Fundamentals of organizing medical care for the rural population. Organization of medical care for the rural population. Organization of the work of medical and preventive institutions at different stages of medical provision of the rural population. Features of rural healthcare
The main feature of rendering medical care rural population lies in its phasing. Conventionally, there are three stages in organizing medical care for the rural population.
Tab. 3. Stages of providing medical care to the rural population
The first stage is rural health care institutions, which are part of a complex therapeutic area. At this stage, rural residents receive pre-medical, as well as basic types of medical care (therapeutic, pediatric, surgical, obstetric, gynecological, dental).
The first medical institution that a rural resident, as a rule, turns to is a paramedic and obstetric station (FAP). It functions as a structural unit of a local or central district hospital. It is advisable to organize FAPs in settlements with a population of 700 or more, with a distance to the nearest medical facility of more than 2 km, and if the distance exceeds 7 km, then in settlements with a population of up to 700 people.
The feldsher-midwife station is responsible for solving a large complex of medical and sanitary tasks:
Carrying out activities aimed at preventing and reducing morbidity, injuries and poisoning among the rural population
Reducing mortality, primarily infant, maternal, and working age;
Providing pre-medical care to the population;
Participation in ongoing sanitary supervision of children's preschool and school educational institutions, communal, food, industrial and other facilities, water supply and cleaning of populated areas;
Conducting door-to-door surveys according to epidemiological indications in order to identify infectious patients, persons in contact with them and persons suspected of infectious diseases;
Improving the sanitary and hygienic culture of the population.
Thus, the FAP is a healthcare institution with a more preventive focus. It may be entrusted with the functions of a pharmacy selling ready-made dosage forms and other pharmaceutical products to the public.
The work of the FAP is directly headed by the head. In addition to him, the FAP also employs a midwife and a visiting nurse.
Despite the important role of FAPs, the leading medical institution at the first stage of providing medical care to village residents is the local hospital, which may include a hospital and an outpatient clinic. The types and volume of medical care in a local hospital, its capacity, equipment, and staffing largely depend on the profile and capacity of other medical institutions that are part of the healthcare system of a municipal district (rural settlement). The main task of a local hospital is to provide primary health care to the population.
Outpatient care to the population is the most important section of the work of a local hospital. It can be an outpatient clinic, either part of the hospital structure or independent. The main task of the outpatient clinic is to carry out preventive measures to prevent and reduce morbidity, disability, mortality among the population, early detection of diseases, and medical examination of patients.
Doctors at the outpatient clinic see adults and children, make house calls and provide emergency care. Paramedics can also take part in the reception of patients, but medical care in an outpatient clinic should primarily be provided by doctors. In the local hospital, an examination of temporary disability is carried out and, if necessary, patients are sent to medical examination.
In order to bring specialized medical care closer to village residents, doctors from the central district hospital go to the outpatient clinic according to a certain schedule to receive patients and select them, if necessary, for hospitalization in specialized institutions. Recently, in many regions of the Russian Federation, there has been a process of reorganization of local hospitals and outpatient clinics into centers of general medical (family) practice.
The territory of Russia exceeds 17 million km2. Rural territories - 23.4% of the entire territory - have powerful natural, demographic, economic, historical and cultural potential, which, if used rationally and effectively, can provide sustainable diversified development, employment, and a high standard of living for the rural population.
The demographic resource of rural areas is 38 million people (27% of the total population), including the labor force - 23.6 million people. The population density is low - 2.3 people per 1 km2. The settlement potential includes 155.3 thousand rural settlements, of which 142.2 thousand have permanent residents. 72% of rural settlements have a population of less than 200 people; villages with a population of over 2 thousand people make up only 2%.
Over the past 10 years, positive trends in the demographic situation in rural areas have been outlined. Natural population decline decreased from 281 thousand people in 2000 (-7.3 per 1000 people) to 82 thousand people at the beginning of 2010 (-2.1). The birth rate of the rural population is higher than the Russian average - 14 per 1000 people (compared to 12.6). This has a positive effect on the overall fertility rate.
However, the high birth rate in rural areas is accompanied by high mortality. In 2010, with infant mortality in Russia 7.5 babies per 1000 births
alive in rural areas and in the city, the indicators were respectively LOS and 6.9 infants per 1000 live births. The overall mortality rate per 1000 rural residents is 16.1, which is 6% lower than in 2000, but 19% higher than the mortality rate of the urban population. All this negatively affects the health indicators of the country's population as a whole.
The life expectancy of citizens in rural areas at the beginning of 2010 increased by 2.7 years compared to 2000 and amounted to 66.7 years versus 69.4 in the city.
Rural areas are characterized by low population density and large distances between small settlements from each other. As a result, the average radius of the service area is 60 km, and often the distance of settlements from the regional center exceeds 100 km. The service range of a local therapist can reach 10 km or more.
The seasonality of work in rural areas creates tension in the spring-summer and autumn periods, when workers are mainly outdoors, which leads to overheating or hypothermia of the body. The diet and quality of nutrition are often not respected. The incidence of injuries, joint diseases, and vibration disease is high. Contact with animals creates a risk of specific diseases.
As a result, it is typical for rural residents big number chronic diseases, for which patients practically do not seek medical help, specific diseases associated with the characteristics of agricultural production (injuries, diseases of the peripheral nervous system, eye damage, vibration disease).
Medical care for rural residents based on the principles of protecting the health of the country's population. One of the important organizational principles of public health is maintaining the unity and continuity of medical care for the population in urban and rural areas.
However, the factors that determine the differences between urban and rural areas influence the organizational forms and methods of operation of rural health care institutions.
The main factors contributing to differences in health care between urban and rural populations are:
Features of the settlement of residents in comparison with the city are low density, scattered and remote settlements;
Features of agricultural labor - seasonality, high proportion of manual labor, often a significant distance between the place of residence and the place of work;
The outflow of young people and people of working age to the city;
Aging rural population;
Lower living standards in villages;
Poor condition of roads and transport:
Insufficiency or inaccessibility of new information technologies;
Low availability of medical personnel;
Socio-economic and everyday difficulties.
In general, the rural health care system is characterized by limited availability of medical care and low effectiveness of medical, social and preventive measures. The task of bringing together the levels of medical care for urban and rural populations remains relevant.
