On approval of the procedure for providing medical care According to the profile "Obstetrics and Gynecology (except for the use of auxiliary reproductive technologies)
Ministry of Health of the Russian Federation
ORDER
on November 12, 2012 N 572n
On approval of the procedure for providing medical care for the profile "Obstetrics and Gynecology (except for the use of auxiliary reproductive technologies)
In accordance with Article 37 of the Federal Law of November 21, 2011 No. 323-FZ "On the basis of the health of citizens in Russian Federation"(Meeting of the legislation of the Russian Federation, 2011, No. 48, Art. 6724; 2012, No. 26, Art. 3442, 3446) I order:
1. To approve the attached procedure for the provision of medical care for the profile "Obstetrics and Gynecology (except for the use of auxiliary reproductive technologies)".
2. Recognize invalid:
order of the Ministry of Health and social Development Of the Russian Federation of October 2, 2009 No. 808n "On approval of the procedure for providing obstetric and gynecological assistance" (registered by the Ministry of Justice of the Russian Federation on December 31, 2009, registration No. 15922);
order of the Ministry of Health of the Russian Federation of October 14, 2003 No. 484 "On approval of instructions on the procedure for resolving artificial abortion in late time According to social testimony and conducting an operation of artificial abortion of pregnancy "(registered by the Ministry of Justice of the Russian Federation on November 25, 2003, registration" 5260).
Minister
V.I.Skvortsov
Approved
order of the Ministry of Health
Russian Federation
from "01" November 2012 No. 572n
The procedure for providing medical care for the profile
"Obstetrics and gynecology (except for the use of auxiliary reproductive technologies)"
1. This procedure regulates the issues of providing medical care for the "Obstetrics and Gynecology" profile (except for the use of auxiliary reproductive technologies). "
2. The action of this Procedure applies to medical organizations that provide obstetric and gynecological medical care, regardless of the forms of ownership.
I. The procedure for providing medical care for women during pregnancy
3. Medical assistance to women during pregnancy is within the framework of primary health care, specialized, including high-tech, and emergency, including emergency specialized, medical care in medical organizations that have a license to carry out medical activities, including work (services ) According to "obstetrics and gynecology (except for the use of auxiliary reproductive technologies)."
4. The procedure for providing medical care to women during pregnancy includes two main stages:
ambulatory, in the absence of obstetrician-gynecologists, and in case of their absence, with physiologically flowing pregnancy - general practitioners (family doctors), medical workers of the medical obstetric items (at the same time, in the event of a complication of the course of pregnancy, consultation of an obstetrician should be ensured. - Gynecologist and a specialist doctor of the disease profile);
stationary, carried out in the departments of the pathology of pregnancy (with obstetric complications) or specialized departments (in case of somatic diseases) of medical organizations.
5. The provision of medical care to women during pregnancy is carried out in accordance with the present order on the basis of routing sheets, taking into account the emergence of complications during pregnancy, including in extractive diseases.
6. In the physiological course of pregnancy, the inspections of pregnant women are held:
an obstetrician-gynecologist - at least seven times;
a physician-therapist - at least two times;
dentist doctor at least two times;
an otorinolaryngologist, an ophthalmologist - at least once (no later than 7-10 days after the initial appeal to women's consultation);
other specialist physicians - according to indications, taking into account the concomitant pathology.
Screening ultrasound procedure (hereinafter - ultrasound) is carried out three times: with pregnancy time and 11-14 weeks, 18-21 weeks and 30-34 weeks.
Under the period of pregnancy, 11-14 weeks, a pregnant woman is sent to a medical organization that exercises the expert level of prenatal diagnosis, for the comprehensive prenatal (prenatal) diagnosis of violations of the child's development, including the ultrasound specialist doctor who has been trained and having admission to ultrasound screening surveys in I trimester, and the definition of maternal serum markers (associated with the pregnancy of plasma protein A (RARR-A) and free beta subunit of chorionic gonadotropin) with the subsequent program integrated calculation of the individual risk of the child's birth with chromosomal pathology.
Under the period of pregnancy, 18-21 weeks, a pregnant woman is sent to a medical organization that provides prenatal diagnostics, in order to exclude late manifesting congenital abnormalities for the development of the fetus.
When pregnant time, 30-34 weeks of ultrasound is carried out at the place of observation of a pregnant woman.
7. When the pregnant woman is established in a pregnant woman in chromosomal disorders from the fetus (individual risk 1/100 and higher) in the first trimester of pregnancy and (or) detection of congenital anomalies (malfunctions) in the fetus in I, II and III of the pregnancy trimesters The obstetrician gynecologist sends it to the medical and genetic counseling (center) for medical and genetic counseling and establishing or confirming the prenatal diagnosis using invasive examination methods.
In the case of establishing a prenatal diagnosis of congenital anomalies in the medical and genetic counseling (center) in the fetus, the fetal determination of the further tactics of pregnancy is carried out by the perinatal consultation of doctors.
In the case of the diagnosis of chromosomal violations and congenital anomalies (malfunctions) in a fetal with an unfavorable forecast for the life and health of the child after birth, pregnancy interruption under medical reasons is carried out regardless of the term of pregnancy to solve the perinatal consultation of doctors after receiving the informed voluntary consent of the pregnant woman.
For the purpose of artificial interruption of pregnancy under medical testimony under a period of up to 22 weeks, a pregnant woman is sent to the gynecological department. Abortion of pregnancy (delivery) at 22 weeks and is more carried out under the conditions of the observational branch of the obstetric hospital.
8. With prenatally diagnosed congenital anomalies (defects) in the fetal, the fetal needs to carry out perinatal consultation of doctors, consisting of an obstetrician-gynecologist, a neonatologist doctor and a children's surgeon. If there is a surgical correction in the neonatal period of doctors to conclusted the perinatal conservima of doctors, the direction of pregnant women for delivery is carried out in obstetric hospitals, having intensive care and intensive care chambers for newborns serviced by a 24-hour non-station doctor who owns the methods of resuscitation and intensive therapy of newborns.
In the presence of congenital anomalies (malfunctions) of the fetus, requiring the provision of specialized, including high-tech, health care, or newborn in the perinatal period, a consultation of doctors is carried out, which includes an obstetrician-gynecologist, doctor ultrasound diagnostics, Genetic doctor, neonatologist, doctor's cardiologist and children's surgeon doctor. If it is impossible to provide the necessary medical care in the subject of the Russian Federation, a pregnant woman to conclusted the conservima doctors is sent to a medical organization that has a license to provide this type of medical care.
9. The main task of the dispensary observation of women during pregnancy is the warning and early diagnosis of possible complications of pregnancy, childbirth, postpartum period and the pathology of newborns.
When setting a pregnant woman to accounting in accordance with the conclusions of specialists' profile doctors, an obstetrician-gynecologist before 11-12 weeks of pregnancy makes a conclusion about the possibility of pregnancy.
The final conclusion about the possibility of tooling pregnancy, taking into account the state of a pregnant woman and the fetus, is made by an obstetrician-gynecologist up to 22 weeks of pregnancy.
10. For artificial abortion of pregnancy under medical testimony under a period of up to 22 weeks of pregnancy, women are sent to the gynecological departments of medical organizations that have the opportunity to provide specialized (including resuscitation) medical care to a woman (in the presence of specialist doctors of the corresponding profile, which identifies readings for artificial interruption of pregnancy).
11. The stage of providing medical care to women during pregnancy, childbirth and in the postpartum period is defined by Appendix No. 5 to this Procedure.
12. In the presence of testimony of pregnant women, it is proposed for fake and rehabilitation in sanatorium-resort organizations, taking into account the disease profile.
13. With a threatening abortion, the treatment of a pregnant woman is carried out in the protection institutions of motherhood and childhood (separation of pregnancy pathology, gynecological branch with chambers to preserve pregnancy) and specialized branches of medical organizations focused on pregnancy.
14. The doctors of female consultations carry out a planned direction to the hospital of pregnant women on the root separation, taking into account the degree of risk of complications in childbirth.
Rules of organization of activity female consultationThe recommended full-time standards and the female consultation standard are defined by Appendices No. 1 - 3 to this order.
The rules for the organization of the activities of the Acoucher-Gynecologist of the Women's Consultation are defined by Appendix No. 4 to this Procedure.
15. With extragnemitarian diseases requiring inpatient treatment, a pregnant woman is sent to the profile department of medical organizations, regardless of the term of pregnancy, subject to joint observation and conduct by a specialist in the profile of the disease and an obstetrician-gynecologist.
In the presence of obstetric complications, a pregnant woman goes to an obstetric hospital.
With a combination of pregnancy complications and extragenital pathology, a pregnant woman is sent to the hospital of a medical organization for the disease profile determining the severity of the state.
To provide inpatient medical care for pregnant women living in areas remote from obstetric hospitals and have no direct testimony to send pregnancy pathology, but in need of medical supervision to prevent the development of possible complications, a pregnant woman is sent to the branch of nursing care for pregnant women .
The rules for organizing the activities of the Nursing Department for pregnant women, recommended full-time standards and the standard for equipping the branch of nursing care for pregnant women are defined by Appendices No. 28 - 30 to this Procedure.
In day hospitals, women are sent during pregnancy and in the postpartum period that need invasive manipulations, daily observation and (or) implementation of medical procedures, but not requiring round-the-clock observation and treatment, as well as to continue observation and treatment after staying in the 24-hour hospital. The recommended duration of stay in the day hospital is 4-6 hours per day.
16. In cases premature birth In 22 weeks of pregnancy and more, women are carried out in an obstetric hospital, which has a branch of resuscitation and intensive therapy for newborns.
17. Under the term of pregnancy, 35-36 weeks, taking into account the course of pregnancy in trimesters, assessing the risk of complications of the further course of pregnancy and childbirth on the basis of the results of all studies conducted, including consultations of specialist doctors, an obstetrician-gynecologist formulates a full clinical diagnosis and determined Place of planned delivery.
A pregnant woman and her family members are informed in advance with an obstetrician-gynecologist about a medical organization in which the delivery is planned. The question of the need to send to the hospital to childbirth is solved individually.
18. Pregnant women are sent to the consultative and diagnostic departments of perinatal centers:
a) with extragenital diseases to determine obstetric tactics and further observation, together with specialists in the profile of the disease, including the growth of a pregnant woman below 150 cm, alcoholism, drug addiction in one or both spouses;
b) with a burdened obstetric history (age up to 18 years old, first-hand over 35 years old, unbearable, infertility, perinatal death cases, the birth of children with high and low body, scar on the uterus, preeclampsia, eclampsia, obstetric bleeding, operations on the uterus and appendages , the birth of children with congenital defects development, bubble skid, reception of teratogenic drugs);
c) with obstetric complications (early toxicosis with metabolic disorders, the threat of interrupting pregnancy, hypertensive disorders, anatomically narrow pelvis, immunological conflict (RH and AVO isoossentialization), anemia, improper position of the fetus, the pathology of the placenta, placental disorders, multiplodes, multi-way, lowland, induced pregnancy, suspicion of intrauterine infection, the presence of tumor-like formations of uterus and appendages);
d) with the identified pathology of the development of the fetus for determining the obstetric tactics and the place of delivery.
II. The procedure for providing medical care for pregnant women with congenital vices internal organs Poda
19. In case of confirmation of the congenital developmental definition (hereinafter referred to - the fetus, which requires surgical assistance, a consultation of doctors in the obstetrician-gynecologist, a doctor of ultrasound diagnostics, a genetics doctor, a children's surgeon, doctor, doctor-cardiovascular physician -Sudial surgeon is determined by the forecast for the development of the fetus and life of the newborn. The conclusion of the conservima of doctors is issued to the hands of a pregnant woman for presentation at the place of observation of pregnancy.
20. The attending physician represents a pregnant woman information about the results of the survey, the presence of an industrial complex of the fetus and the forecast for the health and life of newborn, methods of treatment associated with them by risk, possible options Medical intervention, their consequences and results of the treatment, on the basis of which a woman makes a decision on toaling or interrupting pregnancy.
21. In the presence of the fetus of the UPR, incompatible with life, or the presence of combined defects with an unfavorable forecast for life and health, with the UPR, leading to the rapid loss of the body's functions due to the severity and volume of the lesion in the absence of methods effective treatmentIt is provided with information on the possibility of artificial interruption of pregnancy for medical testimony.
22. If a woman fails to interrupt pregnancy due to the presence of HFD or other combined defects incompatible with life, pregnancy is conducted in accordance with section I of this Procedure. The medical organization for the delivery is determined by the presence of extragenital diseases in a pregnant woman, the peculiarities of the course of pregnancy and the presence in the obstetric hospital of the Department (Chamber) of intensive care and intensive therapy for newborns.
23. With the deterioration of the state of the fetus, as well as the development of placental disorders, a pregnant woman is sent to the obstetric hospital.
