Analysis of medical errors in obstetrics. Women's health in Dnepropetrovsk. Diagnosis of infectious and inflammatory diseases

Are you here: Herbalist

L.V. Terentyeva, G.A. Pashinyan FORENSIC MEDICAL EXAMINATION OF ADVERSE OUTCOMES IN OBSTETRIC AND GYNECOLOGICAL PRACTICE

Department of Forensic Medicine (head of the department - Prof. G.A. Pashinyan) MGMSU

This article presents the results of a comprehensive clinical, forensic and medico-legal analysis of adverse outcomes in the provision of obstetric and gynecological care.

Key words: adverse outcomes, obstetrics and gynecology, forensic medicine.

L.V.Terentyeva, G.A.Pashinyan FORENSIC-LEGAL EXAMINATION OF UNFAVORABLE OUTCOMES IN OBSTETRICAL AND GYNECOLOGICAL PRACTICE Moskow

The results of complex clinical and forensic-legal analysis of unfavorable outcomes during obstetrical and gynecological rendering are devoted in the article.

Key words: unfavorable outcomes, obstetric and gynecologic, forensic medicine.

The current development of medicine in the emerging social conditions allows us to assert that one of the pressing problems of the modern healthcare system is the issue of the volume and quality of medical care, as well as the responsibility of medical workers in case of unfavorable outcomes. Great importance is now attached to this problem all over the world.

Recently, there has been a significant increase in cases of patients who have received inadequate medical care to one degree or another, turning to various judicial authorities, which is confirmed by the analysis of commission examinations carried out at the Bureau of Forensic Medical Examination of Moscow. One of the leading places in the number of civil claims is occupied by obstetrics and gynecology. There is a significant increase in such examinations (in 1995, 5 examinations were carried out, and in 2000 - 17, in 2002 - 24).

According to cumulative WHO data, it has been established that more than 200 million women become pregnant every year in the world. In just over half of them, pregnancy ends in childbirth. 570-600 thousand die from abortions, ectopic pregnancy, bleeding, eclampsia, and sepsis. Another 500 thousand women become disabled due to trauma during childbirth and postpartum complications.

Thus, the relevance of studying the problem of forensic medical examination of adverse outcomes of medical care has intensified, and clinical and expert theory and practice, as well as the field of health insurance, are experiencing a lack of information about it. This information is also important for predicting what types of legal liability will prevail in medicine in the coming years.

We analyzed medical documentation (medical histories, outpatient records, commission examination reports) for unfavorable outcomes in the provision of obstetric and gynecological care to 75 patients to identify the reasons underlying these situations at various stages of the treatment and diagnostic process.

In parallel, we conducted an anonymous survey of obstetrician-gynecologists working in medical institutions of various forms of ownership and their patients using a random sampling method. The purpose of the

testing was to determine the relevance of the issue of studying medical and legal norms regulating the activities of doctors, determining the level of legal literacy of patients, as well as determining the causes of conflicts and measures to prevent them.

The analysis led to the following results.

According to our data, in 1993-2000, the factors supporting the high level of adverse outcomes in obstetric and gynecological practice were joined by the factor of increasing the number of obstetric complications (bleeding and gestosis) and the incidence of somatic diseases in pregnant women. In conditions of increasing frequency of pregnancy complications, measures for their timely detection and prevention are important; for differentiated planned hospitalization of pregnant women for delivery in an obstetric hospital, corresponding to the risk of possible complications. So, according to our data, background extragenital morbidity occurs in 91% of cases of all unfavorable outcomes, i.e. the development of obstetric pathology is layered on the initially decompensated state of the body systems.

As for gynecological diseases, according to our data, in the analyzed group of women, they occur in 81% of cases. At the same time, the most unfavorable outcomes that resulted in the death of a woman have a positive correlation with the number of abortions and a history of inflammatory diseases.

We see the greatest reserves that can reduce the number of adverse outcomes in obstetrics in optimizing the management of patients in the outpatient department (antenatal clinics). Thus, we found that 49% of women who filed a lawsuit in court refused the treatment offered to them in the 1st, 2nd and 3rd trimesters of pregnancy.

In 53% of all cases related to improper provision of obstetric and gynecological care, patients were admitted to the hospital on an emergency basis. Moreover, more than half of the cases that led to emergency hospitalization could be recognized at the outpatient stage.

In addition, the timing of a particular manipulation (the time of active intervention) that led to an unfavorable outcome is of no small importance.

According to our data, most of these cases occur at night or in the early morning hours, holidays and weekends, as well as the second half of Friday, when for one reason or another the attention of doctors is dull. According to foreign literature, the continuous work of doctors working in an urgent specialty (obstetricians-gynecologists) should not exceed 6 hours, while according to domestic standards, daily duty lasts 12 hours without the right to sleep. On weekends and holidays, as a rule, some specialists are absent from hospitals, mainly more experienced managers, who on a normal day could provide the necessary assistance in a timely manner. For this same reason, most adverse outcomes occur on Friday, when most doctors have already left the hospital.

There is no clear consensus on the management of childbirth. In more than 50% of cases of all adverse outcomes examined by us, the birth management plan, in the opinion of the expert commission, was drawn up without taking into account abdominal birth. At the same time, modern requirements of perinatal obstetrics imply a more careful delivery.

After the data from an independent analysis of adverse outcomes in obstetric and gynecological practice, it is interesting to present the opinion of obstetricians and gynecologists themselves, based on data from an anonymous survey.

Thus, 68% of doctors consider the main reason for unfavorable outcomes in their practice to be the lack of an individual approach to the patient and an objective assessment of their capabilities, and the lack of a high level of equipment in medical institutions and the availability of modern medications is given secondary importance.

As our study showed, the greatest number of adverse outcomes in obstetric and gynecological practice occur in the period between 10 and 20 years of work for doctors (57% of cases, respectively), i.e. during the transition from the level of additional professionals to professionals. A large percentage (32%) of unfavorable outcomes among doctors with up to 10 years of work experience is explained by qualitative changes in professional status and activities. Working conditions are complicated by the emergence of extreme situations that arise during the provision of urgent care to patients in critical condition, in which responsible independent decisions have to be made. Having 15-20 years of work experience, doctors

over time, they mature to the status of a responsible doctor on duty in obstetric and gynecological hospitals, however, not all doctors are ready to work in such conditions, especially doctors of the outpatient obstetric service, who are deprived of appropriate training in a hospital setting. In an extreme situation, they show inertia of thinking in making quick and adequate decisions, which leads to diagnostic and treatment errors. More than half of all doctors (51% in obstetric cases and 54% in gynecological cases) had the highest or first qualification category and significant work experience. These data are quite comparable with the data referred to in his works by Yu.D. Sergeev (1988), and confirms his point of view that cases of inadequate care are more common among doctors with significant professional experience.

Among the adverse outcomes in gynecological practice, according to our data, the main part (71.5%) is due to complications of abortion. Moreover, the patients have a burdened somatic (68% of cases) and obstetric-gynecological (89.6% of cases) history. Thus, to reduce adverse outcomes in gynecological practice, it is advisable to eliminate the reasons why abortions in our country are performed 3 times more often than in Western European countries, rather than looking for reserves in improving the technique of the operation itself.

When conducting examinations related to the correctness of the provision of obstetric and gynecological care, the expert commission in 80% of cases identified deficiencies in diagnostics and treatment tactics, due not only to objective diagnostic difficulties, but also to underestimation of the severity of the patients’ condition, and the lack of timely and complete examination.

In general, most of the shortcomings in diagnostic and therapeutic care are associated with the lack of an individual approach to the patient; basically, an average approach prevails, which in most cases ceases to justify itself.

However, in the overwhelming majority of cases, the noted deficiencies in the provision of obstetric and gynecological care were not put into a causal relationship with the adverse outcome of pregnancy or childbirth, and thus did not represent prospects in terms of litigation, although they were extremely labor-intensive and required a lot of time and effort when carrying them out.

Currently, the Russian doctor remains in a disadvantageous legal position compared to the patient, upon whose application seven authorities (territorial health authorities, insurance company, prosecutor's office, court, forensic medical examination bureau, professional association, independent medical examination, ethical committee). In the context of such a legislative approach to assessing the business reputation of medical workers, the hope for sincere and voluntary recognition of professional errors by doctors is a chimera, which completely coincides with our data (only 30% of surveyed obstetricians-gynecologists indicate medical errors made in the medical (childbirth) history ).

For this reason, in the overwhelming majority of cases, “working on mistakes” among obstetricians and gynecologists comes down to denying the possibility of preventing a death or justifying it by “objective” factors. Such a reaction from doctors is understandable, but it is not constructive and deprives them of the opportunity to acquire new knowledge from their own negative experience, which subsequently leads to repeated repetition of similar medical errors.

Against the backdrop of an increase in the level of demands placed by patients on the work of obstetricians and gynecologists (noted by 73% of patients), only a third of patients are satisfied with the quality of the doctors’ work.

The main reason for dissatisfaction with the quality of medical services is the low culture of patient care, which was almost twice as often identified by respondents as the professional level of obstetricians and gynecologists.

The main medical and legal document that guarantees protection for the doctor in all higher authorities and in court is a correctly completed medical history (careful maintenance of technological medical documentation, including with emphasis on the features of diagnosis, treatment and features of relations with patients; the presence of recorded written informed voluntary consent or refusal to intervene in medical documents, especially in patients with a high likelihood of making claims (in patients with multiple background or concomitant diseases); careful development and execution of an agreement for the provision of paid medical services and an informed block describing typical and probable adverse outcomes of this type medical care).