The frequency of rural residents seeking medical care is significantly lower than that of urban residents. Moreover, the farther a settlement is from a medical institution, the less often residents turn to medical workers. The bulk of medical care is provided by paramedical personnel. A rural resident spends on visiting a medical facility
much more time than city. The equipment of rural medical institutions is much worse than that of urban ones, and the qualifications of personnel are lower than the average in healthcare.
Features of the organization of medical care for rural residents are significant decentralization of outpatient care and pronounced centralization of inpatient care. The main human resource in rural areas is paramedical workers. Medical personnel are largely concentrated in regional hospitals. by receiving the population at the place of their main work and on trips to remote rural settlements as part of special teams according to a specific plan.
In accordance with the Federal Law “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” dated November 21, 2011 N-323-FZ (Article 5, paragraph 2). The state provides citizens with health protection regardless of place of residence and any other circumstances. For residents of rural areas, it is also necessary to adhere to the principles of health protection:
Ensuring the rights of citizens to health care and related state guarantees:
Priority of the patient’s interests in the provision of medical care;
Priority of children's health;
Social security in case of loss of ability to work;
Responsibility of public authorities and bodies local government, officials for ensuring the rights of citizens to health protection;
Availability and high ILC;
Inadmissibility of refusal to provide medical care;
Priority of prevention and maintaining medical confidentiality.
Organizational basis for providing medical care to rural areaspopulation laid down in the 19th century. zemstvo doctors. The zemstvo medicine system was formed in Russia during the period of zemstvo self-government and operated in 1864-1917. It had new and progressive methods of providing medical care to the population, which have not lost their relevance to this day:
Focus not on the paramedic station, but on the medical level of primary health care;
Local service for the rural population with the organization of several paramedic stations and a pharmacy on the site, in the center of each site there is a hospital with an outpatient clinic;
Maintaining “card” records during outpatient visits to patients, which allows you to collect valuable material for statistical analysis morbidity;
Combination of medical and sanitary-preventive work;
Active promotion of a healthy lifestyle;
Free medical care.
These principles were also implemented in the organization of primary health care for the population in the Soviet health care system (1918-1991). By the beginning of the first Soviet five-year plan in Russia (1929-1932), the rural population was served by 4,677 medical stations and 3,413 paramedic stations. There were 18,200 residents per medical area. Over the five-year period, the network of medical stations grew to 7962, i.e. more than 70%; the number of rural hospital beds increased from 43,600 to 82,000. Healthcare expenditures in the USSR during the first five-year plan increased almost 4 times compared to the Russian Empire (1913). As a consequence of the efforts made. The life expectancy of Soviet people from 1926 to 1972 increased by an average of 26 years. Health care in general in the RSFSR can be judged from the data of the 3rd edition of the Great Soviet Encyclopedia (1969-1978; Table 5.20).
A typical rural medical institution - FAP - is a primary pre-medical structural unit that provides preventive, curative, and health-improving services. sanitary and anti-epidemic, sanitary and educational, hygienic medical and sanitary care.
In subsequent years, the main feature of the organization of medical care to the rural population was the staged nature of its provision. Conventionally, there are 3 stages of providing treatment and preventive care to the population.
The first stage is a rural medical station - a local hospital, a paramedic station and a first aid station, health centers, medical centers of educational institutions. At the first stage, rural residents receive pre-medical, primary and qualified medical care (therapeutic, pediatric, surgical, obstetric, gynecological, dental).
The second stage - healthcare institutions of the municipal district: district and central district hospitals (CRH). which provide basic types of specialized medical care.
The third stage - healthcare institutions of the constituent entity of the Russian Federation. among which the leading place is occupied by regional (regional, republican, district) hospitals. At this stage, specialized, including high-tech, medical care is provided in all major specialties.
IN modern conditions this approach is being revised. During the implementation of the healthcare modernization program, a unified system of providing medical care to both urban and rural populations is being built.
Primary health care for the rural population will consist of three levels. At the 3rd level, all outpatient medical institutions are concentrated: at the 2nd level - intermunicipal centers providing qualified specialized outpatient and inpatient medical care in the most popular profiles in accordance with the procedures for providing specialized medical care: at the 1st level - consultative and diagnostic specialized assistance in regional CDCs.
In rural areas of the Russian Federation there are 1,349 hospital medical institutions, including 727 central district ones. 79 district and 382 district hospitals, with a total number of beds of 153.4 thousand. The provision of hospital beds per 10 thousand rural residents is 40.9, which is 2.7 times less than the provision of hospital beds for the urban population (Table 5.21).
In 2010, in the Russian Federation, 40,650 doctors (7.6% of the total number of doctors) and 207,497 paramedical workers (15.7% of the total number of paramedical personnel) worked in rural medical institutions. The provision of doctors in rural areas in 2010 was 12.2 per 10 thousand population, paramedical personnel - 54.3 per 10 thousand population. In all constituent entities of the Russian Federation in rural areas there was a shortage of doctors and paramedical personnel.
The emerging trend of reducing the number of district and rural district hospitals and increasing the number of central district hospitals is due to the proven economic inexpediency of the existence of hospital medical institutions with low bed capacity. In large medical institutions (central district, regional, regional, republican, district hospitals) they spend less money per bed on economic and technical needs, heating, maintenance of staff, food. engineering and technical services. In addition, they effectively use diagnostic equipment, qualified medical personnel, introduce modern medical technologies and thereby provide the population with higher quality qualified medical care. In this regard, rural district hospitals in a number of regions of the Russian Federation are being repurposed into medical outpatient clinics, medical clinics.
Often, regions, in order to develop central district hospitals, curtail primary care facilities, leaving the rural population without medical care and drug supply.
District hospitals need to be rebuilt taking into account local conditions: population density, transport accessibility, the availability of hospital beds in general, etc.
PHC- the basis of the system of providing medical care to the rural population - includes prevention, diagnosis, treatment of diseases and conditions. medical rehabilitation, monitoring the course of pregnancy, promoting a healthy lifestyle and sanitary and hygienic education of the population.
