The history of labor in obstetrics. Normal birth (first and second)

To display the correct picture of the lifestyle and all the studies of the future mother, a history of obstetrics delivery is compiled. Normal delivery of a woman depends entirely on the examinations and hereditary characteristics. All this the doctor during all 40 weeks writes down in this document. It is considered a legal act with its legal force and is necessary in cases when both parties refuse to take responsibility for themselves. To resolve differences, the history of childbirth at the first request is passed on to the chief physician, his senior management, and if the case takes a serious turn, the prosecutor.

Outlaw

The history of labor in obstetrics, like any other serious document, has its own degree of secrecy. The doctor who leads the pregnancy is obliged to keep silent and not to spread the information to third parties about the child in childbirth. Exceptions are cases where information is requested by law enforcement agencies.

To avoid violating the law of November 21, 2011, N 323-FZ "On the fundamentals of protecting the health of citizens in the Russian Federation" obstetricians and other medical personnel who examine pregnant women are prohibited from copying and photographing medical reports that store the history of obstetrics. Normal delivery also depends on the patient. When filling out a document by a doctor, a pregnant woman should be extremely frank. Only this will help obstetricians to establish clarity and correct diagnosis. Otherwise, the woman runs the risk of receiving the wrong treatment, which can affect the course of labor.

Rules of reference and filling in history

There are basic rules for filling out the document, in which the whole history of obstetrics delivery is maintained.

1. Passport data :

• Name of the patient;
• Date of Birth;
• Place of Birth;
• Place of work (or study);
• Contact address and telephone number;
• Family status;
• Education;
• Information about the husband and his contact details;
• Time of arrival in the hospital.

Further the doctor should describe all complaints which disturb the patient.

2. Medical information since birth

Here, information about previous illnesses and diagnoses should be described. The patient should exactly mention all the information concerning allergic reactions to medications. If there are hereditary diseases, the attending physician should know about them. Also in this section there is information about the onset of maternity leave.

3. Obstetric and gynecological analysis

This section indicates information related to pregnancy and childbirth. The doctor must identify all the details that may affect delivery. For each pregnant woman, information is compiled individually, taking into account previous pregnancies and childbirth. Information on blood is indicated: its losses and transfusions. Here, the doctor makes an assessment of health, based on the above data.

Anamnesis of pregnancy for a period of 38 weeks

This period is considered acceptable for delivery, but still early for the baby. When entering the hospital, the history of obstetrics delivery should be exactly filled. Normal delivery (38 weeks) can go without complications, but after the birth of the child, doctors should conduct a survey to find violations in the development of some organs of the baby.

In some cases, the time could be set incorrectly. This may be influenced by inaccurate information from the mothers on the menstrual cycle and the first ultrasound. At a period of 38 weeks the child takes the right position in the womb and is ready for birth. Most often at this time you can see false births that prepare the woman's body for the present. According to medical statistics, this is a common time for delivery, which often goes well.

Anamnesis of pregnancy for 39 weeks

At this time a pregnant woman can begin delivery at any time. Doctors conduct the necessary examinations, which are transferred to the maternity hospital. At 39 weeks, the baby sinks lower and presses his chin against his knees. When a woman in childbirth enters the maternity hospital, the history of obstetrics delivery should be completed.

Normal delivery (39 weeks) with a good history usually pass quickly and without complications. The document needs descriptions of all examinations and prescribed medications. Since the birth will soon occur, a woman should prepare for them in advance, after a survey, if you feel any changes in the body.

Anamnesis of pregnancy for a period of 40 weeks

This period is considered the termination of pregnancy. If labor activity has not come, you should go to the hospital, since its absence can be caused by internal failures. A woman who is in hospital under surveillance is subjected to a full survey, internal and external. On the basis of all this, the history of labor in obstetrics is filled. Normal delivery (40 weeks) is considered the most favorable - the child is fully ready for birth, the work of all internal organs is coordinated. The doctor should approach responsibly to the management of such a document as the history of labor in obstetrics, this will largely depend on the normal delivery.

4. Objective research

This includes records and conclusions from other narrow specialists. First of all, the psychological condition of a woman is assessed. In many respects, it depends on what kind of childbirth it is. A special mark is also made about this.

First birth

Pregnancy and childbirth are described in an anamnesis, which is fixed in the report. In another way, this is called the history of obstetrics. Normal birth first require doctors to scrutinize. This is due to the fact that it is impossible to foresee the course of this process and the reaction of the body.

The first birth is exciting not only for the staff, but also for the woman. Such patients are less worried because they do not know what will happen next, and curiosity overcomes fear and anxiety. The entire process of delivery from the beginning of the first contraction to the appearance of the baby is described by the obstetrician in the anamnesis. All the information preceding this event contains the history of childbirth. The norm for the first pregnancy is delivery on terms from 38 to 41 weeks. Obstetricians are studying information about complaints and diseases that arose during pregnancy. All these data are written in the column "Objective research".