24. When solving a question about the place and timing of the delivery of a pregnant woman with a cardiovascular disease in a fetus, requiring surgical care, a consultation of doctors as part of an obstetrician-gynecologist, a cardiovascular surgeon (doctor-cardiologist), a doctor-children's cardiologist (pediatrician pediatrician), pediatrician (neonatologist) doctor is guided by the following provisions:
24.1. In the presence of the PRD fetus, requiring emergency surgery after the birth of a child, a pregnant woman is heading for a hospital in a medical organization that has licenses for medical activities, including work (services) on "obstetrics and gynecology (except for the use of auxiliary reproductive technologies)", "Cardiovascular surgery" and (or) "children's surgery" and having opportunities to provide emergency surgical assistance, including with the involvement of cardiovascular surgeons from specialized medical organizations, or in an obstetric hospital, which has an intensive care department and Intensive therapy for newborns and reanimobile for emergency transportation of a newborn in a medical organization providing medical care for the profile "Cardiovascular surgery" for medical intervention.
To the UPU, requiring emergency medical intervention in the first seven days of life, belong:
simple transposition of the main arteries;
hypoplace syndrome of left hearts;
hypoplasia syndrome of the right heart departments;
preceptal aortic coarse;
break arc aorta;
critical stenosis of the pulmonary artery;
critical stenosis of the aorta valve;
complex UPU, accompanied by stenosis of the pulmonary artery;
atresia of the pulmonary artery;
total abnormal drainage of pulmonary veins;
24.2. In the presence of the PRD fetus, requiring planned surgical intervention during the first 28 days - three months of the child's life, a pregnant woman is heading for a delivery to a medical organization, which has an intensity and intensive care unit for newborns.
In confirming the diagnosis and the presence of testimony to the surgical intervention of the Consilium doctors in the doctor-ankuster-gynecologist, a doctor-cardiovascular surgeon (a doctor-child cardiologist), a neonatologist (doctor's doctor) is a treatment plan with an indication of the provision of medical intervention newborn in the cardiac surgery department. Transportation of a newborn to the place of provision of specialized, including high-tech, medical care is carried out by an exit anesthesia-resuscitation neonatal brigade.
To the UPU, requiring planned surgical intervention during the first 28 days of the child's life, belong:
common arterial trunk;
coarctation of aorta (intrauterine) with signs of gradient growth on the height after birth (assessment by dynamic prenatal echocardiographic control);
moderate stenosis of the aortic valve, pulmonary artery with signs of increase in pressure gradient (estimate by dynamic prenatal echocardiographic control);
hemodynamically significant open arterial duct;
big defect of the aorto-pulmonary partition;
anomalous debit of the left coronary artery from the pulmonary artery;
hemodynamically significant open arterial duct in premature.
24.3. The UPU, requiring operational intervention to three months of life, belongs:
the only ventricle of the heart without stenosis of the pulmonary artery; Atrioventricular communication, a complete form without a stenosis of the pulmonary artery;
atresia of the tricuspid valve;
large defects of interprisened and interventricular partitions;
tetrad Fallo;
double exit of vessels from the right (left) ventricle.
25. When solving the question of the place and timing of the delivery of a pregnant woman with congenital defects (hereinafter referred to as the PRD) in the fetus (with the exception of the PRD), requiring surgical assistance, the consultation of doctors in the obstetrician-gynecologist, a doctor-child surgeon, a doctor Genetics and ultrasound diagnostic physician is guided by the following provisions:
25.1. In the presence of an isolated PRD (lesion of one organ or system) and the absence of prenatal data for a possible combination of vice with genetic syndromes or chromosomal anomalies, a pregnant woman is sent to the obstetric hospital, having a branch of resuscitation and intensive therapy for newborns and reanimobile For emergency transportation of a newborn in a specialized children's hospital, providing medical care for the "Children's Surgery" profile, for conducting surgical interference with the status stabilization. Transportation of a newborn to the place of provision of specialized, including high-tech, medical care is carried out by an exit anesthesia-resuscitation neonatal brigade.
Pregnant women with the EPR in the fetus of this type can also be consulted by doctors-specialists of the perinatal consultation doctors (an obstetrician-gynecologist, a children's surgeon, a genetic doctor, a doctor of ultrasound diagnostics) of federal medical organizations. According to the results of counseling, they can be aimed at the obstetric hospital in the obstetric hospitals of federal medical organizations to assist the newborn in the conditions of separating the surgery of newborns, branches of resuscitation and intensive therapy for newborns.
To an arbitrary Arms belongs:
gastroshisis;
intestine atresia (except for duodenal atresia);
bulk education of various localization;
malformations of the lungs;
valves for the development of the urinary system with normal amounts spindle water;
25.2. In the presence of the Fetal of the EPR, often combined with chromosomal anomalies or the presence of multiple VDS, in the highest possible period of pregnancy in the perinatal center, an additional survey is carried out in order to determine the forecast for the life and health of the fetus (consulting a genetics doctor and conducting karyotyping on decreed dates, echoes Cardiography in the fetus, magnetic resonance tomography of the fetus). According to the results of the completion, the doctors-specialists of the perinatal consultation doctors of the Federal Medical Organization to solve the issue of the place of the pregnant woman to decide.
The Fruit, which is often combined with chromosomal anomalies, or the presence of multiple PRDs, belongs:
ommophalcela;
duodenal atresia;
atresia of the esophagus;
congenital diaphragmal hernia;
patterns of the urinary system, accompanied by the lowest.
III. The procedure for providing medical care for women in the period of childbirth and in the postpartum period
26. Medical assistance to women in the period of childbirth and in the postpartum period is within the framework of specialized, including high-tech, and ambulance, including emergency specialized, medical care in medical organizations that have a license to carry out medical activities, including work (services) on "Obstetrics and gynecology (except for the use of auxiliary reproductive technologies)."
27. Rules for the organization of the activities of the maternity hospital (separation), recommended regular standards and the standard for equipping the maternity hospital (separation) are defined by Appendices No. 6 - 8 to this Procedure.
The rules for organizing the activities of the perinatal center, the recommended full-time standards and the standard of equipping the perinatal center are defined by Appendices No. 9 - 11 to this Procedure.
The rules for organizing the activities of the Maternity and Childhood security center are defined by Appendix No. 16 to this Procedure.
28. In order to provide accessible and high-quality medical care for pregnant women, feminine and maternity hospitals, the provision of medical care for women during pregnancy, childbirth and the postpartum period is carried out on the basis of routing sheets, allowing to provide differentiated amount of medical examination and treatment, depending on the risk of complications. Taking into account the structure, shank power, the level of equipment and the provision of qualified personnel of medical organizations.
Depending on the range power, equipment, personnel support medical organizations that provide medical assistance to women in the period of childbirth and in the postpartum period are divided into three groups in the possibility of providing medical care:
a) the first group - obstetric hospitals, in which the round-the-clock stay of the obstetrician-gynecologist is not ensured;
b) the second group - obstetric hospitals (maternity hospitals (separations), including profiled by type of pathology), having in its structure of the Chamber of Intensive Therapy (branch of anesthesiology-resuscitation) for women and the chamber of resuscitation and intensive therapy for newborns, as well as inter-district Perinatal centers that have a branch of anesthesiology-resuscitation (chambers of intensive therapy) for women and a branch of intensive care and intensive care for newborns;
c) the third A group - obstetric hospitals in their composition branch of anesthesiology-resuscitation for women, branch of resuscitation and intensive care for newborns, separation of pathology of newborns and premature babies (II PRIECTION STAGE), obstetric remote advisory center with visiting anesthesiole-resuscitation obstetrician crews to provide emergency and emergency medical care;
d) the third b group - obstetric hospitals of federal medical organizations providing specialized, including high-tech, medical care for women during pregnancy, childbirth, postpartum and newborn, developing and replicating new methods of diagnosis and treatment of obstetric, gynecological and neonatal pathology and carrying out Monitoring and organizational and methodological support of the activities of obstetric hospitals of the constituent entities of the Russian Federation.
29.1. Criteria to determine the stratification of medical care and the direction of pregnant women in the obstetric hospitals of the first group (low degree of risk) are:
lack of extragenital diseases in a pregnant woman or a somatic state of a woman who does not require diagnostic and therapeutic measures to correct the extragenital diseases;
lack of specific complications of the gestational process with a given pregnancy (swelling, proteinuria and hypertensive disorders during pregnancy, childbirth and in the postpartum period, premature genera, delay in the intrauterine fetal growth);
the head prevention of the fetus with a small fruit (up to 4000 g) and normal sizes of the mother's pelvis;
lack of a history of woman Ante-, intra- and early neonatal death;
the absence of complications in previous births, such as hypotonic bleeding, deep breaks of soft tissues of the genital tract, generic injury in the newborn.
At the risk of the emergence of complications of the delivery, pregnant women are sent to the obstetric hospitals of the second, third A and the third B of the group in a planned manner.
29.2. Criteria for determining the stratification of medical care and the direction of pregnant women in the obstetric hospitals of the second group ( middle degree Risk) are:
mutral valve prolapse without hemodynamic disorders;
compensated diseases of the respiratory system (without respiratory failure);
an increase in the thyroid gland without disrupting the function;
myopia I and II degree unchanged on the eye day;
chronic pyelonephritis without disturbing function;
urinary tract infections outside the exacerbation;
diseases of the gastrointestinal tract (chronic gastritis, duodenitis, colitis);
transferred pregnancy;
alleged large fruit;
anatomical narrowing of the I-II degree pelvis;
pelvic prevention of the fetus;
low layout of the placenta, confirmed when ultrasound in a period of 34-36 weeks;
strawing a history;
multiple pregnancy;
cesarean cross-section in history in the absence of signs of the insolvency of the scar on the uterus;
scar on the uterus after conservative momectomy or uterine perforations in the absence of signs of the insolvency of the scar in the uterus;
the scar on the uterus after conservative momectomy or uterus perforations in the absence of signs of the insolvency of the scar;
pregnancy after the treatment of infertility of any genesis, pregnancy after the vitro fertilization and the transfer of the embryo;
multi-way;
premature genera, including antenatal oral influence, under a pregnancy term 33-36 weeks, subject to the possibility of providing resuscitation assistance to the newborn in full and absence of the possibility of sending a third group to the obstetric hospital (high degree of risk);
delay of intrauterine growth of the I-II degree fetus.
29.3. Criteria for determining the stratification of medical care and the direction of pregnant women in the obstetric hospitals of the third A group (high degree of risk) are:
premature genera, including the prenatal influence of the octal water, under the period of pregnancy less than 32 weeks, in the absence of contraindications for transportation;
prelation of the placenta, confirmed with ultrasound on a period of 34-36 weeks;
transverse and oblique position of the fetus;
preeclampsia, eclampsia;
cholestasis, hepatosis of pregnant women;
caesarean cross section in history if there are signs of the insolvency of the scar in the uterus;
scar on the uterus after conservative Miomectomy or uterus perforations in the presence of signs of the inconsistency of the scar;
pregnancy after reconstructive-plastic operations on genitals, crushing ruptures III-IV degree at previous birth;
delay in the intrauterine growth of the fetus II-III degree;
iso immunization during pregnancy;
the presence of the fetus of congenital anomalies (malformations of development) requiring surgical correction;
metabolic diseases of the fetus (requiring treatment immediately after birth);
fetal watering;
severe multiple and lowland;
diseases of the cardiovascular system (rheumatic and congenital defects of the heart, regardless of the degree of blood circulation deficiency, a mitral valve prolapse with hemodynamic disorders, operated heart defects, arrhythmias, myocardits, cardiomyopathy, chronic arterial hypertension);
thrombosis, thromboembolism and thrombophlebitis in history and in real pregnancy;
diseases of respiratory organs, accompanied by the development of pulmonary or cardiopulmonary failure;
diffuse diseases of the connective tissue, antiphospholipid syndrome;
kidney diseases accompanied by renal failure or arterial hypertension, urinary tract development anomalies, pregnancy after nephrectomy;
liver disease (toxic hepatitis, acute and chronic hepatitis, liver cirrhosis);
endocrine diseases ( diabetes Any degree of compensation, thyroid disease with clinical signs of hypo- or hyperfunction, chronic adrenal insufficiency);
diseases of the organs of vision (myopia is highly with changes in the eye day, retinal detachment in history, glaucoma);
blood diseases (hemolytic and aplastic anemia, severe iron deficiency anemia, hemoblastosis, thrombocytopenia, Willebrand disease, congenital defects of blood coagulation);
diseases of the nervous system (epilepsy, multiple sclerosis, brain circulation disorders, states after waschemic and hemorrhagic strokes);
miasti;
malignant neoplasms in history or identified in real pregnancy regardless of localization;
vascular malformations, vascular aneurysms;
in anamnesis, the abnormal brain injuries, spinal injuries, pelvis;
other states, threatening the lives of a pregnant woman, in the absence of contraindications for transportation.
29.4. Criteria for determining the stratification of medical care and the direction of pregnant women in the obstetric hospitals of the third b group (high degree of risk) are:
the states listed in paragraph 29.3 of this Procedure;
states requiring specialized, including high-tech, medical care using innovative technologies.
30. The direction of pregnant women (feminine) in obstetric hospitals is carried out in accordance with the sanitary and epidemiological rules.
In the process of childbirth it is necessary to maintain a partograph.
During the birth and in the first days after birth, a set of measures aimed at preventing the hypothermia of newborns is performed.
Before the discharged birthday, the ultrasound of the union pelvis organs is proposed.
