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Medical care for women during pregnancy
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Medical care for women during pregnancy
Table 1
Medical care for pregnant women in out-patient department
| Term of pregnancy | Diagnostic measures in outpatient settings |
| Examination in the 1st trimester (and at the first visit) | Taking of anamnesis. General physical examination of the respiratory, circulatory, digestive, urinary system, mammary glands. Anthropometry (measurement of height, body weight, determination of body mass index). External pelvimetry. Specula examination. Bimanual vaginal examination. FBC and urinalysis. Determination of the blood groups and Rh- factor, Biochemical screening of serum markers: pregnancy-related plasma protein A (PAPR-A), free beta subunit of chorionic gonadotropin (β HCG) (11- 14 weeks), Wassermann reaction (WR), detection of M, G antibodies against HIV-1 and HIV-2 in the blood, detection of M, G antibodies to the antigen of viral hepatitis B and viral hepatitis C in the blood. A vaginal wet mount. Electrocardiography (ECG) if if recommended by a cardiologist. Ultrasound examination (US) of the pelvic organs (at term11-14 wks). |
| Examination in the 2nd trimester | Anamnesis. General physical examination of vital organs. Determination of the abdominal circumference (AC), the Symphysis Fundal Height (SFH), the tone of the uterus, palpation of the fetus, auscultation of the fetus heart sounds (FHS). CBC and urinalysis. Screening US of the fetus at 18-21 weeks. |
| Examination in the 3rd trimester | Anamnesis. General examination of the vital organs. Determination of the AC, SFH, uterine tone, palpation of the fetus, evaluation of the FHS. After 32 weeks of pregnancy determine the fetus’ lie, position, and presentation. CBC, urinalysis. Determination of WR, detection of M, G antibodies to the HIV-1 and HIV-2 viruses, determination of M, G antibodies to the antigen of viral hepatitis B and viral hepatitis C in the blood. A vaginal wet mount. Screening US of the fetus at 30-34 weeks with Doppler US, CTG of the fetus after 33 weeks. |
| Multiplicity of visits: | obstetrician-gynecologist - at least seven times; therapist - at least two times; dentist - at least two times; otorhinolaryngologist, ophthalmologist-at least once; other specialist - according to the indications, taking into account the concomitant pathology. In the case of a complicated course of pregnancy and concomitant pathology, the frequency of visits, frequency of examinations and consultations of a doctor-obstetrician-gynecologist and medical specialists is determined individually. To exclude asymptomatic bacteriuria (the presence of bacterial colonies more than 105 in 1 ml of the middle portion of urine, determined by the culture method without clinical symptoms), urinary culture should be done for all pregnant women once during pregnancy (after 14 weeks). |
Dispensary System for Pregnant
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A dispensary method is the highest form of synthesis of prevention and therapeutic measures carried out selectively either in separate groups or in all population of the district of treatment-preventive establishment.
In modern conditions of medical care of population all pregnant women registered in maternity welfare clinic and wishing to preserve their pregnancy are under dispensary supervision.
After childbirth (or recovery) women become free from regular medical checkup.
The tasks of regular medical check-up of a pregnant in maternity welfare clinic are as follows:
• to give a systematic checkup of women in chosen groups;
• to get acquainted with living conditions and conditions of work for carrying out health-improving measures;
• early diagnostics of initial form of diseases, timely and qualified treatment preventing complication development and disease progress;
The order of choice for regular medical checkup. The choice of women for regular medical checkup is made by a doctor-obstetrician of maternity welfare clinic in coordination with chief physician, medical consultative commission. Women requiring regular medical checkup are revealed by a district obstetrician-gynecologist in the room of primary inspection. A thorough history-taking (disease origin, features of its clinical course, treatment, obstetric anamnesis, capacity for work), careful examination with applying modern methods of diagnostics, examination of laboratory data in dynamics of observation, consultations on the most important questions contribute greatly to perfection of dispensary system.
