· The woman in labor is in the prenatal ward or in a separate box in the maternity ward. She is allowed to get out of bed if the amniotic sac is intact.

· Monitoring the condition of the woman in labor, coloring skin, pulse, blood pressure (measured outside of contractions).

· External obstetric examination (entry into the birth history every 2-3 hours)

· Assessment of labor activity (strength and frequency of contractions, duration of pauses)

· Determination of the height of the uterine fundus, the shape of the uterus, the position of the presenting part of the fetus.

· Determine the position of the contraction ring (dense border part above the womb between the cervix and the body of the uterus)

· Every 15-20 minutes, listen to the fetal heartbeat in pauses between contractions.

· Emptying bladder every 2-3 hours, if 1 period lasts more than 12 hours, a cleansing enema is given again.

· Toilet the external genitalia every 6 hours, before and after vaginal examination, after emptying the bladder and bowels.

· Childbirth anesthesia is used narcotic analgesics and antispasmodics, tranquilizers, neuroleptics, epidural anesthesia, inhalational anesthetics - nitrous oxide, etc.

Care in the second stage of labor.

The woman in labor is transferred to the delivery room on a gurney and placed on Rokhmanov’s bed.

· Monitor general condition women in labor

Measure blood pressure during pauses

· Pulse rate

After each attempt, listen to the fetal heartbeat

· From the moment of “cutting in” of the presenting part of the fetus, obstetric assistance is provided to protect the perineum:

1. regulation of movements of the erupting fetal head (prevents premature extension of the fetal head)

2. removal of the fetal head

3. removing the shoulders

4. removal of the torso

· monitoring the condition of the external genitalia; if there is a threat of perineal rupture, perineotomy or episiotomy is performed.

Caring for a woman in labor during the third stage of labor:

· Conducted actively and expectantly. Immediately after the baby is born, a weight and cold are placed on the stomach.

· Condition monitoring.

· Urine is removed with a catheter.

· Wait 20 minutes for signs of separation of the placenta from the walls of the uterus:

1. the appearance of mild contractions in a woman in labor

2. change in the shape and size of the fundus of the uterus

3. When pressing with the edge of the palm over the pubis, the section of the umbilical cord does not retract inward.

If the placenta is not born on its own, then it is isolated using manual techniques: Ambuladze, Crede-Lazarevich

· examination of the placenta

counting blood loss

Care in the early postpartum period:

· within 2 hours after birth, the postpartum woman is in the delivery room under observation (condition, blood pressure, pulse, height of the uterine fundus, external massage of the uterus are assessed)

· an audit of soft birth canal and their restoration.

Normal course of the postpartum period

Postpartum period- occurs immediately after the birth of the fetus and lasts about 6-8 weeks.

The postpartum period is divided into:

· early postpartum period - the next 2 hours after delivery;

· late postpartum period - begins from the moment the postpartum woman is transferred to the postpartum ward, lasts 6-8 weeks.

During the postpartum period, changes in the endocrine, nervous, cardiovascular and other systems that arose in connection with pregnancy disappear. The exception is the mammary glands, the function of which reaches its peak in the postpartum period. The most pronounced involutional processes (reverse development) occur in the genitals.

Involution of the genital organs

Uterus. Uterine involution is the reverse development of the uterus. By the end of the 1st day after birth, if the bladder is emptied, the fundus of the uterus reaches the level of the navel (Then the height of the fundus of the uterus decreases daily by 2 cm (approximately by 1 transverse finger).

The uterus returns to the pelvic cavity on days 10-12.

The inner wall of the uterus after separation of the placenta and membranes is an extensive wound surface. Epithelization of the inner surface of the uterus is completed by the end of 7-10 days, with the exception of the placental area, where this process

Characteristics of lochia:

In the first 3 days, lochia (wound secretion of the uterus) has a bright red color
from the 3rd to the 7th day their color changes and becomes brownish-red with a brown tint,
from the 7th-8th day, due to the abundance of leukocytes, it becomes yellowish-white and, finally,
from the 10th day - white, ends by the end of 6-8 weeks.

Cervix. Involution of the cervix occurs from the inside to more superficial areas. This occurs much less intensely than the involution of the uterine body. The internal os of the cervix is closed by the 10th day after birth, the external os closes only by the end of the 2nd or 3rd week after birth. However, even after this its original form is not restored. It takes the form of a transverse slit, which indicates a previous birth.

Vagina. It contracts, shortens, hyperemia disappears, and by the end of the 3rd week it takes on its normal appearance. However, during subsequent births, its lumen becomes wider, and the walls become smoother, the vagina becomes more closed, and the entrance to the vagina remains more open. The hymen is presented in the form of separate leaves.

Crotch. If the perineum was not damaged during childbirth, and in case of ruptures it was properly sewn up, it is restored in 10-12 days.

Fallopian tubes. In the postpartum period, hyperemia and edema fallopian tubes gradually disappear. The tubes in the place with the uterus descend into the pelvic cavity and by the 10th day they take their usual horizontal position.

Ovaries. In the postpartum period, the regression of the corpus luteum in the ovaries ends and the maturation of follicles begins.
In non-breastfeeding women, menstruation usually resumes within the first 6-8 weeks after birth, with ovulation occurring at 2-4 weeks postpartum.
In nursing mothers, ovulation may occur after the 10th week of the postpartum period. In this regard, breastfeeding mothers should be aware that the period of contraception due to lactation lasts only 8-9 weeks, after which the ovulatory menstrual cycle and pregnancy may resume. But you also need to know that this process is individual for each woman.

Abdominal wall. The condition of the abdominal wall is gradually restored by the end of the 6th week. Sometimes some separation of the rectus abdominis muscles remains, progressing during subsequent births. Purple pregnancy scars on the surface of the skin gradually fade and remain in the form of whitish wrinkled stripes.

Mammary glands. The function of the mammary glands after childbirth reaches highest development. In the first days (up to 3 days) of the postpartum period, colostrum is released from the nipples. Colostrum is a thick yellowish liquid. Colostrum contains, in addition to a large amount of protein and minerals, IgA, factors that neutralize some viruses and inhibit the growth of E. coli, as well as macrophages, lymphocytes, lactofferin, lysozyme, vitamins A, D.E.

On the 3-4th day, the mammary glands begin to produce transitional milk, and by the end of the 1st month - mature milk. The main components of milk are proteins, lactose, water, fat, minerals, vitamins, amino acids, immunoglobulins. Immunoglobulins contained in mother's milk act on the entire body of the newborn, especially on his gastrointestinal tract. It has been proven that children fed with breast milk get sick less often than children fed artificially. Human milk contains T- and B-lymphocytes, which perform a protective function.

Lactation stimulates uterine contractions.

Metabolism. In the first weeks of the postpartum period, metabolism is increased, and then becomes normal. The main metabolism becomes normal at 3-4 weeks after birth.

Respiratory system. Due to the lowering of the diaphragm, lung capacity increases. The respiratory rate decreases to 14-16 per minute.

Cardiovascular system. The heart takes its normal position due to the lowering of the diaphragm. A functional systolic murmur is often observed, which gradually disappears. Under the influence of external stimuli, there is greater lability of the pulse, and there is a tendency to bradycardia (60-68 beats/min). Blood pressure may be slightly low in the first days, and then reaches normal levels.

Morphological composition of blood. The composition of the blood has some features: in the first days after birth, the number of red blood cells decreases slightly, the number of white blood cells remains elevated. These changes soon disappear and the picture becomes normal.

Urinary system. Diuresis is normal or slightly increased in the first days of the postpartum period. Bladder function is often impaired. The postpartum woman does not feel the urge or has difficulty urinating.

Digestive organs. Typically, the digestive system functions normally. Sometimes there is intestinal atony, manifested by constipation.

Currently, the principle of active management of postpartum women is being implemented. Postpartum women are recommended to get up early, including those who have sutures in the perineum for a grade I-II tear. In addition, from the first day of the postpartum period until discharge from the obstetric hospital, postpartum women perform a set of exercises therapeutic exercises. An active method of managing the postpartum period increases the vitality of postpartum women, improves the function of the cardiovascular and respiratory systems, as well as the bladder and intestines. Modern method management of the postpartum period also promotes the outflow of lochia, accelerates the involution of the genital organs, thereby being effective measure prevention of postpartum septic diseases. Subject to the principle of getting up early, the postpartum woman uses the personal hygiene room, bidet, and toilets the external genitalia as needed. Postpartum women who have stitches on the perineum are prohibited from toileting the external genitalia on their own until they are removed. They are also not allowed to sit. In the normal course of the postpartum period, the postpartum woman is discharged from the obstetric hospital on the 5-6th day of the postpartum period. A healthy postpartum mother does not need a special diet after childbirth; breastfeeding requires only a moderate increase in calorie intake and the amount of fluid consumed. Without improving the properties of milk, excess nutrition is an unnecessary burden for the body, often leading to disturbances in general fat metabolism and the occurrence of excess body weight. Postpartum women are recommended dairy products (milk, kefir, cottage cheese, sour cream, butter, curdled milk, cheese), as well as vegetables and fruits, meat low-fat varieties, fish, game. Canned food, spices, alcohol should be excluded from the diet, and the consumption of citrus fruits (lemons, oranges, tangerines) should be limited. Food should be easily digestible, freshly prepared, and tasty. You should eat food 3-4 times a day before feeding your baby.

During her stay in the maternity hospital, the mother in labor often has her underwear changed. The shirt, bra, towel for the hands and mammary glands are changed daily; in case of lactorrhea (constant leakage of milk from the mammary glands), the shirt and bra are changed as needed. In the first 3-4 days, if there is a large number of lochia, the lining sterile diaper is changed at least 3-4 times a day, in subsequent days 2-3 times a day. Bed linen is changed at least once every 4 days. The mask is changed after each breastfeeding.

Every morning, the doctor and the nurse make a round of the wards of the postpartum ward, find out the general condition of the postpartum women, and inquire about their well-being, appetite, sleep, and mood. The nurse measures the body temperature of postpartum women 2 times a day and enters information into the birth history, monitors blood pressure and pulse daily. Body temperature is measured at 6 a.m. and 5 p.m. In a healthy postpartum woman, the body temperature should not exceed 36.9 °C; if the body temperature is elevated, it is necessary to inform the doctor about this and, after examination, transfer the postpartum woman to the observational (second obstetric) department.

The process of uterine involution is monitored daily in postpartum women. Correct involution of the uterus is an important criterion for the normal course of the postpartum period. To judge the degree of its severity, the doctor palpates the postpartum uterus daily and notes its consistency, the height of the uterine fundus, and the absence of pain. It is better if the height of the uterine fundus is controlled with a centimeter tape. A necessary condition for determining the height of the uterine fundus above the womb is preliminary emptying of the bladder. When the bladder is full, the fundus of the uterus is located above its true location, since even a well-contracted uterus is lifted upward by the overfilled bladder. If the involution of the uterus occurs correctly, then upon palpation it is dense and painless. It is also necessary to take into account that in women who are breastfeeding, the uterus contracts more actively than in non-breastfeeding women. In this regard, non-lactating mothers should often be prescribed drugs that enhance uterine contractions.