The level of legal literacy of obstetrician-gynecologists looks simply catastrophic: only 40% of them know the regulatory documents regulating their professional activities, and only four doctors have completed medico-legal training courses for doctors.

This situation is used by a number of patients and their lawyers as an excellent opportunity to make money from the low legal literacy of doctors, and consequently, their legal defenselessness.

Moreover, our anonymous survey of patients showed that more than half of the patients surveyed (63%) know their rights, of which a third (24%)

Literature

1. Akopov V.I., Bova A.A. Legal basis for the activities of a doctor. - Expert Bureau. - M., 1997. - pp. 102-164.

2. DiMatteo M. R., Dante DiNicolu D.//Med. Care. -1991. -Vol. 19, N 8. - p. 829-842.

3. Sergeev Yu.D. The medical profession: legal foundations. - Kyiv: VSh Publishing House, 1988.-206 p.

4. Maternal mortality and ways to reduce it: Material of the 2nd National Assembly "Protection of reproductive health of the population" - M., 2000.-p.45-47

5. Abramova G.A., Yudchits Yu.A. Psychology in medicine: Textbook. -M.: Publishing House LPA Department-M, 1998. - 272 p.

A.A. Khalikov ON THE QUESTION OF THE NECESSITY TO CONSIDER THANATOGENESIS IN POST-MORTH THERMOMETRY

Department of Forensic Medicine (head of the department - Prof. V.I. Viter)

Izhevsk State Medical Academy

The article presents the results of an original study of post-mortem cooling from the perspective of taking into account variants of thanatogenesis - the shock reaction of the body preceding death. The values of thermal constants of the exponential cooling stage for various diagnostic zones are considered.

Key words: thermometry, shock, thanatogenesis, post-mortem cooling.

ABOUT NECESSITY OF THANATOGENESIS CONSIDERATION IN POSTMORTEM THERMOMETRY

There are presented the results of original investigation of postmortem cooling with taking into account of different thanatogenesis variants, in particular shock reaction of organism, which precede death. Exponential constants for different diagnostic regions are considered.

Key words: thermometry, shock, thanatogenesis, postmortem cooling.

Establishing the duration of death by degree of determination, many researchers tried to move

neither the severity of cadaveric changes has lost its ty from the subjective assessment of the results of studying cadaveric

meanings up to now. To increase the accuracy of changes to objective methods of their study. At

learns about their rights from television programs, 18% read relevant literature, and 21% of patients already have personal experience in defending their rights, which indicates the high legal literacy of patients.

Patients in most cases prefer to contact, first of all, the doctor who treated them, demanding that the defects of the previous treatment be eliminated. Only a small proportion of patients (10%) are ready to go to court and demand civil or criminal liability from the doctor (16%). However, a significant number of patients are ready to turn to the administration of this medical institution in order to compensate for moral and material damage (37% of cases).

This fact allows us to conclude that further informatization of patients in the field of protecting their rights, which both the press and television are aimed at, may in the near future lead to an even greater number of conflict situations between doctors and patients.

Our analysis of regulatory documents regulating the professional activities of obstetricians and gynecologists allows us to clearly see that they are all focused primarily on protecting the interests of the consumer. Therefore, only strict observance by an obstetrician-gynecologist of all requirements for his professional activity, based on knowledge of the legal documents regulating it, can ensure protection from unfounded claims made by patients.

Analysis of the causes and errors in treatment measures that led to commission forensic medical examinations in obstetrics and gynecology in 2003

bibliographic description:
Analysis of the causes and errors in treatment measures that led to commission forensic medical examinations in obstetrics and gynecology for 2003 / Kirpichenko V.I., Chekmarev A.I., Chernyshev A.P. // Selected issues of forensic medical examination. - Khabarovsk, 2005. - No. 7. — P. 34-39.

html code:
/ Kirpichenko V.I., Chekmarev A.I., Chernyshev A.P. // Selected issues of forensic medical examination. - Khabarovsk, 2005. - No. 7. — P. 34-39.

embed code for forum:
Analysis of the causes and errors in treatment measures that led to commission forensic medical examinations in obstetrics and gynecology for 2003 / Kirpichenko V.I., Chekmarev A.I., Chernyshev A.P. // Selected issues of forensic medical examination. - Khabarovsk, 2005. - No. 7. — P. 34-39.

wiki:
/ Kirpichenko V.I., Chekmarev A.I., Chernyshev A.P. // Selected issues of forensic medical examination. - Khabarovsk, 2005. - No. 7. — P. 34-39.

In 2003, the regional bureau of forensic medical examinations carried out 25 commission examinations, involving an obstetrician-gynecologist as an expert.

From Khabarovsk - 20 examinations
From the districts of the Khabarovsk Territory - 4
From other regions - 1

The main questions asked by the prosecutor's office and the police in almost all cases were the following:

Were there any violations in the provision of medical care to the patient?
Whether there was a violation of current instructions and orders during the provision of medical care.
Was the disease diagnosed correctly and timely?
Medication and other treatment was carried out correctly and in accordance with the established diagnosis.
What is the cause of death, is there a direct causal relationship between the outcome of the disease and the actions of the doctor and medical staff? personnel, performance of their professional affairs.

At the same time, the experts had medical histories, individual records of pregnant women, birth histories, and outpatient records of patients at their disposal.

After examinations, in some cases, defects in the treatment of victims and organizational errors were identified. I noticed that a number of medical documents were carelessly maintained and some entries were unreadable.

The largest number in 2003 (12) was carried out regarding complications arising as a result of parenteral administration of a 5% glucose solution in a number of medical institutions in Khabarovsk. All cases, with the exception of one, resulted in a favorable outcome for the patients. At the same time, some organizational errors were identified. Having received an emergency notification, the older nurses destroyed in most cases the solutions from this series, leaving a small amount for examination. Violations of the sanitary and epidemiological regime were identified, storage of solutions on the floor, without pallets, not far from the entrance. No defects or disorders were identified regarding treatment, diagnosis, treatment.

Of particular interest is the examination sent from area A. In the case, in addition to the questions raised about the quality of treatment, questions were raised about compensation for material and moral damage. The experts were asked questions about the causes of traumatic damage to the pelvic joints, which, according to the plaintiff, arose from the unprofessional actions of the doctors who delivered the child. During the examination, experts decided to decide whether the patient really had a rupture of the pubic and sacroiliac joints.

Based on a thorough analysis, submitted documents, X-ray studies, literature on this issue, the commission came to the conclusion that the woman did not have a rupture of the symphysis pubis (that is, there was no injury at all), but symphysiolysis that developed as a result of physiological processes and the accompanying inflammatory process of the pubic symphysis (symphysitis) and the sacroiliac joint (sacroiliitis). The commission also found that there was no connection between the doctor’s actions (pressure on the stomach with hands).

Nevertheless, the experts identified shortcomings in the management of childbirth: the degree of perinatal risk was not noted, the condition of the symphysis pubis before birth (divergence of the pubic bones during pregnancy) was not noted in the clinical diagnosis, and the diagnosis: Diastasis of the rectus abdominis muscles was not made. There were discrepancies in determining the timing of pregnancy and fetal weight. The commission noted that when providing medical care in the second stage of labor, techniques were used that were not regulated by orders of the Ministry of Health of the Russian Federation; the question of a planned caesarean section was not raised (taking into account the course of pregnancy, the condition of the fetus and other data).

Of particular interest is the examination of the development of severe purulent-septic complications, which led to the development of severe iatrogenic complications and worsening of the disability group (according to the preliminary investigation). Based on the study of medical documents, the expert commission came to the conclusion that the patient’s clinical diagnosis of “fast-growing fibroids” was beyond doubt; the patient needed specialized gynecological medical care. assistance (surgical treatment). At the same time, the commission believes that the patient’s severe pathology of the left lower limb (osteogenic sarcoma of the left thigh) can mask the clinical manifestations of other diseases or pathological conditions, or complications. The commission believes that this clinical case is unusual and dictated the need for a medical consultation (consisting of gynecologists, traumatologists, surgeons, pharmacologists and the administration of the medical institution) to develop a consensus on the plan for managing the patient, which should be reflected in the medical history. When planning surgical treatment of the patient, a complete special gynecological examination was not performed (colposcopy, RDV, followed by histological examination of scrapings, no smears for cytology). The Commission emphasizes that in any institution, the attending physician is responsible for conducting examinations and treating the patient. Planning the scope of surgical treatment is decided by the attending physician together with the head. department or department employee responsible for work in the department.

The commission believes that the temperature reaction that arose in the postoperative period, the absence of changes during vaginal examination, could lead to the idea that the patient’s temperature in the postoperative period was connected with the patient’s disease of the left thigh.

Based on the documents submitted for examination, the commission believes that the diagnosis made after examination by a surgeon and an infectious disease specialist: peritonitis with symptoms of severe intoxication required emergency surgical treatment. Suturing the defect of the sigmoid colon with purulent peritonitis is a mandatory stage of surgical intervention.

The commission also believes that postoperative complications are primarily due to the patient’s severe oncological disease (hip sarcoma), accompanied by immunodeficiency, which was a favorable background for the development of the inflammatory process in the pelvis. The Commission believes that there is no direct cause-and-effect relationship between the incomplete scope of diagnostic measures before elective surgery, the selected volume of surgery on the one hand, and the development of postoperative complications on the other hand.

From the point of view of forensic medicine, complications of operations or complex diagnostic methods used in the absence of defects in their implementation resulting from other reasons (severity of the patient’s condition, unforeseen features of the patient’s reaction, etc.) are not subject to forensic medical severity of harm to the patient’s health.

The next examination is about death in the postpartum period. Based on the submitted medical documents, the commission identified errors and omissions of both treatment and organizational plans.