Pregnant women whose last pregnancy and childbirth were complicated with somatic pathology, and who had incomplete pregnancy, still birth, or birth of children with congenital malformations and defects, or operative delivery should undergo a regular checkup. To such cases the following refer:
• cases with multivalvular mitral disease with stenosis;
• combined involvement of valvar apparatus of rheumatic etiology;
• severe myocardium diseases;
• women operated on lungs and heart;
• women suffering from hypertension;
• women with organic diseases of kidneys and those after nephrectomy;
• women with diabetes mellitus;
• women with habitual noncarrying of pregnancy (miscarriage), prematurity;
• women having undergone cesarean operation;
• patients with toxoplasmosis, listeriosis, brucellosis, cytomegalovirus and other chronic infections;
Into the group of regular medical checkup the women are also included to whom pregnancy is either absolutely or conditionally contraindicated.
In modern opinion such women should not conceive and deliver for further two years. This period is necessary for treatment directed at ill organ compensation, reproductive health recovery, preventive measures of decompensation in pregnancy and delivery.
In cases when new pregnancy may have an unfavourable effect on woman’s health, the task of obstetrician-gynecologist is to take measures to prevent conception and if it occurred — to refer a woman to the in-patient department for abortion by life-saving indication in early period of pregnancy (till 3 months).
In cases when pregnancy is remained for prolongation in a woman with extra genital or gynecologic pathology accompanied with obstetric anamnesis, a regular medical checkup is done during all pregnancy. Pregnant women with extra genital pathology should be hospitalized to the in-patient department in critical pregnancy terms even without complications during gestational process. At the in-patient department such patients undergo a routine medical examination to reveal the state of pregnant woman and fetus, prognosis of pregnancy course. Preventive therapy is administered for prophylaxis of decompensation of a chronic process and complications of pregnancy and delivery.
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The main principle of regular checkup is a differentiated medical treatment based on drawing up a plan of pregnancy management for each woman. Special attention should be paid to a high risk group of women. All women registered in the maternity welfare clinic should be regularly checked up. In order to make examination of a pregnant woman who hasn’t come to a planned examination an obstetrician nursing visit is made. During the visit an obstetrician studies the condition of patient’s health, checks how the woman follows the doctor’s recommendations, reveals the living conditions of the patient, persuades the woman of necessity of attending a doctor, and makes some laboratory and other investigations. An obstetrician also carries out a medical-diagnostic work (measuring blood pressure and pulse, auscultation and estimation of fetal heartbeat).
Sanitary-Educative Work
This work is carried out by all physicians and paramedical staff of maternity welfare clinic. This work includes such forms as individual and group lectures, discussions, exhibitions, “Sanitary Bulletins”, etc. ”Maternity School” aimed at preparing a pregnant woman for child care is widespread nowadays.
In-patient Obstetric Care
In-patient obstetric care for city population is provided in independent maternity hospital and obstetric departments which are included into multitype hospitals, or medical sanitary units. In-patient obstetric care in Ukraine is available for all women. Pregnants, puerperants, parturient women are served according to the territorial principle; territory of maternity home (obstetric in-patient hospital, obstetric department of multitype hospital) is determined by Public Health Service. A patient or her family has the right to choose in-patient hospital or doctor according to mutual agreement. Hospitalization of a pregnant to the in-patient hospital is made according to the direction of emergency or out-patient departments and policlinic medical prophylactic establishments, obstetricians, doctor’s assistants, or nurses of obstetric departments. On hospitalization of a pregnant woman or woman in childbirth to obstetric in-patient department an obstetrician-gynecologist of the reception ward in order to estimate the condition of patient’s health makes general physical examination, takes body temperature, measures blood pressure on both hands, examines internal organs, measures height of uterus fundus, abdominal circumference, pelvis size, listens to fetus’ heart sounds, makes internal obstetric examination. Notes in case history about fetal movements felt by a pregnant woman or woman in childbirth are obligatory. The doctor studies the data of in-patient prenatal card, collects general and in-patient anamnesis, paying special attention to presence of acute respiratory diseases, examines visible mucous membranes in order to reveal pyodermas and cutaneous mycoses, determines the duration of waterless period. The doctor makes blood sampling for Wassermann reaction, HIV-infection, urinanalysis for diagnosing bacteriuria, proteinuria; vaginal discharge sampling is made for urgent diagnosis of grade of vaginal discharge.