To get closer to the territory of residence, primary health care is organized according to the territorial-area principle, which provides for the formation of groups of the population served at the place of residence. Primary pre-hospital health care is provided by paramedics, midwives and other paramedics in the FAP.
FAPs are organized in rural areas with a population of 700 people or more and the distance to the nearest medical facility is more than 2 km. If this
the distance exceeds 7 km, then the FAP is organized in a populated area with a population of up to 700 people. Functions of the FAP according to the current regulatory framework:
Providing first aid:
Providing the population with medicines (according to the approved nomenclature);
Timely and full implementation of doctor’s prescriptions;
Patronage of children and pregnant women, dynamic monitoring of the health of certain categories of citizens;
Implementation of measures to reduce child and maternal mortality;
Teaching the population a healthy lifestyle,
FAP also plays a significant role in carrying out preventive vaccinations according to the National Vaccination Calendar, which is compiled taking into account the age and sex composition of the population.
The main task of the FAP in working with children is timely and high-quality patronage. providing a full range of preventive measures. The procedure for prenatal care and medical examination of children is the same for cities and rural areas.
In addition, the duties of a paramedic include systematic monitoring of the work of children's educational institutions, their sanitary condition, and the conduct of physical education in them; organization of preventive examinations. instilling hygiene skills in children, conducting extensive educational work among parents, children, educators and teachers.
There are 37.8 thousand FAPs in the Russian Federation with a steady trend of network reduction. Compared to 2000, their number was reduced by 12.8%, while a number of GP offices were organized in rural areas. When closing a FAP, it is necessary to first comprehensively assess the availability of medical care, especially in sparsely populated areas where the FAP is the only accessible healthcare unit. This is especially important when the FAP provides the population with medications, monitors the intake of anti-tuberculosis drugs, carries out a set of preventive measures to promote a healthy lifestyle, and patronizes the elderly. Accordingly, the attitude towards a paramedic in rural areas needs to be changed and his working conditions reviewed.
The leading link in the provision of primary health care should be a general (family) practitioner. Its goal is to provide primary health care to the population in a volume that partially replaces the narrow specialists of the clinic, and under the condition of being as close as possible to the place of residence of the assigned citizens.
GPs can work individually or in a group. In individual practice, a doctor works independently, independently of other doctors and specialists, using the assistance of nursing staff working with him. Individual practice is mainly used in rural areas, where
There are only a small number of people living there and the involvement of other doctors is unjustified in terms of the volume of care provided and financial support.
Group practice involves combining the efforts of several doctors to ensure interchangeability, mutual assistance in the provision of medical services to the population and to increase economic efficiency organization of GP offices.
Group practice has a number of advantages:
Possibility of interchangeability during the day and during illness. vacation, training of one of the doctors:
Better equipment of offices, including diagnostic and treatment equipment, creation of a day hospital;
Opportunity for professional communication and consultations;
The possibility of a certain specialization in narrow specialties for each of the doctors (ophthalmology, endocrinology, cardiology);
Reduction of administrative costs;
More efficient use nursing staff.
The location of the GP's office is determined by the size of the locality;!, the ability of the health care facility to provide premises, the CAPABILITIES of the settlement administration to provide premises for the office as close as possible to the place of residence of the attached population (usually on the ground floor of a multi-storey residential building or in a specially constructed building). The location of the GP office in new microdistricts of settlements, where there is usually no developed social infrastructure, is especially convenient. The number of citizens served per GP is established based on the norm of 1,500 people. It has been established in practice; A smaller number of attached residents will not ensure the economic feasibility of the work, and a larger number will not allow the doctor to provide them with a full range of services in a high-quality manner and on time. The specific number of residents is determined for each doctor by the chief physician of the clinic to which the GP belongs, based on the size of the living population and the staffing level of the institution. The service radius can reach 1.5 km in the city, up to 12 km in the countryside,
Attachment to the GP is carried out if there is compulsory medical insurance policy and document. identification of a citizen. Every citizen has the right to choose a treating physician, including a GP. However, in most cases, a GP serves the population living in close proximity to his site: for example, in a multi-storey multi-entrance building - the residents of this one house. This approach allows for assistance to be provided at home and at night.
The GP’s work schedule is determined by the location of the office, the size and composition of the assigned population, service radius and availability of vehicles. GP tasks:
Outpatient reception of the population, including simple studies (electrocardiography, clinical examination of blood and urine, determination of blood sugar levels, visual acuity, etc.);
Providing emergency assistance;
Providing assistance in a day hospital setting;
Visiting patients at home;
Visiting your patients in hospital:
Consultations of patients with specialists:
Interaction with social protection authorities.
The doctor's workload is 4-5 thousand visits per year. Subspecialists in the clinic only accept referrals from a GP.
Despite the important place of the FAP in the primary health care system for the rural population, the leading health care facility at the first stage of rural healthcare is the rural district hospital (RPH) or the corresponding unit of the central district hospital. which and
They include a hospital and a medical outpatient clinic. Primary medical care is provided here by general practitioners, local general practitioners, pediatricians, local pediatricians and GPs (family doctors).
The nature and volume of medical care in a rural district hospital are determined by the capacity, equipment, and availability of specialist doctors. Regardless of the capacity of the SUB, it provides outpatient care to therapeutic and infectious diseases patients, assistance during childbirth, and pediatric and preventive care for children. emergency surgical and trauma care. The staff of the SUB includes doctors in the main specialties: therapy, pediatrics, dentistry, obstetrics and gynecology, surgery. Tasks of the SMS:
Providing the population of the assigned territory with qualified medical care (outpatient and inpatient):
Planning and carrying out activities to prevent and reduce morbidity and injury among various groups of the rural population;
Treatment and preventive health care for mothers and children:
Introduction of modern methods of prevention, diagnosis and treatment, advanced forms and methods of organizing medical care;
Organizational and methodological management and control of the work of the FAP and other medical institutions that are part of the rural medical district.
The organization of outpatient care for the population is the most important section of the work of rural district hospitals. In rural areas there are 2,979 outpatient clinics with 436 thousand visits per shift. These include rural medical outpatient clinics(polyclinics), both included in the structure of other medical organizations and independent. Their main tasks are: carrying out broad preventive measures to prevent and reduce morbidity, early identification of patients, medical examination. provision of qualified medical care to the population, Doctors see adults and children, make house calls and provide emergency medical care. Paramedics can also take part in the reception of patients, but outpatient care in a rural medical outpatient clinic must be provided by doctors.
