RODS

RODS - the physiological process of expulsion from the uterus of the fetus, amniotic fluid and placenta (placenta, membranes, umbilical cord) after the fruit has reached vitality. Viable fetus, as a rule, becomes after 28 weeks of pregnancy, when its mass is not less than 1000 g, and length - not less than 35 cm. Under physiological conditions, labor occurs when the gestation period is 38-42 weeks, when the fetus becomes mature - timely delivery . At the gestational age of 28-37 weeks premature birth occurs , the fetus during this period, although viable, but immature. Childbirth at term of pregnancy over 42 weeks and signs of a ripeness of a fetus - belated (see Perenashivanie pregnancy). A woman during labor is usually called a woman in childbirth.

The approach of birth can be judged by the appearance of a number of signs, called precursors of childbirth. These include the lowering of the abdomen of the pregnant woman by lowering and inserting the presenting part of the fetus into the entrance to the small pelvis and deviating the uterine fundus anteriorly due to a certain decrease in the tone of the abdominal press (observed 2 weeks before delivery); Reduction of the body weight of the pregnant woman by 1 -2 kg (for 2 - 3 days before delivery); Decreased motor activity of the fetus. The most significant forerunners of labor are irregular contractions of the uterus and discharge from the vagina of the cervical mucus (mucous plug). Often painful, but irregular contractions of the uterus in this preparatory period are mistaken for the onset of labor. The beginning of labor is considered the appearance of regular contractions of the uterus - fights.

Clinical course of normal delivery. During childbirth, three periods are distinguished: the first period is the opening of the cervix (in primiparas it lasts 13-18 hours, in repetitious patients 6-9 hours); II period - ejection of the fetus (1-2 hours in the primiparous, from 5-10 minutes to 1 hour in the re-parent); III period - successive (an average of 20 - 30 minutes for those and others). The duration of labor in primiparas is more often 15-20 hours, in repetitious 6-10 hours. The period from the beginning of regular contractions to the opening of the cervix for 3 to 4 cm is called the latent phase of childbirth, from the moment of opening the cervix to 3 to 4 cm until the end of labor - active phase of childbirth.

The period of the opening of the cervix continues from the moment of the appearance of fights until the opening of the uterine throat. In the beginning, contractions alternate after 10 to 15 minutes, then become more frequent and stronger.

During the struggle through the abdominal wall, it is possible to feel the border (transversely located furrow) between the uterus body and its lower segment - the border, or contraction, ring. As the cervix opens, it rises (a sign of Schatz-Unterberger) and when fully open, it is located at a distance of 8-10 cm from the upper margin of the pubic symphysis (lone articulation).

Disclosure of the cervix in primiparas and re-births occurs unequally. In primiparas, the inner pharynx opens first, the cervix of the uterus is smoothed (thinned), and then the outer shed opens. In re-births, the outer cervix is ​​open at the end of pregnancy, during the birth, the opening of the inner and outer throats of the cervix, as well as its smoothing occur simultaneously.

The degree of opening of the cervix is ​​determined from the diameter of the fingers, which can be inserted into the outer cervical cervix during vaginal examination. Thus, the introduction of 1 - 2 - 3-4 fingers into the pharynx corresponds approximately to the opening of the cervix by 2 - 4 - 6 - 8 cm. In case of full opening of the cervix (by 10-12 cm), its edges can not be determined during vaginal examination.

In the period of the opening of the cervix, as a rule, the advance of the presenting part of the fetus (a large part of the fetus, often the head located above the entrance to the mother's pelvis) begins through the birth canal. It descends and, touching from all sides with the lower segment of the uterus, presses it against the bone base of the birth canal. The place of coverage of the fetal head with the walls of the lower segment of the uterus is called the contact zone (fit), it divides the amniotic fluid into the anterior and posterior; The anterior amniotic fluid is below the girdle of contact between the fetal head and the lower pole of the fetal bladder, the posterior ones are located above the girdle of contact. The fetal bladder normally ruptures when the cervix is ​​fully or almost completely opened, and the anterior amniotic fluid is poured (timely discharge of amniotic fluid). If the rupture of the fetal bladder occurs before the onset of labor, then talk about a premature, or prenatal, outpouring of amniotic fluid. The outflow of water after the onset of labor, but with the opening of the cervix less than 6-7 cm, is called early. Occasionally, the fetal bladder is not ruptured, and the fetus is born in the membranes - birth in a "shirt". Sometimes the rupture does not occur at the lower pole of the fetal bladder near the outer throat of the cervix, but above - the "high" rupture of the fetal bladder. In such cases, when the fetal head moves forward, the opening in the fetal bladder closes, then a strained fetal bladder is determined during vaginal examination.

The period of expulsion of the fetus begins after the full disclosure of the cervix and ends with its birth. Exile of the fetus is due to attempts - simultaneous rhythmic contractions of the muscles of the uterus, diaphragm and abdominal press. Abbreviations of abdominal muscles appear reflexively. During the attempt, the mother gives birth to breath, the diaphragm is held at the same level; The pelvic floor muscles are reflexively reduced. At the pressure of the presenting part of the fetus on the pelvic floor, attempts to increase sharply and repeat every 2 to 3 minutes.

Under the influence of attempts, the fetus moves along the birth canal in accordance with the direction of its axis, performing rotational, flexural and extensor movements, overcoming the resistance of the contracting muscles of the pelvic floor and the Boulevard ring. The head (less often the other part of the fetus) is lowered to the pelvic floor, at the time of an attempt appears in the genital gaps, and outside the attempts disappears-the incision of the head. Subsequently, the incised head protrudes more and more from the genital slit and, as it were, is fixed in it, without hiding outside the attempts, - the eruption of the head. In case the nape of the fetus is present, and its back is facing anteriorly (anterior view of the occipital presentation), first the occipital region is cut, then the parietal knolls, after which the head is unbent and A little face is born, facing backwards. At the next attempt, an external turn of the fetal head takes place due to the internal rotation of the shoulders when they pass the small pelvis. At the first position (the frontal back is facing the left side of the uterus), the fetal head rotates with the face to the right thigh of the mother. The anterior shoulder (facing the front) is born first and lingers in the pubic symphysis, and then the posterior shoulder appears above the perineum. Without difficulties, the trunk and legs of the fetus are born, the hilar amniotic fluid is poured. The child takes the first breath and starts screaming.

