572 order of the Ministry of Health. Organization of observation and medical care for pregnant women
Pregnancy management plan antenatal clinic regulated by a certain regulatory document.
Order on the management of 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 assisted reproductive technologies. This order on the management of pregnancy is applicable to all medical organizations and institutions that provide obstetric and gynecological care.
Clinical protocol for pregnancy management: pregnancy management plan according to order 572n.
Pregnant women should be provided not only with primary health care, but also with specialized, high-tech and emergency medical care.
When providing medical care to pregnant women, two main stages are envisaged:
- Outpatient support provided by obstetricians-gynecologists;
- Inpatient pregnancy management in the presence of any complications during pregnancy.
At normal course During pregnancy, a woman should undergo examinations by specialists at certain intervals:
- Obstetrician-gynecologist - at least 7 times during pregnancy;
- Therapist – 2 times;
- Dentist – 2 times.
It is enough to visit an otolaryngologist and an ophthalmologist once during pregnancy. If necessary, you can see other doctors.
Order 572n “pregnancy management” indicates that a pregnant woman must undergo three mandatory ultrasound scans within the following time frame:
- 11-14 weeks;
- 18-21 weeks;
- 30-34 weeks.
If research results show that the fetus has a high risk of chromosomal disorders, then the pregnant woman is sent to a medical genetic center to confirm or exclude a preliminary diagnosis. If the development of congenital anomalies is confirmed, then further tactics for managing pregnancy should be determined by a council of doctors.
If the fetus has serious chromosomal abnormalities, there are birth defects development, then after receiving the conclusion of a council of doctors, a woman can terminate the pregnancy at any stage of its development. Artificial termination of pregnancy can be carried out:
- In the gynecological department, if the period is 22 weeks or less;
- In the observation department of the obstetric hospital, if the period is more than 22 weeks.
Management of pregnancy - order of the Ministry of Health on dispensary observation
The main task of dispensary observation of pregnant women is to prevent and early detect all possible complications during pregnancy, childbirth and the postpartum period.
When a woman registers with the LCD, the standard of pregnancy management is applied to her. Order 572n describes the sequence of tests and diagnostic procedures at a certain stage of pregnancy. For example, after registering, a woman should visit doctors with narrow specializations, such as an ophthalmologist, dentist, otolaryngologist, endocrinologist and others. In addition, all tests must be completed before 12 weeks.
Every pregnant woman wants to be as protected as possible during the period of bearing a child and at the time of its birth. Standard medical care does not always meet the needs of the expectant mother - many tests and examinations have to be carried out in different clinics and laboratories on a paid basis. By taking out a VHI policy, pregnancy and childbirth costs are significantly lower, since a pregnant woman does not pay extra for each necessary examination and provides herself with timely and high-quality medical care.
Position on referral to hospital
If a woman is at risk of abortion, then her treatment should be carried out in specialized medical institutions equipped with all the necessary equipment. Such institutions include:
- Department of Pathology of Pregnant Women;
- Gynecological Department;
- Specialized departments in private medical centers.
When planning to send a woman to a maternity hospital for delivery, doctors must take into account the degree of risk of certain complications. These risks are identified during examination in the third trimester of pregnancy.
VI. The procedure for providing medical care to women with HIV infection during pregnancy, childbirth and the postpartum period
51. The provision of medical care to women with HIV infection during pregnancy, childbirth and 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) in the blood is carried out when registering for pregnancy.
53. If the first test for HIV antibodies is negative, women planning to continue the pregnancy are re-tested at 28-30 weeks. Women who used parenteral psychoactive substances during pregnancy and/or had sexual intercourse with an HIV-infected partner are recommended to be further examined at 36 weeks of pregnancy.
54. Molecular biological examination of pregnant women for HIV DNA or RNA is carried out:
a) upon receipt of questionable results of testing for antibodies to HIV obtained by standard methods (enzyme-linked immunosorbent assay (hereinafter referred to as ELISA) and immunoblotting);
b) upon receipt of negative test results for HIV antibodies obtained by standard methods if the pregnant woman belongs to a high-risk group for HIV infection (intravenous drug use, unprotected sex with an HIV-infected partner within the last 6 months).
55. Blood collection when testing for antibodies to HIV is carried out in the treatment room of the antenatal clinic using vacuum systems for blood collection with subsequent transfer of blood to the laboratory of a medical organization with a referral.
56. Testing for HIV antibodies is accompanied by mandatory pre-test and post-test counseling.
Post-test counseling is carried out for pregnant women regardless of the result of testing for HIV antibodies and includes a discussion of the following issues: the significance of the result obtained taking into account the risk of contracting HIV infection; recommendations for further testing tactics; routes of transmission and methods of protection against HIV infection; risk of HIV transmission during pregnancy, childbirth and breastfeeding; methods of preventing mother-to-child transmission of HIV infection available to a pregnant woman with HIV infection; the possibility of chemoprophylaxis of HIV transmission to a child; possible pregnancy outcomes; the need for follow-up of mother and child; the ability to inform your sexual partner and relatives about the test results.
57. Pregnant women with a positive laboratory test result for antibodies to HIV are referred by an obstetrician-gynecologist, and in his absence, a general practitioner (family doctor), a medical worker at a paramedic and obstetric station, to the Center for the Prevention and Control of AIDS of the subject Russian Federation for additional examination, registration at the dispensary and prescription of chemoprophylaxis for perinatal HIV transmission (antiretroviral therapy).
Information received medical workers about a positive result of testing for HIV infection of a pregnant woman, a woman in labor, a postpartum woman, antiretroviral prevention of mother-to-child transmission of HIV infection, joint observation of a woman with specialists from the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation, perinatal contact of HIV infection in a newborn, not subject to disclosure, except for cases provided for by current legislation.