33. At the discharge of the parental at the attending physician, clarifications are given about the benefits and recommended duration. breastfeeding (from 6 months to 2 years since the child's birth) and the prevention of unwanted pregnancy.
34. After discharge from a medical organization, their parental is sent to the female consultation at the place of residence for dispensary observation in the postpartum period.
IV. The procedure for providing medical care for pregnant women, women in labor and maternity hospitals with cardiovascular diseases requiring surgical care
35. Pregnant women with confirmed cardiovascular diseases requiring surgical assistance, in the period up to 10-12 weeks of pregnancy, examined on outpatient conditions or in the presence of testimony are sent to the hospital of medical organizations licensed for medical activities, including work (services) on "Cardiovascular surgery" and (or) "cardiology" and "obstetrics and gynecology (with the exception of using auxiliary reproductive technologies)."
Consilium doctors consisting of a cardiologist, a cardiovascular surgeon doctor and an obstetrician-gynecologist based on the results of a clinical examination makes conclusion about the severity of the state of the woman and presents it information about its health status, including information on the results of the survey, the availability of the disease, its The diagnosis and forecast, methods of treatment related to them, the possible options for medical intervention, their consequences and the results of the treatment carried out to address the issue of the possibility of further toaling pregnancy.
36. Diseases of the cardiovascular system requiring consultation and (or) directions to the hospital of pregnant women in a period of up to 12 weeks to medical organizations that have a license to carry out medical activities, including work (services) on "cardiovascular surgery" and ( or) "Cardiology", to solve the issue of the possibility of tooling pregnancy relate to the following diseases:
36.1. Rheumatic heart defects:
all the vices of the heart, accompanied by the activity of the rheumatic process;
all the vices of the heart, accompanied by the insufficiency of blood circulation;
rheumatic stenosis and deficiency of cardiac valves II and more severity;
all heart defects accompanied by pulmonary hypertension;
heart disease with heart rate disorders;
heart defects with thromboembolic complications;
heart defects with atriomegaly or cardiomegaly;
36.2. Congenital heart defects:
paintings of the heart S. large size Shunt, requiring cardio surgical treatment;
heart defects with the presence of pathological discharge of blood (a defect of the interventricular partition, a defect of the interproveserving partition, open arterial duct);
heart defects accompanied by circulatory failure;
heart defects accompanied by pulmonary hypertension;
heart defects complicated by bacterial endocarditis;
heart defects with difficult blood release from the right or left ventricle (hemodynamically significant, accompanied by the insufficiency of blood circulation and (or) the presence of post -tenotic expansion);
congenital anomalies of atri-ventricular valves, accompanied by regurgitation II and more degree and (or) violations of the heart rhythm;
cardiomyopathy;
tetrad Fallo;
Ebestein's disease;
complex congenital heart defects;
eisenmenome Syndrome;
aERZA disease;
36.3. Diseases of endocardium, myocardium and pericardium: acute and subacute form myocarditis;
chronic myocarditis, myocardioosclerosis and myocardiodistrophy, accompanied by insufficient blood circulation and (or) complex heart rate disorders;
myocardial infarction in history;
acute and subacute forms of bacterial endocarditis;
acute and subacute form of pericarditis;
36.4. heart rate disorders (complex forms of heart rhythm);
36.5. States after the operations on the heart.
37. In the presence of medical testimony for interrupting pregnancy and consent of a woman, an artificial interruption of pregnancy under medical testimony under a period of up to 22 weeks of pregnancy is carried out under the conditions of the gynecological separation of a multidisciplinary hospital, which has the opportunity to provide specialized (including cardiorean) medical care to a woman.
In case of refusal to break the pregnancy of the Consilium doctors in the doctor's cardiologist (doctor-vascular surgeon) and the obstetrician-gynecologist's doctor decides the question of the further tactics of pregnancy, and if necessary (the presence of a thrombosis of the prosthesis, critical stenosis and deficiency of the heart valves, requiring prosthetics, violation of heart rhythm requiring radio frequency ablation) - on the direction of medical organizations that have licenses for medical activities, including work (services) on "cardiovascular surgery" and "obstetrics and gynecology (except for the use of auxiliary reproductive technologies ) ".
Under the period of pregnancy, 18-22 weeks of a woman with cardiovascular diseases that require surgical assistance are examined outpatient or stationary (according to indications) in medical organizations licensed to carry out medical activities, including work (services) for "cardiology" or "cardiovascular vascular surgery "and" obstetrics and gynecology (except for the use of auxiliary reproductive technologies) "to clarify the functional state of the cardiovascular system, selection (correction) of drug therapy, prenatal diagnostics in order to exclude congenital anomalies (malformations) of the fetus, the ultrasound and Dopplerometry to assess the state of the fetoplacentage complex.
38. Under the period of pregnancy, 27-32 weeks, pregnant women with cardiovascular diseases requiring surgical care are sent to the hospital of medical organizations that have a license to carry out medical activities, including work (services) for "cardiology" and (or) "cardiovascular Vascular surgery "," obstetrics and gynecology (except for the use of auxiliary reproductive technologies) ", to assess the functional state of the cardiovascular system, the implementation of ultrasound and dopplerometry, the selection (correction) of drug therapy, the assessment of the state of the fetoplacentar complex, the definition of the alleged rapid values.
Consilium Doctors of a Medical Organization, in the hospital of which a pregnant woman is directed, as part of a cardiovascular surgeon doctor, a cardiologist and an obstetrician-gynecologist on the basis of inspection, survey results (electrocardiography and echocardiography, ultrasound with dopplerometry) is a conclusion about the severity of the state Women and makes conclusion about the further tactics of pregnancy, and if there are contraindications - about early delivery on medical testimony.
39. Under the pregnancy term, 35-37 weeks of women are sent to the hospital of a medical organization (to clarify the terms of childbirth, the choice of the method of delivery). The medical organization for the delivery, the method and terms of delivery are determined by the consultation of doctors as part of a cardiologist (doctor-vascular surgeon doctor), an obstetrician-gynecologist and an anesthesiologist-resuscity doctor in accordance with the functional class on heart failure and dynamic assessment, and Also the course of pregnancy and features of the state of the fetoplacentage complex.
The functional class on heart failure is specified immediately before childbirth, with the introduction of the necessary adjustments to the plan of pregnancy, terms and methods of delivery.
40. Pregnant women with cardiovascular diseases in need of surgical assistance, in the presence of high risk of developing critical states associated with cardiac surgery pathology (prosthesis thrombosis, critical stenosis and lack of heart valves requiring prosthetics; heart rate disorders requiring radio frequency ablation), and needing emergency cardiac surgical assistance, they are sent for a delivery of medical organizations that have a license to carry out medical activities, including work (services) on "cardiovascular surgery" and "obstetrics and gynecology (except for the use of auxiliary reproductive technologies)" for the relevant Treatment.
41. Further tactics of maternity making are determined by the consultation of doctors as part of a doctor-obstetrician-gynecologist, a cardiologist (doctor of the cardiovascular surgeon according to testimony), an anesthesiologist-resuscitator. In the presence of testimony to cardiac surgery, medical intervention is carried out in the conditions of separation of cardiovascular surgery. For further treatment and rehabilitation, the parental is translated into the cardiology department. In the absence of indications for surgical treatment, the patient is translated into an obstetric hospital.
V. The procedure for providing medical care to women in emergency conditions during pregnancy, childbirth and postpartum period
42. To the main states and diseases requiring activities to resuscitation and intensive therapy of women during pregnancy, childbirth and the postpartum period include:
acute hemodynamic disorders of various etiologies (acute cardiovascular failure, hypovolemic shock, septic shock, cardiogenic shock, traumatic shock);
pre- and eclampsia;
Hellp syndrome;
acute fat gepatosis of pregnant women;
DVS syndrome;
postpartum sepsis;
sepsis during pregnancy of any etiology;
yatrogenous complications (complications of anesthesia, transfusion complications, and so on);
heart defects with blood circulation impairment, pulmonary hypertension or other manifestations of decompensation;
myocardiodestrophia, cardiomyopathy with rhythm impaired or blood circulation failure;
diabetes mellitus with a difficult-critical level of blood sugar and a tendency to ketoacidosis;
severe anemia of any gene;
thrombocytopenia of any origin;
acute violations of cerebral circulation, brain hemorrhage;
severe form of epilepsy;
miasti;
acute disorders of the functions of vital organs and systems (central nervous system, parenchymal organs), acute violations of metabolic processes.
43. For the organization of medical care, requiring intensive treatment and conduct of resuscitation activities, branches of anesthesiology-resuscitation are created in obstetric hospitals, as well as obstetric remote advisory centers with departure anesthesiological and resuscitation officers for emergency and emergency care (hereinafter referred to as an obstetric remote consultative Centre).
The rules for organizing the activities of the branch of the anesthesiology of the reanimity of the perinatal center and the maternity hospital are defined by Appendix No. 12 to this Procedure.
Rules for organizing the activities of the Acoucher Remote Advisory Center with exit anesthesiological-resuscitation obstetric teams to provide emergency and emergency medical care of the perinatal center and maternity hospital, recommended standard standards and the standard for equipping an obstetric remote advisory center with exit anesthesiological-resuscitation officers to provide emergency and emergency medical The help of the perinatal center and the maternity hospital is defined by Appendices No. 13 - 15 to this order.
44. Pregnant women, women in labor and parental with acute hemodynamic disorders of various etiologies (acute cardiovascular insufficiency, hypovolemic shock, septic shock, cardiogenic shock, traumatic shock), and eclampsia, traumatic shock, and eclampsia are sent Respiratory disorders, other acute disorders of the functions of vital organs and systems (central nervous system, parenchymal organs), acute violations of metabolic processes, the parental in the restorative period after the operational delivery, complicated by violations of the functions of vital organs or with a real threat to their development.
If it is necessary to provide medical care for pregnant women, women in labor and maternity hospitals, the doctors of the specialty, to which the disease belongs to resuscitation and intensive therapy should be involved in the department of anesthesiology resuscitation.
The basis for the transfer of pledges to the postpartum separation, pregnant women - to the department of pregnancy pathology (other profile branches according to indications) for further observation and treatment is the resistant reduction of hemodynamics and spontaneous breathing, correction of metabolic disorders and stabilization of vital functions.
45. The provision of emergency and emergency medical care, including measures for resuscitation and intensive therapy, women during pregnancy, childbirth and in the postpartum period are carried out in two stages:
outside a medical organization - is carried out by an exit anesthesia-resuscitation obstetric team to provide emergency and emergency medical care, which is functioning in the obstetric remote advisory center, which consists of anesthetics-anesthetics, which owns the methods of urgent diagnostics, intensive care and intensive therapy in obstetrics and gynecology; obstetrician-gynecologists who own surgical interventions, and nurses-anesthetists who have mastered the skills of providing emergency care in neonatology and obstetrics and gynecology, or in the absence of an outbound anesthesia-resuscitation obstetric team to provide emergency and emergency medical care - ambulance brigades help (hereinafter - SMP);
in stationary conditions, it is carried out in the branches of the anesthesiology-resuscitation of medical organizations.
46. \u200b\u200bIn the event of a clinical situation, the life-threatening life of a pregnant woman, girlfriend or a parental at the level of the Feldsher-Okushetsky point, a medical worker in an emergency manifests a team of SMP and informs the administration of the relevant district hospital about the current situation.
The duty administrator of the district hospital organizes advisory assistance to a medical person who provides medical assistance to a pregnant woman, a woman in labor or a maternity hospital with the involvement of obstetrician-gynecologists and anesthetics doctors before the arrival of the SMP brigade and prepare the units of the medical organization for the reception of a pregnant woman, women in labor or Row birth.
47. Upon receipt of a pregnant woman, girlfriend or a parental in a medical organization, after assessing the severity of the state of a pregnant woman, girlfriend or the parental and the establishment of a preliminary diagnosis, a doctor providing her medical assistance reports the situation by a specialist of the state authority of the constituent entity of the Russian Federation in the field of health Heading the service of thekin, and to the territorial obstetric remote advisory center to harmonize the amount of medical care and the call of the outbound anesthesiological and resuscitation officer brigade to provide emergency and emergency care.
48. The exit anesthesia-resuscitation obstetric team to provide emergency and emergency medical care is sent to provide specialized anesthesiotic-resuscitation assistance to pregnant women, women in labor and maternity hospitals with severe obstetric and extragenital pathology that are in the treatment in obstetric hospitals of the first and second groups to provide medical Assistance in place, as well as for the transportation of women in need of intensive therapy during pregnancy, childbirth and in the postpartum period, in the obstetric hospitals of the third A and B groups.
49. The exit anesthesiolo-resuscatory obstetric team for emergency and emergency medical care transports women with obstetric pathology in the branch of the anesthesiology-resuscitation of obstetric hospitals, with extragenital diseases in the branch of the anesthesiology-resuscitation, as part of multidisciplinary medical organizations in the profile of the disease in which round-the-clock specialized specialized Treatment of this category of patients.
50. In the constituent entities of the Russian Federation, having remote (delivery of a patient on a car to the branch of anesthesiology-resuscitation, takes more than 1 hour) or transport and inaccessible settlements, it is recommended to organize the sanitary and aviation evacuation of patients.
