Maternity Welfare in Prevention of Maternity and Perinatal Disease Incidence and Mortality
Out-patient obstetric-gynecologic assistance is provided in maternity welfare clinics, gynecologic rooms of central regional hospitals, village out-patient clinics, out-patient general medical clinics, doctor's assistant obstetric rooms, family planning centers, rooms for patient's examination in polyclinics.
The basis of treatment-and-preventive work of maternity welfare clinic is a principle of proving service to women according to place of their residence (a territorial-district principle).
The majority of maternity welfare clinics are functional subdivisions of maternity home, polyclinic, sanitary-medical unit or any other medical establishment and are subordinated to them. Some maternity welfare clinics are independent establishments and are subordinated to local health care bodies.
A maternity welfare clinic may be located in a standard or adapted building, or occupy a part of building belonging to obstetric in-patient hospital, polyclinic or medical unit.
Each maternity welfare clinic should have a gowning room for patients and staff, registiy, waiting hall, offices of hospital manager, chief obstetrician, statistician, consulting rooms of obstetricians, doctors-specialists (therapist, dentist), procedure unit for intravenous and intramuscular injections, procedure unit for vaginal examination, endoscopy room, rooms for ultrasound examination, electrocardiogram examination, cardiotocography examination, sterilization, room for psychotherapeutic preparation of pregnant for birth, a room for "Maternity School", family planning room, matron's room, lavatories, etc. In some cities big maternity welfare centres are equipped, which besides their everyday work fulfill the functions of a consultative center of polyclinic obstetric assistance. They are provided with modern diagnostic equipment, consulting rooms of specialists, rooms for special treatment (noncarrying of pregnancy, immunoincompatlible pregnancy, etc.)
The capacity of maternity welfare clinic is determined by a number of doctors' districts, which are formed in accordance with population number, amount of patients' visits. One obstetric district includes a territory with approximately 4,000-4,500 women, among whom 3,000-3,500 persons are older than 15 years and 2,100 women are of childbearing age.
The main tasks of maternity welfare clinic are:
clinical examination of pregnant;
antenatal protection of fetus;
prophylaxis of pregnancy, childbirth, puerperal period complications;
providing qualified obstetric assistance to population of attached district;
work on family planning;
preservation of reproductive health of population;
introduction into practice of modern methods of diagnosis and treatment of pathologic pregnancy, diseases of puerperas, new methods of out-patient obstetric assistance;
provision of human rights in the sphere of maternity and childhood protection;
providing succession in examination and treatment of pregnant, puerperant, maintaining permanent connection with maternity home, emergency, other medical-prophylactic establishments (antituberculous, dermatovenerologic, cancer dispensary, endocrinological, cardiologic, nephrological inpatient departments, etc.).
The follow-up of pregnant woman in maternity welfare clinic is carried out according to recommendations of Public Health Service (Order № 503 of Ministry of Public Health of Ukraine).
During the first antenatal visit of a pregnant to a doctor (until 12 weeks) a thorough history taking is made, medical documentation is filled in (Individual card of pregnant woman and puerperant- form № lii/o, exchange card — form 113/0), the volume of laboratory examination and consultation is determined.
The body weight is measured, blood pleasure on both hands is taken, auscultation of heart and lungs, palpation of mammary glands with the purpose of early detection of abnormalities are carried out.
The external measurement of pelvis is taken, vaginal examination to diagnose pregnancy and its terms, internal measurements of conjugate and determination of real obstetric conjugate are made. On vaginal examination the inspection of neck of uterus and splanchnic vaginal wall with the help of gynecological specula is obligatory. Women with physiologic pregnancy are examined twice — at the beginning of the term and in the period of 30 weeks. Extra vaginal examinations are made according to diagnosis.
The primary laboratory examination includes clinical blood analysis, general urinanalysis, determining blood group, Ph-factor, Wassermann reaction, blood for HIV infection, bacterioscopic examination of vaginal, cervical, urethra smears. The screening test of glucose tolerance is made. If necessary, extra laboratory examinations are made: hepatitis В and С blood test, perinatal infection tests (toxoplasmosis, rubella, cytomegalovirus, herpes), biochemical blood testing, hemostasiagram fibrillation tests).
