there are 2-3 inaccuracies,
errors. Into practice, understands the essence of the question, says confidently, is a faithful representation. Situational problems solved correctly, but the justification answer sufficiently. Actively involved in interactive games, take the right decision. History of diseases, partograph fills with
2-3 grammatical errors, inaccuracies in the description.
5 76-80% Good
"4" correct but incomplete lighting-set questions. The student knows the etiology, pathogenesis,
classification, clinic of the disease, but not completely disassembled diagnosis, treatment and
prevention of this disease. Understands the issue, says confidently. There is an exact representation. Actively involved in the interactive-tion games. On case studies gives partial solutions.
Medical history, partograph fills with 3-4 grammatical errors, inaccuracies in the description.
6 71-75% Good
"4" correct but incomplete lighting-set questions. The student knows the etiology and pathogenesis of the disease, but not completely disassembled diagnosis, treatment and prevention of this
disease. Understands the issue, says confidently, is a faithful representation. On case studies
gives partial solutions. History of diseases, partograph fills with 3-4 grammatical errors, 3-4 errors in the description.
7 66-70% Satisfactory
"3" right answer half the questions. Student knows the etiology of the disease, but do not pay out
50
the classification, clinic-tion of the disease, the treatment and fumbles of prevention. Understands the issues ca, says confidently, has the only views on certain issues topic. Situa-tional
problems are solved correctly, but there is no justification of the answer. Medical history, partograph fills with 3-4 grammatical errors, 3-4 errors in the description.
8 61-65% Satisfactory
"3" right answer half the questions. Errors in the etiology, pathogenesis, poorly versed and confused in the treatment and prevention of this disease. Says uncertainly, has the only views on certain issues topic. Making mistakes in solving situational problems. History of diseases and partograph fills with errors.
9 55-60% Satisfactory
"3" error response to half the questions. Student makes an error in the etiology of the diseasedanno, confused and poorly versed in other matters related to the disease. Says uncertainly has a
partial view on the subject. Situational problems solved incorrectly. Medical history and partograph fills with errors.
10 50-54% unsatisfactory-liminary "2" The correct answer to third-represented supplied questions. Student does not know the etiology of the disease, and poorly versed entangled in other
issues related to the disease. C-ation problems are solved with the right approach is wrong. Medical history and partograph fills with errors.
46-49 11% unsatisfactory-liminary "2" right answer quarter supplied-represented issues. Student
does not know the etiology of the disease, and poorly versed entangled in other issues related to
the disease. C-ation problems are solved with the right approach is wrong. Medical history and
partograph fills with errors.
12 41-45% unsatisfactory-liminary "2" Lighting fifth set of issues with bugs. Student does not
know the etiology of this disease, little versed in other matters related to the disease. Gives an
incomplete and partially incorrect answers to questions on the classification of the clinical disease. Situa-tional problems are solved with the right approach is wrong. More than half of the
patient's history and the partograph filled with errors.
13 36-40% unsatisfactory-liminary "2" Lighting 1/10 of the questions at the wrong approach.
Does not know the etiology of the disease, and poorly versed entangled in other issues related to
data-tion of the disease. Gives incomplete and partially incorrect responses to questions on the
classification, climate-ship of the disease. Situa-tional problems are solved with the right approach is wrong. Bole half medical history and partograph fills with gross errors.
14 31-35% unsatisfactory-liminary "2" to the questions not answers. Does not know and does not
understand the other issues relating to this of diseases. Does not know how to fill out and describe the clinical history and the Party of the program.
9. Typical flow chart of lesson
Stages of work, time-name The content of the
Teachers Students
1etap. Introduction to the training session
(5min) 1.1.Soobschaet topic, purpose, and planned training results. Familiar with the plan, features of the training session.
1.2.Nazyvaet: key categories and concepts from the data subject tion, a list of books for selfstudy
1.3.Soobschaet indicators and criteria of educational work in class
Listen, record,
specify, ask the question.
Stage 2.
Primary
(235 min) 2.1.Provodit updating knowledge through блиц-опроса/вопросно-ответной forms /
brainstorming, etc.
2.2. Consistently describes the steps
51
on the organization of the educational process according to the structure of practical training.
Meet
Abstracts with ethyl.
Working in groups, will present the results of the group work
Stage 3.
The Final-Resultant-regulating (60 min)
3.1.Delaet opinion on the subject, attention was concentrated on the main students, according to
the importance of the work done for future careers.
3.2. Commends the work of groups (some of students) summarizes vzaimootsenki. Analyzes
and evaluates the degree of achievement of lesson.
3.3. Gives the task for independent work, informing schaet and criteria evaluation. Selfevaluation,
interaction assessment.
Ask the question.
Write down the job.
10.Kontrolnye questions
1.Ploskosti pelvic organs, their size?
2.Paper fetal head.
3.Provodnaya line pelvis.
4.Provodnaya, or leading, period.
5.Opredelenie biomechanism birth.
6.Biomehanizm birth at the front as the occipital presentation.
7.What is the stages of labor?
8.Chto a contraction, and retraction of the myometrium distraction?
9.Osobennosti cervical dilatation in nulliparous and multiparous women.
10.Chto is now internal contact?
11.What is the front and rear amniotic fluid?
12.Nazovite basic methods of anesthetic delivery.
13.Perechislite main parameters that characterize attempts.
14.Ukazhite expectancy II stage of labor in nulliparous and multiparous women.
15.Ukazhite ways to determine the position of the head in the pelvis in the II stage of labor.
16.Perechislite principles manual grant on the birth of the fetus.
17.Priznaki separation of the placenta
18.Sposoby separation of the placenta
19.Otsenka of newborn Apgar
20.Fiziologicheskaya blood loss during delivery.
11. Recommended Reading
Summary:
1. Abramchenko, VV Epidural anesthesia in obstetrics: a guide for physicians / 2006. - 229 p.
2. Abramchenko, VV Pregnancy and delivery of high risk: a guide for physicians / - M. Med.
Inform, 2004. - 400 p.
3. Abramchenko, VV Cesarean section in perinatal medicine: a guide for physicians / 2005. 126.
4. Abramchenko, VV Postoperative intensive care in obstetrics / Literature, 2000. - 88.
5. Abramchenko, VV Pharmacotherapy of preterm labor / 2006. - 448.
6. Abramchenko, VV Purulent-septic infection in obstetrics and gynecological
logii.rukovodstvo / 2005. - 459
7. Abramchenko, VV Postoperative intensive care in obstetrics / - St. Petersburg: Spec. Literature, 2000. - 88.
8. Abramchenko, VV Clinical perinatology / IntelTek, 2004. - 424 p.
9. Ailamazyan, EK Midwifery: a textbook for honey. Universities / 2003 - 528.
10. Topical issues of Obstetrics, Gynecology and Reproductive / Ed. EV KOKHANEVICH. 52
Moscow: Triad-X, 2006. - 480.
11. Obstetrics. Ed. GM Savelyeva. - M.: Medicine, 2000. - 816 p.
12. Obstetric and gynecological care: Hands-on. for doctors / Ed. VI Kulakov. - Moscow:
MEDpress, 2000. - 512 p.
13. Obstetrics. Clinical lectures: a manual for schools with a CD / Ed. OV Makarova. - Moscow: GEOTAR Media, 2007. - 640.
14. Obstetrics. Directory of the University of California / Ed. Nisvandera K., A. Evans: Lane.
from English. - M.: Practice, 1999. - 704 p.
15. Barashnev, YI Perinatal neurology / Y. Barashnev. - M.: "Triad - X", 2005. - 670 p.
16. Bodyazhina, VI Akushersvo. The manual for the media. prof. Education / VI Bodyazhina. Rostov-on-Don: Phoenix, 2003. - 480.
17. Resurrection, SL Fetal assessment. CTG. Doplerometriya. Biophysical profile: a manual for
the system of postgraduate medical. Education / SL Resurrection. - Minsk: The Book House,
2004. - 304.
18. Gazhonova, VE Ultrasound in Gynecology / VE Gazhonova. - Moscow: MEDpress-inform,
2005. - 264.
19. Gluhovets, BI Ascending infection of placental / BI Gluhovets. - Moscow: MEDpressinform, 2006. - 240.
20. Humeniuk, EG Obstetrics: Physiology of pregnancy: a training ben-beats / EG Humeniuk. Petrozavodsk: IntelTek, 2004. - 170 p.
21. Demidov, VN Pelvic ultrasound in women. Adnexal cysts and benign ovarian tumors: a
practical guide / V. Demidov. - Moscow: Academy of Medical Sciences, 1999, vol. II. - 100 p.
22. Duda VI Obstetrics: a textbook for high schools in the specialty "General Medicine" / Minsk: High School, 2004. - 639 p.
23. Duda VI Physiological OB / - Minsk: 2000. - 447 p.
24. Duda VI Operative obstetrics: a manual / Minsk Interpresservis, Book House, 2002. - 512 p.
25. Zhilyaev, NI Obstetrics: phantom course / - Kiev, 2002. - 239 p.
26. Zhilyaev, NI Operative Obstetrics: Ouch. Manual / Kiev 2004. - 468 p.
27. Zhilyaev, NI Operative surgery in obstetrics and gynecology / 2004.
28. Selected lectures on obstetrics and gynecology / Ed. AK Strizhakova etc. - Rostov-on-Don:
Phoenix, 2000. - 512 p.
29. Clinical recommendations. Obstetrics and Gynecology: scientific publication / Ed. VI Kulakov. - Moscow: GEOTAR Media, 2006. - 512 p.
30. Clinical lectures on obstetrics and gynecology / Ed. AN Strizhakova etc. - M.: Medicine,
2000. - 379 p.
31. Clinical evaluation of laboratory tests in women: study guide / Moscow Medical and Dental. University. NA Semashko. - M: 2005. - 96 p.
32. Kulakov, VI Preterm birth / VI Kulakov, LE Ants. - M.: Medicine, 2002. - 176.
33. Kulakov, VI Intensive care in obstetrics and gynecology (efferent methods) / - M: MIA,
1998. - 206 p.
34. Drugs used in obstetrics and gynecology / Ed. Acad. RAMS VI Kulakov, Acad. RAMS VN
Serov. 2006. - 375 p.
35. Emergency care in obstetrics and gynecology. Quick Guide - M. GEOTAR - Media, 2007. 52.
36. Perinatology Basics: A tutorial / Ed. MP Shabalov. - Moscow: MEDpress-inform, 2002. 576 p.
37. Practical skills in obstetrics and gynecology: a manual / LY Suprun, TS Divakova and others. - Minsk: New Knowledge, 2002. - 166 p.
38. Rational pharmacotherapy in obstetrics and gynecology: Hands-on. for practitioners / Ed.
VI Kulakov, VN Serov. - M.: 2005.
39. Guide Out - patient care in obstetrics and gynecology / Ed. VE Radzinsky. M: GEOTAR Media, 2007.
53
40. Guide to practical training in obstetrics / Ed. VE Radzinsky. - M.: MIA, 2004. - 576 p.
41. Saveliev, GM Obstetrics: a textbook for schools / GM Savelyev, RI Shalina. - Moscow:
GEOTAR Media, 2008. - 656 p.
42. Sidelnikov, VM AG Antonov Premature birth. A premature baby / VM Sidelnikov, AG Antonov. -M. "GEOTAR" 2006.
43. Smirnov, A. Pregnancy without problems / AN Smirnov. - Moscow: Atris Press, 2002. 208.
44. Smirnov, LM Obstetrics and Gynecology: Textbook / LM Smirnov. - M.: Medicine, 1999. 368 p.
45. Handbook of obstetrics, gynecology and perinatology: uch.posobie for doctors / Ed. GM
Savelevoy.2006. - 720.
46. Trifonov, E. Obstetrics and gynecology: a manual for med._vuzov / EV Trifonov. - Moscow: VLADOS, 2005. - 175 p.
47. Filippova, GG Psychology of motherhood: a manual / GG Filippov. - Moscow: Publishing
House of the Institute of Psychiatry, 2002. - 240.
48. Chernukha, EA Prolonged and prolonged pregnancy. Guide for Physicians / EA Chernukha.
- M.: "GEOTAR - Media", 2007. - 207.
49. Chernukha, EA TK Puchko breech presentation. Guide for Physicians / EA Chernukha, TK
Beam. - M.: "GEOTAR - Media", 2007. - 173 p.
50. Shmagel, KV Immune pregnant women / KV Shmagel, VA Cherries. - Moscow: Medical
Book, 2003. - 226 p.
51. Tskhai, VB Perinatal obstetrics: a manual for honey. Universities / VB Tskhai. - Atlanta:
Med. Academy of RAMS, Moscow, Honey. book, 2003.
52. Amniotic and extraembryonic structures in normal and complicated pregnancy / Ed. VE
Radzinsky. 2004. - 393 p.
53. Congenital, perinatal and neonatal infections: Per. from English. / Ed. A.Grinou, J. Osborne,
S. Sutherland. - M.: Medicine, 2000. - 287.
54. Kulakov VI, Murashko LE Premature birth. M. Medicine, 2002.
55. Serov VN etc. Eclampsia: A Guide for Physicians / V.N.Serov etc. - M.: MIA, 2002. 463 with
56. VM Sidelnikov Habitual loss beremennosti.-M.: Triad-X, 2002.
57. Disseminated intravascular coagulation in obstetrics AD Makatsaria etc. - M.: Triad-X,
2002. - 496.
58. Schechtman, MM, GM Burduli Diseases of the respiratory system and blood circulation in
beremennyh.-M.: Triad-X, 2002. - 230C.
59. Shifman EM Pre-eclampsia, eclampsia, NELLP syndrome / Inteltek, 2002.
More:
60.Uchebnoe grant for the development of practical skills surgical / Edited by prof. Atalieva
AE, prof. Babadjanova BD Tashkent 2003. C102-115
61.Algoritmy diagnosis and treatment of surgical / Edited by Academician Karimov
Sh.I.Tashkent 2003. From 39-64
62.Uchebnoe benefit surgical subjects for medical students / Edited by Academician Karimov
Sh.I.Tashkent -2003 Part II Obstetrics and ginekologiya.S 64-19013. Practical skills in obstetrics and gynecology / Metod.posobie / / Tashkent 2008.
63.Akushersky soft tissue injuries of the birth canal, Kulakov VI, Butova E.A.2004.
64.Akusherstvo. National rukovodstvo._2004.
65.Infektsii in Obstetrics and Gynecology How VK Seagull 2006
66.Hirurgicheskaya technique cesarean secheniya_Strizhakov A.N._2007.
67.Ratsionalnaya pharmacotherapy in obstetrics and ginekologii.2007
Chan_Gynecology_and_obstetrics.2004
68.Rukovodstvo for outpatient care in obstetrics and gynecology, Kulakov V.I.2005.
70.Sidorova_I.S._Rukovodstvo_po_akusherstvu_ (Medicina, 2006) (ru) (1033s
54
71.Posobie for practical development of Obstetrics Voronin (KV) 2007.
72.Kirienko AI, Matyushenko AA, Andriyashkin VV Ostryi tromboflebit/2005
AN 73.Ivanyan - Intrauterine growth ploda/2007
74.DVS_sinrom _v_akusherstve.2004
75.Neonatologiya (Bazhanov NP). - T. I. - 2004
76.Prikaz MZ № 500 "On the reorganization of maternity hospitals to improve the efficiency of
perinatal care and the prevention of nosocomial infections."
77.Internet sites:
http://www.studmedic.narod.ru/, http://med.siteedit.ru/,
http://www.rukovodstvo-po-akusherstvu.-uchebnoe-posobie.html, http://www.materinstvo.ru,
http://mama.ru.http://www.art-med.ru,, http://www.doctor.ru, http://www.rodim.ru,
http://mamka.ru
http://medagent.ru, http://www.art-med.ru, http://www.medsan.ru,
http://mediki.spb.ru, http://medinstitut.e2e.ru, http://www.medstudy.narod.ru
http://www.obgyn.ru, http://www.medsno.ru, http://medrusnet.euro.ru
www.medtext.ru, www.medpoisk.ru, www.medicum.nnov.ru/student/
http://6years.net/, http://preryvanie-beremennosti.pharmabort.ru/
http://med4net.ru/, http://www.med-life.ru/, http://www.pregnant.ru/
http://www.roddom.ru, http://www.medpoisk.ru/, http://www.medlinks.ru
Topic: Physiological postpartum. Physiological neonatal period. 10 principles of breastfeeding. Rooming-in of mother and child. Care of breasts.
1st place to hold classes, has
 Department of Obstetrics and Gynecology, the audience;
 dummy pelvis, female pelvis, doll fetus;
 standard models of pregnancy;
 the classic model of labor;
 gynecologic simulator ZOE;
55
 childbirth simulator Noelle;
 simulator newborn Newborn;
 set of slides on the topics of discipline;
 methods work in small groups: the method of the incident, "a round table" problem solving,
"pen in the middle of the table", "swarm", etc.;
 testing and teaching practical skills in OSKE (objective structured clinical examination).
 video, TV, TV;
 personal computer (Pentium-III);
 set of slides with typical conditions for ultrasound scanning of pregnant women and gynecologic patients;
 set of video blogs "VJOG" (USA), highlighting recent advances in diagnosis and treatment of
obstetric and gynecological conditions;
 set of videos and films demonstrating the typical obstetrician-cal and gynecological procedures
and operations.
 training videos;
 educational software;
 multi media training and testing;
 the use of e-mail and INTERNET;
 business simulations and case studies;
 center for skills training;
 offices and laboratories maternity complex;
 delivery room;
 set of tests;
 phantom with a doll;
 postnatal Chamber;
 the contours of the uterus at different periods of pregnancy;
 Video: "Child-person number one"
 test items I, II, III and IV levels of difficulty;
 step-tests: a general inspection of ro-dilnitsy, assessment of the mammary glands and lactation,
determine the condition of the uterus, the character of lochia, primary treatment newborn;
 slide Apgar score;
 slide scale Silverman;
 diagram showing the contours of the uterus at different times postpartum.
2.Prodolzhitelnost classes
The number of hours-5
3.Tsel classes
 study changes in the cardiovascular, endocrine, highlighter-tems, in the genital and mammary
glands in parturients in the postpartum period;
 explore the clinical management of physiological postpartum period;
 demonstrate parturients inspection methods (physical examination, the state of the mammary
glands, the rate of involution of the uterus);
 discuss the general criteria for the diagnosis of newborn Apgar and Silverman;
 discuss the principles of breast-feeding;
 compare results postpartum When staying mother and child over the postnatal period at separate residence;
 inform the structure and principles of the postpartum department.
Tasks
The student should know:
 changes in the cardiovascular, endocrine, excretory of the system, in the genital and mammary
56
glands in parturients in the postpartum period;
 the course and of the postpartum period;
 sanitation activities in the postpartum period;
 the main principles of breastfeeding.
The student should be able to:
Make a differential diagnosis of physiological and complicated postpartum properly inspect parturients (physical examination, the state of the mammary glands), to determine the rate of uterine
involution opredelnie lochia nature, according to the objective and the additional methods of examination (ultrasound, blood tests, urine tests, swabs for vaginal flora ) to assess the current
postpartum.
4.Motivatsiya
Postpartum or puerperal, called the period, during which the body is in parturients reverse development (involution) of the organs and systems that are subject to changes due to pregnancy,
childbirth. It was during this period of a woman is at risk of infectious diseases, septic diseases.
The main objective of poslerodovgog period is prevention of these diseases in mothers and newborns. Postpartum period coincides with the beginning of the formation of new family ties. Maternal or neonatal disease can disrupt this process.
Intra 5.Mezhpredmetnye and communication
Of teaching of the subject is based on the knowledge of the students basic anatomical mission,
topographic anatomy, histology, normal and abnormal physiology, endocrinology and microbiology ..
Acquired during the course knowledge will be used during the passage of endocrinology, internal medicine, surgery, pathology of obstetrics, gynecology, health, neonatology and pediatrics.
6.Soderzhanie classes
6.1.Teoreticheskaya part
Postpartum (puerperal) period is called the period beginning after the placenta and lasts 6-8
weeks. During this time there is a regression of (involution) of all organs and systems that have
been changed due to pregnancy and childbirth. The exception is the breast, whose function it
flourishes in the postpartum period.
Uterus. Immediately after birth the placenta uterus begins to contract and after a few minutes becomes rounded. Wall it becomes dense, gaping vessels of placental site are compressed. Bottom
of the uterus is at or just below the navel. 2 weeks after birth the uterus is located in the pelvis.
Its size has continued to shrink, and four weeks after birth correspond with the size pregnant
uterus. Within a few days after birth the surface layer of the decidua rejected and isolated as
lochia. Regeneration of the endometrium is due to epithelial glands. The walls of the uterus, with
the exception of placental site, epiteliziruyutsya 7-10 days, the normal endometrium thickness
reaches 2-3 weeks after birth. Epithelization of the placental site is much slower due to creeping
endometrial neighboring area by the end of the 6th week after birth. Delay epithelialization placental site may be the cause of uterine bleeding in the late postpartum period. The most pronounced changes are involutional in the genitals, especially in the uterus. Air involutional changes most pronounced in the first 12.8 days. The next 2-4 hours after delivery, distinguish themselves, and are referred to as the early postpartum period. After this time, begins late postpartum
period.Posle placenta uterus is significantly reduced in size due to a sharp reduction in its muscles. Her body has an almost spherical shape, retains much of the mobility by lowering the tone
of the stretched ligaments. The cervix is the form of thin-walled sac with wide gaping maw with
the outer edges of the torn and hanging in the vagina. Cervical canal freely passes into the uterus
hand. The entire inner surface of the uterus is an extensive wound area with the most severe destructive changes in the placental site. Lumen of the vessel in the placental site are compressed
with uterine muscle, blood clots are formed in them, which helps to stop bleeding after childbirth. In the days that involution of the uterus is very fast. Every day the height of standing uterus decreases by an average of 2 cm is necessary to consider that the rate of involution are dependent on the parity of birth, degree of stretching during pregnancy (large fetus, polyhydram57
nios, multiple pregnancy), breast-feeding during the first hours post-partum period, the functions
neighboring organs. Due to compression of the blood and lymphatic vessels, some of them obliterans. The cytoplasm of the muscle cell undergoes fatty degeneration, and then fatty. Reverse
development is occurring in the intermuscular connective tissue. A significant part of the vessels
obliterans and converted to connective tissue strands.
The healing process inside of the uterus begins to decay and rejection scraps spongy layer decidua, blood clots, blood clots. During the first 3-4 days of the uterus remains sterile. This is facilitated by phagocytosis and extracellular proteolysis. Decaying particles decidua, blood clots and
other rejects tissue elements are lochia. Epithelialization of the inner lining of the uterus occurs
in parallel with rejection decidua and ends the 10 day postpartum period (except placental site).
Endometrium fully restored 6-8 weeks after birth. Normal tone of uterine ligaments restored by
the end of 3 weeks.
2. Cervix. After 2-3 days after birth reduced the tone of the cervix, the inner mouth is revealed at
2-3 cm by the end of the first week after birth cervix is formed completely.
Involution of the cervix is slower. Before other parts of contracts and forms the inner mouth.
This is due to the reduction of the circular muscle fibers. After 3 days the inner mouth missing
one finger. Formation of the cervical canal is completed by the 10th day. By this time, the inner
mouth completely closed. Outer jaws closes at the end of three weeks, and takes the form of slit.
3. Vagina. Within three weeks after the birth of the vaginal wall are swollen, his clearance
somewhat expanded. Edema disappeared completely by the end of the postpartum period.
4. Ovaries. For most women, menstruation are absent during the entire period of breastfeeding.
In the absence of lactation ovulation-tion occurs on average at 10 weeks after birth, and the first
menstrua-tion - on the 12th. Menstruation may appear on the 7-9th week after the ro-Dov, in
such cases the first menstrual cycle is usually anovulatory. Ovaries in the postpartum period ends
regression of the corpus luteum and begins to grow follicles. Due to release of large amounts of
prolactin in lactating women menstruation is absent for a few months or the whole time nursing.
In non-breastfeeding women menstruation is restored within 6-8 weeks after birth. First period
after delivery, usually occurs on the background of anovulatory cycles: the follicle grows, matures, but ovulation does not occur, the corpus luteum and the endometrium are not
obrazuetsya.V processes of proliferation. Due follicle atresia and falling titer of estrogenic hormones comes rejection endometrium - menstruation. Later ovulatory cycles are restored. In some
women, ovulation and pregnancy is possible in the first few months after birth, even with breastfeeding.
5. Breasts. Pregnant women under the influence of estrogen, progesterone, cortisol, prolactin,
placental lactogen and insulin is a rapid development of glandular structures of the breast. During pregnancy, lactation inhibit steroid hormones synthesized by the placenta. After birth, their
rates are falling quickly, and coupled with a high level of prolactin begins lactation. Initially, the
breasts secrete colostrum, which is different from the milk of a higher content of protein and
immunoglobulins
The function of the mammary glands after childbirth reaches peak. During pregnancy under the
influence of estrogen formed milky-currents under the influence of progesterone is the proliferation of the glandular tissue. Under the influence of prolactin is enhanced blood flow to the breast,
and increased milk production, which leads to engorgement, the most pronounced at 3-4 days
postpartum. Milk production is the result of complex reflex and hormonal influences and nervous system and is regulated by lactogenic (prolactin) hormone adenohypophysis. The stimulating
effect is thyroid hormones and adrenal glands, as well as a reflex effect in the act of sucking. In
the first days postpartum breasts secrete colostrum. Colostrum - a thick yellowish liquid with an
alkaline reaction. It contains galactoblast, leukocytes, milk balls, glandular epithelial cells of the
bubbles and the milk ducts. Colostrum is richer than mature breast milk proteins, fats, minerals.
Colostrum proteins in amino acid composition intermediate between the protein fractions of
breast milk and blood serum, which obviously makes it easier to adapt the infant during the transition from placental supply of breast milk intake. Colostrum is greater than in mature human
58
milk protein, binds iron (lactoferrin), which is required for the formation of blood of the newborn. It has a high content of antibodies, hormones (particularly corticosteroids) enzymes. This is
very important because in the first days of life the newborn functions of several organs and systems are immature and immunity in the development stage. Transitional milk, which is formed
by 3-4 per day, for 2-3 weeks with permanent staff and called mature molokom.B.
Other bodies: 1. Urinary tract. The bladder is often injured during birth, resulting in the immediate postpartum period, it may be overstretching and urinary retention. This increases the risk of
urinary tract infection. Postpartum atony of the bladder increases with conduction anesthesia.
Renal blood flow, GFR and reabsorption of electrolytes, amino acids and glucose in the tubules
returned to baseline at 6 weeks postpartum. Expansion of the renal pelvis, ureter and cups can
last up to several months.
2. Cardio-vascular system. For vaginal vaginal blood loss is usually less than 500 ml, and for
caesarean section - 1000 ml. Despite the blood loss after childbirth increases stroke volume (due
to the shutdown of placental blood flow, extravascular fluid back into the bloodstream and increase the venous return). Due to the fact that heart rate decreases, cardiac output remains unchanged or slightly increased. 2 weeks after birth cardiac output returns to normal.
3. The digestive system. Pregnant women under the influence of estrogen increased protein synthesis in the liver, which is manifested by increased levels of serum proteins. 3 weeks after birth,
he returns to normal.
The first 2-4 hours after a normal delivery is travaileth in the delivery room. Obstetrician closely
monitors the overall health of women who have delivered her pulse, blood pressure, constantly
monitors the condition of the uterus: determines its texture, height, floor standing, watching the
degree of blood loss. In the early postpartum period is to examine soft birth canal, if there is evidence for the inspection. Inspect the external genitalia and perineum, vagina and lower third of
the vagina. Examination of the cervix and upper vagina is carried out with the help of mirrors.
All of the identified gaps sewn. In assessing blood loss at delivery consider the amount of blood
released in the sequence and the immediate postpartum period. The mean blood loss was 250 ml,
and the maximum physiological - not more than 0.5% of body weight parturients.
Keeping postpartum
A. Early postpartum. After 2-4 hours postpartum women on a gurney carrying a physiological
postnatal ward. The processes occurring in the body parturients after uncomplicated childbirth
are physiological, so it should be considered a healthy woman. You must consider several characteristics of a post-partum period associated with lactation, the presence on the site of the
wound placental site, reduced defenses mother. So, along with medical supervision for parturients to create a special regime under strict aseptic and antiseptic. In the postpartum unit should
strictly abide by the principle of cyclic filling chambers. The principle is that in one chamber
placed childbirth, birth in the same day. Compliance cycling facilitated by small chambers (2-3
persons) and their correct profiling, ie separation chambers parturients who for health forced stay
in the nursing home for a longer period than healthy parturients. Should follow the principles of
child-friendly, t.e.sovmestnogo host mother and child. This stay significantly reduced the incidence of postpartum women in the postpartum period, and the incidence of children. Mother is
actively involved in the care of the newborn child, limiting contact with the staff of the child's
maternity ward, creates favorable conditions for the settlement of the mother of the infant microflora, reduces the possibility of infecting the newborn hospital strains of opportunistic microorganisms. With this mode, immediately after childbirth newborn baby at a satisfactory condition
can be attached to the mother's breast. The first toilet and newborn care at the first day of exercise room and a nurse mother. The nurse teaches the processing sequence of the skin and mucous
membranes of the child (eyes, nasal passages, cleaning the), teaches use sterile material and disinfectants. Examination of the umbilical cord stump and umbilical wound carries a pediatrician.
Now it is accepted active management of postpartum period, with the early-cluded rising, which
improves blood circulation, accelerate the process of involution in the reproductive system, the
normalization of the functions of the bladder and bowel. Parturients monitored daily for the ob59
stetrician and midwife. Body temperature was measured twice a day. Particular attention is paid
to the character of the pulse, blood pressure was measured. Assess the condition of the breast,
their shape, teat condition, the presence of scratches and cracks (after nursing), the presence or
otsutstvienagrubaniya. Determine the height of standing uterus, its diameter, texture, presence of
pain. Standing height uterus measured in centimeters to the lonnomu articulation. During
pervyh10 days it drops by an average of 2 cm per day. Evaluate the nature and amount of lochia.
Observe the general condition of women in travail, evaluate the consistency, size and tenderness
of the uterus, and the nature of discharge from the genital tract. Beam above, the child stayed
with his mother from the very first days of life.
B. Late postpartum
1. General care. Every 4 h determine vital signs parturients, observe urine output, evaluate uterine tone and character of discharge from the genital tract. Explain how to take care of the external genitalia and perineum, trained to breastfeeding and child care, if necessary - pick analgesics.
2. Laboratory studies. In the first days after birth performed CBC with differential count. If necessary, determine the blood group and Rh-factor. In women with Rh-negative blood examined
blood antirhesus antibodies. To identify postpartum women to be vaccinated, determine the titer
of antibodies to rubella virus (if studies have been conducted previously).
3. Daily check-up
a. Uterus. The rate of reversion of the uterus is judged by the height of standing its bottom and
consistency. Normally, soon after childbirth the uterus becomes dense texture, the bottom of it is
below the navel. Slow contraction of the uterus may be accompanied by significant bleeding,
sometimes blood accumulates in its cavity. After cesarean pay special attention to uterine tenderness to palpation - an early symptom of endometriosis.
b. Stomach. Postoperative patients pay attention to the presence of abdominal distension and peristalsis. On the first day after surgery peristalsis weakened or absent. For the 2nd-3rd day she recovers, and begin to withdraw gases. Bloating, gas delay, lack of peristalsis indicate intestinal
paresis. This may be due to prolonged surgery or an early sign of infection. Some authors recommend start taking liquid food after the appearance of bowel sounds, others - only after the
start of flatus. If the reception of liquid food does not cause nausea or vomiting, a woman is
transferred to a regular diet.
a. Lochia. Pay attention to the number, color and odor emissions. In the first few days after birth
lochia are mainly represented by blood clots and fragments of necrotic decidua. Amount of
bleeding is usually the same as with menstruation. After a few days of blood content in the
mother decreases the discharge, the character becomes a discharge krovjanisto-serous. After a
few weeks of discharge becomes scarce and more lighter. Bad smell lochia indicates infection.
Mr. Crotch. On examination exclude hematoma, inflammation, and perineal tears. Care includes
washing of the external genitals mild disinfectant and warm sitz vanny.Po to foreign authors for
local anesthesia is used cotton swab moistened with the juice of Hamamelis virginiana, and spray
with lidocaine. At perineal III-IV degree appoint softening laxatives, such Duphalac. Postpartum
women discharged home after normalization of stools. When hemorrhoids after prolonged second stage of labor is often a relapse. For the treatment of hemorrhoids using ointments and suppositories gidrokartizonom cotton swab moistened with the juice of Hamamelis virginiana, and
warm sitz baths.
on the bladder. Due to injury at birth or epidural anesthesia may develop bladder atony. Produce
urine catheter. If necessary, re-establish the catheter Foley catheter for a day. In marked periurethral edema or suturing the gaps in the external opening of the urethra to prevent urine retention
can be directly installed on the Foley catheter day.
is breast cancer. Pay attention to breast engorgement and check for signs of inflammation. Encouraged exclusive breastfeeding. In obstetric Establishm should actively introduce and support
the 10 principles of breastfeeding. Conduct classes, to inform, to explain among junior, middle
and senior meitsinskogo personnel, doctors, as well as to pregnancy, labor, childbirth according
to the principles of breastfeeding. If for any reason travaileth refuses to breastfeed, to suppress
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lactation breasts tight bandage or naznachayutbromokriptin, 2.5 mg orally two times a day for 14
days. After the drug can rebound lactation. To eliminate it, bromocriptine is prescribed for another 7 days. Side effects of the drug - orthostatic hypotension, nausea, vomiting, and seizures in
rare cases have a stroke.
Well. Lungs. After cesarean section may be pneumonia. Prevention includes breathing exercises
(spirotrenazher).
s. Limb. In the postpartum period increased risk of deep vein thrombosis and thrombophlebitis
leg.
Neonatology - Section of Pediatrics, studying the physiological characteristics of the disease in
children, and the first month of life. The development of neonatology care at this stage is characterized by the creation of specialized services for families, pregnant women, newborns, infants
and young children, united in perinatal centers. Stages of care babies have work obstetric and
pediatric services.
From the moment of birth and the umbilical cord ligation stops just one, cord connection, mother
and child, about the further development of his in the neonatal period, which lasts 28 days. It is
divided into early (first 168 hours of life) and late neonatal period. The functional state of the
child in the first minutes and hours of life of the response and adaptation of systems to new - extrauterine conditions. Adaptive features of functional systems of the fetus and the newborn depends on the mother, pregnancy and childbirth.
Confinement is a significant burden on the fetus. Three stage of labor are different from each
other. Uterine activity accompanied by changes in the metabolic processes of the mother and fetus deteriorating livelihoods. Each contraction of the uterus leads to a decrease in utero-placental
blood flow. In the first stage of labor in the intervals between contractions of the uterus pressure
of 8-10 mm Hg At the height of battle - 20-50 mmHg In the second stage of labor in vain attempts to pressure can be increased to 70 mm Hg The blood flow in the uterus stops formed
blood pool, which provides power fetus during labor. Deterioration of vital fetal adaptive reactions manifested in the form of physical activity to increase between contractions and the increase in heart rate to 160 beats per minute. In the period of the expulsion may be a decrease in
heart rate of the fetus to 80-110 beats per minute during any attempts and alignment frequency in
10 - 30 seconds after it.
Helps the mother to the fetus to cope with birth stress and adapt to extrauterine existence by increasing cortisol production above its capacity kortikosvyazyvayuschih plasma which has contributed to a certain concentration of cortisol to the fetus.
Neonatal period, the neonatal, begins with the birth of a child, first breath, and umbilical cord
ligation. The first minutes and days of life of the response adaptation of systems and organs to
the new environmental conditions. The adaptation of the child takes place safely with continued
close physical, immunobiological and emotional connection with her mother.
Timing of cord clamping is not indifferent to the child. Due to the additional volume of placental
blood adapts cardiopulmonary system, and increased iron stores. At the same time, late cord ligation leads to hypervolemia, hyperbilirubinemia, and influence the development of sexual crisis.
In premature infants umbilical cord ligation immediately creates a shortage of blood volume, the
risk of respiratory distress syndrome and hyaline membrane disease.
In term infants appropriate pinch the cord in 1-1.5 minutes after birth in preterm - 1.5-2 minutes,
ie after the first breath.
Umbilical cord and placental blood flow shutdown leads to a restructuring of blood circulation in
the child: increased pressure in the systemic circulation. With the onset of spontaneous breathing
blood flow through the lungs increases by 5-10 times compared to the prenatal period. Accordingly, increasing the return of blood to the left atrium, where, as in the aorta, the blood pressure.
High pressure in the left side of the heart valve slam helps oval window (a few hours). Closing
the blood (botallova) flow occurs due to narrowing of its lumen. Shunting of blood from left to
right (from the aorta to the pulmonary artery) can last up to four days of life and is clinically
manifested by noise.
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Fetal lungs are filled with fluid, which is produced by cells of the respiratory epithelium. Since
the development of labor begins preparations for the unfolding of the lung is a mechanical chest
compression and displacement of fetal fluids. Under the influence of the first breath and reflex
contraction of respiratory muscles (more stops) in the chest creates a negative pressure that promotes suck air into the airways. In the mechanism of unfolding light is very important vascular
component. Filling the lung blood vessels leads to a slow expansion of small branches of the
pulmonary artery and ends by 4-5 days of life.
Surfactant system, the epithelium lining the bronchi and bronchioles, modifies them as a force of
surface tension during inhalation and exhalation. This self-regulating multi-component system,
which are important disdilimery, has a high content of unsaturated fatty acids, plays a special
role in the unfolded and residual functional capacity of the lungs.
In the first week of life in the newborn respiratory rate ranges from 30 to 60 per minute, depending on the functional state of organs and systems, and metabolic features.
In the first week of life revealed physiological acidosis and decreased oxygen tension in the
blood, altered glucose and blood lipids. As a source of energy is in use high concentrations of
non-esterified fatty acids. Metabolism in adipose tissue occur active.
SIGNIFICANT neonatal in the delivery room
Immediately after birth, the head must be sucked from the mouth, nose and throat with a catheter
connected to an electrical device or sterile spray, mass, consisting of amniotic fluid, mucus and
blood.
Child take on warm tray, covered with two sterile ne-Lenk, located at the feet of the mother and
realize:
 repeated aspiration of the oral cavity and nasopharynx;
 blenorei prevention;
 Primary dressing cord;
 show mother and child lay out on his stomach;
 assess the state of Apgar score at one minute.
Conducting secondary treatment and secondary prevention of umbilical blenorei performed in a
designated area for infants on a heated changing table, and only, if changing the midwife in a
sterile gown and prepare her hands under aseptic and antiseptic. Bracket to the umbilical residue
does not impose, but replace the ligature provided: thick and juicy cord Rh-negative mother's
blood supplies, low birth weight infants and children in serious condition. Conduct initial processing of skin, weighing, measuring length, head circumference, chest circumference and diapering. Certainly before the translation of mother and child in the postpartum department applied
to the baby's mother's breast.
Initial assessment of the functional state of the newborn performed on a scale of Virginia Apgar
(USA) proposed in 1953. In Russia, the double entry Apgar score: at 1 and 5 minutes after birth,
all newborns regardless of gestational age and birth weight. Vital signs are: heart rate, breathing,
muscle tone, reflex responses activity and color of the skin, which evaluate 0, 1, 2 points. A
healthy newborn is rated 8-10. The prognostic value of scale is a group of full-term children.
Clinical symptoms listed in the Apgar score depends on many factors, primarily on the degree of
maturity, metabolic changes and the severity of asphyxia.
Maturity of the newborn is determined by the totality of clinical, functional, and biochemical parameters. In each age period, from zygote adaptation features of the fetus, newborn and infant
match his calendar age in conjunction with the environment surrounding it and interacting with
it. The central nervous system is informative characteristic of maturity. In the study of child assess posture, position, spontaneous motility face, emotional reactions, birth unconditioned reflexes and activity of sucking. For clinical signs of neonatal maturity is determined by the sum of
scorecard balls each trait.
PHYSICAL ASSESSMENT OF NEWBORN
To assess the physical development of infants using the statistical parameters of the main parameters, depending on gestational-age percentile or scorecards. Parameters of the physical devel62
opment of the newborn, located in the interval M ± 2s (s - standard deviation) or P10 - P90 are
normal physical indicators for gestational age. Physical parameters of born on the parameter and
the age of the parents, eating habits, living conditions and the sequence number of pregnancy in
women. Has a value characteristic of body balance and nutrition in neonates.
Term infants - a baby born at 37-42 weeks gestation. Term infants because of the prevailing development of the brain is the head quarter of the body. Of particular importance is the determination of head circumference at birth (and dynamics) of body weight, as well as its form. To variant of the normal form include the following: dolihotsefalicheskaya - elongated in the anteriorposterior direction, brahiotsefalicheskaya - cross and tower skull. Skull bones susceptible can
join each other in the sagittal and coronal sutures. Particularly reflected in the table of maturity.
Preterm infants - a baby born at term following 37 weeks of pregnancy. Live births with gestational age 22 - 28 weeks, and the survivors of the first 168 hours of life. To the normal parameters of development in terms of 28-37 weeks include children with a body weight of 500.0 to
2500.0 g, 38-47 cm in length, head circumference 26-34 cm and 24-33 cm chest According to
statistics from different countries premature born between 6 and 13% of children.
Body weight may not be the main criterion for prematurity. There is the concept of "low birth
weight" or "underweight" - children with a mass less than 2500.0 g at birth, who were born at
term.
By perenoshennm neonate are children born after 294 days or 42 weeks of gestation. Birth rate
of children from 8 to 12%. The children showed clinical signs of venous disorders: decrease in
skin turgor, the thinning of the subcutaneous fat layer, peeling, dryness, and peeling of the skin,
lack of lubrication, thick skull, often closed by sutures.
When comparing the gestational age and physical development indices are the following groups:
- Newborns with a large body mass, which is above the average for this period for the 2s and 90
percentiles or more;
-With a normal physical development for gestational age;
-With low birth weight in relation to gestational age or with the delay of intrauterine development. There are the following types of IUGR-immaturity or "small for date", dysplastic or
asymmetric and late type or intrauterine malnutrition. Combinations of different types of IUGR
may occur in one child. The pathogenesis of delayed development and growth of the fetus is diverse. With a backlog of body weight on gestational age of the fetus adverse factors generally
work in the last trimester of pregnancy. When retardation in weight and body length of gestational age - unfavorable conditions for the existence of the fruit of the late first and early second
trimester of pregnancy. Violation of body proportions, often combined with disesbriogeneticheskimi stigmas and developmental disabilities, referred to as dysplastic type and occur in children
with chromosomal and genomic disorders, as well as in utero, generalized infections. Different
types of IUGR meet in term and preterm infants postmaturity.
Modern perinatal technologies
(Physiological adaptation, and health of newborns)
Physiological, and psycho-emotional immunobiological relationship of mother and child is not
interrupted to 1.5 years of post-natal development. Physiological adaptation reactions formation
and subsequent development of the newborn baby is only possible if co-host of mother and child
in the maternity hospital. Constant contact between mother and child that begins at birth: after
the initial cut-off Cord. Child spread on the mother's abdomen and attached to the chest. The
formation of the defenses of the child adversely affects handling breast disinfectants or washing
with running water and soap. On the areola is produced (especially before feeding when the
mother hears the voice of her child), a huge amount of biologically active and protective factors
(lysozyme, immunoglobulins new, bifidobacteria, etc.) that are needed for the physiological formation of local and general immune system, microbiota and digestive function. Hygiene
measures woman should only be carried out after nursing, breastfeeding in the first minutes of
life in the future on demand without a certain time period, including night, excluding watering
solutions and purpose adapted formulas. Should (if possible) to feed the baby only milk of his
63
mother. Persists after delivery direct and inverse relationship immunobiological mediated via
lactation milk moms universal composition, ideal only her baby. Composition varies on hours
and days of life the baby and perfectly adapts nutritive processes and the formation of its own
ecological system of the child. Adjustment disorders of the newborn, as his illness affect changes
the quality of the milk and to improve its immunological activity. Despite the small amount of
colostrum in the first 3 days after birth when creating conditions often applying the newborn to
the breast (on request), at least 10-12 times a day in the period of adaptation, provides him with
the necessary calories and protective factors. Frequent applying the newborn to the breast enhancing effect on the product of oxytocin and prolactin in the mother, reduce the risk of postpartum septic diseases and bleeding and are essential for the establishment of lactation function.
Early discharge from the maternity hospital (3-4 days) is possible while the surgical clipping
Cord (after 12 hours of life). By the 3rd day of mothers and newborn stay in the nursing home,
there is increased colonization of hospital strains of bacteria are highly resistant to antibiotics
and disinfectants, the virulence and toxigenicity. By 6 day colonized almost all mothers and
children. This significantly violates endomikroekologicheskoy normal formation of the baby and
the mother weakens the body's defenses.
Parafiziologicheskie state newborn:
 initial loss of body weight, not exceeding 8.6% of body weight at birth;
 expansion of sweat glands;
 toxic erythema;
 sexual crisis;
 physiological hyperbilirubinemia
 transient diarrhea.
Risk factors for the syndrome of impaired adaptation of healthy newborn (from a healthy mother
with physiological pregnancy) often include conditions that separate mother and child in the early neonatal period and interferes with breastfeeding. In all other cases, changes in the functional
state of the newborn due to the risk factors of the mother and fetus.
Principle of breastfeeding
The main purpose is to:
 To understand the importance of breastfeeding
 To understand the risks of artificial feeding
 To know the basic mechanisms of production and allocation of milk
 To know the basic properties of breast milk
 To understand the importance of contact "skin-to-skin" for the beginning of effective breastfeeding
 To be able to advise a woman on the first of breastfeeding
 To know the correct position for breastfeeding
 To be able to observe in order to breastfeeding for mothers
 trained in counseling on breastfeeding
 To be able to promptly identify problems associated with breastfeeding and helping mothers to
solve their
Benefits of breastfeeding
Breast milk contains all the vital substances, macro-and micro-elements necessary for optimal
physical, psychomotor, intellectual, emotional and social
development. Breastfeeding economically and for the family and for society, as well as the likelihood that a mother will leave her baby is reduced.
Essential components of breast milk
Among the infection fighting proteins in breast milk, the most important are: the ironlactoferrin inhibits the growth and reproduction of bacteria, lysozyme, also kills bacteria, as well
as antibodies - immunoglobulin A.
Another important factor is the anti-infective bifidum factor that promotes the growth of lac64
tobacilli, which inhibits the proliferation of pathogenic bacteria. Breast milk also contains antiviral factors.
A child who is exclusively breastfed, 0.5 g of secretory Ig A day. Secretory IgA (of breast
milk) protects against pathogens such as E. coli, as well as protects against antigens.
Being together, mother and child
Being together is a kind of planning their stay in obstetric hospital, where she can be with
the child all the time, constantly.
Rooming promotes thermal protection, breastfeeding, resistance to infection and the establishment of family ties. The mother should care for the baby and touch it, and this helps to prevent cross-infection. Mother and baby need to be together from the moment of birth. So begins
the establishment of contact between mother and child. In addition, the co-host of maternal child
produces seeds flora, it is warm and receive emotional support.
Help the mother's relatives are very important and necessary, especially in cases of operative
delivery (after cesarean section), when the mother is not feeling well.
Hospital staff should not replace a mother to care for the child. Health care providers can help,
advise, listen to his mother and to answer her questions, but they should not replace a mother to
care for the child.
Tell the mother that she can take the child to his bed during feeding (if it's more convenient) there is no risk of injury to a child or to infect.
The use of new educational technologies:
method "handle in the middle of the table"
1.Voprosy, printed on separate sheets.
2.Chistye sheets of paper, pens.
3.Rabochaya notebook.
Progress:
1.All students of the draw are divided into 3 groups.
2.Kazhdaya subgroup sits at a separate table, preparing a clean sheet of paper and a pen.
3.On written sheet date, the group number, department, FI Student-participants in this subgroup
(the name of the business game).
4.Predlagaetsya task: to answer a specific question the whole subgroup.
5.Kazhdy student writes on a piece of his name and one answer sheet and sends neighbor, and
my pen moves to the middle.
6.Pedagog controls the group and the involvement of everyone.
Total correct version is written in the notebook.
7.Studenty who gave the correct answers are maximal score of 100% of the theoretical part of
the rating-0, 8b.
Students zanyavschie 2nd-85, 9% rating. Zanyavschie 3rd-70, 9% of the ratings. Neotvetivschie
otvetivschie or wrong 0 b.
8.Na answer sheet lecturer puts mark and signature.
9.Poluchenny students score counted in the scoring for the current session.
10.V the bottom of the log free annotation on data-tion of the business game, Mayor to sign.
11.Raboty students saved teacher.
6.2Analiticheskaya part
Case studies:
1. 1 minute after birth, the newborn examination revealed: acrocyanosis, scream loud, 146 heart
beats per minute, muscle tone is somewhat reduced, reflexes were brisk.
Assess the newborn Apgar.
A: At Apgar 8 points
2. One minute after birth, the newborn examination revealed: acrocyanosis skin, weak cry, heartbeat 140 beats per minute, muscle tone and reflexes are reduced. Fetal weight 2400 g, length 45
cm newborn, skin pronounced vellus cover and abundant syrovidnaya lubrication, low position
of the umbilical ring and ears, labia not cover small.
65
Assess the newborn.
A: The infant was born with signs of prematurity. With Apgar score of 6 points
3. A woman, postnatal day 2. General condition satisfactorily, body temperature 36,6 °. Ps 68
beats. in 1 minute. The internal organs revealed no pathology. Slightly enlarged breasts, nipples,
clean, no redness and cracking. Uterus dense WDM at the navel, painless on palpation. Allocation - lochia, bloody, in moderation. Urination free b / w. The chair was.
Put diagnosis.
In the first days postpartum, which is produced by the mammary gland and its composition.
Where should the GMR is on the 2nd day after birth.?
A: Postpartum day 2. In the first days postpartum periods of colostrum produced. Colostrum - a
thick yellowish liquid with an alkaline reaction. It contains galactoblast, leukocytes, milk balls,
glandular epithelial cells of the bubbles and the milk ducts. Colostrum is richer than mature
breast milk proteins, fats, minerals. Colostrum proteins in amino acid composition intermediate
between the protein fractions of breast milk and blood serum, which obviously makes it easier to
adapt the infant during the transition from placental supply of breast milk intake. Colostrum is
greater than in mature human milk protein, binds iron (lactoferrin), which is required for the
formation of blood of the newborn. It has a high content of antibodies, hormones (particularly
corticosteroids) enzymes. This is very important because in the first days of life the newborn
functions of several organs and systems are immature and immunity is being stanovleniya.Na
2nd day WYD must be on two cross fingers below the navel.
4.Zhenschina B. Postpartum day 5. General condition is satisfactory, the body temperature of
36,8 °. Ps 64 u. / Min .. The internal organs revealed no pathology. There is a slight engorgement, nipple clean, no cracks and redness. The uterus is dense, b / w, GMR-halfway between the
navel and vagina. Discharge light yellowish, bloody, minor. Urination free, b / w, once a day.
Regular chair.
Put diagnosis.
How does the character of lochia in the postpartum period?
That is produced by the mammary glands day 5 postpartum, composition.?
What do you think of the urinary tract that woman?
A: Postpartum the 5th day. In the first few days after birth lochia are mainly represented by
blood clots and fragments of necrotic decidua. Amount of bleeding is usually the same as with
menstruation. After a few days of blood content in the mother decreases the discharge, the character becomes a discharge krovjanisto-serous. After a few weeks of discharge becomes scarce
and more lighter. Bad smell lochia indicates infection. On the 5th day vyrabatyvaetya transitional
milk. Due to injury at birth or epidural anesthesia may develop bladder atony. Urine catheter can
be released.
5. Woman in labor for 38 years. In the history of 6 genera and 3 miscarriages. Recent births
complicated hypotonic hemorrhage. On admission Hb-70 g / L, Ps-88 beats / min. Blood pressure 100/60 mm Hg. 30 minutes after receipt of delivery has occurred.
What are the complications in the postpartum period may be assumed from this woman? Give
advice on breastfeeding.
Answer: In the postpartum period may be hypotonic or atoniche-mechanical hemorrhage, hemorrhagic shock, disseminated intravascular coagulation. Breastfeeding is recommended to take
antianemic, restorative treatment.
6.3. Graphic organizer: Making graphic organizer
"Venn Diagram" on "Postpartum"
Venn diagram
Used to compare or contrast or matching
2 - 3 aspects and show their similarities. Develops systems thinking, the ability to compare,
compare, analyze and synthesis.
6.4.Prakticheskaya part
Assessment of the newborn Apgar.
66
Purpose: To determine the state of the newborn
Performs step (steps):
№ Events Not you-complete
(0 points) Fully
correctly
performed
(20 points)
1.
Assessment is carried out in the first minute and 5 minutes after the birth of five criteria: heart
rate, respiratory activity, reflex irritability, muscle tone, color of the skin.
Each feature is evaluated by a three-point system: 0, 1, 2. Things are going and is determined by
the state of the newborn 0 20
2. Healthy newborns have on this scale assess 07.10 points. 0 20
3. Children born in the light of asphyxia, is obtained evaluation scores 5.6 0 20
4. Children with signs of asphyxia secondary severity 4-5 0 20
5 In severe asphyxia - 1.3 rating points.
When near death - a score of 0 0 20
7.Formy control of knowledge, skills and abilities
-Oral;
-Written;
Testing;
Solution situational problems;
And demonstration of skills mastered.
8.Kriterii assessment monitoring
№ Progress
Score in% level of students' knowledge
1 96-100% Excellent
"5" full correct answer to the question of the etiology, pathogenesis, classification, clinic, diagnostics, treatment and prevention of this disease. To sum up and make decisions, creative thinking cally, self-analyzes, case studies resolves correctly, with a creative approach, with full justification of the answer. Actively and creatively involved in interactive games, take the right decisions and summarizes and analyzes. Medical history, partograph fills correctly.
2 91-95% Excellent
"5" full correct answer to the question of the etiology, pathogenesis, classification, clinic, diagnostics, treatment and prevention of this disease. Think creatively, independently is analyzed,
case studies decides correctly, with a creative approach, with full justification of the answer. Actively and creatively involved in interactive games, take the right decision. History of diseases,
partograph fills with 1 grammatical mistake.
3 86-90% Excellent
"5" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis, treatment and prevention of diseases of the covered completely, but have 1-2 errors in the
response. Own analyzes, inaccuracies in the solution B-ation problems, but with the right approach. Actively involved in interactive games, make the right decisions. Medical history, partograph fills with 2-3 grammatical errors.
4 81-85% Good
"4" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis,
treatment and prevention of diseases of the covered completely, but there are 2-3 inaccuracies,
errors. Into practice, understands the essence of the question, says confidently, is a faithful representation. Situational problems solved correctly, but the justification answer sufficiently. Actively involved in interactive games, take the right decision. History of diseases, partograph fills with
2-3 grammatical errors, inaccuracies in the description.
5 76-80% Good
67
"4" correct but incomplete lighting-set questions. The student knows the etiology, pathogenesis,
classification, clinic of the disease, but not completely disassembled diagnosis, treatment and
prevention of this disease. Understands the issue, says confidently. There is an exact representation. Actively involved in the interactive-tion games. On case studies gives partial solutions.
Medical history, partograph fills with 3-4 grammatical errors, inaccuracies in the description.
6 71-75% Good
"4" correct but incomplete lighting-set questions. The student knows the etiology and pathogenesis of the disease, but not completely disassembled diagnosis, treatment and prevention of this
disease. Understands the issue, says confidently, is a faithful representation. On case studies
gives partial solutions. History of diseases, partograph fills with 3-4 grammatical errors, 3-4 errors in the description.
7 66-70% Satisfactory
"3" right answer half the questions. Student knows the etiology of the disease, but do not pay out
the classification, clinic-tion of the disease, the treatment and fumbles of prevention. Understands the issues ca, says confidently, has the only views on certain issues topic. Situa-tional
problems are solved correctly, but there is no justification of the answer. Medical history, partograph fills with 3-4 grammatical errors, 3-4 errors in the description.
8 61-65% Satisfactory
"3" right answer half the questions. Errors in the etiology, pathogenesis, poorly versed and confused in the treatment and prevention of this disease. Says uncertainly, has the only views on certain issues topic. Making mistakes in solving situational problems. History of diseases and partograph fills with errors.
9 55-60% Satisfactory
"3" error response to half the questions. Student makes an error in the etiology of the diseasedanno, confused and poorly versed in other matters related to the disease. Says uncertainly has a
partial view on the subject. Situational problems solved incorrectly. Medical history and partograph fills with errors.
10 50-54% unsatisfactory-liminary "2" The correct answer to third-represented supplied questions. Student does not know the etiology of the disease, and poorly versed entangled in other
issues related to the disease. C-ation problems are solved with the right approach is wrong. Medical history and partograph fills with errors.
46-49 11% unsatisfactory-liminary "2" right answer quarter supplied-represented issues. Student
does not know the etiology of the disease, and poorly versed entangled in other issues related to
the disease. C-ation problems are solved with the right approach is wrong. Medical history and
partograph fills with errors.
12 41-45% unsatisfactory-liminary "2" Lighting fifth set of issues with bugs. Student does not
know the etiology of this disease, little versed in other matters related to the disease. Gives an
incomplete and partially incorrect answers to questions on the classification of the clinical disease. Situa-tional problems are solved with the right approach is wrong. More than half of the
patient's history and the partograph filled with errors.
13 36-40% unsatisfactory-liminary "2" Lighting 1/10 of the questions at the wrong approach.
Does not know the etiology of the disease, and poorly versed entangled in other issues related to
data-tion of the disease. Gives incomplete and partially incorrect responses to questions on the
classification, climate-ship of the disease. Situa-tional problems are solved with the right approach is wrong. Bole half medical history and partograph fills with gross errors.
14 31-35% unsatisfactory-liminary "2" to the questions not answers. Does not know and does not
understand the other issues relating to this of diseases. Does not know how to fill out and describe the clinical history and the Party of the program.
9. Typical flow chart of lesson
Stages of work, time-name The content of the
Teachers Students
1etap. Introduction to the training session
68
(5min) 1.1.Soobschaet topic, purpose, and planned training results. Familiar with the plan, features of the training session.
1.2.Nazyvaet: key categories and concepts from the data subject tion, a list of books for selfstudy
1.3.Soobschaet indicators and criteria of educational work in class
Listen, record,
specify, ask the question.
Stage 2.
Primary
(235 min) 2.1.Provodit updating knowledge through блиц-опроса/вопросно-ответной forms /
brainstorming, etc.
2.2. Consistently describes the steps
on the organization of the educational process according to the structure of practical training.
Meet
Abstracts with ethyl.
Working in groups, will present the results of the group work
Stage 3.
The Final-Resultant-regulating (60 min)
3.1.Delaet opinion on the subject, attention was concentrated on the main students, according to
the importance of the work done for future careers.
3.2. Commends the work of groups (some of students) summarizes vzaimootsenki. Analyzes and
evaluates the degree of achievement of lesson.
3.3. Gives the task for independent work, informing schaet and criteria evaluation. Selfevaluation,
interaction assessment.
Ask the question.
Write down the job.
Kontrolnye questions
1. What is postpartum?
2. What do you call a woman after giving birth?
3. How long does postpartum period?
4. Classified as postnatal maturity?
5. How to do the immediate postpartum period?
6. What should a doctor before you put a woman in the postpartum department?
7. How is the regression of cancer?
8. How is the involution of the cervix?
9. When does epithelialization inside of the uterus?
10. What is "lochia"?
11. How does the function of the mammary glands?
12. What is the composition of human milk?
13. How is the process of lactation? Exclusive breast-feeding.
14. What is the normal postnatal clinic?
15. Violated any of the functions in the postpartum period, and how to fight it?
16. What is "subinvolution uterus" and what remedial measures in this case?
17. What are the activities in breast engorgement?
18. As caring for women who have delivered at the crotch which stitches?
19. What is the mode of parturients?
20. What diet parturients?
21. What is the care of the woman in childbirth?
22. Hygiene when feeding a newborn.
23. What is the duration of the child?
24. What is the Apgar score?
69
25. Signs of maturity of the newborn.
26. What is necessary for a 2 moment of infant?
27. What Apgar score has a healthy baby?
28. The value of the first cry of the newborn.
29. The reasons for and duration of neonatal jaundice.
30. How is the treatment of newborn eye? Write down required for this drug.
31. Rules primary treatment of the newborn.
32. What you need for secondary treatment of a newborn?
33. How is the treatment of residual umbilical cord?
34.Pravila secondary treatment of the newborn.
35. Features of the skin of newborns.
36. Especially cardiovascular newborns.
37.Chem explain sexual crisis in the newborn?
11. Recommended Reading
Summary:
1. Abramchenko, VV Epidural anesthesia in obstetrics: a guide for physicians / 2006. - 229 p.
2. Abramchenko, VV Pregnancy and delivery of high risk: a guide for physicians / - M. Med.
Inform, 2004. - 400 p.