An important criterion for the correct course of the postpartum period is also an assessment of the quality and quantity of lochia. If the discharge from the uterus is bloody for a long time and is released in large quantities with clots, one can think about the retention of pieces of the placenta in the uterine cavity or the development of an inflammatory process. If a postpartum woman experiences heavy bloody discharge with clots, the nurse must inform the doctor about this, and before he arrives, measure her blood pressure, count her pulse, and re-determine her body temperature. The postpartum woman should be put to bed, an ice pack should be placed on the lower abdomen, and uterine contractants (oxytocin) should be prepared (drawn into a syringe).

The nurse can be the first to note the postpartum woman bad smell discharge from the genital tract; This should also be reported to your doctor. Most often, the appearance of an unpleasant odor indicates the development of a purulent-septic disease. After examining the postpartum woman by a doctor and identifying a postpartum disease, the postpartum woman is transferred to the observation department.

The postpartum woman is recommended to empty her bladder every 3-4 hours, since a full bladder delays the involution of the uterus and the outflow of lochia. If during the first 3 days the postpartum woman does not have a bowel movement, the intestines are emptied using a cleansing enema or a laxative. With sutures on the perineum, the intestines are emptied on the 5th day of the postpartum period.

Maternity toilet. In caring for a postpartum mother, the toilet of the external genitalia is important. Discharge from the uterine cavity (lochia) from the 3-4th day of the postpartum period contains a large number of microbes that can contaminate underwear, external genitalia and cause the development of postpartum septic diseases. In this regard, keeping the external genitalia clean, frequent change pad diapers are an important measure for the prevention of postpartum septic diseases. Toilet of the external genitalia in the physiological postpartum department is carried out at least 2 times a day - at 7 a.m. and 5 p.m. When using the toilet three times a day, it is done for the third time at 11 p.m., after the last breastfeeding of the child. The midwife (nurse) prepares in advance everything necessary for toileting women in labor. For this purpose, she places a set of sterile forceps on a special mobile table-wheelchair, covering it with two sterile diapers, in an amount corresponding to the number of postpartum women in the postpartum department. Nearby is a box with sterile material - gauze balls and padding diapers, as well as a set of disinfected oilcloths, 1 % or 2% alcohol solution of brilliant green. Below on the same gurney there is a jug with a solution of potassium permanganate (1:1000) with a solution temperature of 38-40 °C. The midwife washes her hands, puts on a clean apron over her gown, and sterile gloves on her hands. The nurse picks up a jug with a disinfectant solution. The toilet is carried out as follows: the midwife takes each forceps in her hands, with her left hand takes out a sterile gauze ball from the bix, transfers it to the forceps of her right hand. The nurse pours the solution onto the pubic area, the stream should be directed from top to bottom without flowing into the vagina. The midwife gently washes the labia majora, inner thighs, and perineum. If there are seams on the perineum, try not to let the solution touch them. The area of the sutures on the perineum is dried from lochia with a sterile gauze ball and treated with a disinfectant solution (2% alcohol solution of brilliant green, 5% alcohol solution of iodine).

Before treating the stitches, the midwife carefully examines their condition on the perineum. If there is hyperemia, swelling of the skin around the sutures or a deposit of pus on the sutures, the midwife (nurse) informs the attending or duty doctor. After examination by a doctor, the postpartum woman, if her diagnosis of a postpartum ulcer in the perineal area is confirmed, is transferred to the observational (second obstetric) department. At the end of the postpartum woman’s toilet, the nurse removes the bedpan, diaper and oilcloth from under her, covers with a clean oilcloth, and then a sterile diaper. Dirty laundry is placed in a special bin. After the mother has used the toilet, the bedpan is thoroughly washed, disinfected and, having been marked, is reinstalled for the same mother in a special stand attached to the bed. Backing oilcloths are soaked in a disinfectant solution, washed under running water, dried, treated with a disinfectant solution, and only then given to postpartum women. Before toileting the external genitalia, postpartum women are asked to empty their bladder and bowels. After the mothers have finished using the toilet, the nurse washes the floor and ventilates the rooms.

Breast care. Should begin during pregnancy and continue throughout lactation. All procedures for caring for the mammary glands during pregnancy and lactation are aimed at preventing the development of inflammatory processes in the mammary gland - mastitis.

In the maternity hospital, breast care is carried out as follows. Every morning, the postpartum mother washes the mammary glands with running warm water under a tap and soap: first the nipple, then the mammary gland, and the armpit. Then, using a special towel for the mammary glands, which is changed daily, thoroughly dries the mammary glands. Before each feeding, the postpartum mother carries out a set of preventive measures aimed at preventing infection of the mammary gland. She washes her hands with soap, puts a scarf on her head, a mask on her mouth and nose, covers the pillow with medical oilcloth and a sterile diaper, preparing a place for the newborn. The mask is changed before each feeding, the towel, scarf, oilcloth for the newborn - daily. The fingernails of the postpartum mother should be cut short.

Starting from the 3rd day of the postpartum period, the postpartum woman uses a bra, which she changes daily. It should correspond to the size of the mammary gland, not constrain it, but only maintain it in an elevated state. For the proper functioning of the mammary glands, their regular and complete emptying is extremely important. The principles of breastfeeding have currently been introduced in the obstetric hospital:

♦ strictly adhere to the established rules of breastfeeding and regularly bring these rules to the attention of medical personnel and women in labor;

♦ train medical personnel with the necessary skills to practice breastfeeding;

♦ inform all pregnant women about the benefits and techniques of breastfeeding;

♦ help mothers initiate breastfeeding within the first 30 minutes after birth;

♦ show mothers how to breastfeed and how to maintain lactation, even if they are temporarily separated from their children;

♦ do not give newborns any food or drink other than breast milk, except for medical reasons;

♦ practice keeping mother and newborn side by side in the same room around the clock;

♦ encourage breastfeeding on demand rather than on a schedule;

♦ do not give breastfed newborns any sedatives or devices that imitate the mother's breast;

♦ encourage the organization of breastfeeding support groups and refer mothers to these groups after discharge from the maternity hospital or hospital.

In recent years, the practice of placing mother and newborn together has become the rule of every obstetric institution. Shared accommodation has a number of important advantages: it helps to strengthen the mother-child bond, allows breastfeeding on demand, and creates the opportunity for closer contact with the father and other family members. Maintaining contact between mother and child, established immediately after birth, favors the formation of colonies of maternal microorganisms on the skin and in the gastrointestinal tract of the child, which, as a rule, are non-pathogenic and against which the mother has antibodies in her breast milk. In this way, the child is protected from organisms against which active immunity will only be developed later in his life.

On the first day, the feeding procedure is carried out in a horizontal position of the postpartum woman in bed; on subsequent days, if there is no perineal injury during childbirth, sitting on the bed. The postpartum woman must be taught proper breastfeeding techniques and techniques for expressing breast milk. Each obstetric hospital has a nurse who monitors these processes, and also collects expressed milk, pasteurizes it and subsequently uses it in the neonatal department to feed weakened and injured children. Compliance correct technique Breastfeeding prevents the formation of cracked nipples. The first few feedings are best done with a nurse present. When feeding, the baby should grasp not only the nipple of the mammary gland, but also part of the areola. With such a grip, the nipple is less injured at its base by the jaws of the newborn, and nipple cracks occur less frequently. It is equally important that the newborn grasps the nipple evenly throughout its entire periphery. After feeding, the nipple must be carefully removed from the child’s mouth without injuring him. If the baby does not let the nipple out of his mouth, you need to pinch the baby's nose with your fingers and carefully remove the nipple. To avoid maceration of the nipple skin, you should not feed the baby for more than 15 minutes. For flat, inverted nipples and cracked nipples, feeding is done through a glass plate with a rubber nipple. Before each feeding, the postpartum mother receives a sterile pad. The first application of a healthy baby to the breast of a healthy postpartum mother is recommended 20-30 minutes after birth. After breastfeeding, the nipple should be dried and washed with running warm water under a tap and soap. After this, the postpartum woman takes an air bath for 10-15 minutes - lies in bed with her mammary glands exposed. An air bath is carried out after the room has been ventilated and during irradiation of the air with a bactericidal lamp.

After each feeding, the mother expresses milk from the gland to which the newborn was attached. Expression can be done by hand after learning the pumping technique. The milk remaining in the mammary gland after feeding is favorable environment infection, and therefore all excess milk after feeding should be expressed. In the process of expressing milk from the mammary gland, you should avoid trauma, kneading its lobules, maceration and excoriation of the skin of the mammary gland, as this contributes to the development of mastitis. An important measure for the prevention of mastitis is the prevention and timely treatment of excessive engorgement of the mammary glands and pathological lactostasis. If there is excessive engorgement of the mammary glands, limit fluid intake to 600-800 ml per day, and prescribe laxatives and diuretics. Pathological lactostasis is quickly resolved when prescribed antispasmodics(papaverine, no-shpa), oxytocin solution (5 units of 0.5 ml 2 times a day) and papaverine (2 tablets of 0.02 g 3 times a day).

Bladder function. For normal involution of the uterus, the postpartum woman is recommended to empty the bladder frequently, every 3-4 hours. An overfilled bladder due to the common innervation of the uterus and bladder leads to a delay in the reverse development of the uterus and difficulty in the outflow of lochia. In a conversation with a postpartum woman on the 1st day after birth, among other recommendations, it is necessary to provide her with this information. With active management of the postpartum period, difficulties with urination in healthy postpartum women are rare.

Bowel function. Most often, defecation in postpartum women occurs 2-3 days after birth. In case of perineal injuries, defecation is artificially delayed for up to 5 days by prescribing a gentle diet, and before removing the sutures from the perineum, the postpartum woman is prescribed a laxative the night before. The principle of early rising and active management of the postpartum period contributes to the timely normalization of intestinal functions.

Health education conversation with a postpartum mother upon discharge from the maternity hospital. Before a postpartum woman is discharged from the maternity hospital, a conversation is held with her about the need to follow the rules of personal hygiene at home. These rules boil down to the following: a postpartum mother should eat regularly and rationally, sleep at least 6-7 hours a day, walk with her child in the fresh air for at least 4 hours a day; Just as in the maternity hospital, carefully clean the mammary glands and external genitalia. Bras and tights should be changed daily, washed with boiling water and ironed, and sanitary dressings should be changed when soiled. For 2 months after giving birth, you cannot take a bath; it is enough to use only a shower. You should not lift heavy weights to avoid uterine bleeding and the formation of an abnormal position of the uterus. Sexual activity can be resumed only 2 months after birth. When resuming sexual activity, you should protect yourself from unwanted pregnancy. The method of contraception should be discussed with your local antenatal clinic doctor.

6.3. Caring for a postpartum mother after obstetric surgery

Caring for a postpartum mother after obstetric surgery largely depends on her state of health before surgery. If obstetric surgery was performed on a patient with an extragenital disease (glomerulonephritis, heart disease, hypertension, diabetes mellitus), in the postoperative period, careful treatment of the underlying disease is carried out. In a postpartum woman, after bleeding during childbirth, which required an operative method of delivery, intensive therapy is continued, aimed at replenishing blood loss, normalizing the volume of circulating blood, acid-base status and microcirculation. In patients with severe forms of late gestosis, intensive therapy for this condition is continued.