In order to prevent and make early diagnosis of possible genetic pathology of fetus a special medical-genetic examination is made.
The second visit of a pregnant woman is appointed in 7-10 days. This time a group and level of obstetric and perinatal risk is determined with the help of F. Coopland score scale.
The degree of risk is evaluated thrice during pregnancy: during the first visit, in the period of 20-21 and 32-36 weeks of pregnancy.
After examination, determination of risk degree and group, results of specialists' examination (therapist, cardiologist, nephrologist, endocrinologist), the question of pregnancy prolongation is decided and the plan of its management is composed.
Ultrasound examination is made in the period of 9-11,16-21,32- 36 weeks of pregnancy. In the period of 32-34 weeks cardiotocography and Doppler's investigation according to indications are made.
All data received during examination of a pregnant woman in maternity welfare clinic are registered in the individual out-patient card of pregnant.
During an uncomplicated course of pregnancy the frequency of visits to maternity welfare clinic is once a month till 30 weeks of pregnancy and once a fortnight after 30 weeks of pregnancy.
If any complications and the necessity of treatment occur, the question of therapeutic approach and hospitalization to the inpatient department is solved for each pregnant individually.
Dispensary System for Pregnant
A dispensary method is the highest form of synthesis of prevention and therapeutic measures carried out selectively either in separate groups or in all population of the district of treatment-preventive establishment.
In modern conditions of medical care of population all pregnant women registered in maternity welfare clinic and wishing to preserve their pregnancy are under dispensary supervision.
After childbirth (or recovery) women become free from regular medical checkup.
The tasks of regular medical check-up of a pregnant in maternity welfare clinic are as follows:
to give a systematic checkup of women in chosen groups;
to get acquainted with living conditions and conditions of work for carrying out health-improving measures;
early diagnostics of initial form of diseases, timely and qualified treatment preventing complication development and disease progress;
The order of choice for regular medical checkup. The choice of women for regular medical checkup is made by a doctor-obstetrician of maternity welfare clinic according to Order No. 503 of Ministry of Public Health of Ukraine and also in coordination with chief physician, medical consultative commission. Women requiring regular medical checkup are revealed by a district obstetrician-gynecologist in the room of primary inspection, a thorough history-taking (disease origin, features of its clinical course, treatment, obstetric anamnesis, capacity for work), careful examination with applying modern methods of diagnostics, examination of laboratory data in dynamics of observation, consultations on the most important questions contribute greatly to perfection of dispensary system.
Pregnant women whose last pregnancy and childbirth were complicated with somatic pathology, and who had incomplete pregnancy, still birth, or birth of children with congenital malformations and defects, or operative delivery should undergo a regular checkup. To such cases the following refer:
cases with multivalvular mitral disease with stenosis;
combined involvement of valvar apparatus of rheumatic etiology;
severe myocardium diseases;
women operated on lungs and heart;
women suffering from hypertension;
women with organic diseases of kidneys and those after nephrectomy;
women with diabetes mellitus;
women with habitual noncarrying of pregnancy (miscarriage), prematurity;
women having undergone cesarean operation;
patients with toxoplasmosis, listeriosis, brucellosis, cytomegalovirus and other chronic infections;
Into the group of regular medical checkup the women are also included to whom pregnancy is either absolutely or conditionally contraindicated.
In modern opinion such women should not conceive and deliver for further two years. This period is necessary for treatment directed at ill organ compensation, reproductive health recovery, preventive measures of decompensation in pregnancy and delivery.
In cases when new pregnancy may have an unfavorable effect on woman's health, the task of obstetrician-gynecologist is to take measures to prevent conception and if it occurred — to refer a woman to the in-patient department for abortion by life-saving indication in early period of pregnancy (till 3 months).