At the stage of the antenatal clinic, the algorithm for examining and monitoring the pregnant woman was not followed, no measures were taken to prevent and treat gestosis, and there was no continuity between the antenatal clinic and hospitals. In the maternity ward, the patient was not assessed for the severity of gestosis, and blood and urine tests were not performed for emergency indications. When foul-smelling green amniotic fluid is discharged, a diagnosis of chorioamnionitis is not made, antibacterial therapy is not prescribed, and chronic DIC is not treated. When massive postpartum hemorrhage (more than 4,500) developed, no blood or blood products were transfused. Surgical treatment was prolonged for one hour and was carried out on an agonizing patient. The commission recognized that the woman in labor, against the background of long-term gestosis, chronic disseminated intravascular coagulation syndrome, which was not treated at all stages of pregnancy and medical care during delivery, experienced massive postpartum unrepaired bleeding (more than 4,500), which led to the development of stage 3 hemorrhagic shock - the immediate cause of death . An analysis of medical documents, as well as a re-examination of pathohistological material from the internal organs of a corpse shows that a woman in labor, who suffered from long-term and untreated gestosis and intrauterine infection, gave birth with severe complications - infection of the placenta, amniotic fluid and the fetus itself, which led to its bacterial death as well as the development of necrotic purulent endometritis and postpartum sepsis, the morphological signs of which were: focal interstitial myocarditis, acute reactive hepatitis (with acute fatty hepatosis), septic hyperplasia of the splenic pulp, necronephrosis, necrosis of the adrenal gland. The expert commission believes that there is a direct cause-and-effect relationship between the quality of medical care for pregnancy with violations of the observation and treatment algorithm at all stages of its course and during childbirth, on the one hand, and an unfavorable (lethal for the mother and fetus) outcome. The Forensic Medical Expert Commission considers it appropriate to point out organizational and tactical defects committed by the head of the department for the management of childbirth (failure to follow instructions and job responsibilities), and a lack of control on the part of the administration over the work of the maternity ward and blood transfusion station. The department is not provided with modern infusion equipment, there is no control over the reserves of blood and its components, as well as lists of reserve donors.

Cases concerning complications that arose during the pre- and postpartum period, surgical and other medical measures, rape, and treatment of inflammatory diseases were submitted for consideration by experts. An analysis of documents and findings of commission forensic medical examinations shows that in most cases the provision of medical care corresponds to the modern level and the outcomes of diseases are not in a direct cause-and-effect relationship with this care. But in a number of cases there were defects in treatment and organizational measures, and the outcome was in a direct causal relationship with this. The most common reason for initiating cases and inspections carried out by the prosecutor's office and the police were complaints from relatives and victims themselves about the actions of medical staff, and deontological aspects were a frequent reason for this.

OBSTETRICS AND GYNECOLOGY, 2007, No. 5
V. E. RADZINSKY, I. N. KOSTIN

SAFE MISTRY
Department of Obstetrics and Gynecology with a course of perinatology (head - Prof. V. E. Radzinsky) Peoples' Friendship University of Russia, Committee on the Quality of Medical Care of the Russian
Society of Obstetricians and Gynecologists, Moscow

“Safe obstetrics” is a term that naturally replaces the expression safe motherhood. If in the last third of the last century the world community made efforts to unite humanitarian organizations, sociologists, educators, and doctors in the fight for a woman’s right not to die for reasons related to pregnancy and childbirth, then already in 1995 at the World Congress on Maternal Mortality there was not a single official representative of the UN, WHO, UNICEF or other international organizations. There are at least two reasons for this. It turned out that to transfer so-called home births to hospital births requires huge financial costs (up to 72 trillion US dollars). In addition, by the end of the 20th century, it became obvious that the WHO program (1970) to reduce maternal mortality by 2 times was not only not implemented, but by 2000 the situation had even worsened: instead of 500 thousand women dying annually due to pregnancy and childbirth, there were 590 thousand of them. There are many reasons for this, in particular, the priority of family planning turned out to be unrealized. However, the main reason is a change in attitude towards the family problem - it has been placed under the jurisdiction of national administrations. The consequences of this were not slow to be felt: there were significantly fewer program reports on the problems of maternal mortality at the last FIGO congresses (2003, 2006), and there was practically no unified interdisciplinary strategy at all.
The determination of maternal mortality by average annual per capita income (API) has long been proven. Thus, in Uganda the MDI is US$100, the maternal mortality rate is 1100 per

100,000 live births; in Egypt, the SOP is $400, maternal mortality is 100. Thus, the natural way to reduce maternal mortality is to increase the welfare of the state. This also applies to countries where there is no state system for the protection of motherhood and childhood.
Statistics show that more than half a million women around the world die every year without fulfilling the function intended by nature - reproduction. It should be noted that every tenth case of maternal mortality is, to one degree or another, a consequence of medical errors. It is medical errors (real or imaginary) that become a real danger for a doctor, who is subject not only to legal prosecution and sanctions from insurance companies, but also to “pressure” from society.
In general, the number of lawsuits against doctors has increased more than 5 times over the past 4 years. In this regard, two facts are interesting. First, there were no counterclaims from obstetricians-gynecologists against the plaintiffs at all. The second - in an anonymous survey of gynecologists in the Moscow region (A.L. Gridchik, 2000) to the question: how often were you a direct or indirect culprit of maternal mortality, the doctors answered very differently depending on their work experience. 15% of doctors with up to 15 years of experience, 43% with 16-25% years of experience, and 50% with more than 25 years of experience considered themselves guilty.
It is known that there are different types of medical errors. Firstly, these are gross violations of generally recognized norms, rules, protocols due to

low professional knowledge of medical personnel. Secondly, “strict” compliance with the same generally accepted norms, rules, protocols, etc. The situation is paradoxical.
Like any science, obstetrics is a dynamically developing discipline that constantly absorbs all the latest achievements of medical science and practice. This is typical for any scientific field, but it must be borne in mind that pregnancy and childbirth are a physiological process, and not a set of diagnoses. Therefore, any intervention in this area should be undertaken only as a last resort. However, in recent decades there has been a large information boom, which is manifested by the emergence of contradictory theories, ideas, and proposals for the management of pregnancy and childbirth. Under these conditions, it is difficult, and sometimes impossible, for practical doctors to understand the expediency and benefits of some provisions or, on the contrary, the risk for the mother and fetus of others: what is the effectiveness of certain methods of managing pregnancy and childbirth, what is the degree of their aggressiveness for the mother and fetus, how they affect the child’s health in the future.
At the present stage of development of obstetrics, there is a number of erroneous, scientifically unsubstantiated ideas and approaches, the consequences of which in most cases can be characterized as manifestations of “obstetric aggression”. The latter sometimes becomes the “norm” for pregnancy and childbirth, unfortunately, not always with a favorable outcome. As an example, I would like to cite data from the Netherlands: the frequency of use of oxytocin during childbirth by doctors is 5 times higher than when childbirth is managed by nursing staff, and the frequency of caesarean sections is 3 times higher in medical hospitals.
In Russia, against the background of the most acute problem of population reproduction, in 2005 more than 400 women died from causes related to pregnancy and childbirth. The dynamics of the maternal mortality rate in the Russian Federation over the past decade inspires cautious optimism. As for the structure of the causes of maternal mortality, it fully corresponds to the global one, which is 95% “provided” by the countries of Africa and Asia (bleedings, abortions - 70%, sepsis, gestosis).
The reasons for such unfavorable outcomes of pregnancy and childbirth for the mother and fetus are, to a large extent, the so-called obstetric aggression.
Obstetric aggression is iatrogenic, scientifically unsubstantiated actions, supposedly aimed at benefit, but as a result bringing only harm to the mother and fetus. This leads to an increase in complications of pregnancy and childbirth, an increase in perinatal mortality, infant and maternal morbidity and mortality. In this regard, a natural question arises about the so-called safe obstetrics.
Safe obstetrics is a set of scientifically proven approaches based on the achievements of modern science and practice.

The overall goal of safe obstetrics is primarily to reduce maternal and perinatal morbidity and mortality. However, this provision is currently insufficient.
In recent decades, revolutionary changes have occurred in all spheres of life in our society. Modern socio-economic conditions put forward new requirements for the organization of healthcare. At the same time, such an indicator as the quality of services provided becomes one of the most important factors determining the activities of any healthcare institution.
The formation and development of the health insurance system and market relations also changed the social behavior of patients and contributed to the establishment of social control over the quality of medical services.
Therefore, the most important feature of modern healthcare is the strengthening of trends in the legal regulation of medical activities. One of the directions of legal reform in healthcare should be the determination of measures of responsibility for non-compliance or formal implementation of legislation for all healthcare authorities involved in ensuring the constitutional right of citizens to receive appropriate medical care, and in relation to a citizen doctor - ensuring his constitutional rights and professional activities, including liability insurance.
The risk of adverse outcomes of pregnancy and childbirth or the development of legal conflicts accompanies the “interested parties” - the doctor and the patient - from the first days of pregnancy, and sometimes extends to the period of pre-conception preparation.
Unobtrusive “aggression” often begins with the very first appearance of a pregnant woman at the antenatal clinic. This applies to unnecessary, sometimes expensive, research and analysis, as well as treatment. The prescription of a standard complex of drugs (vitamin and mineral complexes, dietary supplements, etc.) often replaces pathogenetically based therapy. For example, in case of threatening early termination of pregnancy, in all cases, without appropriate examination, progesterone drugs, ginipral and others are prescribed, which costs over half a billion rubles.
Separately, it should be said about the biotope of the vagina - the most unprotected area of the reproductive system from medical actions. It has become common practice for doctors to identify the presence of any type of infection in the vaginal contents, while prescribing inadequate treatment (disinfectants, powerful antibiotics without determining sensitivity to them, etc.). No less a mistake is the desire to restore vaginal eubiosis. As is known, “nature abhors a vacuum,” therefore, after antibacterial therapy, the microbiological niche is quickly populated by the same microorganisms that, at best, were the target of treatment (staphylococci, streptococci,