In addition, the functions of the rural outpatient clinic include:
Bringing outpatient medical care closer to rural residents;
Carrying out a set of sanitary and anti-epidemic measures (preventive vaccinations, ongoing sanitary supervision of institutions and facilities, water supply and cleaning of populated areas);
Scheduled visits of doctors to subordinate FAPs and children's educational institutions to provide practical assistance and monitor their work.
Maternal and child health care plays an important role in the work of a rural medical hospital. Medical care for children at a rural medical site provided by doctors and paramedics under the guidance of the chief physician of the local hospital. If there is a pediatrician at a rural medical site, he is responsible for organizing medical care for children (as a rule, the chief physician). In the absence of a pediatrician, the chief physician of a rural district hospital has the right to assign responsibility for medical care to children to one of the general practitioners, allocating him a certain time to work with children.
The main responsibilities of a doctor responsible for medical care for children at a rural medical site:
Constant preventive monitoring of children in villages assigned to the local hospital;
Periodic medical examination of all children in the area, especially in the 1st year of life;
Active identification of sick and weakened children, taking them to the dispensary for regular observation and recovery:
Timely and complete coverage of children with preventive vaccinations;
Regular supervision of children in organized groups, monitoring the correct neuropsychic and physical development of children. carrying out necessary health measures;
Active identification of sick children, timely provision of qualified medical care and provision of hospitalization if necessary;
Constant study of the conditions and lifestyle of children in the family, identification and assistance in eliminating unfavorable environmental factors;
Monitoring the work of the FAP by regular (according to schedule) field visits, providing them with the necessary organizational and methodological assistance;
Extensive educational work among parents, children, teachers, educators on child health issues.
Doctors from rural outpatient clinics travel according to a certain schedule to the FAN of their site for a consultation. At the same time, they should strive to improve the qualifications of their assistants by transferring knowledge and experience to them. The population is notified of the departure schedule.
Pediatricians from central district hospitals must travel to rural district hospitals on schedule to improve medical care for children in rural areas. The population is notified in advance of the pediatrician’s arrival.
Materials from inspections of the work of rural district hospitals and first-aid posts on medical care for children are summarized by district pediatricians and organizational and methodological offices of the Central District Hospital. are periodically heard at district conferences and medical councils. Based on the results of the discussion, appropriate organizational measures are taken.
In accordance with these tasks, the main responsibilities of the doctor (doctors) of the rural medical district are determined;
Outpatient reception of the population;
Inpatient treatment of patients in a rural district hospital:
Providing assistance at home;
Providing medical care in case of acute diseases and accidents;
Referring patients to other health care facilities for medical reasons;
Examination of temporary disability and issuance of certificates of incapacity for work:
Organization and conduct of preventive examinations;
Timely registration of patients for dispensary registration:
Carrying out a complex of medical and health measures, ensuring control of clinical examination;
Active patronage of children and pregnant women;
Carrying out a set of sanitary and anti-epidemic measures;
Sanitary educational work, promotion of a healthy lifestyle;
Scheduled visits to the first aid station.
The structure of a rural medical district is formed depending on the size of the population served, the service radius, the distance to the central district hospital and the condition of the roads. The number of people served in a rural medical district can reach 2.5 thousand people.
Primary specialized health care is provided by medical specialists, including medical specialists from medical institutions providing specialized, including high-tech, medical care. Primary health care is provided on an outpatient basis and in a day hospital setting.
To provide primary health care to citizens in case of acute diseases, conditions, exacerbation of chronic diseases that are not accompanied by a threat to the patient’s life and do not require emergency medical care, medical care units are created within the structure of medical institutions that provide it in an emergency form.
The organization of medical care for residents of rural areas, its volume and quality depend on the distance of medical institutions from the place of residence of patients, the availability of qualified personnel, equipment, the possibility of receiving specialized medical care, and the implementation of medical and social security standards at the regional and federal levels.
Central District Hospital(CRH) is the main medical institution for providing qualified medical care to the rural population. At the same time, the Central District Hospital is a center for organizational and methodological management of healthcare in a municipal district, responsible for organizing medical care for the population, increasing the efficiency, quality and accessibility of this care.
In different regions of the country, there are central district hospitals of different capacities, which depend on the population size, the provision of hospital facilities and other factors. The optimal capacity of the central district hospital is at least 250 beds. The structure of the Central District Hospital includes:
Hospital with departments for main specialties;
Clinic with treatment and diagnostic rooms and laboratory:
Emergency departments:
Pathology Department:
Organizational and methodological office;
Auxiliary structural units (pharmacy, kitchen, medical archive, etc.).
The profile and number of specialized departments of the central district hospital depend on its capacity, but their optimal number should be at least 5: therapeutic, surgical with traumatology, pediatric, infectious diseases, obstetrics and gynecology (if there is no maternity hospital in the area).
The main tasks of the Central District Hospital:
Providing the population of the district and regional center with qualified specialized inpatient and outpatient medical care;
Operational, organizational and methodological assistance to medical organizations in the region;
Organization of material and technical support for the departments of the Central District Hospital:
Development and implementation of measures aimed at increasing the IMP of the population, reducing morbidity, infant and general mortality, improving health;
Arrangement, rational use, advanced training of medical personnel;
Implementation of activities to promote a healthy lifestyle.
The chief physician of the Central District Hospital has deputies in the main areas of activity: medical department, outpatient work, organizational and methodological work (head of the organizational and methodological department), administrative and economic work, security, and in areas with a population of 70 thousand or more - on childhood and obstetrics.
To provide methodological, organizational and advisory assistance to doctors of rural medical districts, the Central District Hospital allocates district specialists who, within the framework of their specialty, organizationally and methodologically manage all medical institutions in the district - often heads of departments of the Central District Hospital or the most experienced doctors. Each of them heads medical work in the region in his specialty, travels for consultations, conducts demonstration operations, examinations and treatment of patients, sends teams of medical specialists to medical institutions of rural medical districts, listens to reports from doctors of local hospitals, heads of first aid stations, analyzes their work, statistical reports, conducts scientific conferences, seminars, advanced training in the workplace.