In cases when pregnancy is remained for prolongation in a woman with extra genital or gynecologic pathology accompanied with obstetric anamnesis, a regular medical checkup is done during all pregnancy. Pregnant women with extra genital pathology should be hospitalized to the in-patient department in critical pregnancy terms even without complications during gestational process. At the in-patient department such patients undergo a routine medical examination to reveal the state of pregnant woman and fetus, prognosis of pregnancy course. Preventive therapy is administered for prophylaxis of decompensation of a chronic process and complications of pregnancy and delivery.
According to Order N0.503 of Ministry of Public Health of Ukraine the distinct criteria of health estimation of a pregnant woman and group of dynamic case follow-up are determined.
The criteria of health estimation of a pregnant woman are as follows:
presence or absence of obstetric and extra genital pathology;
belonging of a pregnant woman to this or that group of perinatal pathology risk;
a functional state of the main body systems of a pregnant woman;
a physical and functional state of fetus.
The I group of dynamic follow-up (D1 — healthy) includes pregnant women without any extra genital and gynecologic diseases, who carry pregnancy till the term of 38-32 weeks and who do not have any risk of perinatal pathology, but availability of functional disorders of some organs and systems do not cause any complications during the whole pregnancy period.
The II group (D2 — practically healthy) includes pregnant women without any genital and gynecologic diseases. The total estimate of risk factors revealed in them corresponds to low level of perinatal pathology (according to Coopland scale), and functional disorders of some organs and systems do not cause any complications during all pregnancy period.
The III Group (D3 — ill women) comprises women with diagnosed cases of extra genital or obstetric pathology. The total estimate of risk factors corresponds to a very high level of perinatal or maternity pathology.
The main principle of regular checkup is a differentiated medical treatment based on drawing up a plan of pregnancy management for each woman. Special attention should be paid to a high risk group of women. All women registered in the maternity welfare clinic should be regularly checked up. In order to make examination of a pregnant woman who hasn't come to a planned examination an obstetrician nursing visit is made. During the visit an obstetrician studies the condition of patient's health, checks how the woman follows the doctor's recommendations, reveals the living conditions of the patient, persuades the woman of necessity of attending a doctor, and makes some laboratory and other investigations, an obstetrician also carries out a medical-diagnostic work (measuring blood pressure and pulse, auscultation and estimation of fetal heartbeat).
Sanitary-Educative Work
This work is carried out by all physicians and paramedical staff of maternity welfare clinic. This work includes such forms as individual and group lectures, discussions, exhibitions, "Sanitary Bulletins", etc. "Maternity School" aimed at preparing a pregnant woman for child care is widespread nowadays.
In-Patient Obstetric Care
In-patient obstetric care for city population is provided in independent maternity hospital and obstetric departments which are included into multitype hospitals, or medical sanitary units. In-patient obstetric care in Ukraine is available for all women. Pregnants, puerperants, parturient women are served according to the territorial principle; territory of ma- 26 ternity home (obstetric in-patient hospital, obstetric department of mul- titype hospital) is determined by Public Health Service, a patient or her family has the right to choose in-patient hospital or doctor according to mutual agreement. Hospitalization of a pregnant to the in-patient hospital is made according to the direction of emergency or out-patient departments and policlinic medical prophylactic establishments, obstetricians, doctor's assistants, or nurses of obstetric departments. On hospitalization of a pregnant woman or woman in childbirth to obstetric in-patient department an obstetrician-gynecologist of the reception ward in order to estimate the condition of patient's health makes general physical examination, takes body temperature, measures blood pressure on both hands, examines internal organs, measures height of uteaxs fundus, abdominal circumference, pelvis size, listens to fetus' heart sounds, makes internal obstetric examination. Notes in case history about fetal movements felt by a pregnant woman or woman in childbirth are obligatory. The doctor studies the data of in-patient prenatal card, collects general and in-patient anamnesis, paying special attention to presence of acute respiratory diseases, examines visible mucous membranes in order to reveal pyodermas and cutaneous mycoses, determines the duration of waterless period. The doctor makes blood sampling for Wassermann reaction, HlV-infec- tion, urinanalysis for diagnosing bacteriuria, proteinuria; vaginal discharge sampling is made for urgent diagnosis of grade of vaginal discharge.
According to results of examination a pregnant or puerpera is hospitalized to physiological or observation obstetric department.
