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MiscarriageMiscarriage

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Miscarriage or spontaneous Miscarriage or spontaneous abortion is defined as loss abortion is defined as loss

of a pregnancy without of a pregnancy without outside intervention in the outside intervention in the

term between the beginning term between the beginning of pregnancy and 37 weeks of pregnancy and 37 weeks

gestation.gestation.

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- Early spontaneous abortion: - Early spontaneous abortion: spontaneous abortion that occurs in spontaneous abortion that occurs in the first 11 weeks of pregnancy + 6 the first 11 weeks of pregnancy + 6 days;days;

- Late spontaneous abortion: from 12 - Late spontaneous abortion: from 12 to 21 weeks + 6 days;to 21 weeks + 6 days;

- Preterm delivery: from 22 to 36 - Preterm delivery: from 22 to 36 weeks + 6 days (154 – 259 days).weeks + 6 days (154 – 259 days).

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МК-10 Classification.МК-10 Classification.

Threatened abortion О20.0.Threatened abortion О20.0. Spontaneous abortion О03:Spontaneous abortion О03: Incomplete abortion О03 – О03.4;Incomplete abortion О03 – О03.4; Complete abortion О03.5 – О03.9.Complete abortion О03.5 – О03.9. Habitual abortion №96.Habitual abortion №96. Preterm delivery О60.Preterm delivery О60.

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Causes of miscarriage.Causes of miscarriage.

1. Uterus pathology: 1. Uterus pathology: maldevelopment maldevelopment of Mullerian duct (ductal septum, of Mullerian duct (ductal septum, arcuate or bicornous uterus), synechii, arcuate or bicornous uterus), synechii, uterus hypoplasia, hysteromyoma, uterus hypoplasia, hysteromyoma, isthmic cervical insufficiency.isthmic cervical insufficiency.

2. Chromosomal anomaly:2. Chromosomal anomaly: structural structural abnormalities or quantitative abnormalities or quantitative aberrations of chromosomes.aberrations of chromosomes.

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3. Immunological abnormalities:3. Immunological abnormalities: cellular and humoral immunity cellular and humoral immunity dysfunctions, histocompatibility dysfunctions, histocompatibility antigens, isoserological blood group antigens, isoserological blood group and Rh-factor feto-maternal and Rh-factor feto-maternal incompatibility.incompatibility.

4. Endocrinal pathology:4. Endocrinal pathology: ovarian ovarian hypofunction, lutein phase hypofunction, lutein phase insufficiency, hyperandrogyny of insufficiency, hyperandrogyny of suprarenal and ovarian genesis.suprarenal and ovarian genesis.

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5. Infection factor:5. Infection factor: acute and chronic acute and chronic infectious diseases of the mother, infectious diseases of the mother, local genital lesions caused by local genital lesions caused by bacterial flora, mycoplasma, bacterial flora, mycoplasma, chlamydia, toxoplasmosis, viruses.chlamydia, toxoplasmosis, viruses.

6. Somatic diseases and 6. Somatic diseases and intoxications.intoxications.

7. Psychogenic factor.7. Psychogenic factor.

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PathogenyPathogeny

Cause

Increase in uterine contractive activity

Separation of the fetus from the uterine walls

Cervical dilatation

Expulsion of fetus

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Spontaneous abortion Spontaneous abortion (miscarriage)(miscarriage) – – expulsion of expulsion of embryo/fetusembryo/fetus in the term of in the term of gestation up to 22 weeks or up to gestation up to 22 weeks or up to 500 grams of weight regardless of 500 grams of weight regardless of presence or absence of vital presence or absence of vital signs.signs.

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Miscarriage stages.Miscarriage stages.

1. Threatened abortion.1. Threatened abortion. 2. Abortion in progress.2. Abortion in progress. 3. Incomplete abortion.3. Incomplete abortion. 4. Complete abortion.4. Complete abortion.

- Missed abortion - Missed abortion (embryonic/fetal (embryonic/fetal demise abortion).demise abortion).