According to results of examination a pregnant or puerpera is hospitalized to physiological or observation obstetric department.
Structure of Obstetrical Hospital
The structure of maternity home or obstetric-gynecologic department includes: admission department, the first (physiological) and second (observation) obstetric department, pathologic pregnancy department, infants department (or reserve infant wards in case of rooming-in), department of functional diagnostics (ultrasound, cardiotocography, oculist rooms). Apart from these an independent maternity home has an administrative service, laboratory, drugstore and some other economic services.
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The structure of obstetric in-patient department is considered optimal when 45% of total amount of obstetric beds are located in the physiological obstetric department, 25 % — in observation and 30% — in pathologic pregnancy department. Such distribution of beds helps to provide unfailing hospitalization of pregnant women and absolutely isolate all ill women and children in maternity home.
In order to define the needs of population in in-patient obstetric care, the data about birth rate and obstetric sickness rate, average number of patients in the hospital per year, average number of occupied beds per year are necessary. The necessity of city population in obstetric beds makes up on average about 8 per 10, 000 people.
Therapeutic-Protective Regimen in Obstetrical Institutions
All work with pregnant women, puerperas, women in childbirth, and gynecologic patients is based on the necessity of following a therapeutic-protective regimen.
A therapeutic-protective regimen is a set of measures producing a favourable effect on women’s nervous system and eliminating negative emotions, uncertainty in pregnancy and delivery outcome. The therapeutic-protective regimen assists in occurrence of trustful attitude towards medical workers’ actions and confidence in positive outcome of delivery or disease. The establishment of therapeutic-protective regimen mostly depends on general level of state of obstetrical institution. General view of institution, cleanness of all premises and territory are of importance. A therapeutic-protective regimen depends basically on organizational management of maternity welfare clinic and maternity home. The work should be organized in such a way that during her first visit to maternity welfare clinic a woman would feel care and friendly attitude of medical staff.
Pregnant women and patients should be treated with delicacy and tact. General and special obstetric examination is made thoroughly, with great attention; advice about hygiene, diet, and other questions is given in a friendly and clear way. An obstetrician should be especially tactful while revealing pregnancy complications and gynecologic diseases. She tells her opinion with cautiousness and explains the necessity to visit a doctor. She also calms a patient and instills confidence in a positive outcome of pregnancy or disease.
The correctly organized patronage promotes the creation of therapeutic-protective regimen. During patronage visits an obstetrician tries to make contact with a pregnant woman in order to teach her all sanitary-hygienic skills and carry out all prophylactic measures at home. It is necessary to create such conditions at the in-patent hospital that each woman should come there without any anxiety and fears.
The maternity home staff should pay maximum attention to a woman, be tactful and delicate. The right way of treatment of pregnant women and women in childbirth is an important element of therapeutic-protective regimen; success of medical prophylactic measures to a great extent depends on it.
Quiet conditions should be arranged at the in-patient department, which should exclude any fears of pregnant woman for her or her child’s state. Order, quietness, absence of fuss in work influence positively on nervous system. Daily routine should be organized in such a way that pregnant women, puerperas, gynecologic patients would have enough time to sleep. Besides night sleep there should be day sleep which is especially necessary for nursing mothers.