3. Abramchenko, VV Cesarean section in perinatal medicine: a guide for physicians / 2005. 126.
4. Abramchenko, VV Postoperative intensive care in obstetrics / Literature, 2000. - 88.
5. Abramchenko, VV Pharmacotherapy of preterm labor / 2006. - 448.
6. Abramchenko, VV Purulent-septic infection in obstetrics and gynecological logii.rukovodstvo
/ 2005. - 459
7. Abramchenko, VV Postoperative intensive care in obstetrics / - St. Petersburg: Spec. Literature, 2000. - 88.
8. Abramchenko, VV Clinical perinatology / IntelTek, 2004. - 424 p.
9. Ailamazyan, EK Midwifery: a textbook for honey. Universities / 2003 - 528.
10. Topical issues of Obstetrics, Gynecology and Reproductive / Ed. EV KOKHANEVICH. Moscow: Triad-X, 2006. - 480.
11. Obstetrics. Ed. GM Savelyeva. - M.: Medicine, 2000. - 816 p.
12. Obstetric and gynecological care: Hands-on. for doctors / Ed. VI Kulakov. - Moscow:
MEDpress, 2000. - 512 p.
13. Obstetrics. Clinical lectures: a manual for schools with a CD / Ed. OV Makarova. - Moscow:
GEOTAR Media, 2007. - 640.
14. Obstetrics. Directory of the University of California / Ed. Nisvandera K., A. Evans: Lane.
from English. - M.: Practice, 1999. - 704 p.
15. Barashnev, YI Perinatal neurology / Y. Barashnev. - M.: "Triad - X", 2005. - 670 p.
16. Bodyazhina, VI Akushersvo. The manual for the media. prof. Education / VI Bodyazhina. Rostov-on-Don: Phoenix, 2003. - 480.
17. Resurrection, SL Fetal assessment. CTG. Doplerometriya. Biophysical profile: a manual for
the system of postgraduate medical. Education / SL Resurrection. - Minsk: The Book House,
2004. - 304.
18. Gazhonova, VE Ultrasound in Gynecology / VE Gazhonova. - Moscow: MEDpress-inform,
2005. - 264.
19. Gluhovets, BI Ascending infection of placental / BI Gluhovets. - Moscow: MEDpressinform, 2006. - 240.
20. Humeniuk, EG Obstetrics: Physiology of pregnancy: a training ben-beats / EG Humeniuk. Petrozavodsk: IntelTek, 2004. - 170 p.
21. Demidov, VN Pelvic ultrasound in women. Adnexal cysts and benign ovarian tumors: a practical guide / V. Demidov. - Moscow: Academy of Medical Sciences, 1999, vol. II. - 100 p.
22. Duda VI Obstetrics: a textbook for high schools in the specialty "General Medicine" / 70
Minsk: High School, 2004. - 639 p.
23. Duda VI Physiological OB / - Minsk: 2000. - 447 p.
24. Duda VI Operative obstetrics: a manual / Minsk Interpresservis, Book House, 2002. - 512 p.
25. Zhilyaev, NI Obstetrics: phantom course / - Kiev, 2002. - 239 p.
26. Zhilyaev, NI Operative Obstetrics: Ouch. Manual / Kiev 2004. - 468 p.
27. Zhilyaev, NI Operative surgery in obstetrics and gynecology / 2004.
28. Selected lectures on obstetrics and gynecology / Ed. AK Strizhakova etc. - Rostov-on-Don:
Phoenix, 2000. - 512 p.
29. Clinical recommendations. Obstetrics and Gynecology: scientific publication / Ed. VI Kulakov. - Moscow: GEOTAR Media, 2006. - 512 p.
30. Clinical lectures on obstetrics and gynecology / Ed. AN Strizhakova etc. - M.: Medicine,
2000. - 379 p.
31. Clinical evaluation of laboratory tests in women: study guide / Moscow Medical and Dental.
University. NA Semashko. - M: 2005. - 96 p.
32. Kulakov, VI Preterm birth / VI Kulakov, LE Ants. - M.: Medicine, 2002. - 176.
33. Kulakov, VI Intensive care in obstetrics and gynecology (efferent methods) / - M: MIA,
1998. - 206 p.
34. Drugs used in obstetrics and gynecology / Ed. Acad. RAMS VI Kulakov, Acad. RAMS VN
Serov. 2006. - 375 p.
35. Emergency care in obstetrics and gynecology. Quick Guide - M. GEOTAR - Media, 2007. 52.
36. Perinatology Basics: A tutorial / Ed. MP Shabalov. - Moscow: MEDpress-inform, 2002. 576 p.
37. Practical skills in obstetrics and gynecology: a manual / LY Suprun, TS Divakova and others.
- Minsk: New Knowledge, 2002. - 166 p.
38. Rational pharmacotherapy in obstetrics and gynecology: Hands-on. for practitioners / Ed. VI
Kulakov, VN Serov. - M.: 2005.
39. Guide Out - patient care in obstetrics and gynecology / Ed. VE Radzinsky. M: GEOTAR Media, 2007.
40. Guide to practical training in obstetrics / Ed. VE Radzinsky. - M.: MIA, 2004. - 576 p.
41. Saveliev, GM Obstetrics: a textbook for schools / GM Savelyev, RI Shalina. - Moscow: GEOTAR Media, 2008. - 656 p.
42. Sidelnikov, VM AG Antonov Premature birth. A premature baby / VM Sidelnikov, AG Antonov. -M. "GEOTAR" 2006.
43. Smirnov, A. Pregnancy without problems / AN Smirnov. - Moscow: Atris Press, 2002. - 208.
44. Smirnov, LM Obstetrics and Gynecology: Textbook / LM Smirnov. - M.: Medicine, 1999. 368 p.
45. Handbook of obstetrics, gynecology and perinatology: uch.posobie for doctors / Ed. GM
Savelevoy.2006. - 720.
46. Trifonov, E. Obstetrics and gynecology: a manual for med._vuzov / EV Trifonov. - Moscow:
VLADOS, 2005. - 175 p.
47. Filippova, GG Psychology of motherhood: a manual / GG Filippov. - Moscow: Publishing
House of the Institute of Psychiatry, 2002. - 240.
48. Chernukha, EA Prolonged and prolonged pregnancy. Guide for Physicians / EA Chernukha. M.: "GEOTAR - Media", 2007. - 207.
49. Chernukha, EA TK Puchko breech presentation. Guide for Physicians / EA Chernukha, TK
Beam. - M.: "GEOTAR - Media", 2007. - 173 p.
50. Shmagel, KV Immune pregnant women / KV Shmagel, VA Cherries. - Moscow: Medical
Book, 2003. - 226 p.
51. Tskhai, VB Perinatal obstetrics: a manual for honey. Universities / VB Tskhai. - Atlanta:
Med. Academy of RAMS, Moscow, Honey. book, 2003.
52. Amniotic and extraembryonic structures in normal and complicated pregnancy / Ed. VE
71
Radzinsky. 2004. - 393 p.
53. Congenital, perinatal and neonatal infections: Per. from English. / Ed. A.Grinou, J. Osborne,
S. Sutherland. - M.: Medicine, 2000. - 287.
54. Kulakov VI, Murashko LE Premature birth. M. Medicine, 2002.
55. Serov VN etc. Eclampsia: A Guide for Physicians / V.N.Serov etc. - M.: MIA, 2002. 463 with
56. VM Sidelnikov Habitual loss beremennosti.-M.: Triad-X, 2002.
57. Disseminated intravascular coagulation in obstetrics AD Makatsaria etc. - M.: Triad-X, 2002.
- 496.
58. Schechtman, MM, GM Burduli Diseases of the respiratory system and blood circulation in
beremennyh.-M.: Triad-X, 2002. - 230C.
59. Shifman EM Pre-eclampsia, eclampsia, NELLP syndrome / Inteltek, 2002.
More:
60.Uchebnoe grant for the development of practical skills surgical / Edited by prof. Atalieva AE,
prof. Babadjanova BD Tashkent 2003. C102-115
61.Algoritmy diagnosis and treatment of surgical / Edited by Academician Karimov
Sh.I.Tashkent 2003. From 39-64
62.Uchebnoe benefit surgical subjects for medical students / Edited by Academician Karimov
Sh.I.Tashkent -2003 Part II Obstetrics and ginekologiya.S 64-19013. Practical skills in obstetrics
and gynecology / Metod.posobie / / Tashkent 2008.
63.Akushersky soft tissue injuries of the birth canal, Kulakov VI, Butova E.A.2004.
64.Akusherstvo. National rukovodstvo._2004.
65.Infektsii in Obstetrics and Gynecology How VK Seagull 2006
66.Hirurgicheskaya technique cesarean secheniya_Strizhakov A.N._2007.
67.Ratsionalnaya pharmacotherapy in obstetrics and ginekologii.2007
Chan_Gynecology_and_obstetrics.2004
68.Rukovodstvo for outpatient care in obstetrics and gynecology, Kulakov V.I.2005.
70.Sidorova_I.S._Rukovodstvo_po_akusherstvu_ (Medicina, 2006) (ru) (1033s
71.Posobie for practical development of Obstetrics Voronin (KV) 2007.
72.Kirienko AI, Matyushenko AA, Andriyashkin VV Ostryi tromboflebit/2005
AN 73.Ivanyan - Intrauterine growth ploda/2007
74.DVS_sinrom _v_akusherstve.2004
75.Neonatologiya (Bazhanov NP). - T. I. - 2004
76.Prikaz MZ № 500 "On the reorganization of maternity hospitals to improve the efficiency of
perinatal care and the prevention of nosocomial infections."
77.Internet sites:
http://www.studmedic.narod.ru/, http://med.siteedit.ru/,
http://www.rukovodstvo-po-akusherstvu.-uchebnoe-posobie.html, http://www.materinstvo.ru,
http://mama.ru.http://www.art-med.ru,, http://www.doctor.ru, http://www.rodim.ru,
http://mamka.ru
http://medagent.ru, http://www.art-med.ru, http://www.medsan.ru,
http://mediki.spb.ru, http://medinstitut.e2e.ru, http://www.medstudy.narod.ru
http://www.obgyn.ru, http://www.medsno.ru, http://medrusnet.euro.ru
www.medtext.ru, www.medpoisk.ru, www.medicum.nnov.ru/student/
http://6years.net/, http://preryvanie-beremennosti.pharmabort.ru/
http://med4net.ru/, http://www.med-life.ru/, http://www.pregnant.ru/
http://www.roddom.ru, http://www.medpoisk.ru/, http://www.medlinks.ru
72
Topic: breech. Biomechanism birth. External cephalic fetus in breech presentation. Lovseta techniques and Maurice-Smale-Veit.
1st place of training, equipping,
 Department of Obstetrics and Gynecology, the audience;
 dummy pelvis, female pelvis, doll fetus;
 standard models of pregnancy;
 the classic model of labor;
 gynecologic simulator ZOE;
 childbirth simulator Noelle;
 simulator newborn Newborn;
 set of slides on the topics of discipline;
 methods work in small groups: the method of the incident, "a round table" problem solving,
"pen in the middle of the table", "swarm", etc.;
 testing and teaching practical skills in OSKE (objective structured clinical examination).
 video, TV, TV;
73
 personal computer (Pentium-III);
 set of slides with typical conditions for ultrasound scanning of pregnant women and gynecologic patients;
 set of video blogs "VJOG" (USA), highlighting recent advances in diagnosis and treatment of
obstetric and gynecological conditions;
 set of videos and films demonstrating the typical obstetrician-cal and gynecological procedures
and operations.
 training video, "breech presentation"
 educational software;
 multi media training and testing;
 the use of e-mail and INTERNET;
 business simulations and case studies;
 center for training in practical skills
 offices and laboratories maternity complex
 delivery room
 set of test items.
 phantom with a doll
 Apgar score;
 scale Silverman.
2.Prodolzhitelnost classes
The number of hours-5
3.Tsel classes
 breech explain the concept and its variants;
 to analyze the course of pregnancy in breech presentation;
 to explain the principles of pregnancy;
 analyze the peculiarities of I stage of labor in breech presentation and its management;
 demonstrate a phantom Biomechanism birth of the fetus in breech presentation;
 analyze the possible complications in the II stage of labor;
 show on the phantom hand breech benefits (benefits Tsovyanovu, classic hand-manual);
 discuss possible complications for the fetus and newborn at delivery in breech presentation.
The student should know:
 etiology, classification, Biomechanism birth;
 features of the flow and delivery;
 used for assisted delivery;
 complications arising in 1 and 2 stages of labor with breech presentation.
The student should be able to:
External methods to examine pregnant women and mothers, diagnosed Vat breech presentation,
show a phantom all moments biomechanism labor with breech presentation, raspoznovat them
in-house study, to determine the location of the presenting part in the birth canal, to provide benefits Lovsetu hand, classical obstetrical allowance, removal of the fetal head to demonstrate the
method of Maurice-Smale-Veit, properly recorded in the history of the survey data delivery,
make a diagnosis and determine the tactics of birth (birth vaginally or cesarean section).
4.Motivatsiya
The question of the management of pregnancy and delivery in breech presentation is very relevant, due primarily to increased perinatal mortality rate 3-5 times in comparison with childbirth
in cephalic presentation. Breech increased incidence of children and there are adverse long-term
results in the form of central paresis, epilepsy, hydrocephalus, mental retardation and other complications of the mother should be noted a higher frequency of delayed rupture of membranes,
abnormal labor, prolonged labor, surgery, infection, etc. Early diagnosis and correction is one of
the primary stages of cure, which is assigned to the doctor the first link.
74
5. Intra and interdisciplinary communication
Teaching of the subject is based on the knowledge students the basics of anatomy, topographic
anatomy, histology, normal and abnormal physiology, endocrinology, and microbiology. Acquired during the course will be used for the passage of endocrinology, internal medicine, surgery, pathology of obstetrics, gynecology, hematology, health, pediatrics. The importance of
studying this disease on an expanded scale, together with the related professions, due to the high
risk of disease during pregnancy, childbirth and the postpartum period, and even a successful
outcome of pregnancy requires more of the rehabilitation therapy in a family health center.
6.Soderzhanie classes
6.1.Teoreticheskaya part
Breech presentation are pathological obstetrics, breech delivery - to the pathological.
Breech more frequently than in the brain, there are grass-matic injury and maternal morbidity
(torn soft birth canal and perineum, pubis injury and sacro-iliac joints under-bleeding, postpartum infectious diseases).
Perinatal morbidity and mortality in breech presentation is much higher than the head, and due to
many factors-tors, such as prematurity, hypoxia, birth injury (torn cerebellar gallop, hemorrhage), damage to the abdominal cavity for ¬ and spinal cord abnormalities fruit, etc.
Perinatal loss in pelvic predlezhanin with different methods of delivery ¬ Dah from 0.5 to
14.3%, ie 3-5 times higher compared with that at birth in cephalic presentation. Most ¬ Chiyah
perinatal losses observed during childbirth Foot presentation. Perinatal losses largely depend on
the method of delivery. The main causes of perinatal losses are premature birth, birth defects,
birth trauma. At autopsy the most affected brain and spinal cord, liver, adrenal glands, spleen.
When vaginal operative delivery is sometimes affected the brachial plexus, the sternocleidomastoid muscle, pharynx.
The study of long-term effects on children born in the breech position, found that they often have
hip dysplasia or dislocation of joints, retarded psychomotor development, patii encephalopathy,
hydrocephalus, etc.
Breech occur in 3-5%.
CLASSIFICATION
There are the following types of breech presentation: I) breech (flexion) and 2) leg (extensor)
previa.
Breech delivery are further subdivided into pure and mixed gluteal breech delivery. Some authors purely breech called incomplete and mixed buttock - complete.
In purely gluteal (incomplete) previa to the entrance to the pelvis facing buttocks: legs extended
along the body - bent at the hip and knee joints to straighten up and the feet are in the chin and
face.
In mixed gluteal (complete) previa buttocks facing the entrance of the pelvis with the legs bent at
the tazobed ¬ indigenous-tion and knee joints, straighten a few in the ankles, the fruit in the position to "squat".
Foot previa share for full, partial and knee. At full foot previa to the entrance to the pelvis
predlezhat both legs of the fetus, a slightly open in the hip and bent at the knee joints. At partial
foot previa - predlezhit one leg, straighten up in the hip and knee, and the other bent at the hip
and knee, is higher. When knee previa legs straighten up on hips and knees bent and knees
predlezhat to the entrance to the pelvis. Foot previa formed during childbirth.
Among breech buttocks occur in about 30% of cases and often primiparous. Among the foot
previa more common parent, which are 30% and delivery moving and full.
Positions and types of positions fetal breech defined as when the head - the back of the fetus.
Etiology breech still remains insufficiently understood. It is believed that changes in the shape of
the uterus contribute to the formation of fetal malposition, including pelvic. Conjectured for the
availability of, fruit, ¬ placental factors, contributing to breech.
To maternal factors include abnormalities of the uterus, uterine tumors, narrow pelvis, pelvic
tumors, decreased or increased uterine tone in multiparous, the scar on the uterus after opera75
tions, including after cesarean, etc.
To the natural factors include premature birth, multiple pregnancy, intrauterine growth retardation and congenital anomalies of the fetus (anencephaly, hydrocephalus), incorrect chlenoraspolozhenie fetus, especially weight-machine tibulyarnogo fetus and others have found significant violations of cytomorphological and neurosecretory hypothalamic nuclei in breech presentation, the death of a large number neurons that increase the functional activity of neurosecretory
cells, the presence of hemorrhage. The above changes may adversely affect the course of the
acute phase of adaptation and further development of the newborn child, as this is an increase of
physiological concentrations of neurohormones (oxytocin, vasopressin) contained in neurosecretion. Found that breech term infants nervous elements of the medulla oblongata are less mature
(along with the neurons are neuroblasts) in contrast to children born in cephalic presentation.
Placental factors include placenta previa, the location of the bottom or corners of the uterus, oligohydramnios or polyhydramnios, etc.
Among the etiological factors, the most common nedonoshen alia, small and polyhydramnios,
genital malformations, impaired uterine tone in multiparous, narrow pelvis.
Noteworthy is the view that the formation of the breech fetus depends on the maturity of his vestibular system, and therefore the lower the pregnancy, the more often identified breech presentation, so at 21-24 weeks of pregnancy breech occur on 33%, and at full-term pregnancy - 3.54.5%
The nature of fetal presentation is finally formed to 34-36 weeks of pregnancy.
DIAGNOSIS
Recognition of breech presentation is mainly based on the ability to distinguish between palpation of fetal buttocks.
For external use obstetrical study four receptions Leopold-Levitsky.
The first method allows us to determine in the bottom of the uterus round, thick, running head,
often shifted from the middle line of the abdomen to the right or left. Bottom of the uterus in
breech presentation is higher than with cephalic presentation, at the same gestational age, due to
the fact that the pelvic end of the fruit is usually located above the entrance to the pelvis to the
end of pregnancy and the onset of labor.
With the second method determines the back of the fruit, which is usually located on one side of
the abdomen, and small parts - on the other.
In the third admission at the entrance or at the entrance to the pelvis palpable large, irregular presenting part myagkovataya consistency, unable to balloting.
On the fourth admission confirmed presenting part (it is usually a large, irregularly "form myagkovataya consistency) and its relation to the entrance of the pelvis. Pelvic end of the fruit is
usually up to the end of pregnancy is the entrance to the pelvis.
The heartbeat of the fetus in breech position most clearly heard above the navel, sometimes on
his own level, to the right fire to the left (depending on position). Position and type of positions
are determined by the image of the fetus (as in cephalic presentation).
Breech diagnosis usually causes difficulties only with the express voltage anterior abdominal
wall muscles and increased uterine tone, obesity, twins, anencephaly.
To confirm the diagnosis and determine the breech of his time, short-sighted use of vaginal examination.
When vaginal examination during pregnancy through the front arch is felt bulky myagkovataya
consistency presenting part of the fetus, which differs from the head, which is more dense and
round.
Breech easily diagnosed by ultrasound, which allows to determine not only the breech, but also
gender, appearance, weight of fetal head position (bent, straighten), cord entanglement, the localization of the placenta, the size and the degree of maturity of the cross, the amount of water to
determine the fetal abnormalities, etc.
When electrocardiography QRS complex ventricular fetus faces downward, not upward, as in
cephalic presentation.
76
Can be used successfully amnioscopy at which establishes the character ¬ vayut fetal presentation, number and color of amniotic fluid, umbilical cord loops possible presentation.
There are four variants of position of the head of the fetus in breech presentation (the angle
measured between the spine and the occipital bone of the fetal head):
 head bent (angle greater than 110 °),
 head slightly to straighten (military posture) - I degree of extension (angle
from 100 to 110 °),
 head moderately straighten - II degree of extension (the angle from 90 to 100 °),
 excessive extension of the head ("looking at the stars") - III degree
extension (angle less than 90 °).
Clinical signs of extension of the fetal head are unconformity estimated size of the fetal head to
its mass (size head is large), the location of the head in the bottom of the uterus, the presence of
severe cervical-occipital sulcus.
Most clearly define the position of the fetal head can ultrasound.
Causes of excessive extension of the head, except for the presence of tumor in the neck of the
fetus is unclear.
DELIVERY MECHANISM
At the end of pregnancy and the onset of labor to their buttocks are the transverse size of one of
the input size of skew in the pelvis (in the form of the front, the first position - over the left
oblique size). Promotion of fruit through the birth canal usually begins at the end of full disclosure uterine mouth. Taken to distinguish six points delivery mechanism breech fetus.
The first point - internal rotation buttocks. It begins at the transition from the widest part of the
buttocks pelvis to narrow. Rotation is performed in such a way that the outlet of the pelvis is the
transverse dimension of the buttocks in the forward rate of the pelvis. Front buttock fit pubic
arch (between the greater trochanter and the edge of the ilium), forming a point of fixation, the
rear is mounted above the tailbone. In this case, the body of the fetus is subjected to a slight lateral flexion posterior bulge under the curve of the sacrum.
The second point - the lumbar lateral flexion of the spine of the fetus. Further forward movement
of the fetus results in more lateral flexion of the fetal spine. In this case, the rear buttock rolls
over the perineum, followed by the final out of the pubic joint front breech birth. At this time,
take your shoulders transverse size on the same size of an input oblique to the pelvis, through
which passed the buttocks.
The third point - the internal and external shoulder rotation rotate the torso. This rotation is completed setting shoulder forward rate yield. In this case, turns back to the side, the front shoulder
of the fruit comes under the pubic arch (on the border of the upper and middle third), and the rear
is set in front of the coccyx over the perineum.
The fourth point - juices flexion cervical-thoracic spine. From this moment due to the birth of the
shoulder girdle and arms.
The fifth point - internal poporot head (occiput anterior). Head comes in sizes small oblique
oblique input size to the pelvis, the opposite of what has guided the shoulders. In the transition
from the wide to the narrow part of the pelvis head performs internal rotation, which resulted in
the sagittal plane (sagittal) suture is in the amount of direct output, and suboccipital fossa - under
the pubic joint, where the image of the point of fixation.
Sixth point - bending the head. The result is a head-tion slits (birth) consistently roll out over the
perineum-Stew's chin, mouth, nose, crown and nape. Head erupt small oblique size. Rarely observed eruption average oblique head size, which leads to a strong stretching of the perineum and
to the possibility Nome rupture.
Generic tumor at breech with its large on one of the buttocks: the first position - on the left buttock, the second - on the right. Often generic tumor goes from the buttocks to the outer organs of
the fetus, which is manifested by edema of scrotum or labia.
When foot previa generic tumor located on the legs, which become swollen and blue and purple.
Because of the rapid subsequent birth of the head there is no configuration, and it has a round
77
shape.
In the normal mechanism back during birth torso rotates anterior (front view). In some cases, the
back of the fetus turns backwards, there is a rear fork, during labor slows down or the head is
flexed, it rests on the bridge of the nose and above the symphysis crotch rolls his head. Often
there is a serious complication due to straightening head: chin rests over the symphysis, and the
head to be born in a state of extension. Without obstetric birth head is delayed and the fruit dies
of asphyxia. The head should be released quickly and carefully with the help of special techniques.
Pregnancy and Childbirth
Multiple pathogenetic factors of breech presentation are the cause of a higher number of complications of pregnancy.
The most frequent complications of breech presentation in the first half of pregnancy are the
threat of termination (45%), which heaven every fifth pregnancy was clinical evidence of isthmic-cervical insufficiency, toxemia first half of pregnancies ¬ ty (27.5%), etc.
In the second half of pregnancy are the following complications of pregnancy hypertensive varying severity (35.6%), threat of termination of pregnancies ¬ ty (39.3%), small for gestational
(4.9%), cord entanglement (40.8%) , oligohydramnios (25.3%), etc.
During labor in breech presentation has a large scrap the number of complications. In the first
stage of labor is the most common wound-it or premature rupture of membranes. Particularly
common complication observed in the leg presentation. Pelvic end is smaller than the head, at
the introduction into the basin it is not fitted tightly to the birth canal-rays. Time is no contact,
front and rear strict separation of water is not bounded. With every fight amniotic fluid rushing
into the lower uterine membranes can not withstand much stress and disruption, are premature.
At the time of the outpouring of water loss can occur cord loops and small parts of the fruit. Prolapsed umbilical cord loops breech occurs 5 times more frequently than in the head. However,
even the breech, although less frequently than in the brain, may be precipitated loop of umbilical
cord compression, leading to hypoxia and fetal death if not promptly assist
Breech frequently observed weakness of labor activity, especially in the early and premature discharge okoloplod-waters. In this case, the cervix is slow pelvic end for a long time is the entrance to the pelvis, delivery delayed. Non-timely outpouring of water and prolonged labor lead
to a breach of the utero-placental blood flow and the development of hypoxia in the fetus as well
as contributes to the penetration of infection into the uterus. It is possible infinitesimal tsirovanie
membranes, placenta, uterus and fetus.
Period of exile in breech presentation has its own characteristics-mentioned related to the fact
that the largest part of the fruit - the head is born of the latter. The first moves down the birth canal less voluminous pelvis-first end, which can not extend the birth canal to the extent necessary
for the gentle passage of the shoulder girdle and head. Therefore, when entering into the basin
shoulder belts can be complications, dangerous for the fetus: crowding pens and extension of the
head (pinch the head). In these birth complications shoulder girdle and head delayed fetus threatens hypoxia and death.
When passing through the basin of the upper torso and head but inevitably arises cord compression. Loop body and the expulsion of the head-tyagivaetsya over 3-5 minutes, there is a severe
fetal hypoxia, which could lead to his death. These complications are more common with foot
previa, because their legs with a small amount of insufficient extend the birth canal.
One of serious complications is vkolachivanie buttocks gas at breech and it is often the manifestation of clinical inconsistencies fetus and maternal pelvis. A serious complication - fetal poporot
back backwards when the chin is fixed under the pubic sym-fizom, unbent head: there is a risk of
hypoxia, injury of the fetus and the mother. At birth in breech injuries often occur in the mother
in the form of tears of the cervix, vagina and perineum.
Often, there is a shift in labor breech one type to another. Thus, the transition incomplete foot
presentation at full noted in 30% of cases. Such a transition is considered inauspicious and is the
basis for the expansion of indications for cesarean section.
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Of pregnancy and childbirth
Breech presentation, diagnosed before 28 weeks of pregnancy, requires only expectant observation.
In 70% of multiparous and 30% nulliparous pregnant cephalic spontaneously before birth and in
a small percentage of the birth.
If we consider that pelvic prellezhanie is unfavorable for those genera-tion and their outcomes
for the fetus, gestation 29-30 weeks, many more authors recommended to carry out actions
aimed at changing nye breech to a head. Much attention is paid to the complex of physical exercises.
The simplest set of exercises is as follows: pregnant and bureau lying na couch, alternately turns
to the right and left side, and lay on each of them for 10 minutes. The procedure is repeated 3-4
times.
Classes are held three times a day. Turning the fetal head may pro-radiate in the first week. Effectiveness of the system of gymnastic exercises due to a change in muscle tone the abdominal
wall and uterus in the stimulation of mechanical - and baroreceptor cancer, effects on the vestibular system of the fetus. Proved that with the help of physical exercises can not only promote the
rule used breech fetus to the head, but also adjust the tone and spontaneous activity of the uterus.
Pregnant women with differentiated-tion selection exercise noted patch breech fetus to the head
in 76.3% of cases.
Risks of breech presentation:
To the fetus likely:
- Cord prolapse
- Birth trauma
- Disability
Perinatal outcome in breech presentation is worse than at the head, regardless of the method of
delivery
External cephalic fetus in breech
For external rotation preventive fetal head in breech presentation are not unanimous, although its
effectiveness is high - 67-70%.
External cephalic fetus at term significantly reduces the incidence of surgical delivery by caesarean section.
Should be offered and discussed with women:
- With uncomplicated singleton pregnancies
- Breech fetus
- At 36 weeks gestation
Should be performed at 37 weeks of pregnancy
Routine use of tocolytics:
- Reduces the failure rate
- Facilitates the procedure
- Prevention of fetal bradycardia
Contraindications: oligohydramnios, rupture of membranes, mnogoplo-que, previa and placental
abruption, fetal distress, cesarean cross section in the history of bleeding.
External rotation preventive proposed B.A.Arhangelskim requires certain conditions: it must perform highly skilled doctor and hospitals, where, if necessary (bleeding, acute hypoxia) can be
produced cesarean. Recently, external cephalic version is proposed to conduct after 36-37 weeks
of pregnancy with enough amniotic fluid under ultrasound guidance. This is mandatory for the
purpose of β-mimetics to reduce the tone of the uterus. You should also exercise control over the
monitor fetal heart rate before turning and within an hour after its implementation.
However, when you consider that for the outer turning a preventive enough contraindications
(threatened miscarriage, narrow pelvis, primiparous age over 30 years, infertility or miscarriage
history, genital abnormalities, the scar on the uterus, multiple, low-or polyhydramnios, diseases
of the circulatory system, etc.) and during the meeting were frequently observed complications
79
such as premature placental abruption, fetal bladder dissection, acute hypoxia, amniotic fluid
embolism, spinal cord injury in the fetus, and others, it becomes clear why questioned the appropriateness of external rotation of fetal head is still the subject of debate, and many prefer to
breech delivery or manufacture elective caesarean sections.
Selecting the method of delivery in breech presentation depends on the woman's age, gestational
age, condition and fetal weight, degree by bent head, "maturity" of the cervix, the size of the pelvis, concomitant extragenital pathology, complications of the pregnancy (long-term threat of
miscarriage, hypertensive status during pregnancy, premature birth and perenashivanie), etc.
Tactics breech delivery should be determined by the county prior to delivery. It could be:
- Spontaneous onset of labor and delivery through natural ro-dovye way;
- Labor induction at term or before the due date;
- Cesarean delivery on schedule.
Very important when choosing a method of delivery is to determine the expected weight of the
fruit. Found that the lowest mortality rate for breech presentation at its mass from 2500 to 3500,
the fruit of more than 3600 g breech is considered to be the largest. When fetal weight 15002500 g often unfavorable birth outcomes for vaginal delivery, because the head, being the largest
part of the fetus is subjected to injury (intracranial hemorrhage), especially at Foot presentation.
The most objective method of determining the estimated fetal weight is an ultrasound.
Serious and dangerous complication in the birth of the head is its over-extension, so that often
arise hemorrhagic of the cerebellum, subdural hematoma, injury of the cervical spinal cord and
cerebellum breaks gallop. The presence of III degree extension head (by ultrasound) is the basis
for delivery by caesarean section. When I and II degrees of extension at time of manual aids the
birth of the fetus requires caution during injection head.
To assess the condition of the fetus in breech presentation shows a study of its cardiac and uteroplacental and fruit-placental blood flow (Doppler).
Great importance in breech presentation, an assessment of the size and shape of the pelvis.
Breech, even a small decrease in one of the pelvis can lead to injury of the fetus and the birth
process, as when the placenta does not have time to adjust the head to the pelvis of the mother.
An objective assessment of the size and shape of the bone of the pelvis can be obtained at radiopelvimetry. When radiopelvimetry, measure the direct and transverse dimensions of the pelvis
in all planes, which allows to select appropriate method of delivery.
Great importance in determining the readiness of a woman's body for childbirth with breech
presentation is "maturity" of the cervix to select the method of delivery, both during pregnancy
and in preterm rupture of membranes.
To select the mode of delivery all the clinical data and results obtained from objective research
methods should be assessed on a scale of forecast delivery in breech presentation at term fetus.
Evaluation is conducted on 13 parameters from 0 to 2 points each. If the amount is 16 points or
more, the delivery can be carried out through the birth canal. Cesarean section is shown, if at
least one of the inner pelvis evaluated with 0 points, there is an excessive extension of the fetal
head, the estimated its weight 4000 g or more, in patients with severe intrauterine fetal distress,
with "immature" the cervix, prolonged pregnancy, as well as 3500-3999 g fetal weight and size
of the pelvis, valued at 1 point, primiparous.
Currently, due to the risk of fetal trauma at rodorazreshayuschih operations vaginally most obstetricians consider appropriate expansion of indications for cesarean section for breech presentation (the operation is carried out in 80-90% of cases). Same outcome for the fetus at caesarean
section is much better than at birth vaginally. In the conduct of birth vaginally tactics can be
changed depending on the obstetric situation. Indications for elective caesarean section at breech
presentation are perenashnvanie pregnancy, lack of preparation of the birth canal at term, abnormal development of the genital organs, anatomically narrow pelvis, severe chronic fetal hypoxia,
fetal weight more than 3600 g and less than 2000 g, head extension III degree. In addition to
these indications, a significant place combinative testimony, namely the combination of breech
primipara with age over 30 years, a long history of infertility, poor outcome of previous births,
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uterine scar after cesarean
section, etc.
In good condition of pregnancy and fetal normal pelvis and medium size fruit, with his head
bent, with "mature" cervix childbirth should maintain vaginal msnitornym under control. In the
process of childbirth complications may arise from the mother and (or) of the fetus, and the plan
of birth can be changed in the direction of operative delivery.
With the onset of labor should specify the nature of the pelvic proposals, facilitated after rupture
of membranes, and with a significant disclosure of uterine zeia. In purely breech sentence voluminous myagkovataya palpable consistency of the fruit, you can identify with the sacrum, coccyx, the ischial tuberosity, the gap between the buttocks, anus, genitals fetal inguinal fold. The
position of the sacrum recognize the position and appearance of the fruit: at the front as the first
position, he turned to the left and in front, at the back a second position - to the right and to the
back. In mixed breech near the buttocks palpable stop.
Can mistakenly confuse purely breech proposal from the front, taking the anus for his mouth, the
sciatic spine for molar elevation. Careful study should prevent the error. Analyzed finger feels
resistance of muscles anus, while firmer jaw felt when passing into the mouth. Moreover, thumb,
derived from the anus, sometimes colored meconium. Roth and molar elevation have a triangular
shape, while the buttocks and anus are located on the same line. Palpation of the sexual organs
and the anus should be done very carefully so as not to cause injury.
When foot previa metatarsal tubercle, short and straight fingers, no thumb abduction of distinguishing stem from the handle of the fetus. Knee is different from the elbow of moving kneecap.
In the first stage of labor to prevent early-coating membranes new mother should in bed. Woman
in childbirth is placed on one side, whither the back of the fetus, which facilitates insertion of the
presenting part of the fetus, increased labor, loss prevention cord loops.
Immediately after the outpouring of water produce vaginal examination to clarify the diagnosis
and exclude loops of umbilical cord prolapse.
When conducting a breech birth is required for the control monitor fetal heart rate and uterine
activity.
The fetal heart rate in breech presentation at the beginning of the first stage of labor is no different from the fetal heart rate with cephalic presentation and has the features at the end of the first
and second stages of labor: have higher basal heart rate (BCHSS) aktseleratsy appearance in response to a fight and Early decelerations during any attempts. To the initial signs of fetal hypoxia
in the first stage of labor are moderate tachycardia (BCHSS 175-190 beats / min) or bradycardia
(BCHSS to 100 beats / min), periodic short-term arrhythmia or monotonous rhythm in the second stage of labor have declined to BCHSS SO beats / min, the periodic rhythm of monotony
combined with arrhythmia. It marked signs of hypoxia in the first stage of labor include tachycardia up to 200 beats / min or bradycardia to 80 beats / min, persistent monotony of rhythm, or
arrhythmia, prolonged late deceleration of heart rate. In the second stage of labor - tachycardia
over 200 beats / min or bradycardia below 80 beats / min, persistent arrhythmia in conjunction
with the monotony of a long or late deceleration of heart rate.
For the assessment of the generic process (uterine mouth opening)
must maintain the partograph. For a normal birth rate of cervical dilatation in the active phase of
labor with breech presentation should be at least 1.2 cm / h in nulliparous and not less than 1.5
cm / h - in multiparous.
At a steady routine of labor (cervical opening pas 3-4 cm) shows the introduction of anesthetics
(promedol etc.) and antispasmodics (no-spa, baralgin etc.). Good results were obtained during
epidural anesthesia, which (except for analgesic effect) helps to regulate labor, more rapid disclosure of the cervix in the second stage of labor for the relaxation of the pelvic floor. Necessary
to carry out activities to prevent fetal hypoxia: 2-4 ml of a 1% solution Sygethin, 50-100 mg cocarboxylase, 10-20 ml of 40% glucose solution, inhalation of humidified oxygen, etc.
An important task is the timely diagnosis of anomalies of labor and an appropriate treatment. In
detecting violations of uterine breech fetus more often than in the head, you should decide on
81
rodorazreshenin by Caesarean section.
The most common indications for emergency caesarean section in women with breech is the
weakness of labor, lack of labor for 2-3 hours after the rupture of membranes, fetal hypoxia.
When a loop of umbilical cord prolapse at term viability, tucked her failure and lack of conditions for rapid-rodorazre sheniya vaginally should make Caesar cross section.
In the second stage of labor to strengthen the monitoring of the fetus, the fetal heart should listen
after each attempts. Preferred to carry out the monitor with the control features of the fetal heart
in women with breech. In contrast to the cephalic presentation appearance of meconium during
expulsion is not a sign of hypoxia, as meconium is forced out of the intestine mechanically
In the second stage of labor for prophylaxis recommended intravenous drip of uterotonic (oxytocin). By the end of the second stage of labor to prevent spasm of the cervix is recommended to
introduce 1.0 ml of 0.1% solution of atropine sulfate, and 2.0 ml of 2.0% solution of papaverine
hydrochloride, or other antispasmodics.
Since vrezyvaniya buttocks woman in childbirth is laid so that cross on the edge of the pelvis
was birthing bed. During any attempts maternity recommend resting the foot stand, a hand held
device or a special press hands hips to stomach any attempts to increase and decrease the angle
of inclination of the pelvis.
Before the eruption of the buttocks to intervene during labor should not be. When cutting the
pelvic end to make the mid-lateral epiziotomnyu
At birth in breech are 4 stages: 1) the birth of the fetus to the navel;
2) The birth of the fetus from the navel to the lower angle of blades, and 3) the production of the
shoulder girdle and pens, and 4) production of the head.
As shown in the bottom slot umbilical ring, the moment, it is extremely dangerous to the fetus.
At this time the head enters the pelvis and holds the cord, leading to fetal hypoxia.
If a generic process is correct, the birth of the body and the head is completed quickly. The
whole mechanism of the expulsion of the shoulder girdle and head to end in the next 3-5
minutes, otherwise the fruit will be born in a state of asphyxia. Pressing of the cord more than 10
minutes can result in fetal death. Fruit, in addition to clamping the umbilical cord, face another
danger - detachment of the planet, due to the sharp decline in the uterus in the birth of the body
of the fetus. Therefore, after the birth of the fetus before the umbilical ring need emergency obstetric care and skilled.
Deliveries are expectantly until the fetus is born to the navel. Premature stretching the leg or
groin crease is contraindicated, since it leads to a violation of chlenoraspolozheniya, crowding
pens and extension of the fetal head. Should pay attention to whether the umbilical cord is not
under tension (the nature of its pulsations), and if possible to weaken it 'or even cross, and then
speed up the birth of the fetus.
In the period of exile in childbirth breech to provide manual manuals, which is different for pure
and foot breech presentation. Manual guide is aimed at preserving chlenoraspolozheniya fetus
and following the natural flow of labor.
In our country, the most common case of purely breech and foot previa benefits received by the
method and the method Lovseta Maurice boldly-Veit for subsequent removal of the fetal head.
Manual guide for pure breech predlezhanin method Tsovyanova. The main purpose - to keep the
feet during the period of exile outstretched and pressed to the body of the fetus, which helps
maintain normal chlenoraspolozheniya fetus. This will prevent the occurrence of these adverse
events, as crowding pens and straightening head.
In purely breech fetus legs extended along the trunk and pressed folded hands to the chest and
feet, reaching the level of individuals, support the head bent, unless it is in a straightened position. This arrangement of the legs of the fetus's body turns into a cone, gradually expanding upwards. At the level of the shoulder girdle it reaches its maximum size (average 42 cm), which is
composed of the volume of the chest, both folded handles fruit and feet pressed against him - all
this exceeds the subsequent head (32-34 cm), so the birth it takes place without difficulty.
Manual technique benefits Tsovyanovu for purely breech presentation is as follows. After the
82
eruption of the buttocks to grab his hands so that the thumbs of both hands placed on the thighs
pressed against the belly of the fetus, and the other four fingers of both hands - on the surface of
the sacrum. With this trapping feet prevent premature hair loss and it promotes physiological
mechanism of sorts - the movement of the nascent body anteriorly (to the mother's abdomen) by
wire axis of the pelvis.
With the birth of the body of the fetus presses the doctor carefully to the belly of the fetus feet
thumbs, fingers hand moves up the back, gradually moving his hands to the genital slit, what
prevented fetal loss feet and crowding pens per head. Must hold the body so that it was not
formed rear view (back of the fetus did not turn backwards). With good fruit of labor quickly
comes to the umbilical ring, and after that, and to the lower corners of the blades. In this case, the
transverse dimension of the fruit goes to shoulder one of the oblique size, and by the time of
birth of the shoulder girdle - in direct output size of the pelvis. Buttocks fetus should be directed
somewhat posterior to facilitate the birth of the front handle of the fetus from the pubic arch. For
the birth of the rear handle fruit forward and lift out of the sacral dimples born rear handle. After
that, in the depths of the yawning gender gap appears chin, mouth, nose, fruit. If at this time attempts are strong enough to release the head of the fetus to send buttocks over and up. In this
case, the head is born without any further intervention.
If birth handles and heads is delayed, the last free hand techniques.
With difficulty removing head uses techniques Maurice-Smellie-Veit.
Stages of the reception:
-Put the baby's body face down over the palm of your hand and forearm
-Put your index and ring fingers of the hand on the child's cheek bones and the middle finger in
the baby's mouth to drain jaw down and bending head
-Use your other hand to grab a coat hanger baby
-Upper arm with two fingers gently bend the head of the child toward the chest until the applied
pressure on the lower jaw is not you, is the head of the fetus down until the border hairline
-Gently pull the head for the birth
-To keep the head flexed need to gently apply pressure to hand assistant to the bottom of the
uterus so that it is always in contact with movable head.
At the rear a clean breech gently penetrates the body rotates around the longitudinal axis of the
back in front, to the right fire to the left, depending on the position. If the turn is difficult, childbirth are in the rear view. When you rotate the fetus from the rear view in the front can occur
crowding pens fetus, usually causing considerable difficulties in their derivation. When foot previa complications of childbirth and stillbirths are more common than in the gluteal. Of complications related to the fact that the legs are born can not extend the birth canal for a smooth birth
bulky shoulder belt to the head. Therefore, when the leg previa often seen crowding pens, extension head and pinching her frantically narrowed considerably in the cervix. These complications
can be prevented by the time the expulsion of the shoulder girdle cervix will be disclosed in full.
At present, the foot presentation, especially on a roll leg (or legs) at part uterine mouth of choice
rodorazreshepiya consider cesarean section.
Manual payment at the leg by the method Tsovyanova previa. Until recently, the widely used
manual N.A.Tsovyanovym proposed allowance at foot presentation, in which legs held in the
vagina to the full disclosure of uterine os.
Vaginal examination by adding foot presentation, sterile tion diaper cover genitals and palm applied to the vulva, prevent premature hair loss leg of the vagina. Fetus during attempts like
squats and properly mix breech presentation, and then moving down the birth canal, putting
strong pressure on the nerve sacriplex, strengthening contractions and pushing.
Countering nascent legs should provide for as long as the disclosure was complete uterine
mouth, as indicated by a strong bulging crotch of the presenting part of the fetus, gaping anus,
frequent and vigorous attempts, state of the contraction of the ring finger cross for 5 "above the
pubis. The buttocks down to the vestibule, the legs of the fetus, despite its harmful reaction,
begin to act out the side of his hand obstetrician. This corresponds to a full disclosure of uterine
83
mouth. Once installed the full development of uterine os, opposition will not have the legs and
feet, followed by the buttocks of the fetus and its body are born without difficulty.
After the birth of the body to the lower corners of the blades have a manual guide, as in breech
presentation.
Imperative for a successful birth dictates this method is the intravenous administration of uterotonic means systematic (after each attempts) auscultation of fetal heart tones stethoscope, preferably an ultrasonic sensor with a digital text or using kardpotokografa, observation of high standing kontraktsnonnogo ring for discharge from the genital tract ( possible detachment of the placenta, rupture of the cervix). Manually benefit Tsovyanovu not always warns fallout feet, crowding pens and difficulty in breeding pens (shoulder area) and the fetal head. In such situations, recourse to classical hand allowance in order to handle birth and the fetal head. Classical manual
guide is in spontaneous labor, birth and the lower torso angle blades or in the provision of benefits Tsovyanovu if birth shoulder girdle and the head is not completed within 2-3 min.
When sipping fetus trunk and delayed its deviation can occur anteriorly sharp straightening head
injury and vertebral arteries, which are held in the transverse processes of the cervical vertebrae
and supply blood to the brain and cervical spine. It is important to note that at level of the spinal
cord in the fetus are cells of spinal respiratory center. Even minor damage to the wall of the vertebral artery can cause it to spasm, violation of vertebrobasilar circulation and cause lightning
fetal death during labor or the development of paralysis in the newborn. In addition, rough handling, but the time of aids in deriving the head can lead to injury of the cervical spine and spinal
cord injuries.
Method Bracht. In Europe during childbirth breech method Bracht, where the fetus is born spontaneously to the navel. Then the child's body and hold, without squeezing, deflected towards the
symphysis mother. The force used in this procedure should be moderate. Retention of the child
in this position strengthens uterine contractions and moderate pressure over the pubis assistant to
the head of the fetus is often enough to end the labor spontaneously.
In some cases, the body of the fetus after its emergence from the birth canal is not turned back in
front, as is the case with a typical mechanism of delivery and posteriorly. Formed in this rear
view complicates the process of delivery, as the subsequent head erupt in the back straight as
their size, not small oblique, as in the front view. The challenges for the passage of the head
through the birth canal are often the cause of fetal death from intracranial trauma, mother has
deep perineal tears.
Rear view of breech presentation often spontaneously goes to the front. If not, you need to provide appropriate assistance Once discovered that the sacrum, the popliteal fossa, the heel of the
fruit turned backward, born calf fetus grasping a sterile drapes and stretches down while rotating
it to the side of the big toe, so that the body of the fetus before the appearance of the lower corners of the genital slit blades established in one of the oblique sizes with back facing the front.
If you prevent the rear view failed, which is a serious complication of surgery, the proposed
methods for such cases removing the heads are rarely favorable results. And most of these cases,
children are born dead or dying of severe birth trauma. Gets injured and lying.
During cesarean section in women with breech presentation child must retrieve the leg or groin
folds.
To provide first aid newborn in the delivery room to the presence of neonatology. On examination, the child not only assessed his condition Apgar scores at 1 and 5 th minute of life is determined by CBS cord blood, but also draws attention to the identification of signs of intracranial
injury, cerebrovascular accidents. Frequently (up to 20-22%) in infants born in breech presentation, hip dysplasia is detected, requiring corrective therapy from the first days of life. Children
born in the breech position, should be classified as high risk.
The course and management of the third stage of labor is not different from that of cephalic
presentation.
Postpartum most parturients proceeds normally. However, post-partum infections occur more
frequently than in cephalic presentation. This is due to the more frequent damage to the soft birth
84
canal, due to increased use of tools and surgical procedures in connection with the occurrence of
complications.
Prognosis for the fetus is less favorable than in cephalic presentation in terms of short-and longterm effects.
The use of new educational technologies:
method of "pig in a poke"
To work needed:
1.Nabor options issues
2.Nomerki to draw the number of students in the group.
3.Chistye sheets.
Progress:
1.All students draw deyatsya group into small groups of three students in a subgroup.
2.Kazhdaya subgroup sits at a separate table, prepares a blank sheet of paper and a pen.
3.On written sheet date, the group number, department, FI Student participants in this subgroup
(the name of the business game).
4.Odin members of each group comes to the parties and takes questions from the envelope option for each individual sub-option, but the level of complexity of tasks for all subgroups is about
the same.
5.Studenty rewritten to list your questions and takes the time 15 min. to do the work.
6.Malye groups, each in his own circle, discuss the job and write a reply within reach, accurately.
7.Prepodovatel must strictly ensure that students do not write off (this is the main condition!)
And did not communicate with other subgroups.
8.Po after 15 minutes. answer sheets are collected.
9.Prepodovatel during class checks the correctness, completeness and accuracy of the job.
10.Vsem small group participants exhibited the same point:
Maximum-0, 8 points.
0,8-0,7 "5"
0.6-0.4 "4"
0,4-0,1 "3"
0 "2"
11.Na answer sheet lecturer puts mark and signature.
12.Poluchenny students score recorded for billing classes running total as an estimate for the in
theory part.
13.V free bottom of the log to make notes on the data-tion of the business game warden puts his
signature.
14.Protokoly work remains a teacher.
6.2.Analiticheskaya part
Case studies:
1.Povtornorodyaschaya 30 years in a labor 8 hours. Attempts after 2 - 3 minutes for 50 - 60 seconds. Fetal heart clear, rhythmic, 130 beats per minute. During any attempts cut into the buttocks
of the fetus.
I. The diagnosis?
Answer: breech presentation. II stage of labor.
II. What is obstetric tactics?
A: The manual benefits Lovsetu.
2. Labor is in a sheath offer, conducted on Tsovyanovu.
Fetus was born to the lower corners of the blades and all further production of the fetus stopped.
Fetal heart is clear, rhythmic, 132 beats per minute.
What was the tactic of the doctor?
A: The application of the method Maurice-Smale-Veit.
3. Woman in labor in the II stage of labor. BP - 180/120 mm Hg column are swelling in the lower extremities and abdominal wall. There was a twitching of facial muscles person
85
What method of rational rodorazreshit woman?
A: emergency cesarean section.
4.Povtornorodyaschaya 25 years admitted to hospital with a fallen umbilical cord. Amniotic fluid
moved down the road to the hospital, contractions started 5 hours ago. Pregnancy 3, uneventful,
full-term. First pregnancy 3 years ago over normal urgent delivery. The child is alive, the second
pregnancy - a year ago. Pelvic dimensions: 26 - 29 - 33 - 20. The longitudinal position of the fetus, the first position, breech presentation. Sertsebienie fetus 100 bpm. per minute, rhythmic,
muffled.
Vaginal examination: the discovery is complete, no membranes, vagina detectable fetal stem and
loop pulsating umbilical cord prolapsed. Buttocks pressed against the entrance to the pelvis.
I. The diagnosis?
A: Foot presentation. Prolapsed umbilical cord loops.
II. Future Tactics:
Answer: c-section
5. New mother 30 years old, third pregnancy, the second term delivery. Pelvis June 26 - 29 - 31 20 cm longitudinal position of the fetus, the fetal head in the bottom of the uterus. The estimated
fetal weight 3400 Sertsebienie fetus 132 bpm. In 1 minute. Contractions of 30-35 s, 3-4 min. Duration of labor 6 hours
At vaginal examination has 6 neck is short, the edges of the thin, stretchable, opening the throat
by 5 cm predlezhat buttocks and feet over the entrance to the pelvis, mezhvertikalnaya line in the
left oblique plane of the entrance to the amount of the pelvis. Fetal bladder intact. Diagonal conjugate of 13 cm
1.Diagnoz.
2. Plan of sorts.
3.Vozmozhnye complications.
6.3. Graphic organizer: Making graphic organizer
"T-circuit" on "breech"
T-circuit
T-circuit universal graphic organizer to record binary (yes / no, for / against) or compare 2 aspects of a single concept of information. This is a comparative table. Develop critical thinking
skills.
It is used in the final lecture to complete thematic.
6.4.Prakticheskaya part
1. METHOD OUTSIDE RECEPTION obstetric research Leopold Lewicki
Purpose: To detect the position, the position and type of fetal presentation
Performs step (steps):
Events number does not hold nil
(0 points) Fully
Correctly
Finished
(20 points)
1. Pregnant laid on the couch in the supine position with outstretched leg-mi. The doctor sits
down on the right is a woman. 0 20
2. 1 point - palmar surface of the hand obeh have firmly to the bottom of the uterus so that the
nail phalanx facing each other. This technique determines the height of standing uterus and part
of the fruit, which is in the bottom. 0 20
3. 2nd method - hands descend from the bottom of the uterus on the right and left side of her to
the level of the navel and below. Carefully jam la donyami and fingers of both hands on the sides
of the uterus, determine which side facing back of the fetus and small parts, ie the position of the
fetus. At one position back is turned to the left side of the uterus, with 2 positions - in the right 0
20
4. Third method - the right hand cover the presenting part of the fetus, then carefully make the
86
movement of the hand to the right and the left. This method allows you to specify that the presenting part of the fetus. 0 20
5. 4th method - is investigating whether the feet-Tzom pregnant and puts her hands flat on either
side of the lower part of the uterus. Fingers of both hands, facing the entrance to the pelvis, gently and slowly penetrate between the presenting part and sides of the entrance to the pelvis and
palpate accessible areas of the presenting part. This technique determines proposed ac-cess part
and its relation to the pelvis. 0 20
Total 0100
2. LISTEN FETUS
Purpose: Evaluation of fetal
Performs step (steps):
Events number does not hold nil
(0 points) Fully
Correctly
Finished
(20 points)
1. Auscultation of fetal STET-produced en masse, which is applied to the woman's abdomen. 0
20
2. With neck-set positions serdtsebie auscultated below the navel, in pelvic - above the navel, at
transverse positions - at the navel closer to the head. 0 20
3. At one position to the left heart auscultated, with 2 - to the right, with vain attempts - above
the pubis. 0 20
4. Auscultation stethoscope must rely distribution perpendicular, ie at right angles to the back of
the alleged fruit, broad funnel tightly applied to the pregnant belly, and the other end - an ear
doctor. Auscultation should not hold up his hand, as this breaks the conduction of sound stethoscope. 0 20
5. In a normal heart rate of 120-160 beats per minute, regular and clear. 0 20
Total 0100
3.Opredelenie intrauterine fetal weight.
Purpose: To determine the intrauterine fetal weight
Performs step (steps):
Events number does not hold nil
(0 points) Fully
correctly
performed
(20 points)
1. In a study of pregnant women is defined abdominal circumference and height of standing
uterus with a tape. 0 20
2. Woman laid on the couch in the position on his back, the doctor is the side facing her belly 0
20
3. Measuring tape girded To-lovische women on the front of the navel, and back - in the middle
of the lumbar region and determine the circumference of the abdomen, which at the end of pregnancy up to 100 cm 0 20
4. Height standing uterus is measured by applying the beginning of tape with one hand by the
middle of the upper edge of the symphysis pubis to top of the uterine fundus, which is defined by
an edge palm of the other hand. At the end of pregnancy is normal, it is 32 cm 0 20
5. Abdominal circumference multiplied by the height of the state of the uterus and is determined
by the estimated fetal weight 100 x 32 = 3200 g.
0 20
Total 0100
7.Formy control of knowledge, skills and abilities
-Oral;
87
-Written;
Testing;
Solution situational problems;
And demonstration of skills mastered.
8.Kriterii assessment monitoring
Number having time-duro
Score in% level of students' knowledge
1 96-100% Excellent
"5" full correct answer to the questions on the etiology, pathogenesis, classification, climate nicknames, diagnosis, treatment and prevention of this disease. To sum up and make
decisions, creative thinking, self-analyzes, case studies resolves correctly, with a creative
approach, with full justification of the answer. Actively and creatively involved in interactive games, take the right decisions and summarizes and analyzes. Medical history, partograph fills correctly.
2 91-95% Excellent
"5" full correct answer to the questions on the etiology, pathogenesis, classification, climate nicknames, diagnosis, treatment and prevention of this disease. Creative thinking,
self-analyzes, case studies resolves correctly, with a creative approach, with full justification of the answer. Actively and creatively involved in interactive games, take the right decision. Medical history, filled with partograph one grammatical error.
3 86-90% Excellent
"5" The questions on the etiology, patho-genesis, classification, clinic, diagnostic-ki, the
treatment and prevention of this disease is completely covered, but have 1-2 errors in the
response. Own analyzes, inaccuracies in the solution B-ation problems, but with the right
approach. Actively involved in the interactive games, make the right decisions. Medical
history, partograph fills with 2-3 grammatical errors.
4 81-85% Good
"4" The questions on the etiology, patho-genesis, classification, clinic, diagnostic-ki, the
treatment and prevention of this disease is completely covered, but there are 2-3 inaccuracies, errors. Into practice, understands the essence of the question, says confidently, is a
faithful representation. Situational problems solved correctly, but the justification answer
sufficiently. Actively involved in interactive games, take the right decision. Medical history, partograph fills with 2-3 grammatical errors, inaccuracies in the description.
5 76-80% Good
"4" Correct, but incomplete coverage of the issue. The student knows the etiology, pathogenesis, classification, clinic of the disease, but not completely disassembled diagnosis,
treatment and prevention of this disease. Understands the issue, says confidently. There is
an exact representation. Actively participate in the games. On case studies gives partial solutions. Medical history, partograph fills with 3-4 grammatical errors, inaccuracies in the
description.
6 71-75% Good
"4" Correct, but incomplete coverage of the issue. The student knows the etiology and
pathogenesis of the disease, but not completely disassembled diagnosis, treatment and prevention of this disease. Understands the issue, distribution predicts confidently, has the
submission to the. On case studies provides part-nye solutions. Medical history, the partygram filled with 3-4 grammatical errors, 3-4 errors in the description.
7 satisfies 66-70% solvent, but
"3" right answer half the questions. Student knows the etiology of the disease, but do not
pay out the classification of the disease clinic, confused in the treatment and prevention.
Understands the issue, said confidently, has accurate representations only on specific issues
topic. Situational problem solving HN is true, but there is no justification of the answer.
His-Riya disease partograph filled with 3-4 grammatical errors, 3-4 errors in the descrip88
tion.
8 satisfies 61-65% solvent, but
"3" right answer half the questions. Errors in the etiology, pathogenesis, poorly versed and
confused in the treatment and prevention of this disease. Says uncertainly, has the only
views on certain issues topic. Making mistakes in solving situational problems. Medical
history and partograph fills with errors.
9 satisfies 55-60% solvent, but
"3" error response to half the questions. Student makes an error in the etiology of this disease, poorly versed and confused in other matters relating to the disease. Says uncertainly
has a partial view on the subject. Situational problems solved incorrectly. Medical history
and partograph fills with errors.
10 50-54% of dissatisfaction with solvent, but "2" The correct answer to third set of issues.
Student does not know the etiology of the disease, and poorly versed entangled in other issues related to the disease. Situational problems solved correctly if the right approach.
Medical history and partograph fills with errors.
11 46-49% of dissatisfaction with solvent, but "2" The correct answer to fourth set of issues. Student does not know the etiology of the disease, and poorly versed entangled in
other issues related to the disease. Situational problems solved correctly if the right approach. Medical history and partograph fills with errors.
12 41-45% of dissatisfaction with solvent, but "2" Lighting fifth of the questions correctly.
Student does not know the etiology of the data-tion of the disease, little versed in other
matters related to the disease. Gives an incomplete and partially incorrect answers to questions on the classification of the clinical disease. Situational problems solved correctly if
the right approach. More than half of the medical history and partnership gram filled with
errors.
13 36-40% of dissatisfaction with solvent, but "2" Lighting 1/10 of the questions at the
wrong approach. Does not know the etiology of the disease, and poorly versed entangled in
other issues related to the disease. Gives an incomplete and partially incorrect answers to
questions on the classification of the clinical disease. Situational problems solved correctly
if the right approach. Bole half medical history and partograph fills with gross errors.
14 31-35% of dissatisfaction with solvent, but "2" to the questions not answers. Does not
know and does not understand the other issues related to the disease. Does not know how
to fill out and describe the history and the partograph.
9. Typical flow chart of lesson
Stages of work, time-name The content of the
Teachers Students
1etap. Introduction to the training session
(5min) 1.1.Soobschaet topic, purpose, and planned training results. Familiar with the plan,
features of the training session.
1.2.Nazyvaet: key categories and concepts from the data subject tion, a list of books for
self-study
1.3.Soobschaet indicators and criteria of educational work in class
Listen, record,
specify, ask the question.
Stage 2.
Primary
(235 min) 2.1.Provodit updating knowledge through блиц-опроса/вопросно-ответной
forms / brainstorming, etc.
2.2. Consistently describes the steps
on the organization of the educational process according to the structure of practical training.
Meet
89
Abstracts with ethyl.
Working in groups, will present the results of the group work
Stage 3.
The Final-Resultant-regulating (60 min)
3.1.Delaet opinion on the subject, attention was concentrated on the main students, according to the importance of the work done for future careers.
3.2. Commends the work of groups (some of students) summarizes vzaimootsenki. Analyzes and evaluates the degree of achievement of lesson.
3.3. Gives the task for independent work, informing schaet and criteria evaluation. Selfevaluation,
interaction assessment.
Ask the question.
Write down the job.
10. Test questions
1.What is a breech baby?