- Septic abortion- Septic abortion

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Habitual abortion Habitual abortion (recurrent miscarriage)(recurrent miscarriage) – – is normally diagnosed after is normally diagnosed after two or more pregnancies two or more pregnancies end in miscarriages.end in miscarriages.

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Table 1. Table 1. Signs of pregnancy in Signs of pregnancy in the first trimesterthe first trimester

Case history Case history datadata

Objective Objective examination examination datadata

UltrasonograpUltrasonography (US)hy (US)

Laboratory Laboratory

tests datatests data

Delay of Delay of menstruation.menstruation.

Enlargement of Enlargement of uterus, change uterus, change of its form and of its form and

consistencyconsistency..

Embryonic/fetal Embryonic/fetal visualization visualization (according to (according to

gestation term).gestation term).

Positive Positive pregnancy test.pregnancy test.

Nausea, Nausea, vomiting, vomiting, changed sense changed sense of smell and of smell and

tastetaste

Softening of Softening of cervix. Cyanosis cervix. Cyanosis of vaginal walls.of vaginal walls.

Enlargement and Enlargement and engorgement of engorgement of

mammary glands.mammary glands.

Increase of Increase of human chorionic human chorionic gonadotropin gonadotropin (HCG) level in (HCG) level in blood serum.blood serum.

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Threatened abortion.Threatened abortion.

Patient complaints.Patient complaints.

1. Abdominal cramps, after 16 weeks 1. Abdominal cramps, after 16 weeks of gestation possible cramp-like of gestation possible cramp-like pain.pain.

2. Weak or moderate bloody 2. Weak or moderate bloody discharge from genital tractsdischarge from genital tracts

3. Delay of menstruation.3. Delay of menstruation.

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Examination.Examination. Speculum examination.Speculum examination. 1. External orifice of uterus is closed.1. External orifice of uterus is closed. 2. Weak or moderate bloody discharge.2. Weak or moderate bloody discharge.

Bimanual vaginal examination. 1.The uterus is irritable, the uterine tone is

heightened. 2. The size of uterus corresponds to the term of

gestation.

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US: general signs.US: general signs.

1. Cushion-like local myometrial 1. Cushion-like local myometrial thickening protruding into the thickening protruding into the uterine cavity.uterine cavity.

2. Gestational sac contour 2. Gestational sac contour deformation.deformation.

3. Visualization of placental or 3. Visualization of placental or chorionic detachment areas.chorionic detachment areas.

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Table 2. Table 2. Prognostic criteria for Prognostic criteria for pregnancy progression.pregnancy progression.

SignsSigns Favorable Favorable prognosisprognosis

Unfavorable Unfavorable prognosisprognosis

Case historyCase history Pregnancy in Pregnancy in progressprogress

Spontaneous Spontaneous abortions in abortions in past past history;Woman’history;Woman’s age › 34 s age › 34 years.years.

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SonographicSonographic Present Present heartbeat; heartbeat; absence of absence of bradicardia; the bradicardia; the size of the size of the embryo embryo corresponds to corresponds to the size of the the size of the gestational sac; gestational sac; the sac is the sac is dynamically dynamically developingdeveloping

Heartbeat absent; Heartbeat absent; bradicardia; empty bradicardia; empty emty gestational emty gestational sac; the size of the sac; the size of the embryo does not embryo does not correspond to the correspond to the size of the sac; size of the sac; absence of fetal absence of fetal sac growth after 7-sac growth after 7-10 days; 10 days; subchorionic subchorionic hematoma.hematoma.

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BiochemicalBiochemical Normal level of Normal level of biochemical biochemical markers.markers.

Serum HCG level is Serum HCG level is below normal for the below normal for the corresponding term of corresponding term of gestation; HCG level gestation; HCG level increase is below 66% increase is below 66% within 48 hours (up to within 48 hours (up to 8 weeks of gestation) 8 weeks of gestation) or HCG level or HCG level decreases; decreases;

progesterone level is progesterone level is below normal rate for below normal rate for the term of gestation the term of gestation and decreases in and decreases in dynamics.dynamics.

