To display the correct picture of the lifestyle and all the studies of the expectant mother, a history of obstetric birth is compiled. Normal childbirth of a woman depends entirely on the tests performed and hereditary traits. All this the doctor throughout all 40 weeks writes in this document. It is considered a legal act with its legal force and is necessary in cases where both parties refuse to take responsibility. In order to resolve disagreements, the delivery history is, upon request, passed on to the head physician, his superior management, and if the case takes a serious turn, to the prosecutor.
Outlaw
The history of obstetric labor, like any other serious document, has its own degree of secrecy. The doctor who is pregnant is required to remain silent and not to disseminate information to third parties about the woman in childbirth. An exception is when information is requested by law enforcement agencies.
In order to avoid violation of the law of November 21, 2011 N 323- “On the basics of protecting the health of citizens in the Russian Federation”, obstetricians and other employees of a medical institution who examine pregnant women are prohibited from copying and photographing medical reports that keep the history of obstetric births. Normal delivery also depends on the patient. When filling out a document by a doctor, a pregnant woman should be extremely frank. Only this will help obstetricians to establish clarity and the correct diagnosis. Otherwise, the woman runs the risk of receiving improper treatment, which can affect the course of childbirth.
Rules for maintaining and filling history
There are basic rules for filling out a document in which the entire history of obstetrics is conducted.
1. Passport data :
- Name of the patient;
- Date of Birth;
- Place of Birth;
- Place of work (or study);
- Contact address and telephone;
- Family status;
- Education;
- Information about the husband and his contact information;
- Arrival time at the hospital.
Next, the doctor should describe all the complaints that disturb the patient.
2. Medical information from birth
Here, information about previous diseases and the presence of diagnoses should be described. The patient should accurately mention all information regarding allergic reactions to medications. If there are hereditary diseases, then the attending physician should know about them. Also in this section there is information about the onset of maternity leave.
3. Obstetric and gynecological analysis
This section provides information related to pregnancy and childbirth. The doctor must identify all the details that may affect the delivery. For each pregnant woman, information is compiled individually, taking into account previous pregnancies and childbirth. Information about blood is indicated: its losses and transfusions. Here, the doctor puts a health score based on the above data.
38-week pregnancy history
This period is considered acceptable for delivery, but still early for the baby. Upon admission to the hospital, the history of obstetric birth must be exactly completed. Normal childbirth (38 weeks) can pass without complications, but after the birth of a child, doctors should conduct an examination to detect violations in the development of some organs of the baby.
In some cases, the deadline could be set incorrectly. This can be affected by inaccurate information of the woman in labor about the menstrual cycle and the first ultrasound. At 38 weeks, the baby is in the right position in the womb and is ready for birth. Most often, at such a period, false births can be observed that prepare a woman's body for the present. According to medical statistics, this is a common term for delivery, which most often goes well.
A 39-week pregnancy history
At this time, a pregnant woman can begin giving birth at any time. Doctors carry out the necessary examinations, which are transmitted to the maternity hospital. At 39 weeks, the baby falls lower and presses his chin to his knees. Upon receipt of a woman in labor at the maternity hospital, the history of obstetric birth must be filled.
Normal births (39 weeks) with a good history usually pass quickly and without complications. The document needs descriptions of all examinations and prescribed medications. Since childbirth will soon come, a woman should prepare for them in advance, having passed the examination, if any changes in the body are felt.
40-week pregnancy history
This period is considered the end of pregnancy. If labor activity has not arrived, you should go to the hospital, as its absence can be caused by internal malfunctions. A woman who has been admitted to the hospital is subjected to a full examination, internal and external. Based on all this, the history of obstetric birth is filled. Normal births (40 weeks) are considered the most favorable - the baby is completely ready for birth, the work of all internal organs is coordinated. The doctor must approach responsibly to the maintenance of such a document as the history of obstetric labor, the normal birth will largely depend on this.
4. Objective research
This includes notes and opinions from other specialized specialists. First of all, the psychological state of a woman is assessed. In many respects it depends on what kind of childbirth in a row. A special mark is also made about this.
First birth
Pregnancy and childbirth are described in the medical history which is fixed in the report. It is called differently - the history of obstetric labor. Normal births first require a thorough study from doctors. This is due to the fact that it is impossible to predict the course of this process and the reaction of the body.
The first birth is exciting not only for the staff, but also for the woman. Such patients have less anxiety because they do not know what will happen next, and curiosity overpowers fear and excitement. The entire process of childbirth from the beginning of the first fight to the birth of the baby is described by an obstetrician in history. All information preceding this event contains the history of childbirth. The norm for the first pregnancy is delivery at a period of 38 to 41 weeks. Obstetricians study information about complaints and diseases that occurred during pregnancy. All these data are recorded in the column "Objective research".