After transection, the patient is transported from the operating table on a gurney to the intensive care ward, where she remains for the first two days. If the intensive care ward is equipped with functional beds, then the patient is immediately transferred from the operating table to a functional bed. The height of the functional bed corresponds to the height of the operating table, which makes it easier to shift the patient and subsequently carry out intensive care. First, the nurse warms the bed with heating pads and removes the pillow. The patient is in a horizontal position without a pillow for the first hours after surgery. Per region postoperative wound put an ice pack and a medical oilcloth bag filled with sand (heaviness), weighing 800 g. A sand bag and an ice pack contribute to the development of spasm of the vessels of the anterior abdominal wall damaged during surgery, accelerate their thrombosis, and improve hemostasis. Cold and heaviness are prescribed for 3-4 hours after surgery. The nurse prepares an ice pack in advance. You must make sure that the cap is screwed on tightly so that water will not leak into the patient’s bed. 5-6 hours after surgery, you are allowed to turn in bed. In the following days, the activity of patients after obstetric operations largely depends on the state of health before surgery and the course of postoperative period. On the 2-3rd day, if the postoperative period is uncomplicated, the postpartum woman is transferred to the ward of the postpartum physiological department. Care for postpartum women after surgical methods of delivery is carried out according to the same rules as for healthy postpartum women: the principles of asepsis and antiseptics, the norms of deontology, and the therapeutic protective regime are carefully observed. A nurse regularly performs toileting of the mammary glands and external genitalia for postpartum women. The question of the time of the first breastfeeding and the admissibility of lactation is decided jointly by an obstetrician-gynecologist, a therapist and a neonatologist. In patients with severe extragenital diseases, in some cases, lactation can aggravate the course of the underlying disease, and therefore it is suppressed, and the newborn is transferred to artificial feeding.

In the postoperative period, patients need a balanced diet and a special diet. On the 1st day after surgery, patients are prohibited from eating and drinking. For fear of vomiting, they only moisten the lips and oral cavity with a damp swab. Subsequently, if there is no vomiting, they are given to drink in small portions; from the 2nd day the patient drinks 400-600 ml of liquid per day. It is advisable to drink alkaline mineral waters. On the 2nd day a liquid diet is prescribed: broth, jelly, tea, on the 3rd - a semi-liquid diet: slimy soups, soft-boiled eggs, cottage cheese, liquid porridge, yogurt, kefir; from the 5th-6th day, if the postoperative period is uncomplicated, patients are transferred to a general diet.

During the physiological course of the postoperative period, intestinal peristalsis is usually active, on the 2nd day the patient passes gas on her own, and on the 3rd-4th day spontaneous defecation occurs. However, in a number of patients, on the 1st day of the postoperative period, intestinal motility decreases and intestinal paresis develops. Clinically, this is manifested by bloating and gas retention. The development of intestinal paresis can be prevented. This is achieved by active management of the postoperative period (breathing exercises, active behavior in bed, getting up early, performing a complex of general therapeutic exercises). WITH for preventive purposes drug therapy is prescribed: during the first three days, patients are administered intravenously 40 ml of 10% sodium chloride solution

1 time per day, 1 ml of 0.05% proserin solution subcutaneously 2 times a day; in addition, a hypertensive enema is performed. When paresis has developed, these measures are carried out for therapeutic purposes.

A number of patients after obstetric transsection experience difficulty urinating and even the impossibility of doing so. In such cases, the nurse should take measures to stimulate spontaneous urination: open the water tap to stimulate the urination reflex, warm up the bedpan, and irrigate the external genitalia with warm water. If these measures do not give the desired effect, resort to drug stimulation urination: a decoction of bear ears is prescribed orally, taking an increased amount of liquid (1000-1500 ml), subcutaneous administration of pituitrin, etc. Before spontaneous urination resumes, catheterization of the bladder is used every 3-4 hours.

If purulent-septic complications occur in the postoperative period (suppuration of the skin and subcutaneous tissue in the area of a postoperative wound, endometritis, mastitis, peritonitis, etc.) the patient is transferred to an observational unit or a specialized institution to continue intensive care.

Postoperative wound care. A postoperative wound in postpartum women can be located on the anterior abdominal wall after a cesarean section, amputation or extirpation of the uterus and in the perineal area after its dissection (perineotomy, episiotomy) or rupture. The condition of the wound requires careful monitoring and preventive measures aimed at preventing the development of purulent-septic complications. When using a transverse suprapubic incision of the anterior abdominal wall, a subcutaneous catgut suture is applied, which is subsequently not removed. During lower-median transection, silk is applied to the skin, which is removed on the 7-8-9 days of the postoperative period.

Care for a wound on the anterior abdominal wall is carried out as follows. If the aseptic dressing applied to the wound immediately after surgery remains dry, then it is changed only on the 3rd day of the postoperative period. The nurse prepares the following for the procedure of examining and changing the dressing on the wound area: a kidney-shaped sterile tray into which 2-3 sterile tweezers are placed, sterile gauze balls, a 5% alcohol solution of iodine, large sterile wipes, cleol. After removing the bandage, carefully examine the wound with tweezers, make sure there is no hyperemia and infiltration of the skin, or swelling around the wound. During lower-median laparotomy, the sutures are carefully inspected, making sure that there is no purulent or fibrinous plaque on them. If wound healing occurs by primary intention, the listed signs inflammatory reaction absent, the wound area is treated with 5% alcohol solution iodine and the wound is again covered with an aseptic bandage (sticker).

If there are signs of an inflammatory reaction, which indicate the development of a purulent-septic complication in the wound area, the postpartum woman is transferred to the second obstetric department for treatment of this complication. With transverse suprapubic transection on the 8-9th day of the postoperative period aseptic dressing remove again, inspect the wound area, lubricate it with a 5% alcohol solution of iodine, and when the wound heals by primary intention, do not re-apply the bandage, but keep the wound area open and in the coming days the postpartum woman is discharged home. During lower-median transection, on the 7-8th day, the bandage is removed from the wound area, the sutures are treated with a 5% alcohol solution of iodine, and the sutures are sequentially removed using tweezers and sharp pointed scissors. The suture area is once again treated with a 5% alcohol solution of iodine, an aseptic bandage is again applied, which is removed after 1-2 days and the wound area is then kept open. On days 8-9, with a normal course of the postoperative period, the postoperative woman is discharged home.

The nurse (midwife) prepares for the procedure for removing sutures in the same way as for examining a wound on the 3rd day after surgery, and also puts sterile scissors in the tray.

Care behind the seams on the crotch has its own characteristics. The risk of developing purulent-septic complications in the area of a wound on the perineum is significantly higher than with a wound on the anterior abdominal wall. In the postpartum period, lochia constantly flows onto the wound area (perineum), which loses sterility on the 3rd-4th day of the postpartum period. In addition, the sutures on the perineum are located in close proximity to the anus, therefore, the risk of intestinal flora entering the suture area is very high.

All this necessitates even more careful implementation of preventive measures aimed at preventing the occurrence of purulent-septic complications in the area of the perineal wound. Postpartum women with stitches in the perineum are prescribed a slightly different regimen in the postpartum period. Like other postpartum women, they are allowed to get up on the 2nd day of the postpartum period, but are warned that they cannot sit; the sterile pad diaper must be changed more often as it becomes contaminated with lochia. In addition, the postpartum woman is warned not to hold the diaper near the seams on the perineum. The diaper should be under the buttocks. A postpartum woman with stitches in the perineum is recommended to adhere to a liquid and semi-liquid diet (broth, porridge, cottage cheese, jelly) for 5 days so that bowel movements after childbirth occur for the first time on the 5th day. The postpartum woman is forbidden to eat fruits, black bread, kefir, and yogurt. When toileting the external genitalia, the seams in the perineal area are not treated with a disinfectant solution, but are only dried from lochia and lubricated with an antiseptic solution (1% or 2% alcohol solution of brilliant green, 5% alcohol solution of iodine). During the daily rounds, the doctor carefully examines the area of the postoperative wound on the perineum; the nurse (midwife) also monitors the area of the sutures on the perineum during the toilet for postpartum women. When the wound heals by primary intention, the sutures from the perineum are removed on the 5th day of the postpartum period. The postpartum woman first empties her intestines using a laxative. The midwife (nurse) prepares for the procedure for removing sutures from the perineal area in the same way as for removing sutures from a wound on the anterior abdominal wall. After the sutures are removed, the wound area is treated with a 1% or 2% alcohol solution of brilliant green. The postpartum woman is again warned not to sit down for another 1-2 weeks.

Postpartum gymnastics. Postpartum gymnastics is carried out from the 1st day of the postpartum period and continues until the day the postpartum woman is discharged from the hospital. Gymnastics classes are held daily in the morning before breakfast (in summer - with the windows open, in winter - after the room has been ventilated). Gymnastics are performed by a methodologist who has special training to work in an obstetric hospital with pregnant and postpartum women. Exercises can be common to all postpartum women in the ward. For postpartum women who have stitches in the perineum, there is a special set of exercises. The duration of the lesson each day of the postpartum period does not exceed 10-15 minutes.

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Ministry of Health of the Sverdlovsk Region

State Budgetary Institution

Secondary vocational education

Sverdlovsk Regional Medical College

Coursework

Features of nursing care for postpartum septic conditions

Ekaterinburg 2015

Introduction

Relevance of the topic.

In some cases, the postpartum period is complicated by the occurrence of infectious purulent-septic diseases. The entry gate for infectious agents is the wound surface that occurs during ruptures of the cervix, vagina and perineum, dissection of the anterior abdominal wall and uterus during operations (caesarean section, amputation, hysterectomy). The role of the entrance gate can also be played by the internal wound surface of the uterus after childbirth, cracked nipples. Factors contributing to the development of infections in postpartum women are violation of the sanitary and hygienic regime in the obstetric hospital and non-compliance with personal hygiene rules by staff and postpartum women. The risk of infection increases with the pathological course of labor: protracted labor, a large number of vaginal examinations, a long anhydrous interval, bleeding during childbirth, as well as obstetric operations. In recent years, HAI (health care associated infection) or nosocomial infection has played a special role. It has gained particular importance in the last 10-15 years as a result of the widespread use of antibiotics.

In recent years, the most antibiotic-resistant microbes have begun to cause the majority of postpartum diseases: staphylococcus, E. coli, Proteus vulgaris, blue-green pus bacillus, Klebsiella, anaerobic flora.

Purpose of the study: features of the work of a nurse in postpartum septic conditions.

Practical significance: Expanded understanding of significant factors of infected risk of realization of postpartum purulent-septic diseases. A certain role of low-frequency ultrasonic irrigation in the prevention of the development of postpartum purulent-septic diseases. The proposed method of low-frequency ultrasonic irrigation of the vagina and cervix is well tolerated by patients, easy to use and contributes to the reliable prevention of purulent-septic diseases.

Object of study: patients of the maternity ward.

Subject of research: the activities of a nurse in the maternity ward.