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IMPORTANT!!!IMPORTANT!!! When clinical signs of threatened When clinical signs of threatened

abortion are present in the term of abortion are present in the term of gestation less than 8 weeks and the gestation less than 8 weeks and the prognosis for pregnancy progression is prognosis for pregnancy progression is unfavorable it is not recommended to unfavorable it is not recommended to start a pregnancy maintenance therapy.start a pregnancy maintenance therapy.

- high rate of chromosomal anomalies - high rate of chromosomal anomalies in this term of gestation;in this term of gestation;

- low efficiency of the therapy.- low efficiency of the therapy.

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Table 3. Table 3. Therapy applied in Therapy applied in threatened abortion cases.threatened abortion cases.

Medical approachMedical approach EfficiencyEfficiency Bed rest and total sex abstinence.Bed rest and total sex abstinence. According to various research According to various research

data the efficiency is moderate.data the efficiency is moderate.

Spasmolytics (papaverine Spasmolytics (papaverine hydrochloride, riabal, etc);hydrochloride, riabal, etc);

There is no evidence that this There is no evidence that this approach can be used efficiently approach can be used efficiently and safely as means of and safely as means of miscarriage prevention.miscarriage prevention.

Hormonal therapy (progesterone Hormonal therapy (progesterone or its synthetic analogs):or its synthetic analogs):

- 1% progesterone solution, - 1% progesterone solution, intramuscularly; utrogestan intramuscularly; utrogestan (vaginally or orally);(vaginally or orally);

- dufaston (orally).- dufaston (orally).

Indications for progesterone use:Indications for progesterone use:

1 Two or more spontaneous abortions 1 Two or more spontaneous abortions during the first trimester in the during the first trimester in the patient’s case history (recurrent patient’s case history (recurrent miscarriage).miscarriage).

2 Lutein phase insufficiency confirmed 2 Lutein phase insufficiency confirmed before pregnancy.before pregnancy.

3 Cured infertility.3 Cured infertility.

4 Pregnancy as a result of implementation 4 Pregnancy as a result of implementation of supporting reproductive of supporting reproductive technologies.technologies.

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Table 4. Table 4. Treatment efficiency Treatment efficiency monitoring.monitoring.

MethodMethod Application modeApplication mode

Dynamics monitoring of clinical Dynamics monitoring of clinical

symptoms change.symptoms change. Twice daily.Twice daily.

Estimation of the patient’s hormonal Estimation of the patient’s hormonal status using one or several methods status using one or several methods stated below:stated below:

- determination of serum HCG level in - determination of serum HCG level in dynamics; - determination of serum dynamics; - determination of serum progesterone level in dynamics;progesterone level in dynamics;

- hormonal colpocytology;- hormonal colpocytology;

- basal temperature measurement until - basal temperature measurement until 12 weeks of gestation.12 weeks of gestation.

In the term of gestation before 8 In the term of gestation before 8 weeks – every 48 hours, after 8 weeks – every 48 hours, after 8 weeks – once weekly.weeks – once weekly.

Once weekly, until symptoms stop.Once weekly, until symptoms stop.

Once weekly.Once weekly.

During the course of treatment.During the course of treatment.

USUS Is applied to confirm the Is applied to confirm the

progressing pregnancy.progressing pregnancy.

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Abortion in progress.Abortion in progress.Examination for making the diagnosis.Examination for making the diagnosis.

Speculum examination.Speculum examination.

1. The cervix is shortened, the external 1. The cervix is shortened, the external orifice of the uterus is open.orifice of the uterus is open.

2. Profuse bloody discharge.2. Profuse bloody discharge.

3. Parts of gestational sac present in the 3. Parts of gestational sac present in the cervical canal.cervical canal.

4. Amniotic fluid leakage (absent in the early 4. Amniotic fluid leakage (absent in the early terms of gestation).terms of gestation).

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Bimanual examination to Bimanual examination to determine:determine:

- uterine tone;- uterine tone;- size of uterus;- size of uterus;- rate of cervical canal opening.- rate of cervical canal opening.

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US as needed for US as needed for visualization of placental visualization of placental detachment (after 12 detachment (after 12 weeks gestation), weeks gestation), gestational sac (before 12 gestational sac (before 12 weeks gestation).weeks gestation).

