Глава V

№

Criterion of the assessment.

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1

To greet a patient respectfully and benevolently. To present

yourself. To explain confidentiality of a information.

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2

Collect the passport’s date: name, surname, age, address,

profession, having a family.

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3

Asking and finding the main complains, check a reasons of its , factors, that increasing f its or make less.

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4

To take an anamnesis of disease: to make a note of a disease’s beginning, on which day of a menstrual cycle the symptoms of disease appear,sequence of a disease ‘s symptoms a appearance, conducted treatment.

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To collect a special anamnesis : menstrual function ( the age of a menarche, coming to be of a menstrual function, regularity, continuation, painful/ painless, the amount of the blood lost) the date of the last menstruation; sexual function ( from which age), in/ out of marriage; generative function ( duration and outcome of the all previous pregnancies)

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6

To collect the anamnesis of life : which number she is , according the counting in the family, a mass in the time of delivery, a pubertal and post pubertal period duration. To clear up the having common illnesses in the past, hepatitis, tuberculosis, a contact with a patients, having a tuberculosis, sexual transmitted diseases..

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7

To clear up a using by patient a contraceptive drugs during of her life, it

‘s effectiveness, previous gynaecological diseases, methods of treatment , include antibiotic therapy.

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To clear up the allergic anamnesis, heredity.

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To clear up of operation- hemo transfusion in anamnesis.

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10

According to received date to make a conclusion..

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№

Criterion of the assessment.

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1

To explain for a patient the essence of examination. .

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2

To put a patient on the gynecological armchair. .

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3

Follow rules of aseptic and antiseptic wash your hands and put on the sterile gloves.

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4.

For collection of smear are using only sterile instruments , collection of smear is performing before gynecologic examination and performing of gynecological procedure for treatment..

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5.

For collection of smear a spoon of Folkman is using from the all infected places. Collected material is put on the clean slaide. Discharges from cervix and vagina is put with particularity - like “U”-from ureter,, “C”–from cervix, “V”-vagina.

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In the beginning we are collecting smear from ureter. We are performing with index finger massage of ureter from anterior wall of vagina. The first portion of discharges we are removing with a sterile ball and after that we are taking a discharges with Folk man spoon on depth 1,5-2 sm. Collected material is put as “U” on slid .

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7.

Opening of uterine cervix in speculum, before that treat the cervix with sterile material and collect a smear from cervical channel ( with light scrubbing movements, because of some infection is not on superficial of mucous but under its. Collected smear is putting on slid as “C”–cervix of uterus.

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8.

Vaginal smear is taken from fornex posterior and put on slid as V”-vagina.

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9.

Collected material is drying and taken in laboratory for microscopy. Take off gloves and through away at the special conteiner. Wash your hand and dry with disposable tower.

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10.

During the procedure explain your actions using a temper and friendly tone, answer the patients’ s questions..

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1.

Explain for patient essence of examination..

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2.

Put woman on gynecological armchair.

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3.

Wash our hands and dry with disposable towel. Take on a sterile gloves.

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4.

Using of index finger and middle finger of the left hand , take away of labia major , in vagina introduce two fingers ( in the beginning – the middle finger , that press a perineum , after that index finger).

Make examination of uterus , its size, site, consistence, mobile , painful).

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5.

Make examination of uterine adnexa , beginning with healthy side, We check its size, position , consistence, form ,painful and etc..

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6.

Choose the particularity of vaginal fornecies ( smoothing, hardness, going away, painful, fluctuation.).

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7.

Take away fingers from vagina, assess the character of discharges( bloody, purulent, mucous).

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8.

Take away of gloves , through away its in special container for utilization and wash our hands..

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9.

Make a notices at the chart of out patient department patient or case history..

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10

During a procedure explain for patient our actions , using temper and friendly tone , make possibility to ask questions..

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№

Criterion of the assessment.

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1

To greet a pregnant woman ,parturient respectfully and benevolently. To present yourself. To explain confidentiality of a information.

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2

To collect the passport’s date: name, surname, age, address, profession, having a family.

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3

Ask and check the main complains , we should know the reason of complains , factors , that increase or make a weak this complains.

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4

Ask of anamnesis of life. Make shoe in chronological order , beginning with childhood, which types of diseases and operations she had. In the cases of chronic diseases , make clear how long it is , periodic supervision by specialist , date of the last acute stage. We have interest rather a woman was sick with virus hepatitis , tuberculosis, sexual transmitted diseases , her epid, surrounding. Has band, his age, condition of health..