Vi. The procedure for providing medical care to women with HIV infection during pregnancy, childbirth and in the postpartum period
51. The provision of medical care to women with HIV infection during pregnancy, childbirth and in the postpartum period is carried out in accordance with sections I and III of this Procedure.
52. Laboratory examination of pregnant women for the presence of antibodies to the human immunodeficiency virus (hereinafter referred to as HIV) is carried out when registered with pregnancy.
53. With a negative result of the first survey on HIV antibodies, women planning to preserve pregnancy, re-test at 28-30 weeks. Women who, during pregnancy, used parenteral psychoactive substances and (or) entered into sex with HIV-infected partner, it is recommended to examine an additional 36 week of pregnancy.
54. Molecular biological examination of pregnant women on DNA or HIV RNA is carried out:
a) in obtaining questionable results of testing on antibodies to HIV, obtained by standard methods (immunoassay analysis (hereinafter referred to as IFA) and immune blotting);
b) when receiving negative test results on the antibodies to HIV, obtained by standard methods in the event that a pregnant woman belongs to a high-risk group on HIV infection (drug use intravenously, unprotected sex with HIV-infected partner in the last 6 months).
55. Blood fence when testing for antibodies to HIV is carried out in the procedural office of women's consultation using vacuum systems for blood intake, followed by blood transmission to the laboratory of a medical organization with a direction.
56. Testing for antibodies to HIV is accompanied by a mandatory dotesting and post track consulting.
Postvestment consulting is carried out by pregnant women regardless of the test results on HIV antibodies and includes a discussion of the following questions: the value of the result obtained, taking into account the risk of HIV infection; recommendations for further testing tactics; transmission paths and ways to protect against HIV infection; risk of HIV transmission during pregnancy, childbirth and breastfeeding; Methods for the prevention of HIV infections from the mother to the child, available for a pregnant woman with HIV infection; The possibility of conducting the chemoprophylaxis of HIV transfer to the child; possible outcomes of pregnancy; the need to follow the observation of the mother and the child; The possibility of informing about the results of the penis of the sexual partner and relatives.
57. Pregnant women with a positive result of a laboratory survey on HIV antibodies, an obstetrician-gynecologist, and in the case of its absence - a general practice doctor (family doctor), a medical worker of the Feldsher-Okushetsky point, sends to the Center for the Prevention and Fight of AIDS Subject Of the Russian Federation for an additional examination, layouts on the dispensary accounting and purpose of the chemoprophyphylaxis of the perinatal transmission of HIV (antiretroviral therapy).
Information obtained by medical workers about a positive result of testing for HIV infection of a pregnant woman, girlfriend, the parental, the antiretroviral prevention of the transfer of HIV infection from mother to a child, joint observation of a woman with specialists from the Center for the Prevention and Fight against AIDS of the constituent entity of the Russian Federation, perinatal contact HIV The infection in the newborn is not subject to disclosure, except in cases provided for by the current legislation.
58. Further observation of a pregnant woman with a diagnosed diagnosis of HIV infection is carried out jointly by a physician infectiousness center for the prevention and control of AIDS of the subject of the Russian Federation and an obstetrician-gynecological doctor of women's consultation at the place of residence.
If it is impossible for the direction (observation) of a pregnant woman to the Center for the Prevention and Control of AIDS of the Subject of the Russian Federation, observation is carried out by an obstetrician-gynecologist at the place of residence in the methodical and advisory support of the infectious examinist of the Center for the Prevention and Fighting of AIDS.
An obstetrician-gynecologist of female consultation during the monitoring of a pregnant woman with HIV infection to the center of prevention and control of AIDS of the constituent entity of the Russian Federation information on the course of pregnancy, concomitant diseases, pregnancy complications, the results of laboratory research to adjust the antiretroviral prevention schemes for HIV transmission The mother of the child and (or) antiretroviral therapy and requests from the center of the prevention and control of AIDS of the constituent entity of the Russian Federation information about the features of HIV infection in a pregnant woman, the mode of receiving antiretroviral drugs, coordinates the necessary methods of diagnosis and treatment, taking into account the health status of women and pregnancy .
59. During the entire period of observing a pregnant woman with HIV infection, an obstetrician-gynecologist of women's consultation in conditions of strict confidentiality (using code) notes in medical records of its HIV status, presence (absence) and reception (refusal of admission) Antiretroviral drugs needed to prevent the transfer of HIV infection from the mother to a child appointed by the specialists of the Center for the Prevention and Fighting of AIDS.
On the absence of a pregnant woman antiretroviral drugs, the refusal of their admission, an obstetrician-gynecologist for women's consultation immediately informs the center for the prevention and control of AIDS of the constituent entity of the Russian Federation to take appropriate measures.
60. During the period of dispensary monitoring of a pregnant woman with HIV infection, it is recommended to avoid procedures that increase the risk of fetal infection (amniocentesis, chorion biopsy, etc.). The use of non-invasive methods for assessing the state of the fetus is recommended.
61. Upon receipt of women in the obstetric hospital for HIV infection, women without medical documentation or a single survey on HIV infection, as well as psychoactive substances used intravenously during pregnancy, or who had unprotected sex with HIV-infected partner, Laboratory examination is recommended by the express method on HIV antibodies after receiving informed voluntary consent.
62. Testing of the manufacturers on HIV antibodies in the obstetric hospital is accompanied by a dotesty and post-advising counseling, including information on testing, methods for preventing HIV transmission from mother to the child (the use of antiretroviral drugs, the method of delivery, the features of feeding a newborn (after birth, the child is not applied to the chest and It is not fed by maternal milk, but translates into artificial feeding).
63. The survey on HIV antibodies using diagnostic express test systems allowed to use in the Russian Federation is carried out in the laboratory or the receiving department of the obstetric hospital with medical professionals who have passed special training.
The study is carried out in accordance with the instructions attached to a specific express test.
A part of the blood sample, taken to conduct the express test, is sent to conduct an examination on HIV antibodies according to the standard method (ELISA, if necessary, immune blot) in the screening laboratory. The results of this study are immediately transmitted to the medical organization.
64. Each HIV study with the use of express tests must be accompanied by a mandatory parallel study of the same portion of blood by classical methods (ELISA, immune blot).
Upon receipt of a positive result, the remaining part of the serum or plasma of blood is sent to the laboratory of the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation for conducting a verification study, the results of which are immediately transmitted to the obstetric hospital.
65. In the case of obtaining a positive result of HIV testing in the laboratory of the Center for the Prevention and Fighting of AIDS of the Directory of the Russian Federation, a woman with a newborn after extracting from the obstetric hospital is sent to the Center for the Prevention and Fight against AIDS of the Directory of the Russian Federation for counseling and further surveys.
66. In emergency situations, if it is impossible to expect the results of standard testing for HIV infection from the Center for the Prevention and Fight against AIDS of the constituent entity of the Russian Federation, the decision to conduct a preventive course of antiretroviral treatment of HIV transmission of HIV to the child is accepted when antibodies are detected to HIV antibody with an express test - Systems. The positive result of the express test is the basis only for the appointment of antiretroviral prevention of the transfer of HIV infection from the mother to the child, but not for the diagnosis of HIV infection.
67. To ensure the prevention of the transfer of HIV infection from the mother to the child in an obstetric hospital, the necessary supply of antiretroviral drugs constantly should have.
68. Conducting antiretroviral prevention in a woman in the period of childbirth is carried out by a obstetrician-gynecologist, leading childbirth, in accordance with the recommendations of specialist doctor's doctors of the Center for the Prevention and Fight against AIDS of the constituent entity of the Russian Federation, in the absence of recommendations in accordance with the current modern Russian protocols, recommendations and standards for the prevention of HIV transfer to the mother.
69. The preventive course of antiretroviral therapy during childbirth in the obstetric hospital is carried out:
a) in the guinea with HIV infection;
b) with a positive result of express testing women in childbirth;
c) in the presence of epidemiological testimony:
the impossibility of express testing or timely obtaining the results of a standard test for HIV antibodies to the Hife;
a history of fever in the period of real pregnancy parenteral use of psychoactive substances or sexual contact with a partner with HIV infection;
with a negative result of a survey on HIV infection, if from the moment of the last parenteral use of psychoactive substances or sexual contact with HIV-infected partner passed less than 12 weeks.
70. Measures are taken to prevent an obstetrician-gynecologist to prevent the duration of anhydrous gap for more than 4 hours.
71. When conducting birth through natural generic paths The vaginal treatment is carried out with a 0.25% aqueous solution of chlorhexidine when entering childbirth (at the first vaginal study), and in the presence of coloring - with each subsequent vaginal study. With anhydrous interval of more than 4 hours, chlorhexidine vagina is carried out every 2 hours.
72. While conducting birth to a woman with HIV infection with a living fruit, it is recommended to limit procedures that increase the risk of fetal infection: relatives; Rhodesion; Perinao (episio) Tomiya; amniotomy; the impulse of obstetric tongs; Vacuum extraction of the fetus. Performing data of manipulations is made only on life indications.
73. Planned caesarean section for the prevention of intranatal infection of the child with HIV infection is carried out (in the absence of contraindications) prior to the beginning of the generic activity and influence the accumulative water in the presence of at least one of the following conditions:
a) the concentration of HIV in the blood of the mother (viral load) before childbirth (on the period not earlier than 32 weeks of pregnancy) is more or equal to 1 000 kopecks;
b) the mother's viral load before childbirth is unknown;
c) Antiretroviral chemoprophylaxis was not carried out during pregnancy (or was carried out in monotherapy mode or its duration was less than 4 weeks) or it is impossible to apply antiretroviral drugs in childbirth.
74. If it is impossible to conduct chemoprophylaxis in kinds of caesarean section, a cross section can be an independent preventive procedure that reduces the risk of infection with HIV infection during the birth period, it is not recommended to conduct it at an anhydrous interval for more than 4 hours.
75. The final decision on the method of the delivery of a woman with HIV infection is made by an obstetrician-gynecologist, leading childbirth, individually, taking into account the state of the mother and fetus, comparing in a particular situation to reduce the risk of infection of the child during operation cesarean section With the probability of occurrence of postoperative complications and features of the flow of HIV infection.
76. The newborn from HIV-infected mother immediately after birth is a blood pressure for testing for HIV antibodies using vacuum systems for blood intake. Blood is sent to the laboratory of the Center for the Prevention and Fight against AIDS of the constituent entity of the Russian Federation.
77. Antiretroviral prevention The newborn is appointed and is carried out by a neonatologist or pediatrician, regardless of the reception (refusal) of antiretroviral drugs by the mother during pregnancy and childbirth.
78. Indications for the appointment of antiretroviral prevention of newborn, born of a mother with HIV infection, a positive result of express testing on HIV antibodies in childbirth, unknown HIV status in obstetric hospital are:
a) the age of a newborn no more than 72 hours (3 days) of life in the absence of feeding with maternal milk;
b) in the presence of feeding with maternal milk (regardless of its duration) - a period of not more than 72 hours (3 days) from the moment the latter feeding with maternal milk (subject to subsequent cancellation);
c) Epidemiological testimony:
unknown HIV Mother's status that consumes parenteral psychoactive substances or having sexual contact with HIV-infected partner;
a negative result of the Mother survey on HIV infection that consumes parenterally during the last 12 weeks of psychoactive substances or having sexual contact with a partner with HIV infection.
79. A newborn is a hygienic bath with a chlorhexidine solution (50 ml of 0.25% chlorhexidine solution by 10 liters of water). If it is impossible to use chlorhexidine, a soap solution is used.
80. When discharged from the obstetric hospital, a neonatologist or a pediatrician in an affordable form explains the mother or persons who will carry out a newborn care, a further function of receiving chemotherapy by a child, issues antiretroviral drugs to continue antiretroviral prevention in accordance with applicable modern Russian protocols, recommendations and standards.
When conducting a preventive course of antiretroviral drugs, emergency prevention methods, an extract from the maternity hospital of the mother and the child is carried out after the end of the preventive course, that is, not earlier than 7 days after delivery.
In obstetric hospital, women with HIV are counseling on the issue of breastfeeding, with the consent of the woman, measures are taken to stop lactation.
81. Data on a child born mother with HIV infection, carrying out antiretroviral prevention to a woman in childbirth and newborn, methods of delivery and feeding a newborn (with a contingent code) in the medical records of the mother and child and are transferred to the Center for the Prevention and Fight against AIDS Federation, as well as a children's clinic, in which the child will be observed.
VII. The procedure for providing medical care for women with gynecological diseases
82. Medical assistance in gynecological diseases is within the framework of primary health, specialized, including high-tech, medical care in medical organizations licensed to carry out medical activities, including work (services) on "obstetrics and gynecology (except for using auxiliary Reproductive technologies). "
The rules for organizing the activities of the Gynecological Department of the Medical Organization, recommended full-time regulations and the standard for equipping the gynecological department of a medical organization are defined by Appendices No. 17 - 19 to this Procedure.
Rules for organizing the activities of the Family and Reproduction Health Center, recommended standard standards and the standard for equipping the Family and Reproduction Health Center are defined by Appendices No. 22 - 24 to this Procedure.