Research objectives:

Study scientific literature

1. Create a manipulation algorithm

2. Conduct research

3. Formulate conclusions

nursing care postpartum septic

1. Postpartum purulent-septic diseases and their classification

Postpartum purulent-septic diseases occur in 4 - 6% of women in labor. They can be the result of infection during pregnancy and exposure to an infectious agent during childbirth or immediately after it. This is facilitated by a violation of the integrity of the soft tissues of the birth canal during childbirth, and a decrease in immunity during pregnancy. At the same time, indiscriminate use of antibiotics currently leads to the manifestation of altered forms of microorganisms and can cause purulent-septic diseases.

The main causative agents of purulent-septic diseases in women in labor are anaerobes, enterococci, Escherichia coli, streptococci, and staphylococci.

Postpartum endometritis

Postpartum endometritis can develop after infection of the uterine mucosa after childbirth, especially surgical ones (caesarean section, application of obstetric forceps, vacuum extraction, manual separation of the placenta and release of the placenta, manual examination of the uterus). Infection causes an inflammatory process most often in the decidua, but can also spread beyond the basement membrane, leading to leukocyte infiltration in the endometrium.

With endometritis, the mucous membrane is loose, swollen, with an abundance of easily bleeding vessels. In places, fibrous deposits are visible on it. With a long process, purulent expansion of tissues with a dense fibrinous coating occurs. With the development of the endometrium after cesarean section, the greatest changes can be in the area of uterine dissection, often for short distances, and sometimes completely.

Postpartum mastitis

The disease is caused by pyogenic microbes (usually staphylococcus), which are carried by contaminated hands, underwear or by drip. Sometimes the infection occurs endogenously. The development of mastitis is promoted by cracked nipples, improper pumping and stagnation of milk.

The initial stage (serous inflammation), the infiltration stage and the suppuration stage (purulent mastitis) are distinguished. Mastitis often begins with a sudden rise in temperature to 39 °C or higher, sometimes with chills. Pain appears in the mammary gland, malaise, headaches occur, sleep is disturbed, and appetite decreases. The mammary gland increases in size, a painful, hardened area is palpated deep in it, and the skin over it sometimes turns red. Axillary lymph nodes on the side, the lesions are usually enlarged and painful. Under unfavorable conditions, the process progresses, and the inflammatory infiltrate suppurates (purulent mastitis). The general condition worsens, the temperature is high, often accompanied by chills. The pain in the mammary gland intensifies, an area of ripple appears, the skin over it is purple and bluish in color. The most common form of purulent mastitis is abscess. Abscesses can be superficial, located in the thickness of the mammary gland and behind the mammary gland.

Treatment should begin at the first signs of the disease. Antibiotics and warm compresses on the mammary gland (Vishnevsky ointment or camphor oil) are prescribed. It is imperative to administer staphylococcal toxoid. In case of suppuration, surgical intervention is indicated.

IN initial stage disease, it is better to stop feeding for 1-2 days, and then limit the number of feedings to 1-2 per day. If the baby does not latch on to the breast, you need to carefully express the milk. In case of purulent mastitis and severe course, as well as in case of extensive suppuration, it is necessary to stop feeding the affected breast, and sometimes suppress lactation.

Postpartum thrombophlebitis

Thrombophlebitis, a venous disease, occupies a significant place among postpartum septic diseases. The main factors in the development of thrombophlebitis are increased blood clotting, slower blood flow and vascular spasms.

Factors contributing to the development of thrombophlebitis in women in labor are varicose veins, which often occur during pregnancy, disorders of fat metabolism, hypochromic anemia pregnant women, bleeding during childbirth, late toxicosis.

For thrombophlebitis lower limbs Damage to superficial and deep veins is possible. The most pronounced clinical manifestations develop with lesions of the deep veins.

The disease occurs in the 2nd - 3rd week of the postpartum period with manifestations of pain in the leg, chills, and increased body temperature. On the damaged limb there is swelling along the vascular bundle - compaction and pain.

Postpartum sepsis

This is the most severe form of postpartum septic disease. From the source of infections during sepsis, microbes constantly or periodically enter the general bloodstream. In some cases, purulent metastases form (septicpyemia); in other cases, there is no formation of metastases.

The general condition of the patient is serious, the body temperature is high and hectic in nature (the difference between morning and evening temperatures ranges from 2 to 4 C). Chills, heavy sweating, rapid pulse, and severe shortness of breath occur periodically.

Peritonitis after cesarean section

It is an extremely life-threatening complication of the postoperative period. The development of peritonitis is facilitated by the presence of pathogenic flora in the body of a pregnant woman and woman in labor, the performance of operations during a long anhydrous interval of protracted labor with a large number of vaginal examinations, violations of the principle of antisepsis and asepsis in obstetric institutions and especially in the operating room. The disease already manifests itself on the first or second day of the postoperative period, the patient’s temperature rises, abdominal pain appears, gas retention and intestinal bloating appear. Intestinal peristalsis is weakened or absent, the tongue is dry, coated, the pulse is frequent, breathing is rapid. With peritonitis after cesarean section there is no symptom of peritoneal irritation, which makes its diagnosis difficult. At the same time only modern diagnostics, repeated transection and removal of the uterus along with the tubes save the woman in labor from death.

Postpartum ulcer

Postpartum ulcers are infected wounds of the perineum, vaginal mucosa, and cervix. Their boundaries are clear, slightly swollen, with inflammatory hyperemia and infiltration of surrounding tissues. The bottom of the ulcer is covered with a dirty gray or gray-yellow coating with areas of necrosis. A disease that occurs on the 3rd - 4th day of the postpartum period in the soft tissue of the birth canal: in the perineum, vagina, cervix, usually as a result of wound infection. Swelling, hyperemia and tissue infiltration develop around the sutures; the sutures become covered with purulent plaque. The woman in labor feels a burning sensation and pain in the wound area. The patient's general condition is almost unaffected. A woman in labor with a postpartum ulcer is transferred from the physiological maternity department to the observatory department.

Pathogenesis of purulent-septic postpartum diseases.

Postpartum endometritis

The mild form begins relatively late, on days 5–12 of the postpartum period. Body temperature rises to 38 -39 C. Chills are occasionally observed at the first increase in temperature. The pulse quickens to 80 - 100 beats/min and its increase corresponds to a rise in temperature. The blood picture shows leukemia, minor neutrophil changes in residual nitrogen remain within normal limits. The general well-being of the woman in labor does not suffer significantly. Patients experience uterine soreness, which persists for 3 to 7 days. The size of the uterus is not slightly increased, and the lochia remains bloody for a long time. Assessment of the severity of the patient’s condition and the effectiveness of complex treatment is based on the results of dynamic observation over the next 24 hours. At the same time, indicators of hemodynamics, respiration, urination, the condition of the uterus, the nature of lochia, and laboratory data are monitored.

The severe form usually begins earlier, on the 2nd to 4th day after birth. Moreover, in almost ½ cases this complication develops after a complicated birth or surgical intervention.

During dynamic observations in patients with a severe form of postpartum endometritis, there is no improvement within 24 hours, and in a number of observations there is even a negative dynamics of the process. The patient is worried about headaches, weakness, and pain in the lower abdomen. There is a disturbance in sleep, appetite, tachycardia up to 90 - 120 beats/min, the temperature often rises to 39 C and above, accompanied by chills.

Upon examination, pain and slowing of uterine involutions are revealed. Lochia becomes violent from 3 to 4 days and subsequently acquires a purulent character.

After the start of treatment, the temperature usually normalizes within 2 to 4 days.

The disappearance of pain on palpation and the normalization of the nature of lochia occur by 5 - 7 days of treatment. The blood picture improves by 6 - 9 days.

However, most often in practice clinical picture diseases does not reflect the severity of the patient’s condition. Postpartum endometritis has an erased character and its detection presents certain difficulties.

The erased form can occur both after spontaneous and after operative birth. The disease often begins on the 3rd - 4th day. In some patients, postpartum endometritis may begin to appear both on the 1st day and on the 5th - 7th day after birth. In most patients, the body temperature initially does not exceed 38 C and chills are rare.

During treatment, body temperature normalizes within 5 to 10 days. However, in some patients, low-grade fever can last up to 12-46 days.

The erased form of postpartum endometritis can also lead to generalization of infections due to underestimation of the severity of the patient and inadequate therapy.

Postpartum mastitis

Most often, the causative agent is staphylococcus in the form of a monoculture or in association with other microorganisms (Escherichia coli, Proteus, Streptococcus, Bacteroides). The infection enters through the thoracic duct and nipple fissures. Against the background of a decrease in the body's resistance, a weakening of the immunological protection factor and an increase in the stabilization of the body, a hyperemic reaction occurs with a local manifestation - mastitis. Its development is facilitated by complications even during pregnancy (anemia, pyelonephritis, threat of miscarriage, prenatal rupture of water). Mastitis may be caused by lack of preparedness. mammary glands to the release of milk from it and feeding (in women giving birth for the first time). In this case, stagnant milk in the acini of the gland serves as a breeding ground for the development of microbes.

Peculiarities purulent process in the glands there is a limited possibility of its localization, due to the delicate structure of the parenchyma of the mammary gland. The inflammation spreads quickly and can progress even after the abscess is cut. In phase serous inflammation gland tissue is soaked serous fluid, leukocytes accumulate around the vessels. Over time, diffuse purulent infiltration develops with the formation of abscesses. The localization of the latter can be very diverse: under the circle (areola) of the mammary gland, under the skin, directly in the gland itself and behind the mammary gland.

Postpartum ulcer

Manifests itself as a result of infection of cracks, abrasions and ruptures of the vaginal mucosa of the cervix and perineum

Onset of the disease 3-4 days after birth

Complaints: pain and burning in the external genital area (especially loss of urine on the wound), increased body temperature to 37 - 38 C, weakness.

The clinical picture of the disease is determined mainly by local manifestations: local pain, itching associated with skin irritation discharged from the wound, and sometimes dysuric phenomena.

Treatment consists of prescribing antibacterial therapy, local use of antiseptic and anti-inflammatory agents. The wound is treated with hydrogen peroxide and hypertonic sodium chloride solution. Good results are obtained by using enzymes (trypsin, chymotrypsin) to remove necrotic and fibrinous deposits and accelerate regeneration and epithelization.

The main causative agents of postpartum purulent-septic diseases

Group A, B streptococci, enterococci, gram-negative bacteria: Klebsiella.

A postpartum infection should be suspected if, within 10 days after birth (except for the first 24 hours), the body temperature reaches 38 C for 2 days in a row with temperature measurements at least four times a day.

The spread of the pathological process is divided into four stages:

The first stage is an infection limited to the area of the birth wound: postpartum ulcer on the perineum, vaginal wall and cervix, lochimeter.

The second stage - the infection spreads beyond the wound, but remains localized: endometritis parametritis, localized thrombophlebitis,

The third stage is infection clinical manifestations similar to generalized: diffuse postpartum peritonitis, progressive thrombophlebitis.

The fourth stage is a generalized infection: sepsis without visible metastases, septic shock.

This group of postpartum diseases also includes mastitis.