To bring specialized medical care closer to the rural population, regional centers are creating interdistrict specialized departments(centers, medical districts) equipped with modern equipment. The functions of inter-district centers are performed by health care facilities. capable of providing the population with specialized, highly qualified inpatient or outpatient care if the central district hospitals of neighboring areas do not have the ability to provide specialized care or its volume in each health care facility is minimal, and the necessary specialists are not available. Along with performing the functions of a structural unit of health care facilities, interdistrict specialized centers (departments) carry out:
Consultative appointments in the clinic for patients referred by doctors from medical institutions of the attached areas;
Hospitalization of patients from assigned areas:
Organizational, methodological and advisory assistance (including examination of work capacity) to doctors of health care facilities in the assigned areas, including scheduled visits:
Introduction into the work of healthcare institutions of modern means and methods of prevention, diagnosis and treatment of patients in the relevant specialty;
Analyzing the results of providing medical care to residents of the assigned districts, providing information on the work of the interdistrict medical center;
Conducting joint thematic conferences and seminars. Medical institutions in the attached areas transport patients
and pregnant women to the interdistrict center (by agreement), refer patients for consultation only subject to a complete examination in accordance with the standards of medical care, inform the population about the work hours of the center’s specialists. To coordinate the work of interdistrict medical centers and assigned areas, interdistrict medical councils are created.
Polyclinic Central District Hospital provides qualified medical care to the rural population in 8-10 medical specialties. The tasks of the clinic include:
Providing qualified outpatient care to the assigned population of the district and regional center;
Organizational and methodological management of outpatient departments of the district;
Planning and implementation of activities aimed at preventing and reducing morbidity and disability;
Introduction into the work of all outpatient clinics in the region of modern methods and means of prevention and treatment of diseases, best practices in providing outpatient care;
Implementation of measures to promote a healthy lifestyle.
Rural residents come to the district clinic following referrals from medical institutions of rural medical districts to receive specialized medical care, functional examination, and consultations with medical specialists.
To bring specialized medical care closer to the place of residence, mobile medical care teams are created from among full-time doctors and nurses at the Central District Hospital.
The organizational and methodological office of the Central District Hospital plays an important role in organizing medical care for the population of rural areas. which is staffed by the most experienced doctors. He has data on the economy and sanitary condition of the region, the network and staffing of medical institutions, the provision of the population with various types of medical and social security, etc. The organizational and methodological office is headed by the head, who can simultaneously be the deputy chief physician of the Central District Hospital.
Outpatient and inpatient medical care for children in rural areas they are assigned to children's clinics, children's hospitals and children's departments of the central district hospital.
Children's health care in the district is carried out according to a unified plan approved by the chief physician, who is responsible for the quality of medical care for children. However, he places direct responsibility on his deputy for pediatrics and obstetrics or (in the absence of one) on the district pediatrician who manages medical care for children in the rural area.
The position of a district pediatrician is established on the staff of each district hospital, which includes a children's consultation clinic, in addition to the medical positions provided for by the standard staff of a children's clinic.
The main health care facility providing medical care to children at the subject level RF.- Children's regional (regional, district, republican) hospital. and in its absence - a regional (regional, republican, district) hospital with a children's department and a consultative clinic for children.
In the area, except for the Central District Hospital. organize specialized dispensaries (anti-tuberculosis, skin and venereology, drug treatment), which operate as inter-district medical institutions, serving the population of nearby areas.
Highly qualified specialized medical care for the rural population in all main specialties is provided by regional (territorial, republican district) medical institutions. The main one is regional (regional, republican, district) hospital, which provides full medical care not only to rural residents, but also to all residents of the constituent entity of the Russian Federation. It is the center of organizational and methodological management of medical institutions located in the region (region, republic, district), a clinical base for specialization and advanced training of doctors and nursing staff.
The capacity and staffing of the hospital are determined by the population of the administrative territory. The optimal capacity of a regional (regional, republican, district) hospital is 700-1000 beds.
Objectives of the regional hospital:
Highly qualified specialized consultative, diagnostic and therapeutic assistance to the population of the administrative territory in outpatient and inpatient settings using highly effective medical technologies,
Advisory and organizational and methodological assistance to specialists from other medical institutions of the administrative territory;
Qualified emergency and planned advisory medical care using air ambulance and ground transport;
Development and implementation of targeted programs for improving medical care:
Introduction of modern medical technologies, effective management methods and principles into the practice of medical institutions of the administrative territory health insurance:
Participation in training, professional retraining and advanced training of medical workers;
Formation of a healthy lifestyle.
Organizational and methodological department;
Consultative and diagnostic clinic:
Hospital with emergency department;
Department of expert and planned advisory assistance;
Medical Library;
Other structural units necessary for the operation of the hospital (catering department, accounting, medical archive, garage, etc.).
The work of a regional hospital is in many ways similar to the work of a city hospital. but it also has its own characteristics. One of them is the presence within the hospital of a regional consultative and diagnostic clinic.
The main tasks of the consultative and diagnostic clinic: providing patients referred from medical institutions at the local or district level with specialized qualified advisory assistance in diagnosing diseases, recommending the volume and methods of treatment, and, if necessary, inpatient care in the departments of the regional hospital. Consultative and diagnostic clinics not only perform a consultative and therapeutic function, but also evaluate the quality of work of rural doctors, district, city and local hospitals.
Patients are referred to the regional advisory clinic, as a rule, after preliminary consultation and examination by regional medical specialists. To evenly distribute the flow of patients, specialists of the consultative and diagnostic clinic regularly report the availability of free places in hospital departments or appointments for examinations, coordinate the timing of admission of patients from medical institutions in rural areas, organize and conduct on-site consultations with medical specialists, provide a medical report for each patient, which indicates the diagnosis. treatment performed and further recommendations. The clinic systematically conducts quality assessments: significant discrepancies in diagnoses, errors made by doctors in district medical institutions when examining and treating patients locally, etc. are examined.