2.Klassifikatsiya breech presentation.
3.Diagnostika breech presentation.
4.Biomehanizm labor with breech presentation.
6. During pregnancy and childbirth.
5. Complications of labor in breech presentation.
11. Recommended Reading
Summary:
1. Abramchenko, VV Epidural anesthesia in obstetrics: a guide for physicians / 2006. - 229
p.
2. Abramchenko, VV Pregnancy and delivery of high risk: a guide for physicians / - M.
Med. Inform, 2004. - 400 p.
3. Abramchenko, VV Cesarean section in perinatal medicine: a guide for physicians / 2005.
- 126.
4. Abramchenko, VV Postoperative intensive care in obstetrics / Literature, 2000. - 88.
5. Abramchenko, VV Pharmacotherapy of preterm labor / 2006. - 448.
6. Abramchenko, VV Purulent-septic infection in obstetrics and gynecological
logii.rukovodstvo / 2005. - 459
7. Abramchenko, VV Postoperative intensive care in obstetrics / - St. Petersburg: Spec.
Literature, 2000. - 88.
8. Abramchenko, VV Clinical perinatology / IntelTek, 2004. - 424 p.
9. Ailamazyan, EK Midwifery: a textbook for honey. Universities / 2003 - 528.
10. Topical issues of Obstetrics, Gynecology and Reproductive / Ed. EV KOKHANEVICH. - Moscow: Triad-X, 2006. - 480.
11. Obstetrics. Ed. GM Savelyeva. - M.: Medicine, 2000. - 816 p.
12. Obstetric and gynecological care: Hands-on. for doctors / Ed. VI Kulakov. - Moscow:
MEDpress, 2000. - 512 p.
13. Obstetrics. Clinical lectures: a manual for schools with a CD / Ed. OV Makarova. Moscow: GEOTAR Media, 2007. - 640.
14. Obstetrics. Directory of the University of California / Ed. Nisvandera K., A. Evans:
Lane. from English. - M.: Practice, 1999. - 704 p.
15. Barashnev, YI Perinatal neurology / Y. Barashnev. - M.: "Triad - X", 2005. - 670 p.
16. Bodyazhina, VI Akushersvo. The manual for the media. prof. Education / VI Bodyazhina. - Rostov-on-Don: Phoenix, 2003. - 480.
17. Resurrection, SL Fetal assessment. CTG. Doplerometriya. Biophysical profile: a manual for the system of postgraduate medical. Education / SL Resurrection. - Minsk: The Book
House, 2004. - 304.
18. Gazhonova, VE Ultrasound in Gynecology / VE Gazhonova. - Moscow: MEDpress90
inform, 2005. - 264.
19. Gluhovets, BI Ascending infection of placental / BI Gluhovets. - Moscow: MEDpressinform, 2006. - 240.
20. Humeniuk, EG Obstetrics: Physiology of pregnancy: a training ben-beats / EG Humeniuk. - Petrozavodsk: IntelTek, 2004. - 170 p.
21. Demidov, VN Pelvic ultrasound in women. Adnexal cysts and benign ovarian tumors:
a practical guide / V. Demidov. - Moscow: Academy of Medical Sciences, 1999, vol. II. 100 p.
22. Duda VI Obstetrics: a textbook for high schools in the specialty "General Medicine" / Minsk: High School, 2004. - 639 p.
23. Duda VI Physiological OB / - Minsk: 2000. - 447 p.
24. Duda VI Operative obstetrics: a manual / Minsk Interpresservis, Book House, 2002. 512 p.
25. Zhilyaev, NI Obstetrics: phantom course / - Kiev, 2002. - 239 p.
26. Zhilyaev, NI Operative Obstetrics: Ouch. Manual / Kiev 2004. - 468 p.
27. Zhilyaev, NI Operative surgery in obstetrics and gynecology / 2004.
28. Selected lectures on obstetrics and gynecology / Ed. AK Strizhakova etc. - Rostov-onDon: Phoenix, 2000. - 512 p.
29. Clinical recommendations. Obstetrics and Gynecology: scientific publication / Ed. VI
Kulakov. - Moscow: GEOTAR Media, 2006. - 512 p.
30. Clinical lectures on obstetrics and gynecology / Ed. AN Strizhakova etc. - M.: Medicine, 2000. - 379 p.
31. Clinical evaluation of laboratory tests in women: study guide / Moscow Medical and
Dental. University. NA Semashko. - M: 2005. - 96 p.
32. Kulakov, VI Preterm birth / VI Kulakov, LE Ants. - M.: Medicine, 2002. - 176.
33. Kulakov, VI Intensive care in obstetrics and gynecology (efferent methods) / - M:
MIA, 1998. - 206 p.
34. Drugs used in obstetrics and gynecology / Ed. Acad. RAMS VI Kulakov, Acad. RAMS
VN Serov. 2006. - 375 p.
35. Emergency care in obstetrics and gynecology. Quick Guide - M. GEOTAR - Media,
2007. - 52.
36. Perinatology Basics: A tutorial / Ed. MP Shabalov. - Moscow: MEDpress-inform,
2002. - 576 p.
37. Practical skills in obstetrics and gynecology: a manual / LY Suprun, TS Divakova and
others. - Minsk: New Knowledge, 2002. - 166 p.
38. Rational pharmacotherapy in obstetrics and gynecology: Hands-on. for practitioners /
Ed. VI Kulakov, VN Serov. - M.: 2005.
39. Guide Out - patient care in obstetrics and gynecology / Ed. VE Radzinsky. M: GEOTAR - Media, 2007.
40. Guide to practical training in obstetrics / Ed. VE Radzinsky. - M.: MIA, 2004. - 576 p.
41. Saveliev, GM Obstetrics: a textbook for schools / GM Savelyev, RI Shalina. - Moscow:
GEOTAR Media, 2008. - 656 p.
42. Sidelnikov, VM AG Antonov Premature birth. A premature baby / VM Sidelnikov, AG
Antonov. -M. "GEOTAR" 2006.
43. Smirnov, A. Pregnancy without problems / AN Smirnov. - Moscow: Atris Press, 2002.
- 208.
44. Smirnov, LM Obstetrics and Gynecology: Textbook / LM Smirnov. - M.: Medicine,
1999. - 368 p.
45. Handbook of obstetrics, gynecology and perinatology: uch.posobie for doctors / Ed.
GM Savelevoy.2006. - 720.
46. Trifonov, E. Obstetrics and gynecology: a manual for med._vuzov / EV Trifonov. Moscow: VLADOS, 2005. - 175 p.
91
47. Filippova, GG Psychology of motherhood: a manual / GG Filippov. - Moscow: Publishing House of the Institute of Psychiatry, 2002. - 240.
48. Chernukha, EA Prolonged and prolonged pregnancy. Guide for Physicians / EA Chernukha. - M.: "GEOTAR - Media", 2007. - 207.
49. Chernukha, EA TK Puchko breech presentation. Guide for Physicians / EA Chernukha,
TK Beam. - M.: "GEOTAR - Media", 2007. - 173 p.
50. Shmagel, KV Immune pregnant women / KV Shmagel, VA Cherries. - Moscow: Medical Book, 2003. - 226 p.
51. Tskhai, VB Perinatal obstetrics: a manual for honey. Universities / VB Tskhai. - Atlanta: Med. Academy of RAMS, Moscow, Honey. book, 2003.
52. Amniotic and extraembryonic structures in normal and complicated pregnancy / Ed.
VE Radzinsky. 2004. - 393 p.
53. Congenital, perinatal and neonatal infections: Per. from English. / Ed. A.Grinou, J. Osborne, S. Sutherland. - M.: Medicine, 2000. - 287.
54. Kulakov VI, Murashko LE Premature birth. M. Medicine, 2002.
55. Serov VN etc. Eclampsia: A Guide for Physicians / V.N.Serov etc. - M.: MIA, 2002.
463 - with
56. VM Sidelnikov Habitual loss beremennosti.-M.: Triad-X, 2002.
57. Disseminated intravascular coagulation in obstetrics AD Makatsaria etc. - M.: Triad-X,
2002. - 496.
58. Schechtman, MM, GM Burduli Diseases of the respiratory system and blood circulation in beremennyh.-M.: Triad-X, 2002. - 230C.
59. Shifman EM Pre-eclampsia, eclampsia, NELLP syndrome / Inteltek, 2002.
More:
60.Uchebnoe grant for the development of practical skills surgical / Edited by prof.
Atalieva AE, prof. Babadjanova BD Tashkent 2003. C102-115
61.Algoritmy diagnosis and treatment of surgical / Edited by Academician Karimov
Sh.I.Tashkent 2003. From 39-64
62.Uchebnoe benefit surgical subjects for medical students / Edited by Academician Karimov Sh.I.Tashkent -2003 Part II Obstetrics and ginekologiya.S 64-19013. Practical skills
in obstetrics and gynecology / Metod.posobie / / Tashkent 2008.
63.Akushersky soft tissue injuries of the birth canal, Kulakov VI, Butova E.A.2004.
64.Akusherstvo. National rukovodstvo._2004.
65.Infektsii in Obstetrics and Gynecology How VK Seagull 2006
66.Hirurgicheskaya technique cesarean secheniya_Strizhakov A.N._2007.
67.Ratsionalnaya pharmacotherapy in obstetrics and ginekologii.2007
Chan_Gynecology_and_obstetrics.2004
68.Rukovodstvo for outpatient care in obstetrics and gynecology, Kulakov V.I.2005.
70.Sidorova_I.S._Rukovodstvo_po_akusherstvu_ (Medicina, 2006) (ru) (1033s
71.Posobie for practical development of Obstetrics Voronin (KV) 2007.
72.Kirienko AI, Matyushenko AA, Andriyashkin VV Ostryi tromboflebit/2005
AN 73.Ivanyan - Intrauterine growth ploda/2007
74.DVS_sinrom _v_akusherstve.2004
75.Neonatologiya (Bazhanov NP). - T. I. - 2004
76.Prikaz MZ № 500 "On the reorganization of maternity hospitals to improve the efficiency of perinatal care and the prevention of nosocomial infections."
77.Internet sites:
http://www.studmedic.narod.ru/, http://med.siteedit.ru/,
http://www.rukovodstvo-po-akusherstvu.-uchebnoe-posobie.html,
http://www.materinstvo.ru, http://mama.ru.http://www.art-med.ru,, http://www.doctor.ru,
http://www.rodim.ru, http://mamka.ru
http://medagent.ru, http://www.art-med.ru, http://www.medsan.ru,
92
http://mediki.spb.ru, http://medinstitut.e2e.ru, http://www.medstudy.narod.ru
http://www.obgyn.ru, http://www.medsno.ru, http://medrusnet.euro.ru
www.medtext.ru, www.medpoisk.ru, www.medicum.nnov.ru/student/
http://6years.net/, http://preryvanie-beremennosti.pharmabort.ru/
http://med4net.ru/, http://www.med-life.ru/, http://www.pregnant.ru/
http://www.roddom.ru, http://www.medpoisk.ru/, http://www.medlinks.ru
Topic: Nausea and vomiting of pregnancy. Etiology, classification, clinical features,
treatment
1st place of training, equipping,
 Department of Obstetrics and Gynecology, the audience;
 dummy pelvis, female pelvis, doll fetus;
 standard models of pregnancy;
 the classic model of labor;
 gynecologic simulator ZOE;
 childbirth simulator Noelle;
 simulator newborn Newborn;
 set of slides on the topics of discipline;
 methods work in small groups: the method of the incident, "a round table" problem solving,
"pen in the middle of the table", "swarm", etc.;
 testing and teaching practical skills in OSKE (objective structured clinical examination).
 video recorder;
 personal computer (Pentium-III);
 set of slides with typical conditions for ultrasound scanning of pregnant women and gynecologic patients;
 set of video blogs "VJOG" (USA), highlighting recent advances in diagnosis and treatment of
obstetric and gynecological conditions;
 set of videos and films demonstrating the typical obstetrician-cal and gynecological procedures
93
and operations.
 training videos;
 educational software;
 multi media training and testing;
 the use of e-mail and INTERNET;
 business simulations and case studies;
 center for skills training;
 offices and laboratories maternity complex;
 delivery room;
 set of tests;
 phantom with a doll.;
 measuring tape, stethoscope.
2. Duration of study subjects
Number of hours, 5 hours
3.Tsel classes
 explain the concept of nausea and vomiting of pregnancy;
 consider the classification of early abortion:
 analyze etiopathogenic aspects of the various forms of early abortion;
 discuss clinic and diagnostic features of the various forms of early abortion;
 discuss treatment policy of various forms of early abortion:
 discuss indications for pregnancy termination in severe forms of early abortion.
 analyze preventive measures for early abortion.
The student should know:
 common forms of toxicosis (salivation, vomiting pregnant)
 and rare forms of toxicosis (chorea pregnant, osteomalacia, dermatitis, acute yellow liver dystrophy)
 the etiology and pathogenesis of vomiting during pregnancy, according to the classification of
clinical picture, diagnosis,
 principles of treatment, indications for abortion.
The student should be able to:
Based on the complaints, medical history, clinical findings, additional research methods to diagnose and determine the severity of toxicity, treatment plan.
4.Motivatsiya
Nausea and vomiting in pregnancy - a unique physiologically complications of pregnancy, having the character of a more or less profound disorders of all kinds of metabolic and neurohormonal correlations with symptoms of general autointoxication body, but with a primary function,
and in severe cases and anatomic injury to organs and systems pregnant woman. Early diagnosis
and correction of this pathological condition is one of the primary stages of cure, which is assigned to the doctor the first link.
Intra 5.Mezhpredmetnye and communication
Teaching of the subject is based on the knowledge students the basics of anatomy, topographic
anatomy, histology, normal and abnormal physiology, endocrinology and mikrobiologii.Poluchennye during classes will be used for the passage of endocrinology, internal medicine, surgery, pathology of obstetrics, gynecology, hematology, health, pediatrics. The importance of studying this disease on an expanded scale, together with related specialties explained involvement in the pathological process of all the vital organs of the pregnant woman,
and even a successful outcome of pregnancy requires further imple-bilitatsionnoy family therapy
in the clinic.
6.Soderzhanie practice session
6.1 The theoretical part
94
Toxemia of pregnancy to include pathological conditions which are apparent only during pregnancy and usually disappears ¬ zayut afterwards. Complications associated with pregnancy can
occur in early pregnancy, often in the first 3 months, then they are called toxicosis.
For most forms of toxicosis characteristic diarrheal disorders and disorders of all kinds of exchange. By toxicosis include vomiting of pregnancy (mild, moderate, extreme) and drooling
(ptia-ism). In addition to the listed ¬ GOVERNMENTAL, rarer forms of toxicity, as dermopathy
(dermatitis), tetany, asthma, hepatopathy (jaundice of pregnancy), osteoma ¬ lyatsiya pregnant,
etc.
Despite numerous studies, the etiology of toxicosis ¬ standing up on time is not specified. Most
researchers say poly etiology of this complication of pregnancy.
Vomiting of pregnancy
Of toxicosis paid special attention to the study of the etiology of vomiting during pregnancy, and
therefore there are different theories .. Vomiting during pregnancy was associated with poisoning by toxic products of metabolism of the body ve ¬ societies. I also believe that it may be the
result of sensitization of maternal fetal antigens gistonesovmestimosti. WHO ¬ penetration vomiting is also due to psychogenic factors (¬ WIDE negative emotions, fear of childbirth), or a
manifestation of hysterical reactions. The most recognized is the neuro-reflex theory, according
to ¬ Torah important role in the development of the disease play a rela ¬ sheniya violation of the
central nervous system and internal organs. At the same time is essential predominance of excitation in the subcortical structures (CNS reticular formation, regulation centers of the medulla
oblongata). In said areas are ¬ zannyh vomiting center and chemoreceptor trigger zone, regulatory gag act. Next to them are breathing, nasal, salivary centers, the olfactory nucleus of the brain.
The close location of these centers causes precedes corresponding gag act of feeling sick, and a
number of commutative-related vegetative disorders: increased salivation, deepen breathing
tahikar-land, pallor of the skin as a result of spasm of peripheral vascular.
Predominance of excitation in the subcortical brain structures with the appearance of the response of autonomic responses associated with pathological processes in the genital organs (after
inflammation disease-tion, intoxication), in violation of the receptor apparatus of the uterus, possibly also its damage fetal egg. Indicated there are likely in violation of the physiological relationships maternal and trophoblast in the early stages of gestation.
Autonomic dysfunction in early pregnancy may be due to both hormonal disorders, particularly
Increasing levels of chorion gonadotropin (hCG) in the body. The proof of this is the fact that the
multiple pregnancy and cystic shown-se, when a large amount of HCG, vomiting of pregnancy is
observed frequently.
Factors predisposing to the development of toxicosis include chronic disease of the gastrointestinal tract, liver, asteniche-sky syndrome.
In the pathogenesis of vomiting pregnant defining element is the violation of the neuroendocrine
regulation of all exchanges due to partial (or full) of starvation and dehydration. With progression of the disease gradually vanii violated water-salt (hypokalemia), carbohydrate, fat and protein metabolism in the mother against the backdrop of increasing dehydration, malnutrition and
weight loss. Due to starvation initially spent glycogen stores in the liver and other tissues. Then
there is a reduction of endogenous resources carbohydrates activated catabolic reactions, are particularly elevated fat and protein metabolism. Against the background of inhibition of enzyme
systems of tissue respiration of the body's energy needs mother-to-met by the anaerobic breakdown of glucose and amino acids. Under these conditions, β-oxidation of fatty acids is not possible, culminating in the body accumulate oxidized metabolites of fat metabolism of ketone bodies (acetone, acetoacetic and 5-hydroxybutyric acid), which are excreted in the urine. In addition,
ketosis is maintained by enhanced anaerobic degradation of ketogenic amino acids. Against this
background, developing ketonuria, the severity of which corresponds to the severity of metabolic
disorders in pregnant, which is observed vomiting, decreased oxygenation of arterial blood, there
is a shift in the direction of CBS acidosis.
Changes in the bodies of pregnant are initially functional in nature, and then, with the rise of de95
hydration catastate-chemical reactions, toxic oxidized products, go to degenerative processes in
the liver, kidneys and other organs. Initially, the protein-broken, antitoxic, pigment and other
functions of the liver, renal excretory function, in the subsequent degenerative changes occur in
the central nervous system, lungs, and heart.
The clinical picture.
Vomiting of pregnancy is often (50-60%) was observed as a physiologically sign of pregnancy,
and in 8-10% seen as a complication of pregnancy - morning sickness. In normal pregnancy,
nausea and vomiting can be no more than 2-3 times a day but the morning cup of fasting, but it
does not violate the general status of women, so treat-ment is required. As a rule, but the end of
the process of placentation to 12-13 weeks. nausea and vomiting stopped.
By toxicosis include vomiting, which occurs several times a day with or without food, accompanied by a decrease in appetite, change in ¬ tion of taste and olfactory sensations, feelings of
weakness, sometimes weight loss. Distinguish vomit pregnant mild, moderate and excessive.
The severity of vomiting is a combination of vomiting with violations that occur in the body
(metabolism, functions, major organs and systems).
Easy vomiting is not much different from that in uncomplicated Be ¬ belt, but there is up to 4-5
times and laziness, accompanied by almost constant feeling of nausea. Despite the vomiting of
the food Refrain ¬ Vaeth and significant weight loss pregnant is not observed. Reducing the
mass of the village is 1-3 kg (up to 5% of the initial mass). General condition is satisfactory, but
may experience lethargy and decreased pa ¬ botosposobnosti. Hemodynamic parameters (heart
rate, blood pressure ¬ tion) in the majority of pregnant remained within normal limits. Sometimes recorded moderate tachycardia (80-90 beats / min). Changes in sea ¬ fologicheskom the
blood available. Diuresis does not change. Acetonuria missing. Easy vomiting quickly treat fire
passes the Self ¬ tions urgently, so special treatment is needed, but in 10-15% of preg ¬ ables it
grows stronger and can move to the next stage.
Mild vomiting (moderate) consisted of increased vomiting up to 10 times a day or more, and the
deterioration of the general condition of the development of metabolic ketoacidosis. Vomiting is
often accompanied by salivation, so that there is an additional significant loss of fluids and nutrients. This results in dehydration and weight loss of 3-5 kg (6% of the initial mass) until exhaustion. General state of pregnancy worsens, there is a considerable weakness and ana ¬ ment. Pale
skin, dry tongue is coated with a whitish bloom, rather dry. So ¬ subfebrplnaya body temperature (not above 37.5 "C), characterized by tachycardia (100 beats / min) and hypotension. The
study of blood can be detected mild anemia, in the analysis of CBS - metabolic acidosis. Urine
output is reduced, in the urine may be Acetone. Often there is constipation. prognosis is right ¬
rule, favorable, but with such a state of pregnancy requires treatment.
Excessive vomiting is rare. For excessive vomiting characteristic dysfunction of vital organs and
systems, until the development of degenerative changes in them as a result of severe intoxication
and dehydration. Vomiting occurs up to 20 times a day, accompanied by abundant ¬ nym salivation and constant nausea. Food and fluid will not hold ¬ vayut. General condition with severe.
Marked weakness, fatigue, headache, dizziness, body weight decreases rapidly (up to 2-3 pounds
per week, more than 10% of initial body weight). Layer of subcutaneous fat disappears, the skin
becomes dry and loose, dry lips and tongue, mouth says the smell of acetone, body temperature,
low-grade, but can be increased to 38 '° C, there are marked tachycardia, hypo ¬ strain. Sharply
reduced urine output.
In the blood, increases the level of residual nitrogen, urea, biliru bean, hematocrit, leukocytosis
observed simultaneously decreases the content of albumin, cholesterol, potassium and chloride.
In the urine are determined by protein and cylindruria, urobilin, bile pigments, red blood cells
and white blood cells, the response to acetone sharply positive.
Forecast excessive vomiting is not always favorable. Signs threatening condition, determining
the indications for emergency pre-pregnancy interrupts are growth weakness, weakness, euphoria, Riya or delusions, tachycardia to 110-120 beats / min, hypotension - up to 90-80 mm Hg.
Art., yellow skin and sclera, pain in the right upper quadrant, decreased urine output of 300-400
96
ml per day, and giperbilirubnnemiya within 100 umol / L, increased residual nitrogen, urea, proteinuria, cylindruria.
Diagnostics.
Diagnosis of vomiting pregnant neslozhno.Dlya determine the severity of vomiting during pregnancy, in addition to the clinical follow-patient general analysis of blood and urine, to the definition of the dynamics of the following indicators: blood - content biliru bean, residual nitrogen
and urea, hematocrit , electrolytes (potassium, sodium, chloride), total protein and protein fractions, enzymes, of indicators CBS, glucose, prothrombin, in the urine - the level of acetone urobili-on, bile pigments, proteins. With significant dehydration and blood thickening-tion may occur lozhnonormalnye figure adopted hemoglobin, red blood cells, protein. The degree of dehydration are determined by the level of hematocrit. Its value is higher than 40% indicates pronounced dehydration.
Treatment.
Treatment of patients with mild vomiting occurs, we can but hold out-patient. with vomiting
moderate and severe - a hundred-tsionare great importance should be attached to storks in connection with the reduction of appetite tion recommend a variety of foods at will. It should to be
easily digestible, contain a lot of vitamins. It should be chilled, small meals every 2-3 hours in
the prone position. Shows the mineral alkaline water in small amounts of 5 - Used once a day.
Medical treatment for vomiting during pregnancy should be an integrated: 1) drugs that regulate
the function of the central nervous system and block the gag reflex, and 2) infusion means for
rehydration dezintok-sikatsii and parenteral nutrition, and 3) drugs, held for the normalization of
metabolism,
To normalize the central nervous system functions are also important well-organized
health-protective regime, eliminating negative emotions. When hospitalization is necessary
Pomeranchuk Stith in a separate room to avoid vomiting reflex.
At the beginning of treatment, given the short period of gestation for the exception of a negative
influence upon the fertilized egg is expedient to appoint non-medical means. To normalize the
functional amounted yaniya cortex and eliminate autonomic dysfunction are shown central elektroanalgeziya, acupuncture, psycho-and-gipnotera Pius. These non-drug treatments may be
sufficient for the treatment of patients with mild vomiting in pregnancy, and in moderate and
severe, they can limit the amount of medication.
In the absence of effective use of funds, directly blocks ¬ ing gag reflex: drugs that act on different neurotransmitter systems of the medulla oblongata: atropine, antigistaminpye drugs (pipolfen, Promethazine, tavegil), blockers of dopa ¬ Minowa receptors (antipsychotics - haloperidol,
droperidol, production ¬ tion Phenothiazine - torekan), and direct dopamine antagonists (reg ¬
lan, Reglan). Most effective clinically following combinations: 1) droperidol (] ml intramuscularly), atropine (0.5 ml of a 0.1% solution intramuscularly), the one-vegil (I mL intramuscularly), 2) Reglan, Reglan (2 mL intramuscularly) , atropine (0.5 ml of a 0.1% solution intramuscularly ¬ muscular). With hypotension that occurs as a consequence of the use of these drugs and
the disease itself, the viability of an 0.1% solution mezatona.
Infusion therapy involves the use of in vomiting kristalloi ¬ Dov, colloids and means for parenteral nutrition. Crystalloid pre ¬ nominated for rehydration. Of crystalloid use complex salt solutions Ringer-Locke Trisol, hlosol. The volume of input Chris ¬ talloidov should be up to 50% of
the infusion. ¬ count of Lois should be used for detoxification and gemodez reopoliglyukin. The
volume of colloids should be 10-15% of the infusion. For parenteral nutrition solution using glucose and amino ¬ goats (alvezin, gidrolizin). In order to better glucose uptake advisable to inject
insulin in small doses. The I ¬ Mykh preparations for parenteral nutrition should be at least 1540% of the total volume of the infusion.
The total volume of fluid therapy is 1-3 liters, depending on the severity of toxicity and body
weight of the patient. Criteria of adequacy of infusion therapy are to reduce dehydration and increase skin turgor, normalization of hematocrit values, increased diuresis.
97
Against the background of infusion therapy prescribed drugs that normalize metabolism. For this
purpose, use of bio-energy cofactors ¬ Menai cocarboxylase (0.1 g), riboflavin mononucleotide
(1 ml of a 1% solution intramuscularly), vitamin C (up to 5 ml of 5% solution). To stimulate ana
¬ bolic reactions in the tissues appoint splenin (2 mL intramuscularly), leridoksalfosfat (2 mL
intramuscularly), riboksin (0.2 g three times a day), folic acid (0,001 g 3 times a day).
Combined therapy is continued until the termination of persistent vomiting, normalization of
general condition, a gradual increase in body weight. Treatment of pregnant vomiting mild to
almost always effective. Excessive vomiting of pregnancy in the absence of the effect of com ¬
plex therapy for 3 days is an indication for abortion.
Drooling
Drooling (ptiyalism) is increased salivation and loss of a significant amount of liquid - up to I
liter per day. It may be an independent manifestation of toxicity or by vomiting pregnant ¬
GOVERNMENTAL. In the development of salivation are not only changes in the CNS, but also
local disturbances in the salivary glands and ducts under the influence of hormonal changes. It is
known that estrogens have an activating effect on the epithelium of the mouth, causing the secretion of saliva. In marked salivation decreased appetite, deteriorating health, there is a maceration
of the skin and mucous membranes of the lips patient loses weight, disturbed sleep due to the
significant loss of fluid, there are signs of dehydration.
Aehene
When salivation spend basically the same treatment as in vomiting (mode, psychotherapy, physiotherapy, infusions, etc.). Recommended treatment in a hospital, where the conditions for compliance with health-protective mode, designate the funds to the regulatory function of the nervous system, metabolism, dehydration - infusion drugs. At the same time recommended mouthwash infusion of sage, chamomile, menthol. With strong salivation can be applied atropine to
0.0005 g, 2 times a day. To prevent maceration of the skin smeared with Vaseline. Drooling is
usually treatable, and after recovery pregnancy is developing normally.
The use of new educational technologies:
method of "The Weakest Link"
To work needed:
1. A set of questions on the physiology of the visual analyzer.
2. A sheet of paper with a list of games for logging.
3. Stopwatch.
Progress:
1.Igru conducts teacher and aide from the school counter.
2.Schetchik wrote on a sheet date, the group number, the faculty and the business name of the
game and a list of student groups.
3.Prepodovatel students consistently asks questions of a set of issues.
4.Student should for 5 seconds. to answer.
5. Teacher of the word "right" or "wrong" answer evaluates if the "wrong" he gives the correct
answer.
6.Schetchik put opposite the name of the student, "+" or "-" depending on the correctness of the
answer.
7.Studenty are thus two rounds of questions.
6.2.Analiticheskaya part
Case studies:
1. The Department received a pregnant, 24 years with complaints of nausea, vomiting 3-5 times
a day, usually after meals, loss of appetite, and irritability. Over the past week weight loss of 1
kg. Gestation period is 6-7 weeks. General condition on admission is satisfactory. Temperature
normal topic. Skin and mucous membranes of normal color and moisture. Pulse 90 beats. in min.
Blood pressure is 120/70 mm Hg Blood and urine tests showed no pathological changes:
The diagnosis?
Answer. Early morning sickness during pregnancy.
98
2. Delivered to the Department by ambulance pregnant T. 21. Pregnancy 7-8 weeks. Complaining of constant nausea, vomiting 15-16 times a day and more often, the food does not hold.
Weakness, apathy. During the 10 days weight loss of 3.5 kg. The patient's average weight, exhausted breath odor of acetone. Low-grade temperature, icteric skin, dry. Pulse 110 beats., Poor
filling and stress. Blood pressure 90/60 mm Hg. Art. Heart sounds are muffled. Tongue coated
with white bloom, dry. The abdomen is soft and painless. Urine output is reduced to 400 ml per
day. In the blood, increased residual nitrogen, urea, bilirubin, decreased albumin, cholesterol,
potassium and chloride. In the analysis of urine protein-and cylindruria, the reaction of acetone
sharply positive.
The diagnosis?
Answer: Early abortion pregnant. Vomiting pregnant severe.
3. Received a pregnant 21 years, a period of 7 - 8 weeks. Complaints of itching all over the
body, insomnia, irritability. Laboratory data intact.
I. The diagnosis?
Answer: Dermatoses pregnant
II. Additional methods of diagnosis:
A: The U.S.
4. Received a pregnant 22 years. Term - 10 weeks. Diagnosis - early toxicosis syndrome, nausea
and vomiting. Vomiting 12 - 15 times a day, dramatic weight loss.
I. The tactics of the doctor:
Reply Abortion
II. Indications for termination of pregnancy (avoid too much):
A: Vomiting 1 - 5 times per day, hypertension.
5. At the clinic she turned 23 years with complaints of drooling. Last period of 5 weeks ago.
I.Diagnoz:
Answer: ptyalism
II. Additional methods of diagnosis:
A: Testing for HCG, ultrasound of the uterus
6. Received a pregnant woman 27 years old with signs of severe intoxication: tachycardia 110 120 bpm. in min., A / D 80/40 mm Hg, the skin and mucous membranes are dry, tongue coated.
Anamnesis: last period 6 weeks ago, neukratimaya vomiting, sudden weight loss. The diagnosis
- excessive vomiting during pregnancy.
I.Osobennosti blood:
Answer: Hypo-disproteinemia. Creatinine.
II. Differential diagnosis:
A nutritional diseases
B. Pyelonephritis
B. Myocardial infarction
G. hypotension
D. Cholecystitis
7. Pregnant 20 years for 7 - 8 weeks appeared muscle cramps of the upper extremities.
I.Predpolozhitelny diagnosis:
Answer: Tetany pregnant.
II. Treatments include:
Answer: parathyroidin, calcium, vitamin D
8.U pregnant with period of 6 - 7 weeks revealed: the incidence of vomiting 7 - 8 times a day,
the body weight loss of 3 kg. 2 weeks, heart rate 90 beats. in min., A / D 100/70 mm Hg, periodically acetonuria.
I. Diagnosis:
A: Vomiting pregnant moderate
II. Physical treatments:
A: electric, reflexology
99
9. Asked a woman complaining of nausea, vomiting, 5 - 6 times a day-ki, dizziness, urine output
700 - 800 ml. a day, an ultrasound pregnancy 7 - 8 weeks.
I. Your diagnosis:
Answer: Early toxicosis
II. Tactics:
A: Admission to the complex therapy
6.3. Graphic organizer: Making graphic organizer
scheme "Why" on "Vomiting pregnant"
Scheme of "WHY?"
This is a whole line of reasoning to identify the root cause of problem my.Razvivaet and activates the system, creative, analytical thinking
6.4. The practical part.
Determination of intrauterine fetal weight.
Events number does not hold nil
(0 points) Fully
Correctly
Finished
(20 points)
1. In a study of pregnant women-ness is defined abdominal circumference and height of standing
uterus with a tape. 0 20
2. Woman laid on the couch in the supine position, the physician is the side facing her belly 0 20
3. Measuring tape girded torso woman on the front of the navel, and back - in the middle of the
lumbar region and determine the circumference of the abdomen, which at the end of pregnancy
up to 100 cm 0 20
4. Height standing uterus is measured by applying the beginning of tape with one hand by the
middle of the upper edge of the symphysis pubis to top of the uterine fundus, which is defined
by an edge palm of the other hand. At the end of pregnancy is normal, it is 32 cm 0 20
5. Abdominal circumference multiplied by the height of the state of the uterus and is determined
by the estimated fetal weight 100 x 32 = 3200 g.
0 20
Total 0100
7.Formy control of knowledge, skills and abilities
-Oral;
-Alphabet;
Testing;
Solution situational problems;
And demonstration of skills mastered.
8.Kriterii assessment monitoring
№ Progress
Score in% level of students' knowledge
1 96-100% Excellent
"5" full correct answer to the question of the etiology, pathogenesis, classification, clinic, diagnostics, treatment and prevention of this disease. To sum up and make decisions, creative thinking cally, self-analyzes, case studies resolves correctly, with a creative approach, with full justification of the answer. Actively and creatively involved in interactive games, take the right decisions and summarizes and analyzes. Medical history, partograph fills correctly.
2 91-95% Excellent
"5" full correct answer to the question of the etiology, pathogenesis, classification, clinic, diagnostics, treatment and prevention of this disease. Think creatively, independently is analyzed,
case studies decides correctly, with a creative approach, with full justification of the answer. Actively and creatively involved in interactive games, take the right decision. History of diseases,
100
partograph fills with 1 grammatical mistake.
3 86-90% Excellent
"5" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis, treatment and prevention of diseases of the covered completely, but have 1-2 errors in the
response. Own analyzes, inaccuracies in the solution B-ation problems, but with the right approach. Actively involved in interactive games, make the right decisions. Medical history, partograph fills with 2-3 grammatical errors.
4 81-85% Good
"4" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis,
treatment and prevention of diseases of the covered completely, but there are 2-3 inaccuracies,
errors. Into practice, understands the essence of the question, says confidently, is a faithful representation. Situational problems solved correctly, but the justification answer sufficiently. Actively involved in interactive games, take the right decision. History of diseases, partograph fills
with 2-3 grammatical errors, inaccuracies in the description.
5 76-80% Good
"4" correct but incomplete lighting-set questions. The student knows the etiology, pathogenesis,
classification, clinic of the disease, but not completely disassembled diagnosis, treatment and
prevention of this disease. Understands the issue, says confidently. There is an exact representation. Actively involved in the interactive-tion games. On case studies gives partial solutions.
Medical history, partograph fills with 3-4 grammatical errors, inaccuracies in the description.
6 71-75% Good
"4" correct but incomplete lighting-set questions. The student knows the etiology and pathogenesis of the disease, but not completely disassembled diagnosis, treatment and prevention of this
disease. Understands the issue, says confidently, is a faithful representation. On case studies
gives partial solutions. History of diseases, partograph fills with 3-4 grammatical errors, 3-4 errors in the description.
7 66-70% Satisfactory
"3" right answer half the questions. Student knows the etiology of the disease, but do not pay
out the classification, clinic-tion of the disease, the treatment and fumbles of prevention. Understands the issues ca, says confidently, has the only views on certain issues topic. Situa-tional
problems are solved correctly, but there is no justification of the answer. Medical history, partograph fills with 3-4 grammatical errors, 3-4 errors in the description.
8 61-65% Satisfactory
"3" right answer half the questions. Errors in the etiology, pathogenesis, poorly versed and confused in the treatment and prevention of this disease. Says uncertainly, has the only views on
certain issues topic. Making mistakes in solving situational problems. History of diseases and
partograph fills with errors.
9 55-60% Satisfactory
"3" error response to half the questions. Student makes an error in the etiology of the diseasedanno, confused and poorly versed in other matters related to the disease. Says uncertainly has a
partial view on the subject. Situational problems solved incorrectly. Medical history and partograph fills with errors.
10 50-54% unsatisfactory-liminary "2" The correct answer to third-represented supplied questions. Student does not know the etiology of the disease, and poorly versed entangled in other
issues related to the disease. C-ation problems are solved with the right approach is wrong. Medical history and partograph fills with errors.
46-49 11% unsatisfactory-liminary "2" right answer quarter supplied-represented issues. Student
does not know the etiology of the disease, and poorly versed entangled in other issues related to
the disease. C-ation problems are solved with the right approach is wrong. Medical history and
partograph fills with errors.
12 41-45% unsatisfactory-liminary "2" Lighting fifth set of issues with bugs. Student does not
know the etiology of this disease, little versed in other matters related to the disease. Gives an
101
incomplete and partially incorrect answers to questions on the classification of the clinical disease. Situa-tional problems are solved with the right approach is wrong. More than half of the
patient's history and the partograph filled with errors.
13 36-40% unsatisfactory-liminary "2" Lighting 1/10 of the questions at the wrong approach.
Does not know the etiology of the disease, and poorly versed entangled in other issues related to
data-tion of the disease. Gives incomplete and partially incorrect responses to questions on the
classification, climate-ship of the disease. Situa-tional problems are solved with the right approach is wrong. Bole half medical history and partograph fills with gross errors.
14 31-35% unsatisfactory-liminary "2" to the questions not answers. Does not know and does
not understand the other issues relating to this of diseases. Does not know how to fill out and describe the clinical history and the Party of the program.
9. Typical flow chart of lesson
Stages of work, time-name The content of the
Teachers Students
1etap. Introduction to the training session
(5min) 1.1.Soobschaet topic, purpose, and planned training results. Familiar with the plan, features of the training session.
1.2.Nazyvaet: key categories and concepts from the data subject tion, a list of books for selfstudy
1.3.Soobschaet indicators and criteria of educational work in class
Listen, record,
specify, ask the question.
Stage 2.
Primary
(235 min) 2.1.Provodit updating knowledge through блиц-опроса/вопросно-ответной forms /
brainstorming, etc.
2.2. Consistently describes the steps
on the organization of the educational process according to the structure of practical training.
Meet
Abstracts with ethyl.
Working in groups, will present the results of the group work
Stage 3.
The Final-Resultant-regulating (60 min)
3.1.Delaet opinion on the subject, attention was concentrated on the main students, according to
the importance of the work done for future careers.
3.2. Commends the work of groups (some of students) summarizes vzaimootsenki. Analyzes and
evaluates the degree of achievement of lesson.
3.3. Gives the task for independent work, informing schaet and criteria evaluation. Selfevaluation,
interaction assessment.
Ask the question.
Write down the job.
9.Kontrolnye questions
1. At what stage of pregnancy is observed early toxicosis?
2. That can prolong the early morning sickness?
3. What types of common form of early abortion you know?
4. At what stage of pregnancy characterized by the development of early toxin Kozov?
5.What kinds redkovstrechaemyh form of early abortion you know?
6.What is the theory of the emergence of early abortion is most appropriate in modern obstetrics?
7.C what pathological conditions necessary to carry out the differential diagnosis of early abortion?
102
8.Pri what forms of early abortion to terminate the pregnancy to save the health and lives of
women?
9.Etiopatogeneticheskaya therapy for early toxicity.
10.Simptomaticheskaya therapy for early toxicity.
11. Recommended Reading
Summary:
1. Abramchenko, VV Epidural anesthesia in obstetrics: a guide for physicians / 2006. - 229 p.
2. Abramchenko, VV Pregnancy and delivery of high risk: a guide for physicians / - M. Med.
Inform, 2004. - 400 p.
3. Abramchenko, VV Cesarean section in perinatal medicine: a guide for physicians / 2005. 126.
4. Abramchenko, VV Postoperative intensive care in obstetrics / Literature, 2000. - 88.
5. Abramchenko, VV Pharmacotherapy of preterm labor / 2006. - 448.
6. Abramchenko, VV Purulent-septic infection in obstetrics and gynecological logii.rukovodstvo
/ 2005. - 459
7. Abramchenko, VV Postoperative intensive care in obstetrics / - St. Petersburg: Spec. Literature, 2000. - 88.
8. Abramchenko, VV Clinical perinatology / IntelTek, 2004. - 424 p.
9. Ailamazyan, EK Midwifery: a textbook for honey. Universities / 2003 - 528.
10. Topical issues of Obstetrics, Gynecology and Reproductive / Ed. EV KOKHANEVICH. Moscow: Triad-X, 2006. - 480.
11. Obstetrics. Ed. GM Savelyeva. - M.: Medicine, 2000. - 816 p.
12. Obstetric and gynecological care: Hands-on. for doctors / Ed. VI Kulakov. - Moscow:
MEDpress, 2000. - 512 p.
13. Obstetrics. Clinical lectures: a manual for schools with a CD / Ed. OV Makarova. - Moscow:
GEOTAR Media, 2007. - 640.
14. Obstetrics. Directory of the University of California / Ed. Nisvandera K., A. Evans: Lane.
from English. - M.: Practice, 1999. - 704 p.
15. Barashnev, YI Perinatal neurology / Y. Barashnev. - M.: "Triad - X", 2005. - 670 p.
16. Bodyazhina, VI Akushersvo. The manual for the media. prof. Education / VI Bodyazhina. Rostov-on-Don: Phoenix, 2003. - 480.
17. Resurrection, SL Fetal assessment. CTG. Doplerometriya. Biophysical profile: a manual for
the system of postgraduate medical. Education / SL Resurrection. - Minsk: The Book House,
2004. - 304.
18. Gazhonova, VE Ultrasound in Gynecology / VE Gazhonova. - Moscow: MEDpress-inform,
2005. - 264.
19. Gluhovets, BI Ascending infection of placental / BI Gluhovets. - Moscow: MEDpressinform, 2006. - 240.
20. Humeniuk, EG Obstetrics: Physiology of pregnancy: a training ben-beats / EG Humeniuk. Petrozavodsk: IntelTek, 2004. - 170 p.
21. Demidov, VN Pelvic ultrasound in women. Adnexal cysts and benign ovarian tumors: a
practical guide / V. Demidov. - Moscow: Academy of Medical Sciences, 1999, vol. II. - 100 p.
22. Duda VI Obstetrics: a textbook for high schools in the specialty "General Medicine" / Minsk: High School, 2004. - 639 p.
23. Duda VI Physiological OB / - Minsk: 2000. - 447 p.
24. Duda VI Operative obstetrics: a manual / Minsk Interpresservis, Book House, 2002. - 512 p.
25. Zhilyaev, NI Obstetrics: phantom course / - Kiev, 2002. - 239 p.
26. Zhilyaev, NI Operative Obstetrics: Ouch. Manual / Kiev 2004. - 468 p.
27. Zhilyaev, NI Operative surgery in obstetrics and gynecology / 2004.
28. Selected lectures on obstetrics and gynecology / Ed. AK Strizhakova etc. - Rostov-on-Don:
Phoenix, 2000. - 512 p.
29. Clinical recommendations. Obstetrics and Gynecology: scientific publication / Ed. VI Ku103
lakov. - Moscow: GEOTAR Media, 2006. - 512 p.
30. Clinical lectures on obstetrics and gynecology / Ed. AN Strizhakova etc. - M.: Medicine,
2000. - 379 p.
31. Clinical evaluation of laboratory tests in women: study guide / Moscow Medical and Dental.
University. NA Semashko. - M: 2005. - 96 p.
32. Kulakov, VI Preterm birth / VI Kulakov, LE Ants. - M.: Medicine, 2002. - 176.
33. Kulakov, VI Intensive care in obstetrics and gynecology (efferent methods) / - M: MIA,
1998. - 206 p.
34. Drugs used in obstetrics and gynecology / Ed. Acad. RAMS VI Kulakov, Acad. RAMS VN
Serov. 2006. - 375 p.
35. Emergency care in obstetrics and gynecology. Quick Guide - M. GEOTAR - Media, 2007. 52.
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45. Handbook of obstetrics, gynecology and perinatology: uch.posobie for doctors / Ed. GM
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Topic: Hypertensive states of pregnancy. The definition and classification, pathophysiology, signs and symptoms, methods of dia-gnostics. Pre-eclampsia, the problems for the
mother and fetus, diagnosis, treatment. Obstetric tactics. Emergency care for severe preeclampsia.
1st place of training, equipping,
 Department of Obstetrics and Gynecology, the audience;
 dummy pelvis, female pelvis, doll fetus;
 standard models of pregnancy;
 the classic model of labor;
 gynecologic simulator ZOE;
 childbirth simulator Noelle;
 simulator newborn Newborn;
 set of slides on the topics of discipline;
 methods work in small groups: the method of the incident, "a round table" problem solving,
"pen in the middle of the table", "swarm", etc.;
 testing and teaching practical skills in OSKE (objective structured clinical examination).
 personal computer (Pentium-III);
 set of slides with typical conditions for ultrasound scanning of pregnant women and gynecologic patients;
 set of video blogs "VJOG" (USA), highlighting recent advances in diagnosis and treatment of
obstetric and gynecological conditions;
 set of movies and video with a demonstration of typical obstetric and gynecological procedures
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and operations.
 educational software;
 multi media training and testing;
 the use of e-mail and INTERNET;
 business simulations and case studies;
 center for training in practical skills
 offices and laboratories maternity complex
 delivery room
 set of test items.
 video, TV, TV;
 fake NOELLE with test software, handouts, including a table of classification of hypertensive
conditions, treatments, their list of antihypertensives and they Annotated, indications for operative delivery, step by step instructions in first aid for severe pre-eclampsia and eclampsia, options and full blood count urine.
 slaydoskop, slides, a prototype history pregnant with this pathology.
2. Lesson time
Hours - 5h
3. Purpose of the lesson
 define GSS;
 consider the theory of the pathogenesis of the GSS;
 explore pathogenetic features of GCR
 cover classification GSS;
 consider the clinical manifestations of the GSS;
 consider methods of diagnosis HBP;
 to study the characteristics of clinical and laboratory data in the GSS;
 learn the principles of management of pregnancy and childbirth in the GSS;
 illuminate the principles of treatment of severe forms of GCR.
 explore methods of prevention and post-partum recovery.
Tasks
The student should know:
 The concepts hypertensive conditions during pregnancy
 classification, pathogenesis, clinical manifestations, diagnosis, differential diagnosis,
 therapy during pregnancy, childbirth, the postpartum period,
 impact on maternal and perinatal morbidity and mortality,
 value of clinical and laboratory studies (PS analysis of blood, urine, hemostasiogram, SPL,
kardiomonitornoe study),
 pharmacological agents used in the treatment of hypertensive states
 the main principles of intensive care and emergency medical care for severe disease, as well as
the principles of labor with the disease.
The student should be able to:
To collect anamnesis, inspect pregnant evaluate laboratory data and additional research, diagnosis and assess the degree of severity of the disease, management of pregnant women know in a
family clinic and hospital, prescribe treatment.
4. Motivation
Hypertensive conditions during pregnancy to date continue to be a very topical issue. Relevance
treated mass severe complications, such as bleeding, occupying a leading position in the structure of maternal and perinatal mortality. Early diagnosis and correction is one of the primary
stages of cure, which is assigned to the doctor the first link.
5. Interdisciplinary and inter-subject relation
Hypertensive disorders in pregnancy are a major factor of maternal morbidity and mortality.
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Complications of hypertensive disorders in pregnancy always appear among the main causes of
maternal mortality in all developed countries. Early diagnosis, prompt correction of this condition is a priority for medical care, not only obstetric areas, but a number of related fields, such as
critical care medicine, hematology, internal medicine, urology, ophthalmology, etc. The importance of studying this disease on an expanded scale, together with related specialties due to
involvement in the pathological process of all vital organs pregnant, and even a successful outcome of pregnancy requires further rehabilitation therapy in a family health center. For example,
after undergoing severe preeclampsia, women are followed up by a physician and urologist to 1
year. Given the urgency of the problem, it is necessary to educate students ethio-pathogenetic
basis of this pathology, classification, methods of early diagnosis of hypertensive conditions during pregnancy. Teach first aid for severe forms of the disease, to teach the basic principles of
critical care illness and rehabilitation. The knowledge gained student can use the lessons in anesthesiology and intensive care, internal medicine, urology, pediatrics.
6. Contents classes
6.1Teoreticheskaya part
Pre-eclampsia is the most threatening complication of pregnancy, which is not only a violation
of somatic and reproductive health of women, but sometimes threatens her life. Preeklapsii frequency generally varies from 2 to 14%. According to WHO (1994), worldwide die annually
65,000 (12%) of the women of hypertensive disorders of pregnancy. According to WHO (1994),
pre-eclampsia - a complication of pregnancy that is characterized by multi-organ failure and
functional seen major triad of symptoms: hypertension, edema, proteinuria, sometimes convulsions and coma.
Until recently there was in obstetrics term "preeclampsia" or "late preeclampsia," or "gangpreeclampsia," abbreviated as OPG triad of symptoms. Earlier this pregnancy complication
called "nephropathy" or "late toxicosis," emphasizing one of the most basic and early complications of this syndrome - Nephrotic.
WHO in 1994 adopted the ICD revision X, which clearly and unambiguously identify the name
of this disease - pre-eclampsia.
Pre-eclampsia - is not a disease, as it never occurs outside of pregnancy, and is a complication
that caused distortion of the structure and function of the placenta microcirculation. After termination of the pregnancy symptoms of preeclampsia usually have subsided and subsequently disappear. However, the violation of function of many organs and systems in the body women after
preeclampsia, come to its normal state for a very long time, and in some severe cases, can no
longer recover and lead to disability women. All this requires a careful and thorough approach to
the management of pregnancy, labor and postpartum women, and created the need for special
programs for the rehabilitation of women who have had pre-eclampsia.
Preeclampsia occurs more frequently in women with various physical illnesses, primiparous, especially among the young (under 18 years of age), pregnant women and mothers older than 30
years. This complication develops in overdistension of the uterus (multiple pregnancy, polyhydramnios, large fruit), as well as in women with signs izogemokonflikta between mother and fetus, hypertension, molar, obesity and malnutrition, as well as with chronic urogenital infections.
There is evidence of the development of so-called familial preeclampsia, ie frequent occurrence
among her sisters and daughters of women who suffer from this disease.
The pathogenesis of pre-eclampsia:
Nature preeclampsia still remains unclear.
In recent years, most researchers have linked the development preek-lampsii with morphological,
functional, biochemical and immunological changes in the placenta.
Due to the increased vascular permeability caused by, on the one hand, a spasm of blood vessels,
and on the other hand - the defeat of endothelial immune complexes, which are produced by the
mother in response to the development of the fetus, the liquid part of the blood "leaves" of the
vascular channels in the fabric of space. Clinically it is manifested in the increased hydrophilicity
tissues, leading to swelling of the loose fiber (ankles, legs, hands, anterior abdominal wall) up to
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a total of edema (anasarca).
Preeclampsia is accompanied by a progressive decrease in blood volume and CGO. in connection with damage to the endothelium increases the permeability of the glomerular nephrons of
the kidneys for the protein, which is manifested proteinuria and proteinemiey. Oncotic pressure
of the blood is reduced, contributing to a big transition from the liquid part of the blood vessels
in the tissue. Violated the rheological properties of blood, increases its coagulation properties.
Observes the "excitement" of platelets leads to adhesion and an increased tendency to thrombosis. Develop chronic DIC. In the kidney, liver, lung, brain, formed parts and ischemic, hemorrhagic minor strokes.
Ischemic kidney produces a large number of renin, which combines with plasma proteins, transforms into a strong pressor amines - angiotensin II, a high concentration of which, as well as other factors pressor, leaves a long and brutal peripheral vasoconstriction and hypertension, which
closes the cycle of the pathogenesis of preeclampsia .
In the deep microcirculation disturbances, chronic tissue hypoxia suffering liver, which breaks
the basic functions: protein and Education (hypoproteinemia) disrupt the synthesis and deposition of glycogen becomes predominantly anaerobic glycolysis, detoxification (increased amount
of nitrogenous wastes, development Vaeth liver failure) , disturbed lipid metabolism, cholesterol
metabolism (hyperlipidemia, hypercholesterolemia), activated lipid peroxidation, reduced antioxidant defense, increased activity of transaminases, alkaline phosphatase.
In the lungs, due to the development of chronic disseminated intravascular coagulation in the
blood vessels are formed loose clots in the vascular walls are deposited immune complexes, fibrin strands, it increases the permeability of capillaries and alveolar membranes. There is some
degree of respiratory failure, and in severe cases - edema.
Especially severe and threatening complications occur in the brain. On the background of
marked vasospasm and toxic lesions of the brain endothelial oxidized products of protein, carbohydrate and lipid metabolism, damage to the vessel wall immune complexes are developed and
peritsillyulyarny perivascular edema, which is clinically encephalopathy varying severity up to
eclampsia (swelling of the brain) or hemorrhage brain.
In the placenta develop severe degenerative and necrobiotic processes, ischemic, and hemorrhagic infarction, lime salts are deposited in fibrinoid walled up naps and intervillous space. Weakened bond placenta to the basement membrane of the myometrium. It develops fetoplacental insufficiency, the fetus - internal riutrobnaya hypoxia, which is the progression of pre-eclampsia
can cause antenatal death, often observed intrauterine growth retardation and fetal malnutrition.
Very often in the background of the above changes occur premature partial or total detachment
of the placenta associated with impaired blood coagulation properties up to hemorrhagic and
hypovolemic shock.
A detailed analysis of the literature and the results of their own practical observations showed
that the main manifestation of preeclampsia is hypertension.
However, by itself, high blood pressure is not a diagnostic criterion for hypertension in pregnancy, because does not provide information about recovery, organ targets or adequate diagnosis
and treatment
In this regard, the need for better classification of hypertension in pregnancy, which will develop
a differentiated management of pregnant women, treatment and delivery.
Classification of hypertensive conditions during pregnancy proposals WHO (ICD-10), is more
approximate to the assessment of the true condition of the patient. If a previously used classifications diagnosis - preeclampsia appears much later, after the swelling, mild preeclampsia, moderate, severe forms, according to the WHO classification in II half when connected to hypertension
proteinuria, exhibited diagnosis - preeclampsia. The diagnosis of preeclampsia, requires only effective treatment - delivery on the background correction of blood pressure and sedation, which
reduces the risk of encephalopathy and cerebral hemorrhage. Timely diagnosis dramatically reduces the time and the tactics of the conservative treatment of preeclampsia. In connection with
the above, the most efficient is the transition to the new WHO classification, which is used in all
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maternity institutions of the European Community (18 countries).
Classification of hypertensive states (U.S., 1990).
I. Hypertension is not specific to pregnancy (chronic hypertension)
a. Primary essential hypertension (EH).
b. Secondary symptomatic hypertension (renal, endocrine, adrenal disease, cardiovascular disease).
II. Passing gestational (transient) hypertension.
III. Specific to pregnancy hypertension (pre-eclampsia and eclampsia, eclampsia superimposed
on preexisting hypertension).
Classification of hypertensive conditions during pregnancy.
I. Pregnancy-induced hypertension
I.A. Hypertension without proteinuria - hypertension of pregnancy (gestational hypertension)
IBArterialnaya hypertension with proteinuria - preeclampsia
II. Chronic hypertension, pre-pregnancy
III. Chronic hypertension with superimposed pre-eclampsia or eclampsia
Pregnancy-induced hypertension (GiB) - this increase in blood pressure after 20 weeks.
Increase in blood pressure during pregnancy is an adaptive response of the body that occurs in
response to inadequate perfusion of different parts of the vascular bed pregnant, vital organs
GiB criteria:
Increase in diastolic blood pressure above 90 mm Hg
Increase in systolic blood pressure above 140 mm Hg (Conditionally)
The true increase in blood pressure can be judged on the basis of at least 2-fold measurement of
blood pressure for 4 hours
Risk factors for the development GiB:
1. Pregnancy
2. Signs of a lack of increase in the first intravascular volume (increase in Hb greater than 130 g /
L, elevated hematocrit 40 and more)
3. The lack of physiological reduction in diastolic blood pressure during the second trimester
(less than 75 mm Hg)
4. Increase in systolic blood pressure by 30 mm Hg from the original, but does not reach 140 mm
Hg
5. Increase in diastolic blood pressure by 15 mm Hg from the original, but not reached 90 mmHg
6. Intrauterine growth restriction
At high risk for the development GiB include women, have-ing:
 chronic hypertension
 chronic kidney disease
 diabetes
 age <16 and> 35 years
 severe preeclampsia in previous births
 multiple pregnancy
Pregnancy-induced hypertension without proteinuria (gestational hypertension)
If preeclampsia is not confirmed, then:
1.Rekomenduetsya bed rest in the left lateral position for 1-2 hours after each meal
2. Antihypertensive therapy is indicated only in those cases where the diastolic blood pressure
greater than 110 mmHg and starts to really threaten mother (threatening blood pressure above
160/110, or mean blood pressure (SBP) above 125 mm Hg)
3. When antihypertensive therapy is not necessary to reduce blood pressure to low numbers, it is
sufficient to reduce to a safe level of 90-100 mm Hg
SBP = systolic blood pressure. 2 BP DIA.
normally does not exceed 85 mm Hg
Pregnancy-induced hypertension with proteinuria, pre-eclampsia
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Is hypertension + proteinuria in the II half of pregnancy (after 20 weeks).
The main clinical manifestations of preeclampsia are the three main symptoms: hypertension,
proteinuria, edema
Diagnostic criteria
On the recommendation of the WHO pre-eclampsia is divided into two forms: light and heavy
Easy preeclampsia - is double marked rise in diastolic pressure over 90 mm to 110 mm rt.st.v for
4 hours with proteinuria over 0.3 g / l to 1 g / l
Severe preeclampsia - is the rise in diastolic pressure over 110 mmHg + Proteinuria greater than
1 g / l, or mild preeclampsia to join any of the signs of threatening eclampsia
Signs of threatening eclampsia
 sudden change in the emotional state
 sudden and very high blood pressure
 hyperreflexia
 acute headache (often increasing, not cropped conventional analgesics)
 impairment (improvement or worsening of vision)
 oliguria (<400 ml of urine in 24 hours)
 signs threatening eclampsia (continued)
 pain in the epigastric region or in the upper right quadrant
 jaundiced skin
 sudden swelling, especially in the lower back and face
 elevated liver enzymes in the blood
 thrombocytopenia
 changes in coagulation
 signs of pulmonary edema
Forms of severe pre-eclampsia, a life-threatening pregnancy:
I. Eclampsia - a severe form of preeclampsia with the sudden appearance of the Su-roads and
loss of consciousness caused by cerebral edema.
II. HELLP-syndrome is a severe, life-threatening form of preeclampsia with a typical current
combination of laboratory parameters: microangiopathic hemolytic anemia, increased liver enzymes in the blood, and thrombocytopenia.
III. Acute steatosis pregnant (OZHGB) - a relatively rare, but the most dangerous manifestation
of severe pre-eclampsia in which there is diffuse fatty degeneration of hepatocytes without inflammatory reaction and necrosis. Very quickly develop acute hepatic and renal failure, disseminated intravascular coagulation. Maternal mortality rate is 70-90%.
Violations of health and productivity, resulting in severe pre-eclampsia, eclampsia, NELLR syndrome and OZHGB:
 brain swelling
 bleeding in the brain;
 DIC;
 gepatargiya;
 acute renal failure;
 koagulopaticheskoe hypotonic or uterine bleeding;
 endometritis and other pyo-inflammatory complications;
 intranatal ante-and fetal death;
 premature birth;
 premature detachment of normally situated placenta;
 loss of reproductive organ (hysterectomy as a result of combat or hypotonic koagulopaticheskim bleeding rd).
Clinical diagnosis of preeclampsia
1. Measurement of blood pressure.
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For pre-eclampsia is characterized by:
- Systolic blood pressure. > 140 mm Hg. Art. or + 30 mm Hg. Art. of the original;
- BP DIA. 2: 90 mm Hg. Art. or + 15 mm Hg. Art. at double the initial measurement at intervals
of 2 hours.
2. Urinalysis:
Proteipuriey is the presence of urine protein> 0.3 g / l in any sample or> 0,033 g / l in daily
urine.
Heat test,. In the case of protein and salt in boiling urine at the top of the tube appears as a
blurred cloud "precipitation." When you add 2-3 drops of 3.2% acetic acid or 20% sulfosalicylic
acid in the presence of the upper part of the protein becomes more turbid, in the absence of protein darkened urine is clear.
3. Edema:
 swelling in the legs occur more than 40% of pregnant women with physiological pregnancy;
 swelling of the hands and face - a sign of pre-eclampsia;
 generalized edema (trace remains under pressure after 12 hours of bed rest or weight gain,
2000 for 1 week).
4. Laboratory studies.
- CBC with obligatory determination of hematocrit and platelet count.
- Biochemical analysis of blood:
a. proteinogram;
b. electrolyte composition of blood plasma;
c. urea, creatinine, bilirubin;
d. Liver enzymes (ALT, ACT, alkaline phosphatase).