58. Further observation of a pregnant woman with an established diagnosis of HIV infection is carried out jointly by an infectious disease specialist at the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation and an obstetrician-gynecologist at the antenatal clinic at the place of residence.
If it is impossible to refer (observe) a pregnant woman to the Center for Prevention and Control of AIDS of a constituent entity of the Russian Federation, observation is carried out by an obstetrician-gynecologist at the place of residence with methodological and advisory support from an infectious disease specialist at the Center for Prevention and Control of AIDS.
During the period of observation of a pregnant woman with HIV infection, an obstetrician-gynecologist at a antenatal clinic sends information about the course of pregnancy, concomitant diseases, pregnancy complications, laboratory test results to the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation, to adjust the regimens of antiretroviral prevention of HIV transmission from mother-to-child and (or) antiretroviral therapy and requests from the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation information about the characteristics of the course of HIV infection in a pregnant woman, the regimen for taking antiretroviral drugs, coordinates the necessary methods of diagnosis and treatment, taking into account the woman’s health condition and the course of pregnancy .
59. During the entire period of observation of a pregnant woman with HIV infection, the obstetrician-gynecologist of the antenatal clinic, in conditions of strict confidentiality (using a code), notes in the woman’s medical documentation her HIV status, presence (absence) and admission (refusal to admission) antiretroviral drugs necessary to prevent mother-to-child transmission of HIV infection, prescribed by specialists from the Center for Prevention and Control of AIDS.
If a pregnant woman does not have antiretroviral drugs or refuses to take them, the obstetrician-gynecologist at the antenatal clinic immediately informs the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation in order to take appropriate measures.
60. During the period of clinical observation of a pregnant woman with HIV infection, it is recommended to avoid procedures that increase the risk of infection of the fetus (amniocentesis, chorionic villus biopsy). The use of non-invasive methods for assessing the condition of the fetus is recommended.
61. When admitted for childbirth to an obstetric hospital, women who have not been examined for HIV infection, women without medical documentation or with a one-time examination for HIV infection, as well as those who used psychoactive substances intravenously during pregnancy, or had unprotected sex with an HIV-infected partner, Laboratory testing using a rapid method for HIV antibodies is recommended after obtaining informed voluntary consent.
62. Testing of a woman in labor for antibodies to HIV in an obstetric hospital is accompanied by pre-test and post-test counseling, including information about the importance of testing, methods of preventing the transmission of HIV from mother to child (use of antiretroviral drugs, method of delivery, features of feeding the newborn (after birth the child is not put to the breast and is not fed with mother's milk, but is transferred to artificial feeding).
63. Testing for HIV antibodies using diagnostic rapid test systems approved for use on the territory of the Russian Federation is carried out in a laboratory or emergency department of an obstetric hospital by medical workers who have undergone special training.
The study is carried out in accordance with the instructions attached to the specific rapid test.
Part of the blood sample taken for the rapid test is sent for testing for antibodies to HIV using standard methods (ELISA, if necessary, immune blot) in a screening laboratory. The results of this study are immediately transmitted to the medical organization.
64. Each HIV test using rapid tests must be accompanied by a mandatory parallel study of the same portion of blood using classical methods (ELISA, immune blot).
If a positive result is obtained, the remaining part of the serum or blood plasma is sent to the laboratory of the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation to conduct a verification study, the results of which are immediately transferred to the obstetric hospital.
65. If a positive HIV test result is obtained in the laboratory of the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation, a woman with a newborn, after discharge from the obstetric hospital, is sent to the Center for Prevention and Control of AIDS of a constituent entity of the Russian Federation for counseling and further examination.
66. In emergency situations, if it is impossible to wait for the results of standard testing for HIV infection from the Center for Prevention and Control of AIDS of a constituent entity of the Russian Federation, the decision to conduct a preventive course of antiretroviral therapy for mother-to-child transmission of HIV is made when antibodies to HIV are detected using a rapid test -systems A positive result of the rapid test is the basis only for prescribing antiretroviral prevention of mother-to-child transmission of HIV infection, but not for making a diagnosis of HIV infection.
67. To ensure the prevention of mother-to-child transmission of HIV infection, the obstetric hospital must always have the necessary supply of antiretroviral drugs.
68. Antiretroviral prophylaxis for a woman during childbirth is carried out by an obstetrician-gynecologist leading the birth, in accordance with recommendations and standards for the prevention of mother-to-child transmission of HIV.
69. A preventive course of antiretroviral therapy during childbirth in an obstetric hospital is carried out:
a) in a woman in labor with HIV infection;
b) with a positive result of rapid testing of a woman during childbirth;
c) in the presence of epidemiological indications:
inability to conduct rapid testing or timely obtain results of a standard test for HIV antibodies in a woman in labor;
a history of parenteral use of psychoactive substances or sexual contact with a partner with HIV infection during the current pregnancy;
with a negative test result for HIV infection, if less than 12 weeks have passed since the last parenteral use of psychoactive substances or sexual contact with an HIV-infected partner.
70. The obstetrician-gynecologist takes measures to prevent the water-free period from lasting more than 4 hours.
71. When conducting childbirth through the natural birth canal, the vagina is treated with a 0.25% aqueous solution of chlorhexidine upon admission to childbirth (during the first vaginal examination), and in the presence of colpitis - at each subsequent vaginal examination. If the anhydrous interval is more than 4 hours, the vagina is treated with chlorhexidine every 2 hours.
72. During labor management in a woman with HIV infection and a living fetus, it is recommended to limit procedures that increase the risk of infection of the fetus: labor stimulation; childbirth; perineo(episio)tomy; amniotomy; application of obstetric forceps; vacuum extraction of the fetus. These manipulations are performed only for health reasons.