83. The stratification of medical care to women with gynecological diseases is defined by Appendix No. 20 to this Procedure.
84. The main task of primary health care gynecological patients is prevention, early detection and treatment of the most common gynecological diseases, as well as providing medical care for emergency conditions, sanitary and hygienic education aimed at preventing abortion, reproductive health protection, the formation of a stereotype of a healthy image Life, using effective informational and educational models (patient schools, round tables with patients, health days).
At the stage of primary health care, an obstetrician-gynecologist interacts with a specialist in social work in terms of measures to prevent abortion, consultations on issues social protection Women who appeal about the interruption of unwanted pregnancy, the formation of a woman of consciousness of the need to raise pregnancy and further support during pregnancy and after delivery.
In the framework of primary health care, preventive medical examinations of women are carried out, aimed at the early detection of gynecological diseases, the pathology of the mammary glands, sexually transmitted infections, HIV infection, the selection of methods of contraception, preconceptacry and pre-launching training.
When conducting preventive inspections of women, cytological screening is carried out for the presence of atypical cervical cells, mammography, ultrasound organs of a small pelvis.
85. According to the results of preventive inspections of women, health groups are formed:
I Group are practically healthy women who do not need to be dispensary observation;
Group II - women with the risk of the appearance of the pathology of the reproductive system;
III Group - Women who needed an additional survey on outpatient conditions for clarification (establishment) of the diagnosis with the first established chronic disease or with the existing chronic disease, as well as needing treatment in outpatient conditions;
IV Group - women who need additional examination and treatment under hospital conditions;
V Group - Women with first identified diseases or observed in chronic disease and have indications to provide high-tech medical care.
Women referred to I and II health care groups are recommended preventive inspections at least once a year.
If there is a risk of the occurrence of the pathology of the reproductive system in a childbearing age, women are focused by an obstetrician-gynecologist for childbearing, followed by the selection of contraceptive methods.
Women referred to III, IV, V Group of Health, depending on the identified diseases drawn up an individual treatment program, if necessary, a dispensary observation by the obstetrician-gynecologist at the place of residence is established.
1 dispensary group - women with chronic diseases, benign tumors and hyperplastic processes of the reproductive system and breast, background diseases of the cervix;
2 Dispensary group - women with congenital anomalies of development and position of genitals;
3 Dispensary group - Women with impaired reproductive system (unbearable, infertility).
Women with chronic diseases, benign tumors and hyperplastic processes of the reproductive system are examined for the elimination of malignant neoplasms.
Medical assistance to women in order to identify the diseases of the mammary glands turns out to be an obstetrician-gynecologist who has passed the thematic improvement on the pathology of the breast.
Women with detected cystic and nodal changes in the mammary glands are sent to the oncological dispensary to verify the diagnosis. After the exclusion of malignant neoplasms, women with benign diseases of the dairy glands are under the dispensary observation of an obstetrician-gynecologist, which provides medical care for the diagnosis of benign pathology of the mammary glands and the treatment of benign diffuse changes taking into account the concomitant gynecological pathology.
86. Women with gynecological diseases that need invasive manipulations, daily observation and (or) medical procedures, but not requiring round-the-clock observation and treatment, as well as to continue observation and treatment after staying in a 24-hour hospital, are sent to the day hospitals. The recommended duration of stay in the day hospital is 4-6 hours per day.
If there are indications for the provision of specialized, including high-tech, medical care women with gynecological pathology are sent to medical organizations that have licenses and specialist doctors of the corresponding profile.
VIII. The procedure for providing medical care girls with gynecological diseases
87. The provision of medical care to girls (under the age of 17 inclusive) with gynecological diseases is carried out within the framework of primary health, specialized, including high-tech, medical care.
88. Primary health care girls includes:
a) prevention of violations of the formation of the reproductive system and diseases of the genital organs;
b) early detection, treatment, including urgent, and medical rehabilitation measures in identifying a gynecological disease;
c) personalized advising girls and their legal representatives on intimate hygiene, risk of infection with sexually transmitted infections, abortion prevention and contraceptive choice;
d) Sanitary and hygienic enlightenment of girls held on the territory of a medical organization, and aimed at mastering a stereotype of a healthy lifestyle, acquiring the skills of responsible attitudes towards the family and its reproductive capabilities using effective information and educational models.
89. Primary health care for girls with the aim of prevention, diagnosis and treatment of gynecological diseases is in medical organizations: in the children's clinic, women's consultation, the reproductive health center of adolescents, family health center and reproduction, the Maternity and Childhood Security Center, Perinatal Center , in the polyclinic department of the health part, urban hospital, clinics, which is part of educational and scientific organizations carrying out medical activities, other medical organizations licensed to carry out medical activities, including work (services) for "obstetrics and gynecology (except Use auxiliary reproductive technologies) "and (or)" Pediatrics ".
The rules for organizing the activities of the reproductive health of adolescents, recommended full-time standards and the standard for equipping the center for the protection of the reproductive health of adolescents are defined by Appendices No. 25 - 27 to this Procedure.
Medical organizations provide accessibility, interdisciplinary interaction and continuity in providing medical care, including the use of rehabilitation methods and sanatorium-resort treatment.
90. Primary health care assistance to girls in order to identify gynecological diseases is organized on outpatient conditions and in a daytime hospital with an obstetrician-gynecologist who has passed thematic improvements in the peculiarities of the formation of a reproductive system and the flow of gynecological pathology in children, and in the absence of the specified doctor A specialist is any obstetrician-gynecologist, a pediatrician, a pediatrician-pediatrician, a general practitioner (family doctor), Feldsher, Obstetrician or Medical Sister of the Feldscher-Okushetsky Point.
Girls living in remote and hard-to-reach areas, primary health care are obstetrician-gynecologists, pediatrician doctor, specialist doctors or other medical workers as part of the exit brigades.
Gynecological obstetrician doctors who provide medical care girls with gynecological diseases should be sent to training on a cycle of thematic improvements on the features of the formation of a reproductive system and the flow of gynecological pathology in children at least 1 time in 5 years.
91. The main responsibility of the Acoucher-Gynecologist or other medical worker in the provision of primary health care is to conduct preventive examinations of girls aged 3, 7, 12, 14, 15, 16 and 17 years in order to prevent and early diagnosis of gynecological diseases and the pathology of the mammary glands.
In the remaining age periods, the girl inspection is conducted by a pediatrician, a pediatrician teacher, a general practitioner (family doctor), a Feldsher, an obstetrician or medical sister of the Feldsherasky-Okushetsky point and the direction of the girl to the Akuster-Gynecologist's doctor in accordance with the list of testimony Appendix No. 21 to the procedure for providing medical care for the profile "Obstetrics and Gynecology (except for the use of auxiliary reproductive technologies)", approved by this order.
92. When conducting preventive medical examinations of girls decreated ages after receiving informed voluntary consent to the medical intervention, an obstetrician-gynecologist or other medical worker clarifying complaints, conducts a general inspection, measurement of growth and body weight with the determination of their compliance with age standards, assessing the degree of sexual Development on Tanner, inspection and manual study of the mammary glands and outdoor genital organs, counseling on personal hygiene and sexual development. With a prophylactic examination of the girl under the age of 15 years, the presence of its legal representative is allowed.
93. According to the results of preventive inspections of girls, health groups are formed:
I group - practically healthy girls; Girls with risk factors for the formation of the pathology of the reproductive system.
Group II - Girls with menstruation disorders per year of observation (less than 12 months); with the functional cysts of the ovaries; with benign diseases of the mammary glands; With an injury and with acute inflammation of the internal genitals in the absence of complications of the underlying disease.
III group - girls with menstruation disorders for more than 12 months; with benign formations of the uterus and its appendages; with violation of sexual development; with vices of the development of genital organs without disturbing the outflow of menstrual blood; With chronic, including recurrent, diseases of external and internal genital organs, in the absence of complications of the underlying disease, as well as when they are combined with extragneenital, including endocrine, pathology under compensation.
IV Group - Girls with sexual disorders; with vices for the development of genital organs accompanied by a disorder of the outflow of menstrual blood; with menstruation disorders and chronic diseases of external and internal genital organs in the active stage, stages of unstable clinical remission and frequent exacerbations requiring supportive therapy; with possible complications of the underlying disease; with disabilities learning and labor due to the main disease; with concomitant extragenital, including endocrine, pathology with incomplete compensation of the corresponding functions.
V Group - Disabled girls with accompanying sexual disorders, menstruation disorders and diseases of external and internal genital organs.
Girls from the I and II Health Group are subject to planned preventive inspections by an obstetrician-gynecologist or other medical worker.
Girls attributed to III, IV, V health care groups, depending on the identified diseases drawn up an individual treatment program, if necessary, the dispensary observation at the place of residence is established.
Dispensary monitoring groups:
1 dispensary group - Girls with sexual disorders;
2 Dispensary group - Girls with gynecological diseases;
3 Dispensary Group - Girls with menstruation disorders against the background of chronic extragnenital, including endocrine pathology.
94. Medical interventions are conducted after receiving informed voluntary consent of girls aged 15 years and older, and in case of examination and treatment of children who have not reached the specified age, as well as recognized in accordance with the procedure established by law, if they are not able to give informed voluntary voluntary Consent - in the presence of informed voluntary consent of one of the parents or other legal representative.
95. In the presence of a pregnancy of any period of the girl under the age of 17, inclusive observation is carried out by an obstetrician-gynecologist of a medical organization.
In the absence of an obstetrician-gynecologist, a girl with a pregnancy of any long-term is observed by a general practice doctor (family doctor), a physician, a doctor-pediatrician, paramedic, obstetrician or medical sister of the Feldsher-obstetric item in accordance with the sections of the I-VI of this Procedure.
96. Emergency and emergency medical care for girls with acute gynecological diseases that require surgical treatment, it turns out in medical organizations that have licenses for medical activities, including work (services) on "obstetrics and gynecology (except for the use of auxiliary reproductive technologies)" and ( or) "Children's Surgery", "Surgery", having a hospital around the clock with a branch of anesthesiology-resuscitation, obstetrician-gynecologists, childish surgeons, surgeon doctors. When performing emergency surgical interventions on a small pelvic organs in girls, it is recommended to use minimally invasive access (laparoscopy) with ensuring the conservation of the uterus function and its appendages.
Solving the issue of the removal of ovaries, uterine pipes and uterus when performing an emergency operation, childish surgeons or surgeons are recommended to be coordinated with an obstetrician-gynecologist.
97. To provide specialized, including high-tech, medical care, an obstetrician-gynecologist or other medical worker sends a girl with gynecological pathology in a 24-hour or day hospital of a medical organization that has gynecological beds for children and a license to carry out medical activities, including work (services) on "obstetrics and gynecology (except for the use of auxiliary reproductive technologies)" and "Pediatrics".
98. If you need rehabilitation and rehabilitation treatment, medical care girls with gynecological diseases are in medical organizations (sanatorium-resort organizations) licensed for medical activities, including work (services) on obstetrics and gynecology (except for the use of auxiliary reproductive technologies) "
99. Girls who have reached the age of 18 are transferred under the supervision of an obstetrician-gynecologist of women's consultation after registration of transferable epicrosis. Female consultation doctors provide acceptance of documents and examination of the girl to determine the group of dispensary surveillance.
100. Rules of organization of the activities of the Acoucher-Gynecologist, providing medical care for girls with gynecological diseases, are defined by Appendix No. 21 to this Procedure.
IX. The procedure for providing medical care for women in artificial pregnancy interruption
101. Artificial abortion of pregnancy, including minors, is conducted by an obstetrician-gynecologist in medical organizations licensed for medical activities, including work (services) on obstetrics and gynecology (except for the use of auxiliary reproductive technologies). "
102. Artificial interruption of pregnancy is carried out in the presence of an informed voluntary consent of a woman.
Artificial abortion of pregnancy in minors under 15 years old, as well as minors, patients with drug addiction under 16, is carried out on the basis of the voluntary informed consent of one of the parents or other legal representative.
103. To obtain a direction for an artificial abortion of pregnancy, a woman appeals to the doctor-akuster-gynecologist, and in case of his absence to a general practitioner (family doctor), a medical worker of the Feldsher-Okushetsky point.
104. With a primary handling of a woman for an artificial interruption of pregnancy at the request of a woman or by a social indication, an obstetrician-gynecologist, and in case of its absence, a general practice doctor (family doctor), a medical worker of the Feldsher-Okushetsky point, directs pregnant in the Cabinet of Medical Social assistance for women's consultation (Center for medical and social support for pregnant women, founded in a difficult life situation) to consult a psychologist (a medical psychologist, a specialist in social work). In the absence of a Cabinet of Medical and Social Assistance (Center for Medical and Social Support for Pregnant Women, Founding in a Difficult Life Situation), counseling conducts a medical worker with a higher or secondary medical education, which has passed special training, based on informed voluntary consent of a woman.
The rules for organizing the activities of the Center for Medical Social Support for Pregnant Women, which found themselves in a difficult life situation, the recommended staff standards and the standard for equipping the Center for Medical and Social Support for Pregnant women who were in a difficult life situation are defined by Appendices No. 31 - 33 to this order.