Structure of Obstetric In-Patient Hospital
The structure of maternity home or obstetric-gynecologic department includes: admission department, the first (physiological) and second (observation) obstetric department, pathologic pregnancy department, infants department (or reserve infant wards in case of rooming-in), department of functional diagnostics (ultrasound, cardiotocography, oculist rooms). Apart from these an independent maternity home has an administrative service, laboratory, drugstore and some other economic services.
The structure of obstetric in-patient department is considered optimal when 45% of total amount of obstetric beds are located in the physiological obstetric department, 25 % — in observation and 30% — in pathologic pregnancy department. Such distribution of beds helps to provide unfailing hospitalization of pregnant women and absolutely isolate all ill women and children in maternity home.
In order to define the needs of population in in-patient obstetric care, the data about birth rate and obstetric sickness rate, average number of patients in the hospital per year, average number of occupied beds per year are necessary. The necessity of city population in obstetric beds makes up on average about 8 per 10,000 people.
Therapeutic-Protective Regimen in Obstetrical institutions
All work with pregnant women, puerperas, women in childbirth, and gynecologic patients is based on the necessity of following a therapeutic-protective regimen.
A therapeutic-protective regimen is a set of measures producing a favorable effect on women's nervous system and eliminating negative emotions, uncertainty in pregnancy and deliveiy outcome. The therapeutic-pro- tective regimen assists in occurrence of trustful attitude towards medical workers' actions and confidence in positive outcome of delivery or disease. The establishment of therapeutic-protective regimen mostly depends on general level of state of obstetrical institution. General view of institution, cleanness of all premises and territory are of importance, a therapeutic-pro- tective regimen depends basically on organizational management of maternity welfare clinic and maternity home. The work should be organized in such a way that during her first visit to maternity welfare clinic a woman would feel care and friendly attitude of medical staff.
Pregnant women and patients should be treated with delicacy and tact. General and special obstetric examination is made thoroughly, with great attention; advice about hygiene, diet, and other questions is given in a friendly and clear way. an obstetrician should be especially tactful while revealing pregnancy complications and gynecologic diseases. She tells her opinion with cautiousness and explains the necessity to visit a doctor. She also calms a patient and instills confidence in a positive outcome of pregnancy or disease.
The correctly organized patronage promotes the creation of ther- apeutic-protective regimen. During patronage visits an obstetrician tries to make contact with a pregnant woman in order to teach her all sanitary-hygienic skills and carry out all prophylactic measures at home. It is necessary to create such conditions at the in-patent hospital that each woman should come there without any anxiety and fears.
The maternity home staff should pay maximum attention to a woman, be tactful and delicate. The right way of treatment of pi'egnant women and women in childbirth is an important element of therapeutic-protective regimen; success of medical prophylactic measures to a great extent depends on it. Quiet conditions should be arranged at the in-patient department, which should exclude any fears of pregnant woman for her or her child's state. Order, quietness, absence of fuss in work influence positively on nervous system. Daily routine should be organized in such a way that pregnant women, puerperas, gynecologic patients would have enough time to sleep. Besides night sleep there should be day sleep which is especially necessary for nursing mothers.
In the presence of woman the talks about unfavorable cause of pregnancy and delivery, about future operations, etc. are not admissible. In case of operation necessity a woman is informed about it carefully; thus she is assured of positive outcome of operation and other procedures. Women in childbirth should be daily informed about their children's condition not to arouse anxiety for their condition.
Gymnastics after delivery strengthening the whole woman's body including nervous system is of great importance.
The proper organization of sanitary-educative work is one of the most important elements of therapeutic-protective regimen. Pregnant women and woman in childbirth are explained the rules of personal hygiene, dietary habits, rules of feeding and care of newborn children.
Psychoprophylaxis of birth pangs in maternity welfare hospital and maternity home is closely connected with therapeutic-protective regimen. Psychoprophylaxis is an integrity part of therapeutic-protective regimen.
The lawyer's consultations are arranged at maternity welfare departments in order to provide social legal assistance to mothers. If necessary, legal assistance is provided to women in maternity homes.