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Special anamnesis : collect od information about menstrual function ( beginning of menstruation( menarche ), when menstruation became stable, duration , in how many days repeated , amount, heavy, moderate, scanty , date of the last menstruation.

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Make shoe the age of sexual life starting , if she married or not , quantity of marriages. Date about gynecological diseases ( which types ,when).

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Collect of obstetrical anamnesis , previous pregnancies at the chronological order, its results, body mass of children after delivery. Complications in labor ( when, which)..

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Determine the duration of this pregnancy , term of pregnancy and date of the first visit to female consultation , date about of pregnancy duration according to trimesters..

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9

Examine the color of skin and visible mucous , presence of peripheral edema , condition of veins on the low extremities. Check a blood pressure, pulse rate , performing of a heart, lungs auscultation, palpation ,of abdomen , liver, percussion of liver if it is necessary.

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On the way of procedure explain our actions for pregnant woman / parturient using a friendly and temper tone, give a possibility to ask a questions.

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Explain for pregnant woman, parturient the essence of examination , Wash a hands, dry with disposable towel , Take on a disposable gloves.

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Put a pregnant woman , parturient, on the high . hard coach with putting together and extended at knee, and cox – femur articulations legs.

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3

Standing or sitting with a face to a pregnant woman, parturient to the right. Branches of pelviometer аre taken with the large and finger indexes . so the fingers should be very closed to the bottoms of pelviometer..

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Bottoms of pelviometer are very closed to the external edges or the spine iliac anterior one and another side , checking the diameter between them distantia spinarum, (at norm 25-26sm).

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After that put bottoms of pelviometer from spines to the external crist of iliac and check the biggest distance – distantia cristarum (at norm 28-29sm).

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Ask woman to make movements with legs , find the more upper part of tuber femoral bones and press to them bottoms of pelviometer , checking the distantia trоchanterica (at norm 30-31 sm).

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After that ask a woman to lie on the one side , flexing the low leg at articulation cox – femur and knee’s, upper one to extend and stretch..

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Bottom of the one branch put on the middle of upper - external edge of symphysis , another one press to the sacrum’s fossa and measure of external conjugate (20-21sm).

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9

Solovjov index ( circumference of radial articulation ) measure with belt. This index in norm is 14, 5- 15см. The true conjugate is measure by minus from previous size 9 sm..

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On the base of receiving date we will make a conclusion about individual particularity of bone’s pelvis of woman.

Take away gloves and through away at the special container. Wash our hand.

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Explain for pregnant woman, parturient the essence of examination , Wash a hands, dry with disposable towel , Take on a disposable gloves..

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2

The pregnant woman, parturient is lying down on the back side with bent her legs at the cox- femoral and knee joints for relaxation of the abdominal muscles.

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Stand up with face to patient , to the right side from her.

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4

The first method : palms of both hands are situated on the fundus of uterus with fingers ends of arms, directed to each other and find the height standing of uterus fundus., his site,( presence or absence of a big part in the fundus and high of fundus over a pubic.

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The second method : palms of both hands put on the lateral parts of uterus , from a fundus. Palm surface of arms we are palpate the lateral parts of an uterus changing the action of the left and right arms. Receive the conclusion about situation of a fetus back and small parts , make a conclusion about position and view of fetus .

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The third method : determine the presenting part of fetus , for that the palms of the right hand we are putting over a pubic and fingers are taken the presenting part . Finding a hard and balloting part we think about cephalic presentation , at finding of the soft and non – balloting part will tell us about pelvic presentation.

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For performing of the next method , investigator is standing with face to legs of patient , to the right..

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The forth method is for the determination of coordination of presenting part with plane of inlet in small pelvis and useful in labor ..

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Palms of both hands are situated lateral from the middle \line over horizontal branches of pubic bones. Palms are situated lateral from the middle line over horizontal branches of pubic bones . Constantly changing the position of fingers between presenting part and plane of inlet we check the relationship of presenting part to the plane of inlet..

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Make a conclusion on the base of receiving da about of fetus sites , position, view presenting part and coordination of presenting part to the plane of inlet in small pelvis.. Take away of gloves, through away its in container for utilization, wash our hands.

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Explain of pregnant woman, parturient aim of examination. Patient is lying on a backside with flexed legs at the pelvic- femoral and knee’s articulations and situated far from each other..

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2

Performing a cleaning of the external sexual organs of patient. Wash our hands and dry with disposable towel. Take on sterile gloves.

