Vinnitsa Nathional Medical University named after N.I. Pyrogov
Head of Obstetrics and Gynaecology department№ 2 PhD, prof. BulavenkоО.V.______
the «____» ______of 20___ year
METHODICAL RECOMMENDATIONS
FOR THE STUDENT’S OF STOMATOLOGICAL FACULTY
FOR PREPARING TO PRACTICAL CLASS
Subject / ObstetricsModule 1. / Physiologicaland pathological course ofpregnancy, childbirth and the postpartumperiod.Perinatalcomplications.
Semanticmodule 1. / Physiologicaland pathological course ofpregnancy, childbirth and the postpartumperiod.Perinatalcomplications.
Subjectlessons / Physiology ofpregnancy, childbirth and the postpartumperiod.Survey methodspregnant. Obstetricterminology.
Year of study / 4
Faculty / Dental
Author / Assistant, Goncharenko O.M.
Vinnitsa 2013
1.Topicality. The main purpose of antenatal surveillance is the prevention of maternal and perinatal mortality. It is generally accepted the fact that pregnancy is determined considerable number of factors, but the primary importance given to the process of fertilization and development of a fertilized egg, placentation, organogenesis, development prolific membranes, functioning of the new body - the placenta, which connects the mother and the fetus.
Reduction of maternal and perinatal morbidity and mortality contribute to knowledge about the teratogenic and embryotoxic effects chynnnykiv environment on embryo and fetus at a critical time.
To ensure the life, growth and development of the embryo and fetus in the mother's of significant changes regarding almost all body systems. Compensatory changes in the orga ¬ tries and body systems of pregnant homeostasis lead to a state of unstable equilibrium hard. Violation of this balance can lead to changes in homeostasis and implementation of an obstetric or extragenital pathology, what you need to know doctors of all specialties.
Diagnosis of pregnancy in the early period (before 12 weeks) is important in the overall preparation of doctor of any profession, because early detection allows time to diagnose pregnancy obstetric and extragenital pathology and decide on appropriate further pregnancy. Only such an approach is the key to favorable ¬ Volyn end of pregnancy for the mother and fetus.
In recent years the practice obstetrics were a number of changes in direction pereusvidomlenni assist mothers that are based on the principles of evidence-based medicine, more humanistic attitude in postpartum women and to avoid pharmacological and drug aggression, which contributed more physiological partum period, reduce the frequency of complications postpartum period, emergency psychological adaptation of women after childbirth.
Despite the fact that the postpartum period is a physiological process, it requires a doctor's knowledge of all its stages and characteristics, namely the processes of involution in the organs and systems of women after childbirth, lactation, allowing detect the initial signs of diseases and complications that may arise a woman in labor.
2. The student must:
Know
1. Physiological changes in women during pregnancy (zina psychological state and the central nervous system, changes in the endocrine system, the changes in the genitals and breasts, changes in the cardiovascular, respiratory system and blood changes in the gastrointestinal tract and kidneys, changes in metabolism. changes in the skin, changes in the musculoskeletal system that occur in pregnant women).
2. Survey methods pregnant.
3. Methods outdoor midwifery examination;
4. Goals and methods of I, II, III, IV techniques Leopold;
5. The method of measuring the height of standing uterus (GMR);
6. Measurement contours of the abdomen;
7. Methods for calculating estimated fetal weight;
8. Methods tazovymiryuvannya;
9. Method of listening to the heartbeat of the fetus;
10. Diagnosis of early pregnancy.
11. Obstetric terminology. Location of the fetus in the uterus (position, positions, types, presentation of the fetus, small and large segments of the head of the fetus).
12. Determination of prenatal vacations (diagnostic methods 30-week pregnancy.) And date of birth.
13. The reasons for the onset of labor, regulation of labor activity.
14. Biomehanizma delivery at the front and rear types occipital presentation.
15. Features involution genital character lohy.
16. The formation and progress of lactation.
17. Features of early and late postpartum period.
18. Measures to prevent complications in the postpartum period.
Be able to:
1. Differentiate physiological changes in the body during pregnancy with abnormal.
2. Carry out inspection of the external genitalia and cervix and assess ix condition.
3. Hold vaginal examination and determine the size of the uterus.
4. Make a plan with additional tests for the diagnosis of pregnancy in the early periods.
5. Conduct external (determining the position, position, type of fetal presenting part, calculating estimated fetal weight) obstetric examination.
6. Set of pregnancy in the later periods, to determine the estimated time of childbirth.
7. Conduct internal obstetric examinations of pregnant women, to assess the maturity of the cervix.
8. Hear out fetal and according to instrumental methods to assess functional status and physical development of the fetus during pregnancy.