The postpartum period comes after the birth of the fetus. During this period, the placenta separates from the walls of the uterus and the expulsion of the placenta (placenta, membranes and umbilical cord) from the genital tract due to contractions - rhythmic contractions of the uterus. After the birth of the fetus, the uterus contracts and takes a spherical shape, the bottom of it is located approximately at the level of the navel. In 10 - 15 minutes from the moment of a birth of the child at the woman there are easy fights, testifying to the beginning of separation of a placenta, then at small attempt the latter is born. Detachment of the placenta can begin with its center (central detachment) or edges (marginal detachment). With a central detachment, the blood flows out into the space between the placenta and the uterine wall, forming a retropacental hematoma. In this case, external bleeding, as a rule, does not happen, the placenta is born by the fruit surface outward, after the birth of the after-flow blood is poured. The first symptom of marginal placental abruption is external uterine bleeding. With an edge detachment, the placenta is born from the mother surface to the outside. After the expulsion of the afterbirth, the postpartum period begins, the woman after the termination of childbirth is called the mother.

The mechanism of delivery is the set of translational and rotational movements of the fetus when passing through the small pelvis of the parturient woman and the soft parts of the birth canal. Progressive movements of the fetus occur in the direction of the wire axis of the pelvis, which connects the middle of all the direct dimensions of the pelvis. In connection with the curvature of the sacrum and the presence of a powerful layer of pelvic floor muscles and perineum, the wire axis of the pelvis resembles a fish hook. Movement of the fetal head begins simultaneously with the appearance of regular labor. When passing through the birth canal, the head successively performs movements, the character of which depends on the presentation of the fetus. For normal births, the occipital presentation of the fetus (to the entrance to the small pelvis the head of the fetus is facing) is the flexural type of the head presentation. The frontal back can be turned to the left or right side of the uterus (respectively, the first and second position of the fetus), anteriorly or posteriorly (respectively, front and rear view). Approximately 95% of parturients have a front view of the occipital presentation of the fetus. The head of the fetus during normal delivery is located in the plane of the entrance to the small pelvis, usually in such a way that the sagittal seam (between the parietal bones) is at the same distance from the cape of the sacrum and pubic symphysis-synclic insertion, or synclytism. Sometimes a small temporal anterior asynclism (a shift of the arrow-shaped suture to the cape of the sacrum, is possible, as a result of which a parietal bone in front of the small pelvis is inserted into the entrance to the small pelvis). The pronounced displacement of the arrow-like suture to the cape of the sacrum or to the pubic symphysis (posterior asynclitism, in which the parietal bone is inserted, facing posteriorly) is an abnormal phenomenon, observed mainly in the narrow pelvis.

There are 4 points of the mechanism of childbirth in the forward view of the occipital presentation of the fetus. The first moment is the flexion (flection) of the head of the fetus, that is, its rotation around the transverse (frontal) axis. Due to bending, one pole of the head (small fontanelle) becomes the lowest point of the head moving forward. This point is called wire, since it first descends into the entrance to the small pelvis, is located all the time in front and the first is shown from the genital slit.

The second point is the internal rotation of the head of the fetus with the occiput anteriorly (rotation), i.e., rotating it around the longitudinal axis. When the fetal head rotates, the swept suture passes from the oblique or transverse size of the pelvis in a straight line. The rotation of the head ends in the plane of the narrow part of the small pelvis. As a result of turning the head, a small fontanelle turns to the pubic symphysis.

The third point - extension of the fetal head - comes after the area of ​​the suboccipital fossa is under the pubic arch. The area of ​​the suboccipital fossa is the fulcrum (fixation point), around which the head rotates during extension. The beginning of the extension corresponds to the insertion of the head, then during the extension process the head is eroded.

The fourth point is the inner turn of the trunk and the outer turn of the fetal head. As a result of the rotation of the trunk of the fetus, the diameter of its frontal girdle (the distance between the acromion of the scapula), located at the entrance to the small pelvis in transverse or oblique dimensions, in the outlet of the small pelvis is fixed at its right size: one shoulder is at the same time towards the pubic symphysis, The sacrum. The fetal head makes an external turn and is set at the first position with the back of the head to the left thigh of the mother, at the second position to the right thigh. Then the shoulder belt is born: first the upper third of the shoulder, facing the front, then the shoulders facing backwards. Next, the trunk and limbs of the fetus are born.

The mechanism of labor in the posterior form of the occipital presentation of the fetus includes five points.

The first moment is the bending of the fetal head. A wedge point at the entrance to the small pelvis due to the bending of the head becomes the area between its small and large fontanel - the crown.

The second point is the internal rotation of the fetal head, which can occur in two ways. Either a small fontanel turns backwards to the sacrum, and a large fontanel - to the pubic symphysis, or the head of the fruit, making a turn by 135 °, is set a small fontanel anteriorly, thus forming a front view of the occipital presentation.

With the retinitis of the occipital presentation, the third moment of the delivery mechanism is the additional folding of the fetal head during eruption: the fetal head, resting on the border of the forehead and the scalp in the pubic arch (the first fixation point), strongly bends, with the parietal and occipital knolls erupting.

The fourth point is the extension of the fetal head: the head in the region of the suboccipital fossa (the second fixation point) rests against the sacrococcygeal joint and unbends, with the forehead and the face of the fetus being released from under the pubic arch.

The fifth moment is the inner turn of the trunk and the outer turn of the fetal head.

Management of normal delivery. In many obstetric hospitals, normal births are performed by an obstetrician-gynecologist and a midwife who provides midwifery at birth; Normal birth can take a midwife.

In the inpatient facility, the obstetrician-gynecologist (or skilled midwife) decides which obstetric ward (physiological, observational) to direct the mother in childbirth. To do this, find out the history, examine the skin and mucous membranes, measure body temperature, determine the position of the fetus and listen to his heart tones. In the absence of signs of infection and a live fetus, the woman is sent to the physiological department. The basis for placement in the observational department is the detection of signs of infectious (including venereal) disease, elevated body temperature, dead fetus. In some infectious diseases (for example, scarlet fever, erysipelas, viral hepatitis), the woman is transported to an infectious hospital where a midwife is sent to conduct labor and, if necessary, an obstetrician-gynecologist.

From the waiting room, the woman in childbirth enters the examination room of the corresponding ward, where the midwife and obstetrician-gynecologist conduct a full obstetric examination. At the same time, the somatic status is evaluated, the urine is examined for protein (if necessary, clinical tests of urine and blood are prescribed), the pelvis is measured, external obstetric and vaginal examinations are performed, and the fetal condition is determined. External obstetric examination allows to establish the position, presentation, position and type of the fetus, inserting its head into the entrance to the small pelvis.