- Coagulogram blood
- Urinalysis.
- Urine culture on flora and antibiotic sensitivity.
- ECG.
- EEG - indicated.
Principles of treatment of pre-eclampsia and eclampsia:
Antihypertensive therapy (dibazol, papaverine, aminophylline, korinfar, clonidine, ganglionic)
Magnesian therapy. Magnesium sulfate has a mild narcotic and tranquilizing effect, diuretic, hypotensive, anti-inflammatory, antispasmodic effect, reduces intracranial pressure
Pattern of use of magnesium sulphate in severe pre-eclampsia and eclampsia
Loading dose:
• 25% MgSO4 solution of 4 g (16 mL) for 5 minutes intravenously
• Then immediately 40 ml of 25% solution of 20 ml MgSO4 (PA5 d) in each buttock / m with 1
mL of 2% lidocaine in the syringe
If convulsions recur after 15 minutes, enter 2 g (8ml) 25% MgSO4 in / in 5 minutes
If the attack continues, introduced centuries diazepam 10mg for 2 minutes
Maintenance dose:
• 5 g (10 ml of 25%) MgSO4 + 1 mL of 2% lidocaine / m every 4 hours in different buttocks
• Continue treatment with magnesium sulfate for 24 hours after delivery or the last convulsion,
depending on what happens last.
Before the re-introduction ensure that:
-Respiratory rate of at least 16 per minute
Presence knee reflexes
Urination, not less than 30 mL per hour for the last 4 hours
If the above symptoms pathological cancel or postpone the introduction of MgSO4 and enter the
antidote - calcium gluconate 10 ml of 10% solution in / slow to restore breathing, to relieve the
side effects of magnesium sulfate.
In the absence of magnesium sulfate can be used diazepam.
There is a risk of neonatal respiratory depression, as Diazepam passes freely across the placenta.
112
A single injection of diazepam to relieve seizures rarely cause respiratory depression in the newborn. Prolonged and continuous intravenous its use increases the risk of respiratory depression in
the newborn.
Scheme of using diazepam
• Use diazepam only in the absence of magnesium sulfate
• Loading dose: 10 mg / slow in 2 minutes
• If convulsions resumed, repeat loading dose
• Maintenance dose: 40 mg in 500 ml saline. solution / drip to keep women in sedation, but leaving it in the mind.
• Respiratory depression is the mother may occur if the dose exceeds 30 mg for 1 hour:
Ventilator-spend-do not use more than 100 mg of diazepam in 24 hours
Antihypertensives:
Hydralazine (apressin), labetalol (atenalol) Nifedipine (korinfar)
• Start antgipertenzivnye money if diastolic blood pressure of 110 mm Hg
• Keep the diastolic pressure at 90-100 mmHg for the prevention of bleeding in the brain
Pattern of use of antihypertensive drugs
• Hydralazine 5 mg / slow every 5 minutes, until the blood pressure is not lowered. Repeat every
hour if necessary, or type in the 12.5 mg / m² every 2 hours, if necessary
• If there is no hydralazine - labetalol 10 mg / in:
-If an inadequate response (DBP> 110 mmHg) after 10 minutes, enter 20 mg labetalol in / in;
-Increase the dose to 40 mg and then to 80 mg if the blood pressure is not reduced for 10
minutes after each dose
• or 5 mg of sublingual nifedipine: - if the blood pressure is not reduced after 10 mi-chick give an
additional 5 mg of sublingual nifedipine
Obstetric Management of hypertensive states
Management of pregnant women, the question of the admissibility and prolonging it in different
types of hypertension.
. Pregnancy with chronic hypertension - a hyper-tonic disease - is admissible in mild to moderate severity in a close monitoring of hemodynamics (echocardiography), the level of intracranial
pressure, lack of complicating factors, such as other extragenital disease (severe anemia, pyelonephritis, endocrine diseases, etc.) and, most importantly, in the presence of sensitivity to antihypertensive drugs 1ryada (calcium antagonists, blockers, diuretics).
With resistance to therapy, or when layering preeclampsia, pregnancy must be terminated, regardless of the pregnancy.
 . Pregnancy with symptomatic secondary hypertension: renoparenhimatoznoy, renovascular,
renotransplotantsionnoy - absolutely contraindicated, and in the event is subject to immediate
termination.
  . Endocrine Hypertension:
 Acromegaly
 Hyperparathyroidism
 Hyper and hypothyroidism
 Primary giperreninizm
 deoxycorticosterone producing tumors
 Endothelin producing tumors - pregnancy is strictly prohibited and in case of interrupted at
any stage.
Arterial hypertension in lesions adrenal cortex:
• If you have Cushing's syndrome, the question of whether or prolongation of pregnancy depends
on the stage of the disease. Permitted in mild and manageable with medication. With pheochromocytoma, lesion of the adrenal medulla adrenogenital syndrome - pregnancy is absolutely contraindicated.
IV. Hypertension caused by cardiovascular disease (CVD)
113
 Coarctation of the aorta
 Syndrome hyperkinemia
 aortic valve
 aortic stenosis
 Severe bradycardia
 cleft of the ductus arteriosus - pregnancy is strictly prohibited.
V. Transient gestational hypertension occurs in the last trimester of pregnancy and is usually the
most severe complications cause. Pregnancy and childbirth according to obstetric situation.
VI. Hypertension specific to pregnancy: preeclampsia mild to be treated for 7-10 days.
Severe preeclampsia - preparation and termination of pregnancy for 24 hours.
VII. Eclampsia: preparing for delivery within 12 hours.
Initial evaluation and management of eclampsia:
 Call for help - mobilize staff
 Quickly assess breathing and state of mind
 Check the airway, measure blood pressure and pulse
 Place the woman on her left side
 Protect from injury, but do not hold it to actively
 Start / v infusion needle of large caliber (№ 16)
 Give oxygen at a rate of 4 liters per minute
Management of pregnant women with pre-eclampsia
In identifying the clinical signs of preeclampsia requiring hospitalization in intensive care units
of obstetric facilities.
In the hospital confirmed obstetric situation, taking into account the clinical diagnostic and research generated tactics, conducted a comprehensive intensive care mild preeclampsia. If the effect of the treatment is prolonged pregnancy to term viability or to elective delivery, which is
reasonable to induce in 36-37 weeks.
Due to the possible need for induction of labor, it is reasonable, even for admission of pregnant
women with mild preeclampsia begin preparation of the birth canal at any stage of pregnancy.
In the hospital at all stages of patients with preeclampsia the need to closely monitor the hemodynamic status, respiratory function of the kidneys, the liver, the dynamics of biochemical women and the state of the fetus. Determine the daily body weight, blood pressure, levels of protein
in the urine, serum creatinine, platelet count.
In severe forms, all manipulations, vaginal study, injections are given on the background
of anesthesia.
It should always be remembered that the disease is often not amenable to treatment and relapses.
He is often seen in the progression of the hospital on a background therapy. Attempts discharged
from the hospital with this disorder lead to readmission, but with a more severe form of
preeclampsia, and sometimes with irreversible changes.
Delivery is the primary etiology and pathogenetic treatment of preeclampsia. However, it is an
additional load Coy's pregnant need to prepare for it, applying intensive care.
The indications for early delivery in preeclampsia is:
1. Lack of effect of the treatment:
Mild pre-eclampsia in 10 days
Severe pre-eclampsia in 24 hours
2. Eclampsia eclamptic coma, acute renal hepatic failure, brain hemorrhage, anuria, HELLPsyndrome, retinal detachment and retinal hemorrhages, amaurosis.
An additional indication for delivery: fetoplacental insufficiency (intrauterine fetal hypoxia and
malnutrition) to preparation for surgery - up to 2 hours.
Vaginal delivery is preferable to cesarean section, as in preeclampsia 1 and 2 degrees of additional surgical trauma causes a variety of physiological disorders, exacerbating the severity of
the patient.
114
The biological availability of the body for childbirth ("the maturity of the cervix") method of
choice - labor induction by amniotomy with subsequent intravenous drip of oxytocin, prostaglandins or a combination. When unripe cervix labor induction is better to start with prostaglandins.
For the prevention of amniotic fluid embolism and tetanic contractions of the uterus for 30
minutes before oxytocin should enter 10 mg and 25 mg promedola diprazina.
If there is no effect on the ongoing labor induction to solve the problem of abdominal delivery.
This requires carefully evaluate the condition of the mother, the fetus, the effectiveness of intensive therapy. A necessary condition for the operation is the availability of a sufficient amount of
blood plasma substitute.
When abdominal delivery is appropriate curettage - to remove the source of spasmogenic substances and required a full refund of blood loss.
Indications for cesarean section:
 The deterioration of the woman or the rise-ing signs of threatening eclampsia
 Eclampsia
 Uncontrolled hypertension
 ZVURP or deterioration of the fruit (by ultrasound and CTG)
 Suspected brain hemorrhage
 retinal hemorrhages
 Amaurosis
 ARF
 OPPN
 HELLP-syndrome
 OZHGB
 obstetric situation (PONRP, the CUT, the trauma of the uterus)
The main objective in the management of pregnant women: adequate analgesia and effective antihypertensive therapy for treatment-conservative regime and a safe level of blood pressure.
Antihypertensive treatment is carried out under the constant control of blood pressure and is the
introduction of drugs used during pregnancy. High blood pressure, the threat of the progression
of pre-eclampsia is an indication for controlled relative normotonii carried out under the supervision of an anesthesiologist. Infusion therapy during labor should be limited to 500-800 ml.
Treatment of chronic fetal hypoxia during labor includes intravenous Sygethin 2.3 ml in 20 ml of
40% glucose solution, 5 ml of 5% solution of ascorbic acid, aminophylline 2.4% - 10ml, 100 mg
cocarboxylase, periodic inhalation of humidified oxygen -from.
In sorts shown early amniotomy (cervix 3-4 cm).
If it is impossible to provide a safe level of blood pressure, shown off any attempts (forceps extraction of the fetus pelvic end). Vacuum operation - ekstratsiya fetus in preeclampsia is not applicable because it does not provide an exception attempts. When a dead fetus is shown plodorazrushayuschaya operation.
To prevent bleeding in the early postpartum periods of the third period is active. Pathological
blood loss in postpartum women with pre-eclampsia should be fully replenished blood substitutes and plasma substitutes.
Postnatal care:
- Analgesia. Parenteral administration promedola is preferred for patients after cesarean section
and for those who have been a delivery, require subsequent anesthesia.
- Antihypertensive treatment. Launched in the prenatal period, is to be continued in the postpartum period. However, after other signs of preeclampsia resolved, hypertension may persist for
days and weeks, so antihypertensive therapy may be required for a long time.
- Monitoring. The patient should continue to be observed in the emergency department and intensive care for at least 24 hours after birth. Condition often worsens patients in the first 24 hours
after birth, at 3 and 6 hours. The absence of objective and subjective symptoms of severe
115
preeclampsia, increased diuresis, normalization of blood pressure - all of which are signs of a
resolution of preeclampsia.
Rehabilitation of women who have had pre-eclampsia
The results showed that 70% of women have a propensity to recur in subsequent pregnancies,
80%, carrying the re-eclampsia or eclampsia, a few months after the ro-Dov marked disorders of
the central nervous system, 20% hypertension, 15 % renal failure, 25% of visual impairment.
This calls for rehabilitation measures, which are implemented in accordance with the tasks carried out in stages:
Stage I - performed after birth in hospital. Duration - up to 3 weeks.
The objective of this phase of the elimination of residual effects of pre-eclampsia and eclampsia:
the normalization of the functional state of the central nervous system, cardiovascular system,
protein, water and electrolyte balance. At moderate and severe forms of preeclampsia - specifying the nature of comorbidity and treatment. Important at this stage is the selection of the optimal
method of contraception.,
II stage - held throughout the year in the clinic, and specialized hospitals.
The objectives of this phase - diagnosis and treatment of both diseases, which developed as a
consequence of pre-eclampsia and associated pathology. Necessary for each patient to develop a
specific program of remedial action with respect to age, social status, and the severity of the preeclampsia, pre-existing and arising after the pathology, mode of family planning on effective
contraception.
III stage - performed in the clinic and the specialized agencies.
The objectives of this phase:
- Provision of birth spacing between births of at least 3 years
- Conducting due diligence, consulting related professionals, for a year before you plan to conceive, to address the possibility or the possibility of pregnancy planning, development and implementation of individual program of integrated management and full preparation for it
- Women with a history of pre-eclampsia or eclampsia, but do not plan-ing pregnancy or have
contraindications to it, should be under the supervision of local therapist, gynecologist and related professionals.
Program of rehabilitation of women who have had severe and moderate severity preeclampsia
1. Duration of follow-up - 1 year.
2. Turnout in the treatment group - at least 2 times per month, diagnostic - in 3, 6, 9, 12 months.
3. The amount and duration of the survey.
In the absence of complaints:
• Urinalysis - 3, 6, 9, 12 months;
• CBC - 3 months;
• ophthalmoscopy - for the registration of and indications;
• ECG - for the registration of and indications;
• Measurement of blood pressure in the face of a specialist of any profile.
When complaints (headache, irritability, urinary syndrome, increased blood pressure):
• inspection of the hospital;
• sample Nechiporenko;
• active leukocytes;
• sample Zimnitsky;
• blood creatinine, urea, total protein - sample Rehberg;
• excretory urography;
• plain film of the kidneys;
• consulting nephrologist, urologist, cardiologist indicated.
In the event of acute upper respiratory tract infections (acute exacerbations of chronic infection ¬
tion) - control of urine analysis, blood pressure.
In severe preeclampsia, eclampsia:
• consulting endocrinologist, neurologist, ophthalmologist at 3, 12 months;
116
• biochemical analyzes to study the function of the liver, prothrombin-st index, total protein, bilirubin, cholesterol.
4. Preventive therapy.
In identifying the AD lability, its asymmetry, the position of resident ¬ GOVERNMENTAL
tests with load, asthenic-neurotic syndrome:
• courses electroanalgesia № 5-6, total darsonvalization № 4-5, inductothermy on perirenal area
№ 4-5;
• sedatives;
• improvement of microcirculation (papaverine, Papazol, no-spa, aminophylline)
• If you have proteinuria - survey nephrologist.
In severe pre-eclampsia to prevent diffuse hypo-amnesia:
• aminolon, piracetam for 1.5-2 months;
• lipotropic means, treat, B vitamins
Basic preventive measures in SVP and family health centers.
I. Identification of women during pregnancy and beyond with the following facto-ry increased
risk of pre-eclampsia:
 Age below 18 and above 35.
 The first pregnancy at an early age.
 Hereditary factors - daughters of women with preeclampsia-bolevayut 8 times more often.
 Izoserologicheskaya incompatibility of maternal and fetal blood ABO and Rh systems.
 Frequent abortion or miscarriage history.
 defective, insufficient, unbalanced diet, low social status.
 Severe preeclampsia in anemneze
 Stress, psycho-emotional discomfort, "anxiety, fear of pregnancy"
 Anemia
 Violation of the regulation of vascular tone: hypertension, arterial hypertension (family history
of hypertension), vascular hypotension.
 Heart Disease
 Kidney
 endocrine disorders: diabetes, obesity, dientse-falny hypothalamic syndrome, hypothyroidism,
syndrome-Chiari Frommelya, pituitary microadenoma.
 Liver and biliary tract.
 Hranichesky and acute diseases of bronchi and lungs.
 Encephalopathy in violation of the processes of the brain microcirculation
 twins and polyhydramnios
 molar
 Reduced vascularization of the uterus, reducing the blood supply to the myometrium, the
gradual failure prediction ma-just-placental blood flow in hypoplasia, infantilism, myoma of the
uterus changes, defects and anomalies of development, as well as in atrophic and degenerative
changes in the myometrium after the abortion, scraping, inflammatory processes.
II. Holding women at high risk due diligence, consulting related professionals, and to the course
of pregnancy, to address sanitation and contraception, the possibility of pregnancy planning, rational and complete preparations for the possibility of its prolongation.
III. Intensive dynamic monitoring of pregnant at the risk of preeclampsia. Visiting one of clinic
every 7-10 days during the first months of pregnancy.
IV. Comprehensive prevention of preeclampsia and preventive therapy in high-risk groups at 1416 weeks (the period of intensive growth of the fetus), 20-30 weeks, 26-29 weeks, 32-35 weeks.
- The elimination of avoidable risk factors (foci of infection, anemia, stress), treatment of genital
and extragenital pathology, adherence rest
V. With a history of pre-eclampsia or eclampsia is necessary to conduct rehabilitation and recovery after childbirth before the onset of the next pregnancy. The interval between births of at least
117
3 years.
VI. Conducting programs on reproductive health and contraception among women at risk for
pre-eclampsia.
The use of new educational technologies:
METHOD "black box"
The method provides for joint activities and active participation in a-nyatiyah each student, the
teacher works with the whole group.
Each student gets from a "black box" unknown drug, brief annatatsiya is written on the cards.
(Options annotations attached). Students should determine the drug in detail justifying your answer.
To think about the student is given 3 minutes. The response is then discussed, given supplement
on pharmacodynamics, pharmacokinetics.
This methodology promotes student speech, formation oc-new critical thinking, because In this
case, the student learns to defend their opinion,
analyze responses band members participating in this contest.
Options for abstracts:
1.Opredelit preparation: The preparation belonging to the group of sedatives, is the drug of
choice for hypertensive conditions during pregnancy. Has anticonvulsant effects on the central
nervous system at high doses can have a depressing effect on neuromuscular transmission, reduce the excitability of the respiratory center, and reduce blood pressure. Antagonist of the drug
is - calcium gluconate.
(Magnesium sulfate 25% - 5,10,20 ml)
2.Opredelit preparation: The preparation belonging to the group of drugs, has a powerful anticonvulsant activity is effective in small doses, is used for severe hypertensive states in pregnancy. It also has anti-arrhythmic properties and reduces nocturnal secretion of gastric juice.
(Diazepam-syn. Seduksen, Relanium, sibazon tablets 5mg, 0.5% solution of 2 ml)
3. Determine the drug: A drug belonging to the group of selective beta - blockers, used for severe
hypertensive states in pregnancy as an additional antihypertensive medication. Inhibits the excitability of the myocardium, lowers blood pressure. (Atenalol - Tab. 50, 100 mg)
4. Determine the drug: A drug belonging to the group of calcium antagonists, used for severe
hypertensive states in pregnancy as an additional antihypertensive medication. Has koronarorasshiryayuschego effect, reduces myocardial oxygen demand, does not suppress the conductivity
of the myocardium, greatly reduces diastolic blood pressure. (Korinfar - tab. 10 mg)
6.2Analiticheskaya part
Case studies:
1. In the maternity ward delivered machine "first aid" primigravida 24 years. 35nedel preterm
pregnancy. Within 2 hours of notes, epigastric pain, nausea, headache. On examination, there
are fibrillar twitching of facial muscles, blood pressure 160/110 mm Hg. Art. Pasty face and
lumbar region. When vaginal study found "immature" cervix, cephalic presentation.
The diagnosis? Your tactics.
A: Diagnosis: Beremennost1 35nedel. Hypertensive syndrome of pregnancy-eclampsia.
Tactics: hospitalized in the intensive care unit. Place the woman on her left side. Start of
magnesia therapy. Prepare equipment to provide resuscitation (oxygen, mask, etc.). Prepare
for delivery within 12 hours. The choice of method of delivery cesarean section (the serious
state of pregnant and the immaturity of the birth canal).
2. In the maternity hospital received 20 years primigravida with 38 weeks of pregnancy.
Notes an increase in weight of 2 kg over the past two weeks, marked swelling of the upper
and lower extremities, increased blood pressure to 140/90 mm Hg On examination found: in
the analysis of urine protein 0.99 g / l. After 4 hours of observation of blood pressure remains
118
elevated 150/95. Fetal heart rate 145 beats / min. When vaginal study found "mature" cervix,
cephalic presentation.
The diagnosis? Your tactics.
A: Diagnosis: Beremennost1 38nedel. Mild preeclampsia.
Tactics: hospitalized in the department of pathology of pregnant women. Place the woman on
her left side. Start of magnesia therapy. In the near future given the full-term pregnancy to
prepare the patient for delivery through the birth canal with the maximum use of analgesic
agents.
3. In the maternity hospital received multigravida 26 years of pregnancy 28 weeks. There is
an increase in blood pressure to 140/90 mm Hg during the week. On examination found: in
the analysis of urine protein ABS. After 4 hours of observation of blood pressure remains elevated 140/90. In the history of a family history of von maternal hypertension, the patient indicates that after the first birth was repeatedly observe a transient increase in blood pressure.
The diagnosis? Your tactics.
A: Diagnosis: Pregnancy 2 28nedel. Hypertension induced by pregnancy.
Tactics: hospitalized in the department of pathology of pregnant women. Place the woman on
her left side. Start of magnesia therapy, pick up one of the long-term use of antihypertensive
drugs. The dynamics inspect clinical analyzes. Spend the extra Doppler survey to assess the
status and development of the fetus.
4. In the maternity ward delivered machine "first aid" primigravida 27 years. Full-term pregnancy 40nedel. Within 3 hours Notes stuffy nose, flashing "fly" before the eyes, headache,
nausea. On examination, there was an increase in blood pressure 160/110 mm Hg. Art., pastoznost face and lumbar region. In the analysis of urine protein 2 g / l. Lagging behind in the
development of the fetus, intrauterine fetal hypoxia. When vaginal study found "immature"
cervix, breech presentation.
The diagnosis? Your tactics.
A: Diagnosis: Beremennost1 40nedel. Breech presentation. Severe preeclampsia Art.
Tactics: hospitalized in the intensive care unit. Place the woman on her left side. Start of
magnesia therapy. Prepare for delivery within 24 hours. The choice of method of delivery cesarean section (the serious state of pregnant, fetal hypoxia and fetal malnutrition, the immaturity of the birth canal).
5. Outside, there was a pregnant woman attack clonic-tonic seizures.
Your preliminary diagnosis? Your tactics?
A: Diagnosis: Eclampsia
Tactics: medical emergencies, contact the nearest obstetric maternity hospital. Move pregnant in a safe place, put on a level surface, remove the next are broken glass, stones (if any).
Loosen constricting clothing items. After the attack, a pregnant turn to the left side, remove
the bandage or a handkerchief from the mouth possible vomit or foam. Wait for medical care.
6.3. Graphic organizer: Making graphic organizer
scheme "fishbone" on "state of Hypertensive Pregnancy"
SCHEME "fishbone"
Allows us to describe a range of (field) problem and try to solve it. Develops and activates
the system, creative, analytical thinking.
6.4. The practical part
Name how many milliliters of a loading dose of intravenous and intramuscular injection, and
the maximum daily dose of magnesium sulfate in severe preeclampsia. Calculate how many
grams of magnesium sulfate dry matter contained in these doses. You are available ampoules
25% - 10 ml of magnesium sulfate.
Purpose: Develop a student pharmacological knowledge, skills, guidance and reference drug
119
dose calculation of magnesium sulfate in the treatment of severe pre-eclampsia and eclampsia.
Performs step (steps):
Events number does not hold nil
(0 points) Fully
correctly
performed
(20 points)
1. Loading dose of magnesium sulfate for intravenous administration of 16 mL was administered for 5 minutes slow.
0 20
2. Then continues to introduce a loading dose of magnesium sulfate intramuscularly 40 ml in
each buttock to 20 ml with 1 mL of 2% lidocaine in the syringe.
0 20
3. The maximum daily dose of magnesium sulfate in severe preeclampsia with amounts to 96
ml. 0 20
4. In 10 ml of 25% solution of magnesium sulfate contains 2.5 g of dry matter, and 1 ml of
0.25 g dry matter. 0 20
5. In the loading dose of magnesium sulfate for intravenous injection is 16 mL contains 4 g
of dry matter (16ml * 0.25 g = 4r), and a dose for intra-muscular administration of 40 ml - 10
g dry matter (40ml * 0.25 g = 10 g).
The maximum daily dose of magnesium sulfate contains 24g 96ml (96ml * 0.25 g = 24 g).
0 20
Total 0100
7.Formy control of knowledge, skills and abilities
-Oral;
-Alphabet;
Testing;
Solution situational problems;
And demonstration of skills mastered.
8.Kriterii assessment monitoring
Number has time-dependence
Score in% level of students' knowledge
1 96-100% Excellent
"5" full correct answer to the questions on the etiology, pathogenesis, classification, clinical
manifestations, diagnosis, treatment and prevention of this disease. To sum up and make decisions, creative thinking, self-analyzes, case studies resolves correctly, with a creative approach, with full justification of the answer. Actively and creatively involved in the interactive games properly takes substantiate Nova solutions and summarizes and analyzes. Medical
history, partograph fills correctly.
2 91-95% Excellent
"5" full correct answer to the questions on the etiology, pathogenesis, classification, clinical
manifestations, diagnosis, treatment and prevention of this disease. Creative thinking, selfanalyzes, case studies resolves correctly, with a creative approach, with full justification of
the answer. Actively and creatively involved in the interactive games, take the right decisions. Medical history, partograph fills with one grammatical error.
3 86-90% Excellent
"5" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis, treatment and prevention of the disease covered completely, but have 1-2 errors in the
120
response. Own analyzes, inaccuracies in solving situational problems, but with the right approach. Actively involved in interactive games, make the right decisions. Medical history,
partograph fills with 2-3 gram-matic error.
4 81-85% Good
"4" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis, treatment and prevention of the disease covered completely, but there are 2-3 inaccuracies, errors. Into practice, understands the essence of the question, says confidently, is a
faithful representation. Situational problems solved correctly, but the justification answer
sufficiently. Actively involved in interactive games, take the right decision. Medical history,
partograph fills with 2-3 grammatical errors, inaccuracies in the description.
5 76-80% Good
"4" Correct, but incomplete coverage of the issue. The student knows the etiology, pathogenesis, classification, clinic of the disease, but not completely disassembled diagnosis, treatment and prevention of this disease. Understands the issue, says confidently. There is an exact representation. Actively participate in the games. On case studies gives partial solutions.
Medical history, partograph fills with 3-4 grammatical errors, inaccuracies in the description.
6 71-75% Good
"4" Correct, but incomplete coverage of the issue. The student knows the etiology and pathogenesis of the disease, but not completely disassembled diagnosis, treatment and prevention
of this disease. Understands the issue, says confidently, is a faithful representation. On case
studies gives partial solutions. Medical history, filled with 3-4 partograph grammatical error
cal, 3-4 errors in the description.
7 satisfies 66-70% solvent, but
"3", the correct answer to put half-tion issues. Student knows the etiology of the disease, but
do not pay out the classification of the disease clinic of, confused in the treatment and prevention. Understands the issue, said with confidence is accurate representations only on specific issues topic. Situational lems solved correctly, but there is no justification of the answer.
Medical history, filled with 3-4 partograph grammatical error-tion, 3-4 errors in the description.
8 satisfies 61-65% solvent, but
"3", the correct answer to put half-tion issues. Errors in the etiology, pathogenesis, poorly
versed and confused in the treatment and prevention of this disease. Says uncertainly, has the
only views on certain issues topic. Making mistakes in solving situational problems. Medical
history and partograph fills with errors.
9 satisfies 55-60% solvent, but
"3" error response put on half-tion issues. Student makes an error in the etiology of this disease, poorly versed and confused in other matters relating to the disease. Says uncertainly has
a partial view on the subject. Situational problems are solved, not true. Medical history and
complements the partograph for properly.
10 50-54% of dissatisfaction with solvent, but "2" The correct answer to third set of issues.
Student does not know the etiology of the disease, and poorly versed entangled in other issues related to the disease. Situational problems solved correctly if the right approach. Medical history and partograph fills with errors.
11 46-49% of dissatisfaction with solvent, but "2" The correct answer to fourth set of issues.
Student does not know the etiology of the disease, and poorly versed entangled in other issues related to the disease. Situational problems solved correctly if the right approach. Medical history and partograph fills with errors.
12 41-45% of dissatisfaction with solvent, but "2" Lighting fifth of the questions correctly.
Student does not know the etiology of this disease, little versed in other matters related to the
121
disease. Gives an incomplete and partially incorrect answers to questions on the classification
of the clinical disease. Situational problems solved correctly if the right approach. More than
half of the patient's history and the partograph filled with errors.
13 36-40% of dissatisfaction with solvent, but "2" Lighting 1/10 of the questions in the misdimensional approach. Does not know the etiology of the disease, and poorly versed entangled in other issues related to the disease. Gives an incomplete and partially incorrect answers to questions on the classification of the clinical disease. Situational problems solved
correctly if the right approach. Bole half medical history and partograph fills with gross errors.
14 31-35% of dissatisfaction with solvent, but "2" to the questions not answers. Does not
know and does not understand the other issues related to the disease. Does not know how to
fill out and describe the history of the disease and the partograph.
9. Typical flow chart of lesson
Stages of work, time-name The content of the
Teachers Students
1etap. Introduction to the training session
(5min) 1.1.Soobschaet topic, purpose, and planned training results. Familiar with the plan,
features of the training session.
1.2.Nazyvaet: key categories and concepts from the data subject tion, a list of books for selfstudy
1.3.Soobschaet indicators and criteria of educational work in class
Listen, record,
specify, ask the question.
Stage 2.
Primary
(235 min) 2.1.Provodit updating knowledge through блиц-опроса/вопросно-ответной
forms / brainstorming, etc.
2.2. Consistently describes the steps
on the organization of the educational process according to the structure of practical training.
Meet
Abstracts with ethyl.
Working in groups, will present the results of the group work
Stage 3.
The Final-Resultant-regulating (60 min)
3.1.Delaet opinion on the subject, attention was concentrated on the main students, according
to the importance of the work done for future careers.
3.2. Commends the work of groups (some of students) summarizes vzaimootsenki. Analyzes
and evaluates the degree of achievement of lesson.
3.3. Gives the task for independent work, informing schaet and criteria evaluation. Selfevaluation,
interaction assessment.
Ask the question.
Write down the job.
10.Kontrolnye questions
1. Definition of hypertensive states in pregnancy?
2. The main pathogenetic links of hypertensive states in pregnancy.
3. Classification. hypertensive conditions during pregnancy
4. Clinical manifestations of the various forms of hypertensive states in pregnancy.
5. Methods of diagnosis and differential diagnosis.
122
6. Principles of therapy light preeclampsia
7. The principles of treatment of severe preeclampsia.
8. First aid and principles of Intensive Care eklamp-sion.
9. Ways to prepare for childbirth and labor management features in severe pre-eclampsia
10. Complications of hypertensive states in pregnancy.
11. Recommended Reading
Summary:
1. Abramchenko, VV Epidural anesthesia in obstetrics: a guide for physicians / 2006. - 229 p.
2. Abramchenko, VV Pregnancy and delivery of high risk: a guide for physicians / - M. Med.
Inform, 2004. - 400 p.
3. Abramchenko, VV Cesarean section in perinatal medicine: a guide for physicians / 2005. 126.
4. Abramchenko, VV Postoperative intensive care in obstetrics / Literature, 2000. - 88.
5. Abramchenko, VV Pharmacotherapy of preterm labor / 2006. - 448.
6. Abramchenko, VV Purulent-septic infection in obstetrics and gynecological
logii.rukovodstvo / 2005. - 459
7. Abramchenko, VV Postoperative intensive care in obstetrics / - St. Petersburg: Spec. Literature, 2000. - 88.
8. Abramchenko, VV Clinical perinatology / IntelTek, 2004. - 424 p.
9. Ailamazyan, EK Midwifery: a textbook for honey. Universities / 2003 - 528.
10. Topical issues of Obstetrics, Gynecology and Reproductive / Ed. EV KOKHANEVICH.
- Moscow: Triad-X, 2006. - 480.
11. Obstetrics. Ed. GM Savelyeva. - M.: Medicine, 2000. - 816 p.
12. Obstetric and gynecological care: Hands-on. for doctors / Ed. VI Kulakov. - Moscow:
MEDpress, 2000. - 512 p.
13. Obstetrics. Clinical lectures: a manual for schools with a CD / Ed. OV Makarova. - Moscow: GEOTAR Media, 2007. - 640.
14. Obstetrics. Directory of the University of California / Ed. Nisvandera K., A. Evans: Lane.
from English. - M.: Practice, 1999. - 704 p.
15. Barashnev, YI Perinatal neurology / Y. Barashnev. - M.: "Triad - X", 2005. - 670 p.
16. Bodyazhina, VI Akushersvo. The manual for the media. prof. Education / VI Bodyazhina. - Rostov-on-Don: Phoenix, 2003. - 480.
17. Resurrection, SL Fetal assessment. CTG. Doplerometriya. Biophysical profile: a manual
for the system of postgraduate medical. Education / SL Resurrection. - Minsk: The Book
House, 2004. - 304.
18. Gazhonova, VE Ultrasound in Gynecology / VE Gazhonova. - Moscow: MEDpressinform, 2005. - 264.
19. Gluhovets, BI Ascending infection of placental / BI Gluhovets. - Moscow: MEDpressinform, 2006. - 240.
20. Humeniuk, EG Obstetrics: Physiology of pregnancy: a training ben-beats / EG Humeniuk. - Petrozavodsk: IntelTek, 2004. - 170 p.
21. Demidov, VN Pelvic ultrasound in women. Adnexal cysts and benign ovarian tumors: a
practical guide / V. Demidov. - Moscow: Academy of Medical Sciences, 1999, vol. II. - 100
p.
22. Duda VI Obstetrics: a textbook for high schools in the specialty "General Medicine" / Minsk: High School, 2004. - 639 p.
23. Duda VI Physiological OB / - Minsk: 2000. - 447 p.
24. Duda VI Operative obstetrics: a manual / Minsk Interpresservis, Book House, 2002. - 512
p.
123
25. Zhilyaev, NI Obstetrics: phantom course / - Kiev, 2002. - 239 p.
26. Zhilyaev, NI Operative Obstetrics: Ouch. Manual / Kiev 2004. - 468 p.
27. Zhilyaev, NI Operative surgery in obstetrics and gynecology / 2004.
28. Selected lectures on obstetrics and gynecology / Ed. AK Strizhakova etc. - Rostov-onDon: Phoenix, 2000. - 512 p.
29. Clinical recommendations. Obstetrics and Gynecology: scientific publication / Ed. VI
Kulakov. - Moscow: GEOTAR Media, 2006. - 512 p.
30. Clinical lectures on obstetrics and gynecology / Ed. AN Strizhakova etc. - M.: Medicine,
2000. - 379 p.
31. Clinical evaluation of laboratory tests in women: study guide / Moscow Medical and
Dental. University. NA Semashko. - M: 2005. - 96 p.
32. Kulakov, VI Preterm birth / VI Kulakov, LE Ants. - M.: Medicine, 2002. - 176.
33. Kulakov, VI Intensive care in obstetrics and gynecology (efferent methods) / - M: MIA,
1998. - 206 p.
34. Drugs used in obstetrics and gynecology / Ed. Acad. RAMS VI Kulakov, Acad. RAMS
VN Serov. 2006. - 375 p.
35. Emergency care in obstetrics and gynecology. Quick Guide - M. GEOTAR - Media,
2007. - 52.
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45. Handbook of obstetrics, gynecology and perinatology: uch.posobie for doctors / Ed. GM
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80.Internet sites:
http://www.studmedic.narod.ru/, http://med.siteedit.ru/,
http://www.rukovodstvo-po-akusherstvu.-uchebnoe-posobie.html,
http://www.materinstvo.ru, http://mama.ru.http://www.art-med.ru,, http://www.doctor.ru,
http://www.rodim.ru, http://mamka.ru
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http://mediki.spb.ru, http://medinstitut.e2e.ru, http://www.medstudy.narod.ru
http://www.obgyn.ru, http://www.medsno.ru, http://medrusnet.euro.ru
125
www.medtext.ru, www.medpoisk.ru, www.medicum.nnov.ru/student/
http://6years.net/, http://preryvanie-beremennosti.pharmabort.ru/
http://med4net.ru/, http://www.med-life.ru/, http://www.pregnant.ru/
http://www.roddom.ru, http://www.medpoisk.ru/, http://www.medlinks.ru
Topic: The course of pregnancy, childbirth and the postpartum period in renal disease and
anemia. Asymptomatic bacteriuria
1st place of training, equipping,
 Department of Obstetrics and Gynecology, the audience;
 dummy pelvic doll fetus;
 standard models of pregnancy;
 the classic model of labor;
 gynecologic simulator ZOE;
 childbirth simulator Noelle;
 simulator newborn Newborn;
 set of slides on the topics of discipline;
 methods work in small groups: the method of the incident, "a round table" problem solving,
"pen in the middle of the table", "swarm", etc.;
 testing and teaching practical skills in OSKE (objective structured clinical examination).
 video, TV, TV;
 personal computer (Pentium-III);
 set of slides with typical conditions for ultrasound scanning of pregnant women and gynecologic patients;
 set of video blogs "VJOG" (USA), highlighting recent advances in diagnosis and treatment of
obstetric and gynecological conditions;
 set of movies and video with a demonstration of typical obstetric and gynecological procedures
and operations.
 training video, "Iron deficiency in pregnant and postpartum women, modern aspects of diagnosis and treatment";
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 educational software;
 multi media training and testing;
 the use of e-mail and INTERNET;
 business simulations and case studies;
 center for skills training;
 offices and laboratories maternity complex;
 tazomera, measuring tape, a stethoscope, a set of tests;
 delivery room;
 set of tests;
 handout that includes a table of classification of kidney disease and anemia, treatment regimens, the list of antibiotics, antanemic to them Annotated, indications for hospitalization, the
options detailed analyzes of blood and urine;
 slaydoskop, slides, a prototype history pregnant with this condition, a set of test items.
2. Duration of study subjects
Number of hours, 5 hours
3. Purpose of the lesson
 consider the classification of anemia;
 to study the etiology of iron deficiency anemia;
 to analyze the impact of anemia on the fetus during pregnancy, childbirth and the postpartum
period;
 learn the principles of treatment of pregnant women with anemia and tactics of pregnancy and
childbirth in women with anemia;
 learn the principles of prevention of anemia in women of childbearing-age;
 consider the classification of renal disease;
 analyze the impact of renal disease on the fetus during pregnancy, childbirth and the postpartum period;
 learn the principles of treatment of pregnant women with anemia and tactics of pregnancy and
childbirth in women with anemia;
 consider the principles of the prevention of complications during pregnancy and the postpartum period, with renal disease.
Tasks
The student should know:
 the structural features of the urogenital system in women and the effects of the development of
pregnancy;
 classification of kidney disease and anemia;
 methods of clinical and laboratory tests (blood and urine sample Nechiporenko, Zimnitsky,
hemostasiogram, SPL, kardiomonitornoe study), pharmacological agents used in the treatment of
kidney disease and anemia;
 learn the stages of pregnancy, childbirth and the postpartum period.
 The student should be able to:
 examine pregnant with kidney disease and anemia, according to laboratory studies and in clinical manifestations;
 assess the activity of the pathological process, know the possible complications of pregnancy
and childbirth;
 able to order tests and treatment for these conditions;
 to choose the right tactics delivery.
4. Motivation
One of the most common systemic diseases that occur during pregnancy are anemia and pyelonephritis. Anemia is a regional pathology of Central Asia and its occurrence in some areas
reaches 78%, anemia is often a complication of chronic kidney disease. The direct connection of
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these diseases can be seen in the interrelated processes of production of erythropoietin by the
kidneys. Relevance of these pathologies treated more severe complications, such as miscarriage,
bleeding, infection of the fetus, occupying a leading position in the structure of maternal and perinatal mortality. Early diagnosis and correction is one of the primary stages of cure, which impact on the doctor-lozhena first link.
5. Intra and interdisciplinary communication
Teaching of the subject is based on the knowledge students the basics of anatomy, topographic
anatomy, histology, normal and abnormal physiology, endocrinology, and microbiology.
Acquired during the course will be used for the passage of endocrinology, internal medicine,
surgery, pathology of obstetrics, gynecology, hematology, health, pediatrics. The importance of
studying this disease on an expanded scale, together with related specialties explained involvement in the pathological process of all the vital organs of the pregnant woman, and even a successful outcome of pregnancy requires further rehabilitation therapy in a family health center.
6. Contents classes
6.1Teoreticheskaya part
Pregnancy and asymptomatic bacteriuria
Asymptomatic bacteriuria, bacteriuria, quantitatively true (more than 100,000 bacteria in 1 ml of
urine) in at least two samples in the absence of clinical infection.
Asymptomatic bacteriuria detected in 6% (2-11%) of women, depending on their socioeconomic status.
Etiology
Generally asymptomatic bacteriuria detected Esherichia coli.
More rarely provided by other members of the family Enterobacteriaceae and Staphilococcus
epidermidis, Staphilococcus saprophiticus.
Diagnostics
The required survey methods for medical observation, which should be conducted on a monthly
basis for all pregnant women, include clinical and biochemical analyzes of blood and urine, urine
culture, renal ultrasound and the fetus. The courses of antibiotic therapy reduces the risk of septic
forms of acute pyelonephritis, fetal malnutrition and premature births, which had more than 30%
of pregnant women with untreated bacteriuria.
The clinical picture
Asymptomatic bacteriuria has significant clinical value. The vast bolschinstve cases bacteriuria
during pregnancy can be diagnosed at the first visit to the doctor in the early stages of pregnancy,
lisch 1% of bacteriuria develops at a later date.
Complications of gestation:
 the threat of termination of pregnancy;
 anemia during pregnancy;
 hypertensive state pregnancies;
 threat of premature birth;
 placental insufficiency;
 IUGR;
 fetal death.
Treatment
The main treatments for asymptomatic bakterurii during pregnancy:
Amoxicillin 250-500mg three times a day for 3 days.
Amoxicillin - clavulanic acid is 375-625 mg 2-3 times a day.
Kanefron 1tabletki H by 2 times a day for 14 days.
Kidney disease in pregnancy is second only to cardiovascular disease. Among infectious second
only to colds. Pyelonephritis is most common (20%), glomerulonephritis (0.1 - 0.2%), urolithiasis (0.1 - 0.2%). Pyelonephritis during pregnancy occurs in 48% of women in the postpartum period, 35%, 17% at delivery.
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Occurrence of pyelonephritis (PN) contribute to the hormonal changes of the characteristic of
pregnancy, the growing uterus ureteral compression, the presence of foci of infection in the body
(angina, carious teeth, abrasions, etc.). Under the influence of progesterone produced by the placenta, there is a relaxation of smooth muscles of the intestine, bladder and ureters. There is a
tendency to constipation and a significant slowdown in the passage of urine. Marked expansion,
elongation, distortion of the ureter with the excesses and looping, increasing the pelvis cavity.
Disturbed urodynamics upper urinary tract and blood flow in the kidney. These conditions create
a favorable background for the spread of infection by the rising of the urethra, bladder subepithelial layer of tissue in the pelvis. Know the infection lymphatic and hematogenous route from the
source of inflammation of the tonsils, teeth, genitals, gall bladder, etc. Any obstruction of urine
outflow aggravates it possible to develop a urinary tract infection - stones, abnormalities, bends
ureteral etc. By the development of gestational Mon predispose a favorable environment for the
activation of latent infection in the kidneys flowing: urodynamic disorders of the upper urinary
tract and kidney hemodynamics impair renal excretion of infectious agents, entered it haematogenously. At the same time, dysuria, bladder dysfunction, increased its volume by lowering the
tone, impairs the evacuation of urine from the upper urinary tract, which contributes to its delay
and the development of inflammation in the kidney. Pathological process develops in the interstitial renal tissue and ends its sclerosis, compression of the renal tubules, and the early impaired
urinary concentrating ability. Against this background, can develop renal hypertension, which
occurs in 20% of pregnant women with Mon In malignant hypertension develops during the contracted kidney and chronic renal failure. Infection of the wall violates his ureter peristalsis, leading to stasis of urine. Infection in the renal pelvis contributes to the formation of stones, injuring
the epithelium of the urinary tract. A vicious circle - and pregnancies reduced the evacuation of
urine, promoting the development of infection, and urinary tract infection exacerbates stasis and
severity of the pathological process.
Mon pathogens in pregnant women are often opportunistic pathogens.
E. coli is planted in 36-88% of pregnant women and causes sclerosis renal pelvis, perirenal fat
and renal capsule. Proteus (5-20%) for its enzyme breaks down proteins and urea to form ammonia and other substances that damage the epithelial cells of the kidneys and ureters. This infection causes the formation of stones and has a relapsing course. From the urine of pregnant sow as
Klebsiella, Enterococcus, etc. But the most common pathogens are gram-negative microorganisms Mon - streptococcus group D and B, staphylococci and micrococci. Inflammation of the
kidneys can also cause Candida, Mysoplasma hominis, Ureaplasma urealyticum, Trichomonas
vaginalis, anaerobic bacteria. As a rule, the process of finding fresh, one agent, and at a LongRunning - a few.
Terms of pyelonephritis.
During pregnancy on the 23-28 week (maximum lift corticosteroid Dov).
At 32-34 weeks, when the uterus reaches a maximum size
39-40 weeks - the head is pressed against the entrance to the pelvis.
After delivery - 2-5 days, 10-12 days.
Clinical picture:
There are acute and chronic Mon The emergence or worsening Mon often occurs in 22-28 weeks
of pregnancy, when sharply rising levels of sex hormones and corticosteroids. This period is critical for pregnant women with Mon
Acute MO: starts with raising the temperature to 38-40o C, chills, headache, pain in the limbs.
Expressed signs of intoxication accompanied by pain in the lower back, enhances breathing, radiating along the ureter, into the groin, thigh, labia. Sign Pasternatskogo positive. When joining
frequent cystitis appears painful urination. In some cases, the temperature increases to subfebrile
figures without chill. Lower back pain occurs only in 2-3 days, first two-way, then - on the one
hand, more often on the right. It is associated with compression of the ureter, right ovarian vein,
varicose expands during pregnancy. It is in the same compartment as the connective close ureter.
Isolated interstitial, serous and purulent forms Mon The latter is divided into apostematozny
129
jade, emerald and renal abscess. If developed purulent Mon, intoxication accompanied tachycardia (120-140 beats / min), headache, malaise, weakness, icteric sclera, nausea, vomiting. In 25%
of cases, the symptoms of bacterial toxic shock from the fall in blood pressure, sudden pallor,
acrocyanosis, confusion. In severe Mon showing signs of renal hepatic failure with azotemia,
severe jaundice. With the spread of perirenal tissue stress symptom appears anterior abdominal
wall muscles, pain in the ribs and lumbar muscle strain.
Differential diagnosis. In acute appendicitis, acute cholecystitis, is colitis, renal or hepatic colic,
common infectious the disease.
On the part of obstetrics: the threat of premature birth, premature detachment of normally situated placenta, amniotic fluid embolism, horionamnionit, endometritis, miometroendometrit, adnexitis.
Chronic PN: usually begins in childhood. The long period of remission promotes frivolous attitude to the disease. Aggravation of are associated with hormonal changes (puberty, marriage,
pregnancy, childbirth). Without exacerbation patients feel good, sometimes appear indistinct
complaints of malaise, headache, dull pain in the lower back. At 5-10% of pregnant women
asymptomatic bacteriuria occurs without any signs of inflammation of the urinary tract or in the
present, either before pregnancy. In 40% of women, it becomes symptomatic in Mon Sometimes
regarded as asymptomatic bacteriuria predstadiya Mon
Pyelonephritis adverse effect on pregnancy and the fetus. Preeclampsia joins at least 40% of patients with PN, especially chronic. Miscarriage they reach 30% by premature birth. Perinatal
mortality is 25-50%. Babies are signs of intrauterine infection, which are more prone to postpartum pyo-septic diseases. Some children are born with congenital vezikulezom, but none of the
infants was not detected congenital Mon In the presence of renal hypertension is much more
likely to have pregnancy complications, prematurity and perinatal mortality of children.
Laboratory diagnosis:
Blood. Acute process high leukocytosis with a left shift, accelerated erythrocyte sedimentation
rate, decreased hemoglobin. In the biochemical analysis of blood - hypoalbuminemia. In severe
cases, elevated creatinine and urea. In chronic process - reduction of hemoglobin, since the kidneys are involved in eritrpoeze as vyrabatyayut humoral factor - erythropoietin. Against the
background of low leukocytosis and elevated ESR.
Urine. Sample Zimnitsky - gipoprotenuriya, nocturia. Total urine - alkaline, urine sediment leykotsitouriya (upper limit of normal - 6-8 in sight), the lack of cylinders, Pyuria (pyuria). Rarely in zakupokre ureter on one side may not pus and urine does not contain white blood cells.
Sample Nechiporenko, Addis Kakovskogo, Amburzhe - quantification of the formed elements.
Sample Nechiporenko - the norm for pregnant women: WBC 4000, 100 cylinders, erythrocyte
2000.
Urinalysis for bacteriuria is conducted only in bacteriological laboratory. Bacteriuria true - abjection in mono-culture (that is one) in the amount of 0.1 million or more cells in several urine.
Bacteriological examination reveals abjection, the degree of bacteriuria, permits antidiagrammu.
The method is labor intensive, so there are other lighter approximate methods: bacterioscopy smear microscopy of urine sediment. If the 10 bacteria in a useful view - that corresponds to 0.1
million / ml. Under phase contrast microscopy - 1 corresponds to the microbe 0.1 million / ml.,
Chemical rapid tests: accuracy of 80-85%. Needed to select patients for more accurate research:
nitrite tests, TTX-test, catalase test. These substances are labeled biochemical composition,
changing its color.
In laboratory studies can reveal significant bacteriuria, which is not accompanied by clinical
symptoms - the so-called asymptomatic bacteriuria - significant bacteriuria in the absence of
clinical signs of pyelonephritis and no other laboratory abnormalities (not changed Zimnitsky
test, etc.). asymptomatic bacteriuria can be regarded as a phase transition of acute to chronic pye130
lonephritis, or the beginning or end of an acute process.
But there may be a long time - most consider it in this case, a manifestation of chronic pyelonephritis. Asymptomatic bacteriuria should be considered a form of pyelonephritis until this diagnosis is significantly rejected (different samples up to renal biopsy).
Ultrasound. In the routine investigation of the pregnant uterus along with ultrasound, placenta,
etc. always inspect the kidneys. Signs of - Change the thickness chasheno-pelvis system, expansion CHLS.
Pregnancy and childbirth:
Depending on the form Mon allocated 3 risk by NIJ-onset complications of pregnancy and
childbirth.
1 risk - uncomplicated pyelonephritis has occurred during pregnancy for the first time.
2 risk - chronic pyelonephritis occurs until the pregnancy.
3 risk - chronic pyelonephritis before pregnancy with azotemia, hypertension.
Pyelonephritis single kidney.
At 1-2 tbsp. You can allow the pregnancy, while women must be followed up by a urologist,
nephrologist and obstetrician-gynecologist, and subject to regular monitoring of urine: every 2
weeks, urinalysis, and between 22-28 weeks of daily.
With 3 tbsp. Contraindicated in pregnancy because of the kidneys threatens the health and life of
the woman and the fetus.
Hospitalization is shown: in the event of pregnancy complications, exacerbation Mon at any
stage of pregnancy - a specialized hospital, in critical periods (22-28 weeks) for examination and
determination of renal function, with the identification of hypoxia or fetal malnutrition. The most
favorable outcome of pregnancy is observed in acute Mon encountered during pregnancy with
good effect of the treatment. If you have any indications for urological surgery first performed
the operation, and then decide on continuation of the pregnancy. Termination of pregnancy does
not improve the flow of purulent process in the kidney. Treatment should be aimed at restoring
the function of the kidneys. Particular attention should be paid to the prevention of complications
of pregnancy in women with PN, to monitor the dynamics of blood pressure, body weight, tone
the uterus, the fetus and carry out prevention of miscarriage.
Clinical management of women with pyelonephritis present before pregnancy.
The first time women with pyelonephritis have her hospitalized in a planned way - during which
the diagnosis should be specified (set form). Second hospitalization shown an exacerbation.
Third hospitalization is indicated for the development of complications of pregnancy preeclampsia, fetal hypoxia, malnutrition.
Treatment: always in the hospital.
Principles of treatment of PN:
 Increased passage of urine
 Eliminate stagnant urine
 Intensive breeding of germs and their toxins
 Sanitation of the urinary tract - antibiotics and uroseptiki
 antispasmodics
 Diuretic herbs
 Bozeman's position
 Fortified Diet
 Principles of antibiotic therapy
 urine culture with the definition of sensitivity to antibiotics
 Security for the mother and fetus
 High Performance
 The objectives of antibiotic therapy:
 The rapid relief of symptoms
 Rehabilitation
131
 Prevention of complications of the mother and fetus
 Prevention of relapse
 Security antibiotics for UTI in pregnancy (FDA)
In the first trimester of antibiotic drugs of choice are penicillin and cephalosporins as high risk of
teratogenicity. After 15 weeks, the possibility of significantly increasing.
Penicillin antibiotics: ampicillin, ampioks, amoxiclav, carbenicillin, baktoks - less toxic, are used
throughout pregnancy.
In the second trimester: a group of macrolides - erythromycin, oleandomycin, sulfa drugs urosulfan, etazol. Derivatives of 8-hydroxyquinoline - 5 NOC nitroksilin, blacks (nalidixic acid)
- a combination of drugs nalidixic acid unfavorably with nitrofurans because it leads to a decrease in the bacteriostatic effect, nitrofurans (furadonin, furagin, furozolidon) best furagin as the
least irritating to the stomach , other drugs of this series often lead to nausea and vomiting.
Contraindicated: streptomycin, chloramphenicol (leads to functional immaturity of the fetal liver
tion, leukopenia and aplastic anemia), tetra-ratsiklin (has an adverse effect on bone and teeth tab,
children have teeth yellow), sulfa drugs prolonging the deyvtviya (biseptol 480 baktrin - effects
on red blood germ).
Means, which influence on the macro-.. To improve the flow of urine - antispasmodics, desensitizing agents. Infusion therapy for severe conditions (physical solution, glucose, sodium, reopoligljukin, polyionic solutions. Overall amount of fluid injected 2.5 - 3 L). If there is a combination of pre-eclampsia, the amount of liquid to 1 liter.
Additional treatments: Plant and equipment - improve the flow of urine and disinfect the urine:
bearberry, cranberry leaf, birch leaves, rose hips, corn silk, fruits, cherry, strawberries, mountain
ash, pumpkin seeds, cranberry juice (contains sodium benzoate, is converted in the liver kotoray
in hippuric acid which has a disinfectant).
The preparation of the combined action of plant origin, which do not cause side effects and do
not affect the fetus. Recently in urological practice, a herbal preparation Kanefron N. It has antiseptic, anti-inflammatory, antispasmodic, antibacterial, diuretic effect, reduces the permeability
of the capillaries of the kidneys, which corresponds to the pathogenesis of the pathological process in the kidneys at Mon
Medicinal plants belonging to kanefron (centaury, lovage, rosemary), contain active substances
(phenol carbonic acid, bitter, essential oils, phthalide, flavonoids) that provide versatility effects
of the drug on the body.
Diet: No limit salt and fluids.
From prevention to treatment and the woman should take the positional therapy, knee-elbow position for 5 minutes several times a day.
Indications for termination of pregnancy:
 pyelonephritis combined with severe preeclampsia
 No effect of the treatment
 acute renal failure
 hypoxia
Interrupt can be produced by labor induction. Cesarean section is acceptable only under strict
obstetric indications, preferably without opening the abdominal cavity (extraperitoneal route) to
avoid severe septic complications in the postoperative period.
Delivery in patients Mon preferably vaginally. Widely used analgesics and antispasmodics, even
with nephrostomy possible spontaneous labor.
Pyelonephritis adverse effect on pregnancy and the fetus. Preeclampsia joins at least 40% of patients with PN, especially chronic. Miscarriage they reach 30% by premature birth. Perinatal
mortality is 25-50%. Babies are signs of intrauterine infection, which are more prone to postpartum pyo-septic diseases. Some children are born with congenital vezikulezom, but none of the
infants was not detected congenital Mon In the presence of renal hypertension is much more
likely to have pregnancy complications, prematurity and perinatal mortality of children
132
About 20% of women after suffering gestational pyelonephritis renal function is reduced. Exacerbation of the disease observed in the 4 th and 12-14 days (critical periods). Need to conduct a
survey, the prevention of exacerbation Mon before hospital discharge. In the future - seeing a
urologist.
Exacerbation during delivery is due to occlusion mochetochni-ing, so during childbirth prescribed antispasmodics required.
Dangers in the postpartum period.
In the first days after birth is not restored until the end of the modified urinary system and join
the same changes that have occurred in labor.
Births: head always hurts - leads to swelling of the mucous, Punctate hemorrhages. Impaired
function of the mucous membrane of the urinary bladder and urethra. Characterized by the absence of urges to urinate (the first day).
All this leads to a violation of self-cleaning mechanisms of urinary IP-Staring (phagocytosis).
If the changes are not deep, then after 3 days bacteriuria disappears. If depth of the change, then
the germs in the bladder gives rise to the emergence of new or worsening of the disease.
Treatment after delivery should be done within 2-3 weeks. Vano recommended compulsory up
early from bed, which contributes to the outflow of urine. Treatment is carried out with the same
medications, but you have to give up erythromycin (has a very high concentration in milk), but it
is possible to use long-acting sulfonamides. Criteria for recovery - 2-3 normal urinalysis. After
discharge, put on record a urologist, watch for 3-5 years. Women with pyelonephritis hormonal
contraceptives are contraindicated because they create the conditions for an exacerbation.
Anemia in pregnant women
The problem of anemia in pregnant women remains valid for the whole world, and for Uzbekistan, due to the steady growth of this disease in pregnant women. In the structure of morbidity
pregnant iron deficiency anemia (IDA) is the second largest after the thyroid gland.
Under the anemia of pregnancy understand several anemic conditions characterized by reduction
in the number of red blood cells and a decrease in hemoglobin per unit volume of blood that occur during pregnancy, complicating its course and usually stops at the completion or termination
of pregnancy.
Physiological pregnancy is usually accompanied by a decrease in hemoglobin concentration by
increasing the volume circulates blood and blood components. The minimum values of hemoglobin and hematocrit observed in 32-34 weeks of pregnancy. In these terms and their average
value in women not treated with iron supplements, are 105-110 g / L and 32-34 L / L, respectively. It is assumed that hemodilution contributes to the normal course of pregnancy, improve the
utero-placental circulation and is probably a compensatory mechanism of blood loss at delivery.
In the normal course of pregnancy, all these changes are compensated and do not go beyond the
"corridor of physiological changes."
Anemia often accompanies chronic illness (pielone-Frith, rheumatoid arthritis, systemic lupus
erythematosus, endocarditis, osteomyelitis, tuberculosis) and is observed in 35-72% of pregnant
women with signs of inflammation in the kidney.
The main aspects of the pathogenesis:
One of the most important trace elements essential iron is required for the normal functioning of
many biological systems. Everyone knows that with the participation of iron in the human body
are carried out almost all metabolic processes, it performs the enzymatic functions, providing
vital functions of each cell.
About 30% of the total iron in the body is deposited in the depot. Ferroproteinami, deposits of
iron in a non-toxic and physiologically available form, are ferritin and hemosiderin, which are
compounds of apoferritin protein molecules with a large number of iron atoms. The major irontransport protein transferrin, the plasma is related to β-globulins.
Allocate a set of risk factors in women at childbirth allowance for the development of IDA in
the gestational period. According to Smirnova LA (2002) The commitment to anemia in early
pregnancy is set at 51.6% of women with a normal hemoglobin level, including 34.5% have
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predlatentny, and 19.5% - latent iron deficiency. According to Kasabulatova NM (2003), almost
half of all women in the beginning of pregnancy iron reserves are insufficient.
Pathological background for the development of IDA in pregravid period are:
1. Chronic blood loss
 endometriosis;
 uterine fibroids;
 use of intrauterine contraceptive devices;
 dysfunctional uterine bleeding;
 gynecological diseases associated with internal or external bleeding;
 heavy and prolonged menstrual period;
 multiple pregnancies and births (more than three) with an interval of less than two years;
 twins;
 pregnancy, which occurs on the background of lactation;
 artificial and spontaneous abortions prior to the pregnancy;
 disease of the gastrointestinal tract (stomach ulcer and duodenal ulcers, erosive gastritis, intestinal diverticula of various departments, hemorrhoids, ulcerative colitis);
 bleeding diathesis;
 nosebleeds
2. Nutritional iron deficiency
Most often, this type of iron deficiency is found in countries with low economic level.
Most completely absorbed heme iron, that is a member of the heme of myoglobin and hemoglobin, as its optimal bioavailability and requires no pre-conditions: heme complex is absorbed by
cells lining the small intestine as a whole. It is contained in lean meats, fish, and poultry. The absorption of iron from various animal products ranging from 6% to 22%. Phytates, phosphates,
and ascorbic acid did not affect the absorption of heme iron
From plant foods is absorbed about 1% iron (non-heme iron). Condition of non-heme iron absorption are its preliminary translation into a soluble form and restore to the divalent state. Negligible absorption from plant foods is associated with the presence of phytates in them. Ascorbic
acid, cysteine, promotes absorption of non-heme iron. While vitamin C is not only restores the
ferric iron in the ferrous, but it forms a chelate compound, readily soluble at low pH. Assimilation of trace elements is reduced by the use:
1. coffee, tea,
2. eggs (phosphates).
3. fats (lard, butter, and vegetable)
4. soy protein,
5. dairy products (containing calcium), coffee.