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Abortion in progress Abortion in progress management approach.management approach.

Term of gestation less than 16 weeks.Term of gestation less than 16 weeks. Emergency vacuum aspiration or Emergency vacuum aspiration or

curettage of uterine cavity walls is curettage of uterine cavity walls is performed with adequate anesthesia.performed with adequate anesthesia.

! It is essential to conduct a ! It is essential to conduct a pathohistological study of aborted tissues.pathohistological study of aborted tissues.

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Term of gestation more than 16 Term of gestation more than 16 weeks.weeks.

Vacuum aspiration or curettage of Vacuum aspiration or curettage of uterine cavity walls is performed after uterine cavity walls is performed after spontaneous expulsion of gestational spontaneous expulsion of gestational sac.sac.

For prevention of endometritis For prevention of endometritis antibiotic therapy is prescribed.antibiotic therapy is prescribed.

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In cases of bleeding after the expulsion of In cases of bleeding after the expulsion of gestational sac or during the curettage, gestational sac or during the curettage, uterotonics are used to stimulate uterotonics are used to stimulate contractive function of the uterus:contractive function of the uterus:

- oxytocin 10 units i.m. or i.v. by drop - oxytocin 10 units i.m. or i.v. by drop infusion for 500 ml 0,9% NaCl;infusion for 500 ml 0,9% NaCl;

- ergometrin 0,2 mg i.m. or i.v.;- ergometrin 0,2 mg i.m. or i.v.; - misoprostol 800 mg per rectum.- misoprostol 800 mg per rectum.

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Medical method of uterine Medical method of uterine contents evacuation.contents evacuation.

This non-surgical abortion This non-surgical abortion method may be used when the method may be used when the patient refuses from surgical patient refuses from surgical hemostasis and general hemostasis and general anesthesia.anesthesia.

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Necessary conditions for Necessary conditions for performing medical hemostasis.performing medical hemostasis.

1. Provided incomplete abortion in the first 1. Provided incomplete abortion in the first trimester of gestation has been trimester of gestation has been confirmed.confirmed.

2. No absolute indications for surgical 2. No absolute indications for surgical evacuation have been established.evacuation have been established.

3. The patient has agreed to be hospitalized 3. The patient has agreed to be hospitalized in a medical establishment with in a medical establishment with emergency healthcare facilities available emergency healthcare facilities available 24 hours a day.24 hours a day.

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Contraindications.Contraindications. AbsoluteAbsolute::

- adrenal insufficiency;- adrenal insufficiency; - long-term glucocorticoid - long-term glucocorticoid

therapy;therapy; - anticoagulation therapy - anticoagulation therapy

or hemoglobinopathies;or hemoglobinopathies; - anemia (Hb ‹ 100 g/l);- anemia (Hb ‹ 100 g/l); - mitral stenosis;- mitral stenosis; - glaucoma;- glaucoma; - intake of nonsteroidal - intake of nonsteroidal

anti-inflammatory agents anti-inflammatory agents within previous 48 hours.within previous 48 hours.

RelativeRelative:: - hypertension;- hypertension; - severe bronchial - severe bronchial

asthma.asthma.

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Cases when surgical evacuation Cases when surgical evacuation is required:is required:

- beginning of profuse bleeding;- beginning of profuse bleeding; - presence of infection symptoms;- presence of infection symptoms; - if evacuation of uterine contents does not - if evacuation of uterine contents does not

start within 8 hours after mesoprostol was start within 8 hours after mesoprostol was administered;administered;

- if US examination reveals remaining fetal - if US examination reveals remaining fetal membranes in the uterine cavity after 7 – membranes in the uterine cavity after 7 – 10 days.10 days.

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Complete abortion management Complete abortion management approach.approach.

It is not required to perform instrumental It is not required to perform instrumental revision of the uterus provided the patient revision of the uterus provided the patient has no complaints, there is no bleeding, has no complaints, there is no bleeding, and the US examination does not show and the US examination does not show tissues in the uterine cavity.tissues in the uterine cavity.