73. Planned C-section to prevent intrapartum infection of a child with HIV infection, it is carried out (in the absence of contraindications) before the onset of labor and effusion amniotic fluid if at least one of the following conditions is present:
a) the concentration of HIV in the mother’s blood (viral load) before birth (at no earlier than 32 weeks of pregnancy) is more than or equal to 1,000 kopecks/ml;
b) the mother’s viral load before birth is unknown;
c) antiretroviral chemoprophylaxis was not carried out during pregnancy (or was carried out in monotherapy or its duration was less than 4 weeks) or it is impossible to use antiretroviral drugs during childbirth.
74. If it is impossible to carry out chemoprophylaxis during childbirth, cesarean section can be an independent preventive procedure that reduces the risk of contracting a child with HIV infection during childbirth, but it is not recommended for an anhydrous interval of more than 4 hours.
75. The final decision on the method of delivery of a woman with HIV infection is made by the obstetrician-gynecologist leading the birth on an individual basis, taking into account the condition of the mother and fetus, weighing in a specific situation the benefit of reducing the risk of infection of the child during a cesarean section with the probability the occurrence of postoperative complications and features of the course of HIV infection.
76. Immediately after birth, blood is collected from a newborn from an HIV-infected mother for testing for HIV antibodies using vacuum blood collection systems. The blood is sent to the laboratory of the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation.
77. Antiretroviral prophylaxis for a newborn is prescribed and carried out by a neonatologist or pediatrician, regardless of the mother’s intake (refusal) of antiretroviral drugs during pregnancy and childbirth.
78. Indications for prescribing antiretroviral prophylaxis to a newborn born from a mother with HIV infection, a positive result of rapid testing for HIV antibodies during labor, or an unknown HIV status in an obstetric hospital are:
a) the age of the newborn is no more than 72 hours (3 days) of life in the absence of breastfeeding;
b) in the presence of breastfeeding (regardless of its duration) - a period of no more than 72 hours (3 days) from the moment of the last breastfeeding (subject to its subsequent cancellation);
c) epidemiological indications:
unknown HIV status of the mother who uses parenteral psychoactive substances or has sexual contact with an HIV-infected partner;
a negative test result for HIV infection of a mother who has used psychoactive substances parenterally within the last 12 weeks or has had sexual contact with a partner with HIV infection.
79. A newborn is given a hygienic bath with a chlorhexidine solution (50 ml of a 0.25% chlorhexidine solution per 10 liters of water). If it is not possible to use chlorhexidine, a soap solution is used.
80. Upon discharge from the obstetric hospital, the neonatologist or pediatrician explains in detail in an accessible form to the mother or persons who will care for the newborn, the further regimen of chemotherapy drugs for the child, hands out antiretroviral drugs to continue antiretroviral prophylaxis in accordance with the recommendations and standards.
When conducting a prophylactic course of antiretroviral drugs using emergency prophylaxis methods, the mother and child are discharged from the maternity hospital after completing the prophylactic course, that is, no earlier than 7 days after birth.
In the obstetric hospital, women with HIV are consulted on the issue of giving up breastfeeding, and with the woman’s consent, measures are taken to stop lactation.
81. Data on a child born to a mother with HIV infection, antiretroviral prophylaxis for the woman during labor and the newborn, methods of delivery and feeding of the newborn are indicated (with a contingent code) in the medical documentation of the mother and child and transferred to the Center for the Prevention and Control of AIDS of a constituent entity of the Russian Federation Federation, as well as to the children's clinic where the child will be observed.
At first When a woman consults about pregnancy, the doctor gets acquainted with the general and obstetric-gynecological history, turning Special attention on family history, somatic and gynecological diseases suffered in childhood and adulthood, features of the menstrual cycle and reproductive function.
When familiarizing yourself with the family history, you should find out if relatives have diabetes mellitus, hypertension, tuberculosis, mental illness, cancer, multiple pregnancies, and the presence of children in the family with congenital and hereditary diseases.
It is necessary to obtain information about the diseases the woman has suffered, especially rubella, toxoplasmosis, genital herpes, cytomegalovirus infection, chronic tonsillitis, diseases of the kidneys, lungs, liver, cardiovascular, endocrine, oncological pathologies, increased bleeding, operations, blood transfusions, allergic reactions, and also about the use of tobacco, alcohol, narcotic or toxic drugs,
The obstetric and gynecological history includes information about the characteristics of the menstrual cycle and generative function, including the number of pregnancies, the intervals between them, duration, course and their outcomes, complications during childbirth and the postpartum period; weight of the newborn, development and health of children in the family. The history of sexually transmitted infections (genital herpes, syphilis, gonorrhea, chlamydia, ureaplasmosis, mycoplasmosis, HIV/AIDS infection, hepatitis B and C), and the use of contraceptives is specified. The age and health status of the husband, his blood type and Rh status, as well as the presence of occupational hazards and bad habits are determined.
During the first examination of a pregnant woman, the nature of her physique is assessed, information about the initial body weight shortly before pregnancy, and the nature of her diet are clarified. Particular attention is paid to women with overweight and underweight. During the examination of the pregnant woman, body weight, blood pressure in both arms are measured, attention is paid to color skin mucous membranes, angry tones, lungs are heard, the thyroid gland, mammary glands, regional lymph nodes are palpated, the condition of the nipples is assessed. An obstetric examination is carried out: the external dimensions of the pelvis and lumbosacral rhombus are determined, a vaginal examination is performed with a mandatory examination of the cervix and vaginal walls in the speculum, as well as the area of the perineum and anus. In women with a physiological course of pregnancy in the absence of changes in the vaginal and cervical areas, a vaginal examination is carried out once and the frequency of subsequent examinations is according to indications.