A special feature of the regional hospital is the presence in its composition departments of emergency and planned advisory assistance, which provides emergency and advisory assistance with travel to a remote locality. The department transports the patient to a medical organization, sends specialists on calls from areas and maintains contact with teams sent to provide medical care. The emergency department organizes the delivery of patients, accompanied by medical personnel, to specialized institutions outside the region, urgent delivery of medications and supplies necessary to save the lives of patients.
This department usually has a fleet of cars for traveling to rural areas. In addition to the manager, its staff includes doctors, specialists
those involved in providing emergency medical care, paramedics, nurses. All specialists from the regional hospital and other medical institutions can be involved in the work of the department. The department of emergency and planned advisory care in some regions is the basic medical unit of the regional center for disaster medicine. In this case, specialized medical care teams work in almost constant readiness.
To bring medical care closer to village residents, specialists from regional institutions practice scheduled visits by integrated teams to consult with pre-selected patients who need clarification of the diagnosis. correction of prescribed treatment, determination of the need for hospitalization in regional medical institutions. This work is also carried out by specialists from central regional hospitals.
Research work- one of the areas of activity of the regional (regional, republican, district) hospital: conducting scientific research, introducing the results of new developments and methods into the practice of medical institutions, organizing scientific conferences and seminars, the work of scientific societies of doctors.
In a regional hospital, unlike a city hospital, the functions organizational and methodological department much wider. In fact, it serves as a scientific and medical basis for the state health management body of the region for the introduction into practice of advanced organizational forms and methods of medical care to the population. Its main functions:
Analysis of the activities of medical institutions in the region:
Organizational, methodological and advisory assistance:
Study and analysis of population health indicators:
Organization of staff training;
Work planning.
The organizational and methodological work of medical institutions in the region involves the main staff (chief surgeon, therapist, pediatrician, obstetrician-gynecologist) and freelance (often heads of specialized and highly specialized departments) specialists.
Emergency medical care in rural areas at the level of FAP, SUB. Family medical outpatient clinics are provided by the medical staff of these institutions at any time of the day.
The most important issues in organizing emergency medical care for the rural population:
Schedule and procedure for providing emergency medical care in all rural medical organizations;
Availability of styling, bags and their necessary equipment;
Emergency medical care standards;
Registration of calls received and measures taken;
Continuity (based on the feedback principle) between the EMS service, outpatient clinic service, dispatch services of farms and enterprises:
Preparing the population to provide self- and mutual assistance, increasing the sanitary literacy of the population;
Development and availability of incentives for participation in this type of assistance for all health workers, including nursing staff, including their training, equipment and financial incentives;
Training of medical personnel to provide ambulance and emergency medical care;
Priority of medicinal and logistical support.
To improve medical care for the rural population, a lot of work is being done as part of the implementation of the healthcare modernization program. which provides organization of households, further strengthening of the material and technical base of medical institutions in rural areas, advanced training, training and retraining of personnel.
The modernization program provides for the opening of more than 3,800 households in settlements with a population of less than 100 people.
The concept of housekeeping implies a local resident who has agreed to provide first aid to sick or injured residents of the settlement. To do this, specialists in the field of disaster medicine will teach such a resident the basic skills and techniques of first aid, and local authorities will equip him with a telephone connection for promptly calling a paramedic, a doctor, an emergency medical team and a first aid kit. Such work is already being actively carried out in some regions of the Russian Federation.
It is planned to open 1,093 first aid stations and paramedic stations in rural areas. 226 medical outpatient clinics, 1,381 GP offices.
The situation with medical personnel, working in rural areas has been deteriorating in recent years. In 2005-2010 the number of doctors in rural areas decreased by 1,653 people (from 42.2 thousand to 40.6 thousand doctors), the coefficient of part-time doctors increased by 6.7%.
From January 1, 2012, by Decree of the Government of the Russian Federation of October 17, 2011 No. 39, medical and pharmaceutical workers living and working under an employment contract in rural settlements, workers' settlements (urban-type settlements), who are on staff at their main place of work in federal government institutions subordinate to federal executive authorities, a monthly cash payment has been established as a measure of social support to compensate for payment expenses residential premises, heating and lighting in the amount of 1200 rubles.
To reduce the shortage of medical personnel in rural areas, it was proposed to create additional incentives for doctors who transfer to work in rural areas, in the form of one-time payments in the amount of 1 million rubles for arrangement, solution of housing and other everyday problems.
It is planned to implement one-time compensation payments medical workers under the age of 35. arrived in 2011-2012. after graduating from a higher educational institution to work in a rural locality or having moved from another settlement.
The condition for receiving these payments is the conclusion between the doctor and the authorized executive body of the constituent entity of the Russian Federation of an agreement on moving to work in a rural locality for a period of at least 5 years.
The executive authorities of a constituent entity of the Russian Federation have the right to provide for payments to paramedical personnel at the expense of the funds of the constituent entity of the Russian Federation.
Federal target program “Social development of rural areas until 2013” (as amended by Decrees of the Government of the Russian Federation dated April 29, 2005 No. 271 and April 28, 2011 No. 336) provides for the implementation of additional measures for the development of a network of primary health care institutions:
Strengthening the material and technical base of healthcare facilities in rural areas, taking into account the creation of mobile units, centers, and departments of general medical (family) practice;
Improving primary health care for the rural population by introducing general medical (family) practice;
Providing the rural population with emergency medical care by improving regulatory, logistical and personnel support;
Improving consultative, diagnostic and therapeutic assistance by introducing on-site forms of medical care;
Staffing healthcare institutions primarily with specialists from general medical (family) practice:
Development of the Institute of GP (family doctor).
As a result of the implementation of measures, the rural population's access to the services of medical institutions and their departments will be expanded.
To increase the effectiveness of the implementation of the Concept of Demographic Policy of the Russian Federation for the period up to 2025, approved by Decree of the President of the Russian Federation of October 9, 2007 No. 1351, in relation to rural areas, additional measures are necessary in order to:
Reducing the mortality rate, especially in working age:
Reducing infant mortality rates;
Preserving and strengthening the health of the rural population: increasing life expectancy;
Creating conditions for a healthy lifestyle;
Reducing the incidence of socially significant diseases,
Reducing the migration flow of the rural population. In this regard, in the regions it is necessary to provide:
Strengthening primary health care in rural areas:
Increasing the availability of medicines for rural residents;
Forming motivation for a healthy lifestyle, including programs to reduce the consumption of alcohol and tobacco products, non-medical use of narcotic drugs and psychotropic substances, prevention of alcoholism, drug addiction, cardiovascular and other diseases;
Ensuring the operation of health centers in rural areas.
