MODULE 2: PATHOLOGICAL DURATION OF PREGNANCY, LABOR AND POSNATAL PERIOD
1. Curation of women with pregnancy induced hypertension.
2. Curation of pregnant with extragenital pathology
ALGORITHM 1
Taking of the history in the pregnant woman
I. Anamnesis (in translation from Greek - flashback, reminder) is the taking of information about the origin and motion of disease. At the inspection of pregnant in detail obstetric anamnesis is found out. Finding is added to the individual card of pregnant and postpartum patient. A woman is asked in special order:
1. Passport data. The last name, name, patronymic, age, profession, place of work, address.
2. Reasons, that forced a woman to appeal for the medical help (stopping of menstruation, bloody discharge, increase of frequency of urination, enlargement of milk glands, pains in a abdomen or back and in.).
3. Domestic anamnesis. Heredity: psychical diseases, alcoholism, drug addiction, lacks of development and other diseases which can be inherited or be had unfavorable influence on development of fetus.
4. Carried more early disease. Rachitis, effecting on deformations of pelvis; infectious diseases which can affect sexual development of girl, illnesses of liver, heart, lungs.
5. Menstrual function:
1) age of menarhe (the first menstruation);
2) term of establishment of regular menstrual function;
3) duration of cycle;
4) duration of bleeding;
5) type of menstruation - painfull, recurrence, regularity;
6) bloodloss;
7) character of menstruations after the beginning of sexual life, births, abortions;
8) data of the first day of the last menstruation;
6. Secretory function:
1) Presence of discharge from sexual ways;
2) quantity, character of the discharge (bloody, festering, mucous, watery).
7. Sexual function:
1) age of beginning of sexual life;
2) what marriage and his duration;
3) health of man (alcoholism, tuberculosis, gonorrhoea, Syphilis);
4) application of contraceptives, duration, efficiency
5) presence of sterility in anamnesis, its duration, methods of medical treatment.
8. Genital function or obstetric anamnesis:
1) quantity of pregnancies;
2) result of every pregnancy: births, abortion, ectopic pregnancy, stillborn, features of motion of pregnancy, births, post-natal period;
3) quantity of living children, their mass at birth, features of development.
9. Gynaecological diseases, operations on the pelvic organs.
10. Motion of the given pregnancy – what term the complications were in, as treated oneself – ambulatory or in permanent establishment, what methods of medical treatment were used.
11. Fetal movement:
а) data of the first fetal movement;
б) intensity and frequency of movement.
ALGORITHM 2
Calculation pulse rate
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1. Necessary tool. |
Clock or stop-watch |
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2. Position of patient. 3. Order. |
The patient is in bed or sits on a chair in comfortable position 1. Switch a stop-watch or mark on a watch the time. 2. Overcome the left hand of patient by a right hand in the area of radiocarpal joint. Place a thumb finger on the external surface of joint, and index, mid and nameless – on internal. 3. To find the radial artery. 4. To calculate the frequency of pulse for a 1 minute. 5. To fill in the results in a temperature chart. |
Pay attention to filling, strenght, rhythm of pulse. Fill in the pulse in a temperature chart by a red pencil. |
ALGORITHM 3
Estimation of arterial blood pressure
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Necessary tool |
Tonometer, phonendoscope. |
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Position of patient |
The patient is in bed or sits on a chair near table, an arm is located on the table higher than elbow. |
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Order |
1. To put on the shoulder of patient a blood pressure cuff so that its lower edge should be present on 2-3 cm above elbow. 2. To connect a cuff with the bulb of tonometer. 3. To find the place of pulsation of radial artery in the area of elbow. To put phonendoscope into this place. 4. Close a valve. 5. Pressing a pear, force air in a cuff. 6. After disappearance of sound of pulse blows force air still on 2-3 points. 7. Halt to force air, open a valve and slowly let out air. 8. Mark a mark on a scale, when with¢there will be the first pulse blow. It is the size of systolic pressure. 9. Continuing to let out air, mark on a scale a mark which pulse blows disappear on. It is the size of diastolic pressure. |
One finger only should pass through the cuff. At pregnant arterial pressure is measured on both hands |
ALGORITHM 4
Leopolds’ maneuvers
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Necessary tool |
Not needed |
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Position of patient |
The pregnant lies on the back. The doctor sitting to the right from pregnant. |
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Order |