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In the presence of woman the talks about unfavourable cause of pregnancy and delivery, about future operations, etc. are not admissible. In case of operation necessity a woman is informed about it carefully; thus she is assured of positive outcome of operation and other procedures. Women in childbirth should be daily informed about their children’s condition not to arouse anxiety for their condition.
Gymnastics after delivery strengthening the whole woman’s body including nervous system is of great importance.
The proper organization of sanitary-educative work is one of the most important elements of therapeutic-protective regimen. Pregnant women and woman in childbirth are explained the rules of personal hygiene, dietary habits, rules of feeding and care of newborn children.
Psychoprophylaxis of birth pangs in maternity welfare hospital and maternity home is closely connected with therapeutic-protective regimen. Psychoprophylaxis is an integrity part of therapeutic-protective regimen.
The lawyer’s consultations are arranged at maternity welfare departments in order to provide social legal assistance to mothers. If necessary, legal assistance is provided to women in maternity homes.
Self Test
1. Out-patient obstetric care is provided in:
A. maternity welfare clinics
B. maternity homes
C. multifield clinic hospitals
D. general medical practice rooms of central regional hospitals
2. In-patient assistance to obstetric patients is provided in:
A. maternity homes
B. village medical out-patients departments
C. medical obstetric units (medical attendant’s unit)
3. The service of women in maternity welfare department is based on the following principle:
A. out-patient-policlinic
B. district-territorial
C. special
D. mixed
4. One obstetric district of maternity welfare department includes territory with the following number of female population:
A. 2, 000-3, 000 women
B. 4, 000 — 4, 500 women
C. 1, 000 –2, 000 women
D. 5, 000-5, 500 women
5. Ultrasound of a pregnant woman is made in the following terms:
A. 12-14, 22-23, and 38-40 weeks of pregnancy
B. 9-11, 16-21, and 32-36weeks of pregnancy
C. 6-7, 11-13, and 34-36 weeks of pregnancy
D. 22-23, 32-33, and 38-40 weeks of pregnancy
7. Doppler’s investigation in the maternity welfare department is made
A. according to indications.
B. to all pregnant woman who are checked up in maternity welfare department.
8. Bimanual examination, as a step of following up in pregnancy, is made:
A. every visit
B. once a month
C. once a trimester
D. at the first visit to the doctor for registration in pregnancy, ерут at 30th week,
and if specially indicated
CHAPTER 3. Asepsis and Antisepsis in Obstetrics
After delivery of afterbirth the internal surface of uterus is a broad wound area; on the cervix of uterus, in vagina and on the perineum often abrasions and ruptures occur. The presence of personal conditionally pathogenic flora of genital tract, reduction of body immune properties characteristic of gestational process, decrease of resistance due to delivery, as well as the possibility of pathogenic flora attachment contribute to the development of septic diseases.
Before septics and antiseptics were introduced in obstetrics, septic diseases in afterbirth period (puerperal fever) occurred very often. Mortality from puerperal fever was about 25 % and over.
The first assumption that puerperas can infect one another with puerperal fever was made by Gordon (1795). In the middle of the last century I. F. Zemmelweis who worked in obstetric clinic in Vienna mentioned the fact that sickness and mortality rate were much higher in those clinics where students had practical training and simultaneously studied anatomy on corpses. I. F. Zemmelweis supposed that postpartum diseases occurred when “putrescent animal-organic material” which penetrates to maternal passages by means of dirty instruments and hands of medical staff. Comprehension of the fact that puerperal fever is an infectious disease came much later, when Pasteur discovered streptococcus isolated form the body of mother died of puerperal fever in 1880.
Nevertheless, I. F. Zemmelweis introduced the method of disinfection of doctors’, obstetricians’ hands with chlorine water (1847). This simple prophylactic method resulted in sharp decrease of puerpera mortality by 1. 5%. Application of chlorine water by I. F. Zemmelweis laid the foundation for antiseptics in obstetrics.