In the field of medical care, it is planned to expand the access of the rural population to qualified primary health care. emergency and specialized medical care based on strengthening the FAP network. district hospitals, the creation of general medical practice outpatient clinics, taking into account territorial characteristics. strengthening the material and technical base of district, central district hospitals and inter-district centers using telemedicine, ensuring transport accessibility for the rural population of inter-district centers, regional, republican and federal medical institutions. It is planned to expand the emergency medical services service, the pharmacy network, on-site forms of specialized medical care and the use of remote forms of diagnostics in rural areas. The entire rural population should be covered by dispensary observation.
To popularize a healthy lifestyle and attract rural residents to physical education and sports, it is planned to expand the network of sports facilities and playgrounds.
All activities proposed and carried out by the Government and local health authorities should really change the existing rural health care system and bring it to a new, higher quality level that meets modern medical requirements.
Obstetric and gynecological care for the rural population
Features of the living and working conditions of the rural population, expressed in the dispersion of settlements, the difference in the forms of organization of agricultural production, the variety of types of agricultural work (farming, livestock farming, poultry farming), the large scope of these works, their seasonality, determine the features of the organization of all medical care in a rural area, in including obstetrics and gynecology. Obstetric and gynecological care is provided to the rural population by a complex of medical and preventive institutions. Depending on the degree of proximity to the rural population, on the specialization and qualifications of medical care, the level of material and technical equipment in the system of providing obstetric and gynecological care, it is customary to distinguish three stages.
Stages of obstetric and gynecological care. First stage: implementation of pre-medical and first medical aid. This stage is a rural medical site. It includes a rural district hospital with an outpatient clinic and a hospital, paramedic and obstetric stations (FAP), and maternity hospitals. The location of the first stage is the periphery of the area.
The second stage: provision of qualified medical care. It includes district (registered) and central district hospitals, which include obstetrics and gynecology departments and antenatal clinics. The location of the second stage is the regional center.
Third stage: providing the rural population with highly qualified (specialized) obstetric and gynecological care. It includes a regional (territorial, republican) hospital, which includes obstetrics and gynecology departments and a antenatal clinic or an independent maternity hospital with a antenatal clinic. The location of the third stage is the regional (territorial, republican) center.
Medical obstetric and gynecological care at a rural medical site is carried out by a general practitioner - the chief physician of the rural district hospital (if there are two doctors in the district hospital - one of them). Under his direct supervision, a midwife works at the local hospital, who helps the doctor both in the hospital (takes part in the management of childbirth) and in the outpatient clinic (takes part in monitoring pregnant women, postpartum women and treating gynecological patients). The number of maternity beds in a rural district hospital usually does not exceed 3–5. To bring qualified medical care closer to rural residents, there is a gradual reduction in the number of maternity beds in rural district hospitals and an expansion of the number of beds in district and central district hospitals. However, in a number of areas where, due to local conditions, it is not possible to provide the population with obstetric and gynecological care in district and central hospitals, rural district hospitals are being consolidated, and in accordance with this, the number of maternity beds is being expanded to eight, and the position of an obstetrician-gynecologist is provided.
Pregnant women and women in labor with a pathological course of pregnancy and childbirth and a burdened obstetric history should not be admitted to a local hospital (if there is no obstetrician-gynecologist on staff). Despite the presence of a medical hospital on the periphery of the region - a rural district hospital, the bulk of obstetric and gynecological care in a rural medical district relates to pre-medical care, and is carried out by midwives from a medical and obstetric station and a collective farm (inter-collective farm) maternity hospital. The work of these institutions is carried out under the direct supervision of the chief physician of the rural district hospital. If there is an obstetrician-gynecologist on staff at the local hospital, the latter provides all medical and advisory assistance at the medical assistant station and in the collective farm maternity hospital.
FAP: work structure
Paramedic and midwife stations (FAP) are provided for by the nomenclature of medical institutions. A FAP is organized in a village with a population of 300 to 800 residents in cases where there is no rural local hospital or outpatient clinic within a radius of 4–5 km. All work of the FAP is provided by a paramedic-midwife, midwife, and nurse. The number of service personnel is determined by the capacity of the FAP and the size of the population it serves. The FAP provides the following positions:
paramedic - 1 position for a population of 900 to 1300 people; 1 position for a population of 1300 to 1800 people; 1.5 positions with a population of 1800 to 2400 people. and 2 positions with a population of 2400 to 3000 people;
nurse - 0.5 positions for a population of up to 900 people and 1 position for a population of over 900 people.
Depending on local conditions, the FAP may provide only outpatient care or have maternity beds. In the latter case, the FAP provides inpatient care along with outpatient care. Due to the fact that the FAP provides medical care to the entire rural population, and not just women, the room in which it is located should consist of two halves: a paramedic and an obstetrician.
Obstetric part of the FAP. The obstetric part of the paramedic-midwife station (FAP) should have the following set of premises: an entrance hall, a waiting room and a midwife's office. FAPs that have maternity beds, in addition to these premises, must have an examination room, delivery and postpartum wards. The FAP midwife carries out all the work on organizing and providing obstetric and gynecological care to rural residents within the service radius of the point. The responsibilities of the FAP midwife include: identifying all pregnant women in the service area as early as possible, ensuring dispensary observation of them, including carrying out the necessary treatment and preventive measures, patronage of pregnant women, postpartum women and children under the age of 1 year; carrying out health education work among women; provision of medical care during normal childbirth; identifying gynecological patients, referring them to a doctor and providing them with medical care as prescribed by the doctor. Significant assistance in the early detection of pregnant women is provided by door-to-door visits conducted by the FAP midwife. When monitoring pregnant women, the midwife performs the bulk of the necessary research. So, at the first visit of a pregnant woman, the midwife collects a detailed history, general (heredity, previous diseases, etc.) and special obstetric (menstrual, sexual, generative, lactation functions, gynecological diseases, etc.). From the medical history, the midwife finds out the peculiarities of the course of previous pregnancies, the presence of extragenital diseases and other abnormalities in the woman’s health that can affect the course of pregnancy and childbirth.