105. An obstetrician-gynecologist when dealing with a woman behind the direction of artificial pregnancy, examines a survey to determine the period of pregnancy and the exclusion of medical contraindications.
Artificial abortion is not carried out in the presence of acute infectious diseases and acute inflammatory processes of any localization, including female genitals. The abortion is carried out after curing these diseases.
In the presence of other contraindications (disease, condition in which the abortion of pregnancy threatens life or makes serious damage to health) the question is solved individually by the consultation of doctors.
106. Before the direction of the artificial interruption of pregnancy under the period of up to twelve weeks, a microscopic study of the separated female genital organs is recommended, the definition of the main blood groups (A, B, 0) and RUS, accessories, ultrasound of the small pelvis organs.
107. Artificial interruption of pregnancy depending on the period of pregnancy, testimony and contraindications can be carried out using a drug or surgical method based on informed voluntary consent of a woman.
With a medication method of pregnancy interrupts used medicinal productsregistered in the territory of the Russian Federation, in accordance with the instructions for medical use of drugs.
When using the surgical method of artificial abortion of pregnancy, vacuum aspiration is recommended.
108. The abortion of pregnancy by the drug method is carried out as part of the provision of primary specialized health care with a period of observation of at least 1.5-2 hours after receiving drugs.
109. Interrupting pregnancy on time to twelve weeks the surgical method is carried out in conditions of daytime hospitals of medical organizations and in the hospital. The duration of the woman's observation in a day hospital after the pregnancy interruption produced without complications is determined by the attending physician, taking into account the state of the woman, but is at least 4 hours.
Artificial interruption of pregnancy at a time to twelve weeks in women with a burdened obstetric history (scar in the uterus, ectopic pregnancy), uterine, chronic inflammatory diseases with frequent exacerbations, anomalies for the development of genital organs and other gynecological pathology, in the presence of severe extragenital diseases, severe allergic diseases (states) are produced under hospital.
110. Before the surgical interruption of pregnancy at primariable women in all terms, and re-pregnant after eight weeks and in the presence of the cervical anomalies (innate or acquired as a result of surgery or injuries), the cervix is \u200b\u200bprepared.
111. Control of emptying of the uterine cavity is carried out by visualizing remote tissues. If necessary, an ultrasound and (or) definition of beta subunit of chorionic gonadotropin quantitative method in dynamics are performed.
112. The question of the artificial interruption of pregnancy for social indication is solved by the Commission as part of the head of the medical organization, a doctor-acus-gynecologist, a lawyer, a specialist in social work (if available). The Commission considers the written statement of the woman, the conclusion of the obstetrician-gynecologist about the period of pregnancy, documents confirming the existence of a social indication for the artificial interruption of pregnancy, approved by the Decree of the Government of the Russian Federation of February 6, 2012 No. 98 "On Social Indication for Artificial Pregnancy Interrupt".
In the presence of a social indication for artificial abortion of pregnancy, the Commission is issued a conclusion certified by the signatures of the Commission members and the seal of a medical organization.
113. To confirm the availability of medical testimony to interrupt pregnancy, approved by the Order of the Ministry of Health and Social Development of the Russian Federation of December 3, 2007 No. 736 (registered by the Ministry of Justice of Russia December 25, 2007 No. 10807), with amendments made by the Order of the Ministry of Health and Social Development of Russia from 27 December 2011 No. 1661n (registered by the Ministry of Justice of Russia on February 3, 2012 No. 23119), in medical organizations a commission is being formed as part of an obstetrician-gynecologist, a physician of the specialty, to which the disease (condition) of a pregnant woman is a medical testimony for artificial interruption of pregnancy, and the head of the medical organization (hereinafter - the Commission).
The personal composition of the Commission and the procedure for its activities is determined by the head of the medical organization.
If there are medical indications for the artificial interruption of pregnancy, the Commission issued a conclusion about the pregnant woman in a pregnant woman, which is an indication for the artificial interruption of pregnancy, certified by the signatures of members of the Commission and the seal of a medical organization.
114. Before the direction of the artificial interruption of pregnancy in the II trimester, a survey is conducted: a common (clinical) blood test, the blood test, biochemical general metering, coagulogram (approximate study of the hemostasis system), defining antibodies of classes M, G to HIV-1 immunodeficiency virus and HIV -2 Blood, definition of antibodies of m classes M, G to antigen of viral hepatitis B and virus hepatitis C in blood, definition of antibodies to pale treponime in the blood, determination of basic blood groups (A, B, 0) and Rh, urine analysis, general , microscopic examination of the separated female genital organs, ultrasound of uterus and appendages transabdominal (transvaginal), registration of the electrocardiogram, the reception of a doctor-therapist. According to the testimony, consultation of related doctors specialists.
115. Artificial abortion of pregnancy under medical testimony under time up to 22 weeks of pregnancy is carried out under the conditions of the gynecological department of a multidisciplinary hospital, having the opportunity to provide specialized (including resuscitation) assistance to a woman (with the obligatory presence of specialist doctors of the relevant profile, according to which testimony for artificial Interrupts of pregnancy).
116. Interrupting pregnancy (delivery) for medical testimony from 22 weeks of pregnancy is carried out only in the conditions of an obstetric hospital, having the ability to provide specialized (including resuscitation) assistance to a woman taking into account the main disease and newborn, including low and extremely low body weight .
117. For interrupting pregnancy, more than twelve weeks is recommended both surgical and drug methods.
118. Before the surgical abortion with a period of pregnancy for more than twelve weeks, all women are prepared by the cervix.
119. The surgical abortion in the second trimester is recommended to be carried out under the control of the ultrasound.
120. If there are signs of incomplete abortion and (or) detection of the residues of the fetal egg, regardless of the applied method of artificial abortion of pregnancy, vacuum aspiration or cureth are carried out.
After the selection of the placenta, its inspection is carried out in order to determine integrity.
121. When interrupting pregnancy in the period of 22 weeks or more in the presence of congenital anomalies (defects of development) in the fetus, incompatible with life, the intracardial administration of potassium chloride or digoxin is carried out before the artificial interruption of pregnancy.
122. All women who are performed by a surgical abortion are carried out antibioticoprophylaxis.
When conducting medical abortion Antibioticoprophylaxis is carried out at a high risk of inflammatory diseases.
123. Artificial abortion of pregnancy is carried out with mandatory anesthesia based on informed voluntary consent of a woman.
124. After an artificial interruption of pregnancy, women with rhesse-negative blood supply, regardless of the pregnancy of pregnancy, immunization of the human immunoglobulin RHO (D) of a person in accordance with the instructions for medical use of the drug are carried out.
125. After an artificial interruption of pregnancy, consulting is held with each woman, in the course of which the signs of complications are discussed, in which a woman is obliged to immediately consult a doctor; Recommendations are provided on mode, hygienic measures, as well as to prevent abortions and the need to save and nullify the next pregnancy.
126. After the artificial interruption of pregnancy, the control examination of the obstetrician-gynecologist in the absence of complaints is carried out in 9-15 days.
Vi. The procedure for providing medical care to women with HIV infection during pregnancy, childbirth and in the postpartum period
51. The provision of medical care to women with HIV infection during pregnancy, childbirth and in the postpartum period is carried out in accordance with sections I and III of this Procedure.
52. Laboratory examination of pregnant women for the presence of antibodies to the human immunodeficiency virus (hereinafter referred to as HIV) is carried out when registered with pregnancy.
53. With a negative result of the first survey on HIV antibodies, women planning to preserve pregnancy, re-test at 28-30 weeks. Women who, during pregnancy, used parenteral psychoactive substances and (or) entered into sex with HIV-infected partner, it is recommended to examine an additional 36 week of pregnancy.
54. Molecular biological examination of pregnant women on DNA or HIV RNA is carried out:
a) in obtaining dubious test results for antibodies to HIV, obtained by standard methods (immunoassay analysis (hereinafter - IFA) and immune blotting);
b) when receiving negative test results on the antibodies to HIV, obtained by standard methods in the event that a pregnant woman belongs to a high-risk group on HIV infection (drug use intravenously, unprotected sex with HIV-infected partner in the last 6 months).
55. Blood fence when testing for antibodies to HIV is carried out in the procedural office of women's consultation using vacuum systems for blood intake, followed by blood transmission to the laboratory of a medical organization with a direction.
56. Testing for antibodies to HIV is accompanied by a mandatory dotesting and post track consulting.
Postvestment consulting is carried out by pregnant women regardless of the test results on HIV antibodies and includes a discussion of the following questions: the value of the result obtained, taking into account the risk of HIV infection; recommendations for further testing tactics; transmission paths and ways to protect against HIV infection; risk of HIV transmission during pregnancy, childbirth and breastfeeding; Methods for the prevention of HIV infection from mother to a child who are available to a pregnant woman with HIV infection; The possibility of conducting the chemoprophylaxis of HIV transfer to the child; possible outcomes of pregnancy; the need to follow the observation of the mother and the child; The possibility of informing about the results of the penis of the sexual partner and relatives.
57. Pregnant women with a positive result of a laboratory survey on HIV antibodies, an obstetrician-gynecologist, and in the case of its absence - a general practice doctor (family doctor), a medical worker of the Feldsher-Okushetsky point, sends to the Center for the Prevention and Fight of AIDS Subject Of the Russian Federation for an additional examination, layouts on the dispensary accounting and purpose of the chemoprophyphylaxis of the perinatal transmission of HIV (antiretroviral therapy).
Information obtained by medical workers about a positive result of testing for HIV infection of a pregnant woman, girlfriend, the parental, the antiretroviral prevention of the transfer of HIV infection from mother to a child, joint observation of a woman with specialists from the Center for the Prevention and Fight against AIDS of the constituent entity of the Russian Federation, perinatal contact HIV The infection in the newborn is not subject to disclosure, except in cases provided for by the current legislation.
58. Further observation of a pregnant woman with a diagnosed diagnosis of HIV infection is carried out jointly by the doctor of the infectiousnessist of the Center for the Prevention and Fight against AIDS of the Directory of the Russian Federation and the obstetrician-gynecologist of women's consultation at the place of residence.
If it is impossible for the direction (observation) of a pregnant woman to the Center for the Prevention and Control of AIDS of the Subject of the Russian Federation, observation is carried out by an obstetrician-gynecologist at the place of residence in the methodical and advisory support of the infectious examinist of the Center for the Prevention and Fighting of AIDS.
An obstetrician-gynecologist of female consultation during the monitoring of a pregnant woman with HIV infection to the center of prevention and control of AIDS of the constituent entity of the Russian Federation information on the course of pregnancy, concomitant diseases, pregnancy complications, the results of laboratory research to adjust the antiretroviral prevention schemes for HIV transmission The mother of the child and (or) antiretroviral therapy and requests from the center of the prevention and control of AIDS of the constituent entity of the Russian Federation information about the features of HIV infection in a pregnant woman, the mode of receiving antiretroviral drugs, coordinates the necessary methods of diagnosis and treatment, taking into account the health status of women and pregnancy .
59. During the entire period of observing a pregnant woman with HIV infection, an obstetrician-gynecologist of women's consultation in conditions of strict confidentiality (using code) notes in medical records of its HIV status, presence (absence) and reception (refusal of admission) Antiretroviral drugs needed to prevent the transfer of HIV infection from the mother to a child appointed by the specialists of the Center for the Prevention and Fighting of AIDS.
On the absence of a pregnant woman antiretroviral drugs, the refusal of their admission, an obstetrician-gynecologist for women's consultation immediately informs the center for the prevention and control of AIDS of the constituent entity of the Russian Federation to take appropriate measures.
60. During the period of dispensary monitoring of a pregnant woman with HIV infection, it is recommended to avoid procedures that increase the risk of fetal infection (amniocentesis, chorion biopsy). The use of non-invasive methods for assessing the state of the fetus is recommended.
61. Upon receipt of women in the obstetric hospital for HIV infection, women without medical documentation or a single survey on HIV infection, as well as psychoactive substances used intravenously during pregnancy, or who had unprotected sex with HIV-infected partner, Laboratory examination is recommended by the express method on HIV antibodies after receiving informed voluntary consent.
62. Testing of the manufacturers on HIV antibodies in the obstetric hospital is accompanied by a dotesty and post-advising counseling, including information on testing, methods for preventing HIV transmission from mother to the child (the use of antiretroviral drugs, the method of delivery, the features of feeding a newborn (after birth, the child is not applied to the chest and It is not fed by maternal milk, but translates into artificial feeding).
63. The survey on HIV antibodies using diagnostic express test systems allowed to use in the Russian Federation is carried out in the laboratory or the receiving department of the obstetric hospital with medical professionals who have passed special training.
The study is carried out in accordance with the instructions attached to a specific express test.
A part of the blood sample taken to conduct an express test is sent to conduct an examination for HIV antibodies according to the standard method (ELISA, if necessary, immune blot) in a screening laboratory. The results of this study are immediately transmitted to the medical organization.
64. Each HIV study with the use of express tests must be accompanied by a mandatory parallel study of the same portion of blood by classical methods (ELISA, immune blot).