The first and main task of treating septic infections should be to strengthen the body’s resistance and mobilize all its protective forces to fight infection.

From this point of view, rest, proper nutrition, proper care and general drug treatment. All these measures relate to general nonspecific therapy of septic infections. Rest, along with favorable conditions for the diseased organ, prevents further spread of infection. The protective regime also has a positive effect on the central nervous system.

Bed rest is also necessary for superficial forms of infections in all local processes in the pelvic cavity.

Food should be varied, easily digestible and contain at least 2000 kcal per day in a small amount. Such patients should be given broths, sugar up to 200 g per day, butter, cream, boiled fish, cottage cheese. Drinking plenty of tea, alkaline waters, fruit drinks, and fruit juices is beneficial. We must remember that the patient must be fed without waiting for her to ask.

An important part of treatment is bacterial therapy aimed at combating the infectious agent. For this purpose, antibiotics are prescribed.

Of particular importance in the complex against septic therapy are control over the hemodynamic indicator and rational infusion therapy. First of all, it is necessary to replace fluid in order to improve microcirculation and detoxify the body.

Prevention of purulent-septic diseases.

The woman herself should be primarily interested in the prevention of postoperative (postpartum) purulent-septic complications. You need to clearly understand for yourself that responsibility for the state of your health lies entirely on the shoulders of the pregnant woman herself.

Initial preventive measures are carried out subject to a timely visit to the antenatal clinic, where they will carry out the entire necessary range of examinations (and more than once during pregnancy). The antenatal clinic doctor will determine the risk group to which you belong, taking into account the presence of diseases internal organs (cardiovascular system, kidneys and others), complications of pregnancy (preeclampsia of the second half, various options) and other factors that may affect the course of the postpartum period (postoperative).

Risk factors for the development of postpartum (postoperative) inflammatory complications are as follows.

1. the presence of various types of diseases of internal organs in a pregnant woman, accompanied by impaired microcirculation - anemia, cardiovascular diseases, diabetes mellitus and others;

2. acute and chronic infections - genital (adnexitis - inflammation of the appendages, colpitis - inflammation of the vaginal mucosa, endometritis - damage to the inner layer of the uterus) and other organs of the body (pyelonephritis, gastrointestinal infections And inflammatory diseases gallbladder, respiratory tract, oral cavity);

3. complications of pregnancy (late gestosis, threat of miscarriage, insufficiency of the isthmic-cervical cervix and complications of its correction, bleeding during pregnancy);

4. duration of labor is more than 12 hours.

5. the duration of the water-free period is more than six hours.

6. number of vaginal examinations during childbirth - three or more, instrumental invasive examinations.

7. surgical technique - corporal incision on the uterus.

8. The duration of the operation is more than one hour.

9. errors in suturing a uterine wound.

10. bleeding before and during childbirth (surgery), especially with unrecovered blood loss.

11. high contamination of the birth and urinary tract without clinical manifestations.

12. multiparous woman.

13. unfavorable epidemiological situation in the obstetric hospital.

14. a pregnant woman’s long stay in the hospital before delivery.

15. emergency caesarean section.

A woman who has one of these risk factors needs to especially carefully monitor her health.

Necessary measures for examination and treatment at the initial stage of pregnancy are carried out in the antenatal clinic. If diseases of internal organs or chronic foci of infection are detected, a course of treatment is carried out. We advise pregnant women to pay special attention to the sanitation of the oral cavity (carious teeth, etc.), since this issue has traditionally received little attention due to the widely held opinion that treating and removing teeth during pregnancy is harmful. However, this statement is just prejudice, and the harm that the spread of chronic infection from the oral cavity can cause is sometimes irreparable for both mother and child.

The next point that is important in the prevention of postpartum (postoperative) purulent-inflammatory complications is careful hygienic preparation before childbirth (surgery). For example, on the eve of the operation, pubic and axillary hair is shaved, nails are cut, and the pregnant woman takes a hygienic shower with a complete change of linen. When a woman is admitted in labor, she must undergo a cleansing enema, she takes a shower, and the vagina and external genitalia are treated antiseptics. In the morning before the operation, the skin of the abdomen is treated with antiseptic solutions (chlorhexidine, furacillin and others). Immediately before surgery (as well as before childbirth), all women undergoing emergency surgery undergo a single treatment of the vagina with disinfectant solutions. For pregnant women who have undergone biological prevention of ascending infection, vaginal treatment with an antiseptic solution before a planned cesarean section is not used. The number of vaginal examinations before childbirth (surgery) should be reduced as much as possible; for women in labor undergoing emergency surgery, each vaginal examination should be strictly justified.

Nursing care for purulent and septic postpartum diseases.

Toilet mother in bed.

Equipment: table, bottle with furatsilin solution, oilcloth, vessel, sterile forceps, tweezers, sterile balls, 3% H2O2 solution, 1% iodonate solution, liners, rubber gloves.

Execution order:

1. Explain to the woman the need for the procedure and the progress of its implementation. 2. Place the patient in a supine position with the knees and hips bent and legs apart.

3. Place an oilcloth under the buttocks of the postpartum woman and place a bedpan.

4. Pour furatsilin solution from the bottle onto the perineum.

5. Wearing gloves, use a ball on a forceps to carefully wash the genitals from the pubis to the anus, then wash the inner surface of the thighs.

6. Remove the vessel.

7. Place a lining under the maternity ward, asking to raise the buttocks. 8. Using a forceps with a dry ball, wet the external genitalia and inner thighs.

9. If there are seams, treat them with a ball moistened with 3% H2O2 solution. 10. Dry the seams with a dry ball.

11. Treat the seams with 1% iodonate solution.

12. Apply a dry cloth to the wound with tweezers and secure.

13. Place used instruments, dressings, and removed gloves in containers with disinfectant. r-rum.

Preparing to remove sutures

Equipment: Esmarch mug, disinfected tip, sterile tray, sterile forceps, tweezers, sterile balls, 3% H2O2 solution, 1% iodonate solution, liners, rubber gloves.

Procedure: 1. The day before and in the morning before the stitches are removed, the postpartum woman is given a cleansing enema.

2. Explain to the woman the need for the procedure and the progress of its implementation. 3. Place the patient in a supine position with the knees and hips bent and legs apart.

4. Treat the external genitalia.

5. When removing sutures, follow the doctor’s instructions.

6. Apply a dry cloth to the wound with tweezers and secure.

7. Place a lining under the mother, asking her to raise her buttocks. 8. Place the used instrument, dressing material, and removed gloves in containers with disinfectant. r-rum.

Blood pressure measurement

Procedure for measuring blood pressure:

1. Obtain informed consent from the patient for the procedure.

2. Select the appropriate cuff size.

3. Ask the patient to sit down at the table, place her hand correctly on the table - in an extended position, palm up, with the free hand placed under the elbow, clenched into a fist.

4. They suggest moving your sleeve up or removing clothes from your arm.

5. Place the cuff on the patient’s bare shoulder 2-3 cm above the elbow; clothing should not compress the shoulder above the cuff. The cuff is secured so that only a finger passes under it; center of the cuff - above the brachial artery

6. Find the place of pulsation of the brachial artery in the ulnar fossa and firmly apply the phonendoscope membrane to it.

7. With the other hand, close the valve on the bulb, turning it to the right; with the same hand, quickly pump air into the cuff with the bulb until Korotkoff sounds (or pulsations) disappear radial artery). At the same time, the pressure in it does not exceed 30 mm Hg.

8. Release air from the cuff at a speed of 2-3 mmHg. in 1 s, turning the valve to the left. At the same time, the tones on the brachial artery are listened to using a phonendoscope and the readings on the pressure gauge scale are monitored; When the first sounds appear, mark on the scale and remember the number that corresponds to systolic pressure.

9. Continuing to release air from the cuff, note the value of diastolic pressure corresponding to the weakening or disappearance of Korotkoff sounds.

10. The patient is informed of the measurement result.

11. Repeat the procedure after 2-3 minutes.

12. Measurements are recorded as a fraction - systolic pressure in the numerator, diastolic pressure in the denominator.

13. Wipe the phonendoscope membrane with a napkin moistened with ethyl alcohol.

14. Record the results of the study in the appropriate documentation.

15. Wash your hands.

Conclusion

Postpartum purulent-septic diseases develop in 4-6% of cases, this figure is higher after cesarean section. The problem of postpartum purulent-inflammatory diseases is directly related to: infection of pregnant women and women in labor with intrauterine infection of the fetus and newborn

The exacerbation of the latent infectious process is due to a decrease in immunity, the root cause of which is: pregnancy itself, extragenital diseases, environmental factors, complications of pregnancy, which also contribute to the activation of latent infection and the manifestation of the pathogenicity of endogenous flora.

The negative impact of reduced immunity is manifested by: changes in composition normal microflora intestines, vagina, skin, transformation of opportunistic microflora into pathogenic, emergence of new types of viruses (for example, HIV). Significant changes in biological processes are caused by the uncontrolled use of antibiotics and antiseptics.

References

1. Abrahamyan K.N. Prevention and treatment of complications of extraperitoneal vaginopexy (Prolift operation): Author. Ph.D. honey. Sci. M 2011; 25.

2. Obstetrics. National leadership. Ed. E.K. Ailamazyan, V.I. Kulakova, V.E. Radzinsky, G.M. Savelyeva. M: GEOTAR-Media 2011; 1200.

3. Belaya Yu.M. Medical aspects of the prevention of human papillomavirus infection in teenage girls in the Moscow region): Author. Ph.D. honey. Sci. M 2010; 25.

4. WHO. Project “Global Strategy for the Prevention and Control of Sexually Transmitted Infections, 2006--

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Chapter 10. Care for pregnant women, women in labor, postpartum women and gynecological patients (A. L. Kaplan, V. I. Kulakov)

Pregnancy

Pregnancy- the period during which a fertilized egg develops. This process is accompanied by various changes throughout the woman’s body. The main condition for the normal course of pregnancy and the prevention of possible complications is adherence to a rational regimen. During pregnancy, all hygiene measures that are mandatory for a woman are carried out, but with some changes and additions in each individual case.

Bandage used from the VI-VII months of pregnancy to maintain the abdomen, prevent the divergence of the fibers of the deep layers of the skin and the appearance of pregnancy scars, significant divergence of the rectus abdominis muscles. The bandage must be put on and laced while lying on your back; it should not put too much pressure on your stomach. As the volume of the abdomen increases, it is necessary to adjust the lacing. A bandage selected according to the size and volume of the waist is recommended to be worn after childbirth to prevent sagging of the abdominal wall; it helps maintain the correct position of internal organs and prevent their prolapse. Elastic bands are attached to the bandage to hold the stockings in place.

Varicose veins peripheral veins are observed in pregnant women mainly on the legs, less often on the external genitalia and in the vagina. The reasons are pathological changes in the walls of the veins, damage to the venous valves, and sometimes their disappearance. For varicose veins on the legs, it is necessary to bandage the leg with an elastic bandage in the direction from the foot up the shin, and if necessary, further along the thigh, or use a special elastic stocking.