9. Demonstrate on the phantom biomehanizm delivery at the front and rear types occipital presentation.
10. Identify the beginning of the first stage of labor, objectively assess the dynamics of labor activity (degree of opening of the cervix, duration Rename).
11. Identify and assess fetal heart (auscultatory and hardware method ¬ ladies).
12. Determine the beginning of the second stage of labor, objectively estimate the moving head of the fetus through the birth canal.
13. Assist in the delivery and conduct Psychophysiological anesthesia delivery.
14. Litter inspect and determine its integrity.
15. Determine the total blood loss in childbirth.
16. Assess the state newborn Apgar.
17. Determine the status of mammary glands and lactation character, teach bears a properly feed your baby and express milk.
To master practical skills:
1. Methods outdoor midwifery survey of pregnant women using techniques Leopold.
2. Conducting auscultation.
3. Form obstetric diagnosis based obstetric terms.
4. Methods for determination of gestational age (according to history and objective research).
5. Methods for determining the gestational age of the fetus and its mass, determining the estimated delivery.
6. Play biomehanizm births in both types of occipital presentation.
7. Maintaining a normal delivery.
8. Based on the survey data puerperas using laboratory methods, performance rate, blood pressure, body temperature to assess the progress of the postpartum period, to provide guidance on hygiene ne postpartum period.
3.Basic knowledge, skills necessary forstudying the topic(interdisciplinaryintegration)
Departmentof Human Anatomy
/ determine theanatomical structureof external and internalgenitalia.
Department ofBiological Chemistry / describe thefeatures of metabolismin pregnantbiochemicalcharacterizationof amniotic fluid.
Department ofhistology
/ describethe structureof germ cells.fertilizationand development of thefertilized egg, placentation, organogenesis, development prolificmembranes.
Department of Normaland PathologicalPhysiology
/ identifyfeatures ofphysiologicalchanges in womenduring pregnancy, effects on embryo and fetusenvironmental hazards. Collectmaterial forGore-monalnoho andbiochemical studies
Department ofInternal Medicine / medical history, conduct physicalexaminations¬tion, recognition of clinicalsyndromesandsymptoms,determinethe required volume andsequence¬ARRANGEMENTSmethods of examination, evaluation paraclinicalmethods
Content topics:
Critical periods of development of the embryo and fetus.
Critical periods of development have the highest sensitivity to adverse environmental factors.
There are 4 main critical periods:
1. Pre embryonic (development and maturation of sex cells).
2. fertilization
3. preimplantation period (from fertilization to 6 days) and implantation (6-9 days after fertilization).
4. Organogenesis (especially the 3.6 week) and placentation (3 - 4 weeks of pregnancy).
5. fetal (fetal) period. starting from the 9th week of pregnancy
Effects on embryo and fetus environmental hazards.
The main groups teratogenic chynnnykiv:
Drugs and chemicals.
Ionizing radiation.
Infections.
Metabolic disorders and bad habits pregnant.
The etiological basis distinguish three groups of defects: a) hereditary, b) exogenous c) multychynnykialni.
Physiological changes in a woman's body during pregnancy.
During pregnancy a woman's body there are substantial changes concerning practically all body systems.
Psychological status
Changes psychological condition manifested in the form of emotional feelings: irritability, depression and others. The development of psychological disorders during pregnancy influence following factors:
• hormonal and physiological changes;
• personal property;
• socio-economic status;
• relation in the family;
• unresolved conflicts;
• Genetic peredlehlist (eg, depression);
• physical and mental illness;
• Alcohol and Other Drugs.
Emotional and physical sensations expectant mothers to doctors to consider during surveillance pregnancy, during delivery and in the postpartum period.
Discomfortstatus
During pregnancy, there are typical quite often uncomfortable condition, with no serious consequences, but lead to significant discomfort and unpleasant sensations in the pregnant woman. These conditions must be taken: fatigue, morning nausea / vomiting, heartburn, constipation, back pain, hemorrhoids, swelling of the legs.
Timely pregnant clarification of the essence of such feelings and professional doctor's advice greatly improve the quality of life of the pregnant woman.
Immune System
• factors inhibited local and general immunity in the mother's body. Reactions caused by the action of hCG, placental lactogen, glucocorticoids, estrogen, progesterone, alpha-fetoprotein, alpha-2-glycoprotein trophoblast specific globulin;
•formed immunological tolerance between mother body and fatus.