The main objective method for assessing the course of labor is vaginal examination. Preliminary examination of the external genitalia (varicose nodules, scars, etc.) and perineum (height, old ruptures, etc.). With vaginal examination, assess the condition of the pelvic floor muscles (elastic, flabby); Determine the width of the vagina and its patency (scars, septums); Find out the condition of the cervix: it is shortened or smoothened, the degree of opening of the pharynx, the thickness and consistency of its edges (thick, thin, soft or rigid). With a vaginal examination in the area of ​​throat, it is possible to detect a placental tissue, a loop of the umbilical cord or a small part of the fetus. In addition, it allows, with a whole fetal bladder, to find out the degree of its tension during the contraction and pause (excessive tension of the bladder even during pause indicates multivoran, flattening - on low water, flabbiness - weakness of labor); Determine the presenting part of the fruit and the identification points on it. At the head presentation during the vaginal examination, the position of the seams and fontanels is established with respect to the planes and pelvic dimensions, which makes it possible to judge the position of the fetus and the insertion of the head (synclytic or asynclical), to clarify the presentation of the fetus: flexor or extensor (anterior, frontal, facial) . If recognition of the recognition points on the fetal part is difficult (large generic swelling, significant head configuration, developmental defects) or the presenting part can not be determined, the vaginal examination is carried out not with two fingers but with four fingers or with the entire hand lubricated with sterile vaseline oil. With vaginal examination, the features of the osseous basis of the birth canal are also clarified.

Based on the data of external obstetric and vaginal studies, the position of the head is determined with respect to the pelvic planes. Distinguish the following positions of the fetal head: above the entrance to the small pelvis of the parturient, at the entrance to the small pelvis small or large segment, in the wide or narrow part of the pelvic cavity, in the pelvic outlet. The head of the fetus, located above the entrance to the small pelvis, is mobile, moves freely during jerks (runs) or is pressed against the entrance to the small pelvis. With a vaginal examination, a high standing of the head is determined, which does not prevent the feeling of nameless lines of the pelvis, the cape of the sacrum (if it is reachable), the inner surface of the sacrum and pubic symphysis.

The head, located in the entrance to the small pelvis by a small segment, i.e., in such a way that most of it is above the entrance to the pelvis and only a small segment of the head - below the plane of entry into the small pelvis, is stationary. When the fourth reception of the external obstetrician is carried out, the ends of the fingers of the investigator converge, and the bases of the palms diverge. With a vaginal examination, the sacral cavity, formed by the bend of the pelvic surface of the sacrum, is free, to the cape of the sacrum (if it is reachable) it is possible to "approach" the bent finger, the inner surface of the pubic symphysis is accessible to the study.

When the head is located in the entrance to the small pelvis with a large segment, the plane passing through the large segment of the head coincides with the plane of entry into the pelvis. In the fourth reception of external obstetric examination, the palms of the investigator are located either in parallel or the ends of the fingers diverge. When a vaginal examination reveals that the head covers the upper third of the inner surfaces of the pubic symphysis and sacrum, the cape of the sacrum is unreachable, the sciatic tubercles are easily palpable.

If the head is located in the wide part of the cavity of the small pelvis, the plane passing through the large segment of the head coincides with the plane of the wide part of the pelvis. When using the third method of external obstetric examination over the entrance to the small pelvis, it is possible to probe a small part of the head. When vaginal examination is determined that most of the head is in the plane of the wide part of the cavity of the small pelvis, two thirds of the inner surface of the pubic symphysis and the upper half of the sacral cavity are covered with a head; Freely probed IV and V sacral vertebrae and sciatic tubercles.

If the head is located in a narrow part of the cavity of the small pelvis, the plane of the large segment of the head coincides with the plane of the narrow part of the small pelvis. The head above the entrance to the small pelvis is not probed. With vaginal examination, it is found that the two upper third of the sacral cavity and the entire inner surface of the pubic symphysis are covered with the head of the fetus; Sciatic hillocks are difficult to reach.

When the head is located in the pelvic outlet, the plane of the large segment of the head is at the level of the exit plane of the small pelvis. When vaginal examination is established that the sacral cavity is completely filled with the head, the ischiatic hillocks are not determined.

All data of an anamnesis and objective research of a parturient woman are recorded in the history of childbirth. After the cleansing enema, the mother is sanitized (shaving the hair from the external genitalia, washing with an antiseptic solution, a shower), changing into a clean, preferably sterile laundry. Then it is transferred to the prenatal (during the disclosure of the cervix) or the birth chamber (during the fetal expulsion).

Keeping the period of cervical dilatation. With a whole fetal bladder, not very violent bouts or when the fetal head is fixed to the entrance to the fetus, the parturient woman is allowed to stand and walk beside the bed. Lying is better on your side. To speed birth, it is recommended to lie on the side where the nape of the fetus is defined. If the mother is lying on her back, it is advisable to give her a position close to the half-sitting, since the longitudinal axes of the fetus and uterus coincide, which favors the insertion of the fetal head into the small pelvis. It is necessary to ensure regular intake of easily digested food. Milk, liquid porridges, mashed soups, jelly, tea are recommended.

An individual ship is allocated to the parturient who is disinfected after each use. Every 6 hours, as well as after defecation and before vaginal examination, the external genitalia are washed with a solution of an antiseptic agent (for example, a solution of furacilin). Before vaginal examination, they are also treated with 5% alcohol solution of iodine, or iodonate solution containing about 1% free iodine (five times diluted with boiled distilled water, iodonate stock solution), or 0.5% aqueous alcohol solution of chlorhexidine. Vaginal examination in the first stage of labor is carried out at the first examination of the parturient woman (in the examination room), after the discharge of amniotic fluid, and also in the case of obstetric complications (bleeding, fetal hypoxia , etc.).

It is necessary to carefully monitor the condition of the parturient woman: find out her state of health (the degree of pain, fatigue, dizziness, headache, vision disorders, etc.), listen to the heart, systematically examine the pulse and measure blood pressure. The body temperature is measured 2 - 3 times a day (if necessary - more often). It is important to monitor the function of the bladder and intestines. To avoid overflow of the bladder, the mother is offered to urinate every 2 to 3 hours; If an independent urination is impossible, resort to a catheterization of the bladder.