The first maneuver. The hands of both hands very tightly are laid horizontally, in the area of uterine fundus. Carefully press on a uterine fundus. The second maneuver. Both hands are placed on the lateral surfaces of uterus at the level of umbilicus. By turns by a right and left hand palpation of fetal parts is performed. Carefully pressing by hands and fingers of hands on the lateral surfaces of uterus, dense, smooth, wide and shiny part is determined from one side - the back of fetus, from opposite – small parts are palpated . The third maneuver. By a right hand presented part of fetus is grasped (large finger from one side and four - from the opposite side of lower segment of uterus). The character of presented part and its station is determined. Fourth maneuver. A doctor is standing towards patient’s feet. The hands of both hands are located on the lateral surfaces of lower uterine segment and carefully try to insert the fingers between presented part and pelvic inlet. |
The level of uterine fundus location and part of fetus, located in a fundus, is determined. Gestational age is determined. By this maneuver the lie, position,variety, and also uterine tone, quantity of amniotic fluid waters and fetal movement, are determined. Presented part station is determined. Presented part station is determined. |
ALGORITHM 5
Fetal heart tones auscultation
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Necessary tool |
Obstetric stethoscope |
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Position of patient |
The pregnant occupies position, lying on a the back with extended feet. |
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Order |
Stetoscope is located on the place of the most clear feeling of fetal movement on the anterior abdominal wall. One end of watering-can of stetoscope is very tightly pressed on the pregnant’s abdomen, the second end of stetoscope a doctor puts to the area of ear. Fetal heart tones are most distinctly listened from the side of the back of fetus, to the left - at the first position, to the right - at the second position, below the umbilicus – at cephalic presentation, above – at breech presentation. |
The rate of fetal heart tones is - 120-140per minute. Tones of heart are double, rhythmic, do not correspond with the pulse of pregnant. |
ALGORITHM 6
Estimation of uterine height and circumference of the abdomen
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Necessary tool |
Centimeter’ tape |
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Position of patient |
The pregnant occupies position lying on he back with extended feet. |
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Order |
1. By a right hand, beginning of centimeter tape is fixed to the middle of the symphysis. The end is touch in a midline to the uterine fundus. The left hand determines the uterine height. It is marked on the tape. 2. The onset of centimeter’s tape is taken by the left hand, a tape is stretched out under the back of pregnant at the level of iliac spines, at the level of umbilicus for estimation of circumference of the abdomen |
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ALGORITHM 7
Determination of the expected fetal weight
For determination of the expected weight of fetus (EFW) it is necessary to know the height of standing of uterine fundus (UF) and circumference of abdomen(AC) of pregnant.
Volscov’ formula:
EFW = UF x AC
For example: UF= 32 cm, AC = 100 cm. Multiply: 32х100, we received 3200cm. The expected weight of fetus is 3200 g.
Yacubova’ formula: EFW= (AC+UF) : 4 x 100
For example: UF= 32 sm, AC = 100 sm. Adding 32+100, we get 132, dividing on 4, we get 33, multiply on 100, we have the expected fetal weight – 3300 g.
ALGORITHM 8
Determination of gestational age of the pregnancy and probable day of delivery
1. from data of WOH a date which we get is considered the date of births, deducting 3 calendar months backwards from the 1th day of the last menstruation;
2. on a method Negele: from the 1th day of the last menstruation to deduct 3 calendar months and add 7 days. For example: date of beginning of the last menstruation – on January, 26. We add 7 days – we get on February, 2. From February, 2 we deduct backwards 3 months. Term of births – on a November, 2.
3. Date of non-permanent sexual intercourse. If to the number, when sexual intercourse happened, to add 273 days, the got number will be considered the date of the expected births.
4. Date of ovulation. For determination of term of births it is needed from the first day of the expected menstruation which did not come, to take away 14 days and to the got number add 273 days.
5. Date of the first feeling of motions of fetus. That to get the date of births in primapara, to the day of the first feeling of motions of fetus to add 20 weeks, and inmultipara - 22 weeks.
ALGORITHM 9
Measuring of external sizes of pelvis
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Necessary tool |
Pelvimeter |
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Position of patient |
The pregnant occupies position, lying on a bed on the back with extended feet. |
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Order |
Distantia spinarum - is measured between liac spines. It has 25-26 cm. Distantia cristarum - is measured between the prominent points of iliac bones In has 28-29 cm. Distantia trochanterica - is measured between the prominent parts of trochanter major. It has 30-31 cm. External Conjugate is measured from the middle of symphysis til fossa suprasacralis. It has 20-21 cm. |
The formula of pelvis is written down so: 25-28-31-20cm |
Solovjov Index - the average circumference of the radiocarpal joint.
It has 14-16 cm. An index is used for estimation of thickness of pelvic bones.