Endocrine System
• hypothalamus: supraoptic and paraventricular nucleus increases the formation
oxytocin and vasopressin, they are also involved in regulating the secretion
adenohypophysis folitropin, lutropin, corticotropin and tyrotropinu;
• pituitary gland: an increase in the anterior pituitary gland due to hyperplasia and hypertrophy of its cells, increases secretion of gonadotrophins increases the production of prolactin, growth hormone production is suppressed;
• thyroid gland: increases in size (in 35-40% of pregnant women) function yiyizbilshuyetsya but remains euthyroid, amplified products thyroxine-binding globulin (estrogen effect), increased levels of total T3 and T4, free T4 level is within normal limits ;
• parathyroid gland function with increased activity in the case of reducing their function develops hipokaltsiemiya, manifesting convulsions, spasms pyloric stomach, asthmatic symptoms;
- strengthen the adrenal glands produce glucocorticoids, which regulate carbohydrate and protein metabolism and mineralocorticoids, which regulate mineral metabolism;
- increased insulin resistance (insulin sensitivity is reduced by 50-80%), decreased tissue glucose use, decreased blood glucose levels;
- ovaries: new forms of endocrine glands - corpus luteum, which produces progesterone (reduces excitability and contractile ability of the uterus, creates conditions for the implantation of a fertilized egg and the proper development of pregnancy), operates the first 3.5-4 months pregnant;
- placenta: with 7 days of pregnancy has been an increasing concentration of human chorionic gonadotropin (beta-hCG) and progesterone estroeeny synthesized predominantly complex placenta-fetus from the mother cholesterol metabolites, and their products are steadily increasing rate that ensures the growth and development of the uterus, the regulation of biochemical processes in the myometrium, increased activity of enzyme systems, improving energy metabolism, the accumulation of glycogen and ATP. Placental lactogen (PL) - formed syntsytiotrofoblaetom placenta with 5-6 weeks of pregnancy (90% SW is in the plasma of pregnant women and 10% - in the amniotic fluid) and its maximum concentration determined at 36-37 weeks of pregnancy, then the level has stabilized and began to decline from 40-41 weeks of pregnancy. Concentration TL directly correlated with fetal weight and dramatically increases with kidney disease in the mother.
Central Nervous System
• excitability of the cerebral cortex is reduced to 3-4 months, and then a gradual increase in excitability (due to the formation of the cerebral cortex foci of increased excitability - gestational dominant, manifested some halmovanistyu pregnant and direction of its interests inpregnancy);
• reduced CNS excitability departments that are below and the turn-reflek apparatus uterus. Before birth excitability of spinal cord and nerve elements of the uterus increases;
• changes the tone of the autonomic nervous system, which leads to early pregnancy symptoms such as drowsiness, irritability, tearfulness, dizziness.
Cardiovascular system
• notes: reduction of adaptation to physical stress, increase
blood jugular veins, edema peripheral tissues;
• Heart: systolic murmur (95%) and systolic gallop rhythm (90%);
• central hemodynamics: an increase in the volume of blood circulating (BCC) begins with 6 weeks of pregnancy, increased rapidly to 20-24 weeks and at 36 weeks an increase of 35-45%. The increase in CBV occurs by increasing the volume of plasma that circulates (ORC);
• cardiac output (CO): increased by 30-40% since early pregnancy and peaking at 20-24 weeks of pregnancy. In the first half of pregnancy increases cardiac output by increasing stroke volume of the heart (at thirty - 40%). In the second half of pregnancy pe ¬ preferably by increasing the heart rate (HR) by 15%. Rising CO explain the action on the myocardium of placental hormones (estrogen and progesterone) and partly as. Consequent formation uteroplacental circulation;
• reduction in systolic and diastolic ATZ early pregnancy before 24 weeks of pregnancy (at 5-15 mm Hg from baseline), decreased systemic vascular resistance ¬ ing a 21% reduction in pulmonary vascular resistance by 35% (due sudynoroz ¬ shyryuvalnoyu action of progesterone) ;
• peripheral vascular resistance decreases (relaksyvna effect on the vascular wall hCG, estrogen, progesterone and formation uteroplacental circulation, which has a low vascular resistance);
• central venous pressure (CVP) in the third trimester is on average 8 (4-12) cm of water. century., in nonpregnant 3.6 (2-5) cm water column;
• increased venous pressure (7-10 mm Hg) in the lower extremities (due to mechanical pressure of the uterus on the inferior vena cava and pelvic more than 10 times increasing uterine blood flow during pregnancy), relaxing effect of progesterone on the vascular wall, lower osmotic blood pressure, increased permeability of capillaries (the action of progesterone and aldosterone) ZRO ¬ a handling interstitial pressure (sodium retention), which explains the tendency to edema, varicose veins and hemorrhoids;