Weighing allows you to promptly notice fluid retention in the body of a pregnant woman; weighing is carried out at each visit to a pregnant antenatal clinic or a feldsher-midwife station, at least once a month in the first half and every 2 weeks (at least) in the second half of pregnancy. The woman should be weighed undressed, leaving only her shirt on; a pre-pregnant woman must urinate; on the day of weighing, the pregnant woman should have stool (either on its own or after an enema). In the first weeks of a normal pregnancy, body weight does not increase, and sometimes even decreases slightly, especially with nausea and vomiting. From the 16th week of pregnancy, an increase in body weight is noted; from the 23-24th week the weekly increase reaches 200 g, and from the 29th week it does not exceed 300-350 g; a week before giving birth, body weight usually decreases by 1 kg, which is associated with tissue fluid loss. Throughout pregnancy, a woman’s body weight increases by 10 kg (mainly due to the weight of the fetus, amniotic fluid and placenta).

Listening to the fetal heartbeat(auscultation) is performed with an obstetric stethoscope. The heartbeat can be heard starting from the end of the 5th lunar month of pregnancy (20 weeks), but as the gestational age increases, the heartbeat can be heard more and more clearly. It is best heard closer to the head and on the side where the back of the fetus is facing: with a cephalic presentation - below the navel, with a pelvic presentation - above the navel, with a transverse position of the fetus - at the level of the navel on the right or left, closer to the head. The frequency of audible fetal heartbeats at the end of pregnancy usually corresponds to 120-140 per minute. The fetal heartbeat is determined more accurately and earlier using electrocardiography and fetal electrophonocardiography.

Miscarriage- termination of early pregnancy (up to 28 weeks). Predisposing factors: general diseases of the pregnant woman, diseases and abnormalities of the development of the ovum, insufficient function of the ovaries (corpus luteum) and other disorders of a nervous and endocrine nature; The possibility of early pregnancy termination as a result of injury (fall, bruises) cannot be ruled out. However, injuries usually lead to miscarriage in those women who have predisposing conditions. Ordinary household injuries themselves are extremely rarely accompanied by pregnancy disorders. A miscarriage without any intervention is called spontaneous, spontaneous, in contrast to an artificial miscarriage caused by various interventions; produced outside a medical institution - out-of-hospital miscarriage. When spontaneous threatened miscarriage a pregnant woman complains of slight, sometimes cramping pain in the lower abdomen; there is no bleeding. Particular attention should be paid to such complaints from women who already have a history of spontaneous miscarriages. Rest, hospitalization, complete abstinence from sexual activity for a more or less long period, and the use of progesterone sometimes allow pregnancy to be maintained. As an anti-plasma agent, suppositories with papaverine are prescribed, 0.02-0.03 g twice a day; no-shpu, vitamin E 1 teaspoon 2 times a day. At beginning miscarriage Along with cramping pain in the lower abdomen, there is also slight bleeding, which indicates that the ovum has begun to detach. At this stage, miscarriage is limited to bed rest (hospital, maternity hospital); sometimes further detachment is prevented and the pregnancy continues. To reduce the excitability of the uterine muscles, no-shpu, progesterone, and suppositories with papaverine are prescribed. Do not apply ice to the lower abdomen - this increases uterine contractions.

If the detachment of the ovum continues, the bleeding intensifies, blood clots are released, i.e. there is a progressive miscarriage, then in most cases it proceeds as incomplete miscarriage: part of the fertilized egg comes out, and part of it is retained in the uterus. As a rule, such a patient is immediately sent to the hospital, where she has the remains of the fertilized egg removed (scraping); Remnants of the fertilized egg lingering in the uterus prevent uterine contractions and support further bleeding.

It is worth mentioning the so-called complete miscarriage. At the same time, the fertilized egg came out of the uterus, the bleeding stopped and the uterus contracted. However, small pieces of the placenta may remain in the uterine cavity, which in the future will lead to prolonged bleeding, the formation of so-called placental polyps. In such a case, a test curettage of the walls of the uterine cavity is necessary, and the patient must be urgently hospitalized; in all cases of miscarriage, the patient should be urgently sent to the hospital.

Ectopic pregnancy, in most cases tubal, in the first weeks it almost does not manifest itself with characteristic symptoms. A woman with suspected ectopic pregnancy must be urgently hospitalized. Tubal pregnancy is diagnosed using ultrasound. Interrupt tubal pregnancy may occur as a tubal abortion: a pregnant woman complains of cramping pain in the lower abdomen, pain on palpation of the abdomen, especially on the side of the pregnant tube due to irritation of the peritoneum; dark, bloody, spotting discharge from the genitals appears. When the pregnant tube ruptures, a different picture is observed: the rupture of the tube in most cases is accompanied by shock and internal bleeding- the patient suddenly develops acute pain in the lower abdomen, and a short-term fainting state occurs; there is a sharp pallor of the skin, pale, slightly cyanotic lips; pupils dilated; the stomach is slightly swollen and painful when touched; pulse is fast, very weak filling; body temperature is normal, the patient complains of tinnitus, flickering in the eyes; in some cases there is pain radiating to the shoulder and scapula. On palpation of the abdomen - sharp pain in lower section, Shchetkin's symptom is expressed; with percussion of the abdomen - muffling percussion sound in the iliac regions and above the womb. The spilled blood accumulated in the pouch of Douglas protrudes the posterior vaginal vault - a uterine blood tumor. The presence of blood in the rectouterine cavity (pouch of Douglas) is determined by puncture through the posterior fornix. Only timely transsection - removal of a ruptured tube or tube with a fertilized egg with simultaneous blood transfusion (during and after surgery) - saves the patient’s life.

Prenatal care should be understood in a broad sense - as women’s hygiene and at the same time as prenatal, so-called antenatal, infant health care. It is wrong to talk about the hygiene of a pregnant woman in isolation from the hygiene of a woman before pregnancy, starting from her early childhood. The most favorable age for the first pregnancy in terms of the health of both the mother and her unborn child is considered to be 20-25 years old. Starting sexual activity too early and especially early pregnancy unfavorable for both the mother and her unborn child. At first sexual intercourse hymen breaks and bleeds. Sometimes this bleeding is significant and in very rare cases may require medical attention. After the first sexual intercourse, you should take a break for 2-3 days. Sexual excesses adversely affect the state of the nervous system of both spouses. Sexual intercourse during pregnancy should be limited in the first 2 months and, if possible, excluded in the last month of pregnancy. Frequent sexual intercourse in the first months of pregnancy can lead to miscarriage, and in the last month it is possible to introduce pathogenic microbes into the vagina, which threatens the risk of infection during childbirth. A woman's body during pregnancy is the environment in which the fetus develops from the embryo. From this environment the fetus extracts the nutrients necessary for its growth and development, and here it gives the final metabolic products it produces. The body of a pregnant woman provides the growing fetus with the necessary nutritional materials and at the same time neutralizes and removes the end products of the fetus's metabolism.

Through sanitary work carried out in antenatal clinics, in production, in the agro-industrial complex, the nurse ensures that every pregnant woman attends a consultation, a medical and midwifery station from the first weeks of pregnancy, which allows for timely detection possible pathology. Pregnancy represents a new qualitative state of the body, which during this period requires some changes and additions in the implementation of hygiene measures. Healthy woman, observing a rational regime, combining work with rest (see. Occupational safety for pregnant women), eating normally (see. Nutrition for pregnant women), who takes sufficient advantage of fresh air, copes well with pregnancy. If the proper regimen is not followed, a physiological pregnancy can unnoticeably acquire a pathological course. By carefully monitoring a woman from the first month of pregnancy, it is possible to timely identify certain deviations in her health, anticipate possible pathologies during pregnancy and timely implementation of preventive and therapeutic measures prevent pathology. This is what our doctors, midwives and nurses do, working in maternity hospitals and antenatal clinics in cities, and in rural areas - midwives and nurses at feldsher-obstetric stations with periodic consultation with a doctor.

Gymnastics for pregnant women and physiopsychoprophylaxis improve the general condition of a woman, strengthen the nervous system, help prevent toxicosis, improve and facilitate the course of labor, contribute to the favorable course of childbirth and the postpartum period. Gymnastics strengthens the abdominal muscles and increases the elasticity of the pelvic floor muscles, which improves pushing during childbirth and prevents prolapse and prolapse of the internal genital organs. With the help of physical education, a woman learns to control her breathing during childbirth; Gymnastics enhances oxidative processes in the body, which contributes to the normal development of the fetus. The combination of systematic physical education and psychoprophylactic preparation of a pregnant woman for childbirth ensures a painless course of labor. Systematic monitoring of the implementation of physiopsychoprophylaxis begins in the antenatal clinic, and, once mastered, is further carried out at home by the pregnant woman herself. The method of psychoprophylaxis is based on the elimination of labor pains by positive impact to the higher parts of the central nervous system. The goal of physical and psychoprophylactic preparation for childbirth is to remove the psychogenic component of labor pain, eliminate the idea of the inevitability of labor pain, and the oppressive feeling of fear. A woman is taught calm and active behavior during childbirth. Physical exercises and physiopsychoprophylactic preparation for childbirth are recommended for all women. Healthy pregnant women can practice physiopsychoprophylaxis on their own at home, and pregnant women with various diseases in the stage of compensation are under the supervision of a doctor and a visiting nurse, who monitors the well-being of the pregnant woman at each visit and brings this to the attention of the doctor.

Worm infestation negatively affects the condition of the pregnant woman (anemia, general malaise) and the fetus; may lead to pathological changes in the placenta, which, along with anemia, causes oxygen starvation fetus, termination of pregnancy. At the first consultation visit, the stool is examined for worm eggs and, if necessary, treatment is carried out.

Clinical examination- a method by which preventive medical examinations of the population are carried out to identify patients, register them, systematically monitor and improve their health.

Medical examination of pregnant women is carried out by antenatal clinics at the place of residence, and in rural areas - by district and local hospitals and clinics. Consultations register all pregnant women in their area and provide systematic dispensary monitoring of them. The most important task of the antenatal clinic is the early registration of all pregnant women and the identification of pregnancy complications (toxicosis, narrow pelvis, abnormal position of the fetus, bleeding, etc.), as well as diseases of internal organs (cardiovascular system, respiratory system, liver, kidneys, etc.). During pregnancy, a woman should attend a consultation 10-14 times (in the first half of pregnancy, once every 3 weeks, from the 20th to the 32nd week of pregnancy - 2 times a month, after the 32nd week - every 10 days, and when more often if necessary).

Basic antenatal clinic provides not only advisory and therapeutic advice, but also methodological assistance to all outpatient institutions, including medical and sanitary units.

Shop obstetrics and gynecology areas are organized in territorial basic antenatal clinics. The shop doctor - obstetrician-gynecologist gets the opportunity to systematically go to industrial enterprises, to state farms, to study the working conditions of women, to work closely with the administration, party and trade union activists.

On-site antenatal clinics - modern form services for women agricultural workers. The tasks of these consultations include qualified examination by specialists of pregnant and gynecological patients, conducting the necessary laboratory tests for preventive examinations, dispensary observation of certain groups of gynecological patients, identification and timely hospitalization of women with complicated pregnancy.