MODULE 3: DISEASES OF THE FEMALE REPRODUCTIVE SYSTEM. FAMILY PLANNING
1. Assessment of results of the cytological examination
ALGORITHM 10
Inspection of cervix in Sims’ speculum
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Position of patient |
The gynaecological inspection is helded on a gynaecological arm-chair. A woman lies on the back with half-bent in knee and heeps. |
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Necessary tool |
Sims’ speculum, sterile gloves |
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Preparation of patient |
To evacuate urinary bladder and rectum, for some indications - necessary to perform an evacuant enema. |
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Order |
1. By the thumb and index fingers of the left hand sexual labias are opened. 2. Speculum is grasped by the right right hand and inserted into vagina, turning it firstly in oblique, later in direct position to pudendal cleft. 3. To put a speculum on the back wall of vagina and slightly press on it. 4. The retractor is inserted in parallel direction inside the vagina and pressing into anterior vaginal wall. 5. The cervix is inspected. 6. After cervical inspection the speculum and retractor are removed in reverse order: retractor - at first, then speculum. |
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ALGORITHM 11
Inspection of cervix in
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Position of patient |
The gynaecological inspection is performed on a gynaecological arm-chair. A woman lies on the back with half-bent in knee and heeps. |
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Necessary tool |
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Preparation of patient |
To evacuate a urinary bladder and rectum, if it is necessary cleansing enema is made. |
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Order |
1. Sterile gloves are dressed. 2. By the thumb and index fingers of the left hand labias major are opened in the lower third. 3. A speculum is inserted in vagina, placing blades parallel to the pudendal cleft. 4. After insertion of the speculum inside it is returned on 90 0, blades are opened so that vaginal part of cervix was found between blades. 5. After the cervical inspection blades are removed from vagina. |
A speculum is fixed by lock in some conditions. |
ALGORITHM 12
Taking smears for cytological examination
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Position of patient |
A woman lies on a gynaecological arm-chair on the back with half-bent in knee and heaps. |
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Necessary tool |
Cusco or Sims speculum, Folchman’ spool, spatula Eyra or cervix brush for taking smears, pincers, wadding marble, subject slide, sterile gloves. |
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Preparation of patient |
1. A patient is present on gynaecological arm-chair. 2. To insert a gynaecological speculum into a vagina, to examine a speculum. |
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Order |
1.The material for research is taken from the anterior lateral vault making a scrub. To put the material on the slide. 2. By other instrument (the best – by a brush) the material is taken from cervicolumnar junction – tranzition zone. For this purpose a brush is rotated into the channel of cervix on 360°. The received material is putted on subject slide, revolving a brush. 3. If on the cervix there are some changes, a smear is taken also from the pathologically changed areas exposed during colposcopy. 5. A speculum is removed. 6. The surname of the women is written in the special list, the material is sent to the histological laboratory. |
Carefully by the wadding marble clutched in pincers, tailings of mucus are taken off from the cervix. |
Types of PAP smears:
n I – normal
n II a- inflammatory process
n II b – mild dysplasia
n III a - moderate dysplasia
n III b – severe dysplasia
n IV – suspicion of cancer
n V – carcinoma in situ
n VI – smear is not informative
2. Curation of the patient with benign tumors of the female sexual organs.
3. Curation of the patient with abnormal menstrual cycle.
4. Curation of the patient with inflammatory diseases’ of female sexual organs.
ALGORITHM13
Taking of patients history
Gynaecological anamnesis is taken in such order:
I. Menstrual function.
1. In what age does the menstruations begin?
2. In which age do the y become regular?
3. How many days does the menstruation last?
4. In how many days does the menstruation repeat?
5. What quantity of blood is lossed during menstruation?
6. Are the menstruations regular?
7. Is menstruation accompanied by the unpleasant feeling?
8. When the last menstruation was?
9. Did the character of menstrual function during this disease change?
II. Sexual function.
1. In what age does the sexual life begin?
2. Do you use oral contraceptives? Which exactly? What their efficiency?
3. Did the character of sexual function during this disease change?
III. Generative function.
1. How many pregnancies were?
2. How did pass each of them, which complications were present? What every pregnancy finished by?
3. How many births were? How did they pass? Which complications were present?
4. How did post-natal periods pass?
5. How many abortions were? What term of pregnancy did they come in?
6. How many artificial abortions were?
IV. Secretory function.
1. Is any discharge from sexual ways are present?
2. What character of discharge? Their color? Smell ?
3. Does the character of discharge during a menstrual cycle change?
4. Did a secretory function change during disease ?