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3

Internal examination should be started with examination of the external sexual organs( growing of hair , development, edema of the external sexual organs ( vulva), various veins, perineum( its high, rigidity , presence of scars ) and introits in vagina.

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At a vagina phalanx of middle and index fingers are introduced and performing its examination( wide of its, length, folding’s, stretching of the vaginal walls , scars presence , tumors, and another pathological conditions ). Palpation of the internal surface of bone’s pelvis is performing..

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If there is pregnant woman uterine cervix is found and degree of maturation should be checked : situation of its on the longitudinal axis of small pelvis , size, form, consistence , shortness , permeability of channel by investigated fingers.

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6

In labor we determine the condition of cervix ( shorten, smooth), the degree of uterine cervix dilatation in centimeters , condition of edges (soft , hard, thick, thin. Check the condition of fetal bladder ( whole, is disturbed, the degree of tenderness, quantity of anterior amniotic fluid).

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Determination of the presenting part – buttocks, head, legs, with orientation on the definite points, on the head sutures and fontanels , on the pelvic end – sacrum and coccygeal part. Determine, where is a presenting part :over the plane of inlet, very closed to the plane of inlet, with small segment, the large segment , into the cavity of small pelvis , in the plane of outlet.

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8

If presenting part is high and promontories of sacrum is reached , we should measure the diagonal conjugate ( conjugate diagonal ) between the promontories and low part of articulation pubic.( at norm it is 13 sm.) with finger in vagina we try to reach promontories and with end of a middle finger reach its. Index finger of free hand we should touch the low part of pubic articulation that directly contacted with low edge of the pubic arch.

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9

Take away fingers from vagina , Measure on the internal hand the distance marked on the arm by tape-measure or pelviometer. Take away fingers from vagina . According to sizes od diagonal conjugate we think about sizes of true conjugate.

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10

Make a conclusion on the base of the received date. Take off gloves and through away in container for utilization, wash a hands.

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Explain for pregnant woman, parturient essence of examination.

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2.

Determine the term of pregnancy on the date of the last menstruation (LM). The first day is counted as 0 day, but not as the first . Days from 0 -6 are coordinated as “ full zero moon’s week”, but days fro 7 till 13 – the full the first moon week. If the first day of LM is unknown , the term of pregnancy is counted on the base of the more suitable clinic date..

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Determine the term of pregnancy on ovulation. From the first day of waiting but not came menstruation 14 – 16 days should be minus , depending on the continuation of cycle and counting on calendar the term on the day of investigation.

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4.

Determine the term of pregnancy on the date of the first of fetus movement . If woman is prime gravid a it is 20 weeks, for malty pare – 18 weeks of pregnancy, after that , using a calendar cunt the term of pregnancy.

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For determination of the date of labor among prime gravid woman to the date of the first of fetus movement plus 20 weeks, malty pare – plus 22 weeks.

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According to term of pregnancy on the first , with condition – early visit to FDA, female consultation, make exact date of the first visit..

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According to objective date , counting the circumference of abdomen index and height of fundus and date of bi – manual examination in the term of pregnancy below 12 weeks..

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Determine a term of pregnancy according to USI date in condition of the first examination till 16 weeks.

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Determine date of labor on the Nigella formula : from the date of the first day of last menstruation minus 3 months and add 7 days..

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10.

In the counting of the term of pregnancy should be count as days , as a weeks.

According to receive date to make a conclusion about the term of pregnancy and possible date of labor..

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Explain for pregnant woman, parturient essence of examination. Hands, dry with disposable towel Take on a disposable gloves.

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2

Take a sizes of circumference of abdomen (CA) on the level of umbilicus and lateral angle of Michaels rhombus with belt.

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Measure the height of uterine fundus standing with sm. -. The beginning of belt is on the upper edge of pubic articulation, belt should be situated on the middle line of abdomen. With a rubber of a palm we determine height of fundus in centimeters.

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Determination of the fetus mass according to Zordania method., us multiplication of circumference of abdomen on the height of fundus . .

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Determination of the possible fetus mass according to S, according to formula: Х =

Mass of woman in grams/ on constant ( depending on a mass of woman) + (CA HUF

2

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Determine a mass of fetus according to Yakubova ‘s method prime gravid, head presentation, the whole amniotic membranes mass of fetus is = (CA+ HUF )100

4

In case of the 2^nd labor +50, 4-th+150, more+300.

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Determination of fetus mass according to Jonson method: (HUF-11)155

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Determination of fetus mass on Bublichenko method . Possible mas of fetus is 1/20 body mass of a woman

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In cases of prognosis of big baby mass of fetus is determine on Nurcasymov method ( for doctors in internship)

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On the base of received date to make a conclusion about possible mass of fetus . Remove a gloves and through its in special container for utilization., wash a hands.