^ OBSTETRICS AND GYNECOLOGY, 2007, No. 5

cocci, Escherichia coli, fungi, etc.), but with a different antibacterial resistance.
High-quality PCR gives a lot of incorrect information, forcing the doctor to make certain “aggressive” decisions. Therefore, in the USA this research is carried out 6 times less often than in the Russian Federation, for the reason that it is “too expensive and overly informative.” In order to get rid of the desire to “treat tests,” since 2007 in the United States, even conducting bacterioscopic examinations of pregnant women without complaints was prohibited.
The study of the evolution of the composition of the biotope of the genital tract over the past decades gives the following results: in every second healthy woman of reproductive age, gardnerella and candida can be identified in the vaginal contents, in every fourth - E. coli, in every fifth - mycoplasma. If the CFU of these pathogens does not exceed 105, and the CFU of lactobacilli is more than 107 and there are no clinical manifestations of inflammation, then the woman is considered healthy and does not need any treatment. High-quality PCR does not provide this important information. It is informative only when detecting microorganisms that should practically be absent from the vagina (treponema pallidum, gonococci, chlamydia, trichomonas, etc.).
Another manifestation of so-called obstetric aggression in antenatal clinics is the unreasonably widespread use of additional research methods. We are talking about numerous ultrasound examinations, CTG in the presence of a physiological pregnancy. Thus, prenatal diagnostic methods should be used not to find something, but to confirm the assumptions that have arisen about the risk of developing perinatal pathology.
What is the way out of this situation? Risk strategy - identifying groups of women whose pregnancy and childbirth may be complicated by disruption of the vital functions of the fetus, obstetric or extragenital pathology. These risks must be assessed in terms of significance not only throughout pregnancy, but, very importantly, during childbirth ("intrapartum gain"). Many births that had unfavorable outcomes for both the mother and the fetus are based on underestimation or ignorance of intrapartum risk factors (pathological preliminary period, meconium fluid, labor anomalies, etc.).
The tactics of managing pregnant women at the end of the third trimester of pregnancy also requires revision: unreasonable hospitalization in sometimes extremely overloaded departments of pathology of pregnant women. In particular, this applies to dropsy in pregnancy. According to modern concepts, normal weight gain in pregnant women fluctuates in a fairly wide range (from 5 to 18 kg) and is inversely proportional to the initial body weight.
The majority (80%) of pregnant women in need of treatment can successfully use the services of a day hospital, saving material and

financial resources for the maternity hospital, and without separating the woman from her family.
A pregnant woman hospitalized in pregnancy pathology departments without convincing reasons at the end of pregnancy has one way - to the maternity ward. It is believed that in this pregnant woman, using various methods, first of all, the cervix should be prepared. This is followed by amniotomy and labor induction. It should be noted that amniotomy in the department of pathology of pregnant women is performed in more than half of the patients and is not always justified. This includes amniotomy when the cervix is not mature enough, under the pressure of a diagnosis (dropsy, at best - gestosis, doubtful post-maturity, placental insufficiency with a fetal weight of 3 kg or more, etc.). It should be emphasized that amniotomy for an “immature” cervix significantly increases the incidence of complications during childbirth and cesarean section. Expert estimates show that every fourth caesarean section is the result of obstetric aggression.
The introduction of elements of new perinatal technologies does not find proper understanding: an excess of sterilizing measures (shaving, the use of disinfectants in practically healthy pregnant women) does not leave a chance for any biotope (pubic, perineal, vaginal) to perform its protective functions during childbirth and the postpartum period.
It is impossible to ignore the supposedly resolved, but at the same time eternal question - how long on average childbirth should last. This is a strategic question, and therefore incorrect answers to it entail a chain of incorrect actions.
According to the literature, the duration of labor for first- and multiparous women at the end of the 19th century averaged 20 and 12 hours, respectively, and by the end of the 20th century - 13 and 7 hours. Analyzing the time parameters of this value, we can assume that on average each decade the duration labor in primiparous women decreased by almost 1 hour, in multiparous women - by 40 minutes. What has changed during this time? Genetically determined, centuries-old physiological process of childbirth? Hardly. Anthropometric indicators of the female body, in particular the birth canal? No. A natural process of development of scientific thought? Without a doubt! Of course, most achievements in obstetric science and practice have a noble goal - reducing perinatal mortality, maternal morbidity and mortality. But an analysis of the current state of obstetrics shows that we often drive ourselves into a dead end. Why are the world averages for the duration of labor the starting point for making, most often hasty and in most cases, wrong decisions in a particular pregnant woman (the frequency of use of uterotonic drugs in the world reaches 60%, and this is only the data taken into account). Time, and not the dynamics of the birth process, became the criterion for the correct course of labor. Conducted studies indicate that women who begin labor in a maternity institution

^ OBSTETRICS AND GYNECOLOGY, 2007, No. 5

nii have a shorter duration of labor compared to those who present in the middle of the first stage of labor. It should be noted that in the 1st group of women in labor, more difficult births are recorded, characterized by a large number of various interventions and a higher frequency of cesarean sections. No one knows the true figures for the use of prohibited benefits during childbirth (Kristeller’s method, etc.).
An assessment of the obstetric situation using the Kristeller manual was described by E. Bumm in 1917. E. Bumm emphasized that this method is the most aggressive and dangerous intervention in childbirth.
Currently, at the proposal of the French Association of Obstetricians and Gynecologists, the European Union is considering the issue of depriving a doctor of the right to practice obstetrics in all countries of the community if he declares the use of the Christeller benefit. Presented at the last World Congress of Obstetricians and Gynecologists (FIGO, 2006), this initiative was warmly welcomed by delegates.
A retrospective analysis of births that resulted in injuries to newborns, their resuscitation, including mechanical ventilation, revealed the main mistake: the use of the Kristeller method instead of surgical delivery that was not carried out on time.
Issues of providing obstetric care using episiotomy require strict restrictive frameworks. The desire to reduce the length of the incision leads to the exact opposite result: up to 80% of so-called small episiotomies turn into banal perineal tears. Therefore, instead of stitching up a cut wound, you have to stitch up a laceration. As a result, incompetence of the pelvic floor muscles occurs in young women. It has been established that episiotomy during fetal hypoxia is not a radical method of accelerating labor, and if the head is high, this operation does not make sense at all. Therefore, the growing number of cases of pelvic floor muscle failure is a consequence not only of poor restoration of the perineum, but also of the so-called sparing, and often unnecessary, dissection.
As you know, the leading cause of maternal mortality in Russia, as well as in the world, is obstetric hemorrhage. There are still ongoing discussions about the quantity and quality of infusion therapy when replenishing blood loss in obstetrics. Old views on this issue are now being critically assessed. Now there is no doubt that the priority of infusion therapy is the high-quality composition of transfused solutions. This is especially true for infusion therapy in women with gestosis, in which overhydration can lead to dire consequences. And refusal from such “aggressive” infusion media as gelatinol, hemodez, reopolyglucin, etc. significantly reduces the occurrence of disseminated intravascular coagulation syndrome. Hydroxyethyl starch, 0.9% sodium chloride solution, frozen plasma should be the main infusion media.

But this is only part of the problem of successfully treating obstetric hemorrhage. The main points should include a correct assessment of the quantitative (volume) and qualitative (disturbance of the coagulation system) components of blood loss, timely and adequate infusion-transfusion therapy, timely and adequate surgical treatment (organ-preserving tactics) and constant instrumental and laboratory monitoring of vital functions and homeostasis.
The main causes of mortality in massive obstetric hemorrhages are violation of the above points (delayed inadequate hemostasis, incorrect infusion therapy tactics, violation of the phasing of care).
Oddly enough, even such a trivial thing as assessing the volume of blood loss can play a decisive role in the outcome of the treatment of the bleeding itself. Unfortunately, the assessment of blood loss is almost always subjective.
Timely treatment of hypotonic bleeding using all necessary components allows you to successfully cope with the situation already at the conservative stage of obstetric care. A prerequisite is timely diagnosis of bleeding. Many legal cases brought regarding maternal deaths relate to this issue. Then a thorough assessment of the volume of blood loss and calculation of the infusion-transfusion therapy program (depending on the woman’s body weight) and its correction during treatment are necessary. Of great importance is multicomponent treatment, which involves invasive intervention (manual examination of the walls of the uterus or bimanual compression - forgotten methods of Snegirev and Sokolov), the use of a system for intravenous administration of solutions, the introduction of uterotonics, monitoring hemodynamic and hemostasiological parameters and, importantly, constant assessment of blood loss ( during treatment).
Recently, an intrauterine hemostatic balloon has been widely used to stop hypotonic bleeding. This method cannot be called new, since the first mention of the use of this kind of means dates back to the middle of the 19th century (1855). However, the use of modern materials and solutions has made it possible to once again turn to this method. Its effectiveness is 82%.
The next factor that often leads to dismal birth outcomes is the decision to switch from the conservative to the surgical stage of treatment of obstetric hemorrhage. To a greater extent, it concerns the psychology of the doctor: by any means to delay laparotomy and removal of the uterus. When 3,067 uteruses were promptly removed during childbirth in the Russian Federation in 2001, the number of lawsuits in the country regarding deprivation of the reproductive organ exceeded that for cases of maternal mortality. It shouldn't be this way. What options are there to stop bleeding during surgery?