Teeth, oral cavity. Timely treatment diseased teeth and oral cavity in a pregnant woman is especially important, since foci of infection in oral cavity are a source of constant infection and intoxication of the body and can cause infectious complications during childbirth and the postpartum period. During pregnancy, some women experience a significant depletion of calcium salts in the body, which also affects the condition of the teeth and leads to their rapid destruction. At the antenatal clinic, all pregnant women must be examined by a dentist and given the necessary treatment.

Maternity file carried out for early and systematic identification of pregnant and postpartum women who do not appear for consultation at the appointed time. The file cabinet is available in the office of each local doctor and consists of the main medical document- individual cards for pregnant women (registration form No. 96). Pregnant women's cards are located in a special box according to the dates of the next scheduled visit. The cards of pregnant women with any diseases or complications are marked with a colored flag, since these women need to be given special attention and inspect them more often. Cards remaining in the file cabinet at the end of the working day indicate that pregnant women did not show up for appointments; the latter are subject to urgent patronage. The file for gynecological patients is compiled from control cards of patients undergoing dispensary observation (registration form No. 30). The cards are arranged by disease, and within groups - by the date of scheduled appearance, which allows you to immediately identify a patient who did not appear on time and carry out the necessary patronage. The file is kept by a nurse and systematically checked by a doctor.

Blood. A clinical blood test is performed several times during pregnancy, especially in the second half of pregnancy; Repeated blood tests make it possible to promptly identify diseases that require special treatment. For all pregnant women, blood is taken from the ulnar vein twice (in the first and second half of pregnancy) for serological testing (Wassermann, Sachs-Georgi reaction). Treatment of patients identified in this way is carried out at a venereology clinic with the obligatory involvement of the father of the unborn child in treatment.

All patients must have their blood type and Rh status determined; With Rh-negative blood, the mother often experiences hemolytic disease of the newborn. If Rh-negative blood is detected in a pregnant woman, it is necessary to examine the blood of her husband as well. If the father Rh positive blood and the fetus has inherited the father's Rh status, then during such a pregnancy a Rh conflict arises between the mother and the fetus: the fetus may die in utero, be born prematurely or with signs of hemolytic disease. To increase the fetus's resistance to the harmful effects of Rh antibodies and improve placental blood circulation, all pregnant women with Rh-negative blood undergo desensitizing treatment (at 12-14, 22-24, 32-34 weeks of pregnancy). Therapeutic and preventive measures are designed to create the most favorable conditions for fetal development: food should be rich in proteins and vitamin C (up to 1 g per day during pregnancy with short breaks).

The Coombs test is used to detect antibodies in the mother's blood. When antibodies appear in the mother's blood long before birth, the most severe forms of fetal disease occur. In approximately 30% of newborns from such mothers, hemolytic disease begins in the prenatal period.

Bleeding in early pregnancy cm. Miscarriage.

Bleeding in late pregnancy may be associated with abruption of the placenta at the beginning of labor, with its low location in the uterus, or with placenta previa, if the placenta is located above the internal os of the uterus (in this case, bleeding usually appears without any noticeable labor, without contractions), or associated with premature abruption normally placenta located in the uterus (usually there are contractions). All women in labor with bleeding should be urgently hospitalized in the nearest hospital, accompanied by a nurse, or a doctor or midwife should be urgently called to see them.

Mammary glands. During pregnancy, the mammary glands are prepared for the upcoming feeding of the child so that the mammary glands develop correctly, the nipples become stronger and cracks do not form on them. Every day, with cleanly washed hands, it is necessary to wash the mammary glands with water at room temperature and soap (preferably baby soap) and wipe with a shaggy towel. If the skin of the nipples is dry, they should be lubricated with sterile petroleum jelly. With flat or inverted nipples, a kind of gymnastics is performed on the latter. To do this, the nurse thoroughly washes her hands (nails should be cut short), lightly sprinkles her fingers and nipples with sterile talcum powder, grabs the nipple at its base with two fingers and pulls it in the direction from the areola to the top of the nipple with a simultaneous light massage; This is done daily once or twice a day for 5 minutes. If the massage does not achieve the goal, it should be stopped and subsequently used when feeding the child, if necessary, with a special pad. Air baths for the mammary glands for 15-20 minutes are very useful. This strengthens the nipple and skin; It is advisable to carry out air baths in the morning and evening.

Urine. The kidneys function under great strain during pregnancy, as they remove waste products from the body of both the pregnant woman and the growing fetus. Therefore, a pregnant woman’s urine must be examined every time she visits a antenatal clinic. If protein appears in the urine, the pregnant woman is taken into special registration, and if the protein increases, she must be hospitalized.

Maternity clothes should be comfortable, light and free. You should not wear tight belts, round garters, or tight bras. Stockings should be held in place with long elastic bands fastened to a belt or bandage. It is better for a pregnant woman to wear loose dresses or a sundress with straps so that the weight of the clothes falls on the shoulders. Cleanliness of clothing during pregnancy is especially important. Shoes should be comfortable, with low heels.

A maternity bra should be made of rough material or lined with canvas and should not put too much pressure on the mammary glands. This contributes to the roughening of the skin of the nipples, which to a certain extent prepares them for feeding. The bottom edge of the bra should be at least 5-6 cm wide. The mammary glands in the bra should be slightly raised and moderately pressed. A bra of the same cut is recommended for postpartum women. A bra with straps should be fastened at the front so that it is convenient to expose the mammary glands when washing them and feeding the baby. Bras need to be clean, so you should have several and change them often.

Maternity and child care leave is provided for a duration of 56 calendar days before childbirth and 56 calendar days after childbirth with payment of state social insurance benefits for this period. In case of complicated pregnancy and childbirth or the birth of two or more children, leave after childbirth is granted for 70 calendar days. Since the duration of maternity leave is calculated in calendar days, this vacation count includes not only working days, but also weekends and holidays.

Postpartum leave is calculated from the day of birth, including the day of birth. After childbirth, at the request of the woman, if there is a common length of service Partially paid leave to care for a child is provided for at least one year until the child reaches the age of one year, with payment of state social insurance benefits for these periods. Mothers studying in vocational educational institutions, courses and schools for advanced training and personnel training are granted partially paid leave regardless of their length of service. In addition to the specified leaves, a woman, upon her application, is granted additional leave without pay to care for a child until the child reaches the age of one and a half years. Additional leave without pay is counted towards the total and continuous work experience, as well as into the length of service in the specialty and, in particular, the length of service giving the right to annual leave. Before maternity leave or immediately after it, a woman, upon her application, is granted an annual labor leave regardless of length of service at a given enterprise, as well as, if desired, leave without pay.

Occupational safety for pregnant and breastfeeding women. Pregnant women from the fifth month of pregnancy and breastfeeding women are allowed only to do light work (excluding overtime and night work). Women cannot be sent on business trips without their consent. When transferring to more light work The pregnant woman retains her average salary based on the last 6 months. It is prohibited to dismiss a pregnant or breastfeeding woman from work. Breastfeeding mothers and women with children under 1 year of age are provided, in addition to a general break for rest and nutrition, additional breaks for feeding the child - at least every 3 hours, lasting at least 30 minutes each. If there are two or more children under the age of 1 year, the duration of the break is set at least 1 hour. Breaks for feeding the child are included in working hours and are paid according to average earnings. The timing and procedure for providing breaks are established by the administration together with the factory, plant, and local trade union committee, taking into account the wishes of the mother. It is prohibited to refuse to hire women and reduce their wages for reasons related to pregnancy or breastfeeding. The dismissal of pregnant women, breastfeeding mothers, and women with children under 1 year of age is not allowed at the initiative of the administration.

Patronage for pregnant women aims to monitor them at home. The tasks of patronage include: clarifying the general condition and complaints of a pregnant woman, postpartum woman or a patient with gynecological diseases; familiarization with the life of a pregnant and postpartum woman, teaching her the rules of hygiene and caring for a newborn; education of sanitary and hygienic skills and assistance in improving the hygienic environment, based on specific living conditions; checking the implementation of the assigned mode; sanitary educational work. When caring for pregnant and postpartum women, it is necessary to pay special attention to balanced nutrition and compliance with all doctor’s recommendations. The sister records the data received during the first visit in detail on a visitation sheet, which she pastes into the pregnant woman’s individual card. During repeated visits, the nurse notes on the visitation sheet everything that has been done to eliminate the noticed shortcomings, and reports her observations to the doctor.

Nutrition for pregnant women. Proper nutrition during pregnancy is extremely important for maintaining the health of the mother and the normal development of the fetus. In the first half of a normal pregnancy, a special diet is not necessary. Food should be varied and tasty prepared. Nutrition in the second half of pregnancy should take into account the physiological characteristics of the body. The diet must include proteins up to 100-120 g per day. Among products containing complete proteins, we should recommend kefir, yogurt, milk, cottage cheese, eggs, cheese, lean meat (100-120 g per day), fish (150-250 g per day). The amount of carbohydrates in the diet should not exceed 500 g per day, and if a pregnant woman is overweight - 300 g. It is necessary to include fruits, berries, vegetables, and bread in the diet. Fats are recommended in the amount of 100-110 g per day, mainly in the form butter, sour cream and vegetable oils. The amount of liquid is limited to 1-1.2 liters, and the amount of table salt, especially in the second half of pregnancy, is limited to 8-5 g per day. During pregnancy, food should contain vitamins A, B, C, D, E. Vitamin A increases the body's resistance to infection. It is found in the liver of fish. Carrots contain carotene, which is converted into vitamin A in the body; You can also use a ready-made synthetic preparation in the form of pills or liquid. Vitamin B 1 prevents the development of vomiting in a pregnant woman. A lack of vitamin B 1 in the body leads to rapid fatigue, the development of neuromuscular weakness, and weakness of labor. Vitamin B1 is found in black bread, yeast and beans; You can also use ready-made preparations in the form of dragees. Vitamin C (ascorbic acid) helps maintain pregnancy; If there is a deficiency of this vitamin in a pregnant woman’s body, pregnancy termination often occurs. Vitamin C is found in large quantities in rose hips, black currants, cabbage and other vegetables, berries and fruits, which a pregnant woman should consume widely. If this is not possible (in winter, spring), it is recommended to take vitamin C in the form of ascorbic acid with glucose or in the form of proprietary tablets. Vitamin D, otherwise called antirachitic, prevents the development of rickets in the fetus and plays an important role in the regulation of calcium and phosphorus metabolism in a pregnant woman. Contained in fish oil (use 1 tablespoon 2 times a day before meals). Vitamin E helps maintain pregnancy, especially indicated for women with a history of premature pregnancies; promotes normal development of the embryo and fetus. Vitamin E is found in sprouted wheat grains and salad. There is a ready-made complex of vitamins specifically for pregnant women - gendevit; it is taken 2-3 tablets per day. Food should be taken in small portions, in the first half of pregnancy 4 times with three-hour breaks: first breakfast - 25-30% of the diet, second breakfast - 10-15%, lunch - 40-45%, dinner - 10-15%. In the last months of pregnancy, food is taken 5-6 times a day, dinner - 1-1.5 hours before bedtime (tea with milk, a glass of milk or curdled milk with a roll or cookies). Night break - 8-9 hours.