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At the upper part of partogram is fixated name, surname of parturient, obstetrical dates ( quantity of labor, pregnancies) in anamnesis), № of case of labor , date and time of hospitalization to the stationary( maternity home) , period without amniotic fluid ( in hours ), time of partogram filling started.

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The dilatation of uterine cervix is filling as "X" on graphic. Latent phase – period of slowly dilatation of uterine cervix from 0 till 3 sm.,with constant shortness of uterine cervix . Active phase is period of fast of uterine cervix dilatation from 3 till 10 sm. Dilatation of cervix from 0 – 3 sm. , is reflected of latent period of labor , in cases of going labor to active phase , reflection of dilatation uterine cervix we put on Alarming line on a way of interrupted line. If woman is in an active phase of dilatation of uterine cervix , we put on Alarming ;line with coordination of the degree dilatation and time we put exact under the place of X. on the “ time “ line.

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Contractions of uterus are reflected with interrupted lines : points, oblique lines and not interrupted lines below the axis of time , where is written “ contractions of uterus “.during 10 minutes . Every small part is coordinated with from 1 to 5. Every small part is coordinated with one contraction. If during 10 minutes will be 2 contractions , we should use two small parts and etc..

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Going down of fetus head is reflected “0” on the left part of graphic on scale “ going down of fetus head “ with mark from 5 till o( situation of head is over the edge of pubis in a wide distance of 5 fingers, head its part which is over the pubic , is measured the smaller quantity of fingers ( 4/5, 3/5 and etc.)

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Frequency of fetus heart beating we registries every 30 minutes at the upper part of partogram.

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Condition of amniotic fluid is reflected at the graph “ amniotic fluid”.We make registration of the amniotic fluid color : clear amniotic fluid “C”, bloody “ B”< with meconium “ M” < whole membranes “ I”.

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Make reflection of a head bones configuration on a place bellow line “ amniotic fluid .If bones separated fro each to other , sutures are palpable , we make fixation ,as “0”; if its touch each other a little (+). If its going over each other ( ++), very serious going over ( +++)

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We should reflect prescriptions of oxytocin injections at IU/l or drops . .

Prescriptions of another medicine and i/v solutions is reflected on line, below oxytocin reflection.

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Supervision of a parturient condition we reflected on partogram below . BP and PS rate is measured ever 1 hour, t-ra every 4 hours. Volume of urine presence of protein and acetone in urine is redistricted too.

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During procedure we must explain our actions with temper and friendly tone, give the possibility to ask a questions.

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Explain for parturient the essence of the conducting manipulation . Wash our hands ,dry with disposable towel.Put on disposable gloves..

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Perform of abdominal palpation for exclude the second fetus present in uterus. During the 1 minute after a fetus delivery make injection of 10 U of oxytocin at the upper third of femur i/m..

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Umbilicus cord is pressed with forceps more close to perineum.. Pressed umbilicus cord I with forceps end hold in one hand. Another hand put on supra pubic region of woman. надлобковую область женщины.Umbilicus cord are holding at the stretched condition and waiting sever contraction of uterus ( as a rule, after 2-3 minutes)..

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In case of uterine contraction and elongation of umbilicus cord , very carefully try to stretch on cord on yourself and down for delivery of placenta , another hand , in the same time displace of uterus at the opposite direction of stretching of umbilicus cord, for prevention of uterine insertion. When after birth is delivered , we hold its with both hands and carefully turned, for delivery of amniotic membrane4s..

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After delivery of afterbirth , immediately performing of uterine massage through the anterior abdominal wall of woman till the uterine contractions appearing.

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Assess the integrity of after birth . Placenta should be put on the quadrate tray with maternal surface to up and determinate the presence of all lobes , carefully examine the edges of placenta . After that turn its with maternal surface down , elevate after birth, holding of umbilicus cord , the second hand put inside of membranes , making a fingers separate , to be shoe in its integrity

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.In the same time put attention if there is no between membranes ruptured vessels , going from the edge of placenta ( ruptured vessels tell us about the additional lobe of placenta , that remains at the uterine cavity.)

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Check od blood lost volume , put a blood in the vessel for measurement.

Perform of external sexual organs examination .In case of rupture – repair the integrity..

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Assess the general condition of parturient , counting pulse rate , measure .blood pressure..

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Take away of gloves , through its in special container for utilization , wash our hands ..