Of great importance is the observation of the nature of labor, the state of the uterus, the opening of the cervix, the advancement of the fetal head and its condition. The contracting activity of the uterus (duration, strength and frequency of contractions) can be determined by palpation of the maternity belly. More objective about the nature of fights can be judged by the results of hysterography - registration of contractile activity of the uterus with the help of various instruments. In recent years, cardiotocography has been widely used, which makes it possible to monitor simultaneously the frequency of cardiac contractions of the fetus and the tone of the uterus. Violations of the contractile activity of the uterus (weakness, excessive force, discoordination) are reflected in the curves recorded with the help of various instruments.

To determine the degree of cervical dilatation, the height of the contraction ring above the pubic symphysis is measured. When this ring is located at a distance of 4-6 or 8-10 cm from the upper margin of the pubic symphysis, the pharyngeal opening is respectively 4 to 6 or 8 to 10 cm. More precisely, the dynamics of cervical dilatation is determined by vaginal examination.

With the help of external obstetric and vaginal examinations, it is possible to monitor the position of the fetal head with respect to the generic canal, ie, monitor its progress. In the normal course of labor there is a consistent advance of the head through the birth canal, it is not permanently in one plane of the pelvis. Continuous standing of the head in one plane of the pelvis, which is noted when there are any obstacles to expelling the fetus or weakening labor, leads to compression of the soft tissues of the birth canal and bladder, a violation of blood circulation in them, which can cause the formation of postpartum fistula.

The rupture of the fetal bladder and the outflow of amniotic fluid is the crucial moment of delivery and requires special attention. The addition of meconium in the amniotic fluid usually indicates the onset of hypoxia of the fetus, the admixture of blood - to rupture the edges of the uterine throat, detachment of the placenta and other pathological processes.

Auscultation of palpitations of the fetus during the opening of the cervix with an intact fetal bladder is carried out every 15 to 20 minutes, and after the outflow of amniotic fluid - after 5 to 10 minutes. Pay attention to the rhythm and sonority of heart tones, calculate the heart rate of the fetus. In the period of the opening of the cervix with the head presentation of the fetus, its parameters are as follows: the average heart rate of the fetus varies from 125 to 160 beats per minute, the rhythm is correct with the amplitude of instantaneous heart rate changes from 5 to 10 beats per minute. The reaction of cardiac activity of the fetus to the fight is either absent or manifests by early heart rate changes that begin with the beginning of the bout and coincide in time with the duration of the bout.

In the period of the disclosure of the cervix, the anesthesia of labor begins.

Keeping the period of fetal expulsion. In maternity hospitals, the woman in labor during the expulsion of the fetus is placed on a special, so-called Rakhman bed. Lying on her back with her legs bent in the knee and hip joints, the woman in labor with her feet rests against the bed, and hands clings to special handles. During the expulsion of the fetus, a great strain of the physical forces of the woman is required. The fetus suffers more often during this period of labor, as its head is squeezed and intracranial pressure rises, and with strong and prolonged attempts, the uterine-placental circulation is disturbed. In this regard, especially careful monitoring of the parturient and fetus is necessary.

In the period of fetal exorcism, one should listen to his heart tones and count the heart rate after each attempt (at least every 10-15 minutes). The average heart rate of the fetus in this period of labor ranges from PO to 170 (usually 110-130) beats per minute. After attempts, as a rule, early heart beat decreases (up to 80 beats per minute) or short-term increases in heart rate. The deviation of fetal heart rate from normal indicates fetal hypoxia.

The advancement of the fetal head during the fetal ejection period is monitored using the third and fourth methods of external obstetric examination, as well as the Piskacek method based on palpation through the perineal tissue of the lower pole of the head. At the position of the parturient woman on her back, the person who examines the fingers in sterile gloves (or wrapped with a sterile tissue) tends to reach the lower pole of the fetal head through the perineal tissues outside the right large labia. If the head is in the wide part of the pelvic cavity or below, it is palpable. With a large generic tumor, the method does not give a reliable result.

Of great importance is monitoring the condition of the external genitalia of the mother and the nature of vaginal discharge. The appearance of the edema of the external genital organs indicates the compression of the soft tissues of the birth canal. Isolation of blood from the vagina may indicate a beginning placental abruption or damage (rupture, abrasion) of the soft tissues of the birth canal.

From the time of insertion of the fetal head, it is necessary to prepare for delivery. The external genitals and the inner surfaces of the mother's thighs are washed with an antiseptic solution. The area of ​​the anus is covered with a sterile diaper. The deliverer handles the hands, wears sterile gloves and a sterile dressing gown. From the moment of eruption of the head of the fetus proceed directly to the delivery of labor - conducting obstetric hand techniques that contribute to the natural course of labor.

The right hand protects the perineum, supporting it with the palm, while the left (with the front view of the occipital presentation of the fetus) is delayed premature extension of the head, while the head passes the vulvar ring with its smallest size.

In pauses between attempts, the fingers of the left arm of the receiving genera lie on the head of the fetus, and with the right hand it eliminates the excessive stretching of tissues in the posterolateral regions of the vulvar ring. To do this, the clitoris and small labia lips "lower" from the nasal birth of the fetus, the less stretched tissues of the anterior section of the vulvar ring are reduced as far as possible back to the perineum. Since the birth of the nape of the fetus (the area of ​​the suboccipitary fossa rests on the lower edge of the pubic symphysis) and until the entire head is removed, the maternity child is forbidden to push. If there is a threat of rupture of the perineum (blanching of the skin, the appearance of cracks), it is dissected.

The birth of the fetal head must itself rotate the face to the right or left thigh of the mother (depending on the position). If the external turn of the head is delayed, the mother is offered to labor. During the attempt, the inner turn of the shoulders and the outer turn of the fetal head take place, the shoulders rise in a straight pelvic size and are probed through the vulvar ring. First contribute to the birth of the upper third of the shoulder, facing the front, and then back, gently "reducing" from his crotch. If the self-eruption of the shoulder girdle is delayed, the fetus head is grasped with both hands so that the palms rest on the auricles (the ends of the fingers should not touch the fetal neck because of the danger of squeezing the vessels and nerves) and deflect it downwards, and after the front shoulder is born upward. The fetal posterior shoulders can also be removed by the following method: the fetal head is grasped with the left hand and withdrawn to the top, with the right hand lowered from the shoulder of the crotch tissue. If you can not get the hangers off with these techniques, from the side of the fetal back to the axillary cavity of the front shoulder is introduced the index finger, the mother is offered to press and at this time sip on the shoulder until it fits the pubic arch. Then release the back of the shoulder.