Treatment-protective regime in the care of pregnant women, women in labor and postpartum, in addition to observing the strictest asepsis and antisepsis, includes the creation of a favorable, calm, benevolent environment, timely, accurate, painless execution of all appointments, attentive and helpful attitude to the patient’s requests, a calm tone in conversation, concern for cleanliness around the patient , in the room, clean linen, delicious food, etc.; vanity and bustle in the work of medical personnel are eliminated. All this - the most important tasks a nurse working in an obstetric hospital, in a antenatal clinic and a clinic. Positive emotions contribute to increased reactivity of the body, more quick recovery. And, conversely, negative emotions lower the overall tone and reduce the body’s resistance to infection. There are known cases of miscarriage and premature birth due to severe nervous experiences. Pregnant women, especially with a pathological pregnancy, and postpartum women, after undergoing great physical and mental stress, such as childbirth, need favorable conditions for rest and sleep. Sleep restores the performance of a tired, exhausted body. It is necessary to eliminate noise in the department; the clicking of heels, creaking doors, etc. is unacceptable; it is necessary to maintain the appropriate temperature in the room. The postpartum woman should be provided with at least 8-9 hours of good sleep during the day, with mandatory continuous night sleep of at least 6 hours. All manipulations, diagnostic and therapeutic procedures should be carried out by a nurse painlessly. It is necessary to try to ensure that every pregnant woman is promptly prepared at the antenatal clinic, at the feldsher-midwife station for a painless course of labor by conducting special classes - conversations using the method of psychoprophylactic training. To assimilate ourselves and systematically introduce junior medical staff to the principles of the medical and protective regime - these are the tasks of nurses at the antenatal clinic, maternity hospital and feldsher-obstetric station.

Gestational age. The average duration of pregnancy for a woman is 280 days, i.e. 40 weeks, or 10 obstetric (lunar) months. The gestational age in the first months is determined by simply counting the time that has passed since the last menstruation. To calculate the due date from the first day of the last menstruation, count 3 months ago and add 7 days. For example, the first day of the last menstruation is December 10, 1987: count 3 months ago (November, October, September), it turns out - September 10; add 7 days - it turns out September 17, 1988. This will be the expected due date, which in some cases may vary between September 10 and 20. To more accurately calculate the gestational age, along with anamnesis data, they use the determination of the size of the pregnant uterus, the height of its fundus above the symphysis, the position of the head, its size, the length of the fetus and the circumference of the pregnant woman’s abdomen.

Until 3 months, the uterus is still in the pelvic cavity - pregnancy is determined by vaginal examination. Starting from the fourth month of pregnancy, the fundus of the uterus emerges from the small pelvis and at the end of the fourth obstetric month of pregnancy (16 weeks) stands three transverse fingers (5 cm) above the symphysis pubis; at the end of the fifth obstetric month of pregnancy (20 weeks), the fundus of the uterus is in the middle between the womb and the navel (11 cm above the womb); at the end of the VI obstetric month of pregnancy (24 weeks) - at the level of the navel (22 cm above the womb); at the end of the VII obstetric month of pregnancy (28th week) - 26 cm above the womb; at the end of the 8th obstetric month of pregnancy (32 weeks) - 30 cm above the womb; at the end of the 9th obstetric month of pregnancy (36 weeks) - 36 cm above the womb. By the end of the X obstetric month of pregnancy (40 weeks), the fundus of the uterus drops approximately to the level at which it stood at the end of the VIII obstetric month, i.e., 30 cm above the womb.

Toxicoses of pregnant women- a multi-symptomatic disease manifested by dysfunction of the metabolic, cardiovascular system, kidneys, liver, central and peripheral nervous systems; often occur against the background of existing chronic diseases of internal organs.

Early toxicoses may appear from the first days and weeks of pregnancy and disappear in the second half. Some early toxicoses of pregnant women do not completely disappear and persist until the end of pregnancy. Early toxicosis of pregnant women can manifest as dermatoses, a rash similar to urticaria, itching of the external genitalia, eczema, and herpes. Early toxicoses include vomiting and salivation. Many women, from the first days and weeks of pregnancy, develop intolerance to certain smells and tastes (an aversion to some foods and a need for others). Vomiting of pregnancy- the most common form of toxicosis; in most cases does not require special treatment. More severe forms are accompanied by rapid loss of body weight, dry skin, rapid pulse, low-grade fever. Uncontrollable vomiting- severe form of early toxicosis of pregnant women; vomiting is repeated 20 or more times a day and leads to exhaustion of the body, and in some cases, especially if untreated, can lead to death. As a result of fasting, pregnant women with indomitable vomiting develop severe dystrophy, diuresis sharply decreases, protein, hyaline and granular casts, and acetone appear in the urine. The patient’s mouth smells of acetone (smells like apples), and the general condition deteriorates greatly. A pregnant woman with excessive vomiting should definitely be hospitalized. If treatment is not started immediately, the patient is at risk of death due to profound (irreversible) changes in the organs (kidneys, liver). Sometimes the only salvation can be a timely termination of pregnancy.

Drooling (ptialism) manifested by almost continuous secretion of saliva, often causing irritation and maceration of the skin of the chin, and significant weight loss. To measure the daily amount of saliva secreted (and vomit), use a graduated glass mug with a lid. The nurse records the amount of saliva (and vomit) collected in the medical record; large loss of fluid is compensated by drip infusion of fluid (glucose, vitamins, isotonic solutions).

Late toxicosis of pregnant women. At dropsy of pregnancy fluid accumulates mainly in the subcutaneous fat layer. Fluid accumulation depends on disruption of water-salt metabolism and increased capillary permeability. The disease begins in the second half of pregnancy. First, pastiness occurs, and then swelling of the feet and legs. With edema, body weight increases by 500-700 g or more per week. For mild forms of hydrocele in pregnant women, bed rest and a diet with limited fluid and salt, inclusion of complete proteins (boiled lean meat, boiled fresh fish, cottage cheese, kefir), vitamins, light dairy and vegetable foods, control of diuresis. If the pregnant woman's treatment is incorrect, dropsy can progress to a more severe stage of toxicosis - nephropathy.

Nephropathy of pregnancy (kidney of pregnant women)- a disease accompanied by edema, the appearance of protein in the urine, and increased blood pressure. Treatment for nephropathy is aimed at increasing diuresis, reducing and completely eliminating edema, lowering blood pressure, improving cardiac activity, and preventing seizures. Intravenous infusions of glucose are used, calcium chloride is administered orally, and magnesium sulfate is administered intramuscularly. Treatment is carried out with intermittent sleep.

The diet for nephropathy consists of excluding table salt, limiting fluids (up to 500 ml per day until swelling disappears); in food - at least 100 g of proteins (cottage cheese or lean meat, boiled or steamed, or boiled fish), animal fats or vegetable oil in the amount of 50 g per day; sufficient amount of sugar and vitamins. The use of soda is prohibited, which is replaced if necessary with magnesium compounds. The nurse very carefully monitors the general condition of the patient, the symptoms of nephropathy (blood pressure, albuminuria, edema, condition of the fundus vessels according to the ophthalmologist). Timely recognized nephropathy can be suspended with proper nursing care for the patient (diet, treatment, medical and protective regimen).

Preeclampsia. If treatment and preventive measures do not stop nephropathy, then the amount of protein in the urine increases, swelling increases, blood pressure rises, and complaints of pain in the epigastric region, headache, “veil” before the eyes; at this stage, hemorrhage into vital organs is possible, premature detachment placenta and other complications dangerous to the pregnant woman and the fetus. Treatment of preeclampsia comes down to an appropriate regimen - the patient is placed in a separate room, providing her with peace and individual, constant care from a nurse. The windows in the ward are covered to avoid harsh light irritation. Magnesium sulfate is administered, the diet is strictly followed (see above), treatment is carried out with long sleep, and the necessary care is provided; This prevents the transition of preeclampsia to the convulsive stage of eclampsia. The nurse must perform all manipulations and injections under general anesthesia.

Eclampsia- the most severe stage of late toxicosis. The growing symptoms of preeclampsia as a result of increased intracranial pressure are accompanied by severe headache, sometimes vomiting, blurred vision, and agitation. Convulsions in eclampsia begin with twitching of the facial muscles; First, blinking of the eyelids appears, then fibrillary twitching occurs facial muscles, then the spasms spread to the muscles of the trunk and limbs, turning into tonic spasms of the muscles of the whole body. The neck muscles are tense, the veins in the neck are dilated, a sharp blueness of the face appears and upper limbs(due to respiratory distress); consciousness is lost; pupils are dilated. A convulsive attack can last from 30 seconds to 1 minute, then the convulsions gradually stop, the patient makes a deep, long exhalation, foam is released from the mouth, sometimes stained with blood due to biting the tongue, then breathing is gradually restored, the cyanosis disappears, and after a while consciousness returns. The amount of protein in the urine increases sharply. Sometimes, with frequently recurring seizures, the blood supply to the central nervous system progressively deteriorates and the patient, without regaining consciousness, may die from asphyxia, cerebral hemorrhage or pulmonary edema. Eclampsia can occur in pregnant women, women in labor and postpartum women in the first days of the postpartum period.

The nurse must constantly remain with the patient. Before the onset of a seizure, the patient experiences increased agitation, slight twitching of the eyelids, the pulse becomes more intense, and blood pressure rises. At this moment, you need to insert the handle of a spoon wrapped in gauze into the patient’s mouth from the side between the molars (to avoid biting the tongue), and keep the spoon in the mouth until the seizure ends. If possible, the patient is immediately given anesthesia. Before the doctor or midwife arrives, in order to prevent the next seizure, the nurse injects the patient intramuscularly with 20 ml of a 25% solution of magnesium sulfate (this can be repeated every 4 hours, but no more than 4 times a day). If this drug is not available, you can inject 1 ml of a 1% morphine solution under the skin. A patient with eclampsia cannot be transported. The nurse, while staying with the patient, is obliged to provide everything possible to create a therapeutic and protective regime (see. Treatment-protective regime).

Prevention of toxicosis in pregnant women includes correct and qualified management of a pregnant woman from the first weeks of pregnancy; rational nutrition, abstaining from large amounts of fluids and food, limiting salt, regulating physical and mental labor, staying in the fresh air, healthy night sleep, implementation of all recommendations of the antenatal clinic. Those who have suffered toxicosis must be under medical supervision after childbirth.

Toilet external genitalia during pregnancy, it is done with warm water and soap (preferably baby soap). You must first wash your hands thoroughly. They wash themselves over the basin, pouring water from a jug or a kettle with their left hand, or in the bath with warm water from a hose; movements of the washing hand are made from the womb to the anus (but not in the opposite direction).

A nurse washes a bedridden pregnant woman: an oilcloth is laid under the woman and an individual bedpan is placed; use sterile cotton swabs on a forceps. In the second half of pregnancy, a woman washes herself while lying down from Esmarch's mug with a not very strong stream. When washing, water should not pour into the vagina; only the external genitalia are washed.