During the physiological course of pregnancy, the frequency of observation by an obstetrician-gynecologist can be established up to 6-8 times (up to 12 weeks, at 16 weeks, 20 weeks, 28 weeks, 32-33 weeks, 36-37 weeks) subject to regular (every 2 weeks ) observation by a specially trained midwife after 28 weeks of pregnancy. A change in the number of visits by pregnant women to an obstetrician-gynecologist can be introduced by a regulatory document of the local health care authority, subject to the availability of conditions and trained specialists.
At the first visit to a woman, the duration of pregnancy and expected birth are clarified. If necessary, the issue of gestational age is resolved consultatively, taking into account ultrasound data. After the first examination by an obstetrician-gynecologist, the pregnant woman is sent for examination to a therapist, who examines her twice during a physiological pregnancy (after the first examination by an obstetrician-gynecologist and at 30 weeks of pregnancy).
The pregnant woman is also examined by doctors: dentist, ophthalmologist, otolaryngologist and, if indicated, other specialists. Advisory assistance to pregnant women is provided in specialized antenatal clinics, hospitals, departments of educational medical institutions, and research institutes.
If there are medical indications for termination of pregnancy and the woman’s consent, she is given a commission report with a full clinical diagnosis, certified by the signatures of specialists (depending on the profile of the disease), an obstetrician-gynecologist, the chief physician (head) of the antenatal clinic, and the seal of the institution is affixed.
All pregnant women at risk are examined by the chief physician (head) of the antenatal clinic, and, if indicated, are referred for consultation to relevant specialists to decide on the possibility of prolonging pregnancy.
Individual cards of a pregnant woman and a postpartum woman are stored in each obstetrician-gynecologist's file cabinet according to the dates of the next visit. The card index should also contain records of women who have given birth, those subject to patronage, and pregnant women hospitalized in a hospital.
Cards of women who do not appear on time are selected for patronage. Patronage at home is carried out by a midwife as prescribed by a doctor. To conduct an examination at home, the midwife must have a tonometer, phonendoscope, measuring tape, obstetric stethoscope or portable ultrasound machine.
In the most difficult cases, home visiting is carried out by an obstetrician-gynecologist,
Pregnant women with obstetric pathology, according to indications, are hospitalized in the department of pathology of pregnant women of the maternity hospital (department); in the presence of extragenital pathology, hospitalization is recommended in the department of pathology of pregnant women of the maternity hospital, and also in the period up to 36-37 weeks of pregnancy - in the department of the hospital according to the profile of the disease. Pregnant women with severe obstetric and/or extragenital pathology may be hospitalized in a specialized maternity hospital or perinatal center.
For hospitalization of pregnant women whose condition does not require round-the-clock monitoring and treatment, it is recommended to establish day care hospitals in antenatal clinics or maternity hospitals (departments).
If there are harmful and dangerous working conditions, pregnant women from the moment of their first appearance are issued a “Medical certificate on the transfer of the pregnant woman to another job” with the preservation of the average earnings for the previous job.
The antenatal clinic doctor issues to the pregnant woman at 22-23 weeks the “Exchange Card” of the maternity hospital or maternity ward. When deciding on the employment of pregnant women, one should use hygienic recommendations for the rational employment of pregnant women.
The antenatal clinic doctor issues to the pregnant woman at 22-23 weeks an “Exchange card for the maternity hospital, maternity ward of the hospital.”
A certificate of incapacity for work for pregnancy and childbirth is issued by an obstetrician-gynecologist, and in his absence, by a general practitioner. A certificate of incapacity for work is issued from 30 weeks of pregnancy at a time for a duration of 140 calendar days (70 calendar days before childbirth and 70 calendar days after childbirth). In case of multiple pregnancy, a certificate of incapacity for work for pregnancy and childbirth is issued at a time from 28 weeks of pregnancy for a duration of 194 calendar days (84 calendar days before childbirth and 110 calendar days after childbirth).
If for any reason the right to timely receipt of maternity leave is not used or if premature birth occurs, a certificate of incapacity for work is issued for the entire period of maternity leave.
For childbirth that occurs during the period from 28 to 30 weeks of pregnancy and the birth of a live child, a certificate of incapacity for pregnancy and childbirth is issued by the antenatal clinic on the basis of an extract from the maternity hospital (department) where the birth took place, for 156 calendar days, and in the case of a stillbirth child or his death during the first 7 days after birth (168 hours) - for 86 calendar days; when a woman temporarily leaves her place of permanent residence - the maternity hospital (department) where the birth took place.
In case of complicated childbirth, a certificate of incapacity for work for an additional 16 calendar days can be issued by the maternity hospital (department) or the antenatal clinic at the place of residence on the basis of documents from the medical institution where the birth took place.
When applying for maternity leave, women are explained the need to regularly attend consultations and are provided with detailed information on caring for their unborn child. During pregnancy, women should be educated about the benefits of breastfeeding and the contraceptive methods recommended after childbirth.
The procedure for providing medical care according to the profile"obstetrics and gynecology"
APPROVED by order of the Ministry of Health of the Russian Federation dated November 01, 2012 No. 572n
1. This Procedure regulates the provision of medical care in the field of “obstetrics and gynecology (except for the use of assisted reproductive technologies).”
2. This Procedure applies to medical organizations providing obstetric and gynecological medical care, regardless of their form of ownership.
I. Procedure for providing medical care to women during pregnancy
3. Medical care for women during pregnancy is provided within the framework of primary health care, specialized, including high-tech, and emergency, including emergency specialized, medical care in medical organizations licensed to carry out medical activities, including work (services) ) in “obstetrics and gynecology (except for the use of assisted reproductive technologies).”