After birth of the shoulder girdle of the fetus with both hands gently wrap around his chest and direct the trunk up, with the birth of the lower body without difficulty. If after the birth of the fetal head, the umbilical cord that surrounds the neck is visible, it should be removed through the head. If it is impossible to do this, especially if the umbilical cord is stretched and restrains the movement of the fetus, it must be cut between two clamps and quickly extracted from the fetus.

The management of uncomplicated births in the back of the occipital presentation of the fetus should be wait and see. The period of expulsion of the fetus may be longer than with the anterior form of the occipital presentation, but usually the labor terminates spontaneously. First, they help to further bend the head of the fetus and give birth to the occiput, and then unbend and release from under the pubic symphysis of the face. Further management is the same as in the forward view of the occipital presentation of the fetus. With complications that occur more often in the posterior form of the occipital presentation of the fetus than in the anterior one, there may be a need for surgical intervention (application of obstetric forceps, vacuum extraction of the fetus, etc.).

Keeping the postpartum period of childbirth. The most active is the wait-and-see tactic of conducting the follow-up period. After the birth of the child, the woman in childbirth continues to lie on her back. Place a sterile tray under the sacrum to collect blood from the birth canal. It is poured into a graduated vessel to account for blood loss. With the help of a catheter, the bladder is emptied, since its overflow inhibits successive contractions and disrupts the process of detachment of the placenta and discharge of the placenta. During the follow-up period, the changes in the size and shape of the uterus are observed (visually and with the help of light palpatory movements), which is especially important for central placental abruption, when the absence of external bleeding does not allow to judge the magnitude of blood loss. It is necessary to avoid rough palpation of the uterus, as this can disrupt the normal process of separation of the placenta and lead to bleeding. Constantly observe the condition of the parturient woman (complaints, skin color, blood pressure, pulse , etc.). When blood loss is not more than 250 ml, wait (no more than 20 - 30 min) of spontaneous birth of the afterbirth. During this time, follow signs of separation of the placenta. The most reliable are the signs of Schroeder and Kyustner-Chukalov.

A sign of Schroeder is a change in the shape of the uterus and the height of the standing of its bottom. Immediately after the birth of the fetus, the shape of the uterus is rounded, the bottom of it is approximately at the level of the navel. After the placenta is separated, the latter descends into the lower part of the uterus, partially into the vagina, pushing the uterus upward, while the uterus acquires an elongated shape and deviates to the right, its bottom is somewhat higher than the navel. After the birth, the bottom of the uterus is below the navel along the midline of the abdomen.

Sign of Kustner - Chukalov - when pressing the palm of the hand on the anterior abdominal wall of the parturient child over the pubic symphysis, the outer (visible) part of the umbilical cord in the case of the separated placenta is not drawn into the vagina, with the unplaced placenta being retracted.

If signs of separation of the placenta are present, it is necessary to promote the release of the placenta. Usually it is enough to offer a woman to strain. In case of ineffectiveness of this event, resort to Abuladze: two hands grasp the anterior abdominal wall in the longitudinal crease, thereby reducing the volume of the abdominal cavity, and suggest that the woman again stiffen. The most effective is the reception of Krede-Lazarevich. It is performed with a bladder emptied. After the external massage of the uterus and removing it to the midline of the abdomen, the uterus's bottom is grasped with the hand so that the thumb is located on the front surface of the uterus, and four others on the back. Squeezing fingers and pushing to the bottom of the uterus in the direction of the sacrum, secrete the latter.

Receiving Krede-Lazarevich with an unplaced placenta is quite dangerous, since it can contribute to increased bleeding. Therefore, before it is performed, it is necessary to prepare for manual examination of the uterus and manual removal of the placenta. Violation of the technique of taking Krede-Lazarevich may lead to a reversal of the uterus.

An important point in managing the after-care period is a thorough investigation of the afterbirth. First, inspect the maternal surface of the placenta; In norm it is smooth with even edges, lobules distinctly expressed and covered with a thin layer of the decidual (falling off) shell of the uterus. The area of ​​the placental defect differs from the surrounding tissue and is usually of a dark red color. Turning the placenta, examine its fertile surface and membranes. The presence between the fetal membranes of ragged vessels that extend from the edge of the placenta, indicates the placental segments remaining in the uterus. During the examination of the membranes, attention is drawn to the localization of their laceration, which can be used to judge the place of attachment of the placenta to the wall of the uterus (for example, if the fetal membranes are ruptured at the edge of the placenta, it was attached near the inner uterine pharynx, if far from the edge, the placenta was attached High in the area of ​​the body or the bottom of the uterus). Inspection of the membranes in multiplicity allows to establish whether twins are monogamous or bipartite. Upon examination, the umbilical cord is determined by its thickness, length, the color of the varton jelly, the presence of nodes, and the location of the attachment of the umbilical cord to the placenta. The placenta is measured, weighed.

In case of suspicion of a violation of the integrity of the placenta or the remaining lobules in the uterus, a manual examination of the uterus is necessary (in the uterine cavity, under anesthesia, the arm that examines the walls of the uterus is inserted into the uterus under the aesthetic rules) and the lagging part of the placenta is identified.

After the birth, the external genitalia, perineum and inner surface of the thighs of the puerpera are washed with a solution of an antiseptic agent, gently untreated labial pushes are opened with sterile tampons, the entrance to the vagina, the perineum is examined to reveal their ruptures. In all primiparous, as well as in re-birth after delivery operations or with a large fetus, you should examine the vagina and cervix using vaginal mirrors. The ruptures of the perineum, vagina, cervix are sutured immediately after birth.

After the termination of childbirth, the puerpera remains in the delivery room for 2 to 3 hours. During this period, her condition is monitored, the pulse is periodically monitored, the uterus palpated, and the vaginal discharge is monitored. If by the end of this period the condition of the puerpera is satisfactory, the uterus is dense, there are no signs of bleeding, it is transported to the postpartum department.

In maternity hospitals it is necessary to allocate physiological and observational departments (chambers) for newborns. For children, the brightest, warmest and most spacious rooms are allocated. One bed for a healthy newborn should have at least 2.5 m2 of area, for premature babies and children in the observatory, at least 4 m2. As part of the observatory department, half-boxes are provided for the temporary isolation of diseased newborns.