3. Iron deficiency due to increased demand for it in the period of growth and maturation
 high iron requirements due to the rapid growth of bodies and tissue;
 at menarche against malnutrition,
 in sporting activities due to the increase of muscle mass, loss of iron through sweat during
training, decreased iron absorption during prolonged physical overload
4. increased need for iron in patients with B12-deficiency anemia
May occur during treatment with vitamin B12, which is explained by the intensification normoblasticheskogo hematopoiesis and use for this purpose a large amount of iron.
5. resorption of iron deficiency
This type of IDA due to lower absorption of iron in the area ha Street duodenitis, enteritis, gastric resection, and large areas of the small intestine.
6. violation of iron transport
 congenital hypo-and atransferrinemiya;
 hypoproteinemia various origins (nephrotic syndrome, impaired protein-liver with cirrhosis,
severe hepatitis, malabsorption syndrome);
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 the appearance of antibodies to transferrin and its receptor.
Need for iron in the first trimester was close to normal, at II-increased to 3 mg, III - to 3.5-4 mg
per day. During intrauterine life the fetus receives all the necessary iron from the mother, mainly
from the reserve fund, and after exhausting the supply of essential fetal hemoglobin iron comes
from women, which leads to anemia. According to WHO (1998), a pregnancy a woman's body
spends about 1000 mg of iron:
• 300 mg is transferred to the fetus (a process that occurs during pregnancy, but it will continue from 28-32 weeks of gestation). Insufficient intake of selenium in the body of the fetus is observed in pregnancy complications associated with impaired uterine-placental blood flow. The
expression of placental insufficiency is correlated with the degree of iron deficiency.
• 50 mg is required for the development of the placenta
• 450 mg spent to increase the mass of circulating red blood cells of pregnant,
• 240 mg of basal iron loss (sweat and feces - 0.8 mg / day, with exfoliated epithelium of the skin
- 0.1 mg / day in the urine - 0.1 mg / day, for a total of 1 mg / day)
• 150-200 mg spent on blood loss at delivery (estimated 2-2.5 ml of blood contains 1 mg of
iron);
• during lactation spent an additional 50-100 mg of iron.
Savings due to the lack of menstruation is 300-400 mg. There is a healthy woman with iron
stores of 600 mg or more of these physiological losses are fully covered from the reserve fund at
the expense of iron from food. In the presence of pregravid latent iron deficiency and pregnancies developing IDA.
True IDA caused by immunological reactions gemoimmunnoy system, depressing erythropoiesis
in the bone marrow.
Along with IDA allocate redistributive iron deficiency or anemia of chronic disease. Such anemia develops in the presence of large foci of infection, including the female reproductive organs,
during convalescence after infectious diseases, acute and chronic infectious and inflammatory
diseases of the lungs, kidneys and urinary system. Железоперераспределительные anemia are
second in frequency among all anemias after IDA.
Anemia of chronic disease has permanent signs:
 always secondary;
 arises because of the prolonged inflammatory process;
 severity depends on the source of inflammation;
 celebrated refractory to treatment with iron.
This type of anemia is associated with defective iron reutilization, in which macrophages are not
able to release iron, obtained by phagocytosis of red blood cells in the circulating pool. Recent
research found that the inflammation induced by infection, iron becomes inaccessible for
erythroid precursors due to a lack of transferrin and the transformation of much of the iron reserves in nonutilizable hemosiderin. The consequence is the observed rise in serum ferritin levels, which can be considered as a protein ferritin acute phase. When
железоперераспределительной anemia is not true iron deficiency in the body, it is stored in the
depot as ferritin and hemosiderin in cells macrophage system.
Microorganisms provide a non consume primarily serum iron, which forms a tenuous connection
with the serum globulins. On the one hand, its high content of serum activates the virulence of
microorganisms embedded and on the other - a low amount of iron reduces the biological and
humoral factors of defense.
Diagnosika:
The most commonly used in clinical practice for diagnosis of IDA peripheral blood. According
to the WHO criteria (2001) IDA ascertain the concentration of hemoglobin less than 120 g / l in
women of childbearing age and less than 110 g / l in pregnant women and in the number of red
blood cells less than 3,5 • 10 ¹ ² / liter. IDA pregnant women against the background of ferroprofilaktiki diagnosed when the level of hemoglobin in the first trimester of less than 110 g / l, in the
second and third less than 105 g / l.
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The classification of the severity of anemia in pregnant women in terms of hemoglobin:
 Mild - from 109-91 g / l,
 medium - from 90 to 71 g / l,
 severe degree and 70 g / L or less.
Diagnose latent iron deficiency on the basis of peripheral blood is almost impossible. Therefore,
the most important place in determining the body's iron saturation belongs specific biochemical
methods. Most appropriately and adequately state reserve of iron in the body reflects the level of
serum ferritin (SF) in the blood. SF concentration 1 mg / L corresponds to 8 mg of stored iron in
the body. Based on the determination of the level of this protein in the blood serum can be set
latent iron deficiency in women, which promotes early prevention of IDA in the gestational period.
According to WHO (2001) IDA in pregnant women diagnosed reduction tion level SF below 15
ug / l.
Modern diagnostic methods can detect three stages depleted body iron. Initially reduced iron
stores in the liver, spleen, bone marrow, which is reflected in the reduction of the SF in the
blood. This occurs without obvious external disturbances, but in fact is giposiderozom or
predanemicheskim state (sideropenia). Intake of iron for hematopoiesis is not reduced, and the
hemoglobin level is within normal limits. In this situation, it is clear that in order to detect clinically giposideroz, you only need a little push. The first stage of iron deficiency is defined only by
special, not intended for implementation in daily practice, instrumental and laboratory studies of
tissue iron stores. The next stage of iron deficiency is a latent iron deficiency, which develops in
the "depletion" of tissue iron stores and is described as a complete depletion of trace elements in
the depot and transport pool. SF level recorded at least 12-15 mg / l. At this stage, marked compensatory enhancement of iron absorption in the intestine and increased mucosal and plasma
transferrin. In this case, the rate of synthesis of hemoglobin, its overall content and erythrocyte
hemoglobin saturation is not changed. It should be noted that the latent iron deficiency is always
preceded by IDA, and it can occur for a long time without anemia, causing persistent sideropenic
syndrome.
Later depleted depot body can not provide erythropoietic bone marrow function and significantly
reduced the content of SJ in the blood, hemoglobin synthesis, developing iron deficiency anemia
and subsequent tissue disorders.
One of the criteria for diagnosis of iron deficiency at the current stage of development of medicine is to determine the level of erythropoietin, as a measure of the effectiveness of erythropoiesis. Thus, the decrease in hemoglobin concentration in the blood stimulates the production of this
hormone. In addition, allocate an inappropriate response of erythropoietin for anemia, particularly in patients with moderate to severe iron deficiency, which is evident weakening its dependence on the blood level of hemoglobin or hematocrit.
In detecting elevated levels of erythropoietin in early pregnancy in the serum of patients may
serve as a marker of pre-clinical development opportunities in IDA later in gestation. Indicators
of erythropoietin as inflammation, and in the same type of IDA and point to the activation of
erythropoiesis.
IDA clinic:
The clinical picture of IDA consists of two main syndromes: sideropenic and obscheanemicheskogo.
Sideropenic syndrome is caused by tissue iron deficiency, decreased activity of iron-containing
enzymes and appears Nutritional:
• Zayed in the corners of the mouth
• glossitis - is characterized by a feeling of pain and fullness in the field of language, redness of
the tip, and further atrophy of the papillae
• inflammation of the red portion of the lips
• degenerative changes in the skin and its appendages (dry and pale skin, premature wrinkles,
brittle nails and hair, koilonychia, the occurrence of small cracks)
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• sideropenic dysphagia caused by atrophy of the esophageal mucosa, inhibition of secretion,
which leads to poor painful swallowing solid food.
• due to the depletion mioglobinovogo iron pool and enzymes of tissue respiration develops
muscle weakness that does not meet the degree of anemia, there is a physiological sphincter
weakness, urinary incontinence in laughter and coughing, compelling urge to urinate.
• taste perversion (a desire to eat non-food items - chalk, tooth powder, coal, clay, sand, raw
dough, minced)
• distortion of the sense of smell (attracted to the smell of gasoline, kerosene, acetone, lacquer,
paint, humidity), which is probably due to the decrease in the amount of iron in substancia nigra
of the brain.
• syndrome "blue" of the sclera (violation of hydroxylation of proline and lysine, and then the
synthesis of collagen in the sclera, it becomes thinner and through rayed choroid).
• «sideropenic subfebrilitet
• high susceptibility to SARS and other infectious and inflammatory processes, chronic infection
that is caused by a violation of the function of white blood cells and weakening the immune system.
The above symptoms can occur against the background of anemia, and without it, in the form of
latent iron deficiency.
When the level of hemoglobin and red blood cells behaves general anemic syndrome:
• pale, light yellow hands and nasolabial triangle due to metabolic carotene iron deficiency
(moderate and severe IDA)
• shortness of breath, tachycardia, arrhythmias sometimes, fainting (especially with the rapid
transition from horizontal to vertical position)
• systolic murmur at the apex of the heart and into the pulmonary artery projection point, voiceless heart tones.
• palpitations, chest pain
• myocardial that occurs on a background of latent iron deficiency and IDA, creates prerequisites
for the delivery of cardio - vascular disease, when the load on the heart increases sharply
• fatigue
• tissue hypoxia also leads to weakness, dizziness, shallow-kaniyu "fly" before the eyes, drowsiness during the day and at night insomnia, impaired concentration, loss of memory, performance,
irritability, tearfulness
• Due to poor circulation skin patients hypersensitive to cold.
• Sometimes there is a heaviness in the epigastric region, worsening Annette titans, nausea, flatulence
• increase in the permeability of small vessels leads to swelling of the face in the morning, pastosity legs
• hypoproteinemia occurs only in severe anemia
• hypoalbuminemia
• a tendency to hypotension
Severity of complaints depends on adaptation to anemia. Moreover, patients often get used to its
malaise, fatigue to explain his work, psycho-emotional overload.
It should be noted that iron deficiency contributes to enhanced absorption of lead in the gastrointestinal tract, and, consequently, chronic lead intoxication. Elevated levels of lead in the body of
the mother and the fetus can cause serious nephrology, hematology, or neurological disorders.
The course of pregnancy, childbirth and the postpartum period:
Is now generally accepted that the IDA is pregnant is the pathological background, which promotes the development of a variety of complications of pregnancy and childbirth. Iron deficiency
exacerbates violations vitamin metabolism, resulting in an imbalance of morphological and functional and metabolic processes in the body, which further complicates the course and outcome of
pregnancy.
Complications of pregnancy, childbirth, postpartum and neonatal adaptation period proportional
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to the severity of IDA and the most typical:
 threatening preterm labor (65%)
 chronic intrauterine hypoxia (30%)
 chronic feto-placental insufficiency (30%)
 preeclampsia (25%)
 delayed rupture of membranes (39%)
 weakness of labor (34%)
 abnormal blood loss at delivery (15%)
 anemia postpartum women (27%)
 postnatal purulent - septic complications (7-12%)
 neonatal anemia (17%)
 violation of the adaptation period (24%)
Discirculatory and degenerative changes in the myometrium with iron defi-tsite, impaired
neuromuscular transmission is likely to disrupt the contractile activity of the myometrium and
contribute to the development of premature detachment of normally situated placenta, may be
prolonged labor or fast and swift. True IDA pregnant may be accompanied by a violation of coagulation properties of the blood, which leads to increased blood loss during delivery and hypotonic bleeding  10% of women who are in direct proportion to the severity of anemia and exceeding the average rates of 3-4. In 12.8% of cases of postpartum complicated by purulent-septic
diseases subinvolution uterus. Many studies have shown a positive correlation between the severity of anemia and the degree of violations of the lactation function, and there are both quantitative and qualitative changes in the breast milk for iron deficiency.
Adversely affected by the IDA and the condition of the fetus, contributing to fetal growth retardation syndrome, chronic intrauterine hypoxia. Reduction of fetal adaptation in the early neonatal period is recorded in 51.4% of cases. Several authors have found that even the subsequent introduction of iron into the body of the newborn, whose mother suffered during pregnancy IDA
does not lead to the accumulation of iron in the brain for a full functional activity of ironcontaining enzymes, which can then affect the psychomotor development of the child.
Infants of mothers with IDA on the 4th day had significantly lower hemoglobin and red blood
cell count in the blood, compared with newborns of mothers with other extragenital pathology
Treatment of IDA:
IDA treatment determined by the degree of severity, the presence of accom-interacting extragenital diseases and complications of pregnancy.
The goal of therapy is to eliminate iron deficiency deficit of iron and restore its reserves. This
can be achieved only by eliminating the causes underlying the IDA and the simultaneous recovery of iron deficiency in the body.
For a rational ferrotherapy must adhere to the basic principles:
The first principle - the mandatory introduction of drugs that contain salt glands. Currently, there
are numerous and convincing evidence that the deficit of iron in the body with the help of only
dietary correction is not possible, due to limited intake of trace elements from food in the digestive tract. Limit intake of selenium in the intestine is 2-2.5 mg.
When choosing a diet, as one of the components of the treatment of IDA, should focus not on the
total iron content in the products, and the form in which it is presented. Most completely absorbed hemic iron because its optimal bioavailability. From plant foods is absorbed about 1%
iron. Ferropreparatov of intake of iron in the body is 10-15 times more
The second principle - the stages and duration sufficient ferrotherapy. IDA treatment consists of
two phases: relief of anemia and replenishment depots. The first stage lasts from the beginning
of therapy to normalize hemoglobin levels and usually takes about 4-6 weeks. At the same dose
should match the severity of IDA, as iron is a prooxidant and contributes to the activation of lipid peroxidation. The second stage, "therapy saturation" spend 2-3 months at a dose of 30-60 mg
of elemental iron (EJ) per day. Thus, the full two-phase treatment of IDA takes 3 to 5 months
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The third principle - the correct calculation of the daily dose. The basis of this calculation is figure EJ. Therapeutic dose for patients 70-80 kg from 100 mg to 200 mg of EJ. WHO recommends
optimal dose is 120 mg per day. Currently used drugs containing divalent iron, as it is much better absorbed in the intestine, mainly orally.
The therapeutic effect is somewhat later after taking oral drugs than intravenous or intramuscular
injection, but the side their properties are much more frequent and more severe. Simultaneous
administration of vitamin C improves the absorption of iron, forming with it a chelate compound, readily soluble at low pH and reduces side effects. At the same time pointed out that the
only long-term administration of iron, helps displace important health micronutrients such as iodine, nickel, manganese, cobalt, from the body.
Better absorption observed fasting is recommended iron supplements for 30 minutes before a
meal, but this admission can be side effects: diarrhea, nausea, epigastric pain, bloating, a metallic
taste in the mouth and headache. The severity of these effects is stronger, the more there is in the
gut nevsosavsheysya iron, ie more active absorption, the better tolerability. Some patients have
constipation against ferrotherapy. This is due to the fact that iron sulfide binds intestines which is
a biological stimulant perestaltiki. Side effects are much smaller for sustained-release preparations of the metal ions, and drugs that contain various additives such as vitamin C (at a dose of
0.1-0.3 g), glucose, succinic acid, mukoproteaza, the latter has a masking effect on iron ions and
protects the mucosa from inflammation. Improves tolerability iron supplementation after 1-2
hours after eating. During the meal, take iron supplements is not recommended, as it reduces the
absorption of 10.
Ascorbic acid is a component of a number ferropreparatov: tardiferon, ferropleksa, Sorbifer. Folic acid is introduced into drugs to prevent neural tube disease in the fetus during the first half of
pregnancy, for the prevention of fetal malnutrition in the second half: gyno-tardiferon, fefol,
makrofer.
Of general recommendations for the use of iron supplements include the following: tablets, capsules should be swallowed whole without chewing, not to combine the drug doxycycline, almagel, calcium-drugs not drink milk, yogurt, tea, coffee, drink allowed bleached (no pulp) juices.
In some cases, treatment with oral iron supplementation is ineffective, which could be due to:
 ongoing blood loss
 improper technique or inadequate dose of the drug
 incorrect diagnosis (anemia of chronic disease, the one-lassemiya, sideroblastic anemia)
 combined deficit (most of all - iron and vitamin B12)
 malabsorption
Indications for parenteral preparations:
1. intolerance to oral iron preparations,
2. the need for rapid replenishment of iron (severe IDA, the postoperative period, the last weeks
of pregnancy, recurrent bleeding in hemorrhagic diseases)
3. gastrointestinal diseases (peptic ulcer and duodenal ulcer, ulcerative colitis)
4. malabsorption (sprue, enteritis, chronic pancreatitis, after extensive resection of the small intestine or stomach resection).
Iron preparations, used parenterally:
"Ferbitol" - an aqueous solution of iron-sorbitolovogo complex, 2 ml vial contains 100 mg, administered / muscle, 1 ampoule per day.
"Ferrum-Lek" - contains a tri-iron complexed with maltose, comes in 2 ml ampoule (for a / muscular injection) and 5 ml (in / vennogo), is introduced in 10.0 mL of 0.9% sodium chloride sodium / muscle in a day, in / veno scheme: 1st day - 2.5 ml, 2 nd - 5 ml. 3rd - 10 ml, then 2 times a
week for 10 ml slow.
"Ferkoven" - iron sucrose, cobalt gluconate solution and carbohydrates, 5 ml vial contains 20 mg
of iron and 0.09 mg of cobalt, is entered in / tively, every 10 - 15 days, the first two days of 2 ml,
followed by 5 ml.
"Venofer" - 5 ml vial, enter into / in saline for 1 ampoule per day.
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"Kosmofer" - 2 ml vial, enter into / in saline for 1 ampoule per day.
"Sorbifer" 1 tablet 2 times a day per os.
"Gemofer" 1 tablet 2 times a day per os.
"Totem" 1 ampoule 1 per day per os.
Number of parenteral iron preparation needed for a course of treatment, calculated as follows:
Fe + (mg) = (Hb normal - Hb patient) x body weight (kg) x 0.221 + 1000
Ampoules = Fe + / 100
Ampoules = weight (kg) x (166,7 - Hb, g / L) x 0.004
Iron preparations for systemic effects have happy side effects, which occur in 20% of patients:
 tissue irritation at the injection site
 pain and infiltration at the injection site (with a / muscular injection)
 heart pain
 tachycardia
 allergic reactions
 vomiting
 collapse
 liver hemosiderosis
 phlebitis (at / Venn introduction)
 arthralgia
 myalgia
In the application of these drugs is mandatory control SJ. Parenteral administration of iron is
contraindicated in hemochromatosis, hypertension, II and III level, coronary insufficiency, liver
diseases.
In IDA therapy should carry pathogenic character and, along with the completion of iron deficiency, contribute to the correction of metabolic abnormalities, normalization of hemodynamics,
and to participate in the treatment of associated complications of gestational process. Violation
of one or more links of the mechanism of AOP in the development of hypoxia in patients with
IDA may lead to destabilization of cell membranes and development in them of free radical reactions in response to the administration of certain drugs. This, in turn, could accelerate the destruction of red blood cells and contribute to increasing severity of anemia. The basis of the impact on the pathogenetic links is complex and the use of antioxidant antihypoxants (Actovegin,
vitamin and mineral complex for pregnant "Sana-Sol", ascorbic acid, vitamin E).
Found that iron supplementation of pregnant women with anemia in the presence of increasing
the number of red blood cells and hemoglobin in the general analysis of blood leads to increase
significantly the number of infectious diseases, especially of the urogenital tract (increased risk
of pyelonephritis and obesity).
Low efficiency of the treatment with iron deficiency anemia of chronic disease associated with
the deposition of iron-containing enzymes in inflammation, hemorrhage and around them, as
well as the presence of these pigments in the blood of the arteries and the umbilical cord, in macrophages. Some authors attribute the low efficiency of the treatment of anemia of pregnancy iron
products with the development of placental insufficiency, which further increases the lipid peroxidation, and increased amounts of oxidized iron negative effect on hematopoiesis.
In the combined therapy of anemia of acute pyelonephritis appropriate to include hyperbaric oxygenation. Followed by ferrotherapy makes possible latent iron deficiency. A new drug for the
treatment of anemia is now a product of recombinant erythropoietin.
Several authors of the opinion that the routine prescribing of iron may increase blood viscosity
and leads to impaired placental blood flow, increased fetal weight and the appearance of premature birth. Hemoglobin levels above normal values (more than 144g / l) manifests itself as a sign
of pregnancy complications, and not as an indication of adequate saturation of the body with
iron, because the iron supplements can increase the hemoglobin concentration above the optimum required to maintain oxygen delivery to the tissues
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Of pregnant women with a high risk of anemia and pyelonephritis am bulatornom stage:
Women planning pregnancy, it is recommended to conduct a clinical examination that includes
inspection therapist, urologist, otolaryngologist, dentist, screened for infection, sexually transmitted diseases, to identify hidden pockets of infection in the body.
A necessary component of pregravid for women at high risk of anemia and pyelonephritis should
be considered to determine the level of serum ferritin as an indicator of the most adequate and
adequately characterizes the state reserve of iron in the body, the immune system and the subsequent correction of violations, including the reorganization of foci against the background of antioxidant therapy.
In setting woman on record about the pregnancy for the prevention of anemia, pyelonephritis
pregnancy and related complications at all levels of health care should be the following events:
1) A thorough medical history and identification of groups at risk for:
• Anemia of pregnancy. High risk of developing this disease is possible if you have a history of
uterine fibroids, endometriosis, dysfunctional uterine bleeding, with heavy and prolonged menstrual period, use of intrauterine contraceptive devices, with high parity women, pregnancy occurs with an interval of less than 2 years of age and on the background of lactation. Should be
considered as diseases of the gastrointestinal tract, bleeding diathesis and nosebleeds.
• pyelonephritis during pregnancy. High risk of developing this disease is observed in the presence of cystitis and pyelonephritis in history, especially with frequent recurrences, infection of
the kidneys in a previous pregnancy, for asymptomatic bacteriuria, pathological changes in the
urine.
2) Conduct targeted analysis of complaints and clinical assessment to identify the following
states:
• sideropenic syndrome
• obscheanemicheskogo syndrome
3) Perform the necessary laboratory tests:
a) CBC
b) blood chemistry (serum ferritin, bilirubin, urea, total protein, AST, ALT, electrolytes)
c) Urinalysis
d) analysis of urine Nechiporenko,
e) urine culture on the flora and antibiotic sensitivity on the testimony
f) ultrasound of the kidneys on the testimony
In pregnant women with anemia in combination with pyelonephritis should:
1. Diagnostic measures
1.1.Na early pregnancy to determine the level of serum ferritin and course of the inflammatory
process in the kidneys.
1.2. In the period 26 - 28 weeks of gestation is recommended:
 complete blood count with a certain level of hemoglobin;
 blood chemistry (serum ferritin, protein, glucose, urea, creatinine, bilirubin);
 urinalysis;
 urine on Nechiporenko;
 consulting urologist, physician, dentist, audiologist;
 ultrasound renal indications;
 study of vaginal smears for early revealing of urogenital infections.
2. Medical therapies
2.1.Pri identifying active or latent current infection of the urinary tract during pregnancy prescribing iron is not required when the serum ferritin level of more than 20 mg / l.
The goal of therapy: Renovation of foci of infection with antibiotic treatment step, plant uroseptikov (kanefron, pounding-nyanka, cranberry leaf), correction gemokoagulyatsionnyh, antioxidant-tion and immune disorders.
After the relief of the inflammatory process is necessary to determine the level of serum ferritin.
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In the case of latent iron deficiency (serum ferritin level of less than 20 mg / l) requires ferrotherapy a dose of 120 mg of elemental iron per day for 5-6 weeks.
2.2. In identifying the hemoglobin level less than 110 g / l in women with a high risk of pyelonephritis in pregnancy indicators are normal serum ferritin, more than 20 mg / l to indicate the
need for a deeper examination patsienki to identify latent inflammation in the current the body,
and then (if necessary) holding therapy and the use of antioxidants (vitamin E, 100-150 mg per
day, askorutin 1 tablet 3 times a day for 10-14 days, the vitamin and mineral complex for pregnant and lactating women " Sana-Sol "1 tablet 2 times a day), which contribute to more effective
rehabilitation centers of infection by binding of lipid peroxidation and increased antioxidant status of the organism.
2.3.Beremennye with acute pyelonephritis are at high risk for the development of placental insufficiency and anemia, which requires simultaneous comprehensive treatment.
To normalize the disturbed functions of the body and the mother-relationships of fruit recommended:
1. chimes of 25 mg 3 times a day for 10-14 days
2. metabolic therapy (Actovegin 200 mg per day orally, in the presence of a day hospital in 5.0
ml per 250 ml of 5% glucose solution in a day № 5-7 intravenously with a subsequent transition
to oral medication to 200 mg per day for 3 - 4 weeks, potassium orotate 0.5 g 3 times a day, methionine 0.25 g 3 times a day orally).
3. For the normalization of the structure and function of membranes shows usage Hofitol 2 tablets 3 times a day before meals for 3-4 weeks.
Prophylactic treatment of placental insufficiency in pielone-Frith and anemia in pregnancy is assigned to 12 weeks to 20-22 weeks and 30-32 weeks of pregnancy.
2.4. Hemoglobin level less than 110 g / L and serum ferritin levels less than 20 mg / l in pregnant
women regard as iron deficiency anemia.
Assigned to:
 ferrotherapy a dose of 120 mg of elemental iron for 3 to 4 weeks, followed by the transition to
a prophylactic dose of 30 - 40 mg for 4 weeks
 Folic Acid 400 mcg
 chimes 0,025 g 3 times a day for 14 days
 vitamin and mineral complex for pregnant women ("Sana-Sol" 1 tablet 2 times a day, "Gravitus" 1 tablet a day, "Materna" 1 tablet per day)
2.5. Pregnant with hidden iron deficiency in hemoglobin level of more than 110 g / L and serum
ferritin less than 20 mg / l for the prevention of anemia are assigned:
 iron supplements at a dose of 100 mg of elemental iron for 3 - 4 weeks
 folic acid is 400 micrograms per day
 askorutin 1 tablet 3 times a day for 14 days
 vitamin and mineral complex for pregnant and lactating women ("Sana-Sol", "Materna,"
"Gravitus")
After treatment - monitoring of serum ferritin and hemoglobin.
2.6. Reduction of hemoglobin less than 70 g / dL and hematocrit less than 20% are regarded as
severe anemia complicating pregnancy. Red blood cell transfusions performed only for health
reasons, taking into consideration the gestational age, condition and patient hemodynamic parameters (for the rapid elimination of fetal distress and the mother before the birth). The purpose
of blood transfusion is not an increase in hemoglobin levels to normal, and improvement.
Indications for blood transfusion:
1. severe anemia
2. moderate anemia in the absence of treatment effect
3. hemodynamic instability (tachycardia, hypotension)
4. combination of severe and moderately severe anemia with preeclampsia
5. bleeding during anemia
142
Alternative to blood transfusion in severe iron deficiency anemia, resistance to monotherapy
with iron is the use of recombinant human erythropoietin (Eritrea, Eprex, elreks) for intravenous
and subcutaneous administration permitted for clinical use in pregnant and postpartum women.
2.7. Criteria for the adequacy of the treatment:
1. reticulocyte level rise by 5 to 8 days of treatment (this criterion can not be used to initially increased levels of reticulocytes by chronic blood loss)
2. rise in hemoglobin levels to the third week and the normalization at 5-8 weeks of treatment.
3. normalization of serum ferritin levels (more than 20 mg / l)
4. improve the overall pregnancy
Conclusion:
Evaluation of hematological parameters in pregnant women, comprising schaya determination of
serum ferritin, allows to differentiate iron deficiency anemia and anemia of chronic disease,
which allows an individual approach to treatment and prevention of anemia in pregnant women.
The combination of extragenital pathology such as anemia and pyelonephritis during pregnancy,
requires a differentiated approach to the treatment and prevention of these complications of
pregnancy.
Differentiated approach to the appointment of iron contributes to reduce the frequency of acute
pyelonephritis in pregnant women during gestation and at delivery, susceptibility to acute respiratory viral infections, as well as reducing the incidence of pregnancy complications such as
threatened miscarriage, early gestosis, chronic intrauterine hypoxia, development weakness of
labor in childbirth, a cleaner newborns.
Individual approach to appointing zhelezozamestitelnoy therapy is based on assessment of iron
stores in pregnant women leads to the abandonment of routine appointment ferrotherapy all
pregnant without specific features.
Early detection and warning pregravid period anemic states, more complete coverage of pregnant
women at risk for this disease and the identification of effective management of treatment with a
combination of anemia of chronic foci of infection in the mother will reduce the incidence of
complications of pregnancy, labor and perinatal pathology.
The use of new educational technologies:
METHOD "black box"
The method provides for joint activities and active participation in a-nyatiyah each student, the
teacher works with the whole group.
Each student gets from a "black box" unknown drug, brief annatatsiya is written on the cards.
(Options annotations attached). Students should determine the drug in detail justifying your answer.
To think about the student is given 3 minutes. The response is then discussed, given supplement
on pharmacodynamics, pharmacokinetics.
This methodology promotes student speech, formation oc-new critical thinking, because In this
case, the student learns to defend their opinion,
analyze responses band members participating in this contest.
Options for abstracts:
1.Opredelit drug: drug, ferric iron complexed with maltose, stimulates erythropoiesis. Available
in the form of tablets and capsules for parenteral administration. (Ferrum-lek-amp. 2 ml)
2.Opredelit medicine: antibiotic belonging to the group of penicillins, can be administered to
pregnant women with pyelonephritis. Available in tablets and vials for a / m. (Baktoks 0.5 and 1
g)
3. Determine the drug: antibiotic belonging to the group of penicillin combined with clavulanic
acid, admitted in pyelonephritis during pregnancy. Available in tablets and vials for / in the introduction. (Amoxiclav 0.6 and 1.2 g)
4. Determine the drug: antibiotic belonging to the group of third generation cephalosporins, admitted in pyelonephritis during pregnancy. Available in vials for I / O and a / m. (Ceftriaxone 1.0
g)
143
5. Determine drug: drug based on herbal medicinal herbs have antibacterial properties and
uroseptic authorized for use in pyelonephritis during pregnancy. Available in tablets. (Kanefron)
6. Determine the drug: antibiotic belonging to the group of hydroxyquinoline Permitted pyelonephritis pregnant in 2-3 trimester, which also has a small anti-fungal properties. Available in tablets.
(Nitroxoline syn. 5 - NOC)
Working in small groups
The steps are:
1. Previously students are given time to prepare questions on the passed occupation.
2. The teacher divides the students into 3 small groups. To do this, students are called 3 flowers.
Same flowers attached to one group.
3. Students are asked to engage in the passed. For example: The causes of the anomalies of labor
and allow time for preparation.
4.Kak group will perform this task quickly and correctly, that this group pooscheryayut
6.2Analiticheskaya part
Case studies:
1. Primigravida 27 years, gestational age 28-29 weeks turned into MRAs with complaints of
back pain over the right, chills, fever up to 38-39 C. Uterus normotonuse, longitudinal position
of the fetus, predlezhit head clear rhythmic fetal heartbeat 145 bpm. in min. From the genital
tract not. Sign Pasternatskogo positive right. No edema. A / D 120/80. In the urine of a large
number of white blood cells. The diagnosis? Tactics doctor SVP.
A: Diagnosis: Beremennost1 28-29 weeks. Acute pyelonephritis
Tactic to hospital to hospital.
2. Multigravida 30 years, gestational age 32 weeks taken by ambulance to the hospital with complaints of pain in the lower back but on the left, chills, fever up to 38 C, dizuricheskie phenomenon, swelling of face and hands, feels sick for three days, a history of chronic pyelonephritis.
Uterus normotonuse, longitudinal position of the fetus, predlezhit head, fetal heartbeat muffled
rhythmic 155 bpm. in min. From the genital tract not. Sign Pasternatskogo strongly positive to
the left, slightly positive on the right. A / D 120/80. Blood tests: hemoglobin 92 g / l, in a large
number of urine leukocytes. The diagnosis? Your tactics. What vozmozhnve complications?
A: Diagnosis: Beremennost2 32 weeks. Chronic pyelonephritis in the acute stage. Anemia 1
tbsp.
Tactic to hospital in intensive care. Start therapy include: Antibiotics penicillin or cephalosporins, uroseptiki, antispasmodics, and desensebiliziruyuschuyu detoxication therapy, and a parallel
treatment of anemia with parenteral preparations.
Possible complications: sepsis, renal failure, intrauterine infection, feto-placental insufficiency,
fetal hypoxia, abortion.
3.In the delivery room came multiparous 38 weeks in the first stage of labor. From history during
2 days at home marked the pain area, raising the temperature to 37.5 C, dizuricheskie phenomenon, leading to swelling face in the morning with a history of chronic pyelonephritis. Uterus
normotonuse, longitudinal position of the fetus, predlezhit head, fetal heartbeat muffled rhythmic
150 bpm. in min. From the genital tract not. At the time of the inspection body temperature 37C
symptom Pasternatskogo positive with 2 sides. A / L 110/70. in the urine of a large number of
white blood cells, the protein is not present. The diagnosis? Your tactics. What are the possible
complications in childbirth and the postpartum period?
A: Diagnosis: Beremennost2 38 weeks. Births January 2nd stage of labor. Chronic pyelonephritis in the acute stage.
Tactics: Childbirth be managed conservatively, against antibiotics, antispasmodics, desensebiliziruyuschey and detoxification therapy, and to monitor the condition of the fetus.
Possible complications: septic shock, renal failure, intrauterine infection, PONRP, fetal hypoxia.
In the early postpartum hemorrhage. In the late postpartum subinvolution uterus, endometritis,
sepsis.
144
4. Primigravida 20 years, gestational age 28 weeks turned to hovercraft with complaints of fatigue, weakness, dizziness, flickering "fly" before the eyes, drowsiness during the day and insomnia at night, reduced efficiency, irritability, tearfulness. On examination, pallor of the skin,
light yellow hands and nasolabial triangle, shortness of breath, tachycardia, and sometimes
adults, systolic murmur at the apex of the heart and into the pulmonary artery projection point,
voiceless heart tones. A / D 100/60mm Hg, pulse of 78-88 beats / min. T 36.6. Blood tests: hemoglobin 70 g / l. The diagnosis? Tactics doctor SVP. What are the possible obstetric complications?
A: Diagnosis: Beremennost1 28 weeks. Heavy anemia degree.
Tactic to hospital to hospital. In a hospital-doobsledovat, clarify cause and type of anemia, lead
pregnant with hematologist. In therapy include ferropreparaty parenteral administration, a vitamin, antioxidant and anti-hypoxic therapy.
Possible obstetric complications: Feto-placental insufficiency, PONRP, intrauterine fetal hypoxia
and malnutrition, interruption of pregnancy.
5. Primigravida 22 years, gestational age 19 weeks turned to hovercraft with complaints of
weakness, dizziness, decreased performance. On examination, satisfactory condition, marked
pallor, A / D 110/70mm Hg, pulse 76 beats / min. T 36.6. Blood tests: hemoglobin 98g / l. The
diagnosis? Tactics doctor SVP.
A: Diagnosis: Beremennost1 19 weeks. Anemia 1st.
Tactics: Can outpatient treatment. Should be advised ferropreparaty oral vitamin, diet, to respect
the day, reduced workloads.
6.3. Graphic organizer: Making graphic organizer
Hierarchical chart "How to" on "Asymptomatic bakteruriya"
HIERARCHICAL GRAPH "How?"
Is a logical chain of questions, which gives an overview of the ways and means of solving the
problem.
Develops and activates the system, creative, analytical thinking.
6.4.Prakticheskaya part
Determination of intrauterine fetal weight.
Int: Develop students' skills determine the approximate weight of the fruit.
Performs step (steps):
Events number does not hold nil
(0 points) Fully
correctly
performed
(20 points)
1. To perform this skill are needed: a couch for inspection pregnant measuring tape. 0 20
2. Pregnant due to the nature of the ma-manipulations 0 20
3. Pregnant laid on the couch in the "back" 0 20
4. Measuring tape at the navel is defined abdominal circumference (eg 96cm).
Measuring tape on the level of the womb to the level determined by the height of the uterine
fundus of the uterus (eg 37cm) 0 20
5. Two values obtained multiply-ble determined the approximate weight of the fruit in grams + /
- 100-200g, depending on the thickness of the anterior abdominal wall. (Example: 96 * 37cm =
3360gr) 0 20
Total 0100
7.Formy control of knowledge, skills and abilities
-Oral;
-Alphabet;
Testing;
Solution situational problems;
And demonstration of skills mastered.
145
8.Kriterii assessment monitoring
Number suc-BAE-bridge
Score in% level of students' knowledge
1 96-100% Excellent
"5" full correct answer to the questions on the etiology-ology, pathogenesis, classification, clinic, diagnostics, treatment and prevention of this disease. To sum up and make decisions, creative
thinking, self-analyzes, case studies resolves correctly, with a creative approach, with full justification of the answer. Actively and creatively involved in interactive games, take the right decisions and summarizes and analyzes. Medical history, the party-gram fills correctly.
2 91-95% Excellent
"5" full correct answer to the questions on the etiology-ology, pathogenesis, classification, clinic, diagnostics, treatment and prevention of this disease. Creative thinking, self-analyzes, case
studies resolves correctly, with a creative approach, with full justification of the answer. Actively
and creatively involved in interactive games, take the right decision. Medical history, filled with
1 partograph grammatical errors Coy.
3 86-90% Excellent
"5" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis, treatment and prevention of the disease covered completely, but have 1-2 errors in the response. Self-state analyzes, inaccuracies in solving situational problems, but with the right approach. Actively involved in interactive games, make the right decisions. Medical history, partograph fills with 2-3 grammatical errors.
4 81-85% Good
"4" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis,
treatment and prevention of the disease covered completely, but there are 2-3 inaccuracies, errors. Application exists in practice, understands the essence of the question, says confidently, is a
faithful representation. Situational problems solved correctly, but the justification answer sufficiently. Actively involved in interactive games, take the right decision. Medical history, partograph fills with 2-3 grammatical errors, inaccuracies in the description.
5 76-80% Good
"4" Correct, but incomplete coverage of the issue. Stu-dent knows the etiology, pathogenesis,
classification, clinic of the disease, but not completely disassembled diagnosis, treatment and
prevention of this disease. Understands the issue, distribution predicts confidently. There is an
exact representation. Actively participate in the games. On case studies gives partial solutions.
Medical history, partograph fills with 3-4 grammatical errors, inaccuracies in the description.
6 71-75% Good
"4" Correct, but incomplete coverage of the issue. Stu-dent knows the etiology and pathogenesis
of this disease, but not completely disassembled diagnostic les chenii and prevention of the disease. Pony ripped apart the matter, said confidently, is a faithful representation. On case studies
gives partial solutions. Medical history, the party-gram filled with 3-4 grammatical errors, 3-4
errors in the description.
7 66-70% satisfactory solution is without foundation
"3", the correct answer to a half set of issues. Student knows the etiology of the disease, but do
not pay out the classification of the disease clinic, confused in the treatment and prevention. Understands the issue, said with confidence is accurate representations only by a separate question
topic. Case studies re-sheny true, but there is no justification answer. Medical history, filled with
3-4 partograph grammatical error-tion, 3-4 errors in the description.
8 61-65% satisfactory solution is without foundation
"3", the correct answer to a half set of issues. Errors in the etiology, pathogenesis, poorly versed
and confused in the treatment and prevention of this disease. Says uncertainly, has the only
views on certain issues topic. Making mistakes in solving situational problems. Medical history
and partograph fills with errors.
9 55-60% satisfactory solution is without foundation
146
"3" error response by half set of issues. Student makes an error in the etiology of the diseasedanno, confused and poorly versed in other matters related to the disease. Ras predicts uncertainly has a partial representation of the topic. Situational problems solved incorrectly. Medical history and partograph fills with errors.
10 50-54% Unsatisfactory-vletvori-state "2" The correct answer is 1/3 of the questions. Student
does not know the etiology of the disease, and poorly versed entangled in other issues related to
the disease. Situational problems solved correctly if the right approach. Medical history and partograph fills with errors.
11 46-49% Unsatisfactory-vletvori-state "2" the correct answer to one fourth of the questions.
Student does not know the etiology of the disease, and poorly versed entangled in other issues
related to the disease. Situational problems solved correctly if the right approach. Medical history and partograph fills with errors.
12 41-45% Unsatisfactory-vletvori-state "2" Lighting fifth of the questions with errors. Student
does not know the etiology of this disease, little versed in other matters related to the disease.
Gives an incomplete and partially incorrect answers to questions on the classification of the clinical disease. Situational problems solved correctly if the right approach. More than half of the
patient's history and the partograph filled with errors.
13 36-40% Unsatisfactory-vletvori-state "2" Lighting 1/10 of the questions in the wrong subcourse. Does not know the etiology of the disease, and poorly versed entangled in other issues
related to the disease. Gives an incomplete and partially incorrect answers to questions on the
classification, clinic of the disease. Situations-tional problems are solved with the right approach
is wrong. Bole half medical history and partnership gram fills with gross errors.
14 31-35% Unsatisfactory-vletvori-state "2" to the questions not answers. Knows and-etsya proceedings on other issues relating to this illness, either. Does not know how to fill out and describe the history of the disease and the partograph.
9. Typical flow chart of lesson
Stages of work, time-name The content of the
Teachers Students
1etap. Introduction to the training session
(5min) 1.1.Soobschaet topic, purpose, and planned training results. Familiar with the plan, features of the training session.
1.2.Nazyvaet: key categories and concepts from the data subject tion, a list of books for selfstudy
1.3.Soobschaet indicators and criteria of educational work in class
Listen, record,
specify, ask the question.
Stage 2.
Primary
(235 min) 2.1.Provodit updating knowledge through блиц-опроса/вопросно-ответной forms /
brainstorming, etc.
2.2. Consistently describes the steps
on the organization of the educational process according to the structure of practical training.
Meet
Abstracts with ethyl.
Working in groups, will present the results of the group work
Stage 3.
The Final-Resultant-regulating (60 min)
3.1.Delaet opinion on the subject, attention was concentrated on the main students, according to
the importance of the work done for future careers.
3.2. Commends the work of groups (some of students) summarizes vzaimootsenki. Analyzes and
evaluates the degree of achievement of lesson.
3.3. Gives the task for independent work, informing schaet and criteria evaluation. Self147
evaluation,
interaction assessment.
Ask the question.
Write down the job.
10.Kontrolnye questions
1. List the predisposing factors in the development of renal disease in pregnancy?
2. Pyelonephritis during pregnancy.
3. Treatment of pyelonephritis in pregnancy.
4. Obstetric Management of pyelonephritis.
5. List the predisposing factors of anemia in pregnancy-tion.
6. What is asymptomatic bacteriuria?
7. Etiology, diagnosis, treatment of asymptomatic bacteriuria?
8. What are the classification of anemia in pregnant women.
9. Diagnosis of anemia in pregnant women.
10. List the basic principles of treatment of anemia in pregnant women.
11. List the oral iron preparations.
12. List parenteral iron preparations.
13.Nazovite possible complications of pregnancy anemia.
14.Prognoz to the fetus and newborn in pregnancies complicated by anemia and kidney disease.
11. Recommended Reading
Summary:
1. Abramchenko, VV Epidural anesthesia in obstetrics: a guide for physicians / 2006. - 229 p.
2. Abramchenko, VV Pregnancy and delivery of high risk: a guide for physicians / - M. Med.
Inform, 2004. - 400 p.
3. Abramchenko, VV Cesarean section in perinatal medicine: a guide for physicians / 2005. 126.
4. Abramchenko, VV Postoperative intensive care in obstetrics / Literature, 2000. - 88.
5. Abramchenko, VV Pharmacotherapy of preterm labor / 2006. - 448.
6. Abramchenko, VV Purulent-septic infection in obstetrics and gynecological logii.rukovodstvo
/ 2005. - 459
7. Abramchenko, VV Postoperative intensive care in obstetrics / - St. Petersburg: Spec. Literature, 2000. - 88.
8. Abramchenko, VV Clinical perinatology / IntelTek, 2004. - 424 p.
9. Ailamazyan, EK Midwifery: a textbook for honey. Universities / 2003 - 528.
10. Topical issues of Obstetrics, Gynecology and Reproductive / Ed. EV KOKHANEVICH. Moscow: Triad-X, 2006. - 480.
11. Obstetrics. Ed. GM Savelyeva. - M.: Medicine, 2000. - 816 p.
12. Obstetric and gynecological care: Hands-on. for doctors / Ed. VI Kulakov. - Moscow:
MEDpress, 2000. - 512 p.
13. Obstetrics. Clinical lectures: a manual for schools with a CD / Ed. OV Makarova. - Moscow:
GEOTAR Media, 2007. - 640.
14. Obstetrics. Directory of the University of California / Ed. Nisvandera K., A. Evans: Lane.
from English. - M.: Practice, 1999. - 704 p.
15. Barashnev, YI Perinatal neurology / Y. Barashnev. - M.: "Triad - X", 2005. - 670 p.
16. Bodyazhina, VI Akushersvo. The manual for the media. prof. Education / VI Bodyazhina. Rostov-on-Don: Phoenix, 2003. - 480.
17. Resurrection, SL Fetal assessment. CTG. Doplerometriya. Biophysical profile: a manual for
the system of postgraduate medical. Education / SL Resurrection. - Minsk: The Book House,
2004. - 304.
18. Gazhonova, VE Ultrasound in Gynecology / VE Gazhonova. - Moscow: MEDpress-inform,
2005. - 264.
19. Gluhovets, BI Ascending infection of placental / BI Gluhovets. - Moscow: MEDpress148
inform, 2006. - 240.
20. Humeniuk, EG Obstetrics: Physiology of pregnancy: a training ben-beats / EG Humeniuk. Petrozavodsk: IntelTek, 2004. - 170 p.
21. Demidov, VN Pelvic ultrasound in women. Adnexal cysts and benign ovarian tumors: a practical guide / V. Demidov. - Moscow: Academy of Medical Sciences, 1999, vol. II. - 100 p.
22. Duda VI Obstetrics: a textbook for high schools in the specialty "General Medicine" / Minsk: High School, 2004. - 639 p.
23. Duda VI Physiological OB / - Minsk: 2000. - 447 p.
24. Duda VI Operative obstetrics: a manual / Minsk Interpresservis, Book House, 2002. - 512 p.
25. Zhilyaev, NI Obstetrics: phantom course / - Kiev, 2002. - 239 p.
26. Zhilyaev, NI Operative Obstetrics: Ouch. Manual / Kiev 2004. - 468 p.
27. Zhilyaev, NI Operative surgery in obstetrics and gynecology / 2004.
28. Selected lectures on obstetrics and gynecology / Ed. AK Strizhakova etc. - Rostov-on-Don:
Phoenix, 2000. - 512 p.
29. Clinical recommendations. Obstetrics and Gynecology: scientific publication / Ed. VI Kulakov. - Moscow: GEOTAR Media, 2006. - 512 p.
30. Clinical lectures on obstetrics and gynecology / Ed. AN Strizhakova etc. - M.: Medicine,
2000. - 379 p.
31. Clinical evaluation of laboratory tests in women: study guide / Moscow Medical and Dental.
University. NA Semashko. - M: 2005. - 96 p.
32. Kulakov, VI Preterm birth / VI Kulakov, LE Ants. - M.: Medicine, 2002. - 176.
33. Kulakov, VI Intensive care in obstetrics and gynecology (efferent methods) / - M: MIA,
1998. - 206 p.
34. Drugs used in obstetrics and gynecology / Ed. Acad. RAMS VI Kulakov, Acad. RAMS VN
Serov. 2006. - 375 p.
35. Emergency care in obstetrics and gynecology. Quick Guide - M. GEOTAR - Media, 2007. 52.
36. Perinatology Basics: A tutorial / Ed. MP Shabalov. - Moscow: MEDpress-inform, 2002. 576 p.
37. Practical skills in obstetrics and gynecology: a manual / LY Suprun, TS Divakova and others.
- Minsk: New Knowledge, 2002. - 166 p.
38. Rational pharmacotherapy in obstetrics and gynecology: Hands-on. for practitioners / Ed. VI
Kulakov, VN Serov. - M.: 2005.
39. Guide Out - patient care in obstetrics and gynecology / Ed. VE Radzinsky. M: GEOTAR Media, 2007.
40. Guide to practical training in obstetrics / Ed. VE Radzinsky. - M.: MIA, 2004. - 576 p.
41. Saveliev, GM Obstetrics: a textbook for schools / GM Savelyev, RI Shalina. - Moscow: GEOTAR Media, 2008. - 656 p.
42. Sidelnikov, VM AG Antonov Premature birth. A premature baby / VM Sidelnikov, AG Antonov. -M. "GEOTAR" 2006.
43. Smirnov, A. Pregnancy without problems / AN Smirnov. - Moscow: Atris Press, 2002. - 208.
44. Smirnov, LM Obstetrics and Gynecology: Textbook / LM Smirnov. - M.: Medicine, 1999. 368 p.
45. Handbook of obstetrics, gynecology and perinatology: uch.posobie for doctors / Ed. GM
Savelevoy.2006. - 720.
46. Trifonov, E. Obstetrics and gynecology: a manual for med._vuzov / EV Trifonov. - Moscow:
VLADOS, 2005. - 175 p.
47. Filippova, GG Psychology of motherhood: a manual / GG Filippov. - Moscow: Publishing
House of the Institute of Psychiatry, 2002. - 240.
48. Chernukha, EA Prolonged and prolonged pregnancy. Guide for Physicians / EA Chernukha. M.: "GEOTAR - Media", 2007. - 207.
49. Chernukha, EA TK Puchko breech presentation. Guide for Physicians / EA Chernukha, TK
149
Beam. - M.: "GEOTAR - Media", 2007. - 173 p.
50. Shmagel, KV Immune pregnant women / KV Shmagel, VA Cherries. - Moscow: Medical
Book, 2003. - 226 p.
51. Tskhai, VB Perinatal obstetrics: a manual for honey. Universities / VB Tskhai. - Atlanta:
Med. Academy of RAMS, Moscow, Honey. book, 2003.
52. Amniotic and extraembryonic structures in normal and complicated pregnancy / Ed. VE
Radzinsky. 2004. - 393 p.
53. Congenital, perinatal and neonatal infections: Per. from English. / Ed. A.Grinou, J. Osborne,
S. Sutherland. - M.: Medicine, 2000. - 287.
54. Kulakov VI, Murashko LE Premature birth. M. Medicine, 2002.
55. Serov VN etc. Eclampsia: A Guide for Physicians / V.N.Serov etc. - M.: MIA, 2002. 463 with
56. VM Sidelnikov Habitual loss beremennosti.-M.: Triad-X, 2002.
57. Disseminated intravascular coagulation in obstetrics AD Makatsaria etc. - M.: Triad-X, 2002.
- 496.
58. Schechtman, MM, GM Burduli Diseases of the respiratory system and blood circulation in
beremennyh.-M.: Triad-X, 2002. - 230C.
59. Shifman EM Pre-eclampsia, eclampsia, NELLP syndrome / Inteltek, 2002.
More:
60.Uchebnoe grant for the development of practical skills surgical / Edited by prof. Atalieva AE,
prof. Babadjanova BD Tashkent 2003. C102-115
61.Algoritmy diagnosis and treatment of surgical / Edited by Academician Karimov
Sh.I.Tashkent 2003. From 39-64
62.Uchebnoe benefit surgical subjects for medical students / Edited by Academician Karimov
Sh.I.Tashkent -2003 Part II Obstetrics and ginekologiya.S 64-19013. Practical skills in obstetrics
and gynecology / Metod.posobie / / Tashkent 2008.
63.Akushersky soft tissue injuries of the birth canal, Kulakov VI, Butova E.A.2004.
64.Akusherstvo. National rukovodstvo._2004.
65.Infektsii in Obstetrics and Gynecology How VK Seagull 2006
66.Hirurgicheskaya technique cesarean secheniya_Strizhakov A.N._2007.
67.Ratsionalnaya pharmacotherapy in obstetrics and ginekologii.2007
Chan_Gynecology_and_obstetrics.2004
68.Rukovodstvo for outpatient care in obstetrics and gynecology, Kulakov V.I.2005.
70.Sidorova_I.S._Rukovodstvo_po_akusherstvu_ (Medicina, 2006) (ru) (1033s
71.Posobie for practical development of Obstetrics Voronin (KV) 2007.
72.Kirienko AI, Matyushenko AA, Andriyashkin VV Ostryi tromboflebit/2005
AN 73.Ivanyan - Intrauterine growth ploda/2007
74.DVS_sinrom _v_akusherstve.2004
75.Neonatologiya (Bazhanov NP). - T. I. - 2004
76.Prikaz MZ № 500 "On the reorganization of maternity hospitals to improve the efficiency of
perinatal care and the prevention of nosocomial infections."
77.Partogramma/Sherbaeva DB, Ayupova FM, FI Shukurov / Metod.rekomendatsii. Tashkent2005. 28C
78.Uchebnaya birth history / Sherbaeva DB, Ayupova FM, FI Shukurov / Metod.rekomendatsii.
Tashkent-2005. 13C
79.Prakticheskie skills in obstetrics and gynecology / Me-tod.posobie / / Tashkent 2008.
80.Internet sites:
http://www.studmedic.narod.ru/, http://med.siteedit.ru/,
http://www.rukovodstvo-po-akusherstvu.-uchebnoe-posobie.html, http://www.materinstvo.ru,
http://mama.ru.http://www.art-med.ru,, http://www.doctor.ru, http://www.rodim.ru,
http://mamka.ru
http://medagent.ru, http://www.art-med.ru, http://www.medsan.ru,
150
http://mediki.spb.ru, http://medinstitut.e2e.ru, http://www.medstudy.narod.ru
http://www.obgyn.ru, http://www.medsno.ru, http://medrusnet.euro.ru
www.medtext.ru, www.medpoisk.ru, www.medicum.nnov.ru/student/
http://6years.net/, http://preryvanie-beremennosti.pharmabort.ru/
http://med4net.ru/, http://www.med-life.ru/, http://www.pregnant.ru/
http://www.roddom.ru, http://www.medpoisk.ru/, http://www.medlinks.ru
Topic: The role of the Rh factor in obstetrics. Pathophysiology isoimmunization.
Hemolytic disease of the fetus and newborn. Jaundice of the newborn, diagnosis and
treatment. Indications and methods of immunization
1st place of training, equipped
 Department of Obstetrics and Gynecology, the audience;
 dummy pelvis, female pelvis, doll fetus;
 standard models of pregnancy;
 the classic model of labor;
 gynecologic simulator ZOE;
 childbirth simulator Noelle;
 simulator newborn Newborn;
 set of slides on the topics of discipline, slaydoskop;
 methods work in small groups: the method of the incident, "dark horse", problem-solving,
"swarm", "handle on the middle of the table", etc.;
 testing and teaching practical skills in OSKE (objective structured clinical examination).
 personal computer (Pentium-III);
 set of video blogs "VJOG" (USA), highlighting recent advances in diagnosis and treatment
of obstetric and gynecological conditions;
 set of videos and films demonstrating the typical obstetrician-cal and gynecological procedures and operations.
 video, TV, TV:
 multi media training and testing;
 the use of e-mail and INTERNET;
 center for skills training;
 offices and laboratories maternity complex;
 delivery room;
 set of tests;
 postpartum room and Commerce;
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 intensive care unit and neonatal intensive care;
 fake NOELLE with test software;
 handout that includes a table of classification, hemolytic disease of the newborn and the fetus, treatment regimens, the list of preventive medicines and annotations to them, indications
for operative delivery, the antibodies can cause neonatal jaundice:
 step-blood type and Rh factor, options detailed analyzes of blood and urine;
 prototype history pregnant with this condition;
 ultrasound markers SBP;
 diagram of the main stages of the diagnostic process.
2.Prodolzhitelnost study subjects
Number of hours, 5 hours
3.Tsel classes
 The general concept of the Rh blood factor, provide information about when and by whom
was first discovered the Rh factor;
 introduce the immunology of Rh immunization, rhesus conflict and jaundice;
 give an idea of how immunization during pregnancy, childbirth, the postpartum period;
 give an idea of newborn jaundice, consider a classification of hemolytic disease, the criteria
for severity;
 to introduce the modern types of antenatal and post-natal diagnosis of jaundice;
 learn tactics for pregnancy, childbirth, postpartum and post-abortion period in immunized
women;
 learn the tactics of pregnancy and childbirth are not immunized-tion of women;
 consider the tactics of treatment of neonatal jaundice;
 study prevention of Rh immunization.
Tasks
The student should know:
 study of blood groups;
 neutralizing the function of the liver;
 epidemiology to the problem;
 etiology isoimmunization;
 etiopathogenesis of hemolytic disease of the fetus and newborn (HDN and SBP);
 questions antenatal and postnatal diagnosis;
 different treatment of the fetus and newborn;
 indications for antenatal and postnatal prevention of isoimmunization of Rh-factor.
The student should be able to:
To collect anamnesis, inspect pregnant evaluate data studies (ultrasound, cardiac monitoring,
numbers of bilirubin, Hb and Ht newborn), to determine the blood group and Rh affiliation,
diagnosis, and choose the best time and method of delivery for different severity SBP, while
amniocentesis According to the antibody titer in the blood of the mother and or a history, determine the amount of input the anti D-Rh-globulin depending on the time of termination of
pregnancy, management of pregnant women to know in terms of clinic and hospital, prescribe treatment.
4.Motivatsiya
Clinical management of pregnancy, childbirth, postpartum and post-abortion period in Rhnegative women today continue to be a very important issue. The urgency is treated a lot of
complications, such as miscarriage, non-developing pregnancy, severe toxicosis, bleeding in
the second half of pregnancy and childbirth, hemolytic disease of the fetus and newborn. Early diagnosis and prevention is one of the primary stages of care, which is vested in the doctor's first link.
Intra 5.Mezhpredmetnye and communication
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Early diagnosis, timely prevention isoimmunization, the correction of this condition is a priority for medical care, not only obstetric areas, but a number of related fields, such as pathophysiology, hematology, internal medicine, neonatology, etc. The importance of the study of
this disease in the extended scale, together with the related professions due to involvement in
the pathological process of vital organs pregnant, as the liver, kidneys, and even a successful
outcome of pregnancy requires further prevent isoimmunization. For example, after the birth
of a pregnant determine the presence and titer of antibodies in the blood. Given the urgency
of the problem, it is necessary to educate students etiopathogenetic OS novam this pathology,
classification, methods of antenatal and postnatal diagnosis, in the identification of blood
group and Rh accessories pregnant, teach the basic principles of intensive care HDN. In
preparation for the lesson, students should be aware of the blood, blood biochemistry, physiology and pathophysiological changes in liver function, to be able to determine the blood
type and Rh factor, the physiology of the neonatal period.
Teaching of the subject is based on the knowledge of students the basics of anatomy, histology, normal and abnormal physiology, endocrinology. Acquired during the course knowledge
will be used during the passage of hematology, internal medicine, surgery, pathological obstetrics, gynecology, and pediatrics.
6.Soderzhanie classes
6.1.Teoreticheskaya part
Obstetricians have long been aware of the disease (familial jaundice) newborns, involving
jaundice, often resulting in death. However, the cause and pathogenesis of hemolytic disease
became known only in 1940, when American scientists K. Landsteiner and A. Wiener protein factor found in red blood cells that have antigenic properties. These scientists, the experiment showed that the red blood cells of monkeys (rhesus macaque), when administered to
rabbits caused the latter antibody. Antigen-antibody reaction, as expressed in the agglutination was detected in 15% of people. In the general population such antigen, called D-factor,
Rh (Rh0), contained in red blood cells, and may be in leukocytes, platelets and other cells of
the tissues. Subsequently, it was shown that, in addition to the Rh factor in red blood cells
can be detected and other antigens, which differ from each other, - C (Rh /) and E (Rh / /).
Features of each type Rh is in response to the administration of a blood type Rh-specific serum agglutinins develop appropriate. Serum anti-Rh0 gives 85% of the positive responses,
anti-Rh / - 70%, anti-Rh / / - 30%. Rh-types occur individually or in combination with each
other. Most often erythrocytes YaV-lyayutsya carriers two or three antigens. Of the three
types of Rh factor of the greatest practical importance is the type Rh0, because it has a
stronger antigenic properties. In essence, the blood is Rh-negative only when it lacks all 3
types of Rh factor. Complexity of the system is caused by a large number of Rh mutations of
each gene. The presence of the Rh factor is not related to group affiliation, gender or age of
the person. One feature of the Rh factor is its demise.
Properties of Rh antibodies. First antibodies in the mother's blood, gave birth to a dead baby,
found a talented scientist and physician Philip Levine - comes from Russia, 25-year-old medical doctor. Scientists have suggested that the reason for this is the fruit antigen inherited
from the father. In the years 1944-1946 Wiener and Reyes opened the presence of 2 types
Rh-antibodies: blocking and agglutinating.
Proof of immunization of human Rh factor is the presence of his blood serum of Rh antibodies. However, the absence of Rh antibodies are not always an indication of a lack of immunization. There is the assumption that, in such cases, the antibody fixed cells of the reticuloendothelial system.
There are 3 types of Rh antibodies: agglutinating blocking and hidden. Agglutinating antibodies give visible agglutination with Rh-positive red blood cells of the same name, or null if
they are suspended in serum albumin, gelatin (blocking antibody) or a suspension of red
blood cells in saline (total antibody). By means of blocking antibodies are antibodies that do
not give a visible agglutination. Hidden call these antibodies, which are only detected at a di153
lution of serum AB. Blocking antibodies, without giving visible agglutination, block red
blood cells. With a lower molecular weight than the agglutinating antibodies, they can easily
pass through the placenta and are important in the pathogenesis of HDN.