^ OBSTETRICS AND GYNECOLOGY, 2007, No. 5

The sequence of actions is as follows:
- injection of prostenon into the uterine muscle;
- ischemia of the uterus by applying clamps and ligatures to the vascular bundles;
- application of hemostatic compression sutures B-Lynch and Pereira;
- ligation of the iliac arteries;
- angiographic embolization;
- and only then amputation or extirpation of the uterus.
The tactics for treating obstetric hemorrhage should always be based on the organ-preserving principle. It is unnatural if a woman admitted to a maternity hospital is discharged without a reproductive organ. Of course, there are exceptions to the rule, but today there is no doubt that organ-preserving tactics should become a priority in the treatment of obstetric hemorrhage.
Another cause of death in the Russian Federation is abortion, or rather its complications. Despite the decline in the absolute number of abortions over the past decade, they occupy 2nd place in the structure of causes of maternal mortality in Russia. There are reasons for this. Unfortunately, under the influence of socio-economic factors, abortion in the Russian Federation remains the main method of birth control (the frequency of use of highly effective methods of contraception in the Russian Federation is 3 times lower than in economically developed countries; in addition, more abortions are performed in Russia than in European countries) .
To illustrate the complexity of the relationship between legislative decisions and the reaction of society, I would like to give an example of an ill-conceived decision to abolish a larger number (9 out of 13) of social indications for late termination of pregnancy, after which the number of criminal abortions increased by 30% (!), and not all of them ended well. Banning abortions without offering anything in return is pointless; a comprehensive solution to the problem is necessary.
Until now, the mystery of obstetrics is gestosis. Modern scientific research has seemingly approached the last barrier in the pathogenetic chain of this pregnancy complication - genetics, but there is still no complete picture of the development of preeclampsia. The price of ignorance is the lives of thousands of women dying around the world, including in Russia. Strange as it may seem, gestosis is probably the most easily controlled cause of maternal mortality. The question is timely diagnosis and adequate treatment. Of course, we are talking about treatment conditionally - the only successful method of treating this complication is

The only way to prevent pregnancy is to terminate it in a timely manner. The main task is to prevent the occurrence of eclampsia, from which pregnant women actually die. The gold standard of treatment is oncoosmotherapy, therapy in accordance with the severity of the disease and delivery according to indications. But questions remain: how to determine the severity of gestosis, how long to treat, what method of delivery, etc. The correct solution to these issues is the safety of the patient and the doctor.
The fight against maternal mortality remains and, of course, will remain a priority in the work of the obstetric service, however, the formation and development of the health insurance system and market relations in the country have changed the social behavior and mentality of patients. Their awareness of modern methods of obstetric care, paradoxically, sometimes embarrasses some doctors who do not bother to educate themselves. We are talking about modern perinatal technologies - a set of measures based on evidence-based medicine. Not introducing them where possible is, to put it mildly, short-sighted, and in some situations even criminal (outbreaks of infectious diseases). The worse the sanitary and technical condition of an obstetric hospital, the more it needs the mother and child to stay together, exclusively breastfed, early discharge. Theoretically, everyone knows this; in practice, reluctance to change something gives rise to a pile of misconceptions.
We have already said above that every tenth case of maternal death in the world is due to the fault of a doctor. How can we protect the patient, as well as the doctor himself, from the consequences of incompetent actions? The cheapest but extremely effective way is to develop appropriate standards and protocols. In the modern information world, it is no longer possible to work without this. First of all, we are talking about protocols for the treatment of obstetric hemorrhage, management of pregnant women with gestosis, with prenatal rupture of amniotic fluid, management of childbirth in the presence of a uterine scar, etc., in the future - for each obstetric situation.
In conclusion, it should be noted that this message covers only a small number of current issues and problems of obstetric practice that are in dire need of solution, revision and critical evaluation. Further research into this acute problem will significantly improve the most important indicators of the obstetric service as a whole.

The determination of maternal mortality by average annual per capita income (API) has long been proven. Thus, in Uganda, the MDI is US$100, the maternal mortality rate is 1,100 per 100,000 live births; in Egypt, the SOP is $400, maternal mortality is 100. Thus, the natural way to reduce maternal mortality is to increase the welfare of the state. This also applies to countries where there is no state system for the protection of motherhood and childhood.

Statistics show that more than half a million women around the world die every year without fulfilling the function intended by nature - reproduction. It should be noted that every tenth case of maternal mortality is, to one degree or another, a consequence of medical errors. It is medical errors (real or imaginary) that become a real danger for a doctor, who is subject not only to legal prosecution and sanctions from insurance companies, but also to “pressure” from society.

In general, the number of lawsuits against doctors has increased more than 5 times over the past 4 years. In this regard, two facts are interesting. First, there were no counterclaims from obstetricians-gynecologists against the plaintiffs at all. The second - in an anonymous survey of gynecologists in the Moscow region (A.L. Gridchik, 2000) to the question: how often were you a direct or indirect culprit of maternal mortality, the doctors answered very differently depending on their work experience. 15% of doctors with up to 15 years of experience, 43% with 16-25% years of experience, and 50% with more than 25 years of experience considered themselves guilty.

It is known that there are different types of medical errors. Firstly, these are gross violations of generally accepted norms, rules, and protocols due to the low professional knowledge of medical personnel. Secondly, “strict” compliance with the same generally accepted norms, rules, protocols, etc. The situation is paradoxical.

Like any science, obstetrics is a dynamically developing discipline that constantly absorbs all the latest achievements of medical science and practice. This is typical for any scientific field, but it must be borne in mind that pregnancy and childbirth are a physiological process, and not a set of diagnoses. Therefore, any intervention in this area should be undertaken only as a last resort. However, in recent decades there has been a large information boom, which is manifested by the emergence of contradictory theories, ideas, and proposals for the management of pregnancy and childbirth. Under these conditions, it is difficult, and sometimes impossible, for practical doctors to understand the expediency and benefits of some provisions or, on the contrary, the risk for the mother and fetus of others: what is the effectiveness of certain methods of managing pregnancy and childbirth, what is the degree of their aggressiveness for the mother and fetus, how they affect the child’s health in the future.

At the present stage of development of obstetrics, there is a number of erroneous, scientifically unsubstantiated ideas and approaches, the consequences of which in most cases can be characterized as manifestations of “obstetric aggression”. The latter sometimes becomes the “norm” for managing pregnancy and childbirth, unfortunately, not always with a favorable outcome. As an example, I would like to cite data from the Netherlands: the frequency of use of oxytocin during childbirth by doctors is 5 times higher than when childbirth is managed by nursing staff, and the frequency of caesarean sections is 3 times higher in medical hospitals.

In Russia, against the background of the most acute problem of population reproduction, in 2005 more than 400 women died from causes related to pregnancy and childbirth. The dynamics of the maternal mortality rate in the Russian Federation over the past decade inspires cautious optimism. As for the structure of the causes of maternal mortality, it fully corresponds to the global one, which is 95% “provided” by the countries of Africa and Asia (bleedings, abortions - 70%, sepsis, gestosis).

The reasons for such unfavorable outcomes of pregnancy and childbirth for the mother and fetus are, to a large extent, the so-called obstetric aggression.

Obstetric aggression is iatrogenic, scientifically unsubstantiated actions, supposedly aimed at benefit, but as a result bringing only harm to the mother and fetus. This leads to an increase in complications of pregnancy and childbirth, an increase in perinatal mortality, infant and maternal morbidity and mortality. In this regard, a natural question arises about the so-called safe obstetrics.

Safe obstetrics is a set of scientifically proven approaches based on the achievements of modern science and practice. The overall goal of safe obstetrics is primarily to reduce maternal and perinatal morbidity and mortality. However, this provision is currently insufficient.

In recent decades, revolutionary changes have occurred in all spheres of life in our society. Modern socio-economic conditions put forward new requirements for the organization of healthcare. At the same time, such an indicator as the quality of services provided becomes one of the most important factors determining the activities of any healthcare institution.

The formation and development of the health insurance system and market relations also changed the social behavior of patients and contributed to the establishment of social control over the quality of medical services.

Therefore, the most important feature of modern healthcare is the strengthening of trends in the legal regulation of medical activities. One of the directions of legal reform in healthcare should be the determination of measures of responsibility for non-compliance or formal implementation of legislation for all healthcare authorities involved in ensuring the constitutional right of citizens to receive appropriate medical care, and in relation to a citizen doctor - ensuring his constitutional rights and professional activities, including liability insurance.

The risk of developing unfavorable outcomes of pregnancy and childbirth or the development of legal conflicts accompanies the “interested parties” - the doctor and the patient - from the first days of pregnancy, and sometimes extends to the period of pre-conception preparation.

Unobtrusive “aggression” often begins from the very first appearance of a pregnant woman at the antenatal clinic. This applies to unnecessary, sometimes expensive, research and analysis, as well as treatment. The prescription of a standard complex of drugs (vitamin and mineral complexes, dietary supplements, etc.) often replaces pathogenetically based therapy. For example, in case of threatening early termination of pregnancy, in all cases, without appropriate examination, progesterone drugs, ginipral and others are prescribed, which costs over half a billion rubles.

Separately, it should be said about the biotope of the vagina - the most unprotected area of the reproductive system from medical actions. The desire of the doctor to detect the presence of any types of infections in the vaginal contents, while prescribing inadequate treatment (disinfectants, powerful antibiotics without determining sensitivity to them, etc.), has become widespread. No less a mistake is the desire to restore vaginal eubiosis. As is known, “nature abhors a vacuum,” therefore, after antibacterial therapy, the microbiological niche is quickly populated by the same microorganisms that, in the best case, the treatment was aimed at (staphylococci, streptococci, E. coli, fungi, etc.), but with a different antibacterial resistance .