Second birth
The second birth takes place in a woman faster than the first. As a rule, the history is based on the information of the first pregnancy, which contains the history of obstetric labor. Normal labor can begin from 38-39 weeks. In the history of women, the information of previous pregnancies and childbirth, which is subsequently stored by the history of childbirth by obstetrics, should be clarified.
Normal second births depend on the diagnosis made by the doctor correctly. In addition, information about a previously born child, its development, and congenital diseases, if any, is described. All this will help obstetricians to properly treat a pregnant woman and conduct further labor.
5. Obstetric status
This item is next in the history of childbirth. Here they take measurements of the bottom of the uterus and pelvis, establish the heartbeat of the fetus and its position before childbirth in the womb. If a doctor suspects a woman or fetus is in good health, then until the moment of birth, doctors will constantly monitor the patient and enter all the results in this section. When a woman enters the hospital, she is examined for the opening of the uterus and determine the degree of readiness for childbirth.
6. Diagnosis and rationale
Based on all the data presented, the doctor makes the correct diagnosis. He writes it down in history, necessarily substantiates and confirms analyzes and examinations. In this section, the obstetrician indicates the date of the first visit to the medical institution and information about the last menstrual cycle. In addition, he calculates and records the total weight gain and indicates the intended type of birth.
7. Birth plan
The obstetrician gives a rough outline of the delivery process. This includes data on analgesia, pressure, and fetal head movement. Any emergency should be described in stages with all possible solutions. In this column, prescribed medications are prescribed to maintain and stimulate labor.
8. The course of childbirth
This column describes how periods of childbirth go. Every fight is recorded here. The main goal pursued by the history of obstetric labor is normal birth. The childbearing function of a woman must be preserved for her future health. The obstetrician manipulations described in this paragraph are aimed at preserving the patient’s important organs. After the birth data is entered, the last entry is made about the child and its parameters. The section shows information on assessing the health of the baby and mother. The procedure for preparing the baby for postpartum adaptation and its further processing is described in detail.
9. The postpartum period
This section contains monitoring a woman in labor for two hours. Check the tone of the uterus, general and psychological condition. If a woman begins to have complications after giving birth, this is recorded in history. Pulse and blood pressure data are also included.
10. Epicrisis
The history of obstetric labor ends with an epicrisis. Here is collected information about the date and time of receipt of the woman in labor and her birth. The description of the period of adaptation and recovery of the body is included. In addition, information about the child, the time and date of his birth, as well as an extract from the hospital are recorded. If necessary, there is information about the prescribed treatment and prescribed drugs.
What is a normal birth?
The concept of “normal birth” is controversial. It is impossible to say unambiguously on points what relates to normal delivery. It is also impossible to equate and adjust women to this definition. Childbirth is a delicate process that is virtually immune to accurate forecasts. At the University of KSMU there is a obstetric institution, which brings the birth closer to normal. Here, full studies are conducted to exclude harmful factors that could harm or become more active during childbirth. After all the analyzes and examinations, the history of obstetrics is filled.
Normal childbirth (KSMU) is under the supervision of doctors of the highest category, who carefully monitor all changes in the female body during childbirth. Experts examine the genitals and urinary organs, as well as evaluate the correctness of their formation. Doctors determine the state of the sensory organs and nervous system. A woman during labor experiences great stress not only physically, but also emotionally, so she needs a thorough examination. This helps to avoid further complications that can harm the baby and mother.
According to statistics, “normal birth” is possible when they are perceived as a normal medical procedure. This helps to distinguish between communication between the patient and the doctor, while everyone does everything that is required of him. The doctor completely concentrates on the woman in labor and establishes a complete picture of her condition so that the birth goes well. The woman, in turn, must unquestioningly comply with the recommendations of obstetricians and concentrate on the process itself.
Some statistics
If we turn to statistics, the percentage of normal births is small, only 10-20%. It must be remembered that these include a process in which doctors do not intervene. If in the history of obstetricians find contraindications or diseases, then they will necessarily interfere with childbirth. Today, there are many medical institutions that oversee universities. Experienced qualified doctors and young specialists participate in the labor activity of a woman and try to the maximum so that everything goes well for a woman in labor and the baby. Summing up, we can say that the most important document of a woman in labor is her birth history by obstetrics.
Normal labor activity is possible only with proper management and constant medical supervision. If you give statistics on childbirth, then in 37% of cases, women who did not provide information about their health or did not give it completely did give birth with complications.
Conclusion
The history of obstetric labor is an important document that must be completed with particular care. Further events depend on him. This document contains only reliable and verified data. Here everyone should be extremely frank and attentive, because the life of the woman in labor and the baby depends on this.
Doctors have been teaching for years how to fill out documents, especially such as the history of obstetric labor. Normal practice of filling it exists in all specialized medical institutions. Making a diagnosis, the doctor is obliged to register it in history and attach evidence of this, as well as inform the patient about all the nuances of the course of her pregnancy.