4. The procedure for providing medical care to women during pregnancy includes two main stages:
outpatient, carried out by obstetricians-gynecologists, and in the event of their absence during a physiologically progressing pregnancy - by general practitioners (family doctors), medical workers of paramedic-obstetric stations (at the same time, in the event of a complication of the pregnancy, consultation with an obstetrician should be provided -gynecologist and specialist in the profile of the disease);
inpatient, carried out in pregnancy pathology departments (for obstetric complications) or specialized departments (for somatic diseases) of medical organizations.
5. The provision of medical care to women during pregnancy is carried out in accordance with this Procedure on the basis of routing sheets, taking into account the occurrence of complications during pregnancy, including extragenital diseases.
6. During the physiological course of pregnancy, examinations of pregnant women are carried out:
an obstetrician-gynecologist – at least seven times;
by a general practitioner – at least twice;
by a dentist – at least twice;
an otolaryngologist, an ophthalmologist - at least once (no later than 7-10 days after the initial visit to the antenatal clinic);
by other medical specialists - according to indications, taking into account concomitant pathology.
Screening ultrasound (hereinafter referred to as ultrasound) is carried out three times: at gestational ages of 11-14 weeks, 18-21 weeks and 30-34 weeks.
When the gestation period is 11-14 weeks, a pregnant woman is sent to a medical organization that carries out an expert level of prenatal diagnostics to conduct a comprehensive prenatal (antenatal) diagnosis of child development disorders, including ultrasound by specialist doctors who have undergone special training and are authorized to conduct ultrasound screening examinations in first trimester, and determination of maternal serum markers (pregnancy-associated plasma protein A (PAPP-A) and free beta subunit of human chorionic gonadotropin) followed by a comprehensive software calculation of the individual risk of having a child with a chromosomal pathology.
When the pregnancy period is 18-21 weeks, the pregnant woman is sent to a medical organization that provides prenatal diagnosis, in order to conduct an ultrasound to exclude late-onset congenital anomalies of the fetus.
When the pregnancy is 30-34 weeks, an ultrasound is performed at the place of observation of the pregnant woman.
7. If a pregnant woman is diagnosed with a high risk of chromosomal abnormalities in the fetus (individual risk 1/100 or higher) in the first trimester of pregnancy and (or) detection of congenital anomalies (malformations) in the fetus in the first, second and third trimesters of pregnancy, the doctor The obstetrician-gynecologist refers her to a medical genetic consultation (center) for medical genetic counseling and establishing or confirming a prenatal diagnosis using invasive examination methods.
If a prenatal diagnosis of congenital anomalies (malformations) in the fetus is established at a medical genetic consultation (center), further pregnancy management tactics are determined by a perinatal council of doctors.
In the case of a diagnosis of chromosomal disorders and congenital anomalies (malformations) in a fetus with an unfavorable prognosis for the life and health of the child after birth, termination of pregnancy for medical reasons is carried out regardless of the gestational age by decision of the perinatal council of doctors after obtaining the informed voluntary consent of the pregnant woman.
For the purpose of artificial termination of pregnancy for medical reasons up to 22 weeks, a pregnant woman is sent to the gynecological department. Termination of pregnancy (delivery) at 22 weeks or more is carried out in the observation department of an obstetric hospital.
8. In case of prenatally diagnosed congenital anomalies (malformations) in the fetus, it is necessary to conduct a perinatal consultation of doctors, consisting of an obstetrician-gynecologist, a neonatologist and a pediatric surgeon. If, according to the conclusion of the perinatal council of doctors, surgical correction in the neonatal period is possible, pregnant women are referred for delivery to obstetric hospitals that have intensive care and intensive care units (wards) for newborns, served by a neonatologist working around the clock, who is proficient in the methods of resuscitation and intensive care of newborns.
In the presence of congenital anomalies (malformations) of the fetus that require specialized, including high-tech, medical care for the fetus or newborn in the perinatal period, a consultation of doctors is held, which includes an obstetrician-gynecologist, an ultrasound diagnostics doctor, a geneticist, neonatologist, pediatric cardiologist and pediatric surgeon. If it is impossible to provide the necessary medical care in a constituent entity of the Russian Federation, the pregnant woman, upon the conclusion of a council of doctors, is sent to a medical organization licensed to provide this type of medical care.
9. The main task of dispensary observation of women during pregnancy is prevention and early diagnosis possible complications of pregnancy, childbirth, the postpartum period and pathology of newborns.
When a pregnant woman is registered in accordance with the conclusions of specialized medical specialists, an obstetrician-gynecologist before 11-12 weeks of pregnancy makes a conclusion about the possibility of carrying a pregnancy.
The final conclusion on the possibility of carrying a pregnancy, taking into account the condition of the pregnant woman and the fetus, is made by an obstetrician-gynecologist up to 22 weeks of pregnancy.
10. For artificial termination of pregnancy for medical reasons up to 22 weeks of pregnancy, women are sent to the gynecological departments of medical organizations that have the ability to provide specialized (including intensive care) medical care to the woman (if there are medical specialists of the appropriate profile for which the indications for artificial termination of pregnancy).
11. The stages of medical care for women during pregnancy, childbirth and the postpartum period are determined by Appendix No. 5 to this Procedure.
12. If indicated, pregnant women are offered follow-up treatment and rehabilitation in sanatorium-resort organizations, taking into account the profile of the disease.
13. In the event of a threatened abortion, treatment of a pregnant woman is carried out in institutions for the protection of motherhood and childhood (pregnancy pathology department, gynecological department with wards for maintaining pregnancy) and specialized departments of medical organizations focused on maintaining pregnancy.
14. Doctors at antenatal clinics carry out planned referrals of pregnant women to the hospital for delivery, taking into account the degree of risk of complications during childbirth.