High-quality PCR gives a lot of incorrect information, forcing the doctor to make certain “aggressive” decisions. Therefore, in the USA this research is carried out 6 times less often than in the Russian Federation, for the reason that it is “too expensive and overly informative.” In order to get rid of the desire to “treat tests,” since 2007 in the United States, even conducting bacterioscopic examinations of pregnant women without complaints was prohibited.

The study of the evolution of the composition of the biotope of the genital tract over the past decades gives the following results: in every second healthy woman of reproductive age, gardnerella and candida can be identified in the vaginal contents, in every fourth - E. coli, in every fifth - mycoplasma. If the CFU of these pathogens does not exceed 10 5, and the CFU of lactobacilli is more than 10 7 and there are no clinical manifestations of inflammation, then the woman is considered healthy and does not need any treatment. High-quality PCR does not provide this important information. It is informative only when detecting microorganisms that should practically be absent from the vagina (treponema pallidum, gonococci, chlamydia, trichomonas, etc.).

Another manifestation of so-called obstetric aggression in antenatal clinics is the unreasonably widespread use of additional research methods. We are talking about numerous ultrasound examinations, CTG in the presence of a physiological pregnancy. Thus, prenatal diagnostic methods should be used not to find something, but to confirm the assumptions that have arisen about the risk of developing perinatal pathology.

What is the way out of this situation? Risk strategy - identifying groups of women whose pregnancy and childbirth may be complicated by disruption of the vital functions of the fetus, obstetric or extragenital pathology. These risks must be assessed in terms of significance not only throughout pregnancy, but, very importantly, during childbirth ("intrapartum gain"). Many births that had unfavorable outcomes for both the mother and the fetus are based on underestimation or ignoring of intrapartum risk factors (pathological preliminary period, meconium fluid, labor anomalies, etc.).

The tactics of managing pregnant women at the end of the third trimester of pregnancy also requires revision: unreasonable hospitalization in sometimes extremely overloaded departments of pathology of pregnant women. In particular, this applies to dropsy in pregnancy. According to modern concepts, normal weight gain in pregnant women fluctuates in a fairly wide range (from 5 to 18 kg) and is inversely proportional to the initial body weight.

The majority (80%) of pregnant women in need of treatment can successfully use the services of a day hospital, saving the material and financial resources of the maternity hospital, and without tearing the woman away from her family.

A pregnant woman hospitalized in pregnancy pathology departments without convincing reasons at the end of pregnancy has one way - to the maternity ward. It is believed that in this pregnant woman, using various methods, first of all, the cervix should be prepared. This is followed by amniotomy and labor induction. It should be noted that amniotomy in the department of pathology of pregnant women is performed in more than half of the patients and is not always justified. This includes amniotomy when the cervix is not mature enough, under the pressure of a diagnosis (dropsy, at best - gestosis, doubtful post-maturity, placental insufficiency with a fetal weight of 3 kg or more, etc.). It should be emphasized that amniotomy for an “immature” cervix significantly increases the incidence of complications during childbirth and cesarean section. Expert estimates show that every fourth caesarean section is the result of obstetric aggression.

The introduction of elements of new perinatal technologies does not find proper understanding: an excess of sterilizing measures (shaving, the use of disinfectants in practically healthy pregnant women) does not leave a chance for any biotope (pubic, perineal, vaginal) to perform its protective functions during childbirth and the postpartum period.

It is impossible to ignore the supposedly resolved, but at the same time eternal question - how long on average childbirth should last. This is a strategic question, and therefore incorrect answers to it entail a chain of incorrect actions.

According to the literature, the duration of labor for first- and multiparous women at the end of the 19th century averaged 20 and 12 hours, respectively, and by the end of the 20th century - 13 and 7 hours. Analyzing the time parameters of this value, we can assume that on average each decade the duration labor in primiparous women decreased by almost 1 hour, in multiparous women - by 40 minutes. What has changed during this time? Genetically determined, centuries-old physiological process of childbirth? Hardly. Anthropometric indicators of the female body, in particular the birth canal? No. A natural process of development of scientific thought? Without a doubt! Of course, most achievements in obstetric science and practice have a noble goal - reducing perinatal mortality, maternal morbidity and mortality. But an analysis of the current state of obstetrics shows that we often drive ourselves into a dead end. Why are the world averages for the duration of labor the starting point for making, most often hasty and in most cases, wrong decisions in a particular pregnant woman (the frequency of use of uterotonic drugs in the world reaches 60%, and this is only the data taken into account). Time, and not the dynamics of the birth process, became the criterion for the correct course of labor. Conducted research suggests that women who begin labor in a maternity facility have a shorter duration of labor compared to those who arrive in the middle of the first stage of labor. It should be noted that in the 1st group of women in labor, more difficult births are recorded, characterized by a large number of various interventions and a higher frequency of cesarean sections. No one knows the true figures for the use of prohibited benefits during childbirth (Kristeller’s method, etc.).

An assessment of the obstetric situation using the Kristeller manual was described by E. Bumm in 1917. E. Bumm emphasized that this method is the most aggressive and dangerous intervention in childbirth.

Currently, at the proposal of the French Association of Obstetricians and Gynecologists, the European Union is considering the issue of depriving a doctor of the right to practice obstetrics in all countries of the community if he declares the use of the Christeller benefit. Presented at the last World Congress of Obstetricians and Gynecologists (FIGO, 2006), this initiative was warmly welcomed by delegates.

A retrospective analysis of births that resulted in injuries to newborns, their resuscitation, including mechanical ventilation, revealed the main mistake: the use of the Kristeller method instead of surgical delivery that was not carried out on time.

Issues of providing obstetric care using episiotomy require strict restrictive frameworks. The desire to reduce the length of the incision leads to the exact opposite result: up to 80% of so-called small episiotomies turn into banal perineal tears. Therefore, instead of stitching up a cut wound, you have to stitch up a laceration. As a result, incompetence of the pelvic floor muscles occurs in young women. It has been established that episiotomy during fetal hypoxia is not a radical method of accelerating labor, and if the head is high, this operation does not make sense at all. Therefore, the growing number of cases of pelvic floor muscle failure is a consequence not only of poor restoration of the perineum, but also of the so-called sparing, and often unnecessary, dissection.

As you know, the leading cause of maternal mortality in Russia, as well as in the world, is obstetric hemorrhage. There are still ongoing discussions about the quantity and quality of infusion therapy when replenishing blood loss in obstetrics. Old views on this issue are now being critically assessed. Now there is no doubt that the priority of infusion therapy is the high-quality composition of transfused solutions. This is especially true for infusion therapy in women with gestosis, in which overhydration can lead to dire consequences. And refusal from such “aggressive” infusion media as gelatinol, hemodez, reopolyglucin, etc. significantly reduces the occurrence of disseminated intravascular coagulation syndrome. Hydroxyethyl starch, 0.9% sodium chloride solution, frozen plasma should be the main infusion media.

The main causes of mortality in massive obstetric hemorrhages are violation of the above points (delayed inadequate hemostasis, incorrect infusion therapy tactics, violation of the phasing of care).

Oddly enough, even such a trivial thing as assessing the volume of blood loss can play a decisive role in the outcome of the treatment of the bleeding itself. Unfortunately, the assessment of blood loss is almost always subjective.

Timely treatment of hypotonic bleeding using all necessary components allows you to successfully cope with the situation already at the conservative stage of obstetric care. A prerequisite is timely diagnosis of bleeding. Many legal cases brought regarding maternal deaths relate to this issue. Then a thorough assessment of the volume of blood loss and calculation of the infusion-transfusion therapy program (depending on the woman’s body weight) and its correction during treatment are necessary. Of great importance is multicomponent treatment, which involves invasive intervention (manual examination of the walls of the uterus or bimanual compression - forgotten methods of Snegirev and Sokolov), the use of a system for intravenous administration of solutions, the introduction of uterotonics, monitoring hemodynamic and hemostasiological parameters and, importantly, constant assessment of blood loss ( during treatment).

Recently, an intrauterine hemostatic balloon has been widely used to stop hypotonic bleeding. This method cannot be called new, since the first mention of the use of this kind of means dates back to the middle of the 19th century (1855). However, the use of modern materials and solutions has made it possible to once again turn to this method. Its effectiveness is 82%.

The next factor that often leads to dismal birth outcomes is the decision to switch from the conservative to the surgical stage of treatment of obstetric hemorrhage. To a greater extent, it concerns the psychology of the doctor: by any means to delay laparotomy and removal of the uterus. When 3,067 uteruses were promptly removed during childbirth in the Russian Federation in 2001, the number of lawsuits in the country regarding deprivation of the reproductive organ exceeded that for cases of maternal mortality. It shouldn't be this way. What options are there to stop bleeding during surgery?

The sequence of actions is as follows:

injection of prostenon into the uterine muscle;
ischemia of the uterus by applying clamps and ligatures to vascular bundles;
application of B-Lynch and Pereira hemostatic compression sutures;
ligation of the iliac arteries;
angiographic embolization;
and only then amputation or extirpation of the uterus.

The tactics for treating obstetric hemorrhage should always be based on the organ-preserving principle. It is unnatural if a woman admitted to a maternity hospital is discharged without a reproductive organ. Of course, there are exceptions to the rule, but today there is no doubt that organ-preserving tactics should become a priority in the treatment of obstetric hemorrhage.