Control US examination is done after 1 Control US examination is done after 1 week.week.

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Cervical incompetence (CI).Cervical incompetence (CI).

CI –unrelated to uterine contractive activity CI –unrelated to uterine contractive activity spontaneous effacement and dilatation of spontaneous effacement and dilatation of the cervix which causes miscarriage (more the cervix which causes miscarriage (more frequently in the second trimester).frequently in the second trimester).

Cervical incompetence is normally Cervical incompetence is normally managed by cervical cerclage, which is managed by cervical cerclage, which is placing a preventive or therapeutic suture placing a preventive or therapeutic suture on the cervix.on the cervix.

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Preconditions for placing a Preconditions for placing a suture:suture:

- the fetus is alive, no malformations have - the fetus is alive, no malformations have been detected;been detected;

- gestational sac is intact;- gestational sac is intact; - there are no signs of chorionamnionitis;- there are no signs of chorionamnionitis; - no uterine contractions or bleeding are - no uterine contractions or bleeding are

observed;observed; - first or second degree of vaginal - first or second degree of vaginal

cleanness.cleanness.

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Reproductive system rehabilitation Reproductive system rehabilitation after a spontaneous abortionafter a spontaneous abortion..

1. Prevention of infectious-inflammatory diseases, 1. Prevention of infectious-inflammatory diseases, sanitization of chronic inflammation areas, sanitization of chronic inflammation areas, normalization of vaginal biocenosis, diagnostics and normalization of vaginal biocenosis, diagnostics and treatment of TORCH-infections.treatment of TORCH-infections.

2. Psychological rehabilitation after the miscarriage.2. Psychological rehabilitation after the miscarriage.3. Non-specific pre-gravid preparation:3. Non-specific pre-gravid preparation: - anti-stress therapy;- anti-stress therapy; - nutrition normalization;- nutrition normalization; - 3 months before conception: folic acid 400mcg - 3 months before conception: folic acid 400mcg

daily;daily; - establishing a healthy work-leisure balance;- establishing a healthy work-leisure balance; - giving-up unhealthy habits.- giving-up unhealthy habits.4. Genetic consultation. 4. Genetic consultation.

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Labour diagnostics and Labour diagnostics and confirmation.confirmation.

The onset of cramp-like pains in the lower The onset of cramp-like pains in the lower abdominal regions; appearance of mucinous-abdominal regions; appearance of mucinous-bloody or watery discharge from genital tract.bloody or watery discharge from genital tract.

Every 10 minutes contractions 15-20 seconds Every 10 minutes contractions 15-20 seconds long are registered.long are registered.

The form and location of the cervix changes – The form and location of the cervix changes – the cervix is shortened and smoothed. Cervical the cervix is shortened and smoothed. Cervical dilatation.dilatation.

Gradual descent of the presenting part of the Gradual descent of the presenting part of the fetus into pelvis minor.fetus into pelvis minor.

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Tocolytic therapy.Tocolytic therapy. Tocolytic therapy is administered before 34 weeks Tocolytic therapy is administered before 34 weeks

gestation, in cases when the cervix is less that 3cm gestation, in cases when the cervix is less that 3cm dilated; there is no amnionitis, preeclampsia or bleeding; dilated; there is no amnionitis, preeclampsia or bleeding; and the fetus condition is satisfactory.and the fetus condition is satisfactory.

Tocolytic therapy is prescribed during the period of 48 Tocolytic therapy is prescribed during the period of 48 hours, necessary for performing antenatal preventive hours, necessary for performing antenatal preventive procedures against respiratory distress syndrome (RDS) procedures against respiratory distress syndrome (RDS) with glucocorticoids.with glucocorticoids.

Nifedipin 10 mg sublingually.Nifedipin 10 mg sublingually. Beta-mimetics (ginepral, ritodrin).Beta-mimetics (ginepral, ritodrin). 2 hours after the start of the tocolytic therapy the 2 hours after the start of the tocolytic therapy the

diagnosis of premature labour is confirmed. If the diagnosis of premature labour is confirmed. If the premature labour progresses – the tocolytic therapy is premature labour progresses – the tocolytic therapy is cancelled.cancelled.