The rules for organizing the activities of the antenatal clinic, recommended staffing standards and the standard of equipment for the antenatal clinic are determined by Appendices No. 1 - 3 to this Procedure.
The rules for organizing the activities of an obstetrician-gynecologist at a antenatal clinic are determined by Appendix No. 4 to this Procedure.
15. In case of extragenital diseases requiring hospital treatment, a pregnant woman is sent to the specialized department of medical organizations, regardless of the stage of pregnancy, subject to joint observation and management by a specialist in the profile of the disease and an obstetrician-gynecologist.
If there are obstetric complications, a pregnant woman is sent to an obstetric hospital.
When pregnancy complications and extragenital pathology are combined, a pregnant woman is sent to the hospital of a medical organization according to the profile of the disease that determines the severity of the condition.
To provide inpatient medical care to pregnant women living in areas remote from obstetric hospitals and who do not have direct indications for referral to the pregnancy pathology department, but who need medical supervision to prevent the development of possible complications, the pregnant woman is sent to the department nursing care for pregnant women.
The rules for organizing the activities of the nursing care department for pregnant women, recommended staffing standards and the standard of equipment for the nursing care department for pregnant women are determined by Appendices No. 28 - 30 to this Procedure.
Women are sent to day hospitals during pregnancy and the postpartum period who require invasive manipulations, daily monitoring and (or) medical procedures, but do not require round-the-clock monitoring and treatment, as well as for continued monitoring and treatment after staying in a round-the-clock hospital. The recommended length of stay in a day hospital is 4-6 hours a day.
16. In cases of premature birth at 22 weeks of pregnancy or more, the woman is referred to an obstetric hospital that has a resuscitation and intensive care unit (wards) for newborns.
17. If the pregnancy period is 35-36 weeks, taking into account the course of pregnancy by trimester, assessing the risk of complications in the further course of pregnancy and childbirth, based on the results of all studies performed, including consultations with specialist doctors, the obstetrician-gynecologist formulates a full clinical diagnosis and determines place of planned delivery.
A pregnant woman and her family members are informed in advance by an obstetrician-gynecologist about the medical organization where the delivery is planned. The question of the need for referral to a hospital before birth is decided 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 height of a pregnant woman below 150 cm, alcoholism, drug addiction in one or both spouses;
b) with a burdened obstetric history (age under 18 years, primigravida over 35 years, miscarriage, infertility, cases of perinatal death, birth of children with high and low body weight, uterine scar, preeclampsia, eclampsia, obstetric hemorrhage, surgery on the uterus and appendages , birth of children with congenital malformations, hydatidiform mole, taking teratogenic drugs);
c) with obstetric complications ( early toxicosis with metabolic disorders, threat of miscarriage, hypertensive disorders, anatomically narrow pelvis, immunological conflict (Rh and ABO isosensitization), anemia, fetal malposition, placental pathology, placental disorders, multiple pregnancy, polyhydramnios, oligohydramnios, induced pregnancy, suspected intrauterine infection, presence of tumor-like formations of the uterus and appendages);
d) with identified pathology of fetal development to determine obstetric tactics and place of delivery.
II. The procedure for providing medical care to pregnant women with congenital defects internal organs in the fetus
19. In case of confirmation of a congenital malformation (hereinafter referred to as congenital malformation) in a fetus requiring surgical care, by a council of doctors consisting of an obstetrician-gynecologist, an ultrasound diagnostic doctor, a geneticist, a pediatric surgeon, a cardiologist, a cardiac specialist - the vascular surgeon determines the prognosis for the development of the fetus and the life of the newborn. The conclusion of the consultation of doctors is given to the pregnant woman for presentation at the place of pregnancy observation.
20. The attending physician provides the pregnant woman with information about the results of the examination, the presence of congenital malformations in the fetus and the prognosis for the health and life of the newborn, treatment methods, associated risks, possible options for medical intervention, their consequences and the results of the treatment, on the basis of which the woman makes a decision about pregnancy or termination of pregnancy.
21. If the fetus has congenital malformation incompatible with life, or the presence of combined defects with an unfavorable prognosis for life and health, with congenital malformation leading to persistent loss of body functions due to the severity and volume of the lesion in the absence of methods effective treatment, information is provided on the possibility of artificial termination of pregnancy for medical reasons.
22. If a woman refuses to terminate her pregnancy due to the presence of congenital malformations or other combined defects incompatible with life, the pregnancy is carried out in accordance with Section I of this Procedure. The medical organization for delivery is determined by the presence of extragenital diseases in the pregnant woman, the characteristics of the course of pregnancy and the presence of an intensive care unit (ward) for newborns in the obstetric hospital.
23. If the condition of the fetus worsens, as well as the development of placental disorders, the pregnant woman is sent to an obstetric hospital.
24. When deciding on the place and timing of delivery of a pregnant woman with a cardiovascular disease in the fetus requiring surgical care, a council of doctors consisting of an obstetrician-gynecologist, a cardiovascular surgeon (cardiologist), a pediatric cardiologist (pediatrician), pediatrician (neonatologist) is guided by the following provisions:
24.1. If the fetus has congenital heart disease requiring emergency surgical intervention after the birth of a child, a pregnant woman is sent for delivery to a medical organization that has licenses to carry out medical activities, including work (services) in “obstetrics and gynecology (except for the use of assisted reproductive technologies)”, “cardiovascular surgery” and (or) “pediatric surgery” and having the ability to provide emergency surgical care, including with the involvement of cardiovascular surgeons from specialized medical organizations, or in an obstetric hospital that includes a resuscitation and intensive care unit for newborns and an ambulance for emergency transportation of a newborn to a medical organization providing medical care in the field of cardiovascular surgery for medical intervention.