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Prepare previously equipment , that is necessary for newborn. Wash hands and dry with disposable towel. Take on a sterile gloves..

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At the moment of delivery to assess of a newborn condition on your hand , during 30 sec.

If newborn condition is good, without problems, make his dry with a warm clean napkins , put him on the abdomen of mother . On a head we wear a clean, brought from home a warm cap, on the legs - socks. The wet napkins take away and put on newborn dry and warm napkins , additional cover.

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Umbilicus cord is cut by sterile scissors between two clamps after stopping of vessels pulsation...

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Assessment of breathing of newborn and color of skin every 15 minutes during the first hour and ever 30 minutes during the 2 hour. If a skin became cyanotic or he has difficulty of breathing е (<30or >60 in minute ), give an oxygen through the mask and call a neonatology in urgent order.

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-measurement of body temperature by electronic thermometer in 30 minutes after labor and before going to post partum department , if temperature of body is less 36,5 С — it is necessary to change napkins, cap on more warm , take some measure to warm a newborn ( additional blanket with mother ,central heating lamp over the bed, where mother and child will be etc.;

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-at the end of the first hour we should put in eye of ointment ( tetracycline or erythromycin in an individual package ) to the end of the 2 hour -repeated..

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- to the end of the 2 hour a plastic forceps is put on the umbilicus cord , treated of cord with sterile gas , remains of umbilicus cord will be opened , and newborn is in the skin contact with mother.

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- taken of body mass and measurement of newborn are performing, following the all orders of not interrupted warm defense.

Common examination together with neonatologist is performing to the end of the 2 hour , after that a newborn will have changed clean and dry cloths(baby’s vest and pumpers ). During all time the child has skin to skin contact with mother ( tight swaddling is not recommended);

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Information should be done about importance of breast feeding, particularity of early breast feeding , frequency of feeding and in cases of the first symptoms of newborn preparing for feeding – help during the first feeding..

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Take away of gloves and through away its for utilization. Wash your hands...

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Wash a hands . Dry with disposable towel ,put on a sterile gloves.

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After a newborn delivery to count of frequency of fetus heart beating . Frequency of heart beating more , than 100 beats in one minute -- 2 balls, less, than 100 beats in one minute – 1 ball, absent - 0 balls.

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Count the frequency of respiratory movements. .Frequency of respiratory movements of newborn more ,than 40 – 50 in minute( loud cry) - 2balls , less , than 40 – 1ball, breathing is absent – 0 ball.

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Check and assess of reflected irritability. Active movements, loud cry – 2 balls, movement of grimes on the face of newborn - 1 ball , absence of reaction – 0 balls.

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Assess the skin cover condition. Skin cover is pink – 2 balls , acre cyanosis – 1ball, expressed of skin pale color 0 balls..

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Assess the muscle tonus of newborn. Active movements of newborn – 2 balls, the light degree of extremities flexed -1 ball, absent of movements – 0 balls.

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Assess the condition of newborn on the sum of balls during the 1 minute after delivery.

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Assess the condition of newborn on the sum of balls in 5 minutes after delivery.

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According to sum of balls to make a conclusion about of fetus condition, absence or presence of asphyxia .

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Take away of gloves , through its in special container for utilization.. Wash a hands.

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№

Criterion of the assessment.

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1

To greet a patient respectfully and benevolently .Ask her to take

the lovely pose .Represent yourself. To explain her that all

information will be cconfidentiality.

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2

Ask a patient , when she is planning the next labour or not planning

at All.

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3

Collect a common and reproductive anamnesis of patient: age and condition in family , quantity of pregnancies and labor , quantity of alive children , their age and sex , which methods of family planning were used before, how long, reasons of interruption to use its .

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Give the short information about all methods of contraception , its characteristic , effectiveness, side effects. It is should be remember , that patient has a rule of choosing of contraception method .

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5

To assess a somatic status and check , may be woman already has pregnancy.

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If a patient choose the concrete method of contraception, ask her , what she knows about this method , explain for her any wrong information or not exact information.

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7

Make an instruction about “ alarming” symptoms and signals , demanding

the urgent going to doctor : delay of menstruation after prolonged using, sever pains in low part of abdomen , head ache , heavy bleeding, worst vision.

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8

Ask a patient to repeat of instruction , to be shoe at the right way of information assessment .

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Ask a patient about her questions, if she is not shoe about method.

Answer on this questions.

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10

Give for her another date for attendance. Give for her advice to

come to doctor in any time , if she will have any problems or she will have

a question.

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