In the department of newborns, as well as in the obstetric ward, it is necessary to observe the principle of cyclic filling and sanitization of wards. For this purpose, the number of beds in the wards for the newborn should correspond to the number of beds in the puerperal ward, and the actual number of postpartum and baby beds is 10% higher than the estimated number of beds.

For preterm and traumatized children, it is necessary to allocate separate intensive care units, in which it is possible to place incubators and devices for oxygen therapy, devices for artificial ventilation.

In the wards for healthy full-term newborns, a constant temperature regime is maintained (for the term 21-22 ° C, for premature babies 22-24 ° C) and a relative humidity of 60%. Wet cleaning of wards with disinfectants is carried out at least 6 times a day (at the hours coinciding with the feeding of children). The room is ventilated at the same time. The bed of the child is covered with a mattress without a pillow. On top of the mattress, put on an oilcloth cover, which is soaked in a 1% solution of chloramine (after discharge of each child) and daily wiped with a disinfectant solution (6 times a day).

The first toilet of the newborn is held by a midwife in a specially designated place in the delivery room or in a separate children's room adjacent to the delivery room. The changing table, on which the first toilet of the newborn is held, should have a well-washable coating, which allows it to be treated after each child (1% chloramine solution) and daily washed with warm water and soap. On the side of the changing table, a centimeter tape with a length of up to 60 cm is fixed to measure the length of the child's body. Next to the changing table, place the trays of medical scales.

In the delivery room or children's room, the maternity room must have a mucus suction machine (water jet or vacuum suction) and artificial respiration apparatus. It is necessary to have a children's laryngoscope and a set of sterile intubators, as well as devices for oxygen inhalation. The delivery room should have sterile metal trays for receiving a newborn and a set of sterile catheters and rubber cans for sucking mucus out of the mouth and the pharynx of the newborn.

For the first toilet of the newborn in the delivery room, there should always be kits of sterile underwear and tools. A set of underwear, consisting of a blanket and three diaper diapers, also includes a sterile individual kit, which is necessary for processing the umbilical cord. This set contains a bracket and spitz for its application to the umbilical cord, a silk ligature and a triangular gauze napkin folded into 4 layers, 2 Kocher clips and medical scissors. Such individualization of care items is a measure of preventing the infection of newborns. In addition, the kit contains two wand sticks for processing the umbilical cord with a 5% alcohol solution of iodine, pipette and gauze balls, necessary for the prevention of gonoblenorei. In the kit there is also a tape made of medical oilcloth with a length of 60 cm and a width of 1 cm or an oilcloth to measure the length of the body, the circumference of the head and the breast circumference of the child, as well as two oilcloth cuffs and one oilcloth medallion.

Reception of the newborn. Before taking a newborn, the midwife treats her hands as before the operation, and puts on sterile gloves. At the time of birth of the baby's head, sucking mucus from the upper respiratory tract is carried out with a rubber balloon or a special suction. The midwife takes the child to the tray with a sterile diaper. The first toilet of the newborn is provided by the midwife.

Umbilical cord treatment. 30 seconds after the birth of the newborn is separated from the mother. For this, two clamps of Kocher are placed on the umbilical cord: one at a distance of 10 cm from the umbilical ring, the second - 2 cm outside of it. The umbilical cord located between the clamps is lubricated with 5% alcohol solution of iodine and crossed (the first stage of the umbilical cord treatment).

The child, separated from the mother, the midwife transfers to the changing table and before disinfection the child again disinfects her hands. Then she rubs the remainder of the umbilical cord with a sterile gauze napkin and tightly squeezes the umbilical cord between the index and thumb. In special tongs, insert a metal brace. The umbilical cord is inserted between the sticks of the bracket so that the lower edge of the brace is located 0.5 to 0.7 cm from each edge of the umbilical ring (at the maximum projection of the skin). The forceps with the bracket close over the umbilical cord until they click into place.

If the mother is Rh-negative, a silk ligature is applied to the newborn instead of the brace for the remainder of the umbilical cord 5 cm long so that if necessary, a replacement blood transfusion can be made (see Hemolytic disease of the fetus and newborn). At a distance of 2.5 cm to the outside of the ligature or brace, the cord is cut with sterile scissors. The cut surface of the umbilical cord is treated with a 5% solution of potassium permanganate (second stage of umbilical cord treatment).

The remainder of the umbilical cord with the bracket applied to it is left open and care is taken without bandage. If silk ligature is applied to the remainder of the umbilical cord, then the stump is tied with a gauze napkin in the form of a cap.

Preventive maintenance gonoblenorei eyes at newborns is spent by the midwife after preliminary washing of hands. The child's eyelids are wiped with dry sterile cotton wool from the outer corner of the eye to the inner corner of the eye. The midwife slightly pulls the lower, and then raises the upper eyelid; 30% solution of sulfacyl sodium is applied to the mucous membrane of the lower transitional fold of each eye. Re-treatment of the eyes is performed in the neonatal department 2 hours after the birth of the child.

The midwife cleans the skin of the baby from the damp grease, mucus and blood with a soft gauze pad moistened with sterile vaseline oil. The contents of the bottle (capacity 30 ml) is used for the toilet of only one child.

In the maternity department, the oilcloth cuffs are harvested, on which the surname, name, patronymic of the mother, the birth history number, date, hour and minute of birth, the sex of the child are recorded. Cuffs using sterile gauze ribbons are fixed on the wrists of the child. Weigh the newborn on a tray weigher. Before weighing, the scales are wiped with a diaper soaked in a 1% solution of chloramine.

Measuring the length of the child's body, head circumference and chest are made using a sterile oilcloth tape. The newborn is wrapped in sterile diapers and a blanket. Over the blankets tie a medallion on which the same data as on the cuffs are recorded. After carrying out the procedure of primary treatment, it is recommended to place the child in bed and put a warm water bottle at his feet. Before transferring the child from the delivery room to the department of newborns, inscriptions on medallions with documents are indicated.

Anesthesia of childbirth is a complex of preventive and therapeutic measures aimed at eliminating or reducing pain during delivery.

Pain in the process of labor is the result of the opening of the cervix, which has highly sensitive receptors, as well as contractions of the uterus, accompanied by tension of its ligaments, parietal peritoneum, changes in intra-abdominal pressure, irritation of reflexogenic zones of the pelvis. The increase in pain sensitivity in the first stage of labor is directly proportional to the rate of opening of the cervix. Birth pain can be acute, cutting, blunt, does not always have a certain localization, although its main sources are the uterus and the birth canal. An essential role is played by psychoemotional stress, fear.