Another cause of death in the Russian Federation is abortion, or rather its complications. Despite the decline in the absolute number of abortions over the past decade, they occupy 2nd place in the structure of causes of maternal mortality in Russia. There are reasons for this. Unfortunately, under the influence of socio-economic factors, abortion in the Russian Federation remains the main method of birth control (the frequency of use of highly effective methods of contraception in the Russian Federation is 3 times lower than in economically developed countries; in addition, more abortions are performed in Russia than in European countries) .

To illustrate the complexity of the relationship between legislative decisions and the reaction of society, I would like to give an example of an ill-conceived decision to abolish a larger number (9 out of 13) of social indications for late termination of pregnancy, after which the number of criminal abortions increased by 30% (!), and not all of them ended well. Banning abortions without offering anything in return is pointless; a comprehensive solution to the problem is necessary.

Until now, the mystery of obstetrics is gestosis. Modern scientific research has seemingly approached the last barrier in the pathogenetic chain of this pregnancy complication - genetics, but there is still no complete picture of the development of preeclampsia. The price of ignorance is the lives of thousands of women dying around the world, including in Russia. Strange as it may seem, gestosis is probably the most easily controlled cause of maternal mortality. The question is timely diagnosis and adequate treatment. Of course, we are talking about treatment conditionally - the only successful method of treating this complication of pregnancy is its timely termination. The main task is to prevent the occurrence of eclampsia, from which pregnant women actually die. The gold standard of treatment is oncoosmotherapy, therapy in accordance with the severity of the disease and delivery according to indications. But questions remain: how to determine the severity of gestosis, how long to treat, what method of delivery, etc. The correct solution to these issues is the safety of the patient and the doctor.

The fight against maternal mortality remains and, of course, will remain a priority in the work of the obstetric service, however, the formation and development of the health insurance system and market relations in the country have changed the social behavior and mentality of patients. Their awareness of modern methods of obstetric care, paradoxically, sometimes embarrasses some doctors who do not bother to educate themselves. We are talking about modern perinatal technologies - a set of measures based on evidence-based medicine. Not introducing them where possible is, to put it mildly, short-sighted, and in some situations even criminal (outbreaks of infectious diseases). The worse the sanitary and technical condition of an obstetric hospital, the more it needs the mother and child to stay together, exclusively breastfed, early discharge. Theoretically, everyone knows this; in practice, reluctance to change something gives rise to a pile of misconceptions. We have already said above that every tenth case of maternal death in the world is due to the fault of a doctor. How can we protect the patient, as well as the doctor himself, from the consequences of incompetent actions? The cheapest but extremely effective way is to develop appropriate standards and protocols. In the modern information world, it is no longer possible to work without this. First of all, we are talking about protocols for the treatment of obstetric hemorrhage, management of pregnant women with gestosis, with prenatal rupture of amniotic fluid, management of childbirth in the presence of a uterine scar, etc., in the future - for each obstetric situation.

In conclusion, it should be noted that this report highlights only a small number of current issues and problems in obstetric practice that are in dire need of solution, revision and critical evaluation. Further research into this acute problem will significantly improve the most important indicators of the obstetric service as a whole.

Diagnosis of pregnancy. Oncological alertness.

M.V. Mayorov, obstetrician-gynecologist of the highest category, antenatal clinic of city clinic No. 5, Kharkov

Bene facit, qui ex aliorum erriribus sibi exemplum sumit (“He who learns from the mistakes of others does well” – lat.)

The well-known maxim “Errare humanum est” (“To err is human” – Latin) fully applies to representatives of the medical profession. An error is understood as the actions of a doctor, which are based on the imperfections of modern medical science; working conditions that are not optimal; insufficient qualifications or inability to use available data to make a diagnosis. The defining sign of an error is the inability for a given specialist to foresee and prevent its consequences (N.V. Elshtein, 1991).

Objective circumstances leading to an error should be considered conditions under which it is not possible to conduct a particular study. Significant objective reasons for errors include, first of all, the inconsistency of individual postulates and principles in the field of theoretical and practical medicine, due to which views on the etiology, pathogenesis, and understanding of the essence of many diseases change from time to time. Errors caused by medical ignorance are the most numerous and especially significant in their interpretation. In each individual case, the question of classifying a doctor’s actions as an error, especially when differentiating ignorance due to insufficient qualifications and elementary medical ignorance, is decided based on the specific features of the course of the disease, duration of observation, examination capabilities, etc. It seems wrong to always associate the subjective causes of diagnostic errors only with the qualifications of specialists. Undoubtedly, it is difficult to overestimate the importance of knowledge for correct diagnosis. However, qualification is not only the training of a doctor, but also the ability to accumulate knowledge, understand, as well as apply it, which largely depends on the individual qualities, intelligence, character traits and even temperament of a particular specialist. N.I. Pirogov wrote: “Life does not fit into narrow frameworks, doctrines, and its changeable casuistry cannot be expressed by any dogmatic formulas.”

Taking into account the specifics of outpatient obstetrics and gynecology practice, as well as the fact that “Ignoti nulla curatio morbid” (“You cannot treat an unrecognized disease” - lat.), we will try to group and consider the most typical diagnostic errors.

Diagnosis of pregnancy

So, a considerable number of them are connected with pregnancy diagnosis. Several years ago, when the use of various highly sensitive human chorionic gonadotropin (hCG) tests and ultrasound examinations (US) were the exception rather than the rule, these errors were widespread and quite common. Overdiagnosis of intrauterine pregnancy caused a woman mainly psychological trauma, and its untimely diagnosis was fraught (not only in a figurative sense!) with missed deadlines for performing an artificial abortion, late registration at the antenatal clinic, etc. All of the above, naturally, does not help strengthen the positive image of the doctor. Late diagnosis of progressive ectopic pregnancy, as is known, sometimes leads to very serious consequences, for example, hemorrhagic shock due to rupture of the fetal sac (most often the pregnant tube).

The use of modern highly sensitive tests in combination with ultrasound, which should be performed by a qualified obstetrician-gynecologist, and not by a “general specialist in ultrasound diagnostics”, allows us to avoid gross diagnostic errors. For example, a positive hCG urine test with an “empty” uterine cavity indicates an urgent need for urgent hospitalization of a patient with a well-founded suspicion of an ectopic pregnancy.

A form of ectopic pregnancy called cervical pregnancy, is quite rare, but very dangerous. Usually in the early stages it manifests itself with bleeding, which is associated with the destructive effect of chorion on the vessels of the cervix. Bloody discharge or bleeding is often mistakenly regarded by the doctor as an interruption of a normal intrauterine pregnancy, and only barrel-shaped cervix may serve as a sign of cervical localization of the fertilized egg. However, such changes in the cervix are sometimes considered as a manifestation of an incipient abortion, when the fertilized egg, upon being born, descends into the lumen of the distended cervical canal with an unopened external os. Indeed, in such cases the neck may also have a barrel shape. The existing hypertrophy of the cervix, as well as uterine fibroids in combination with pregnancy, greatly complicates the differential diagnosis.

It is better to suspect a cervical pregnancy where there is none, and promptly send the patient to a hospital, than to miss this extremely dangerous pathology, or even more so to try to terminate the pregnancy in a day hospital at a antenatal clinic. The wrong tactics of a doctor can lead to death.

Oncological alertness

In the work of a antenatal clinic doctor, along with the above actions, oncological vigilance must be constantly present. The frequency of errors during mass preventive examinations is still high. However, it has been established that without the use of cytological examination such examinations are ineffective, because dysplasia and preclinical forms of cervical cancer are not visually detected.

The old and unshakable rule of thumb should always be kept in mind: all sorts of things bleeding from the genital tract not associated with pregnancy in a woman any age should be considered as cancer (!) until this diagnosis is reliably and reliably excluded. Ignoring this rather ominous, although very correct axiom, leads to a lot of trouble. Just like the well-known traffic rules, but, unfortunately, not always followed by drivers and pedestrians, the diagnostic and tactical postulates of gynecological oncology are “written in blood.” We should add to this premature deaths due to late diagnosis. In the figurative expression of E.E. Vishnevskaya, cancer “does not forgive” irresponsibility!

Long-term observation, hormonal examination, prescription of hemostatic drugs or even attempts at hormonal hemostasis for hyperplastic processes of the endometrium without the obligatory previous fractional therapeutic and diagnostic curettage with a thorough histological examination (which, unfortunately, is still often observed in the practice of some colleagues) are certainly rude tactical and diagnostic errors.

Among tumors of female genitalia ovarian cancer It ranks second in frequency after cervical cancer and first in the structure of gynecological mortality from cancer. The main reason for this is the extremely rapid, aggressive clinical course of the disease, manifested by an increase in the degree of malignancy of the tumor and the early onset of implantation, lymphogenous and hematogenous metastasis. The recognition of tumors at a late stage of their development is based on medical errors. It is they who give rise to the neglect of the process, which is observed in 44% of newly diagnosed patients.

For the diagnosis of malignant ovarian tumors, timely recognition of such a formidable symptom as the appearance of free fluid in the abdominal cavity is important. The presence of ascites more often indicates the advanced stage of the tumor process, although this symptom accompanies the development of some benign tumors of the uterine appendages, for example Meigs syndrome (ascites and hydrothorax) with ovarian fibroids. Gynecologists should be well aware of this so that patients with ascites are not mistakenly considered incurable, but promptly switch to a surgical method of treatment, which, after removing the tumor, leads to the rapid elimination of hydrothorax and ascites. It should be noted that even small ascites, the presence of which is sometimes very difficult to determine (especially in overweight patients), is easily diagnosed by ultrasound.