• shift the position of the heart shine to the horizontal and reducing the angle of the arc aorta ¬ ty, which is associated with the raising of the diaphragm and increases the load on the left shlunochyek tion of the heart;
• ECG-shifting electrical axis of the heart to the left
The system of blood
• plasma volume increased from 2600 ml of 45% (1250 ml - first pregnancy, and 1500 ml during subsequent pregnancies) and of 3900-4000 ml;
• total volume of red blood cells increased from 1400 ml of 33%, which is due to erythropoietin, human chorionic gonadotropin and placental lactogen;
• physiological hyperplasmia characterized by reduced numbers of hematocrit 30%, hemoglobin from 135-140 to 110-120 g / l. and necessary for the needs of the mother and fetus, prevents syndrome lower abdominal veins compensate hemorrhageduring childbirth, reduces blood viscosity and thereby reduces peripheral resistance;
• The level of hematocrit and albumin decreased by 25% (the result of hemodilution);
• changing the hemoglobin level and on average it is up to 12 weeks of pregnancy 1227L, up to 28 weeks - 1187L, 1297P up to 40 weeks;
• increased number of leukocytes in peripheral blood and in the first trimester of their number is 3000-15000/mm3 in the second and the third trimesters th 6000-16000/mm3 during childbirth WBC count may reach 20 000-30 000/mm3;
• platelet count is within normal (for pregnant women) values, but with the progression of pregnancy, there is a gradual decline in their level;
• hemostasis system: inherent hypercoagulable state (during the pregnancy progresses constantly increasing level of fibrinogen (factor I) 2 times (up to 600 mg%) and factors \ LI-X fibrinolytic activity levels decrease, ESR increased to 40 - 50 mm / h ;
Metabolism
basal metabolic rate is increased by 20%;
increasing need for kilocalories an average of 2000 - 3200 calories per day (150 kcal / day in the first trimester and 350 kcal / day in the II and III trimester of pregnancy);
reinforced plastic processes' (benefits ofanabolicprocessesofcatabolism);
increases the synthesis of RNA, which leads to increased protein synthesis in ribosomes;
fat metabolism - increased assimilation of fat, reduced process of oxidation, which leads to the accumulation of ketone bodies in the blood, in-aminobutyric acid and atsetouksusnoyi, increased fat deposition in various organs and tissue(adrenals, placenta, skin, mammary gland and etc.).
carbohydrate metabolism - labile blood sugar (slight excess of normal) and the periodic appearance of sugar in the urine;
obmsh vitamins and minerals increases due to significant activation rotsesiv cellular metabolism in the mother and fetus.
Kidneys
anatomical changes: an increase in the size of the kidneys (on average by 1-1.5 cm), expansionpyelocalicealsystem(15mmon the rightand5 mmin the leftkidney), increasing the diameter of the urethra 2 cm (usually right urethra by rotation and displacement of the uterus to the right and pressing the urethra to the terminal line of pelvis), causing an increased risk of pyelonephritis. Dilatation of urinary tract begins in first and reaches a maximum in the I! and III trimester of pregnancy (due to the action of placental progesterone and less compression urinary tract uterus);
functional changes: changing kidney filtration capacity - up to 16 weeks of pregnancy increases renal blood flow by 75%, glomerular filtration increases since 10 days of pregnancy to 50% (due to arteriodilatatsiyeyu and secondary delay N3 and water in the body). In II and NO trimesters of pregnancy reduced glomerular filtration and tubular reabsorption remained unchanged, resulting in an increase of the total amount of fluid in pregnant (up to 7 liters). Creatinine clearance increased by 40%, increases the excretion of glucose, protein filtering does not change. Sometimes it may be physiological (orthostatic) albuminuria (traces of protein) and glycosuria, due to increased capillary permeability.
Genitals
• uterine size increases, volume increases in 1000, the weight of the uterus increases from 50-60 g in non-pregnant state to 1000 g in late pregnancy (increase due mainly hypertrophy myometrial cells);
• shape of the uterus elongated, spherical at 8 weeks and again extended to 16 weeks of pregnancy;
• position of the uterus - a uterus comes from the pelvic cavity, turns and bends to the right;
• consistencyof the uterusprogressivelysoftened, due to increasedvascularization andthe presence ofamnioticfluid;
•cervixsoftens andbecomescyanotic;
o distinction between endo- and ectocervix - limit transitional epithelium shifted outwards and formed ectopia columnar epithelium, which can not be regarded as "erosion";
o contractions in the first trimester irregular and painless (Braxton-Hixson), but in later stages it causes discomfort and can cause false maternity pain;
o uterine capacity increases of 4-8 ml in nonpregnant state to 5000 ml in late pregnancy;
o myometriumhypertrophy(estrogen effect) hiperplazuyetsya(progesterone effect), individual muscle fiberselongate15 times;