Pathogenesis of Rh immunization during pregnancy. Basis izoserologicheskoy blood incompatibility of mother and fetus is antigenic heterogeneity of their factors of red blood cells,
usually in rhesus, rarely in the ABO system. Due to the penetration of the fetal factors that
have antigenic properties in mother's bloodstream, which they do not exist in her body produces alloimmunnye antibodies that penetrate through the placenta to the fetus, and in his
body, thus causing antigen-antibody reaction. Such a reaction causes agglutination and hemolysis of fetal red blood cells, anemia, education indirect bilirubin - to hemolytic disease of
the fetus and newborn (HDN and SBP).
Hemolytic disease of the fetus and newborn may develop also in blood incompatibility of
mother and fetus in AB0. A and B antigens of the fetus can penetrate during pregnancy in
mother's bloodstream, leading to the development of immune α-and β-antibodies, respectively, and the development of fetal antigen-antibody reaction (Aα, Vβ). In this immunological
incompatibility manifested in the event that the mother 0 (I) blood and the fetus - A (II) or B
(III).
Rh-immunization, pregnancy-induced, begins with the formation of the Rh factor in red
blood cells of the fetus. Rh factor appears at the beginning of fetal blood in the liver and peripheral blood entering the enucleated erythrocytes. Rh factor is formed in the early stages of
pregnancy (according to some, starting with 3-8 days of pregnancy), fetal red blood cells in
the blood of pregnant women can occur during the term of 6-8 weeks. Duration of red blood
cells circulating in the bloodstream of the fetus the mother is not certain, but we know that
abortion in early pregnancy, including ectopic pregnancy contribute to immunization.
According to statistical data, the combination of Rh-negative mother and Rh-positive father
occurs in 10-13% of all marriages. However, Rh-immunization does not occur in all Rhnegative women, pregnant Rh-positive fetus, but only 5-10% of them. The reason for increased sensitivity of some Rh-negative women to fetal Rh factor still remains unclear. Suggest the existence of genotypic hereditary factor determining propensity of the organism to
isoimmunization.
Childbirth especially often cause contact antigens in mother's bloodstream with its subsequent sensitization. Risk of sensitization increases with operational delivery, especially during cesarean section and manual removal of the placenta. To a lesser extent probably hit fetal
red blood cells in the mother's bloodstream during pregnancy, but this is not possible in the
presence of factors contributing to the violation of the integrity of chorionic villi and placenta: amniocentesis, the threat of termination of pregnancy, placenta previa, PONRP, intrauterine fetal death.
For immunization is sufficient to introduce 0.1 ml of Rh-positive blood (GK Cohen et al.,
1964). Once emerged, the antibodies do not disappear, and sensitivity to the re-introduction
into the body of Rh-positive red blood cells is high.
The absence of Rh-immunization in the first pregnancy, it usually develops in 2, 3 and 4
pregnancies, as well as abortion, miscarriage and blood transfusion and determines the degree of immunization with the increase of antibodies. This is in turn the cause of miscarriage,
premature birth, SBP and TH.
Hemolytic disease of the fetus and newborn.
Hemolytic disease (erythroblastosis) is often the cause of fetal death and neonatal morbidity
in the postnatal period and adulthood.
For the first time in 1930, a detailed description of hemolytic disease in the pediatric journal
gave thirty pediatrician Louis Diamond. He was invited to the newborn child, who was born
three days ago, which appeared immediately after birth jaundice, increasing to a saffron hue,
were enlarged liver and spleen, anemia was sharp. Her mother, it was the third child: the first
was born healthy, the other also suffered severe jaundice and died. This baby died. Research154
er Louis Diamond found in the blood of a child a lot of young red blood cells, erythroblasts.
This has led him to be called a disease of fetal erythroblastosis.
As a rule, the SBP and HDN occurs after previous Rh immunization. The severity of the SBP
depends on the type of antibodies produced by the immune system of the mother. Major role
in the development of SBP play incomplete antibodies related to IgG, buyout easily cross the
placental barrier. Full antibodies related to IgM, have a high molecular weight and almost
cross the placenta.
Ways of penetration of antibodies through the placenta:
1. During childbirth due to the injury of the villi and increased intrauterine pressure. As a result of hemolytic disease develops after the birth of a newborn - Postpartum, icteric form of
HDN.
2. In complicated pregnancy, accompanied by damage to the placenta (preeclampsia, threatened premature labor, PONRP, PP), develop congenital forms of SBP (edematous, anemic,
icteric).
3. Antibodies circulate in the mother's body (from previous pregnancies), but do not penetrate the placenta. In this case, the mother izosensibilizirovannoy be born healthy Rh-positive
fetus.
Antirezus antibody mother, getting into the bloodstream of the fetus, cause agglutination to
red blood cells. In the following, regardless of the impact of complex options erythrocytes
are destroyed, a large amount of indirect bilirubin, there is anemia and hyperbilirubinemia. If
red blood cells are not destroyed in the bloodstream, they accumulate in the spleen, and there
are under the influence of hemolysis phagocytes.
If the body appears indirect bilirubin, he quickly moved in a straight line through the addition of
two molecules of glucuronic acid produced in the liver. Indirect bilirubin fruit can be output in a
certain amount transplacentally, and then move directly to the mother. However, some indirect
bilirubin circulating in the fetus, which contributes to the functional immaturity of the liver. Furthermore, increased erythropoiesis foci in the liver, bile ducts bile expansion lead to a change of
the liver parenchyma and malfunction of architectonics. Consequences include hyperpoproteinemiya, portal hypertension, ascites and generalized edema. The fetus at GB arise anemia and consequently, tissue hypoxia with acidosis. Indirect bilirubin easily penetrates tissues
rich in lipids, inhibiting the enzymatic processes. In this regard, when hyperbilirubinemia frequently damaged brain tissue, especially the nucleus of the brain.
The severity of the fetus depends on:
 From antibodies:
 The concentration of antibodies in the mother's blood
 Capacity their passage through the placenta
 The duration of passage
 the ripeness of the fruit.
Ripeness of the fruit - is an important factor in its survival in conditions of maternal antibodies.
Than ripe fruit, the more pronounced its compensatory-adaptive and protective reactions. Thus
important to gestational age at which exposure began antibodies to the fetus. In the mature fruit
marked increase in parenchymal organs, increased medullary and extramedullary hematopoiesis
(lesions in the liver, spleen) expressed reaction of the lymphoid organs.
III. Placenta. Performs the function of a powerful eliminator - converts toxic indirect bilirubin
from the body of the fetus in the mother's body. "Decompensation" occurs after birth, because
after stopping Mark-negative function of the placenta in the blood and tissues of newborn quickly accumulate decay products of indirect bilirubin, which is a cause of severe intoxication and
often - death.
Forms of hemolytic disease
1. Fetal death with maceration (early and quite massive impact of antibodies on unripe fruit,
scarcity of morphological manifestations due to the immaturity of the fetus). The diagnosis is
made serologically.
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2. Edematous form (prolonged or repeated moderate impact of antibodies on immature fruit).
Imperfection of compensatory mechanisms, ongoing damage antibodies, despite elimination of
toxic products in the placenta, resulting in the death of the fetus before, during, or immediately
after birth.
Morphological features: sharp edema, hemosiderosis of the liver, sometimes spleen, kidneys, increasing their size, signs of decompensation of the endocrine and lymphatic systems, degenerative and necrotic changes in parenchymal organs, enlargement of the heart.
3.Anemicheskaya form (anemia without jaundice) is the result of continuous duration of prenatal
action of antibodies in a small dose of a sufficiently mature fruit. Damage to the small, elimination of the placenta is sufficient. After birth, mature liver provides sufficient allocation of bilirubin, jaundice does not occur. Prognosis is favorable.
4. Congenital icteric form (jaundice anemia) occurs in a significant prenatal exposure antibody
enough ripe fruit. In this well-defined compensation adaptive mechanisms. The fetus is born with
obvious signs of tension-type headache: anemia, enlarged liver and spleen. Develops or progresses jaundice, bilirubin encephalopathy. The severity of this form of depression is caused by
antibodies the immune system, so that a baby often have infectious complications (pneumonia,
umbilical sepsis).
Mortem changes similar to the changes in the edematous form, but somewhat less pronounced
5. Postpartum icteric form (jaundice without anemia) fetus is born apparently healthy picture of
the disease develops after a few hours or 2-3 days after birth. Indirect bilirubin level is high and
continues to grow. It causes severe toxicity, especially the brain. Impaired function of the brain,
loss of 40.2% of the neurons leads to severe sequelae (poslezheltushnaya encephalopathy), and
with the death of 70-90% of neurons vital centers - to death.
Clinical and anatomical pattern associated with the expression of bilirubin-hand encephalopathy
(kernicterus), a significant hemosiderosis spleen and liver.
Depending on the degree of immunization SBP can develop into various stages of pregnancy,
sometimes very early with 22-23 weeks. At any-bom term may experience the most severe manifestations of the disease - general edema, edematous form of SBP. Most often the disease occurs
in the first hours and days of birth. Depending on the severity of the disease can manifest itself in
the anemic, icteric and universal form of edema. Expressed in all forms of anemia.
Diagnosis is based on:
1.Tschatelnom collecting history
a) ways of immunization (emphasis on abortion!)
b) obstetric history: the birth of living children with hemolytic-New illness, died of hemolytic
disease, extrauterine death from hemolytic disease, intrauterine death of hemolytic disease
2. Determination of antibodies and their titer
Coombs' method, developed for use in forensics and forensic medicine, later was used in obstetrics to detect Rh-antibodies. The method is based on precipitation. Indirect test can detect the
cord blood erythrocytes of the newborn, associated with antibodies (agglutination test your
child's blood with a specific serum Coombs)
This test is not absolute, since the antibodies do not disappear after they develop in the mother,
even if not subsequently develops a disease of the fetus or if the fetal Rh-negative blood. Has a
definite value dynamics of antibody titer. The antibody titer reflects the highest dilution of serum
(1:2, 1:4, 1:16, etc.), which still is hemolysis adds a Rh-+ erythrocytes. During pregnancy, the
antibody titer may rise, some fall, to waver. The increase in antibody titer is not always determined by the increase in the degree of immunization, sometimes it is due to hit them in the
bloodstream to other cells, and the decline - on the contrary, the binding of cells. However, the
increase in antibody titer, especially significant (3-4 orders of magnitude) are recorded as an indirect sign of worsening of the GBP.
Distinguish:
1. Stable titer
2. Uniform increase of titer
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3. Uniform decrease titer
4. The sharp increase in titer of childbirth
5. A sharp drop in titer before delivery
6. The alternation of the ups and downs of antibodies
The first three options: children can be born without HAT (eg, Rh-negative), but often heavy defeat fetus up to intrauterine death.
4th and 5th options: there is only Rh-positive fetus, and is often accompanied by severe HDN.
"Jumpy" title - intrauterine fetal death or severe fetal loss GB.
3.Issledovanie bilirubin in the blood serum of pregnant women.
Hyperbilirubinemia and anemia are some of the main features of the MLP, it is critical to determine the degree of severity, as a certain degree of probability can be judged by the optical density of bilirubin (SB) in the amniotic fluid.
Bilirubinemia, revealed in repeated studies may be due to:
1) as the breeding mother's blood degradation products of fetal red blood cells;
2) violation of the response of the liver in pregnancy.
4. Amniocentesis.
Yellow color combination treatment with fetal hydrops awarded in 1949 Pickles.
For the first time, followed by amniocentesis study water taken in 1950 Bewis. Investigate the
contents of bilirubin in amniotic fluid (> 0.3 mg% - severe HDN). Amniotic fluid obtained by
amniocentesis.
Amniocentesis - operation, the purpose of which is to obtain a near-fetal treatment, biochemical,
hormonal, immunological, cytological and genetic research to judge the condition of the fetus.
Distinguish transvaginal and transabdominal amniocentesis. The operation is always performed
under ultrasound guidance. In pregnant women with Rh-sensitization, when to study RBP, the
sample of amniotic fluid to be quickly transferred to a dark container, in order to avoid changes
in the properties of bilirubin under the influence of light.
OPB set by spectrophotometry at a wavelength of 450 nm with respect to distilled water.
Normal value is less than 0.1 OPB.
When GSP from 0.1 to 0, 15 suggests the presence of SBP mild.
M0 at OPB, 15 to 0.2 - GBP moderate and severe forms.
At OPB 0.2 and above - GBP severe or intrauterine death.
In assessing the RBP may be a false positive results when the needle enters the mother's blood,
meconium, urine or fetal ascites.
More accurately assess the severity of hemolytic process can be when investigating OPB at different wavelengths of light. In such cases, calculate ΔΣ, plotted, divided into three zones based
on the severity of hyperbilirubinemia, and gestation. From that in which zone gets set value OPB
depends further tactics of the doctor (scale Lily schedule Liley).
5.UZI.
It is advisable to carry out the next ultrasound in pregnancy: 20-22, 24-26, 30-32, 34-36 weeks.
and immediately before delivery. Ultrasound can detect changes as the placenta and fetus. Depending on the severity of the disease observed increase in thickness of the placenta. Above
normal for gestational placental thickness of 0.5-1 cm or more indicates a possible disease of the
fetus, in connection with what is required to conduct repeated ultrasonography. The edematous
form of SBP thickness of the placenta may reach 60-80 mm. At GB ultrasound reveals the fetus
enlarged liver and spleen. Signs of edematous forms of GB are marked hepatosplenomegaly, ascites, and polyhydramnios.
Also carry out specific biophysical scale by a modified Vintzileos (1983). In contrast to water
scarcity, which is an unfavorable factor in pregnant women without izoserologicheskoy incompatibility, if any, take into account the polyhydramnios, but rather the degree of maturity of the
placenta - its thickness. Other criteria scale (heart activity, breathing movements, physical activity, tone) is estimated by the standard procedure.
During, pregnancy and childbirth.
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During pregnancy, Rh-sensitized women has a number of features. Pregnant women often
complain of general weakness, drowsiness, shortness of breath, a short loss of consciousness,
frequent abdominal pain. In Rh-immunized pregnant women often in the first half of pregnancy
toxaemia developed (50%), the threat of termination of pregnancy (47%), hypotension (23%). In
the second half of pregnancy edema observed in 13% of women with pre-eclampsia in 16%,
anemia is also common. Additionally, you may experience liver problems. On the part of the
fruit is celebrated chronic hypoxia.
All pregnant the first time you visit the doctor determine the group and Rh blood affiliation. Pregnant women with blood group 0 (I) in the event that the husband other group should be
tested for the presence of blood group of immune antibodies. When Rh-negative blood in a pregnant rhesus determine identity of her husband, and if he has Rh-positive blood, that is, the risk of
izosensibilizatsii.
In patients with Rh-negative blood should be from the early periods, blood tests for antibodies
and determine their title: up to 20 weeks. Pregnancy 1 time per month, after 20 weeks. - 1 time in
2 weeks. Other authors propose the following options for the survey. If a pregnant woman with
Rh-negative blood are not detected antibodies, then 1 every 2 months, if immunized, up to 32
weeks 1 time per month, 32-35 weeks - 2 times a month before delivery - 1 day a week is
checked blood for the presence and growth of antibody titer. Must also be an indirect Coombs'
reaction, which allows to determine which antibodies circulate in the blood related or free.
In the absence of antibodies to 28 weeks of pregnancy, many researchers recommend that
pregnant women with Rh-negative blood prophylactically administered intramuscularly 300mg
Rh Ig, which can block the Rh antibodies. It is important that a product containing antibodies do
not cross the placenta.
Determining the status of the fetus on the basis of the assessment of the biophysical profile
and ultrasound performed weekly from 31 32ned. Pregnant women at high risk for SBP (a history of late miscarriage, premature birth, stillbirth, SBP) ultrasound should be performed daily or
every 1-2 days.
To reduce the sensitization of pregnant women with Rh-negative blood, even in the lack of
Rh antibodies, as well as the presence of AB0-sensitization is recommended that 3-year nonspecific desensitizing therapy for 10-12 days when the term of 10-12, 22-24, 32 - 34 weeks.
Women who have been complicated by the pregnancy, should be admitted to the department of
pathology of pregnancy, which, along with treatment of the underlying disease, a course desensitizing therapy.
Pregnant women with a history of miscarriage and are the fruit of the labor of edematous or
severe icteric form of hemolytic disease, with a high titer of Rh antibodies in treatment and
plasmapheresis may be performed, which consists in the removal of a certain amount of pregnancy (250-300ml) of plasma containing antibodies. Replacement of plasma withdrawn produce
colloidal crystalloid and protein preparations and simultaneously returned to the bloodstream
blood cells pregnant. Plasmapheresis do one once a week under the supervision of the antibody
titer from 23-24 weeks of pregnancy until delivery, plasma exchange may be performed prior to
pregnancy and in preparation for it.
Pregnant women, who are at the Rh sensitization, should be sent to the maternity hospital at
34-36 weeks of gestation, with ABO sensitization 36-37 weeks for further investigation and a
decision on the delivery. In the presence of the SBP to premature delivery, because at the end of
pregnancy increases the supply of Rh antibodies to the fetus. The optimal timing of delivery - 37
38ned pregnancy, as with earlier delivery is due to functional immaturity of GB more severe, the
child is suffering from respiratory distress syndrome. However, if objective evidence indicates
the expression of suffering fetus if a woman has burdened obstetric history, delivery possible in
the earlier stages of pregnancy. It is necessary to undertake activities aimed at accelerating fetal
lung maturation premature. Prescribed dexamethasone for 2 mg 4 times a day for 2-3days before
the expected birth.
In severe edematous form SBP pregnancy is terminated at any stage.
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Typically, delivery is carried out through the birth canal. Caesarean section performed with
additional obstetric complications.
When you are ready to leave the cervix produce amniotomy. If the labors will not develop,
within 5-6 hours after amniotomy begin labor induction with oxytocin or prostaglandins by the
standard technique.
In sorts through careful monitoring of the fetus, prevention of hypoxia. Immediately after
birth he was quickly separated from the mother in order to avoid a massive hit Rh antibodies in
the blood of the newborn. Umbilical cord blood is taken for the determination of bilirubin, hemoglobin, blood child's Rh accessories. Conduct indirect Coombs, allowing red blood cells to
detect newborn associated with antibodies. Given the propensity of the fetus and newborn with
hemolytic disease of bleeding should be carefully conduct the second stage of labor. Suitable
epidural anesthesia and ressechenie crotch. When ABO - sensitization labor management does
not have any features.
Later, if necessary, replace the blood from newborn umbilical vessels use GB, so brace on the
umbilical cord does not impose. Cord tied at 2-3cm from the umbilical ring.
Therapy in Rh-immunization
1. Conservative
2. Surgical (alloplastica skin graft)
3. Early delivery
Hemolytic disease of newborn
Allocate anemic, icteric form of the disease and edema.
Anemic form the first hours of life appears pale skin, physical inactivity, enlarged liver and
spleen. In the blood, decreased hemoglobin levels.
Icteric clinically characterized by early jaundice, enlarged liver and spleen. Usually accompanied by anemia.
Edematous form - the most severe form of the disease, often ending in fetal death. There is a
general swelling, almost all cavities (abdominal, chest) are filled with fluid, the liver and spleen
are large.
Hemolytic disease of newborn ABO system usually has no specific symptoms at the time of
birth.
Based on laboratory and clinical data can be divided into 3 degrees of severity for HDN Rh:
Mild form (I severity) is characterized by a pale skin, a slight decrease of hemoglobin (up to 150
g / l) and a moderate increase in bilirubin levels in cord blood (up to 85.5 mgmol / l), light pasty
fat;
Moderate form (II severity) is characterized by pallor to Ms, decreased hemoglobin level (150110g / l), increased bilirubin (85,6-136,8 mmol / l) in cord blood, pasty, enlarged liver and
spleen;
Severe form (III severity) is characterized by sudden pallor of the skin, a significant decrease in
hemoglobin (less than 110 g / L), a significant increase in bilirubin (136.9 mmol / l) in cord
blood, generalized edema.
Bilirubin encephalopathy - the most severe complication of tension-type headache associated
with toxic damage neurons indirect bilirubin. Factors that increase the risk of CNS newborn include prematurity, asphyxia, hypothermia, acidosis, hypoproteinemia, malnutrition.
Clinical phase currents are 4 bilirubin encephalopathy:
1. Bilirubin toxicity (lethargy, hypo-, weakness, hypo-, arena-flexion);
2. Symptoms of kernicterus (spasticity, seizures, "brain scream," symptom "setting sun");
3. Imaginary being (from 2-week reduction in spasticity, sous-roads);
4. Formation of clinical neurological complications (cerebral palsy, athetosis, paralysis, paresis,
deafness)
Diagnosis of HDN.
1. Degree family history obstetric history
2. Clinical disease
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A) group, Rh-blood baby accessory
B) Direct Coombs (direct proportional relationship titer on the severity of jaundice)
B) Hb and red blood cells in cord blood
D) indirect bilirubin in the serum of umbilical cord blood (in the dynamics to determine the
hourly rate) (0.1 mg% per hour - an alarming sign)
Treatment of HDN. The use of exchange transfusion of blood from newborn HDN, and the introduction of mother-antirezus immunoglobulin (Rh IgG) after the termination of pregnancy by
any means (abortion, birth, ectopic pregnancy) significantly reduced the high values of perinatal
mortality and morbidity. Introduced Rh IgG, binds Rh-antigens that may enter the mother's
bloodstream during pregnancy termination, and thus preventing the production of maternal antibodies and Rh-immunization.
Treatment of tension-type headache:
1. Medication: vitamins, liver protecting, albumin
2. Exchange transfusion of blood (180 ml of blood per 1 kg of the newborn) - Rh-negative.
Indications for surgery blood exchange transfusion (CRCs)
1) The absolute indication for emergency operation carrying out CRCs is severe tension-type
headache;
2) indication for early execution of the operation CRCs (within 24 hours) are the following:
total bilirubin level in cord blood above 77.5 mmol / L;
hemoglobin levels in cord blood below 110 g / L (hematocrit less than 35%)
hourly increase of bilirubin higher than 8.5 mmol / L (rapidly progressive disease), using the
technique CRCs Substitute 2 BCC;
3) only in the absence of the conditions necessary for the effective conduct of complex conservative therapy can be used extensive testimony to the early execution of the operation CRCs:
total bilirubin level in cord blood levels above 68 mmol / l
hemoglobin levels in cord blood below 140g / l
jaundice in infants in the first 6h;
hourly increase total bilirubin level above 6.8 mmol / l
It also uses the technique of CRCs Substitute 2 BCC;
4) in the absence of indications for CRCs in the first days of life basis for this operation are the
levels of total serum bilirubin above
256 mmol / L on day 2 and more than 340 mmol / l in term and more than 256-340 mmol / l in
preterm in subsequent days of life.
Selection of blood and especially their use in CLP:
1. to replace blood with Rh factor used single-group Rh-negative blood;
2. by incompatibility group factors - packed red blood cells 0 (I) Rh group sootvetvenno accessories baby and plasma single-group or AB (IV) in a 2:1 ratio;
3. for incompatibility and Rh factor and blood group - R. weight 0 (I) of Rh-negative and AB
plasma (IV) in a ratio of 2:1 shenii
Prevention of Rh sensitization.
Preventive measures include the following: any ne-relivanie blood balanced against the Rh blood
supplies recipient and donor, to save the first pregnancy in women with Rh-negative blood, prevention and treatment of complications of pregnancy, holding desensitizing therapy, the implementation of specific prevention of Rh sensitization women with Rh-negative blood by introducing antirezus immunoglobulin after any termination of pregnancy.
Specific prevention of Rh-immunization is the introduction of anti-D gamma globulin (drug
horns) in the first 48-72 hours after birth (300 U) or abortion (150 U) Rh-negative women. Condition: The woman should not be immunized during pregnancy. Immunoglobulin-antirezus administered in a single dose intramuscularly once. Parturients specified dose administered within
48 hours after birth, with abortion - is complete. After cesarean delivery and manual removal of
the placenta is necessary to double the dose.
With full implementation of specific prevention methods Rh sensitization can almost solve the
160
problem of Rh-conflict pregnancy.
The use of new educational technologies:
METHOD "dark horse"
To work needed:
1. A set of questions and situational problems, printed on separate sheets.
2. Blank sheets of paper.
3. Pens with colored bars (blue, red, black).
4. Number plates for the draw, the number of students in the group.
Progress:
1. Total time - 60 minutes
2. The group is divided into 3 groups by drawing lots, PA3-4-person groups.
3. Each subgroup sits at a separate table, prepares a blank sheet of paper and takes one of the
colored pens.
4. Written on a sheet date, the group number, name of business ur-ry, F.I.studentov member of
the subgroup.
5. One of the players takes the envelope question or problem, depending on the choice of the
teacher: that this group will be used.
6. For each subgroup a single issue or problem, but the complexity of all sub-about the same.
7. Takes the time to 10 minutes.
8. Small groups (sub-group), each for 10 minutes to discuss the job, write your discussion and at
the end of the time sheets are exchanged with another subgroup of the circle.
9. The next subgroup assesses previous answer and if the answer is not complete or supplement
it offers its own version, if the answer is evaluated as incorrect. At this stage time is given as 10
minutes.
10. At the end of the work (30 minutes) on a sheet of recording time is 3-governmental color
pens.
11. The works shall be the teacher.
12. All participants will discuss the results and choose the most correct answers nye that perfect
score.
13. For discussion of play time of 15 minutes.
14. Subgroup, which gave the most correct answers will receive the maximum score - from 86 to
100%. Subgroup, who took 2nd place from 71 to 85.9%, 3 subgroup of 65 to 70, 9%.
15. Students with scores recorded for billing ongoing evaluation sessions.
16. Student work saved teacher.
Complex issues for the business game
1. Three forms of hemolytic disease of the newborn.
2. Pathogenesis of Rh immunization during pregnancy.
3. In the course of pregnancy isoimmunization.
4. Titer value of Rh antibodies for the outcome of pregnancy.
5. During labor in women with Rh sensitization.
6. ABO-incompatible pregnancy and infant development
7. Treatment of hemolytic disease of the newborn.
8. Prevention of miscarriage, stillbirth, HDN isoimmunization in pregnant women.
9. Prevention of isoimmunization in Rh-negative women.
10. Indications for early delivery.
The methodology of the business game "swarm"
To work needed:
1. A set of setting and situational problems, printed on separate sheets.
2. Number plates for the draw in the number of students in each subgroup.
3. Blank sheets of paper, pens.
Progress:
1. All the students are divided into groups by lot 3 under161
groups of 4 students each.
2. Each subgroup sits at a separate table, preparing the paper and pen.
3. Written on a sheet date, the group number, department, name, name of participating students
in this subgroup and the name of the business game.
4. One of the participants in each subgroup takes the envelope of setting that is used for all subgroups.
5. One of the students in each subgroup rewrites on the job list.
6. All subgroups of students together to discuss the job, and then one of them writes his decision.
7. The decision set to 15 minutes.
8. The teacher watches the progress of the game.
9. After the time of the surrender teacher.
10. All the players discuss the results, choose the best solutions for which to set the maximum
score.
11. For discussion to 15 minutes.
12. Students get points for answering the theoretical part of the rating classes.
13. Subgroup, which gave the most correct answers will receive the maximum score - 100% of
the theoretical part of the rating classes, subgroup took 2nd place 85.9% rating, 3 subgroup
70.9% rating.
14. On the answer sheet scores and teacher puts his signature.
15. Students with scores counted in the scoring for the current session.
16. In the lower part of the magazine is a free stamp on the game with the signature of elders.
17. Student work saved teacher.
Complex issues for the business game
1. The link between hemolysis and bilirubinemia.
2. And characteristics of Rh antibodies.
3. Ways immunization
4. Diagnostic algorithm of SBP
5. Ultrasound markers SBP
6. Indications for surgery replace blood transfusion
7. Forms of hemolytic disease of the newborn.
8. Research terms of antibody titer in pregnant women with Rh-negative blood
9. Specific immunoprophylaxis
10. Clinical management of pregnancy and childbirth and Rh-immunized pregnant women.
11. Clinical management of pregnancy and childbirth and Rh-immunized pregnant women.
12. Determining the amount of anti-D-Rh-globulin depending on the time of abortion.
13. Antenatal and postnatal prevention of isoimmunization of Rh-factor.
14. Timing and method of delivery for different severity GBP.
15. The diagnostic value of the optical density of bilirubin in amniotic fluid by amniocentesis.
6.2Analiticheskayachast
Case studies:
1. Primigravida 24 years appealed to the antenatal clinic at 12 weeks gestation. Blood type - A
(II), Rh (-) (nameplate data).
Q: What kind of research is necessary to? How often should an ultrasound examination?
A: Testing for the presence and titer of antibodies, ultrasound. It is advisable to carry out the next
ultrasound in pregnancy: 20-22, 24-26, 30-32, 34-36 weeks. and immediately before delivery.
2. Multigravida 32 years directed the department of pathology preg-tion with the diagnosis of
pregnancy is 35-36 weeks. Rh-conflict pregnancy (titer AT 1:32).
Q: Tactics hospital doctors? What research is needed in the cord blood?
A: early delivery. Umbilical cord blood is taken for the determination of bilirubin, hemoglobin,
blood child's Rh accessories. Conduct indirect Coombs, allowing red blood cells to detect newborn associated with antibodies.
3. Pregnant woman, 28 years old, was admitted to the obstetric department with a diagnosis of
162
pregnancy 2, 38 weeks, Birth 2, 2 stage of labor. Of history: the first birth of a child died on the
2nd day of kernicterus. A child, a serious condition, pale skin, moaning cry. Blood group B (III),
Rh-positive, hemoglobin 90 g / L, total bilirubin level in cord blood 97.6 mmol / L, the hourly
increase of bilirubin 8.8 mmol / l
The diagnosis? Your tactics?
Diagnosis: Hemolytic disease of the newborn severe. Early the operation will replace the blood
with the replacement of two BCC.
4. Pregnant woman, 26 years old, third pregnancy, 34 weeks, the first coming generations. The
first two pregnancies ended in miscarriage. On examination found that pregnant O (I), Rhnegative blood, the blood found incomplete Rh antibody titre of 1:128.
Q: Your tactics? In what dosage should be administered after the birth of anti-D gamma globulin? What mistakes were made in the management of pregnancy?
Answer: Urgent delivery. You can not enter antirezus-immunoglobin, as the woman is immunized. At first appearance it was necessary to set the group and Rh affiliation. During pregnancy,
it was necessary to conduct spetseficheskuyu (no immunization) and nespetseficheskuyu prevent
isoimmunization.
6.3. Graphic organizer: Making graphic organizer
scheme of "Lotus Flower" on "The role of Rh factor in obstetrics"
SCHEME "Lotus flower"
A means of solving problems. Embodies the image of a lotus flower. It is based on nine large
squares, each of which is formed of nine kvadratikov.Razvivaet and activates the system, creative, analytical thinking.
6.4.Prakticheskaya part
Blood type and Rh accessories.
Purpose: To train students in the identification of blood group and Rh accessories
Performs step (steps):
Events number does not hold nil
(0 points) Fully
correctly
performed
(20 points)
1. Wash hands thoroughly with soap and water, dried-shat, wear sterile gloves on both hands 0
10
2. Apply to the marked holes of the Ad Hoc plates 10 drops of standard sera two series. Add 1
drop of blood in each well. 0 10
3. Stir with a glass rod containing zhimoe holes (thus for each well must have a stick or wand
before another mix thoroughly washed and dried with a cotton ball) 0 10
4. Plate slowly shake C. for 5 min 0 10
5. Evaluate the results on the occurrence of ar-glyutinatsii the appropriate wells:
- If no agglyutinatsiya all wells, the blood group I
- If 1 and 3 wells, the blood group II
- If 1 and 2 wells, the blood group III
- If at all three, the blood group IV 0 10
6. To determine the Rh factor is added to a clean tube UT 2 drops of serum antirhesus 0 10
7. So that they add 1 drop of my blood determined by 0 10
8. Keep the vial in the hands of five minutes, warming 0 10
9. Added 7.5 ml saline. solution 0 10
10. Look under the daylight. If there were grains of agglutinates, then determined Rh-positive
blood. If no agglutination and still be a slight haze of mist in a test tube with a solution, then we
define Rh-negative blood. 0 10
Total 0100
7.Formy control of knowledge, skills and abilities
163
-Oral;
-Written;
Testing;
Solution situational problems;
And demonstration of skills mastered.
8.Kriterii assessment monitoring
Number suc-BAE-bridge
Score in% level of students' knowledge
1 96-100% Excellent
"5" full correct answer to the questions on the etiology-ology, pathogenesis, classification, clinic, diagnostics, treatment and prevention of this disease. To sum up and make decisions, creative
thinking, self-analyzes, case studies resolves correctly, with a creative approach, with full justification of the answer. Actively and creatively involved in interactive games, takes on the correct
decisions and summarizes and analyzes. Medical history, partograph fills correctly.
2 91-95% Excellent
"5" full correct answer to the questions on the etiology-ology, pathogenesis, classification, clinic, diagnostics, treatment and prevention of this disease. Creative thinking, self-analyzes, case
studies resolves correctly, with a creative approach, with full justification of the answer. Actively
and creatively involved in interactive games, take the right decision. Medical history, filled with
1 partograph grammatical errors Coy.
3 86-90% Excellent
"5" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis, treatment and prevention of the disease covered completely, but have 1-2 errors in the response. Self-state analyzes, inaccuracies in solving situational problems, but with the right approach. Actively involved in interactive games, make the right decisions. Medical history, partograph fills with 2-3 grammatical errors.
4 81-85% Good
"4" The questions on the etiology, pathogenesis, classification, clinical manifestations, diagnosis,
treatment and prevention of the disease covered completely, but there are 2-3 inaccuracies, errors. Application exists in practice, understands the essence of the question, says confidently, is a
faithful representation. Situational problems solved correctly, but the justification answer sufficiently. Actively involved in interactive games, take the right decision. Medical history, partograph fills with 2-3 grammatical errors, inaccuracies in the description.
5 76-80% Good
"4" Correct, but incomplete coverage of the issue. Stu-dent knows the etiology, pathogenesis,
classification, clinic of the disease, but not completely disassembled diagnosis, treatment and
prevention of this disease. Understands the issue, distribution predicts confidently. There is an
exact representation. Actively participate in the games. On case studies gives partial solutions.
Medical history, partograph fills with 3-4 grammatical errors, inaccuracies in the description.
6 71-75% Good
"4" Correct, but incomplete coverage of the issue. Stu-dent knows the etiology and pathogenesis
of this disease, but not completely disassembled diagnostic les chenii and prevention of the disease. Understands the issue, says confidently, is a faithful representation. On case studies gives
partial solutions. Medical history, partograph fills with 3-4 grammatical errors, 3-4 errors in the
description.
7 66-70% satisfactory solution is without foundation
"3", the correct answer to a half set of issues. Student knows the etiology of the disease, but do
not pay out the classification of the disease clinic, confused in the treatment and prevention. Understands the issue, said confidently, has accurate representations only on specific issues topic.
Situational problems solved correctly, but there is no justification of the answer. Medical history,
partograph fills with 3-4 grammatical errors, 3-4 errors in the description.
8 61-65% satisfactory solution is without foundation
164
"3", the correct answer to a half set of issues. Errors in the etiology, pathogenesis, poorly versed
and confused in the treatment and prevention of this disease. Says uncertainly, has the only
views on certain issues topic. Making mistakes in solving situational problems. Medical history
and partograph fills with errors.
9 55-60% satisfactory solution is without foundation
"3" error response by half set of issues. Student makes an error in the etiology of this disease,
poorly versed and IP-melts in other matters related to the disease. Says uncertainly has a partial
view on the subject. Situational problems solved incorrectly. Medical history and partograph fills
with errors.
10 50-54% Unsatisfactory-vletvori-state "2" The correct answer is 1/3 of the questions. Student
does not know the etiology of the disease, and poorly versed entangled in other issues related to
the disease. Situational problems solved correctly if the right approach. Medical history and partograph fills with errors.
11 46-49% Unsatisfactory-vletvori-state "2" the correct answer to one fourth of the questions.
Student does not know the etiology of the disease, and poorly versed entangled in other issues
related to the disease. Situational problems solved correctly if the right approach. Medical history and partograph fills with errors.
12 41-45% Unsatisfactory-vletvori-state "2" Lighting fifth of the questions with errors. Student
does not know the etiology of this disease, little versed in other matters related to the disease.
Gives an incomplete and partially incorrect answers to questions on the classification of the clinical disease. Situational problems solved correctly if the right approach. More than half of the
patient's history and the partograph filled with errors.
13 36-40% Unsatisfactory-vletvori-state "2" Lighting 1/10 of the questions in the wrong subcourse. Does not know the etiology of the disease, and poorly versed entangled in other issues
related to the disease. Gives an incomplete and partially incorrect answers to questions on the
classification of the clinical disease. Situational problems solved correctly if the right approach.
Bole half medical history and partograph fills with gross errors.
14 31-35% Unsatisfactory-vletvori-state "2" to the questions not answers. Does not know and
does not understand the other issues related to the disease. Does not know how to fill out and describe the history of the disease and the partograph.
9. Typical flow chart of lesson
Stages of work, time-name The content of the
Teachers Students
1etap. Introduction to the training session
(5min) 1.1.Soobschaet topic, purpose, and planned training results. Familiar with the plan, features of the training session.
1.2.Nazyvaet: key categories and concepts from the data subject tion, a list of books for selfstudy
1.3.Soobschaet indicators and criteria of educational work in class
Listen, record,
specify, ask the question.
Stage 2.
Primary
(235 min) 2.1.Provodit updating knowledge through блиц-опроса/вопросно-ответной forms /
brainstorming, etc.
2.2. Consistently describes the steps
on the organization of the educational process according to the structure of practical training.
Meet
Abstracts with ethyl.
Working in groups, will present the results of the group work
Stage 3.
The Final-Resultant-regulating (60 min)
165
3.1.Delaet opinion on the subject, attention was concentrated on the main students, according to
the importance of the work done for future careers.
3.2. Commends the work of groups (some of students) summarizes vzaimootsenki. Analyzes and
evaluates the degree of achievement of lesson.
3.3. Gives the task for independent work, informing schaet and criteria evaluation. Selfevaluation,
interaction assessment.
Ask the question.
Write down the job.
10.Kontrolnye questions
1.Svyaz honey hemolysis and bilirubinemia?
2.What should be to determine the blood group?
3. Where the neutralization of indirect bilirubin, and how?
4. Maybe the child 0 (I) blood group if the father and mother in (III) blood group?
5. What is the difference between hemosorption and plasmapheresis?
6.Chem can be explained by the physiological jaundice of the newborn?
7.Tri forms of hemolytic disease of the newborn.
8.Chto can be said about a group of human blood, if agglutination occurred in all four standard
sera (in AB0).
9. Based on what Coombs?
10.Pochemu immunoglobulin G can cross the placenta?
11.Kakova goal of intrauterine fetal blood transfusion?
12.Komu, when, how and for what purpose are introduced anti D Rho immune globulin?
13.Kakuyu dose of anti D Rho immune globulin should be applied when released into the mother's bloodstream 20 ml fetal blood?
14.Yavlyaetsya whether postnatal prophylaxis 100% effective? If not, why not?
15.S what period of pregnancy when abortion should be carried out Rh-prevention?
16.Pri what method of abortion more likely immunization (with curettage or vakuumekskohleatsii)?
17.Obyasnite term "kernicterus".
18.Krov which group can be used for intrauterine fetal transfusion with Rh-conflict?
19. On what is the effect of phototherapy?
20.Smysl phenobarbitone or ziksorin for HDN?
11. Recommended Reading
Summary:
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3. Abramchenko, VV Cesarean section in perinatal medicine: a guide for physicians / 2005. 126.
4. Abramchenko, VV Postoperative intensive care in obstetrics / Literature, 2000. - 88.
5. Abramchenko, VV Pharmacotherapy of preterm labor / 2006. - 448.
6. Abramchenko, VV Purulent-septic infection in obstetrics and gynecological logii.rukovodstvo
/ 2005. - 459
7. Abramchenko, VV Postoperative intensive care in obstetrics / - St. Petersburg: Spec. Literature, 2000. - 88.
8. Abramchenko, VV Clinical perinatology / IntelTek, 2004. - 424 p.
9. Ailamazyan, EK Midwifery: a textbook for honey. Universities / 2003 - 528.
10. Topical issues of Obstetrics, Gynecology and Reproductive / Ed. EV KOKHANEVICH. Moscow: Triad-X, 2006. - 480.
11. Obstetrics. Ed. GM Savelyeva. - M.: Medicine, 2000. - 816 p.
12. Obstetric and gynecological care: Hands-on. for doctors / Ed. VI Kulakov. - Moscow:
166
MEDpress, 2000. - 512 p.
13. Obstetrics. Clinical lectures: a manual for schools with a CD / Ed. OV Makarova. - Moscow:
GEOTAR Media, 2007. - 640.
14. Obstetrics. Directory of the University of California / Ed. Nisvandera K., A. Evans: Lane.
from English. - M.: Practice, 1999. - 704 p.
15. Barashnev, YI Perinatal neurology / Y. Barashnev. - M.: "Triad - X", 2005. - 670 p.
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the system of postgraduate medical. Education / SL Resurrection. - Minsk: The Book House,
2004. - 304.
18. Gazhonova, VE Ultrasound in Gynecology / VE Gazhonova. - Moscow: MEDpress-inform,
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26. Zhilyaev, NI Operative Obstetrics: Ouch. Manual / Kiev 2004. - 468 p.
27. Zhilyaev, NI Operative surgery in obstetrics and gynecology / 2004.
28. Selected lectures on obstetrics and gynecology / Ed. AK Strizhakova etc. - Rostov-on-Don:
Phoenix, 2000. - 512 p.
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2000. - 379 p.
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University. NA Semashko. - M: 2005. - 96 p.
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33. Kulakov, VI Intensive care in obstetrics and gynecology (efferent methods) / - M: MIA,
1998. - 206 p.
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Serov. 2006. - 375 p.
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36. Perinatology Basics: A tutorial / Ed. MP Shabalov. - Moscow: MEDpress-inform, 2002. 576 p.
37. Practical skills in obstetrics and gynecology: a manual / LY Suprun, TS Divakova and others.
- Minsk: New Knowledge, 2002. - 166 p.
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Kulakov, VN Serov. - M.: 2005.
39. Guide Out - patient care in obstetrics and gynecology / Ed. VE Radzinsky. M: GEOTAR Media, 2007.
40. Guide to practical training in obstetrics / Ed. VE Radzinsky. - M.: MIA, 2004. - 576 p.
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167
42. Sidelnikov, VM AG Antonov Premature birth. A premature baby / VM Sidelnikov, AG Antonov. -M. "GEOTAR" 2006.
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44. Smirnov, LM Obstetrics and Gynecology: Textbook / LM Smirnov. - M.: Medicine, 1999. 368 p.
45. Handbook of obstetrics, gynecology and perinatology: uch.posobie for doctors / Ed. GM
Savelevoy.2006. - 720.
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VLADOS, 2005. - 175 p.
47. Filippova, GG Psychology of motherhood: a manual / GG Filippov. - Moscow: Publishing
House of the Institute of Psychiatry, 2002. - 240.
48. Chernukha, EA Prolonged and prolonged pregnancy. Guide for Physicians / EA Chernukha. M.: "GEOTAR - Media", 2007. - 207.
49. Chernukha, EA TK Puchko breech presentation. Guide for Physicians / EA Chernukha, TK
Beam. - M.: "GEOTAR - Media", 2007. - 173 p.
50. Shmagel, KV Immune pregnant women / KV Shmagel, VA Cherries. - Moscow: Medical
Book, 2003. - 226 p.
51. Tskhai, VB Perinatal obstetrics: a manual for honey. Universities / VB Tskhai. - Atlanta:
Med. Academy of RAMS, Moscow, Honey. book, 2003.
52. Amniotic and extraembryonic structures in normal and complicated pregnancy / Ed. VE
Radzinsky. 2004. - 393 p.
53. Congenital, perinatal and neonatal infections: Per. from English. / Ed. A.Grinou, J. Osborne,
S. Sutherland. - M.: Medicine, 2000. - 287.
54. Kulakov VI, Murashko LE Premature birth. M. Medicine, 2002.
55. Serov VN etc. Eclampsia: A Guide for Physicians / V.N.Serov etc. - M.: MIA, 2002. 463 with
56. VM Sidelnikov Habitual loss beremennosti.-M.: Triad-X, 2002.
57. Disseminated intravascular coagulation in obstetrics AD Makatsaria etc. - M.: Triad-X, 2002.
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58. Schechtman, MM, GM Burduli Diseases of the respiratory system and blood circulation in
beremennyh.-M.: Triad-X, 2002. - 230C.
59. Shifman EM Pre-eclampsia, eclampsia, NELLP syndrome / Inteltek, 2002.
More:
60.Uchebnoe grant for the development of practical skills surgical / Edited by prof. Atalieva AE,
prof. Babadjanova BD Tashkent 2003. C102-115
61.Algoritmy diagnosis and treatment of surgical / Edited by Academician Karimov
Sh.I.Tashkent 2003. From 39-64
62.Uchebnoe benefit surgical subjects for medical students / Edited by Academician Karimov
Sh.I.Tashkent -2003 Part II Obstetrics and ginekologiya.S 64-19013. Practical skills in obstetrics
and gynecology / Metod.posobie / / Tashkent 2008.
63.Akushersky soft tissue injuries of the birth canal, Kulakov VI, Butova E.A.2004.
64.Akusherstvo. National rukovodstvo._2004.
65.Infektsii in Obstetrics and Gynecology How VK Seagull 2006
66.Hirurgicheskaya technique cesarean secheniya_Strizhakov A.N._2007.
67.Ratsionalnaya pharmacotherapy in obstetrics and ginekologii.2007
Chan_Gynecology_and_obstetrics.2004
68.Rukovodstvo for outpatient care in obstetrics and gynecology, Kulakov V.I.2005.
70.Sidorova_I.S._Rukovodstvo_po_akusherstvu_ (Medicina, 2006) (ru) (1033s
71.Posobie for practical development of Obstetrics Voronin (KV) 2007.
72.Kirienko AI, Matyushenko AA, Andriyashkin VV Ostryi tromboflebit/2005
AN 73.Ivanyan - Intrauterine growth ploda/2007
74.DVS_sinrom _v_akusherstve.2004
168
75.Neonatologiya (Bazhanov NP). - T. I. - 2004
76.Prikaz MZ № 500 "On the reorganization of maternity hospitals to improve the efficiency of
perinatal care and the prevention of nosocomial infections."
77.Partogramma/Sherbaeva DB, Ayupova FM, FI Shukurov / Metod.rekomendatsii. Tashkent2005. 28C
78.Uchebnaya birth history / Sherbaeva DB, Ayupova FM, FI Shukurov / Metod.rekomendatsii.
Tashkent-2005. 13C
79.Prakticheskie skills in obstetrics and gynecology / Me-tod.posobie / / Tashkent 2008.
80.Internet sites:
http://www.studmedic.narod.ru/, http://med.siteedit.ru/,
http://www.rukovodstvo-po-akusherstvu.-uchebnoe-posobie.html, http://www.materinstvo.ru,
http://mama.ru.http://www.art-med.ru,, http://www.doctor.ru, http://www.rodim.ru,
http://mamka.ru
http://medagent.ru, http://www.art-med.ru, http://www.medsan.ru,
http://mediki.spb.ru, http://medinstitut.e2e.ru, http://www.medstudy.narod.ru
http://www.obgyn.ru, http://www.medsno.ru, http://medrusnet.euro.ru
www.medtext.ru, www.medpoisk.ru, www.medicum.nnov.ru/student/
http://6years.net/, http://preryvanie-beremennosti.pharmabort.ru/
http://med4net.ru/, http://www.med-life.ru/, http://www.pregnant.ru/
http://www.roddom.ru, http://www.medpoisk.ru/, http://www.medlinks.ru
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Subject: miscarriage, premature birth, antenatal-st rupture of membranes: causes, diagnosis, management tactics perenashivanie pregnancy, induction of labor: indications,
techniques.
1st place of training, equipping,
 Department of Obstetrics and Gynecology, the audience;
 dummy pelvis, female pelvis, doll fetus;
 standard models of pregnancy;
 the classic model of labor;
 gynecologic simulator ZOE;
 childbirth simulator Noelle;
 simulator newborn Newborn;
 set of slides on the topics of discipline;
 methods work in small groups: the method of the incident, "a round table" problem solving,
"pen in the middle of the table", "swarm", etc.;
 testing and teaching practical skills in OSKE (objective structured clinical examination).
 video, TV, TV;
 personal computer (Pentium-III);
 set of slides with typical conditions for ultrasound scanning of pregnant women and gynecologic patients;
 set of video blogs "VJOG" (USA), highlighting recent advances in diagnosis, treatment of obstetric and gynecological conditions;
 set of movies and video with a demonstration of typical obstetric and gynecological procedures
and operations.
 multi media training and testing;
 the use of e-mail and INTERNET;
 business simulations and case studies;
 center for skills training;
 offices and laboratories maternity complex;
 measuring tape, a stethoscope;
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 delivery room
 set of test items.
 the department of pathology of pregnancy,
 postpartum room and chamber,
 child emergency room, delivery room
 set of test items.
 set of slides, overhead projector.
 tools used during delivery
 diagram of the main stages of the diagnostic process
 step by step implementation of clinical skills of neonatal resuscitation.
2.Prodolzhitelnost study subjects
Number of hours, 5 hours
3.Tsel classes
 define perenashivanie;
 to teach students the principles of diagnosis;
 educate management of pregnant women with pregnancy perenashivanie STI;
 give an idea of induction of labor;
 define miscarriage;
 give an idea of premature rupture of membranes;
 educate management of pregnant women with miscarriage-STI;
 clear definition of abortion and preterm birth;
 teach students prevent complications.
Tasks
The student should know:
 diagnosis of post-term pregnancy,
 differential diagnosis of post-term pregnancy and prolonged pregnancy
 tactics of pregnancy and childbirth,
 complications during pregnancy and childbirth from the mother and the fetus,
 signs of over-ripe fruit and newborn.
 the causes of miscarriage, diagnosis and treatment and methods of delivery in premature birth
pregnancy
 signs of prematurity, complications of the mother and fetus,
 prevention in both pathologies.
The student should be able to:
Determine the due date, plan preparation for childbirth, interpret the data and ultrasound
kolpotsitogramm in preterm and term pregnancy, stages of premature birth, methods and timing
of delivery.
4.Motivatsiya
Post-term pregnancy, and premature birth pregnancy is a problem of great scientific and practical
interest in obstetrics. Its relevance due to the large number of complications in childbirth, high
perinatal mortality.
Intra 5.Mezhpredmetnye and communication
Of teaching of the subject is based on the knowledge of the students basic anatomical mission,
topographic anatomy, histology, normal and abnormal physiology, endocrinology and microbiology ..
Acquired during the course knowledge will be used during the passage of endocrinology, internal medicine, surgery, pathological obstetrics, gynecology, obstetrics, gynecology, hematology,
health, therapy, pediatrics.
6.Soderzhanie classes
6.1Teoreticheskaya part
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Prolonged pregnancy
Perenashivanie pregnancy is a problem that is of great scientific and practical interest. Relevance
due to its large number of PWM complications in childbirth, a high percentage of rodorazre impeding the operations, high perinatal mortality. Many GPs ¬ dew of this disease has not yet been
resolved. To date, the lack ¬ exists even a clear definition of prolonged pregnancy.
Most obstetricians believe post-term pregnancy, the duration of which is longer than the normal
10 - 14 days, or is 290-294 days. However, the fruit is born with a prize ¬ nakami ripeness only
third delayed deliveries. Therefore, not in every case perenashivanie threatening to the fetus. It is
known that the fetus may be born with signs of over-ripeness and during pregnancy, having a
duration. Least 294 days. Appar ¬ ently time for the final "maturation" of the fetus varies over a
wide ¬ rokih limits. Therefore, we can assume that perenashivanie pregnancy (running) and
overripe fruit - have no ¬ equivalent. At the same time found that as the frequency of the symptoms of pregnancy perenashivanie ripeness in the fetus is increased, it was found that not only
the post-term children with signs of over-ripeness, but without them begin to suffer as more time
perenashivanie.
Consequently, post-term pregnancy can not be regarded as a random ¬ vatsya variation of normal pregnancy, and her right ¬ Villeneuve regarded as pathological phenomenon due to certain
characteristics, depending on the state of the body of both the mother and fetus.
Thus, we should distinguish between the true (biological) transferred nashivanie pregnancy and
imaginary (chronological) or prolonged ¬ bathroom pregnancy.
Truly post-term pregnancy should be considered, which lasts 10-14 days after the expected date
of birth (290-294 days). A child is born with signs of over-ripeness (syndrome Bellentayna Runge), and his life is in danger (fetal distress). Usually in such cases, there is a change of placenta (petrifikaty, fatty degeneration, etc.).
Prolonged, extended, or physiologically, should be considered pregnancy that lasts more than
294 days and ends with the birth of a full-term, functionally mature child with no signs of overripeness and the danger to his life.
In the absence of consensus about what kind of post-term pregnancy is considered, in the literature there are very conflicting information about the frequency of perenashivanie. According to
many authors, perenashivanie frequency ranges from 1.4 to 14%, making it an average ¬ 4%.
Premorbid background for perenashivanie pregnancy are as endocrinological pathology, disorders of lipid metabolism, trauma, and transferred earlier childhood infectious diseases (scarlet
fever, mumps, rubella, etc.), which play a significant role in the female reproductive system, as
well as a number of extragenital diseases .
Numerous works revealed that perenashivanie pregnancy contribute infantilism transferred abortion inflammatory diseases of the internal genital organs, which cause the neuromuscular system
of the uterus and lead to endocrine disorders ¬ nym.
We have established menstrual function in 29.2% of women ¬ communities with post-term
pregnancy, 18.5% - in prolonged and 6.6% - at term. It is important to note that good-quality
breast disease, the development of which is to a large extent associated with hormonal disorders,
and diseases of the adrenal glands in prolonged pregnancy vstre ¬ tory more often.
Hypertensive condition during pregnancy in post-term pregnancies observed in 25.5% of women
in prolonged - at 20.9% at term - 8.66%.
Attracted the attention of research points to the value-governmental hereditary factors and the
role of the immune response in perenashivanie pregnancy. In particular, consider that
perenashivanie pregnancy occurs under the influence of factors that reduce the manifestations of
trans-placental immunity. Therefore, we can assume that the imbalance in the ratio of reaction
transplacental immunity and immunological tolerance can lead to a long delay graft (the fetus) in
the mother's body, that is, rise to perenashivanie pregnancy.
Particularly noteworthy are the data that are quite different from the standpoint of reason can explain perenashivanie. Thus, some authors believe perenashivanie pregnancy result ¬ sheniya violation of pituitary-adrenal system of the fetus. They suggest that due to the specific perenoschen172
nost Zabo ¬ eases the fetus, and not just "aging" placenta. Confirmation of the role of the fetus in
pregnant perenaschivenii is the fact that the defects in the fetus in this condition occurs frequently. According to our data, the frequency of congenital malformations in children with prolonged
pregnancy was 9.2%, with prolonged - 1.8% at term - 3.3%. Malformations of the brain (anencephaly, hydrocephalus, microcephaly), Down syndrome, and renal tsolikistoz observed only at
term pregnancy.
Study of the pathogenesis perenashivanie pregnancy is of great importance for the successful solution of the issues of prevention and treatment. Unfortunately, current data on the pathogenesis
perenashivanie restrict ¬ are bounded and contradictory. There are several theories of re ¬ Wearing pregnancy. Some supporters of the theories are based on the features ¬ sion of individual development of a fertilized egg, ¬ sion hereditary or constitutional factors, supporters of other basis
for taking neurogenic and hormonal disorders. Any concept, of course, has its own evidence, but
none of them gives a full explanation of origins-term pregnancy and first of all, the changes de ¬
mechanism offensive timely delivery. Indeed, perenashivanie pregnancy - this is essentially a
temporary untimely (late) onset of labor, so it is logical to assume that the pathogenesis
perenashivanie directly related to the mechanism of delivery. In this regard, we consider it appropriate to consider the pathogenesis perenashivanie. position of modern ideas about the causes
of the onset of labor.
Leading role in the neurohumoral regulation of the functional state of the uterus, including labor,
are the hypothalamus and limbic structures of the complex, especially almond core and crust
formation, located in the temporal lobes of the cerebral hemispheres. Regulatory effect is not excluded and other cortical structures in the hypothalamus and pituitary gland, carried by cortical
pathways through humoral transmission. Ovary, placenta, and other endocrine glands also have
an effect on the motor function of the uterus. However, the main pathogenetic ¬ cal moments
leading to perenashivanie pregnancy YaV ¬ lyayutsya functional changes in the central nervous
system. In the follow up study ¬ native authors conducted in the 50's and 60's, when it was noted
perenashivanie pregnancy change electroencephalography, indicating no evidence of SFOR ¬
normalized dominant clan.
In the regulation of labor is of great importance as the uterus receptor effector. Found that the
stretching of the uterus YaV ¬ it possible one of the factors contributing to onset of labor.
According to N. Vorherr (1975), the expected birth of local incentives myometrial activity (estrogen, etc.) reduced inhibitors (progesterone, etc.) - is raised.
Neyrogistologicheskimi research Baksheeva NS et al (1969) found that in the muscle of the uterus during post-term preg ¬ sion an abrupt disruption of neural structures, as compared to fullterm pregnancy, that in some way this body denies the possibility of synaptic transmission of
nerve stimulation .
In pregnancy, it reaches, the development and nature of labor plays a major part estrogen, guestgenes, corticosteroids, human chorionic gonadotropin, placental lactogenic ¬ Nome, oxytocin,
acetylcholine, serotonin, kinins, prostaglandins, enzymes, electrolytes, trace elements, vitamins,
etc .
Most researchers believe that estrogen levels play an important role in the onset of labor, but
they are not pre ¬ Vym factor in this process. Estrogens play an undeniable role in the increase in
the excitability of the uterus, cervix and induce the maturation of soft birth canal preparation for
childbirth, they inhibit oksitotsinazy, thus preventing endogenous oxytocin on of destruction.
Oksitoticheskoy increase blood activity accompanied by a decrease in cholinesterase activity and
an increase in the concentration of free acetylcholine, has a powerful contractile activity.
Most authors consider that the expected birth characteristic sharp decrease excretion of estriol
and insufficient stabilization of uterine estrogen hormones. When prolonged pregnancy and reduced the number of estrogen receptors.
Numerous studies have shown that the synthesis of estriol carries out in the fetoplacental system.
The synthesis begins with dehydroepiandrosterone (DHEA) in the adrenal glands of the fetus,
which is hydroxylated in the liver to 16-dehydroepiandrosterone (DHEA-16), and the placenta
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becomes estriol. Only small amounts of DHEA and DHEA-16 formed in the body of the mother.
Found that fetal abnormalities, especially of the central nervous system, with severe lesions of
the adrenal perenashivanie lead to pregnancy. Thus, we can assume that the reasons tolerated ¬
shennoy pregnancy are often associated with the fetus and placenta, and not with primary uterine
inertia.
It is of interest to elucidate the role of progesterone in the development of labor and
perenashivanie pregnancy. Numerous studies show that the concentration progeste-tron in the
blood plasma, amniotic fluid and placenta increases with gestational age. Several authors have
not established especially ¬ Byh changes in progesterone and pregnanediol in labor, but this does
not prove the role of progesterone in the development of labor. Deserves attention to suggestions
by some researchers to consider not the absolute amount of progesterone in the blood, and the
quantity ratio of estrogen: progesterone or an inverse relationship. According to our data, the ratio of progesterone: estrogen was highest at-tolerated shennoy pregnancy (41,3:1), whereas at
term it was 10,7:1, if prolonged - 7,7:1.
There is no consensus on the role of corticosteroids in perenashivanie preg ¬ nancy missing, although most authors point to their reduced content of at perenashivanie.
When prolonged pregnancy found insufficient con ¬ tration of oxytocin, which tend to explain
the increased activity oksitotsinazy or perhaps low production of oxytocin in normal or low activity oksitotsinazy.
Catecholamine excretion in perenashivanie significantly reduced. This points to the functional
changes in the sympathetic-adrenal system, which undoubtedly plays a role in the onset of labor.
In recent years, much attention is paid to the role of prostaglandin-DIN in the regulation of labor.
When perenashivanie con ¬ centration of prostaglandin F2K in amniotic fluid by more than 2
times lower than at term. Due to the fact that prostaglandins are stimulators of uterine contractions, it is possible that a decrease ¬ weighted their synthesis or release from a bound to proteins
and the last weeks of pregnancy is one of the causes of untimely ¬ alternating labor. This assumption is confirmed by the lack of offensive ¬ given birth at term pregnancy, regularly receiving acetylsalicylic acid, an inhibitor of prostaglandin synthesis.
Important in the development of labor attach enzymes there that as catalysts play an important
role in the energy of intracellular processes and neurotransmitter metabolism. When
perenashivanie revealed increased activity of a thermostable alkaline phosphatase and lactate dehydrogenase (LDH) in serum and amniotic fluid.