CHDs that require emergency medical intervention in the first seven days of life include:
simple transposition of the great arteries;
hypoplastic left heart syndrome;
hypoplastic right heart syndrome;
preductal coarctation of the aorta;
interruption of the aortic arch;
critical pulmonary stenosis;
critical aortic valve stenosis;
complex congenital heart disease accompanied by pulmonary artery stenosis;
pulmonary atresia;
total anomalous drainage of the pulmonary veins;
24.2. If the fetus has congenital heart disease that requires planned surgical intervention during the first 28 days to three months of the child’s life, the pregnant woman is sent for delivery to a medical organization that has a neonatal intensive care unit.
If the diagnosis is confirmed and there are indications for surgical intervention, a council of doctors consisting of an obstetrician-gynecologist, a cardiovascular surgeon (pediatric cardiologist), a neonatologist (pediatrician) draws up a treatment plan indicating the timing of medical intervention for the newborn in the cardiac surgery department. Transportation of a newborn to the place of specialized, including high-tech, medical care is carried out by a visiting anesthesiology and resuscitation neonatal team.
CHDs that require elective surgical intervention within the first 28 days of a child’s life include:
common arterial trunk;
coarctation of the aorta (in utero) with signs of increasing gradient at the isthmus after birth (assessed by dynamic prenatal echocardiographic monitoring);
moderate stenosis of the aortic valve, pulmonary artery with signs of increasing pressure gradient (assessment through dynamic prenatal echocardiographic monitoring);
hemodynamically significant patent ductus arteriosus;
large aortopulmonary septal defect;
anomalous origin of the left coronary artery from the pulmonary artery;
hemodynamically significant patent ductus arteriosus in premature infants.
24.3. Congenital heart diseases requiring surgical intervention up to three months of life include:
single ventricle of the heart without pulmonary stenosis; atrioventricular communication, complete form without pulmonary artery stenosis;
tricuspid valve atresia;
large defects of the interatrial and interventricular septa;
tetralogy of Fallot;
double origin of vessels from the right (left) ventricle.
25. When deciding on the place and timing of delivery of a pregnant woman with a congenital malformation (hereinafter referred to as congenital malformation) in the fetus (with the exception of congenital defects) requiring surgical care, a council of doctors consisting of an obstetrician-gynecologist, a pediatric surgeon, and a Geneticists and ultrasound diagnostic doctors are guided by the following provisions:
25.1. If the fetus has an isolated congenital malformation (damage to one organ or system) and there is no prenatal data for a possible combination of the defect with genetic syndromes or chromosomal abnormalities, the pregnant woman is sent for delivery to an obstetric hospital, which includes a neonatal intensive care unit and an intensive care unit for emergency transportation of a newborn to a specialized children's hospital that provides medical care in the field of pediatric surgery, for surgical intervention to stabilize the condition. Transportation of a newborn to the place of specialized, including high-tech, medical care is carried out by a visiting anesthesiology and resuscitation neonatal team.
Pregnant women with congenital malformations in a fetus of this type can also be consulted by medical specialists of the perinatal council of doctors (obstetrician-gynecologist, pediatric surgeon, geneticist, ultrasound diagnostic doctor) of federal medical organizations. Based on the results of the consultation, they can be sent for delivery to obstetric hospitals of federal medical organizations to provide care to a newborn in the neonatal surgery department, intensive care unit for newborns.
Isolated CDFs include:
gastroschisis;
intestinal atresia (except duodenal atresia);
volumetric formations various localizations;
lung malformations;
malformations of the urinary system with a normal amount of amniotic fluid;
25.2. if the fetus has congenital malformations, often combined with chromosomal abnormalities or the presence of multiple congenital malformations, to the maximum early dates During pregnancy, an additional examination is carried out in the perinatal center to determine the prognosis for the life and health of the fetus (consultation with a geneticist and karyotyping at the scheduled time, echocardiography of the fetus, magnetic resonance imaging of the fetus). Based on the results of the additional examination, specialists from the perinatal consultation of doctors from the federal medical organization are consulted to resolve the issue of the place of delivery of the pregnant woman.
Fetal congenital malformations, often combined with chromosomal abnormalities, or the presence of multiple congenital malformations, include:
omphalocele;
duodenal atresia;
esophageal atresia;
congenital diaphragmatic hernia;
defects of the urinary system, accompanied by oligohydramnios.
III. The procedure for providing medical care to women during childbirth and the postpartum period
26. Medical care for women during childbirth and the postpartum period is provided within the framework of specialized, including high-tech, and emergency, including specialized emergency medical care in medical organizations licensed to carry out medical activities, including work (services) on “obstetrics and gynecology (except for the use of assisted reproductive technologies).”
27. The rules for organizing the activities of the maternity hospital (department), recommended staffing standards and the standard of equipment of the maternity hospital (department) are determined by Appendices No. 6 - 8 to this Procedure.
The rules for organizing the activities of the perinatal center, recommended staffing standards and the standard of equipment for the perinatal center are determined by Appendices No. 9 - 11 to this Procedure.
The rules for organizing the activities of the Center for Maternal and Child Protection are determined by Appendix No. 16 to this Procedure.
28. In order to provide accessible and high-quality medical care to pregnant women, women in labor and postpartum, the provision of medical care to women during pregnancy, childbirth and the postpartum period is carried out on the basis of routing sheets, which make it possible to provide a differentiated volume of medical examination and treatment depending on the degree of risk of complications. taking into account the structure, bed capacity, level of equipment and provision of qualified personnel of medical organizations.