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Twenty years later, after I. F. Zemmelweis’ invention, surgeon Lister laid the foundation for aseptics, i. e. disinfection of bandaging material, instruments, linen coming into contact with a wound.
Aseptics and antiseptics (from Greece anti — against, a-negation, sepsis — putretaction) are methods of prevention and fight against wound infection. Both methods consist in disinfecting everything that comes into contact with organism tissues and, if possible, the infected tissue itself.
Antiseptics — prevention of infection by use of various chemical disinfectant substances which are used in the wound and outside it. There are mechanical, chemical and biological antiseptic methods. Mechanical antiseptics — the removal from the wound of germs and all infected dead tissues, blood clots, etc. Chemical antiseptics is the usage of different chemical substances to destroy germs and inhibit their growth in the wound. These substances must be harmless for organism and destroying for germs. Biologic antiseptics is the usage of different methods increasing immunobiologic strength of organism (application of vaccine, serum), as well as usage of antibiotics.
Substances which are able to destroy microorganisms are called antiseptics.
In obstetric-gynecologic practice the following antiseptic medicines are most widespread.
• Ethyl alcohol. 90-96% and 50-70% ethyl alcohol is applied. More often 50-70% ethyl alcohol is used, as its effect is faster. 90-96% ethyl alcohol causes plasma protein coagulation of microorganisms on the periphery of microbes. It prevents further penetration of antiseptic substance. Ethyl alcohol is used mainly for disinfecting hands’, operative field, disinfection and preservation of suture material.
• Alcoholic iodine solution is used for disinfecting hands, skin of operative field, around wounds. Alcoholic iodine solution is a strong antiseptic medicine having a bactericidal, bacteriostatic, cauterizing, tanning action.
• Hydrogen peroxide. It is used for cleansing a wound or contaminated surface. When in touch with tissues it decomposes, releasing oxygen which produces a strong oxidizing effect. Thus unfavourable conditions for anaerobic flora and putrefactive microbes are created. While oxygen is released, profuse foam appears, which removes blood clots, pus, scraps of necrotizing tissue, etc.
• Chlorehexidine 0. 5% in 70% alcohol – used for skin disinfection
• Benzalkonium chloride is a common active ingredient of over-the-counter antiseptic first-aid sprays.
Sulfanilamides — it is a group of medicines used for prevention and treatment of infections. It produces a bactericidal and bacteriostatic effect.
Antibiotics are biologically antiseptic medicines. They are used both for prophylaxis and treatment of developed infection.
Aseptics is a prophylactic destruction of bacteria and prevention of their penetration into the wound with the help of physical methods. Microbes are in the air, water, dust, on pregnant’s and puerpera’s body, as well as on hands and bodies of medical staff and all surrounding things. According to aseptic demands, everything that get in touch with the wound must be disinfected and sterilized.
The wound surfaces of the uterine cavity, abrasions and ruptures of the neck of uterus, vagina and perineum caused by delivery are ways for infection penetration. It is the so-called exogenous way of infection penetration. The exogenous infection sources are: air (aerobic infection), drops of liquid penetrating into the wound while talking, cough, etc. (respiratory infection), things which get in touch with wound (contact infection).
Another way of infection penetration is endogeneous (from chronic foci of infection in own organism). The endogenous way of infection penetration is also microbes located in the woman’s body and that gained pathogenic features due to weakening of women’s organism, reduction of immune properties characteristic of gestational process, decrease of resistance as a result of delivery.
The main aseptic measures in maternity homes are directed at fight with aerobic, drop and contact infection, prophylaxis of postnatal septic infection.
The fight with postnatal septic diseases is carried out primarily preventively. Prevention of postnatal septic infection is among the main principles of obstetrics. The bases of postnatal prophylaxis are:
• following the rules of antisepsis and asepsis in maternity obstetric institutions;
• observing rules of personal and common hygiene;
• providing qualified medical assistance to pregnant women and puerperas.
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