Pain is often the only cause of abnormalities in labor and fetal conditions. Timely begun and adequate anesthesia helps prevent discoordination and weakness of labor, fatigue in childbirth, fetal hypoxia.

Depending on the methods used, the methods of anesthetizing labor are divided into drug and non-pharmacological methods. Drug methods include the use of inhalational anesthetics; The introduction of local anesthetics into the subarachnoid space of the spinal cord, into the sciatic-rectum fossa (pudendal anesthesia) or paracervical (paracervical anesthesia), as well as into the epidural space; Use of narcotic and non-narcotic analgesics, antispasmodics, antipsychotics, tranquilizers and sedatives. Non-medicamentous methods include psychoprophylaxis, hypnosis, reflexology (including acupuncture), electroanesthesia (including percutaneous electroneurostimulation).

One of the methods of anesthesia is psycho-preventive preparation for childbirth, contributing to the removal of the conditioned reflex component of the birth pain; It should be held by all pregnant women in a women's consultation. Indications for the use of other methods of anesthesia are defined by the obstetrician-gynecologist in conjunction with the anesthesiologist, taking into account the individual characteristics of the maternity psyche, the fetal condition, the existing obstetric and extragenital pathology, the period of the birth act, the nature of the contractile activity of the uterus. The main principles of the choice of the method of anesthesia: complete safety for the mother and fetus; Absence of depressing effect on generic activity; Shortening of the generic act; Rapid achievement of anesthesia.

Anesthesia of labor usually begins with regular regular labor and the opening of the uterine pharynx not less than 5-6 cm (the psychoprophylactic techniques of the parturient begins to be performed from the moment of the onset of labor). According to individual indications (for example, with toxicosis of pregnant women, cardiovascular diseases), anesthesia is carried out at earlier stages. It is necessary when there is an increase in blood pressure, rapid pulse, motor excitement, sweating.

With caution should be approached to anesthesia with a scar on the uterus, a narrow pelvis, premature birth, anomalies of attachment of the placenta. It is not recommended to use long-acting drugs less than 2 hours before the expected birth time of the child.

Synthetic narcotic analgesics with morphine-like properties (for example, promedol) are widely used. They are often combined with antispasmodics (papaverine, no-spy, etc.). Effective ready-made drugs-spasmoanalgesics, which include narcotic or non-narcotic analgesic and spasmolytic (baralgin, spasmalgon). When using neurotropic drugs, one should remember the danger of oppression of labor, vasomotor and respiratory centers of the parturient woman and fetus, the possibility of developing allergic reactions. If there is a violation of the liver, nephropathy of pregnant women there is a real threat of drug overdose. Premature neonates may have delayed (after 2 to 3 days after delivery) wave of drug depression .

Pharmacological means for the anesthetization of labor It is advisable to administer intramuscularly, subcutaneously or intravenously. The initial dose of promedol ranges from 0.15 to 0.3 mg per 1 kg of the mass of the mother giving birth. Repeatedly according to the indications, promedol can be administered every 2 to 3 hours, reducing the dose. The last injection should be carried out at least 2 hours prior to the birth of the child in order to avoid a drug- induced depression of the newborn.

Epidural anesthesia allows complete anesthesia at any stage of labor, blocking pain impulses at the level of the posterior roots of the spinal cord. This type of anesthesia is preferred in the presence of severe late forms of toxicosis in the childbirth, extragenital pathology (hypertension, heart defects , respiratory disease , high myopia ). Contraindications to epidural anesthesia are diseases of the spine and meninges, craniocerebral trauma, epilepsy , as well as the need to perform emergency obstetric operations, accompanied by massive blood loss. As an anesthetic, trimecaine is used. The dose is determined individually. Initially, a test dose (2 ml of a 2% solution of trimecaine) is injected, then the main dose (6-12 ml) is then divided according to the rostoves indexes. Intervals between the introductions at the beginning of childbirth - 60-90 min, at the height of fights - 30-40 min.

To carry out inhalation anesthesia in childbirth, nitrous oxide and trichlorethylene are often used. Anesthesia is carried out with the help of special devices that allow the woman in labor to put a mask on her face and inhale the gas mixture at the appearance of pain (autoanalgesia).

Electroanesthesia with the application of electrodes on the mastoid processes of the temporal bones is used as an additional method for drug anesthesia. It is contraindicated in severe forms of late toxicosis of pregnant women, arterial hypertension, CNS diseases.

In the postpartum period, it is necessary to take into account the pharmacological effects of drugs and possible adverse reactions of non-drug anesthetic methods. Thus, the cumulative effect of neuroleptic and sedative drugs can lead to uterine hypotension and the appearance in the postpartum period of uterine bleeding; In the conduct of epidural anesthesia, it is possible to develop persistent arterial hypotension.

The procedure for taking a newborn into a children's ward (ward) and caring for him. When a newborn is admitted to the children's department, the sister checks the medical records. In the history of the development of a newborn, she marks the date, hour and minutes of admission, the sex of the child, the condition of admission and body weight. The same check on the cuffs is made when the child is transferred to another ward or hospital, and also at the time of discharge.

When a child enters the ward, a pediatrician or a pediatric nurse examines him. If necessary, with the help of a sterile cotton ball remove the remains of a damp grease, especially in natural folds of the skin, axillary and inguinal folds. Then the skin folds are treated with 1% alcohol solution of iodine.

The morning toilet of the newborn begins with eye washing with a sterile cotton swab dipped in a 0.02% solution of furacilin. Each eye is treated with a separate tampon in the direction from the outer corner of the eye to the inner corner. Toilet nose and ears are carried out with sterile cotton wicks, moistened with sterile vaseline or vegetable oil; Oil is poured in small portions from the vial into a sterile beaker, which prevents contamination of the entire vial.

Then the nurse examines all the folds of the skin and treats them with 1% alcohol solution of iodine. Such treatment is carried out in the first 3 days of life; In the future, skin folds are lubricated only with sterile vegetable oil. The area of ​​buttocks and perineum is washed with warm running water. After washing, the skin is wiped with a clean diaper and lubricated with 1% tannin ointment.

A newborn is weighed daily before the first morning feeding (at 6 am). The nurse measures the temperature of the child's body 2 times a day and records this data in the history of the newborn's development. Each child's room should have several medical thermometers. Store them in a vessel containing 1% chloramine solution.