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Fetal RDS prevention procedures are Fetal RDS prevention procedures are performed from 24th to 34th week of performed from 24th to 34th week of

gestation:gestation: i.m. dexametasone 6 mg every 12 hours, i.m. dexametasone 6 mg every 12 hours,

24 mg for the course of treatment.24 mg for the course of treatment.

When signs of infection are present, When signs of infection are present, intranatal antibacterial therapy is intranatal antibacterial therapy is prescribed.prescribed.

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Peculiarities of the first labor Peculiarities of the first labor stage management.stage management.

Fetal condition evaluation:Fetal condition evaluation: - auscultation of the fetus (every 30 - auscultation of the fetus (every 30

minutes during the latent phase, every 15 minutes during the latent phase, every 15 minutes during the active phase);minutes during the active phase);

- cardiotocography.- cardiotocography.

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In order to achieve reliable auscultation In order to achieve reliable auscultation results the following methods are used:results the following methods are used:

- the patient is placed in lateroposition;- the patient is placed in lateroposition; - the auscultation is started after the end of - the auscultation is started after the end of

the most intensive contraction phase;the most intensive contraction phase; - the auscultation is performed during at - the auscultation is performed during at

least 60 seconds.least 60 seconds.

If the gestational sac is ruptured the surgeon If the gestational sac is ruptured the surgeon should be alerted to the color and amount should be alerted to the color and amount of amniotic fluid.of amniotic fluid.

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Evaluation of maternal condition:Evaluation of maternal condition:

- body temperature measurement every 4 - body temperature measurement every 4 hours;hours;

- pulse rate measurement every 2 hours;- pulse rate measurement every 2 hours; - arterial pressure measurement every 2 - arterial pressure measurement every 2

hours;hours; - urinary output measurement every 4 - urinary output measurement every 4

hours.hours.

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Labour progressing evaluation:Labour progressing evaluation:

- frequency and duration of - frequency and duration of contractions;contractions;

- cervical opening rate;- cervical opening rate;- fetal head descent level.- fetal head descent level.

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Assistance during labor.Assistance during labor.

1. Individual psychological support from the 1. Individual psychological support from the patient’s husband, relatives, medical patient’s husband, relatives, medical staff.staff.

2. Keeping the patient clean.2. Keeping the patient clean.3. Ensuring that the patient‘s mobility.3. Ensuring that the patient‘s mobility.4. Assisting the patient with food and drink 4. Assisting the patient with food and drink

intake.intake.5. Labor pain relief at the patient’s request 5. Labor pain relief at the patient’s request

(narcotic analgetics are not used).(narcotic analgetics are not used).

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Care and assistance during the Care and assistance during the second labor stage.second labor stage.

Auscultation of the fetus is performed every 5 Auscultation of the fetus is performed every 5 minutes.minutes.

Arterial pressure and pulse of the patient are Arterial pressure and pulse of the patient are measured every 15 minutes.measured every 15 minutes.

Obstetric care methods are chosen in Obstetric care methods are chosen in accordance with the phase requirements of the accordance with the phase requirements of the second labor stage.second labor stage.

The patient is either in upright or supine The patient is either in upright or supine position for labor management.position for labor management.

Episioperineotomy and pudendal anesthesia Episioperineotomy and pudendal anesthesia are not performed.are not performed.

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Active management of the third Active management of the third labor stage.labor stage.

Introduction of uterotonics.Introduction of uterotonics. Expulsion of placenta by controlled umbilical Expulsion of placenta by controlled umbilical

cord traction.cord traction. Uterine cavity massage via abdominal wall Uterine cavity massage via abdominal wall

after placenta expulsion every 15 minutes after placenta expulsion every 15 minutes during 2 hours.during 2 hours.

Parturient canal examination after the labor is Parturient canal examination after the labor is performed when bleeding is present, after performed when bleeding is present, after operative delivery or home delivery.operative delivery or home delivery.

Cold compress on the lower abdomen in the Cold compress on the lower abdomen in the early postpartum period is not applied.early postpartum period is not applied.

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