Upon receipt of a positive result, the remaining part of the serum or plasma of blood is sent to the laboratory of the Center for the Prevention and Control of AIDS of the constituent entity of the Russian Federation for conducting a verification study, the results of which are immediately transmitted to the obstetric hospital.
65. In the case of obtaining a positive result of HIV testing in the laboratory of the Center for the Prevention and Fighting of AIDS of the Directory of the Russian Federation, a woman with a newborn after extracting from the obstetric hospital is sent to the Center for the Prevention and Fight against AIDS of the Directory of the Russian Federation for counseling and further surveys.
66. In emergency situations, if it is impossible to expect the results of standard testing for HIV infection from the Center for the Prevention and Fight against AIDS of the constituent entity of the Russian Federation, the decision to conduct a preventive course of antiretroviral treatment of HIV transmission of HIV to the child is accepted when antibodies are detected to HIV antibody with an express test - Systems. The positive result of the express test is the basis only for the appointment of antiretroviral prevention of the transfer of HIV infection from the mother to the child, but not for the diagnosis of HIV infection.
67. To ensure the prevention of the transfer of HIV infection from the mother to the child in an obstetric hospital, the necessary supply of antiretroviral drugs constantly should have.
68. Conducting antiretroviral prevention in a woman in the period of childbirth is carried out by an obstetrician-gynecologist, leading childbirth, in accordance with the recommendations and standards for the prevention of HIV transfer to the child.
69. The preventive course of antiretroviral therapy during childbirth in the obstetric hospital is carried out:
a) in the guinea with HIV infection;
b) with a positive result of express testing women in childbirth;
c) in the presence of epidemiological testimony:
the impossibility of express testing or timely obtaining the results of a standard test for HIV antibodies to the Hife;
a history of fever in the period of real pregnancy parenteral use of psychoactive substances or sexual contact with a partner with HIV infection;
with a negative result of a survey on HIV infection, if from the moment of the last parenteral use of psychoactive substances or sexual contact with HIV-infected partner passed less than 12 weeks.
70. Measures are taken to prevent an obstetrician-gynecologist to prevent the duration of anhydrous gap for more than 4 hours.
71. When conducting birth through natural generics, the vagina is treated with a 0.25% aqueous solution of chlorhexidine when entering childbirth (at the first vaginal study), and in the presence of coloring - with each subsequent vaginal study. With anhydrous interval of more than 4 hours, chlorhexidine vagina is carried out every 2 hours.
72. While conducting birth to a woman with HIV infection with a living fruit, it is recommended to limit procedures that increase the risk of fetal infection: relatives; Rhodesion; Perinao (episio) Tomiya; amniotomy; the impulse of obstetric tongs; Vacuum extraction of the fetus. Performing data of manipulations is made only on life indications.
73. Planned caesarean section for the prevention of intranatal infection of the child with HIV infection is carried out (in the absence of contraindications) prior to the beginning of the generic activity and influence the accumulative water in the presence of at least one of the following conditions:
a) the concentration of HIV in the blood of the mother (viral load) before childbirth (on the period not earlier than 32 weeks of pregnancy) is more or equal to 1 000 kopecks;
b) the mother's viral load before childbirth is unknown;
c) Antiretroviral chemoprophylaxis was not carried out during pregnancy (or was carried out in monotherapy mode or its duration was less than 4 weeks) or it is impossible to apply antiretroviral drugs in childbirth.
74. If it is impossible to conduct chemoprophylaxis in kinds of caesarean section, a cross-section can be an independent preventive procedure that reduces the risk of infection with HIV infection during the birth, while it is not recommended to be carried out at anhydrous interval of more than 4 hours.
75. The final decision on the method of the delivery of a woman with HIV infection is made by an obstetrician-gynecologist, leading childbirth, individually, taking into account the state of the mother and the fetus, comparing in a particular situation of the benefit of reducing the risk of infection of the child when conducting cesarean operation with probability The emergence of postoperative complications and features of the current HIV infection.
76. The newborn from HIV-infected mother immediately after birth is a blood pressure for testing for HIV antibodies using vacuum systems for blood intake. Blood is sent to the laboratory of the Center for the Prevention and Fight against AIDS of the constituent entity of the Russian Federation.
77. Antiretroviral prevention The newborn is appointed and is carried out by a neonatologist or pediatrician, regardless of the reception (refusal) of antiretroviral drugs by the mother during pregnancy and childbirth.
78. Indications for the appointment of antiretroviral prevention of newborn, born of a mother with HIV infection, a positive result of express testing on HIV antibodies in childbirth, unknown HIV status in obstetric hospital are:
a) the age of a newborn no more than 72 hours (3 days) of life in the absence of feeding with maternal milk;
b) in the presence of feeding with maternal milk (regardless of its duration) - a period of not more than 72 hours (3 days) from the moment the latter feeding with maternal milk (subject to subsequent cancellation);
c) Epidemiological testimony:
unknown HIV Mother's status that consumes parenteral psychoactive substances or having sexual contact with HIV-infected partner;
a negative result of the Mother survey on HIV infection that consumes parenterally during the last 12 weeks of psychoactive substances or having sexual contact with a partner with HIV infection.
79. A newborn is a hygienic bath with a chlorhexidine solution (50 ml of 0.25% chlorhexidine solution by 10 liters of water). If it is impossible to use chlorhexidine, a soap solution is used.
80. At discharge from the obstetric hospital, a neonatologist or a pediatrician in an affordable form explains the mother or persons who will carry out a newborn care, a further diagram of receiving chemotherapies by a child, issues antiretroviral drugs to continue antiretroviral prevention in accordance with the recommendations and standards.
When conducting a preventive course of antiretroviral drugs, emergency prevention methods, an extract from the maternity hospital of the mother and the child is carried out after the end of the preventive course, that is, not earlier than 7 days after delivery.
In obstetric hospital, women with HIV are counseling on the issue of breastfeeding, with the consent of the woman, measures are taken to stop lactation.
81. Data on a child born mother with HIV infection, carrying out antiretroviral prevention to a woman in childbirth and newborn, methods of delivery and feeding a newborn (with a contingent code) in the medical records of the mother and child and are transferred to the Center for the Prevention and Fight against AIDS Federation, as well as a children's clinic, in which the child will be observed.
An order to maintain pregnancy 572 regulates issues regarding the provision of medical care in the field of obstetrics and gynecology. It does not apply to the use of auxiliary reproductive technologies.
This order is applicable to all medical organizations and institutions that are engaged in the provision of obstetric and gynecological assistance.
Pregnancy plan by order 572n
Pregnant women should be provided not only by primary health care, as well as specialized, high-tech and ambulance.
When providing medical care for pregnant women, it is envisaged to perform two main stages:
- Outpatient support, which are engaged in gynecologists;
- Inpatient maintenance of pregnancy in the presence of any complications during pregnancy.
With a normal course of pregnancy, a woman should undergo inspections of specialists with certain periodicity:
- Obstetrician gynecologist - at least 7 times per pregnancy;
- Therapist - 2 times;
- Dentist - 2 times.
Otolaryngologist and ophthalmologist It is enough to visit one time for pregnancy. If necessary, you can also go through other doctors.
Order 572n "Maintaining Pregnancy" indicates that a pregnant woman should make three mandatory ultrasound within such terms:
- 11-14 weeks;
- 18-21 week;
- 30-34 weeks.
If the research results showed that the fetus has a high risk of chromosomal disorders, the pregnant woman is sent to a medical and genetic center to confirm or eliminate the preliminary diagnosis. If the fact of the development of congenital abnormalities is confirmed, then the further tactics of pregnancy should be determined by the doctor's consultation.
If the fetus has serious chromosomal disorders, while there are congenital defective defects, then after receiving the conselations of the Consilium, the woman can interrupt pregnancy on any development date. Artificial interruption of pregnancy can be carried out:
- In the gynecological department, if the term is 22 weeks and less;
- In the observation department of the obstetric hospital, if more than 22 weeks.
Maintaining pregnancy - Order of the Ministry of Health of the Dispensary Observation
The main task of the dispensary observation of pregnant women is to prevent and early detecting all sorts of complications during the nodding of pregnancy during childbirth and in the postpartum period.
When a woman is tailored to the LCD, a pregnancy standard applies to it. Order 572n describes the sequence of tests and diagnostic procedures on a certain period of pregnancy. For example, after registering, a woman should visit the doctors of narrow specializations, this is an ophthalmologist, dentist, a otolaryngologist, an endocrinologist and others. In addition, until the period of 12 weeks, you need to pass all the tests.
Position in the direction of hospital
If the woman threatens an abortion, then its treatment should be carried out under specialized medical institutions equipped with all necessary equipment. Related to such institutions:
- Department of pathology of pregnant women;
- Gynecological separation;
- Specialized branches in private medical centers.
With the planned direction of the woman in the hospital for the delivery of doctors should take into account the degree of risk of the emergence of certain complications. These risks are detected during the examination in the third trimester of pregnancy.
Principles of organization of obstetric - gynecological assistance in the Russian Federation are united for all health care:
- Accessibility - the provision of medical and preventive assistance to all women, regardless of age, from the work performed (housewives, students, workers, etc.), and from the place of residence (city, village).
- The approach to the population is the organization of institutions in all areas, cities (FAP, CRH, PC).
- Preventive orientation - carrying out a system of measures to prevent complications of pregnancy, childbirth, postpartum period and gynecological diseases.
- Free is the provision of all types of medicinal care for pregnant women, women in labor, maternity hospitals. Additional service services are currently allowed.
In accordance with Article 37.1 of the Founded of the Legislation of the Russian Federation on the protection of citizens of July 22, 1993 No. 5487 - 1 issued an order No. 808N of October 2, 2009 "On approval of the procedure for providing obstetric - gynecological aid".
The procedure for providing medical assistance to women during pregnancy includes 2 stages:
the first is an outpatient, carried out by obstetricists - gynecologists, and in case of their absence, with physiologically occurring pregnancy - general practitioners (family doctors), medical professionals of the FAP (in the event of a complication of pregnancy, the doctor of the obstetrician and a doctor of a specialist in a specialist profile of the disease)
the second is stationary in the departments of the pathology of pregnancy (under the obstetric pathology) or specialized branches (with the somatic pathology) of health institutions.
Women's consultation is created as an independent health care institution or as a structural division of health care provision for the territorial principle of primary outpatient obstetrician-gynecological assistance to women.
The maternity hospital for the provision of outpatient, inpatient assistance to pregnant women, feminine, maternity hospital and newborn, as well as gynecological patients.
The obstetric hospital institution of objects to provide inpatient care for pregnant women, women in labor, maternity hospitals and newborns.
Perinatal center-establishment of objects to render outpatient, inpatient care for pregnant women, women in labor, maternity hospitals and newborns, including the second stage of sticking newborns.
The main indicators of the objectory. Maternal mortality is the death of a woman who has occurred during pregnancy (regardless of its duration and localization) or within 42 days after its end of the cause associated with pregnancy or its leading, but not from an accident or randomly caused.
Order No. 572n.
Order of the Ministry of Health of Russia of 01.11.2012 N 572n (ed. Dated January 12, 2016) on approval of the procedure for providing medical care for the "Obstetrics and Gynecology" profile (except for the use of auxiliary reproductive technologies)
I. Procedure for the provision of medical care Women's pregnancy period
3. Medical assistance to women during pregnancy is within the framework of primary health care, specialized, including high-tech, and emergency, including emergency specialized, medical care in medical organizations that have a license to carry out medical activities, including work (services ) According to "obstetrics and gynecology (except for the use of auxiliary reproductive technologies)" and (or) "obstetric cause".
4. The procedure for providing medical care to women during pregnancy includes two main stages:
ambulatory-based gynecological doctors, and in case of their absence, with physiologically flowing pregnancy - general practitioners (family doctors), medical workers of the medical obstetric items (at the same time, in the event of a complication of the course of pregnancy, consultation of an obstetrician doctor should be ensured Gynecologist and a specialist doctor of the disease profile);
stationary, carried out in the departments of the pathology of pregnancy (with obstetric complications) or specialized departments (in case of somatic diseases) of medical organizations.
6. In the physiological course of pregnancy, the inspections of pregnant women are held:
an obstetrician-gynecologist - at least seven times;
a physician-therapist - at least two times;
dentist doctor at least two times;
a otorinolaryngologist, an ophthalmologist - at least once (no later than 7-10 days after the initial appeal to women's consultation);
other specialist physicians - according to indications, taking into account the concomitant pathology.
Screening ultrasound examination (hereinafter - ultrasound) is carried out three times: in pregnancy period 11 - 14 weeks, 18 - 21 weeks and 30 - 34 weeks.
Under the term of pregnancy 11 - 14 weeks The pregnant woman is sent to a medical organization that exertes the expert level of prenatal diagnosis for a comprehensive prenatal (prenatal) diagnosis of violations of the child's development, which includes ultrasound specialist doctor with specialist preparations and having admission to ultrasound screening surveys in I trimester, and the definition of maternal serum markers (associated with the pregnancy of plasma protein A (RARR-A) and free beta subunit of chorionic gonadotropin) with the subsequent program integrated calculation of the individual risk of the child's birth with chromosomal pathology.