Second childbirth

The second birth takes place in women faster than the first. As a rule, the anamnesis is based on the information of the first pregnancy, which contains the history of labor in obstetrics. Normal labor can begin with 38-39 weeks. In a woman's history, the details of previous pregnancies and births should be specified, which later stores the history of labor in obstetrics.

Normal second birth depends on the diagnosis correctly diagnosed by the doctor. In addition, information about a child born before, its development and congenital diseases, if any, is described. All this will help obstetricians properly treat pregnant women and carry out further childbirth.

5. Obstetrical status

This item stands next in the history of childbirth. Here, the measurements of the bottom of the uterus and pelvis are performed, the fetal heart rate and its position before birth in the womb are established. If a doctor suspects of a woman's or fetus's health, until the moment of delivery the doctors will constantly monitor the patient and make all the results in this section. When a woman enters a hospital, she is examined for the disclosure of the uterus and determines the degree of readiness for childbirth.

6. Diagnosis and rationale

Based on all the data given, the doctor establishes the correct diagnosis. He writes it down in history, necessarily substantiates and confirms with analyzes and inspections. The obstetrician indicates in this section the date of the first visit to the medical institution and information about the last menstrual cycle. In addition, he calculates and records the total weight gain and indicates the intended type of delivery.

7. Birth plan

The obstetrician gives an approximate plan for the process of delivery. This includes data on pain relief, pressure and movement of the fetal head. Any emergency must be described in stages with all possible remedies. In this column prescribe prescribed medications to maintain and stimulate labor.

8. The course of labor

This graph describes how the periods of childbirth pass. Here, every fight is fixed. The main goal pursued by the history of labor in obstetrics is the normal delivery. The woman's genital function must be preserved, for her future health. The manipulations of obstetricians described in this paragraph are aimed at preserving the important organs of the patient. After the birth data is entered, the last record is made about the child born and its parameters. The section shows information about the evaluation of the health of the baby and mother. The procedure of preparing the child for postnatal adaptation and its further processing is described in detail.

9. Postpartum period

This section contains monitoring of the woman in labor for two hours. Check the tone of the uterus, general and psychological state. If after the birth the woman has complications, this is recorded in the history. Also include data on the pulse and blood pressure.

10. Epicrisis

The history of labor in obstetrics ends with an epicrisis. Here you can find information about the date and time of the delivery of the mother and her childbirth. The description of the period of adaptation and recovery of the organism is attached. In addition, information about the child, the time and date of his birth, as well as an extract from the hospital are recorded. If necessary, there is information about the prescribed treatment and prescribed medications.

What is normal birth

The concept of "normal birth" is controversial. It is impossible to say unequivocally by the points that it relates to normal delivery. Also it is impossible to equate and adjust women under this definition. Childbirth is a delicate process that is virtually beyond the reach of accurate predictions. At the University of KSMU there is a maternity hospital, which brings the births closer to normal. Here, complete research is conducted to eliminate harmful factors that could harm or become more active during childbirth. After all the tests and examinations, the history of obstetrics delivery is filled.

Normal birth (KSMU) are under the supervision of doctors of the highest category, who carefully monitor all changes in the female body during childbirth. Specialists examine the genital and urinary organs, as well as assess the correctness of their formation. Doctors determine the state of the sense organs and the nervous system. A woman during labor experiences great loads not only physically, but also emotionally, so she needs a thorough examination. This helps to avoid further complications that can harm the baby and mom.

According to statistics, "normal delivery" is possible when they are perceived as a normal medical procedure. This helps to distinguish the communication between the patient and the doctor, each doing everything that is required of him. The doctor completely concentrates on the woman in childbirth and establishes a complete picture of her condition, so that the delivery goes well. The woman, in turn, must follow the recommendations of midwives unquestioningly and concentrate on the process itself.

Some statistics

If you look at the statistics, the percentage of normal births is small, only 10-20%. It must be remembered that such include a process in which doctors do not intervene. If in the history of an obstetrician find contraindications or diseases, then they necessarily interfere with childbirth. To date, there are many medical institutions that oversee universities. Experienced skilled doctors and young professionals participate in the labor of the woman and try to maximize that everything went well for the mother and baby. Summing up, it can be said that the most important document of a woman in childbirth is her birth history for midwifery.

Normal labor activity is possible only if it is properly administered and monitored by the doctor. If you give statistics on childbirth, in 37% of cases, women who did not provide information about their health or gave it incompletely gave birth with complications.

Conclusion

The history of labor in obstetrics is an important document that must be filled with special care. The future events depend on it. Only reliable and verified data is entered into this document. Here, all should be extremely frank and attentive, because the life of the mother and baby depends on this.

Doctors for years learn how to properly fill out documents, especially such as the history of obstetrics. Normal practice of its filling exists in all specialized medical institutions. When making a diagnosis, the doctor must prescribe it in history and attach evidence of this, and also inform the patient about all the nuances of the course of her pregnancy.