For early detection of patients with malignant neoplasms of the uterine appendages, a high risk group, which includes:

women with ovarian dysfunction and bleeding during menopause;
previously undergone surgical interventions for benign ovarian cysts with preservation of one of them, breast or stomach cancer;
those under observation for uterine fibroids;
suffering from chronic inflammatory processes of the uterine appendages and tubo-ovarian formations that are not amenable to conservative treatment;
patients with effusion in the serous cavities (abdominal, pleural);
women with primary functional ovarian failure;
patients with genital hypoplasia and a history of infertility.

As is known, uterine fibroids– one of the most common gynecological diseases. A deeper development of the issues of pathogenesis and the study of endocrine metabolic disorders confirm the need for maximum oncological vigilance to identify hyperplastic processes and malignant neoplasms of the endometrium in people with uterine fibroids. Uterine fibroids are often combined with atypical hyperplasia (7.6%), endometrial cancer (4%), uterine sarcoma (2.6%), benign (8.1%) and malignant (3%) ovarian tumors (Ya.V. Bohman, 1989).

Among the clinical symptoms of uterine fibroids, rapid tumor growth, recorded during clinical examination and ultrasound, as well as acyclic uterine bleeding, cause particular oncological suspicion. It is advisable to emphasize that the rapid growth of fibroids is considered to be an increase in its volume, which corresponds to 5 weeks of pregnancy per year.

Although the possible connection of uterine fibroids with hyperplastic processes and endometrial cancer has not been definitively established due to a certain commonality of their pathogenesis, it is necessary to actively identify precancerous diseases, cancer of the cervix and uterine body among patients registered at the dispensary for uterine fibroids, as well as timely detection indications for surgical treatment.

the size of the tumor exceeds the size of the uterus, corresponding to 12 weeks of pregnancy in young women and 15-16 in women after 45 years of age;
suspicion of malignant degeneration of the tumor for any size of the uterus;
its rapid growth (especially during menopause or menopause);
the presence of submucosal and subserous nodes on long stalks, prone to torsion and necrosis;
cervical localization of the tumor;
compression of adjacent organs by the tumor (the appearance of frequent urination, not associated with a urinary tract infection, disturbance of the act of defecation);
dysmenorrhea of the type of menorrhagia or metrorrhagia, accompanied by severe posthemorrhagic anemia.

Many diagnostic difficulties and, as a result, diagnostic errors cause malignant lesions of the vulva and vagina, despite the localization seemingly accessible to visual inspection. Vulvar cancer often develops against the background of degenerative processes such as kraurosis and leukoplakia. However, a true precancerous condition is dysplasia, which cannot be diagnosed without targeted biopsy and histological examination, which are not always performed. Long-term conservative treatment of patients with dystrophic diseases of the vulva without histological examination is a very common mistake and leads to delayed diagnosis. Prescribing ointments and creams with estrogens, corticosteroids and analgesics relieves pain and itching, and women, feeling relief, stop visiting the doctor. After 6-12 months, symptoms resume and a malignant tumor develops with metastases.

According to E.E. Vishnevskoy et al. (1994), long-term observation and symptomatic treatment of women with kraurosis and especially vulvar leukoplakia without the use of special research methods to exclude initial forms of cancer is the main cause of errors that determine the prevalence of the tumor process by the time the true disease is recognized.

It has been established that the diagnosis of such a seemingly easily accessible tumor as vaginal cancer, is also associated with a large number of errors, as a result of which more than 60% of diseases are detected only in stages II or III. In late diagnosis during gynecological examination, the widespread use of the Cusco double-leaf speculum plays a fatal role. As a result of its use, small tumors, especially those located in the middle and lower thirds of the vagina, being covered with a Cusco mirror, do not come into the field of view of the doctor or midwife in the examination room.

As practical experience shows, many defects and diagnostic errors are often associated with insufficient knowledge or failure to comply with some “secrets” of gynecological examination. It is not without reason that it is said: “He who researches well diagnoses well.” An important condition for the information content of any medical examination is the presence of sufficiently intense local lighting. A powerful light source allows for visual diagnostics to be carried out properly, rather than at a glance.

Colleagues-gynecologists often forget about the urgent need for a rectal examination, and in all cases without exception, and not just in virgins. Bimanual rectovaginal examination, somewhat forgotten by many practitioners, is very useful. His technique is quite simple: after a routine vaginal examination, the index finger is placed in the vagina and a well-lubricated middle finger is placed in the rectum. This makes it much easier to palpate the retroflexed uterus, uterosacral ligaments and rectovaginal septum for mass formations, for example in retrocervical endometriosis.

Diagnosis of infectious and inflammatory diseases

Many errors occur in the diagnosis and treatment of infectious and inflammatory diseases of the genitals. Having received the result of a routine examination, informing about the detection of, for example, trichomonas or fungi of the genus Candida, the doctor prescribes a certain specific treatment and even often notes some positive results. Unfortunately, a complete cure does not always occur, since chlamydia, mycouraplasmosis and other urogenital infections often remain “behind the scenes,” the reliable diagnosis of which is impossible only through conventional bacterioscopy of smears.

However, even when sufficiently reliable laboratory results are obtained to determine the type of urogenital infection, drug treatment is not always prescribed correctly and adequately. For example, in case of urogenital chlamydia and mycoplasmosis, it is advisable and effective to use antibacterial drugs of only three pharmacological groups: tetracyclines, macrolides and fluoroquinolones. Reliable and well-tested sulfonamides, even in combination with trimethoprim (Biseptol), due to their low effectiveness in gynecological pathology, are currently of only historical interest. Often, when treating various urogenital infections, they forget that patients almost always have a concomitant anaerobic flora, and therefore the simultaneous use of drugs of the imidazole group (metronidazole, tinidazole, ornidazole, etc.) is indicated.

With regard to drug dosing, two extremes are often observed: unreasonably exceeding the permissible limits or prescribing unjustifiably low doses. For example, the prescription of doxycycline at a dose of 100 mg once a day for 5 days, acceptable for the treatment of acute bronchitis, is completely insufficient for the treatment of acute salpingoophoritis; The WHO recommended dose is 100 mg 2 times a day for at least 10 days.

Recently, it has become fashionable for some medical specialists to become interested in new (or well-forgotten old) pharmacotherapeutic methods of alternative medicine. This is, first of all, homeopathy, antihomotoxic therapy, prescription of dietary supplements, etc. Without underestimating the possible certain effectiveness of these methods, it should be said that they in no way replace appropriate antibacterial therapy, the refusal of which (in favor of natural remedies) is sometimes fraught with severe septic complications.

The use of hormonal drugs, in particular combined oral contraceptives (COCs), is far from simple and quite responsible. When so-called breakthrough bleeding occurs while taking COCs, some doctors, instead of the necessary short-term increase in their doses (until the bleeding stops), often prescribe hemostatic therapy such as Vikasol and calcium chloride, and COCs are completely unreasonably canceled, which is a gross mistake. As a result, increased bleeding occurs.

COCs are also widely used for the treatment of various gynecological diseases (endometriosis, polycystic ovary syndrome, uterine fibroids, etc.). However, this applies only to monophasic COCs, because three-phase ones are absolutely not suitable for medicinal purposes. They do not completely suppress folliculogenesis, so they can contribute to the progression (!) of the pathological process in the above diseases. In particular, with the use of three-phase COCs, glandular regression of the endometrium is not observed, which is contraindicated in its hyperplastic processes (I.V. Lakhno, 2002).

Antiestrogens (clomiphene, clostilbegit, tamoxifen) are often used to stimulate ovulation. It is extremely necessary to carefully (preferably daily) monitor the size of the ovaries (vaginal examination or ultrasound), because in some cases there are phenomena of hyperstimulation, sometimes accompanied by apoplexy.

When prescribing drug therapy, possible chemical and pharmacological incompatibility of individual drugs (for example, calcium and magnesium are antagonists), allergic history, the presence of extragenital pathology, and other significant factors are not always taken into account. This can contribute to the development of complications, because, unfortunately, “Graviora quedam sunt remedia periculis” (“Some medicines are worse than the disease” - lat.).

No equipment can replace the highly qualified and creative thoughts of a doctor. Against the backdrop of a significant number of errors, from which not a single system of training specialists and not a single healthcare system in the world is immune, this problem should be given much more attention.

Editor's Choice

Hazelnuts - beneficial properties and contraindications

Hazelnut is a cultivated variety of wild hazel. Let's look at the benefits of hazelnuts and how they affect the body...

Vitamin B6: why is it needed in the human body and in what quantity? Vitamin 6 for what

Vitamin B6 is a combination of several substances that have similar biological activity. Vitamin B6 is extremely...

Dietary fiber: what is it, what are the benefits, list of products

Soluble fiber draws water into your intestines, which softens your stool and supports regular bowel movements. She not only helps...

Hyperphosphatemia in chronic kidney disease

Overview Having high levels of phosphate - or phosphorus - in your blood is known as hyperphosphatemia. Phosphate is an electrolyte that...

What is anxiety-depressive disorder: causes, symptoms and treatment of the syndrome Anxiety disorders causes

Anxiety syndrome, also called anxiety syndrome, is a separate disease characterized by a peculiar...

How is hysterosalpingography performed?

Hysterosalpingography is an invasive procedure, that is, it requires the penetration of instruments into various...

What to expect during a visit to the urologist?

The prostate gland is an important male organ in the male reproductive system. About the importance of prevention and timely...

Intestinal dysbiosis: degrees, symptoms, diagnosis, treatment

Intestinal dysbiosis is a very common problem faced by both children and adult patients. The disease is accompanied...

Prevention of injuries to female genital organs

Injuries to the genital organs develop as a result of falls, especially on sharp and piercing objects, during sexual intercourse, during insertion into the vagina...

New

Popular