Care of the umbilical remains is performed by a doctor. Before the treatment of the umbilical cord, the doctor washes his hands with warm water and soap. The remainder of the umbilical cord is wiped with a gauze napkin, moistened with alcohol solution, and then with 5% solution of potassium permanganate. After the umbilical cord falls, the umbilical wound is treated with alcohol and 5% solution of potassium permanganate.

Having finished the toilet of one child, the nurse rubs the changing table with a diaper soaked in a 1% solution of chloramine, and washes hands with soap before the toilet of the next child.

On the 5th day of life, all newborns, except those who have contraindications, are vaccinated against tuberculosis by intradermal administration of BCG vaccine.

Feeding a newborn. The first application of a healthy newborn to the maternal breast is recommended 2 to 6 hours after birth. The number of feedings is 5 times a day with a 4-hour interval in the afternoon and a 6-hour night. With insufficient weight gain, control weights are made before and after feeding. If the mother does not have enough milk, the child is fed with expressed breast milk. The amount of breastmilk necessary for a newborn is 20 g per feeder per day, by the 7th day of life it increases to 70 g. By the end of the first month of life, the child needs 700 g of breast milk per day.

Mothers who are breastfeeding are prepared for the hour of feeding. They put on a kerchief, wash their hands with warm water with soap, a sterile swab dipped in a 0.25% solution of ammonium chloride, and wash the nasal region. The mammary glands are washed daily with warm water and soap and wiped with a specially selected clean towel. Mothers who are in the observatory department wear a four-layer gauze mask for the time of feeding.

To facilitate the delivery of children use special trolleys; The placement on them should not be close. Relaxed children and newborns in the observatory, the nurse refers to the mother in her arms. Mothers are issued to place the baby a clean diaper, which is stored in a bed-bag and is changed daily. The nurse watches how the baby sucks in the breast, and helps the mother in feeding. After feeding, the nipples and the parasol are treated by irrigation with a 1: 10,000 solution of furacilin and an alcoholic solution of a brilliant green.

To take into account the amount of sucked milk after feeding, we control the weighing of the children. When there is not enough milk, the mother is given a supplement for the child. As a supplement, you can use donor breast milk or formula B-rice, B-kefir, derived from dairy cuisine, as well as a mixture of "Baby". Cooking and pasteurization of milk is carried out in the milk room. Drinking newborns is prepared in a pharmacy in the form of a 5% solution of sugar or glucose. Food and drink for a newborn is prepared in individual packing of 30-50 ml and stored in a refrigerator specially designated for these purposes. For one child, from 100 to 150 ml of drink per day is needed, which give a fractional 8-10 times in 20-30 ml.

Care for a premature baby. Premature babies need special care, which is due to their immaturity and poor adaptability to environmental conditions. Premature babies with a body weight of 1000 to 2000 g are placed in a bowl in which conditions of high humidity with a temperature of 33-34 ° C and a constant intake of oxygen are created. Feeding of the deep-watered children is carried out with the help of a nylon probe (Nos. 5 and 6), introduced on the day through the nose into the stomach. On the 1st day, the amount of milk per meal (with 8-fold administration) is 2 - 3 ml, 5% glucose solution or isotonic sodium chloride solution - up to 5 ml per administration (with 10-fold administration). By the 5th day, the amount of milk and injected fluid per day should reach 1/5 of the child's body weight. Applying a premature baby to the breast can only be after he has a good sucking reflex and there will be no cyanosis when feeding expressed milk through the nipple. The criteria for discharging a newborn from a maternity hospital are: a satisfactory condition, a tendency to restore the body's physiological mass, an abnormality of the umbilical cord (or signs of a starting cord umbilicus with a satisfactory condition of the umbilical cord and umbilical ring).

Organization of the work of the department of newborns in the maternity hospital. The basic principle of neonatal care is asepsis, impeccable personal hygiene of staff, strict adherence to sanitary and hygienic and anti-epidemic measures. Baby care items, underwear should be sterile. Great importance is the irreproachable cleanliness of the hands of a doctor, a nurse. Children's chambers should not be large. Compliance with hygiene standards is necessary. Accommodation of newborns, as well as puerperas in wards for 4-6 beds significantly reduces the danger of nosocomial infection. In the absence of children (during feeding by their mothers) the wards are ventilated, irradiated with bactericidal or quartz lamps.

Cleaning of the premises is carried out in a wet manner after each swaddling of the children, i. E. 6 times a day. Dirty diapers are placed in special tanks with a removable cover; The cover with diapers in it is changed 6 times a day and taken to the compartments for collection of laundry. In rooms it is necessary to maintain the strictest air purity by airing and systematic quartz irradiation. Each ward of mothers must have a ward for their newborns. Reception of mothers in the ward, the reception of children and their discharge must occur at the same time, i.е. With the same cyclicity.

When observing the cyclical principle, each ward for children undergoes general cleaning 1 time in 5-7 days. The room is treated with 1% chloramine solution or 3% hydrogen peroxide solution, preferably with a spray gun (manual or electric, which is included in the vacuum cleaner kit). The treated chamber is closed for 12 to 24 hours, after which the wet cleaning of all objects and the chamber, panels and floor is carried out using 1% hexachlorophene soap. The room is ventilated with wide open windows. The mattresses are sent to a disinfection room. Oilcloths, oilcloth covers from mattresses and wheelchairs, aprons are soaked in 1% chloramine solution, then washed with hot water and soap and dried. All linen of newborns after washing (diapers, ryazhonki, flannelette blankets, envelopes) are sterilized by autoclaving.

Bacteriological examinations are carried out periodically in the department of newborns. When detecting carriers of infectious agents, they are temporarily suspended from work. In the presence of increased staphylococcal insemination in the maternity hospital, an increase in the carriage of pathogenic microbes among staff and morbidity among mothers, the maternity hospital is closed for preventive treatment.

Of great importance in the prevention of staphylococcal diseases in newborns are the timely diagnosis of the first cases of the disease among children, the rapid isolation of patients and their transfer to the hospital. If there are infectious staphylococcal infants in the department; Diseases (vesiculosis, conjunctivitis , pemphigus, exfoliative dermatitis Ritter, phlegmon and subcutaneous abscesses, osteomyelitis, pneumonia , enterocolitis, purulent meningitis, etc.) the pediatrician is obliged to immediately notify the chief doctor of the maternity hospital and the regional center for sanitary and epidemiological surveillance.