When prolonged pregnancy stimulates glycolytic processes, leading to the accumulation of lactate, acidosis and energy shortages. Empowered anaerobic respiration is accompanied by decreased urinary excretion of catecholamines and estrogen levels decrease SH-groups, elevated
LDH, ¬ zheniem reduce concentrations of a number and an increase in oxidative tsikloferaz
Rs02-eat ¬
The uniformity of the exchange reactions of some weakness in the labor activity and
perenashivanie pregnancy suggests that the mechanisms leading to the occurrence of these complications have common patterns.
A number of researchers found that the level of electrolyte in the cell and the extracellular environment at perenashivanie pregnancy is in a ratio that does not provide a process of cell membrane depolarization and retards the development of labor.
One of the factors contributing perenashivanie pregnancy is a reduction in the blood, placenta
and myometrium of minerals, such as copper, manganese, zinc, which is associated with an increased elimination and insufficient intake of the food in the body were women.
It is believed that perenashivanie vitamin deficiency also contributes new ¬ C, group B, P, E.
To clarify the pathogenesis of post-term pregnancy is very important to study functional and
morphological features of the myometrium and placenta. In true perenashivanie in the muscle of
the uterus is a slight decrease in glycogen, RNA, individual activity of oxidative enzymes and a
significant reduction ¬ tion of succinate dehydrogenase activity in the wall of the large blood
vessels, which constitutes a violation of metabolic and biosynthetic processes in the muscle. Ap174
parently, changes in the rates of biochemical processes in the post-term pregnant myometrium in
¬ sion is one of the reasons for the delay of generic figure ¬ sion, and in childbirth - the cause of
various abnormalities of contractile activity ¬ sequences.
Many authors to compensatory reaction of post-term pregnancies were education of "young villi"
in the placenta, hyperplasia of the capillaries, increasing the number of small, closely spaced
terminal villi.
BI Iron et al (1975) found no perenashivanie with pronounced growth "young villi", but notes the
hyper-perplaziyu and increased blood circulation in the capillaries in the terminal villi capillaries
with the approach to education and plazmodiotrofoblastu sintsitiokapillyarnyh membranes. This
fact the authors are considered as a manifestation of compensatory reactions.
The contradictory results obtained by several authors in the study of the placenta in
perenashivanie, apparently, can be explained by the lack of separate consideration in the analysis
of post-term and prolonged pregnancy.
According to our data, myometrium and placenta in prolonged pregnancy are not clearly defined
macroscopic and microscopic differences between the placenta at term. When histology-agency
study of placentas at term pregnancy showed reduced activity of a number of redox enzymes,
glycogen, lipids, neutral mucopolysaccharides and the accumulation of acid mucopolysaccharides, which indicates the violation ¬ shenii carbohydrate metabolism in the placental tissue. This
suggests that the metabolic disturbances found in the placenta at perenashivanie, are one of the
links in the chain of changes leading to the emergence and development of this pathology ¬ gies.
Thus, the etiology and pathogenesis of perenashivanie preg ¬ sion should be viewed as the result
of the interaction of many factors. The leading role in this complex chain belongs to the neurohumoral regulation, the functional state of the central nervous system (especially the hypothalamus, pituitary gland, the limbic system), uterus and fetus.
Background for the emergence perenashivanie pregnancy are numerous factors that have an adverse effect on the reproductive function of women. Perenashivanie pregnancy contribute to later
puberty, menstrual function of childhood acute infectious diseases (scarlet fever, measles, rubella, mumps), influenza, associated extra-genital diseases, metabolic disorders, endocrinopathies,
elderly primiparas (over 30 years) an indication of the re-nashivanie pregnancy history, transferred gynecological diseases, etc. are also essential condition of the fetus and placenta. Contribute perenashivanie fetoplacental system disorders, and balance the major hormonal and humoral
systems.
When violations of the pituitary-adrenal system of the fetus, particularly evident in the anomalies
and defects of its develop-ment, changing the synthesis of estrogen, progesterone, oxytocin,
which contributes to the preparation of the body for labor. At the onset perenashivanie pregnancy
are important and biologically active substances, such as catecholamines, prostaglandin Dina,
serotonin, kinins, in addition, and electrolyte imbalance of the body. Less certain of hereditary
and immuno ¬ logical factors.
The changes observed in the placenta during pregnancy perenashivanie ¬ sion, apparently secondary. But in the future, they have an effect on steroidogenesis, as well as the status of the fetus
and the emergence of labor activity. Placental insufficiency leads to metabolic disorders in the
fetus. Because of the close relationship of the fetus and placenta of fetal reduction life negatively
reflect ¬ mapped onto function of the placenta. This creates a vicious circle patho ¬ cal processes
inherent in prolonged pregnancy.
Clinic and diagnostics
Clinical symptoms of post-term pregnancy pronounced softly, so its diagnosis is very difficult.
The diagnosis of post-term pregnancy is typically based on anamnesti ¬ cal and objective data,
clinical, laboratory and instrumental studies. It is very important not only to establish the existence of chronological perenashivanie pregnancy, but also to identify its nature, that is, to establish whether there is a true perenashivanie or prolongation of pregnancy. The diagnosis is confirmed perenashivanie ¬ give or reject after birth during the inspection of the child and the placenta.
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Gestational age is determined by the date of last menstrual period and fertilizing intercourse the
day of ovulation expected given the first appearance in the antenatal clinic, the first fetal movements, the results of objective research, formulas Skulsky, Figurnova, Libov, Rudakov, Jordan,
according to the ultrasound scan. In practice, very easy to determine the gestational age and expected date of delivery to use standard "Pregnancy Calendar". The estimated gestational age,
hence, and perenashivanie pregnancy should be as Aggregate-kupnosti data. Much attention in
the diagnosis deserves data obstetrical examination. One of the symptoms of ne-renoshennoy
pregnancy is to reduce the circumference of the abdomen. Along with the decrease in abdominal
circumference observed for ¬ support the growth of body weight a pregnant woman, followed by
a crust ¬ Paet its sharp decline, which could reach 1 kg or more (weighing ¬ tion should be carried out on pregnant women of the same scale and in one ¬ kovyh conditions ). Weight loss in
pregnant perenashi ¬ vanii some authors associated with a decrease in fetal weight, the other with a decrease in body weight the pregnant.
In the dynamic observed for increasing the density of the uterus due to a reduction of amniotic
fluid and uterine muscle retraction. Oligohydramnios leads to some restriction of mobility of the
fetus. At vaginal examination usually mark an increase in density of the skull bones, narrow
joints and springs.
Changes in the nature of fetal heart sounds on auscultation (frequency, sonority, rhythm) specific
for post-term pregnancy ¬ sion, but rather evidence of fetal hypoxia caused by placental insufficiency. Often with post-term pregnancy ¬ sion marked increase or decrease the motor activity of
the fetus, as a manifestation of its intrauterine hypoxia.
In the diagnosis of pregnancy perenashivanie controversial is the value of the "maturity" of the
cervix. Her condition is an indicator of readiness for birth and prognostic tests of labor. "Maturity" of the cervix does not indicate the presence or absence of perenashivanie pregnancy and
therefore can not be used separately ¬ nized as a diagnostic test. According to our data, with the
expected birth of more than half of pregnant women is not marked "mature" the cervix, which
indicates a lack of readiness of the organism to the development of labor.
Thus, for a term pregnancy is characterized by a decrease in the abdominal circumference, oligohydramnios, decreased skin turgor, high standing of the uterine fundus, the lack of increase or
decrease in body weight pregnant, large size of the fetus and the restriction of its mobility particular, an increase in the density of the skull of the fetus, narrow seams race-prone, the changing
nature of fetal heart tones, strengthening or weakening of his movements, the frequent presence
of the "immaturity" of the cervix.
The clinical symptoms perenashivanie discovered after delivery, are signs of over-ripeness
(postmaturity) fruit and macroscopic changes in the placenta (petrifikaty). Signs and symptoms
of post-term baby are dark green color of the skin, membranes, umbilical cord, skin maceration
(a living child), especially in the arms and legs ("bath" of the foot and hand), reduction or absence syrovidnoy lubrication reduce subcutaneous fat ¬ tion fiber and wrinkling, decreased skin
turgor ("old" form of child) the large size of the child (less malnutrition), long finger nails, poorly expressed confi ¬ figuration head, thick skull, narrow seams and small time steps ¬ fontanelles. The fruit can be considered post-term (overripe), if there is a combination of at least two
or three of the above symptoms.
For the diagnosis and choice of optimal tactics preg ¬ nancy at perenashivanie can be successfully used laboratory ¬ Tornier, and special methods. One is the phono-and cardiotocography.
Analysis of electric and fonokardiograficheskih data revealed the most typical indications of the
true Shivani reconfigure their pregnancy. These include: 1) the mono ¬ monotonicity rhythm, 2)
Increasing the voltage of the gastric complex QRS (above 50 V), especially in the dynamics, at
least - reduce it (below 14 mV) for fetal malnutrition, myocardial hypoxia, disruption of the placenta; 3) R-wave splitting at the top, and 4) increase the duration of the QRS complex ¬ sequence of the fruit, and 5) non-uniformity of the amplitude tones at PCG, and 6) the presence or
absence of a perverted the fetal heart rate on respiratory samples.
For prolonged pregnancy is characterized by: 1) increasing the voltage of the ventricular QRS
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complex greater than 50 mV (this feature is found in 2 times less than the expected birth), 2) less
than the duration of the complex QRS (0,064 hours) than tolerated ¬ shennoy pregnancy, and 3)
increase in the ratio of systole to diastole (1:22). When prolonged pregnancy still 1:17, when donoshen Neu ¬ 1.02.
Thus, these electric and fonokardiograficheskih studies give evidence of the maturity of the fruit,
its functional ¬ tional condition and can be used in the differential diagnosis of post-term and
prolonged pregnancy.
In the last decade a lot of attention paid to the study of amniotic fluid (amnioscopy, amniocentesis). Changes in the composition of amniotic fluid reflects fetal metabolism, functions ¬ tional
state. The pathological condition of the fetus or placenta amniotic fluid exchange is broken and
come deter ¬ rms quantitative and qualitative changes in the amniotic fluid. Growing at the expected birth placental insufficiency can also be accompanied by a pronounced disorder exchange
of amniotic fluid.
One of the signs that indicate the true perenashivanie pregnancy is to reduce the amount of amniotic fluid, which clinically manifested a decrease in the uterus, abdominal circumference and
height of standing uterus. Reducing the number of amniotes-cal liquid usually determined indirectly by carefully
Dynamic daily measurements of abdominal circumference and height of standing uterus, as well
as daily weighing pregnant. Determination of the amount of amniotic fluid with high accuracy
became possible after the introduction of obstetric practice transab-dominalnogo amniocentesis
and the introduction of chemicals into the cavity of the amnion. The greatest amount of amniotic
fluid is observed at 38 weeks of pregnancy, then it decreases rapidly (by an average of 145 ml
per week), reaching the 43rd week of pregnancy, 244 ml. It is believed that the decrease in amniotic fluid is a sign of placental dysfunction and biological perenashivanie pregnancy.
Valuable information can be obtained when using the amnio-scopy. According to our data, the
meconium and opalescent near-fetal water during prolonged pregnancy observed in three women. In the early stages perenashivanie amniotic fluid becomes cloudy, opalescent due to exfoliate
the epidermis of the skin, in the later stages of cereals syrovidnoy grease meconium stained
green.
One of the important criteria for the duration of pregnancy and the fetus is the number and size
of flakes syrovidnoy grease. It turned out that the absence of the latter the most frequently observed ¬ given at term pregnancy. It is interesting to determine the degree otslaivaemosti ¬ tion
shells of the lower pole of the amniotic sac from the uterine wall as an indicator of readiness of
the organism to the come ¬ leniyu birth. Most otslaivaemost shells (4 cm or more), there is at
term, the lowest - in the post-term preg ¬ nancy.
Amnioscopy is a fairly reliable method for diagnosis of over-wearing of pregnancy. Amnioskopichesky control when suspicious and cor ¬ rhenium on perenashivanie pregnancy should
be carried out with a 2-daytime ¬ GOVERNMENTAL gap. Data interpretation amnioscopy
should be implemented in co-delivered with the data of clinical and other research methods.
Of considerable interest is the study of amniotic fluid. Based on the physico-chemical and biochemical it yet ¬ indicators to judge the status of the fetus and its degree of maturity.
To assess the maturity of the fetus can also use the definition of the osmotic pressure of the amniotic fluid. Its value is equal to ¬ tion 250 mOsm / kg, sufficient evidence of maturity of the
fruit. At term pregnancy in connection with the re-absorption of "amniotic fluid osmotic pressure
decreases.
An indicator of the degree of maturity of the fruit is the concentration of creatinine in the amniotic fluid. When 'perenashivanie preg ¬ sion, it increases. Of great importance is the determination
of the concentration ¬ tion of urea in the amniotic fluid. Its value is in excess of 3.8 mmol / L,
indicating perenashivanie.
In order to diagnose disorders of the functional state of the fetus and its degree of maturity can
determine the total protein concentration in the waters. When she perenashivanie almost 50%
higher than in full-term and prolonged pregnancy.
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The degree of maturity of the fruit, many authors recommend is defined as the ratio between
lecithin and sphingomyelin (L / S).
Special attention should determine the content of products of carbohydrate metabolism (glucose,
lactate, pyruvate) in amniotic liquids ¬ ty. The concentration of glucose in the post-term pregnancy (0.63 mmol / L) compared with that of full-term and prolonged preg ¬ nancy on average
40% lower. Reducing the concentration of glucose, seems to be explained compensatory ability
of the fetal liver convert glucose from glycogen in the amniotic fluid, which is stored in the liver
and then in the form of glucose into the bloodstream of the fetus.
The concentration of lactic acid in the amniotic fluid during pregnancy shennoy-tolerated (5.91
mmol / L) increased approximately 2-fold compared with that of full-term and prolonged pregnancy, which can be attributed to the high activity of LDH. ¬ cheniyu increase of lactic acid also
contributes to increased motor activity in fetal hypoxia.
In recent years, determining the degree of maturity of the fruit and its functional state of some
importance attached to the study of enzyme activity in serum and, especially, in the amniotic fluid.
To determine the function of the placenta and the fetus with suspected ¬ tion on perenashivanie
pregnancy is recommended to determine ¬ tion of estriol excretion in the urine. Estriolurii level
does not indicate a transition nashivanii pregnancy, and on placental insufficiency. Definition ¬
tion of estriol in the dynamics allows you to set the transition chronological perenashivanie in
biological. Lower limit of physiological estriolurii -41.6 mmol / day. The fall in estriol to this
boundary suggests that the fetus is in danger. Reduction of estriol on 60% or more of its provisions indicate the presence of placental insufficiency. With low estriol in prolonged pregnancy is
correlated not only a high-ante and intranatal mortality, and increased neonatal morbidity and
mortality. This is determined by the fact that the term pregnancy showed a reduction of estriol in
amniotic fluid and blood.
Thus, in post-term pregnancy has been a drastic reduction in the concentration of estrogen, especially estriol in urine, amnio-optical fluid and blood.
Decreased and the content of pregnanediol in the urine, indicating that Pla tsentarnoy failure.
Pregnanediol content decreased and the amniotic fluid.
For the diagnosis of post-term pregnancy is very informative cytology of amniotic fluid. At term
the number of fat cells is approximately 20%, with post-term - more than 59%.
Cytological examination of vaginal smears - a valuable diagnostic method is successfully applied
not only to recognize the re-nashivaniya pregnancy, but also to assess the functional status of the
fetus and placenta. Cytological perenashivanie sign of pregnancy should be considered as a prolongation of III-IV tsitotipa vaginal smear.
One of the objective methods for determining the maturity of the fruit is ¬ Xia ultrasound. The
characteristic ultrasound with ¬ signs of post-term pregnancy are thinning placental calcification
and its increase in size, oligohydramnios, lack of growth of the fetal head biparietal diameter,
thickening of the skull bones, the larger the size of the fetus.
To establish a biochemical term pregnancy, mountain monalnye, cytological and instrumental
investigations should be carried out in the dynamics of an interval of 24-48 hours
However, not all of the above methods are the same diagnostic value, so a comprehensive evaluation of the data is of particular importance. We recommend the following scheme of examination for suspected perenashivanie pregnancy: the determination of the duration of pregnancy
based on history and formulas Naegeli, ('Kul, Jordan, "Pregnancy Calendar" and others, holding
onto the outdoor (standing height uterus, abdominal circumference and etc.) and internal ("maturity" of the cervix, the density of the skull of the fetus, the state of sutures and fontanelles) obstetrical examinations, conducting wieKTpo-and phonocardiography fetal amnioscopy use, sophisticated ultrasound scanning and kolyyutsitologicheskogo studies; determine the level of estrogens, especially estriol of progesterone, placental lactogen, production amniocentesis with
subsequent study of amniotic fluid (lactic acid, glucose, creatinine, total protein, the ratio of lecithin / sphingomyelin, etc.), the use of oxytocin and nonstress tests.
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In conclusion, it should be emphasized that ierenashivaniya pathognomonic signs, but there is a
syndrome by which you can make a diagnosis of post-term pregnancy. All of the above The
methods of research with different probability can judge the degree of maturity of the fruit, its
functional status, assess the function of the utero-placental system. Based on these data, given
the chronological perenashivanie can diagnose ne-renoshennoy or prolonged pregnancy.
Induction of labor: the definition
Induction of labor is the activation of the uterus to initiate labor, aimed at ensuring the child's
birth at a particular point in time, when they are out of the uterus is more secure for his life than
in utero. This includes cases where the bag of waters is intact, and with preterm rupture of membranes without labor. As in any other way, induction of labor may have undesirable consequences. Induction of labor is indicated only in cases where it is determined that the potential benefit
to the fetus or the mother outweighs the potential risk to health in the case of delayed delivery.
The possibility of induction of labor should be considered only in cases where vaginal delivery is
expected the most adequate means of birth.
Induction of labor is widely applied in the early 50's. after receiving the synthetic oxytocin. The
number of cases of induction varies in different settings and countries, and has tended to increase. Recent years have seen a significant insight into the mechanisms of childbirth.
It is important that the cervix is "ripe", was soft before induction of labor. Cervical ripening is
due to many factors. Intermediaries in this process are prostaglandi HN-E2 (PGE2) and F2alfa
(PGF2alpha). Exogenous application of these compounds stimulate the process of cervical ripening. Endogenous and exogenous oxytocin is a major stimulator of uterine contractions. It also
stimulates the production of PGE2 and PGF2alpha.
Should distinguish between induction of labor and gain (stimulation) family activities: both use
similar approaches, but in the first case is to onset of labor, while in the second - this increased
uterine contractions after the spontaneous onset.
Sledet not consider induction of labor simple procedure, because it can be dangerous for both
mother and fetus.
Of labor may be induced after careful consideration and weighing of the potential risks of pregnancy and the risk of further induction of labor. The frequency of induction of labor varies in different settings and geographic regions, and even within the same country. In 1994 in the UK
study was conducted, which showed that among mothers who gave birth in a hospital, the frequency of induction was 19%, while for women giving birth at home this figure was only 0.2%.
According to published reports, he is in the range of 0% to 30%.
The frequency of induction of labor in the U.S. was 9.6% of 5418 planned home births, 21.0% of
births to women with no additional risk factors in maternity homes, and 44% of births to women
of different risk groups in maternity hospitals. There were no significant differences in the level
of fetal and neonatal mortality rates among the three groups were found.
The indications for induction of labor
Induction of labor is shown in those cases where it is determined that it will bring more benefits
to the fetus and the mother in terms of possible health effects compared to delayed delivery.
Induction of labor at term pregnancy
Studies have shown that maternal morbidity and mortality in uncomplicated pregnancies after
increasing excess of the gestational age of more than 42 weeks. The risk of stillbirth at 37 weeks
is 1 in 3000, at 42 weeks - 3 by 3000 and a 43 week - 6 in 3000.
Ultrasound to confirm the pregnancy study be carried out before 20 weeks of pregnancy, as it
can reduce the need for induction of labor in the case of the imaginary term pregnancy.
Policy enforcement ultrasound examination in early pregnancy reduced the incidence of induction of labor (1.9% compared with 2.8% RR 0.69, 95% CI 0,58-0,82; NNT 111). These data
were obtained from four experiments on the effects of ultrasound for early examination of the
fetus in pregnant women.
Women with uncomplicated pregnancy induction of labor follows offer after 41 weeks of pregnancy.
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What are the results of induction of labor after 41 weeks of pregnancy? Routine induction of labor after 41 weeks of pregnancy was uneventful, reduces the risk of perinatal death (13 studies 6073 women, RR 0.23, 95% CI 0,06-0,90, NNT = 476). While also reducing the risk of meconium staining of the amniotic fluid (9 studies - 5662 women). The use of the standard procedure of
induction of labor does not affect the incidence of cesarean sections, vaginal births with surgery,
heart rate abnormalities during child birth, neonatal seizures and meet women from the process
of delivery.
After 42 weeks of pregnancy, women who refuse induction of labor, the need to strengthen antenatal care, including fetal electrocardiography and ultrasound study of amniotic fluid twice a
week.
Contraindications for induction of labor
Labor induction should be limited to situations where it is assumed that vaginal delivery is the
most appropriate method of delivery.
Contraindications to labor induction include situations presented in the slide, but not limited to
them
Conditions for the induction of labor
Before carrying out induction of labor, it is necessary to discuss the need for and possible consequences to the woman.
Labor induction should be done only after informed consent of the first woman. Informed consent should include the reasons for the induction of labor, the method to be used for this purpose,
as well as information about the risks and consequences of failure or decision of induction of labor.
Methods of induction of labor
By non-pharmacological methods of labor induction include finger detachment of amniotic
membranes and penetration of membranes.
For medical induction of labor can be used oxytocin and misoprostol, as well as other drugs. One
of these drugs is effective progesterone antagonist mifepristone (RU 486).
Finger detachment of membranes
The easiest way to detachment of amniotic membranes by carefully introducing the finger in a
sterile glove smeared antiseptic cream, the cervical canal. In the case of an experienced doctor or
midwife, this procedure should not cause significant discomfort. After 40 weeks of pregnancy,
such a procedure can reduce the need for additional induction twice, but when the term of 38-40
weeks, it does not significantly increase the number of women whose birth occurs during the
next 7 days.
Before the formal induction of labor, women should offer Finger detachment of amniotic membranes.
In the case of supply of finger detachment amniotic membranes during preliminary discussions
with the woman must explain that this procedure does not result in:
• Increase the likelihood of infection of the mother or fetus;
• It may cause some discomfort during the examination and blood-stye selection.
Conclusion:
• Detachment of membranes leads to a reduction in time to onset of spontaneous labor.
• Detachment of membranes reduces the likelihood of post-term pregnancy.
• Detachment of membranes reduces the need for the use of formal methods of induction of labor.
• Detachment of membranes associated with an increased feeling of dis-comfort in pregnant
women.
The dosage of prostaglandin
Suppository, controlled release consists of a polymer base containing 10 mg of dinoprostone, to
which is attached a thread of polyester for removal. This suppository releases 0.3 mg of prostaglandin E2 in the hour on a 12-hour period and is placed in the posterior vaginal fornix. Suppository is removed after the onset of labor, in the case of spontaneous breakage of membranes, in180
creased activity of the uterus or after 12 hours.
There are no randomized clinical trials that compared the effects would be the duration of the
interval of time which separates the application of oxytocin and prostaglandin gel. Intravaginal
dinoprostone manufacturer recommends interval of at least 12 hours, whereas the manufacturer
intracervical dinoprostone indicates the duration of the interval of at least 6 hours.
Amniotomy: advantages
Amniotomy (artificial rupture of membranes) is a fairly simple procedure that can be performed
without additional help other medical staff to induce labor if the conditions for its performance
(availability of membranes). Amniotomy avoids pharmacological effects.
The traditional way of induction of labor is to reveal fetal shells and discharge of amniotic fluid.
Front of water can be produced using a simple hook (Amnihook (EMS Medical Group)), a pair
of Kocher's forceps or a pair of special clamps to amniotomy. Selected products in a sterile environment is introduced into the cervical canal. By visual inspection is performed the autopsy of
membranes, leading to the rupture of the amniotic fluid. It should assess the color and size. Immediately after the hearing should then be the fetal heart rate to ensure the absence of any risk to
the fetus. Application cardiotocography recommended in severe cases.
At present, there is insufficient data to assess the effectiveness of amniotomy to induce labor.
One attempt was made comparing amniotomy with disposable vaginal prostaglandins in women
with mature cervix. The group, which produces amniotomy showed an increased need for oxytocin (44% to 15%; RR 2,85, 95% CI 1,82-4,46). The researchers concluded that amniotomy can
be used as a method of induction in the case when more modern methods are not available.
Amniotomy alone is ineffective in more than 50% of women with a mature neck. In such a situation is required oxytocin.
Amniotomy: deficiencies
Artificial rupture of membranes can cause a number of undesirable consequences. They include:
feeling pain and discomfort, uterine infection (which sometimes leads to sepsis), early fetal heart
rate decelerations, prolapsed cord, and bleeding due to possible damage to the blood vessels of
the fetal membranes, cervix, or placenta. Serious complications are rare.
Opinion that amniotomy may cause fetal heart rate decelerations, based primarily on the assumption of a possible pressed against the umbilical cord as a result of reducing the amount of amniotic fluid, but there is no evidence that such a threat is large enough to significantly affect the
choice of method of induction of labor.
Oxytocin
To reduce the frequency of adverse reactions should always use the standard dilution. Following
recommended standard dilution and dosage:
• 30 IU in 500 ml of isotonic solution, ie 1 ml / hour = 1 MED (milliED) per minute
• 10 IU in 500 ml of isotonic solution, at 3 ml / h = 1mED minute.
Marked increase in the number of successful deliveries in case of combined use of oxytocin and amniotomy. The limited contingent of women who participated in these studies does not
allow precise conclusions. When comparing the use of oxytocin and vaginal or intracervical
prostaglandin E2, marked increase in the number of caesarean sections, as well as several unsuccessful vaginal delivery. Such difference was found when comparing the use of oxytocin in
combination with amniotomy and use of prostaglandins. These data indirectly confirm the validity of oxytocin in combination with amniotomy in those cases where the pregnant woman is not
the integrity of the membranes.
Oxytocin: a way of
When comparing the use of oxytocin in small doses (the gradual increase in the low dose of the
higher) with large it was shown that:
• Low doses do not lead to an increase in the number of operational intervention in labor
• Gradually increase the dose of oxytocin from the small to the higher (not more than once every
30 minutes) rarely leads to uterine hyperstimulation
• The use of oxytocin in small doses is not accompanied by an increase in the duration of labor
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• Use of oxytocin in high doses leads to an increase in fast delivery
Meta-analysis has shown that this type of increase in the dose of oxytocin (not more frequently
than once every 30 minutes) observed:
• Reduce the incidence of uterine hyperstimulation
• Increasing the number of vaginal deliveries
• Reducing the number of cases of postnatal infection and bleeding
• Reduce the number of births by caesarean section
In most cases, the initial dose is 0.5 to 2.0 mU / min, with an increase of 1.0 mU / min double
every 30-60 minutes until the maximum dose of 16 to 40 drops / min.
Intravenous oxytocin
On the slide is a table with the recommended dosage of oxytocin. Gray highlighted dosage that
exceeds the recommended maximum in the annotation of the drug dose of 20 mU per minute.
To convert to an equivalent number of drops per minute (20 drops = 1 ml)
At a dilution of 10 IU oxytocin in 500 ml of isotonic solution - 1 mU = 1 drop
At a dilution of 5 units of oxytocin in 500 ml of isotonic solution - 1 mU = 2 drops
At a dilution of 5 units of oxytocin in 500 ml of isotonic solution - 1 mU = 4 drops
At a dilution of 30 IU oxytocin in 500 ml of isotonic solution - 1 mU = 3 drops
Other local reports of oxytocin for induction of labor should be:
• Keep information on doses administered drug (mIU per minute), and not on the volume of the
solution to pour (milliliters per minute)
• Carried out using infusion pumps.
Misoprostol
Misoprostol is an extremely effective way of induction of labor. Among other advantages of this
drug is the fact that it is much cheaper than other currently available tools of similar purpose, it
just keep it stable at room temperature. Ease of use can also be considered as its advantages, as
shown the efficacy and safety of misoprostol for oral administration.
However, misoprostol is associated with an increased risk of negative effects, and the optimal
dosage and mode of application has not yet been established. In addition, many countries have
not approved the use of this drug for induction of labor. Given the above reasons, the Royal College of Obstetrics and Gynaecology (RCOG) recommends limiting the use of this drug clinical
trials as long as there is no defined the optimal mode of his reception.
Misoprostol tablets containing 25 mg of the drug included in the main register of medicines
WHO.
Mode of administration of misoprostol in low doses (25 mg every 6 hours) was less effective
than taking increased doses (25 mg every 3 hours), with less frequent hyperstimulation mat-ki.
Thus, in spite of the high efficiency, low cost and ease of use of misoprostol as a means of labor
induction at this stage it can not be recommended for routine use. In addition, in many countries
it is not registered for use for that purpose.
Significant economic benefits and possible clinical E zoprostola determine the need for further
research to determine its safety.
Monitor the status of the fetus and the induction of labor
Assessment of the fetus - this is just one of the components of care during childbirth. This is an
important area where you want to pay due attention was the wishes and preferences of the mother and thus to consider the possible risks to mother and child. Provision of accurate informa-tion
in such circumstances is an important point that every woman could take for themselves the right
decision.
In the case of induction of labor should be made available funds for ongoing monitoring of uterine activity and fetal heart rate.
When labor induction vaginal prostaglandin (PGE2) monitoring of the fetus should be carried
out continuously since the discovery of the first battles.
For healthy women without pregnancy complications monitoring of the fetus after vaginal prostaglandin should include an assessment of the initial state followed by a continuous electronic
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monitoring of cardiac activity, and then, in the absence of abnormalities may be used periodically monitored.
After administration of prostaglandins, the woman should be offered to lay down and be in the
supine position for at least 30 minutes. Thus the control of the fetal heart is required only after
detecting the start of contractions.
In the case of oxytocin for induction or induction of labor, it is necessary to carry out continuous
electronic fetal monitoring.
Oxytocin is possible not earlier than 6 hours after the application of prostaglandins. It is caused
by a powerful stimulating effect on the uterus of oxytocin in combination with a prostaglandin.
Possible complications of labor induction
Rupture of membranes can cause bleeding because of damage undiagnosed placenta previa or
low placenta position.
There is evidence of uterine hyperactivity and reduced fetal heart rate associated with the stimulation of the nipples.
When using amniotomy for induction of labor, time to start the contractions are often unpredictable, it can be very long, but in combination with intravenous oxytocin, this method is sufficiently effective. Other potential hazards associated with amniotomy, include umbilical cord prolapse,
chorioamnionitis, strong compression of the umbilical cord, as well as the presenting vascular
injury.
Reported an increased level of maternal and fetal infection due to the use of kelp and hygroscopic cervical ripening compared with prostaglandin analogs E2.
In the case of vnutritservikalnogo gel with prostaglandin E2 in 1% of cases of uterine hyperstimulation, while in the case of intravaginal PGE2 gel or vaginal suppositories, the figure is 5%.
Side effects in pregnant women in the case of prostaglandin E2 in small doses (fever, vomiting,
and diarrhea) are observed less frequently than in the case of use of these drugs in high doses.
Examples tion of vaginal suppositories containing prostaglandin E2, in the third trimester increases the risk of uterine rupture. Manufacturers recommend caution on the use of prostaglandin
E2 in patients with glaucoma, acute disorders of the liver or kidneys, as well as asthma.
In the case of 50 mg or higher doses of misoprostol increases the likelihood of uterine hyperstimulation. The use of misoprostol in women with previous caesarean section births increases
the chance of uterine rupture. Misoprostol for the termination of pregnancy in the second trimester is also associated with an increased risk of uterine rupture, especially when used in combination with intravenous oxytocin. In addition, the use of misoprostol reported an increase in the
incidence of meconium getting into the amniotic fluid. Likelihood of complications increases
with increasing dose of misoprostol. Oral misoprostol is accompanied by much less abnormal
fetal heart rate and the incidence of uterine hyperstimulation versus vaginal use, but the data that
would allow us to recommend oral administration of misoprostol as an alternative, not enough.
Side effects of oxytocin is usually dependent on the dosage of the drug-focusing, the most common uterine hyperstimulation with subsequent reduction in fetal heart rate. Hyperstimulation can
lead to placental abruption or uterine rupture (quite rare). Water intoxication can occur in the
case of oxytocin in high concentration with large amounts of hypotonic solution. Antidiuretic
effect is usually observed only after prolonged use of oxytocin in the amount of not less than 40
drops per minute. Rapid intravenous oxytocin can cause a decrease in blood pressure.
In the event of increased uterine activity (especially in combination with a non reassuring fetal
heart rate level) should reduce the activity of uterine contractions. In the case of prostaglandins
(intravaginal or intracervical) to remove the remnants of the drug and stop using oxytocin, put
the woman on her left side and give her oxygen through a mask.
Increased uterine activity during the induction
Increased uterine activity (combined with modified as fetal heart rate or not):
Increased uterine activity without fetal heart rate changes includes tachysystole (more than 5
contractions in 10 minutes for at least 20 minutes) and gipersistolu / hypertonus (contraction that
lasts for at least 2 minutes).
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Uterine hyperstimulation with fetal heart rate changes mean uterine hyperstimulation syndrome
(tachysystole uterus or gipersistolu with fetal heart rate changes, in particular the persistent decrease in heart rate, or a decrease in the short takhikardiey HRV).
In the event of increased uterine activity with suspicion or pathology revealed by cardiotocography after intravenous oxytocin, decrease dosage or stop the introduction.
In case of deviations from the normal fetal heart rate and uterine activity increased, not involving
the use of oxytocin, it should consider the need to reduce the tone of the uterus.
The proposed impact - subcutaneous terbutaline to 0.25 milligrams.
In cases of suspected or confirmed a sharp deterioration of fetal delivery should be completed as
soon as possible, taking into account the degree of abnormality in heart rate and the corresponding figures of the mother. Accepted standard is to complete the delivery in an ideal situation for
30 minutes.
In the case of only prostaglandin debris removal of the drug can help ease the increased uterine
activity. However, you should avoid irritation of the vagina or cervix.
Induction of labor: a very important question!
The decision on the induction of labor should not be easy. To carry out the induction of labor
should be clear evidence necessary to assess the condition of the mother, as well as to choose the
method (medicine) with the biological fitness of the cervix.
Of miscarriage
Miscarriage spontaneous abortion believe it dates from conception to 37 weeks.
Premature birth - is a spontaneous abortion in the period from 22 to 37 weeks, when the baby is
born immature viable weighing 1000-2500 g, increasing from 35-37 to 47 cm
Habitual miscarriage believe repeated spontaneous abortion two times or more.
The frequency of miscarriage varies from 10 to 25% in the I trimester, it can reach 50% in the II
trimester - 20%, in the III trimester - 30%.
The causes of miscarriage are many and varied. Conventionally, they can be divided into the
following groups; pathological states women, immunological factors, genetic and chromosomal
abnormalities, environmental factors.
By pathological condition of the woman, in particular, the anatomical and functional changes in
the reproductive organs. Development of functional changes may contribute to infectious diseases, especially in childhood and adolescence, induced abortions, and inflammatory diseases of the
genital organs, impaired functional status of the endocrine glands (especially the pituitary gland)
after pathological birth, stress, common diseases. In 64-74% of cases the cause of abortion is the
ovarian hormone deficiency and placenta. By anatomical changes include genital infantilism
(underdevelopment of the uterus), malformations of the uterus (or horned unicorn, intrauterine
septum) istmikotservikalnaya insufficient accuracy, traumatic injury to the uterus in induced
abortion and childbirth, and various tumors.
Genital infantilism characterized by a combination of adverse such factors as sex hormone deficiency, hypoplasia of the uterus, the muscular layer of her inferiority, nervousness, etc.
For istmikotservikalnoy failure characterized inferiority ABILITY circular muscles of the internal os, which promotes failure of the isthmus and cervix. Distinguish between organic and functional istmikotservikalnuyu ¬ insufficient accuracy. Organic (anatomic, traumatic) insufficient ¬
sion is caused by traumatic injuries istmicheskogo department cervix during induced abortion,
childbirth large fruit, prompt delivery (forceps, vacuum extraction of the fetus, etc.). Functional
impairment due istmikotservikalnaya infantilism and hormone deficiency usually develop ¬
Vaeth during pregnancy and occurs more frequently than organic.
Traumatic injuries of endometrial and uterine receptor structures, inflammation, developing postabortion, is likely to disrupt the process of implantation and placentation and the coming of miscarriage. After instrumental curettage of the uterus, manual removal of placenta, suffering heavy
¬ logo endometritis may have intrauterine adhesions (adhesions), which are the cause of habitual
miscarriage. With uterine cancer with different localization of nodes and tumors of ovarian pregnancy may occur, but often it ends interrupt ¬ tion.
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Various inflammatory diseases of the cervix and vagina (erosion, cervicitis, colpitis) lead to anatomical and functional change neniyam female reproductive system, which in turn may be the
cause of in spontaneous abortion. A role in the latter belongs to the cervico-vaginal infections
(trichomoniasis, mycoplasma, chlamydia). Special attention honored ¬ ALIVE of viral infections
(rubella, salivary gland disease, herpes, influenza, hell ¬ novirusnaya infection, mumps, etc.),
agents that cross the placental barrier and actively proliferate in the placenta, damage ¬ gives to
it and causing intrauterine infection of the fetus . A role in miscarriage is flowing and latent infection (toxoplasmosis, listeriosis, rickettsiosis, chlamydia).
Neuroendocrine disorders (functional changes adrenal ¬ nicks, thyroid) are an independent etiologic factor abortion. Severe forms of extragenital diseases (decompensated heart disease, hypertension, bo ¬ is useful, anemia, pyelonephritis) contribute to the emergence of placental insufficiency, which leads to impaired fetal growth and nevyna ¬ Shivani pregnancy. According to the
literature, women with complicated pregnancies ¬ sion probability of premature births is 2 times
higher than in uncomplicated. In pregnant women with late toxicosis under-nashivaniya frequency is 24.7%, and the combined forms of toxicity, it is 3 times higher than in the "pure".
In recent years, much attention is paid to immunological abnormalities in the mother - placenta fetus. In some cases the observed decrease ¬ given immunosuppressive factors placenta that exists on sposobst ¬-torzheniyu fetoplacental complex and termination of preg ¬ sion.
Important role in the etiology of spontaneous abortion in early preg ¬ sion play chromosomal
abnormalities, resulting in death of the embryo.
When habitual abortion should check the terms of previous pregnancies interruptions, which can
be "critical" in subsequent pregnancies. When collecting history should find out how previous
generations proceeded at what period they occur, with what weight a child, there was no signs of
prematurity and hypo trophy.
Examination of women should begin with a general examination - she grew up, body weight,
correct body position and the development of secondary signs of O, with a marked character and
body hair, obesity. For proper evaluation should be used anthropological morfogrammu healthy
women to determine the type of teloslozhe (among women with miscarriage is more common
infantile type). Body type allows you to specify the metabolic and hormonal disorders. In establishing a disproportionate body types should include women at risk of pregnancy nevynashiva
NIJ and spend their hormonal examination.
When pelvic exam pay special attention to struc-tion of external genitals, the ratio of the length
of the body and cervix, identifying the signs of genital infantilism, congenital malformations, etc.
Special survey of women with miscarriage should be performed in a specific sequence.
Used for this purpose hysterosalpingography eliminates or detect the presence of congenital
anomalies of the uterus, genital infantilism A detailed, seam (adhesions) in the uterus, a condition Cervical department, the presence of uterine fibroids, internal endo-metriosis, endometrial
pathology.
Laparoscopy allows you to check the status of the uterus, ovaries, tubes matoch GOVERNMENTAL, the presence of adhesions in the pelvis, exclude or twist neck of the uterus and adnexal tumors, instead make minor surgical intervention. With hysteroscopy may be inspected
uterus with suspected pathological changes in the endometrium, the presence of submucosal fibroids, endometriosis internal body walls of the uterus and other pathology.
To reduce the tone and contractility of the uterus applied ¬ UT antispasmodics, which include
papaverine hydrochloride, no-spa, magnesium sulfate, etc. Papaverine hydrochloride administered as rectal suppositories containing 0.02 grams of the drug, 2-3 times a day, in tablets of 0.02
g 2-3 times a day, or injections of 2% solution of 1-2 ml of the skin. But-silos appoint 0.04 g 2-3
times a day, an injection of 2-4 ml of a 2% solution of intramuscular ¬ but 2-3 times a day. When
using magnesium sulphate applied ¬ nyayut 25% solution of 5.10 ml intramuscularly 1-2 times a
day. Tropatsin appoint 0.02 g 1-2 times a day after meals no more than 5-7 days.
At present, the combined treatment of habitual miscarriage include chayutsya immunosuppressive therapy aimed at reducing the immune response during pregnancy complications. Also use
185
desensitizing therapy (within 7 - 10 days administered diphenhydramine to 0.05 g / day 1-2
times, suprastin to 0,025 g / day 1-2 times, or Promethazine pipolfen to 0,025 g / d 2 times), placental gamma globulin. As a natural immunosuppressive drug used contains a high concentration
of immunosup-ressivnye substance. The drug is administered a single dose of 6.5 ml intramuscularly. Along with it for 8-10 days prescribed intended zolon to 0,005 g / d 2 times or dexamethasone to 0.0005 g / day 1-2 times. Treatment should be under the control of urinary 17-KS.
The leading role in treatment of threatening miscarriage in early pregnancy is hormonal therapy.
Its main conclusions of the principles are: 1) strong rationale for the use of hormonal therapy and
methods for monitoring the effectiveness of therapy, and 2) hormonal treatments administered in
minimal doses and mainly during the first 14-16 weeks of pregnancy, and 3) the use of a computer ¬ leksnoe sex steroid hormones (estrogens ¬ UT shall be appointed to the 5th week of
pregnancy, progestins used Minimum 8 weeks of pregnancy, or in combination with estrogen).
When the level of estrogen hormones recommended ¬ HN - mikrofollin 0.0005 g / day or ethinylestradiol to 0.0001 g / d for '/ r-' A tablet with a 5-week pregnancy progestin drugs you ¬ progesterone 0.010 g / day intramuscularly or turinal ¬ Table 1-2 yrs night from 7 to 8 weeks of
gestation. When the level of human chorionic gonadotropin administered injections of 750 IU of
hCG two pa ¬ per week to 9-10th week of pregnancy. At the peak of human chorionic gonadotropin on the 8-9th week of pregnancy, hormone therapy is usually not carried out.
In women with recurrent miscarriage and burdened ¬ nym obstetric history should be carried out
hormonal treatment of sex steroid hormones during the first 14-16 weeks of pregnancy.
When hyperandrogenism abortion caused anti-estrogenic effects of androgens. Corticosteroids
base ¬ but on the suppression of ACTH secretion, which leads to a decrease in androgen biosynthesis in the adrenal glands. Glucocorticoid treatment is initiated when a persistent elevated levels of 17-KS. Prescribed dexamethasone to 0.0005 g / day with a gradual reduction in dose to
normalize until ¬ indicators 17-KS. Hormone therapy should be discontinued at 32-33 weeks of
pregnancy in order not to suppress adrenal function of the fetus.
In connection with normal or slightly elevated progesterone levels in women with hyperandrogenism treat progestins inappropriate. When hyperandrogenism in conjunction with hypoovarian function and a marked reduction in the level of estrogen is necessary to combined treatment with corticosteroids (Dec-sametazon, prednisone) and estrogen (mikrofollin) in small doses, ranging from 5 to 6 weeks of pregnancy under the control of secretion of androgen new and
estrogens.
In II and III trimester of pregnancy for the treatment of miscarriage of pregnancy used allilestrenol (turinal) - a synthetic progesterone, belonging to the class norsteroidov. Drug normalizes ¬ em and stimulates steroidogenesis in trophoblast, increases the secretion of endogenous
progesterone and estriol. The drug is prescribed for 15-30 days 3 times to 0,005 g / d of pregnancy from 6 to 30 weeks.
In recent years in obstetric practice to suppress the decreased-inflammatory activity of the uterus
during pregnancy 20-37 weeks used beta adrenomimeticheskim means (tocolytics), which causes
relaxation of smooth muscles of the uterus.
In practice, the extensive use of ortsiprenalina sulfate (alupent), partusisten, ritodrin. Betamimetic means improving the utero-placental circulation, accelerate blood flow in the intervillous space and normalize the fetus. When ex ¬ adjoint clinical symptoms miscarriage treatment
tocolytics begin with intravenous 0.0005 g partusi-wall alupenta 0.0002 g or 0.001 g ritodrina
diluted in 250-400 ml fiz.rastvora. Drugs administered to 12-15 drops in Techa ¬ tion 6-12
hours, then pass on their oral administration, with a gradual reduction in dose. In applying tocolytics sometimes seen heartbeat, anxiety, some reduction choskogo-diastolic pressure, chills,
headache, nausea. In such cases, ¬ recom mended to use the calcium antagonist verapamil
(Isoptin) to 0.04 g / day 3-4 times. Contraindications for use of beta-mimeti ¬ České funds is
rupture of membranes, intrauterine infection, intrauterine fetal death, premature detachment of
normally situated placenta, diabetes, thyroid disease, various cardiovascular diseases.
Recently, the threat of abortion used prostaglandin inhibitors (indomethacin, aspirin, etc.). Indo186
methacin administered 1-2 times to 0.1 g / day. After the removal of the uterus gonusa on the
admission of the drug in tablets of 0.025 g every 6 h treatment duration of 7-10 days. Acetylsalicylic acid is used in the first two days of 0.5 g 2-3 times a day after meals. The duration of treatment 5-8 days.
Premature birth. Premature rupture of membranes.
Prematurity consider delivery in pregnancies of 22 to 37 weeks, the frequency of 5-8%.
Spontaneous preterm labor or antepartum Easley-ment of amniotic fluid (DIV) are responsible
for about 80% of premature births variables.
Preterm birth is the cause of more than 65% of the perinatal deaths and 50% of cases of CNS,
including cerebral palsy.
Risk factors for preterm birth
 Age 16 years and younger
 Low socio-economic status
 Low weight and growth rate
 Smoking
 Premature birth history
 Multiple Pregnancy
 Cervical incompetence
 uterine pathology
 Infection
 Bacteriuria
 Pyelonephritis
 Bacterial Vaginosis
 Pneumonia
 prenatal premature rupture of membranes
 Twins
 Polyhydramnios
Clinical management of preterm labor determined by the period of pregnancy, fetal weight, the
state of the cervix and the amniotic bubble ¬ series, the nature of labor, as well as complications
arising ¬ E in labor. Therefore, in preterm labor needs individual ¬ ideally suited to their jurisdiction.
To define the tactics necessary to answer the following questions:
-Is the patient in labor?
-There has been a rupture of membranes?
-Gestational age of the fetus?
-What are the risk factors?
Initial treatment
Define:
 The state fruit
 Proximity birth
 The ability of local resources
 Availability of safe transportation to the appropriate center
Transportation mother at less than 32-34 weeks of neonatal mortality by 60%.
All pregnant women with threatened preterm birth at 22 to 34 weeks is necessary to prevent corticosteroid:
- 2 doses of 12 mg betamethasone intramuscularly every 24 hours or
- 4 doses of 6 mg dexamethasone intramuscularly every 12 hours
Place for the reception of preterm birth should be prepared and equipped for the application of
urgent measures, and the temperature should be 28 ° C
At onset of labor at 22-34 weeks of pregnancy and no signs of fetal distress, and in general,
membranes, shortened cervix or opening it for no more than 2 cm, no signs of infection should
187
inhibit uterine activity with a 25% solution of sulfuric Magnesium (7 - 10 ml, 2 times a day), a
2% solution of papaverine (2 mL intramuscular ¬ muscular 3 times a day), beta-mimetic tocolysis means, antispasmodic, be prevented distress syndrome Roma dexamethasone and placental
insufficiency. Each week for premature birth, which can prolong the pregnancy is important because mortality and morbidity decreased with increasing period of pregnancy and fetal development.
Tocolytics should be used in cases where the gain in time will apply effective measures (such as
corticosteroids or transportation)
Routine administration of antibiotics for treatment and prenatal outpouring nedono-shennoy
pregnancy prolongs latency, reduces the frequency of neonatal sepsis, the child's need for oxygen
therapy, the frequency of the central nervous system abnormalities in newborns.
When started preterm labor at term of more than 34 weeks to prolong pregnancy impractical, labor should be managed conservatively.
In the case of premature discharge of amniotic fluid and incomplete pregnancy stored cervix during period up to 34 weeks of pregnancy, cephalic presentation of the fetus, there are no signs of
intrauterine hypoxia and infection, and severe obstetric and extragenital pathology shows expectant management of pregnancy and childbirth. These women are shown strictly ¬ nologies
bed rest, dynamic thermometry, the registration rate, fetal heart, antibiotics, tocolytics and corticosteroids to activate surfaktantnoi of fetal lung maturity. After reaching the 36 weeks period
and the relative maturity of the fruit taking medical labor induction and delivery through the
birth canal.
Deliveries should be conducted per vias naturales with antibiotics ¬ Cove and medication to regulate the decreased ¬ tive activity of the uterus, and the use of corticosteroids for fetal lung maturation.
When the occurrence ¬ rence of complications in childbirth, in particular on a roll loops cord,
acute fetal distress, premature detachment of the normal placenta located ¬ zhennoy that threaten
the life of the mother or the fetus, should be performed cesarean section.
For pregnancies over 34 weeks and breech presentation in women with recurrent pregnancy loss
and complicated the pregnancy rationally produce abdominal rodorazreshe ¬ tion.
The leading role in the prevention of miscarriage belongs clinic. Women with premature termination of pregnancy-to-date, in need of specialized care. To this end, prenatal create specialized
bathroom cabinets for the prevention and treatment of miscarriage of pregnancy.
In specialist doctor's office conducted the following activities: 1) identify and implement clinical
examination for women ¬ schinami with habitual miscarriage, 2) conduct spe ¬ tial examination
of women outside of pregnancy to determine the causes of spontaneous abortion, and 3) determine the risk of miscarriage, development complex therapeutic measures and tactics of the preg
¬ nancy according to the degree of risk, and 4) is admitted in the early and critical stages of
pregnancy ¬ cal and spend pathogenetic therapy.
Important section of the specialized studies are the development and implementation of measures
for the rehabilitation of women with recurrent miscarriage.
Complex of rehabilitation measures are calculated for one year and includes four stages.
In the first phase (first 3 months) underwent a comprehensive anti-inflammatory and restorative
treatment. For this purpose, use antibiotics, biogenic stimulators, immunomodulators, sedation,
different types of physiotherapy (ultrasound, diathermy, electrophoresis of drugs, etc.), spa
treatment, physical therapy.
In the second stage (4-6 months), applies special research in clinics and hospitals to establish the
causes of miscarriage. Conduct a survey on the tests of functional diagnostics, use hysterosalpingography, ultrasound and hormonal tests, hysteroscopy and endometrial biopsy, laparoscopy,
immunological, genetic studies, etc.
In the third stage (6-12 months) spend pathogenetic therapy: hormonal treatment for various neuroendocrine. disorders, surgical correction of isthmic-cervical insufficiency, and anomalies of the
188
uterus. Use different types of physical therapy and spa treatments.
In the fourth step, the hospital in the early, critically and individually critical periods pregnancy.
The following preventive and therapeutic measures directed-represented on the continuation of
the pregnancy.
Women with recurrent miscarriage I ¬ Mestre three shows early admission from the time of
pregnancy.
Critical stages of pregnancy are: a) the period nidatsii and implantation (first 2-3 weeks of pregnancy), and b) the period of placentation (4-12 weeks), and c) the period of slower growth of the
uterus and increase its distance ¬ ther volume (18-22 weeks). Hospitalization in these stages of
pregnancy is required.
Under the individual critical periods of pregnancy understanding ¬ UT offensive term miscarriage in the past, as well as the days corresponding to the period. In these terms hospitalization is
necessary.
The methodology of the business game "Round Table"
Progress:
1. All students of the draw are divided into three subgroups according to four students each.
2. Each subgroup sits at a separate table, prepare a blank sheet of paper and a pen.
3. Written on a sheet date, the group number, department, name participating students in this
subgroup (the name of the business game).
4. One of the participants in each group takes the question out of the envelope. The level of complexity of tasks for all subgroups is about the same.
5. Students rewrite their job on a sheet.
6. Embarks on a circle that sheet.
7. Each student writes down the answer and sends another Dist.
8. The response of each student is given 3 minutes.
9. After the time of the surrender teacher.
10. All participants will discuss results, choose the most correct answers for which to set the
maximum score.
11. For discussion to 15 minutes.
12. Students get points for answering the theoretical part of the rating classes.
13. Students with scores counted in the scoring for the current session.
14. In the lower part of the magazine is a free stamp on the game with the signature of elders.
15. Student work saved teacher.
The use of proverbs, specific to each country.
Objectives: Entertainment, concentration.
Means: Flipkarty, pens, envelopes, chairs.
Approximate time: 10 minutes.
The steps are:
1. At the beginning of the week as a warm, divide participants into groups of three or four. Ask
each group to write down a few sayings commonly used in their country. After 5-7 minutes, ask
participants to read their sayings. During the reading of the teacher should ensure that the entire
team understands each proverb. Save this list for another workout this week. Write each proverb
on a separate sheet of paper and put it in a separate envelope.
2.Cherez few days (for the third or fourth day of the week) Divide participants into two groups
and place them at opposite ends of the room.
3.Poprosite one representative from each group to reach the middle of the room and hand in an
envelope to the proverb. Representatives should read (silently) saying from his envelope and return to their groups.
4.Predstavitel each group should silently draw a picture, describe the preparation of the saying.
Figures should not contain words or parts of words.
5.Kazhdaya group must try to guess the saying, drawn by its representative. The group presented
its first guess the proverbial scores one point.
189
6.When how one group guessed their proverbial, both groups again to send their representatives
to the new center of the room for the envelopes with the sayings, and the game continues in the
same manner.
The event should last about 10 minutes or until all the sayings will not guess. The winner is the
group with a large number of points.
6.2Analiticheskaya part
Case studies:
1.Bolnaya 33 years appealed to the antenatal clinic complaining of the delay menstruation and
small pain in the abdomen and lower back. Last menstrual period was 4 months ago. Considered
herself pregnant. In the history of four pregnancies. The first pregnancy ended forceps. The second and third completed abortion. The fourth pregnancy - spontaneous miscarriage at 24nedele
pregnancy. The patient was admitted to hospital. Abdomen soft, painless. Fundus 4 cross fingers
below the navel. The uterus is easily excitable. Vaginal examination at short cervix, cervical canal passes freely 2 cross fingers. In cervix define the lower pole of membranes.
I. What is the diagnosis?
A: Bear V 22 weeks, cervical insufficiency isthmic
II. Treatment strategy.
Answer: The suture on the cervix
6.3. Graphic organizer: Making graphic organizer
table "insert" on "Nevynaschivanie pregnancy"
Table Inserts
To systematize the information obtained during the independent reading, listening to lectures,
confirmation, clarification, deviation, tracking understanding
information received. Contributes to the ability to link previously mastered informa-tion with the
new.
6.4.Prakticheskaya part
1.AUSKULTATSIYA FETUS
Purpose: Evaluation of fetal vnutriutroutrobnogo
Performs step (steps):
Events number does not hold nil
(0 points) Fully
correctly
performed
(20 points)
1. Auscultation of fetal STET-produced en masse, which is applied to the woman's abdomen 0
20
2. When neck positions heart auscultated below the navel, in pelvic - above the navel, at transverse positions - at the navel closer to the head 0 20
3. At 1-position listening heartbeat etsya left at 2 - to the right, with vain attempts - suprapubic 0
20
4. Auscultation stethoscope must rely distribution perpendicular, ie at right angles to the back of
the alleged fruit, broad funnel tightly applied to the pregnant belly, and the other end - an ear
doctor. Auscultation should not hold up his hand, as this breaks the conduction of sound stethoscope 0 20
5. In a normal heart rate of 120-160 beats per minute, regular, clear 0 20
2.OPREDELENIE due date
Objective: To determine the expected life of pregnancy
Performs step (steps):
Events number does not hold nil
(0 points) Fully
correctly
performed
190
(20 points)
1. On the first day of the last menstrual period (by Naegeli) is counted from that date back three
calendar months and add 7 days 0 20
2. By ovulation: the first day of your last period was added 14 days (period expected ovulation
and conception) and then added 280 ± 7 days 0 20
3. On the first fetal movements: the date of the first fetal movements in primiparous added 20
weeks, multiparous - 22-23 weeks 0 20
4. Date first appearance to the doctor in early pregnancy that date pribav-lyayut the deadline
missing weeks of gestation to 40 and are due date 0 20
5. For objective data: at the time of inspection set term pregnancy and, by adding the missing
week to 40, determine the date of birth 0 20
Total 0100
7.Formy control of knowledge, skills and abilities
-Oral;
-Alphabet;
Testing;
Solution situational problems;
And demonstration of skills mastered.
8.Kriterii assessment monitoring
Number having time-duro
Score in% level of students' knowledge
1 96-100% Excellent
"5" full correct answer to the questions on the etiology, pathogenesis, classification, clinical
manifestations, diagnosis, treatment and prevention of this disease. To sum up and make decisions, creative thinking, self-analyzes, case studies resolves correctly, with a creative approach,
with full justification of the answer. Actively and creatively involved in interactive games, take
the right decisions and summarizes and analyzes. Medical history, partograph fills correctly.
2 91-95% Excellent
"5" full correct answer to the questions on the etiology, pathogenesis, classification, clinical-ki,
diagnosis, treatment and prevention of this disease. Creative thinking, self-analyzes, case studies
resolves correctly, with a creative approach, with full justification of the answer. Actively and
creatively involved in interactive games, take the right decision. Medical history, filled with partograph one grammatical error.
3 86-90% Excellent
"5" The questions on the etiology, pathogenesis, Nezu, classification, clinical picture, diagnosis,
treatment and prevention of this disease is completely covered, but have 1-2 errors in the response. Own analyzes, inaccuracies in solving situational problems, but with the right approach.
Actively involved in interactive games, make the right decisions. Medical history, partograph
fills with 2-3 grammatical errors.
4 81-85% Good
"4" The questions on the etiology, pathogenesis, Nezu, classification, clinical manifestations, diagnosis, treatment and prevention of this disease is completely covered, but there are 2-3 inaccuracies, errors. Into practice, understands the essence of the question, says confidently, is a faithful representation. Situational problems solved correctly, but the justification answer sufficiently.
Actively involved in interactive games, take the right decision. Medical history, partograph fills
with 2-3 grammatical errors, inaccuracies in the description.
5 76-80% Good
"4" Correct, but incomplete coverage of the issue. The student knows the etiology, pathogenesis,
classification, clinic of the disease, but not completely disassembled diagnosis, treatment and
prevention of this disease. Understands the issue, says confidently. There is an exact representation. Actively participate in the games. On case studies gives partial solutions. Medical history,
partograph fills with 3-4 grammatical errors, inaccuracies in the description.
191
6 71-75% Good
"4" Correct, but incomplete coverage of the issue. The student knows the etiology and pathogenesis of the disease, but not completely disassembled diagnosis, treatment and prevention of this
disease. Understands the issue, says confidently, is a faithful representation. On case studies
gives partial solutions. Medical history, partograph fills with 3-4 grammatical errors, 3-4 errors
in the description.
7 66-70% satisfactory solution is without foundation
"3" right answer half the questions. Student knows the etiology of the disease, but do not pay out
the classification of the disease clinic, confused in the treatment and prevention. Understands the
issue, said confidently, has accurate representations only on specific issues topic. Case studies resheny true, but there is no justification answer. Medical history, partograph fills with 3-4 grammatical errors, 3-4 errors in the description.
8 61-65% satisfactory solution is without foundation
"3" right answer half the questions. Errors in the etiology, pathogenesis, poorly versed and confused in the treatment and prevention of this disease. Says uncertainly, has the only views on certain issues topic. Making mistakes in solving situational problems. Medical history and partograph fills with errors.
9 55-60% satisfactory solution is without foundation
"3" error response to half the questions. Student makes an error in the etiology of this disease,
poorly versed and confused in other matters relating to the disease. Says uncertainly has a partial
view on the subject. Situational problems solved incorrectly. Medical history and partograph fills
with errors.
10 50-54% Unsatisfactory-vletvori-state "2" The correct answer is 1/3 of the questions. Student
does not know the etiology of the disease, and poorly versed entangled in other issues related to
the disease. Situational problems solved correctly if the right approach. Medical history and partograph fills with errors.
11 46-49% Unsatisfactory-vletvori-state "2" the correct answer to one fourth of the questions.
Student does not know the etiology of the disease, and poorly versed entangled in other issues
related to the disease. Situational problems solved correctly if the right approach. Medical history and partograph fills with errors.
12 41-45% Unsatisfactory-vletvori-state "2" Lighting fifth of the questions correctly. Student
does not know the etiology of this disease, little versed in other matters related to the disease.
Gives an incomplete and partially incorrect answers to questions on the classification of the clinical disease. Situational problems solved correctly if the right approach. More than half of the
patient's history and the partograph filled with errors.
13 36-40% Unsatisfactory-vletvori-state "2" Lighting 1/10 of the questions at the wrong approach. Does not know the etiology of the disease-tion, poorly versed and entangled in other issues related to the disease. Gives an incomplete and partially incorrect answers to questions on
the classification of the clinical disease. Situational problems solved correctly if the right approach. Bole-half of medical history and partograph fills with gross errors.