Under the period of pregnancy, the 18-21 weeks old, a pregnant woman is sent to a medical organization that provides prenatal diagnostics, in order to exclude late manifesting congenital abnormalities for the development of the fetus.
Under the term of pregnancy, 30 - 34 weeks of ultrasound is carried out at the place of observation of a pregnant woman.
In the case of establishing a prenatal diagnosis of congenital anomalies in the medical and genetic counseling (center) in the fetus, the fetal determination of the further tactics of pregnancy is carried out by the perinatal consultation of doctors.
In the case of the diagnosis of chromosomal violations and congenital anomalies (malfunctions) in a fetal with an unfavorable forecast for the life and health of the child after birth, pregnancy interruption under medical reasons is carried out regardless of the term of pregnancy to solve the perinatal consultation of doctors after receiving the informed voluntary consent of the pregnant woman.
For the purpose of artificial interruption of pregnancy under medical testimony under a period of up to 22 weeks, a pregnant woman is sent to the gynecological department. Abortion of pregnancy (delivery) at 22 weeks and is more carried out under the conditions of the observational branch of the obstetric hospital.
8. With prenatally diagnosed congenital anomalies (developmental defects), the fetal needs to carry out perinatal conservima of doctors consisting of an obstetrician-gynecologist, a neonatologist doctor and a doctor - a children's surgeon. If there is a surgical correction in the neonatal period of doctors to conclusted the perinatal conservima of doctors, the direction of pregnant women for delivery is carried out in obstetric hospitals, having intensive care and intensive care chambers for newborns serviced by a 24-hour non-station doctor who owns the methods of resuscitation and intensive therapy of newborns.
In the presence of congenital anomalies (malfunctions) of the fetus, requiring the provision of specialized, including high-tech, medical care or newborn in the perinatal period, a consultation of doctors is carried out, which includes an obstetrician-gynecologist, an ultrasound physician, a genetic doctor, Neonatologist, doctor - a children's cardiologist and a doctor - a children's surgeon. If it is impossible to provide the necessary medical care in the subject of the Russian Federation, a pregnant woman to conclusted the conservima doctors is sent to a medical organization that has a license to provide this type of medical care.
9. The main task of the dispensary observation of women during pregnancy is to prevent pregnancy interruption in the absence of medical and social indications and its preservation, prevention and early diagnosis of possible complications of pregnancy, childbirth, postpartum period and the pathology of newborns.
In accordance with Article 37 of the Federal Law of November 21, 2011 No. 323-FZ "On the basis of the health of citizens' health in the Russian Federation" (Meeting of the legislation of the Russian Federation, 2011, No. 48, Art. 6724; 2012, No. 26, Art. 3442 , 3446) I order:1. To approve the attached procedure for providing medical care for the "Obstetrics and Gynecology" profile (except for the use of auxiliary reproductive technologies). "
2. Recognize invalid:
Order of the Ministry of Health and Social Development of the Russian Federation of October 2, 2009 No. 808n "On approval of the procedure for providing obstetric and gynecological assistance" (registered by the Ministry of Justice of the Russian Federation December 31, 2009, registration No. 15922);
Order of the Ministry of Health of the Russian Federation of October 14, 2003 No. 484 "On approval of instructions on the procedure for resolving artificial abortion of pregnancy at the later dates for social indications and conducting an operation of artificial abortion of pregnancy" (registered by the Ministry of Justice of the Russian Federation on November 25, 2003, registration number 5260).
^
Minister
IN AND. Skvortsova
Approved
Order of the Ministry of Health
Russian Federation
^ The procedure for providing medical care for the profile
"Obstetrics and gynecology (except for the use of auxiliary reproductive technologies)"
1. This procedure regulates the issues of providing medical care for the "Obstetrics and Gynecology" profile (except for the use of auxiliary reproductive technologies). "
2. The action of this Procedure applies to medical organizations that provide obstetric and gynecological medical care, regardless of the forms of ownership.
^
I. The procedure for providing medical care for women
during pregnancy
3. Medical assistance to women during pregnancy is within the framework of primary health care, specialized, including high-tech, and emergency, including emergency specialized, medical care in medical organizations that have a license to carry out medical activities, including work (services ) According to "obstetrics and gynecology (except for the use of auxiliary reproductive technologies)."
4. The procedure for providing medical care to women during pregnancy includes two main stages:
Ambulatory, in the absence of obstetrician-gynecologists, and in case of their absence, with physiologically flowing pregnancy - general practitioners (family doctors), medical workers of the medical obstetric items (at the same time, in the event of a complication of the course of pregnancy, consultation of an obstetrician should be ensured. - Gynecologist and a specialist doctor of the disease profile);
Stationary, carried out in the departments of the pathology of pregnancy (with obstetric complications) or specialized departments (in case of somatic diseases) of medical organizations.
5. The provision of medical care to women during pregnancy is carried out in accordance with the present order on the basis of routing sheets, taking into account the emergence of complications during pregnancy, including in extractive diseases.
6. In the physiological course of pregnancy, the inspections of pregnant women are held:
An obstetrician-gynecologist - at least seven times;
A physician-therapist - at least two times;
Dentist doctor at least two times;
An otorinolaryngologist, an ophthalmologist - at least once (no later than 7-10 days after the initial appeal to women's consultation);
Other specialist physicians - according to indications, taking into account the concomitant pathology.
Screening ultrasound examination (hereinafter - ultrasound) is carried out three times: in pregnancy timing 11-14 weeks, 18-21 weeks and 30-34 weeks.
Under the period of pregnancy, 11-14 weeks, a pregnant woman is sent to a medical organization that exercises the expert level of prenatal diagnosis, for the comprehensive prenatal (prenatal) diagnosis of violations of the child's development, including the ultrasound specialist doctor who has been trained and having admission to ultrasound screening surveys in I trimester, and the definition of maternal serum markers (associated with the pregnancy of plasma protein A (RARR-A) and free beta subunit of chorionic gonadotropin) with the subsequent program integrated calculation of the individual risk of the child's birth with chromosomal pathology.
Under the period of pregnancy, 18-21 weeks, a pregnant woman is sent to a medical organization that provides prenatal diagnostics, in order to exclude late manifesting congenital abnormalities for the development of the fetus.
When pregnant time, 30-34 weeks of ultrasound is carried out at the place of observation of a pregnant woman.
7. When the pregnant woman is established in a pregnant woman in chromosomal disorders from the fetus (individual risk 1/100 and higher) in the first trimester of pregnancy and (or) detection of congenital anomalies (malfunctions) in the fetus in I, II and III of the pregnancy trimesters The obstetrician gynecologist sends it to the medical and genetic counseling (center) for medical and genetic counseling and establishing or confirming the prenatal diagnosis using invasive examination methods.
In the case of establishing a prenatal diagnosis of congenital anomalies in the medical and genetic counseling (center) in the fetus, the fetal determination of the further tactics of pregnancy is carried out by the perinatal consultation of doctors.
In the case of the diagnosis of chromosomal violations and congenital anomalies (malfunctions) in a fetal with an unfavorable forecast for the life and health of the child after birth, pregnancy interruption under medical reasons is carried out regardless of the term of pregnancy to solve the perinatal consultation of doctors after receiving the informed voluntary consent of the pregnant woman.
For the purpose of artificial interruption of pregnancy under medical testimony under a period of up to 22 weeks, a pregnant woman is sent to the gynecological department. Abortion of pregnancy (delivery) at 22 weeks and is more carried out under the conditions of the observational branch of the obstetric hospital.
8. With prenatally diagnosed congenital anomalies (defects) in the fetal, the fetal needs to carry out perinatal consultation of doctors, consisting of an obstetrician-gynecologist, a neonatologist doctor and a children's surgeon. If there is a surgical correction in the neonatal period of doctors to conclusted the perinatal conservima of doctors, the direction of pregnant women for delivery is carried out in obstetric hospitals, having intensive care and intensive care chambers for newborns serviced by a 24-hour non-station doctor who owns the methods of resuscitation and intensive therapy of newborns.
In the presence of congenital anomalies (malfunctions) of the fetus, requiring the provision of specialized, including high-tech, medical care or newborn in the perinatal period, a consultation of doctors is carried out, which includes an obstetrician-gynecologist, an ultrasound physician, a genetic doctor, Neonatologist, Children's cardiologist and Children's Surgeon doctor. If it is impossible to provide the necessary medical care in the subject of the Russian Federation, a pregnant woman to conclusted the conservima doctors is sent to a medical organization that has a license to provide this type of medical care.
9. The main task of the dispensary observation of women during pregnancy is the warning and early diagnosis of possible complications of pregnancy, childbirth, postpartum period and the pathology of newborns.
When setting a pregnant woman to accounting in accordance with the conclusions of specialists' profile doctors, an obstetrician-gynecologist before 11-12 weeks of pregnancy makes a conclusion about the possibility of pregnancy.
The final conclusion about the possibility of tooling pregnancy, taking into account the state of a pregnant woman and the fetus, is made by an obstetrician-gynecologist up to 22 weeks of pregnancy.
10. For artificial abortion of pregnancy under medical testimony under a period of up to 22 weeks of pregnancy, women are sent to the gynecological departments of medical organizations that have the opportunity to provide specialized (including resuscitation) medical care to a woman (in the presence of specialist doctors of the corresponding profile, which identifies readings for artificial interruption of pregnancy).
11. The stage of providing medical care to women during pregnancy, childbirth and in the postpartum period is defined by Appendix No. 5 to this Procedure.
12. In the presence of testimony of pregnant women, it is proposed for fake and rehabilitation in sanatorium-resort organizations, taking into account the disease profile.
13. With a threatening abortion, the treatment of a pregnant woman is carried out in the protection institutions of motherhood and childhood (separation of pregnancy pathology, gynecological branch with chambers to preserve pregnancy) and specialized branches of medical organizations focused on pregnancy.
14. The doctors of female consultations carry out a planned direction to the hospital of pregnant women on the root separation, taking into account the degree of risk of complications in childbirth.
The rules for organizing the activities of women's consultation, recommended full-time standards and the standard for equipping women's consultations are defined by Appendices No. 1 - 3 to this Procedure.
The rules for the organization of the activities of the Acoucher-Gynecologist of the Women's Consultation are defined by Appendix No. 4 to this Procedure.
15. With extragnemitarian diseases requiring inpatient treatment, a pregnant woman is sent to the profile department of medical organizations, regardless of the term of pregnancy, subject to joint observation and conduct by a specialist in the profile of the disease and an obstetrician-gynecologist.
In the presence of obstetric complications, a pregnant woman goes to an obstetric hospital.
With a combination of pregnancy complications and extragenital pathology, a pregnant woman is sent to the hospital of a medical organization for the disease profile determining the severity of the state.
To provide inpatient medical care for pregnant women living in areas remote from obstetric hospitals and have no direct testimony to send pregnancy pathology, but in need of medical supervision to prevent the development of possible complications, a pregnant woman is sent to the branch of nursing care for pregnant women .
The rules for organizing the activities of the Nursing Department for pregnant women, recommended full-time standards and the standard for equipping the branch of nursing care for pregnant women are defined by Appendices No. 28 - 30 to this Procedure.
In day hospitals, women are sent during pregnancy and in the postpartum period that need invasive manipulations, daily observation and (or) implementation of medical procedures, but not requiring round-the-clock observation and treatment, as well as to continue observation and treatment after staying in the 24-hour hospital. The recommended duration of stay in the day hospital is 4-6 hours per day.
16. In cases of premature births in 22 weeks of pregnancy and more, a woman is carried out in an obstetric hospital, which has a branch (chamber) of resuscitation and intensive care for newborns.
17. Under the term of pregnancy, 35-36 weeks, taking into account the course of pregnancy in trimesters, assessing the risk of complications of the further course of pregnancy and childbirth on the basis of the results of all studies conducted, including consultations of specialist doctors, an obstetrician-gynecologist formulates a full clinical diagnosis and determined Place of planned delivery.
A pregnant woman and her family members are informed in advance with an obstetrician-gynecologist about a medical organization in which the delivery is planned. The question of the need to send to the hospital to childbirth is solved individually.
18. Pregnant women are sent to the consultative and diagnostic departments of perinatal centers:
A) with extragenital diseases to determine obstetric tactics and further observation, together with specialists in the profile of the disease, including the growth of a pregnant woman below 150 cm, alcoholism, drug addiction in one or both spouses;
B) with a burdened obstetric history (age up to 18 years old, first-hand over 35 years old, unbearable, infertility, perinatal death cases, the birth of children with high and low body, scar on the uterus, preeclampsia, eclampsia, obstetric bleeding, operations on the uterus and appendages , the birth of children with congenital defects, bubble skid, reception of teratogenic drugs);
C) with obstetric complications (early toxicosis with metabolic disorders, the threat of interrupting pregnancy, hypertensive disorders, anatomically narrow pelvis, immunological conflict (RH and AVO isoossentialization), anemia, improper position of the fetus, the pathology of the placenta, placental disorders, multiplodes, multi-way, lowland, induced pregnancy, suspicion of intrauterine infection, the presence of tumor-like formations of uterus and appendages);
D) with the identified pathology of the development of the fetus for determining the obstetric tactics and the place of delivery.