Depending on bed capacity, equipment, and staffing, medical organizations providing medical care to women during childbirth and the postpartum period are divided into three groups according to the possibility of providing medical care:
a) the first group – obstetric hospitals that do not provide round-the-clock presence of an obstetrician-gynecologist;
b) the second group - obstetric hospitals (maternity hospitals (departments), including those specialized by type of pathology), which have in their structure intensive care wards (department of anesthesiology and resuscitation) for women and resuscitation and intensive care wards for newborns, as well as inter-district perinatal centers, which include an anesthesiology-resuscitation department (intensive care wards) for women and a resuscitation and intensive care unit for newborns;
c) third A group - obstetric hospitals, which include an anesthesiology and resuscitation department for women, a resuscitation and intensive care unit for newborns, a pathology department for newborns and premature babies (stage II of nursing), a remote obstetric consultation center with on-site anesthesiology and resuscitation obstetrics teams to provide emergency and emergency medical care;
d) third B group - obstetric hospitals of federal medical organizations providing specialized, including high-tech, medical care to women during pregnancy, childbirth, the postpartum period and newborns, developing and replicating new methods of diagnosis and treatment of obstetric, gynecological and neonatal pathology and implementing monitoring and organizational and methodological support for the activities of obstetric hospitals in the constituent entities of the Russian Federation.
29.1. The criteria for determining the phasing of medical care and referral of pregnant women to obstetric hospitals of the first group (low risk) are:
the absence of extragenital diseases in a pregnant woman or the woman’s somatic condition that does not require diagnostic and therapeutic measures to correct extragenital diseases;
absence of specific complications of the gestational process during this pregnancy (edema, proteinuria and hypertensive disorders during pregnancy, childbirth and the postpartum period, premature birth, intrauterine growth restriction);
cephalic presentation fetus with a small fetus (up to 4000 g) and normal size of the mother’s pelvis;
the woman has no history of ante-, intra- and early neonatal death;
absence of complications during previous births, such as hypotonic bleeding, deep ruptures of the soft tissues of the birth canal, birth trauma in the newborn.
If there is a risk of complications of delivery, pregnant women are sent to obstetric hospitals of the second, third A and third B groups as planned.
29.2. The criteria for determining the phasing of medical care and referral of pregnant women to obstetric hospitals of the second group (medium risk) are:
mitral valve prolapse without hemodynamic disturbances;
compensated diseases of the respiratory system (without respiratory failure);
enlargement of the thyroid gland without dysfunction;
myopia I and II degrees without changes in the fundus;
chronic pyelonephritis without dysfunction;
urinary tract infections without exacerbation;
diseases of the gastrointestinal tract (chronic gastritis, duodenitis, colitis);
post-term pregnancy;
expected large fruit;
anatomical narrowing of the pelvis I-II degree;
breech presentation of the fetus;
low location of the placenta, confirmed by ultrasound at 34-36 weeks;
history of stillbirth;
multiple pregnancy;
a history of cesarean section in the absence of signs of uterine scar failure;
a scar on the uterus after conservative myomectomy or perforation of the uterus in the absence of signs of failure of the scar on the uterus;
a scar on the uterus after conservative myomectomy or uterine perforation in the absence of signs of scar failure;
pregnancy after treatment for infertility of any origin, pregnancy after in vitro fertilization and embryo transfer;
polyhydramnios;
premature birth, including prenatal rupture of amniotic fluid, at a gestational age of 33-36 weeks, in the presence of the possibility of providing full resuscitation care to the newborn and the absence of the possibility of referral to a third group (high-risk) obstetric hospital;
intrauterine growth retardation of the I-II degree.
29.3. The criteria for determining the phasing of medical care and referral of pregnant women to obstetric hospitals of the third A group (high risk) are:
premature birth, including prenatal rupture of amniotic fluid, with a gestational age of less than 32 weeks, in the absence of contraindications for transportation;
placenta previa, confirmed by ultrasound at 34-36 weeks;
transverse and oblique position of the fetus;
preeclampsia, eclampsia;
cholestasis, hepatosis of pregnant women;
a history of cesarean section if there are signs of uterine scar failure;
a scar on the uterus after conservative myomectomy or uterine perforation if there are signs of scar failure;
pregnancy after reconstructive plastic surgery on the genital organs, III-IV degree perineal ruptures during previous births;
intrauterine growth retardation of the II-III degree;
isoimmunization during pregnancy;
the presence of congenital anomalies (malformations) in the fetus requiring surgical correction;
metabolic diseases of the fetus (requiring treatment immediately after birth);
hydrops fetalis;
severe polyhydramnios and oligohydramnios;
diseases of the cardiovascular system (rheumatic and congenital heart defects, regardless of the degree of circulatory failure, mitral valve prolapse with hemodynamic disturbances, operated heart defects, arrhythmias, myocarditis, cardiomyopathies, chronic arterial hypertension);
thrombosis, thromboembolism and thrombophlebitis in history and during current pregnancy;
respiratory diseases accompanied by the development of pulmonary or cardiopulmonary failure;
diffuse connective tissue diseases, antiphospholipid syndrome;
kidney diseases accompanied renal failure or arterial hypertension, abnormalities of the urinary tract, pregnancy after nephrectomy;
liver diseases (toxic hepatitis, acute and chronic hepatitis, liver cirrhosis);
endocrine diseases (diabetes mellitus of any degree of compensation, thyroid disease with clinical signs of hypo- or hyperfunction, chronic adrenal insufficiency);
diseases of the visual organs (high myopia with changes in the fundus, history of retinal detachment, glaucoma);
blood diseases (hemolytic and aplastic anemia, severe iron deficiency anemia, hemoblastosis, thrombocytopenia, von Willebrand disease, congenital defects of the blood coagulation system);
diseases of the nervous system (epilepsy, multiple sclerosis, cerebrovascular accidents, conditions after ischemic and hemorrhagic strokes);
myasthenia gravis;
malignant neoplasms in history or detected during current pregnancy, regardless of....