14 31-35% Unsatisfactory-vletvori-state "2" to the questions not answers. Does not know and
does not understand the other issues related to the disease. Does not know how to fill out and describe the history of the disease and the partograph.
9. Typical flow chart of lesson
Stages of work, time-name The content of the
Teachers Students
1etap. Introduction to the training session
(5min) 1.1.Soobschaet topic, purpose, and planned training results. Familiar with the plan, features of the training session.
1.2.Nazyvaet: key categories and concepts from the data subject tion, a list of books for selfstudy
1.3.Soobschaet indicators and criteria of educational work in class
192
Listen, record,
specify, ask the question.
Stage 2.
Primary
(235 min) 2.1.Provodit updating knowledge through блиц-опроса/вопросно-ответной forms /
brainstorming, etc.
2.2. Consistently describes the steps
on the organization of the educational process according to the structure of practical training.
Meet
Abstracts with ethyl.
Working in groups, will present the results of the group work
Stage 3.
The Final-Resultant-regulating (60 min)
3.1.Delaet opinion on the subject, attention was concentrated on the main students, according to
the importance of the work done for future careers.
3.2. Commends the work of groups (some of students) summarizes vzaimootsenki. Analyzes and
evaluates the degree of achievement of lesson.
3.3. Gives the task for independent work, informing schaet and criteria evaluation. Selfevaluation,
interaction assessment.
Ask the question.
Write down the job.
10.Kontrolnye questions
1.What is a true post-term pregnancy?
2. What is prolonged pregnancy?
3. Signs of over-ripe fruit
4 The management of pregnancy and childbirth in prolonged pregnancy
5.What is the induction of labor?
6.Pokazaniya and contraindications to induction of labor?
5. A definition of miscarriage.
7. The causes of miscarriage.
8. What is habitual miscarriage?
9. To classify pregnancy premature birth on the timing and the clinic.
10. Treatment of threatening preterm birth.
11 .. Keeping began preterm labor.
12.Profilaktika distress syndrome in the fetus.
13.Patogenez premature birth pregnancy.
14.Ostry and chronic tocolysis.
15. Scheme of tocolytics
11. Recommended Reading
Summary:
1. Abramchenko, VV Epidural anesthesia in obstetrics: a guide for physicians / 2006. - 229 p.
2. Abramchenko, VV Pregnancy and delivery of high risk: a guide for physicians / - M. Med.
Inform, 2004. - 400 p.
3. Abramchenko, VV Cesarean section in perinatal medicine: a guide for physicians / 2005. 126.
4. Abramchenko, VV Postoperative intensive care in obstetrics / Literature, 2000. - 88.
5. Abramchenko, VV Pharmacotherapy of preterm labor / 2006. - 448.
6. Abramchenko, VV Purulent-septic infection in obstetrics and gynecological logii.rukovodstvo
/ 2005. - 459
7. Abramchenko, VV Postoperative intensive care in obstetrics / - St. Petersburg: Spec. Literature, 2000. - 88.
193
8. Abramchenko, VV Clinical perinatology / IntelTek, 2004. - 424 p.
9. Ailamazyan, EK Midwifery: a textbook for honey. Universities / 2003 - 528.
10. Topical issues of Obstetrics, Gynecology and Reproductive / Ed. EV KOKHANEVICH. Moscow: Triad-X, 2006. - 480.
11. Obstetrics. Ed. GM Savelyeva. - M.: Medicine, 2000. - 816 p.
12. Obstetric and gynecological care: Hands-on. for doctors / Ed. VI Kulakov. - Moscow:
MEDpress, 2000. - 512 p.
13. Obstetrics. Clinical lectures: a manual for schools with a CD / Ed. OV Makarova. - Moscow:
GEOTAR Media, 2007. - 640.
14. Obstetrics. Directory of the University of California / Ed. Nisvandera K., A. Evans: Lane.
from English. - M.: Practice, 1999. - 704 p.
15. Barashnev, YI Perinatal neurology / Y. Barashnev. - M.: "Triad - X", 2005. - 670 p.
16. Bodyazhina, VI Akushersvo. The manual for the media. prof. Education / VI Bodyazhina. Rostov-on-Don: Phoenix, 2003. - 480.
17. Resurrection, SL Fetal assessment. CTG. Doplerometriya. Biophysical profile: a manual for
the system of postgraduate medical. Education / SL Resurrection. - Minsk: The Book House,
2004. - 304.
18. Gazhonova, VE Ultrasound in Gynecology / VE Gazhonova. - Moscow: MEDpress-inform,
2005. - 264.
19. Gluhovets, BI Ascending infection of placental / BI Gluhovets. - Moscow: MEDpressinform, 2006. - 240.
20. Humeniuk, EG Obstetrics: Physiology of pregnancy: a training ben-beats / EG Humeniuk. Petrozavodsk: IntelTek, 2004. - 170 p.
21. Demidov, VN Pelvic ultrasound in women. Adnexal cysts and benign ovarian tumors: a practical guide / V. Demidov. - Moscow: Academy of Medical Sciences, 1999, vol. II. - 100 p.
22. Duda VI Obstetrics: a textbook for high schools in the specialty "General Medicine" / Minsk: High School, 2004. - 639 p.
23. Duda VI Physiological OB / - Minsk: 2000. - 447 p.
24. Duda VI Operative obstetrics: a manual / Minsk Interpresservis, Book House, 2002. - 512 p.
25. Zhilyaev, NI Obstetrics: phantom course / - Kiev, 2002. - 239 p.
26. Zhilyaev, NI Operative Obstetrics: Ouch. Manual / Kiev 2004. - 468 p.
27. Zhilyaev, NI Operative surgery in obstetrics and gynecology / 2004.
28. Selected lectures on obstetrics and gynecology / Ed. AK Strizhakova etc. - Rostov-on-Don:
Phoenix, 2000. - 512 p.
29. Clinical recommendations. Obstetrics and Gynecology: scientific publication / Ed. VI Kulakov. - Moscow: GEOTAR Media, 2006. - 512 p.
30. Clinical lectures on obstetrics and gynecology / Ed. AN Strizhakova etc. - M.: Medicine,
2000. - 379 p.
31. Clinical evaluation of laboratory tests in women: study guide / Moscow Medical and Dental.
University. NA Semashko. - M: 2005. - 96 p.
32. Kulakov, VI Preterm birth / VI Kulakov, LE Ants. - M.: Medicine, 2002. - 176.
33. Kulakov, VI Intensive care in obstetrics and gynecology (efferent methods) / - M: MIA,
1998. - 206 p.
34. Drugs used in obstetrics and gynecology / Ed. Acad. RAMS VI Kulakov, Acad. RAMS VN
Serov. 2006. - 375 p.
35. Emergency care in obstetrics and gynecology. Quick Guide - M. GEOTAR - Media, 2007. 52.
36. Perinatology Basics: A tutorial / Ed. MP Shabalov. - Moscow: MEDpress-inform, 2002. 576 p.
37. Practical skills in obstetrics and gynecology: a manual / LY Suprun, TS Divakova and others.
- Minsk: New Knowledge, 2002. - 166 p.
38. Rational pharmacotherapy in obstetrics and gynecology: Hands-on. for practitioners / Ed. VI
194
Kulakov, VN Serov. - M.: 2005.
39. Guide Out - patient care in obstetrics and gynecology / Ed. VE Radzinsky. M: GEOTAR Media, 2007.
40. Guide to practical training in obstetrics / Ed. VE Radzinsky. - M.: MIA, 2004. - 576 p.
41. Saveliev, GM Obstetrics: a textbook for schools / GM Savelyev, RI Shalina. - Moscow: GEOTAR Media, 2008. - 656 p.
42. Sidelnikov, VM AG Antonov Premature birth. A premature baby / VM Sidelnikov, AG Antonov. -M. "GEOTAR" 2006.
43. Smirnov, A. Pregnancy without problems / AN Smirnov. - Moscow: Atris Press, 2002. - 208.
44. Smirnov, LM Obstetrics and Gynecology: Textbook / LM Smirnov. - M.: Medicine, 1999. 368 p.
45. Handbook of obstetrics, gynecology and perinatology: uch.posobie for doctors / Ed. GM
Savelevoy.2006. - 720.
46. Trifonov, E. Obstetrics and gynecology: a manual for med._vuzov / EV Trifonov. - Moscow:
VLADOS, 2005. - 175 p.
47. Filippova, GG Psychology of motherhood: a manual / GG Filippov. - Moscow: Publishing
House of the Institute of Psychiatry, 2002. - 240.
48. Chernukha, EA Prolonged and prolonged pregnancy. Guide for Physicians / EA Chernukha. M.: "GEOTAR - Media", 2007. - 207.
49. Chernukha, EA TK Puchko breech presentation. Guide for Physicians / EA Chernukha, TK
Beam. - M.: "GEOTAR - Media", 2007. - 173 p.
50. Shmagel, KV Immune pregnant women / KV Shmagel, VA Cherries. - Moscow: Medical
Book, 2003. - 226 p.
51. Tskhai, VB Perinatal obstetrics: a manual for honey. Universities / VB Tskhai. - Atlanta:
Med. Academy of RAMS, Moscow, Honey. book, 2003.
52. Amniotic and extraembryonic structures in normal and complicated pregnancy / Ed. VE
Radzinsky. 2004. - 393 p.
53. Congenital, perinatal and neonatal infections: Per. from English. / Ed. A.Grinou, J. Osborne,
S. Sutherland. - M.: Medicine, 2000. - 287.
54. Kulakov VI, Murashko LE Premature birth. M. Medicine, 2002.
55. Serov VN etc. Eclampsia: A Guide for Physicians / V.N.Serov etc. - M.: MIA, 2002. 463 with
56. VM Sidelnikov Habitual loss beremennosti.-M.: Triad-X, 2002.
57. Disseminated intravascular coagulation in obstetrics AD Makatsaria etc. - M.: Triad-X, 2002.
- 496.
58. Schechtman, MM, GM Burduli Diseases of the respiratory system and blood circulation in
beremennyh.-M.: Triad-X, 2002. - 230C.
59. Shifman EM Pre-eclampsia, eclampsia, NELLP syndrome / Inteltek, 2002.
More:
60.Uchebnoe grant for the development of practical skills surgical / Edited by prof. Atalieva AE,
prof. Babadjanova BD Tashkent 2003. C102-115
61.Algoritmy diagnosis and treatment of surgical / Edited by Academician Karimov
Sh.I.Tashkent 2003. From 39-64
62.Uchebnoe benefit surgical subjects for medical students / Edited by Academician Karimov
Sh.I.Tashkent -2003 Part II Obstetrics and ginekologiya.S 64-19013. Practical skills in obstetrics
and gynecology / Metod.posobie / / Tashkent 2008.
63.Akushersky soft tissue injuries of the birth canal, Kulakov VI, Butova E.A.2004.
64.Akusherstvo. National rukovodstvo._2004.
65.Infektsii in Obstetrics and Gynecology How VK Seagull 2006
66.Hirurgicheskaya technique cesarean secheniya_Strizhakov A.N._2007.
67.Ratsionalnaya pharmacotherapy in obstetrics and ginekologii.2007
Chan_Gynecology_and_obstetrics.2004
195
68.Rukovodstvo for outpatient care in obstetrics and gynecology, Kulakov V.I.2005.
70.Sidorova_I.S._Rukovodstvo_po_akusherstvu_ (Medicina, 2006) (ru) (1033s
71.Posobie for practical development of Obstetrics Voronin (KV) 2007.
72.Kirienko AI, Matyushenko AA, Andriyashkin VV Ostryi tromboflebit/2005
AN 73.Ivanyan - Intrauterine growth ploda/2007
74.DVS_sinrom _v_akusherstve.2004
75.Neonatologiya (Bazhanov NP). - T. I. - 2004
76.Prikaz MZ № 500 "On the reorganization of maternity hospitals to improve the efficiency of
perinatal care and the prevention of nosocomial infections."
77.Partogramma/Sherbaeva DB, Ayupova FM, FI Shukurov / Metod.rekomendatsii. Tashkent2005. 28C
78.Uchebnaya birth history / Sherbaeva DB, Ayupova FM, FI Shukurov / Metod.rekomendatsii.
Tashkent-2005. 13C
79.Prakticheskie skills in obstetrics and gynecology / Me-tod.posobie / / Tashkent 2008.
80.Internet sites:
http://www.studmedic.narod.ru/, http://med.siteedit.ru/,
http://www.rukovodstvo-po-akusherstvu.-uchebnoe-posobie.html, http://www.materinstvo.ru,
http://mama.ru.http://www.art-med.ru,, http://www.doctor.ru, http://www.rodim.ru,
http://mamka.ru
http://medagent.ru, http://www.art-med.ru, http://www.medsan.ru,
http://mediki.spb.ru, http://medinstitut.e2e.ru, http://www.medstudy.narod.ru
http://www.obgyn.ru, http://www.medsno.ru, http://medrusnet.euro.ru
www.medtext.ru, www.medpoisk.ru, www.medicum.nnov.ru/student/
http://6years.net/, http://preryvanie-beremennosti.pharmabort.ru/
http://med4net.ru/, http://www.med-life.ru/, http://www.pregnant.ru/
http://www.roddom.ru, http://www.medpoisk.ru/, http://www.medlinks.ru
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Topic: placental insufficiency syndrome, fetal growth retardation, emergency conditions and problems of the fetus
1st place of training, equipping,
 Department of Obstetrics and Gynecology, the audience;
 dummy pelvis, female pelvis, doll fetus;
 standard models of pregnancy;
 the classic model of labor;
 gynecologic simulator ZOE;
 childbirth simulator Noelle;
 simulator newborn Newborn;
 set of slides on the topics of discipline;
 methods work in small groups: the method of the incident, "a round table" problem solving,
"pen in the middle of the table", "swarm", etc.;
 testing and teaching practical skills in OSKE (objective structured clinical examination).
 video, TV, TV;
 personal computer (Pentium-III);
 set of slides with typical conditions for ultrasound scanning of pregnant women and gynecologic patients;
 set of video blogs "VJOG" (USA), highlighting recent advances in diagnosis and treatment of
obstetric and gynecological conditions;
 set of movies and video with a demonstration of typical obstetric and gynecological procedures
and operations.
 educational software;
 multi media training and testing;
 the use of e-mail and INTERNET;
 business simulations and case studies;
 center for training in practical skills
 offices and laboratories maternity complex
 delivery room
 the department of pathology of pregnancy,
 set of test items.
 phantom with a doll tazomera, measuring tape, a stethoscope;
 tools used during delivery
 diagram of the main stages of the diagnostic process
 step by step implementation of clinical skills of neonatal resuscitation.;
 partograph;
 birth stories of women with abnormal over generations;
 hormones FPN, kardiotokogrammy;
 tazomera, measuring tape;
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2.Prodolzhitelnost study subjects
Number of hours, 5 hours
3.Tsel classes
-A definition of FPN and FGR;
-To define the perinatal period;
-Give an idea of the fetoplacental system (FPS);
-Briefly examine information about the components of the FPS;
Is to study morphological and functional structure of the placenta and the placenta;
, To give an idea of the influence of harmful factors in the function of the placenta;
-Explain the methodology for determining the FBS;
-Brief provides information on feto-placental insufficiency (FPI)
-Causes, diagnosis and treatment;
Is to study ways of preventing the FPI.
Tasks
The student should know:
-Definition of FPN and FGR;
-Definition of the perinatal period;
-Have an idea of the FPS and its role in growth and development and fetus;
-Have an understanding of the functional state of the FPS;
The student should be able to:
Have an understanding of the causes of FPN and be able to diagnose, have an understanding of
methods of treatment and prevention of FPI.
4.Motivatsiya
Antenatal care in pregnancy has a direct otnoschenie reduce perinatal morbidity and smertnosti.Neobhodimost study this, we are, its importance in the study of the course and professional
orientation is to improve and upgrade the knowledge of students, future GPs on the topic. Identify women at risk of FPN and carry out preventive measures during pregnancy. Help students
learn practical skills at SVP, Northeast Asia and to provide first aid at the prehospital level.
Intra 5.Mezhpredmetnye and communication
Of teaching of the subject is based on the knowledge of the students basic anatomical mission,
topographic anatomy, histology, normal and abnormal physiology, endocrinology, and microbiology.
Acquired during the course knowledge will be used during the passage of endocrinology, internal medicine, surgery, pathological obstetrics, gynecology, obstetrics, gynecology, hematology,
health, therapy, pediatrics.
6.Soderzhanie classes
6.1.Teoreticheskaya part
P e r and n a t o l o g and me. Fetoplacental system. Fetoplacental insufficiency
Perinatology - the science of the fetus and its development, the impact of external and internal
environment, diseases of the newborn, resulting from violations of its womb.
Due to the close functional relationship and interdependence of ma-just-placental blood flow and
fetal became widespread, the term "fetoplacental system", although to speak of the motherplacenta-fetus.
Stage of fetal development:
1. Preimplantation development - from the moment of fertilization until the introduction of the
blastocyst in the uterus dezidualnuyu - nidatsin (7 to 8 days after fertilization).
2. Implantation (7-8-day)
3. Organogenesis and placentation - complete by 3-4 months of fetal life
4. Fetal or fetal development period (extended to 40 weeks of gestation).
Perinatal period - the time from the 28th week of fetal development on the 7th day of life of the
newborn.
Divided into:
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1. Ante2. Intra3. Postnatal
In the antenatal period to reflect the state of development of the fetus pregnancy and abnormal
pregnancy.
In the intrapartum period, the fetus is influenced by deviations from the normal course of childbirth, as well as their combination with previous pathology of pregnancy.
Pathology leading to stillbirths and perinatal deaths occur:
1. in the antenatal period - 63%
2. in intrapartum - 21.2%
3. postnatal - 5.7%
Fetoplacental system, or the mother-placenta-fetus
Placenta - "flat cake" - is in the form of round sponge cake with a diameter of 18-20 cm, thickness 2.5 cm to the end of the pregnancy her weight is 15% of the weight of the fruit. It takes
about 1/3 the inner surface of the uterus. Consists of 15-28 clearly visible segments, separated by
connective tissue septa. Each slice contains the blood vessels of the fetus, and chorionic villus
intervillous space. The dark red color is caused by the placenta of fetal Hb, so pale coloring placenta indicate fetal anemia.
The placenta has three main structural elements:
1. Chorionic membrane
2. Basement membrane
3. Between them - parenchymal fraction
Placental parenchyma is composed of:
1. chorionic villus
2. stem
3. intervillous space.
The inner surface of the membrane is covered with chorionic epithelium am Nyon (20 mm). Under it - chorionic connective tissue covered with epithelium trophoblast. Basement membrane the outer surface of the IMP consists of:
1. Syncytiotrophoblast
2. Basal decidua. Between them - fibrinoid zone inclusions in trophoblast cells.
The basic structural and functional unit of the placenta-cotyledon (segment), which is defined
by:
1. Stem villi and their ramifications
2. Attached to the membrane hormalnoy wide base (trunk 1 order)
3. Barrel 1 order is divided into multiple trunks 2 orders
4. Last on 2 barrel 3 order and reach the basement membrane.
Proteolytic enzymes trophoblast cells, and then melted chorionic villi tissue endothermy, including and blood vessels, veins and arteries. Formed numerous gaps, which circulates the blood
coming out of the spiral arteries and the blood flowing through the veins located between the arteries. As the gap in the pregnancy decidua merge to form the intervillous space, separated by
connective tissue septa, and then the space has already form a common reservoir for blood flow.
The average S villous placenta is 12-14 m2 or 4-4.5 m2 per 1 kg of the newborn. All placental
villi length is 50 km. Volume intervillous space ranges from 170 to 260 ml. Blood flow in it (on
the maternal side) supported BP and uterine contractions. Maternal blood of uterine spiral arterioles flows into the intervillous space pressure of 60-70 mm Hg Blood in the intervillous space is
at a pressure of 10-20 mm Hg. Art, and during contractions increased to 60-70 mmHg and then
the blood flow in the area is dramatically reduced. In the umbilical vein (carrying blood from the
placenta to the fetus), the pressure of 30-40 mm Hg in the umbilical artery (from the fetus to the
placenta) - 2 times more.
At the end of the pregnancy from mother to fetus and back through the ma-just-Platz. Circulation
goes to 1 hour more than 3500 cc. The last completely updated for 3-2,5 hours.
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Fetal blood flowing to the placenta through the umbilical arteries 2 incorporated in the navel. After contact with the fetal placental surface arteries branch into branches supplying blood to every
slice of the placenta. As a result of continuous branching they eventually end in a capillary located within each of chorionic villi. Fetal blood in through the villi, receiving oxygen and enriched
with nutrients from the circulatory system of the mother returns to the venous capillaries into
large large veins extending from each lobe of placenta. Lobular veins merge to form the umbilical vein, which departs from the placenta through the umbilical cord is attached to the body of
the fetus. A cross section of the umbilical cord can be seen two thick-walled arteries and one Vienna, but has a thinner wall, while a larger diameter. Umbilical vessels are surrounded by a white
gelatinous substance, called vartonovym jelly.
Fetal circulation
The fetus as an adult there are two circulation - large and small. Third circulation - placental. Peculiar only to the fetus.
Small circle (or pulmonary) begins at the pulmonary valve, which comes out of the right ventricle.
Includes:
A) light
Ends mouths pulmonary veins draining into the left atrium.
Great circle includes all other arterial and venous vessels, available in the body.
Unlike fetal circulation of blood circulation newborn baby or an adult:
1) The presence of anatomical shunts
A) oval hole (between the two atria)
B) Blood (Botallo) Flow - between the pulmonary artery and the aorta)
B) arantsiev duct that a continuation umbilical vein empties into the inferior vena cava.
2. Presence of placental circulation
3. Minimum flow of blood through the lungs), 3-7% of cardiac output).
Fetal circulation is as follows:
1. Blood oxygenated chorionic villus sampling, flowing from the placenta through the umbilical
vein.
2. Vienna umbilical umbilical hole occurs in the abdominal cavity is, then - the left and right
lobes of the liver gives some branches Parenchyma - then as ductus venosus Arantii (venous
flow) - the inferior vena cava (directly under the diaphragm).
3. Of settlement vein into the right atrium.
4. In the main part of the right atrium the blood enters the left atrium, and the rest - mingling
with the blood from the superior vena cava (carries blood from the head, neck and upper limbs)
enters the pr.zheludochek.
5. The left atrium receives additional blood that flows from the lungs through the pulmonary
veins, all this mixed blood in the left ventricle, the ascending aorta, aortic arch.
6. Through the aorta to the coronary arteries and vessels of the head and upper extremities.
7. Right ventricular blood to the pulmonary artery, through which most of the arterial canal in
the descending aorta, which is divided into left and right iliac artery, which runs two epigastric
artery (g.hypogastrica dextra et stnistra). Each surrounds the bladder and out of the abdomen
through the umbilical cord - it is the umbilical artery.
Aminona. Aminoticheskaya liquid
During the first week of embryonic development amnion is given elongation nennogo sac adjacent to the dorsal surface of the embryo. Aminona bag more and more filled with fluid that surrounds the fetus gradually on all sides. Cavity Aminona meets only the umbilical cord, which
runs from the navel to the attachment of the fetus to the placenta.
Thickness - 0.5 mm. 5 microscopic layers. After the development Aminona completely lines the
inner surface of the uterus except for the insertion of the placenta. Last aminalnaya shell covers
the part of the fetal surface, goes to the umbilical cord and completely surrounds it.
Amount of amniotic fluid during pregnancy and increases its volume for delivery approximately
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1000-15000 ml. Despite its continuous updating (for 2.5-3 hours), its value is constant, due to the
equality between the entry and loss (pribl.600 ml).
Formed from:
1) maternal plasma
2) fetal urine
Loss: as a result of absorption into the bloodstream from the gastrointestinal tract in (This proved
amniografiey: in aminoticheskuyu fluid is injected radiopaque substance to study the localization
of the placenta in suspected anomaly attached.
At the end of pregnancy, the fetus swallows amniotic fluid 500 ml per hour. In case of violation
of these processes (atresia of the esophagus, gastrointestinal or decrease urinary incontinence
develops renal anomalies or polyhydramnios or oligohydramnios.
The purpose of the amniotic fluid:
1. Enables active fetal movement
2. Protects the fetus from injury
3. Helps to maintain a constant temperature of the fruit
4. Bag of waters - opens your cervix.
Biochemical function of membranes
Specific function in the metabolism of the fetus do amniotic fluid, the volume of which is the
end of pregnancy 1000-1500 ml.
With the development of the fetus, amniotic fluid pH changes in oxygen-luyu side, ie increases
acidosis. From the early stages of gestation acidosis increases from 7.35 - 7.25 to 6,9-7,0 to 40th
week of pregnancy. This is due to the excretion of acidic metabolites in amniotic fluid.
Glucose levels and amniotic fluid (S) varies 1.17 + 0.3 mmol / l. Its presence in the OB is mainly
due to its excretion in the urine of the fetus, it is known that glycosuria occurs in infants in the
first days of their lives. However, the possible and the transition of glucose in the OB from the
mother.
Of urea in the amniotic fluid (6.9 + 0.56 mmol / l) affects the level of the cord blood and maternal blood upwards in the past. That is to say that the removal of urea from the body of the fetus
occurs mainly in the direction of: fruit, water-mother.
Determination of estrogen - ekstriola in blood and urine of pregnant.
Reduced urinary estrogen to 0-8,5 mg / day is typical for antenatal fetal death. To better define
the placental insufficiency grad offered load between the 2 definitions. Normally when on / in
grad estrogen secretion is increased by 10-35%, with FPN - no reaction. A definition estriolovogo index = estrogen in the blood estrogen in urine
With the progression of placental insufficiency index decreases.
More reliable criterion to consider the content ekstriola OB, which contains all three fractions of
estrogen.
Determination of activity oksitotsinazy - inactivating oxytocin enzyme. Synthesized syncytiotrophoblast already pregnant with the 6th is not Delhi.
TSCHF - highly informative test. The increase in the blood of its activity is due to the increase of
its thermostable fraction. Determined in blood from 18-23 weeks. If any function of the placenta
is first determined abnormally high activity TSCHF by increasing metabolism in the cells of the
placenta, the destructive processes in the placenta, resulting in an enzyme released into the
blood. Further functional reserves depleted, decreasing the amount of functioning placenta, leading to reduced activity TSCHF.
Biochemistry RH: In RH reduces the concentration of all 3 factions estrogen (normally estiriod 208-277, 3 nmol, estrone - 14,70-24,73 and estradiol 10,8-14,85) oksitotsinazy, PL, TSCHF .
Kolpotsitologiya: vagina - the target organ, the zone of application of hormones placenta.
Vaginal epithelium associated svozdeystviem it estrogen, progesterone, gonadotropins produced placenta.
Normally, in the first 2-3 weeks. vaginal swab like premenstrual.
Gradually, the number of superficial cells is reduced, there are boat-shaped. Picture smear is
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normal is constant and varies in 2-3 weeks before delivery - intermediate scaphoid later - superficial appearance in smears parabasal cells and a decrease in the number of intermediate.
Indicate a fetus suffering from placental insufficiency.
Evaluation function of the placenta
Detection of placental insufficiency is indirect by the method of diagnosis of the fetus, as it
combines with the violation of the fetoplacental circulation, delay the development of the fetus.
Function of the placenta:
1. Hormone
} In the interaction. between maternal
2. Metabolic and fruit organisms
3 Respiratory
4. Plastic} with respect to the fetus
5. Exchange
Back in the early XX century, it was found that human placenta is an endocrine organ that
produces a variety of hormones, as a protein and steroid structure.
Non-steroidal hormones hCG and HSMT (PL). CG - glycoprotein protein structure has gonadotrophic activity (similar to the pituitary gonadotropins). In the early stages of pregnancy
produced by cytotrophoblast cells, and later - with the formation of the placenta - spitsintotrofoblasta. Close to LH. The development of a fertilized egg can not be without the HCG. In
the 1st week of pregnancy, hCG increases the secretion of the corpus luteum and the delays
in the involution. HCG is excreted in the urine during the pregnancy. On the 70th day of gestation. Period, the level reaches 150-200 thousand IU per day and is supported by these figures for 3 weeks, and then gradually decreases. The content of it above 10,000 IU indicates
favorable prognosis to maintain pregnancy. By the end of the 1st week after delivery of HCG
in the body parturients not released. In addition to direct-tion of the trophic effect on the fertilized egg, hCG is involved in the synthesis and maintenance of the functional activity of
VT, reduces the excitability of the uterus affects the metabolism of hormones placenta.
HSMT - similar to growth hormone. Has prolactin and growth and activity. Determined in
serum. In this regard, reduced urinary excretion Extrol pregnant women - a sign of a troubled
informative functional state of the FPS. Example: a sharp decrease in excretion Extreme
pregnancy anentsefalnym fruit. Fetuses - anencephaly due to the reduction of adrenal precursors of estrogen produced in small numbers.
Synthesized by the placenta in the dynamics of gestoznogo period. The highest level in the
plasma reaches the amount of 37 weeks. (8 mg / L). Produced by cells syncytiotrophoblast.
The clinical significance of HSMT in maternal blood due to the fact that the decrease in its
concentration in the serum is characteristic of threatened abortion, preeclampsia, of disability
in / utrb. Fetus. Besides the above hCG from the placenta and HSMT highlighted a number
of bioactive substances - ACTH, MSH, oxytocin, insulin, ACh.
Steroid hormones placental
Fetus and placenta are common biological system in the synthesis of hormones ekstrogennyh, called placental complex.
Stage I of estrogen biosynthesis: hydroxylation of cholesterol molecules - occurs in the placenta - pregnenolone
II-pregnenolone formed from the placenta enters the fetal adrenal glands and converted into
adrogenny hormone - DHEA, which the venous blood of the fetus re-enters the placenta.
III - DEA exposed enzyme systems placenta - aromatization of steroids - estrone and estradiol.
After complicated ways hormonal exchange estriol (the active fraction of estrogen OP complex enzymatic processes partially implemented in the adrenal glands of the fetus, that estrogens are produced by the endocrine activity of OP-complex. Estrogen levels in the blood,
urine, amniotic fluid, certainly characterizes the state as placenta and fetus.
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Progesterone. Its biosynthesis in the placenta occurs without fruit. Fetal adrenal glands
quickly convert progesterone to cortisol, and fetal liver can not be ruled metabolism of progesterone to estradiol and estriol. Progesterone is the place of formation of syncytia. Progesterone is an important metabolite pregnanediol, the excretion of which one can judge the usefulness of a functional placenta. No association between the concentration of progesterone
and decrease in the activity of the uterus. There is a theory about the local effect of placental
progesterone: hormone acts directly on the myometrium in the placental site, bypassing the
bloodstream. This is the so-called effect of "progesterone block" in which the concentration
of the hormone in the placental site is 2 times higher than in other parts of the uterus. Thus
the activity of the myometrium not affect the amount of progesterone circulating in the
blood, and a concentration in the myometrium.
Features fetal life
During pregnancy the fetus in the womb is as if in a sterile incubator, where it provides oxygen, glucose, amino acids and electrolytes. Practical benefits without wasting energy on heat
buildup, muscle work, digestion and elimination processes. Most of the energy of the fruit
consumed by synthetic processes, ie on growth and development.
Fetus responds to external stimuli mediated by the mother's body.
Direct stimuli of the fetus, in the end, the following:
1. Changes in quantitative and qualitative terms, the translational tion necessary for its life
agents.
2. Intrauterine pressure fluctuations
3. Changes in placental blood flow
Oxygen supply of the fetus depends on the following factors:
1. They are mediated by maternal
2. Placental} placental
3. Fetal circulation
During the development of the fruit of his inner life, provides its nennye needs through the
placenta. Respiratory surface villous placenta late in pregnancy is 6-10 m2 (body of an adult
subject - 1,4-1,82). Through a complex mechanism naps provide the fetus with oxygen saturation of the blood and removal of CO2.
However, during pregnancy, placental development can not keep up the development of the
fetus: the third month of pregnancy, the placenta is increased by 15 times, the fruit - 800
times. Therefore, fetuses develop compensatory mechanisms to ensure its survival in low
supply of oxygen - hypoxia.
They are:
1. Most V circulation (fetal heart rate of 120-140 in 1 min).
2. The increased number of red blood cells - 6. 1012 to 1 liter.
3. Hb concentration - 210-230 g / l
4. Hb increased affinity for oxygen
5. Active movements of the fetus (reducing muscle blood flow speed)
6. Less need for oxygen
7. Features fetal circulation (oxygenated blood is distributed mainly in the liver and upper
torso.
8. Possibility of the metabolic processes in the absence of oxygen (anaerobic glycolysis).
However, even in normal pregnancy the fetus in her late severe shortages of oxygen. Timely
delivery and the emergence of emerging infant pulmonary respiration save him from intrauterine death.
The cause of fetal hypoxia is fetoplacental insufficiency, which develops when:
1) Pathology of pregnancy
2) delivery of Pathology
3) extragenital diseases mother
4) Diseases of the fetus (fetal napr.GB)
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Fetoplacental insufficiency is divided into:
1) chronic - Mt. Anemia, heart, lungs, etc.
Placenta previa, perenashivanie, preeclampsia, Rh and ABO conflict, etc.
2) Acute:
PONRP, hemorrhagic shock, rupture of the vessel at plevistom placentation, rod.sil abnormalities, uterine rupture, impaired circulation in the vessels of the umbilical cord. Node, loss
of loops, compression loops, the absolute and relative shortness of umbilical cord, etc.
Direct methods for the detection of fetal threat status
1. Registration of motor activity
2. Ultrasonic registration of respiratory movements (Tech. 20 min)
3. Ultrasound scan of the fetus
4. Ultrasound biometry placenta
5. Amnioscopy, oretoskopiya
6. Fetal ECG and PCG
7. Long monitor control for 30-60 minutes to study the heart rate (cardiotocography).
Therapy failure FPS
Based on the application of methods and products that will improve uterine blood flow and
increasing the utero-placental blood flow.
Principles of therapy:
1. Vasodilation m n complex
2. Relaxation of muscles of the uterus (tocolysis)
3. Improve metabolism of the myometrium and placenta
This is achieved by:
1. Bed rest (on the side (eliminating physical voltage, emotional stress).
2. Estrogenic hormones - improve the transport function of the fetus (natural folliculin, estradiol-dipropionate - 20 thousand IU / m c / o 12 hours, 2% -0.5 hexestrol / m, sigetin 1% - 2
ml / m
3. B-mimetics (tocolytics)
4. Antispasmodic and vasodilators - aminophylline, baralgin, maksigan, complamin (theophylline + nikotin.k-ta)
5. Courant (koronarorasshiryayuschego vessels of the placenta and fetus).
6. 6. ATP - improves metabolism placenta.
7. Heparin five thousand units / m
8. Inhalation of oxygen
9. Na b / carbonat
10. Antigipoksanty Solvte
11. Glucose - the main source of energy (for Triad Brown) with insulin
11. Vitamins and amino acids.
Assessment of the fetus during pregnancy and childbirth.
The tests used for pre-natal care for fetal assessment
-Assessment of the motor activity of the fetus
Auscultation of fetal heart-Ultrasound (U.S.)
Auscultation of fetal heart rate
Can confirm that the fetus is alive
Has no prognostic value
Routine hearing is not recommended
Should be carried out at the request of the mother to assure her that the fetus is alive
Ultrasound examination
Routine ultrasound in early pregnancy (before 24 weeks) is effective for:
- Estimates of gestational age
- Early detection of multiple births
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- Early detection of unexpected fetal malformation at a time when termination of pregnancy
is still possible
Routine ultrasound for women in late pregnancy, belonging to the group of low-risk, or
women who are at risk is not defined:
- Is not good for the mother or fetus
General surveys used in antenatal care
Palpation of the abdomen
Measure height of standing uterus
Ultrasound biometry
Biophysical tests and doplerometriya umbilical artery for the diagnosis of IUGR
Antenatal cardiotocography (nonstress test)
Fetal biophysical profile
Doppler umbilical artery
Fetal assessment during labor
To monitor the fetus during labor is to improve birth outcomes for the fetus by determining
hypoxic acidemia, at a time when the process is completely reversible, the use of measures to
protect the fetus and fast delivery
Intrauterine growth retardation (IUGR)
In the problem of perinatal care in pregnancy is one of the main places of working on issues
related to the prevention and treatment of intrauterine growth retardation (ZVURP), a clinical
manifestation of placental insufficiency, which develops in various pathologies of pregnancy.
Risk factors include ZVURP anemia, hypertensive status, polyhydramnios, and others. The
frequency of malnutrition in infants with abnormal proceeding pregnancy ranges from 1 to
69%. According to the modern classification of [10.71] ZVURP syndrome is divided into
two groups:
1 - balanced (proportional or global), which is marked slowdown in the growth rate of all the
parameters of the fetus and is detected at an earlier stage of pregnancy;
2 - asymmetrical (disproportionate, segmental), in which mostly reduced circumference of
the chest and abdomen during normal growth rate biparietal diameter and femur length. This
type detected in the later stages of pregnancy.
I should say that the fetus in utero depends on uteroplacental homeostasis, maternal status,
which is his environment. Therefore ZVURP - a set of morphological and functional disorders of the fetus due to changes in metabolism in the mother-placenta-fetus. In the pathogenesis ZVURP plays an important role placental insufficiency.
Classically distinguish 3 main factors that affect the fetus in placental insufficiency:
• Violation of the utero-placental circulation;
• Chronic hypoxia;
• Insufficient intake of food from the mother's blood to the fetus.
According to GM Savelevoj et al. (1991), when there ZVURP impaired blood flow to the
placenta, which is characterized by three main factors: 1) disruption of the flow of blood in
the intervillous prostanstvo 2) the difficulty of the outflow from it, and 3) changes in the rheological properties of blood coagulation and the mother.
According to modern concepts, guidelines ZVURP therapy should include:
• improving the microcirculation
• control of hypoxia
• normalization of blood coagulation properties, prevention engine
• maintaining the functions of vital organs, anti-hypoxia and fetal malnutrition,
• careful atraumatic delivery.
Small for gestational age fetus (MGVP)
Definition of small for gestational age fetus (MGVP) - heterogeneous group of fetuses that
were not able to reach its potential growth (intrauterine growth retardation (IUGR)) and fruits
that are constitutionally small.
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"Little" child:
IUGR - MGVP a subset (30-50%), which did not reach its potential growth (characterized by
high morbidity and mortality)
The remaining 50-70% MGVP constitutionally small and in most healthy children or those
who have intractable treatment condition (chromosome aberrations).
Measures for managing IUGR:
-Quitting smoking pregnant woman
-Nutritional Supplements for malnutrition
-Malaria Treatment
-Treatment of asymptomatic bacteriuria
Aspirin, for women with a history of preeclampsia
General surveys used in antenatal care to identify MGVP:
-Palpation of the abdomen
-Measure the height of standing uterus
And ultrasound biometry
Biophysical-tests and umbilical artery Doppler for the diagnostics of IUGR / VZRP
Measuring the height of standing uterus
-Has limited diagnostic accuracy in predicting the birth of a child MGVP
Using specially-designed graphics altimetry standing uterus improves the accuracy of forecasting MGVP
-A series of measurements with recording the data on a graph of antenatal fetal growth increases the sensitivity and specificity
Ultrasound biometry
-To diagnose MGVP used indicators abdominal circumference and estimated fetal weight
-Use a threshold below the 10th percentile for the expected weight of the fetus, and for indicators of fetal abdominal circumference
-Use a specially designed graphics ultrasound
-In addition to the performance indicators of the size, use the speed of development
The tests used for antenatal care to observe the fetus with suspected IUGR: antenatal cardiotocography (non-stress test), fetal biophysical profile, Doppler umbilical artery.
Monitoring the fetus with growth retardation during pregnancy
Screening: Gravidogramma - suitable method of screening for IUGR among healthy women
Diagnosis: If it is possible to confirm the diagnosis using ultrasound biometry
Monitoring: Doppler - the best method of fetal monitoring with suspected IUGR. If the Doppler indices are normal, then it is likely that a small-for-gestational age fetus has intrauterine
growth retardation.
The only effective treatment for IUGR - delivery in the most optimal time.
The use of new educational technologies:
METHOD "black box"
The steps are:
The method provides for joint activities and active participation in the activities of each student, the teacher works with the whole group.
Each student gets from a "black box" unknown drug, a brief summary of which is written on
the cards. (Options annotations attached). Students should determine the drug in detail justifying your answer.
To think about the student is given 3 minutes. The response is then discussed, given farmokokinetike addition to the drug.
This technique facilitates the development of speech student, developing the foundations of
critical thinking as In this case, the student learn to defend his opinion, to analyze responses
band members - participants in this contest.
6.2Analiticheskaya part
Case studies:
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1.In the department of pathology of pregnancy received primigravida 26 years. The gestational age 38 weeks. Pelvis 25-28-30-21 cm, 11cm diagonal conjugate.
These ultrasound: fetus in cephalic presentation, expected fetal weight 3200 g, 3 placenta
maturity in the bottom of the uterus. When doplerometrii identified circulatory disorders in
the mother-placenta-fetus 2 degrees and oligohydramnios.
The diagnosis?
Answer: 38 Ber.I ned.FPN.Hr to / from hypoxia
2. In the maternity ward delivered pregnant, complained of abdominal pain, bleeding from
the genital tract. The gestational age 35-36 weeks. Pregnancy was with symptoms of
preeclampsia. General state of moderate severity, pulse 90 per minute, blood pressure
130/90-140/90mm.rt.st. The uterus is enlarged accordingly gestation period, is strained.
Fetal heart rate of 160-170 beats / min, dull. When vaginal studies of a: neck of the uterus is
preserved, from the genital tract moderate bleeding, fetal head is slightly pressed against the
entrance to the pelvis.
What is the most likely diagnosis?
A: Pre-eclampsia is mild. PONRP II degree. Threatening hypoxia.
What should be done?
Answer: Emergency C-section.
3.Cherez 30 minutes after the beginning of the 2nd stage of labor in multiparous emerged
bleeding from the genital tract. A / D 120/65 mm Hg, the bout 2-3 minutes to 50-55 seconds.
The uterus is bad relaxes contractions, painful on palpation in the lower segment, the size of
the pelvis 26-27-33 - 18 cm Fetal heartbeat muffled. When cardiotocography revealed late
decelerations to 70 beats / min. Trying to catheterization failed due to mechanical obstruction.
When vaginal study: opening uterine mouth full, the head of the fetus is pressed against the
entrance to the pelvis, at the head of a large clan tumor. Sagittal suture rejected in front,
reached the big and small fontanelles are located on one level.
The most likely diagnosis?
A: Flat basin. Asinkliticheskoe insertion head. The outbreak of fetal hypoxia.
Tactics of the doctor?
A: emergency cesarean section
4.Zhenschina 35 to 32 weeks gestation has come to the doctor. For external obstetric examination: at the bottom of the uterus palpable volumetric soft part of the fetus, in the left half a vast uniform space, the right - small parts. At the lower end of the uterus - the part of the
fruit is round, dense, moving the entrance to the pelvis.
Where will be the heartbeat of the fetus in the woman?
A: below the belly button to the left.
6.3. Graphic organizer: Making graphic organizer
"Conceptual table" on "fetal malnutrition"
CONCEPTUAL TABLE
Provides a comparison of the phenomena, concepts, attitudes, etc., with the same two or
more aspects. Develops systems thinking, the ability to structure, organize information.
6.4.Prakticheskaya part
LISTEN FETUS
Purpose: Evaluation of fetal vnutriutroutrobnogo
Performs step (steps):
Events number does not hold nil
(0 points) Fully
correctly
performed
(20 points)
1. Auscultation of fetal STET-produced en masse, which is applied to the woman's abdomen
207
0 20
2. With neck-set positions serdtsebie auscultated below the navel, in pelvic - above the navel,
at transverse positions - at the navel closer to the head 0 20
3. At 1-position listening heartbeat etsya left at 2 - to the right, with vain attempts - suprapubic 0 20
4. Auscultation stethoscope must rely distribution perpendicular, ie at right angles to the back
of the alleged fruit, broad funnel tightly applied to the pregnant belly, and the other end - an
ear doctor. Auscultation should not hold up his hand, as this breaks the conduction of sound
stethoscope 0 20
5. In a normal heart rate of 120-160 beats per minute, regular, clear 0 20
Total 0100
7.Formy control of knowledge, skills and abilities
-Oral;
-Alphabet;
Testing;
Solution situational problems;
And demonstration of skills mastered.
8.Kriterii assessment monitoring
Number has time-dependence
Score in% level of students' knowledge
1 96-100% Excellent
"5" full correct answer to the questions on the etiology-ology, pathogenesis, classification,
clinical manifestations, diagnosis, treatment and prevention of this disease. To sum up and
make decisions, creative thinking, self-analyzes, case studies resolves correctly, with a creative approach, with full justification of the answer. Actively and creatively involved in interactive games, take the right decisions and summarizes and analyzes. Medical history, the party-gram fills correctly.
2 91-95% Excellent
"5" full correct answer to the questions on the etiology-ology, pathogenesis, classification,
clinic, diagnostics, treatment and prevention of this disease. Creative thinking, self-analyzes,
case studies resolves correctly, with a creative approach, with full justification of the answer.
Actively and creatively involved in interactive games, take the right decision. Medical history, filled with partograph one grammatical error.
3 86-90% Excellent
"5" The questions on the etiology, pathogenesis, Nezu, classification, clinical picture, diagnosis, treatment and prevention of this disease is completely covered, but have 1-2 errors in
the response. Own analyzes, inaccuracies in solving situational problems, but with the right
approach. Actively involved in interactive games, make the right decisions. Medical history,
partograph fills with 2-3 grammatical errors.
4 81-85% Good
"4" The questions on the etiology, pathogenesis, Nezu, classification, clinical manifestations,
diagnosis, treatment and prevention of this disease is completely covered, but there are 2-3
inaccuracies, errors. Into practice, understands the essence of the question, says confidently,
is a faithful representation. Situational problems solved correctly, but the justification answer
sufficiently. Actively involved in interactive games, take the right decision. Medical history,
partograph fills with 2-3 grammatical errors, inaccuracies in the description.
5 76-80% Good
"4" Correct, but incomplete coverage of the issue. The student knows the etiology, pathogenesis, classification, clinic of the disease, but not completely disassembled diagnosis, treatment and prevention of this disease. Understands the issue, says confidently. There is an exact representation. Actively participate in the games. On case studies gives partial solutions.
Medical history, partograph fills with 3-4 grammatical errors, inaccuracies in the description.
208
6 71-75% Good
"4" Correct, but incomplete coverage of the issue. The student knows the etiology and pathogenesis of the disease, but not completely disassembled diagnosis, treatment and prevention
of this disease. Understand the subject matter is covered in confidence, has accurate representation. On case studies gives partial solutions. Medical history, partograph fills with 3-4
grammatical errors, 3-4 errors in the description.
7 satisfies 66-70% solvent, but
"3", the correct answer to a half set of issues. Student knows the etiology of the disease, but
do not pay out the classification of the disease clinic, confused in the treatment and prevention. Understands the issue, said confidently, has accurate representations only on specific issues topic. Situational problems solved correctly, but there is no justification of the answer.
Medical history, partograph fills with 3-4 grammatical errors, 3-4 errors in the description.
8 satisfies 61-65% solvent, but
"3", the correct answer to a half set of issues. Errors in the etiology, pathogenesis, poorly
versed and confused in the treatment and prevention of this disease. Says uncertainly, has the
only views on certain issues topic. Making mistakes in solving situational problems. Medical
history and partograph fills with errors.
9 satisfies 55-60% solvent, but
"3" error response by half set of issues. Student makes an error in the etiology of this disease, poorly versed and confused in other matters relating to the disease. Says uncertainly has
a partial view on the subject. Situational problems solved incorrectly. Medical history and
partograph fills with errors.
10 50-54% of dissatisfaction with solvent, but "2" The correct answer is 1/3 of the questions.
Student does not know the etiology of this disease, poorly versed and entangled in other issues related to the disease. C-ation problems are solved correctly if correctly approach. Medical history and partnership gram fills with errors.
11 46-49% of dissatisfaction with solvent, but "2" The correct answer to fourth questions.
Student does not know the etiology of this disease, poorly versed and entangled in other issues related to the disease. C-ation problems are solved correctly if correctly approach. Medical history and partnership gram fills with errors.
12 41-45% of dissatisfaction with solvent, but "2" Lighting fifth of the questions with errors.
Student does not know the etiology of this disease, little versed in other matters related to the
disease. Gives an incomplete and partially incorrect answers to questions on the classification
of the clinical disease. Situational problems solved correctly if the right approach. More than
half of the patient's history and the partograph filled with errors.
13 36-40% of dissatisfaction with solvent, but "2" Lighting 1/10 of the questions at the
wrong approach. Does not know the etiology of the disease, and poorly versed entangled in
other issues related to the disease. Gives an incomplete and partially incorrect answers to
questions on the classification of the clinical disease. Situational problems solved correctly if
the right approach. Bole half medical history and partograph fills with gross errors.
14 31-35% of dissatisfaction with solvent, but "2" to the questions not answers. Does not
know and does not understand the other issues related to the disease. Does not know how to
fill out and used to describe the disease and thorium partograph.
9. Typical flow chart of lesson
Stages of work, time-name The content of the
Teachers Students
1etap. Introduction to the training session
(5min) 1.1.Soobschaet topic, purpose, and planned training results. Familiar with the plan,
features of the training session.
1.2.Nazyvaet: key categories and concepts from the data subject tion, a list of books for selfstudy
1.3.Soobschaet indicators and criteria of educational work in class
209
Listen, record,
specify, ask the question.
Stage 2.
Primary
(235 min) 2.1.Provodit updating knowledge through блиц-опроса/вопросно-ответной
forms / brainstorming, etc.
2.2. Consistently describes the steps
on the organization of the educational process according to the structure of practical training.
Meet
Abstracts with ethyl.
Working in groups, will present the results of the group work
Stage 3.
The Final-Resultant-regulating (60 min)
3.1.Delaet opinion on the subject, attention was concentrated on the main students, according
to the importance of the work done for future careers.
3.2. Commends the work of groups (some of students) summarizes vzaimootsenki. Analyzes
and evaluates the degree of achievement of lesson.
3.3. Gives the task for independent work, informing schaet and criteria evaluation. Selfevaluation,
interaction assessment.
Ask the question.
Write down the job.
10.Kontrolnye questions
1.What is the perinatal period?
2.Morforofunktsionalnoe state FPS?
3.Prichiny FPN?
4.Diagnostika FPN?
5.Lechenie and prevention of FPI?
11. Recommended Reading
Summary:
1. Abramchenko, VV Epidural anesthesia in obstetrics: a guide for physicians / 2006. - 229 p.
2. Abramchenko, VV Pregnancy and delivery of high risk: a guide for physicians / - M. Med.
Inform, 2004. - 400 p.
3. Abramchenko, VV Cesarean section in perinatal medicine: a guide for physicians / 2005. 126.
4. Abramchenko, VV Postoperative intensive care in obstetrics / Literature, 2000. - 88.
5. Abramchenko, VV Pharmacotherapy of preterm labor / 2006. - 448.
6. Abramchenko, VV Purulent-septic infection in obstetrics and gynecological
logii.rukovodstvo / 2005. - 459
7. Abramchenko, VV Postoperative intensive care in obstetrics / - St. Petersburg: Spec. Literature, 2000. - 88.
8. Abramchenko, VV Clinical perinatology / IntelTek, 2004. - 424 p.
9. Ailamazyan, EK Midwifery: a textbook for honey. Universities / 2003 - 528.
10. Topical issues of Obstetrics, Gynecology and Reproductive / Ed. EV KOKHANEVICH.
- Moscow: Triad-X, 2006. - 480.
11. Obstetrics. Ed. GM Savelyeva. - M.: Medicine, 2000. - 816 p.
12. Obstetric and gynecological care: Hands-on. for doctors / Ed. VI Kulakov. - Moscow:
MEDpress, 2000. - 512 p.
13. Obstetrics. Clinical lectures: a manual for schools with a CD / Ed. OV Makarova. - Moscow: GEOTAR Media, 2007. - 640.
210
14. Obstetrics. Directory of the University of California / Ed. Nisvandera K., A. Evans: Lane.
from English. - M.: Practice, 1999. - 704 p.
15. Barashnev, YI Perinatal neurology / Y. Barashnev. - M.: "Triad - X", 2005. - 670 p.
16. Bodyazhina, VI Akushersvo. The manual for the media. prof. Education / VI Bodyazhina. - Rostov-on-Don: Phoenix, 2003. - 480.
17. Resurrection, SL Fetal assessment. CTG. Doplerometriya. Biophysical profile: a manual
for the system of postgraduate medical. Education / SL Resurrection. - Minsk: The Book
House, 2004. - 304.
18. Gazhonova, VE Ultrasound in Gynecology / VE Gazhonova. - Moscow: MEDpressinform, 2005. - 264.
19. Gluhovets, BI Ascending infection of placental / BI Gluhovets. - Moscow: MEDpressinform, 2006. - 240.
20. Humeniuk, EG Obstetrics: Physiology of pregnancy: a training ben-beats / EG Humeniuk. - Petrozavodsk: IntelTek, 2004. - 170 p.
21. Demidov, VN Pelvic ultrasound in women. Adnexal cysts and benign ovarian tumors: a
practical guide / V. Demidov. - Moscow: Academy of Medical Sciences, 1999, vol. II. - 100
p.
22. Duda VI Obstetrics: a textbook for high schools in the specialty "General Medicine" / Minsk: High School, 2004. - 639 p.
23. Duda VI Physiological OB / - Minsk: 2000. - 447 p.
24. Duda VI Operative obstetrics: a manual / Minsk Interpresservis, Book House, 2002. - 512
p.
25. Zhilyaev, NI Obstetrics: phantom course / - Kiev, 2002. - 239 p.
26. Zhilyaev, NI Operative Obstetrics: Ouch. Manual / Kiev 2004. - 468 p.
27. Zhilyaev, NI Operative surgery in obstetrics and gynecology / 2004.
28. Selected lectures on obstetrics and gynecology / Ed. AK Strizhakova etc. - Rostov-onDon: Phoenix, 2000. - 512 p.
29. Clinical recommendations. Obstetrics and Gynecology: scientific publication / Ed. VI
Kulakov. - Moscow: GEOTAR Media, 2006. - 512 p.
30. Clinical lectures on obstetrics and gynecology / Ed. AN Strizhakova etc. - M.: Medicine,
2000. - 379 p.
31. Clinical evaluation of laboratory tests in women: study guide / Moscow Medical and
Dental. University. NA Semashko. - M: 2005. - 96 p.
32. Kulakov, VI Preterm birth / VI Kulakov, LE Ants. - M.: Medicine, 2002. - 176.
33. Kulakov, VI Intensive care in obstetrics and gynecology (efferent methods) / - M: MIA,
1998. - 206 p.
34. Drugs used in obstetrics and gynecology / Ed. Acad. RAMS VI Kulakov, Acad. RAMS
VN Serov. 2006. - 375 p.
35. Emergency care in obstetrics and gynecology. Quick Guide - M. GEOTAR - Media,
2007. - 52.
36. Perinatology Basics: A tutorial / Ed. MP Shabalov. - Moscow: MEDpress-inform, 2002. 576 p.
37. Practical skills in obstetrics and gynecology: a manual / LY Suprun, TS Divakova and
others. - Minsk: New Knowledge, 2002. - 166 p.
38. Rational pharmacotherapy in obstetrics and gynecology: Hands-on. for practitioners / Ed.
VI Kulakov, VN Serov. - M.: 2005.
39. Guide Out - patient care in obstetrics and gynecology / Ed. VE Radzinsky. M: GEOTAR
- Media, 2007.
40. Guide to practical training in obstetrics / Ed. VE Radzinsky. - M.: MIA, 2004. - 576 p.
41. Saveliev, GM Obstetrics: a textbook for schools / GM Savelyev, RI Shalina. - Moscow:
GEOTAR Media, 2008. - 656 p.
42. Sidelnikov, VM AG Antonov Premature birth. A premature baby / VM Sidelnikov, AG
211
Antonov. -M. "GEOTAR" 2006.
43. Smirnov, A. Pregnancy without problems / AN Smirnov. - Moscow: Atris Press, 2002. 208.
44. Smirnov, LM Obstetrics and Gynecology: Textbook / LM Smirnov. - M.: Medicine,
1999. - 368 p.
45. Handbook of obstetrics, gynecology and perinatology: uch.posobie for doctors / Ed. GM
Savelevoy.2006. - 720.
46. Trifonov, E. Obstetrics and gynecology: a manual for med._vuzov / EV Trifonov. - Moscow: VLADOS, 2005. - 175 p.
47. Filippova, GG Psychology of motherhood: a manual / GG Filippov. - Moscow: Publishing House of the Institute of Psychiatry, 2002. - 240.
48. Chernukha, EA Prolonged and prolonged pregnancy. Guide for Physicians / EA Chernukha. - M.: "GEOTAR - Media", 2007. - 207.
49. Chernukha, EA TK Puchko breech presentation. Guide for Physicians / EA Chernukha,
TK Beam. - M.: "GEOTAR - Media", 2007. - 173 p.
50. Shmagel, KV Immune pregnant women / KV Shmagel, VA Cherries. - Moscow: Medical
Book, 2003. - 226 p.
51. Tskhai, VB Perinatal obstetrics: a manual for honey. Universities / VB Tskhai. - Atlanta:
Med. Academy of RAMS, Moscow, Honey. book, 2003.
52. Amniotic and extraembryonic structures in normal and complicated pregnancy / Ed. VE
Radzinsky. 2004. - 393 p.
53. Congenital, perinatal and neonatal infections: Per. from English. / Ed. A.Grinou, J. Osborne, S. Sutherland. - M.: Medicine, 2000. - 287.
54. Kulakov VI, Murashko LE Premature birth. M. Medicine, 2002.
55. Serov VN etc. Eclampsia: A Guide for Physicians / V.N.Serov etc. - M.: MIA, 2002. 463
- with
56. VM Sidelnikov Habitual loss beremennosti.-M.: Triad-X, 2002.
57. Disseminated intravascular coagulation in obstetrics AD Makatsaria etc. - M.: Triad-X,
2002. - 496.
58. Schechtman, MM, GM Burduli Diseases of the respiratory system and blood circulation
in beremennyh.-M.: Triad-X, 2002. - 230C.
59. Shifman EM Pre-eclampsia, eclampsia, NELLP syndrome / Inteltek, 2002.
More:
60.Uchebnoe grant for the development of practical skills surgical / Edited by prof. Atalieva
AE, prof. Babadjanova BD Tashkent 2003. C102-115
61.Algoritmy diagnosis and treatment of surgical / Edited by Academician Karimov
Sh.I.Tashkent 2003. From 39-64
62.Uchebnoe benefit surgical subjects for medical students / Edited by Academician Karimov Sh.I.Tashkent -2003 Part II Obstetrics and ginekologiya.S 64-19013. Practical skills in
obstetrics and gynecology / Metod.posobie / / Tashkent 2008.
63.Akushersky soft tissue injuries of the birth canal, Kulakov VI, Butova E.A.2004.
64.Akusherstvo. National rukovodstvo._2004.
65.Infektsii in Obstetrics and Gynecology How VK Seagull 2006
66.Hirurgicheskaya technique cesarean secheniya_Strizhakov A.N._2007.
67.Ratsionalnaya pharmacotherapy in obstetrics and ginekologii.2007
Chan_Gynecology_and_obstetrics.2004
68.Rukovodstvo for outpatient care in obstetrics and gynecology, Kulakov V.I.2005.
70.Sidorova_I.S._Rukovodstvo_po_akusherstvu_ (Medicina, 2006) (ru) (1033s
71.Posobie for practical development of Obstetrics Voronin (KV) 2007.
72.Kirienko AI, Matyushenko AA, Andriyashkin VV Ostryi tromboflebit/2005
AN 73.Ivanyan - Intrauterine growth ploda/2007
74.DVS_sinrom _v_akusherstve.2004
212
75.Neonatologiya (Bazhanov NP). - T. I. - 2004
76.Prikaz MZ № 500 "On the reorganization of maternity hospitals to improve the efficiency
of perinatal care and the prevention of nosocomial infections."
77.Partogramma/Sherbaeva DB, Ayupova FM, FI Shukurov / Metod.rekomendatsii. Tashkent-2005. 28C
78.Uchebnaya birth history / Sherbaeva DB, Ayupova FM, FI Shukurov /
Metod.rekomendatsii. Tashkent-2005. 13C
79.Prakticheskie skills in obstetrics and gynecology / Me-tod.posobie / / Tashkent 2008.
80.Internet sites:
http://www.studmedic.narod.ru/, http://med.siteedit.ru/,
http://www.rukovodstvo-po-akusherstvu.-uchebnoe-posobie.html,
http://www.materinstvo.ru, http://mama.ru.http://www.art-med.ru,, http://www.doctor.ru,
http://www.rodim.ru, http://mamka.ru
http://medagent.ru, http://www.art-med.ru, http://www.medsan.ru,
http://mediki.spb.ru, http://medinstitut.e2e.ru, http://www.medstudy.narod.ru
http://www.obgyn.ru, http://www.medsno.ru, http://medrusnet.euro.ru
www.medtext.ru, www.medpoisk.ru, www.medicum.nnov.ru/student/
http://6years.net/, http://preryvanie-beremennosti.pharmabort.ru/
http://med4net.ru/, http://www.med-life.ru/, http://www.pregnant.ru/
http://www.roddom.ru, http://www.medpoisk.ru/, http://www.medlinks.ru
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