The midwife begins the examination of each pregnant woman with a study internal organs: cardiac activity, measuring blood pressure (on both arms), examining pulse, urine for protein (by boiling). The midwife currently studies the health status of pregnant women based on measuring height, body weight (over time), the presence of edema, pigmentation, the condition of the mammary glands and nipples, and the condition of the abdominals. Carrying out a special obstetric examination, the midwife measures the external dimensions of the pelvis and, through a vaginal examination, determines the gestational age and internal dimensions of the pelvis. In the second half of pregnancy, measures the height of the uterine fundus above the womb, determines the position and presentation of the fetus, and listens to its heartbeat.
For a general blood test, group affiliation, determination of the Rh factor, antibody titer, Wasserman reaction, and a general urine test, the pregnant woman is sent to the nearest laboratory. Here, a bacteriological study of the vaginal flora is carried out to determine the degree of purity, the discharge of the urethra, cervix and vagina for gonococcus, and the reaction of vaginal secretions. X-ray examinations in pregnant women (x-ray of the chest, fetus, pelviography) are performed only if there are strict indications.
A thorough examination of pregnant women makes it possible to identify various pathological conditions, on the basis of which these pregnant women are identified as high-risk groups and require the closest attention to them during pregnancy; during childbirth and the postpartum period, high-risk groups are distinguished for cardiac pathology, bleeding in the postpartum and early afterbirth periods, inflammatory and septic complications after childbirth, endocrinopathies - diabetes mellitus, obesity, adrenal insufficiency and other types of obstetric and somatic pathologies. All individual cards of pregnant women at risk are usually marked with the appropriate color marking, indicating in a certain color the risk of a particular pathology (red - bleeding, blue - toxicosis, green - sepsis). The scope of research in gynecological patients also includes the collection of general and special gynecological history. The study of women's health is currently carried out on the basis of a general clinical examination, similar to the examination of pregnant women. A special gynecological examination includes two-manual and instrumental (examination in mirrors) examination. A bacterioscopic examination of the discharge of the urethra, cervix and vagina for gonococcus is carried out using provocation methods, according to indications - the Bordet-Gengou reaction; examination of a vaginal smear for cell atypia; research on functional diagnostic tests.
If a woman needs a biochemical blood test for cholesterol, bilirubin, sugar, residual nitrogen and a urine test for acetone, urobilin, bile pigments, she is sent to the nearest multidisciplinary laboratory. Women and couples who have a history of hereditary diseases or children with deformities of the central nervous system, Down's disease, or defects of the cardiovascular system are sent for examination, including to determine sex chromatin, to specialized medical genetic centers. When monitoring pregnant women, the FAP midwife is obliged to show each of them to the doctor. If a woman’s pregnancy is progressing normally, then she will meet with a doctor at her first scheduled visit to the FAP. All pregnant women who exhibit the slightest deviation from the normal development of pregnancy should be immediately referred to a doctor.
At each subsequent visit to the FAP, the pregnant woman undergoes the necessary repeated examinations. In the second half of pregnancy, you need to especially carefully monitor the possible development of late toxicosis, for which you need to pay attention to the presence of edema, blood pressure dynamics and the presence of protein in the urine. It is very important to monitor the dynamics of a pregnant woman’s weight.
Organization of patronage work. A mandatory part of a midwife’s work in monitoring pregnant women should be conducting classes on psychoprophylactic preparation for childbirth. In organizing monitoring of pregnant women in rural areas, as well as in the city, patronage work is very responsible. Patronage of pregnant and gynecological patients is an element of the active dispensary method. The goals of patronage are very diverse, so each patronage visit to a woman has a specific goal. First of all, this is an acquaintance with the living conditions of a woman. Knowing the peculiarities of life of each family ( living conditions, family composition, level of material security, degree of culture, including health literacy), it is easier for a midwife to monitor the health status of the population. The purpose of patronage is the need to find out the health status of a pregnant woman who did not show up for an appointment at the appointed time. In this case, the midwife, in a conversation with the pregnant woman, finds out the general condition of the woman, performs a thorough examination, pays attention to the presence of edema, and measures blood pressure. During long periods of pregnancy, she measures the circumference of the abdomen and the height of the uterine fundus, and determines the position of the fetus. Having made sure that there are no deviations from the normal development of pregnancy, the midwife sets a date for the woman to appear for the next examination. If there is the slightest sign of pregnancy complications, the midwife invites the pregnant woman to see a doctor or informs the doctor about this, who decides whether the pregnant woman can be treated at home or whether she needs to be hospitalized. In the latter case, the midwife monitors the timeliness of the woman’s admission to the hospital and continues active monitoring after she is discharged home. The reason for patronage may be the desire to make sure that the woman is following the doctor’s orders correctly, or the need to conduct additional tests (laboratory tests, measure blood pressure).
The FAP midwife is obliged to provide patronage to children, especially the first 3 years of life. In this case, it is necessary to observe the frequency of observations of children of the 1st year of life by the midwife (paramedic) of the FAP: 1st month of life - observation only at home - 5 times; 2nd month of life - observation at home - 3 times; 3–5 months of life - observation at home - 2 times a month; 6–12th months of life - observation at home - once a month. In addition, a child under 1 year of age must be examined by a pediatrician at the FAP at least once a month. Thus, the midwife sees the child during the 1st year of life 12 times during preventive examinations by a doctor and 20 times during home visiting.
The midwife's patronage work is strictly planned. The plan provides for days of visiting villages and hamlets. A special notebook keeps records of patronage work and records all visits to women and children. The midwife enters all advice and recommendations into the home visiting nurse’s work notebook (patronage sheet) for subsequent verification of their implementation.
Mobile teams from the Central District Hospital. The majority of women from rural areas give birth in the obstetric departments of the Central District Hospital. If necessary, inpatient qualified medical care is provided to rural women in large republican, regional, and regional maternity hospitals. To bring medical outpatient care closer to residents of rural areas, visiting teams from the Central District Hospital are created, which arrive at medical and obstetric centers according to the approved schedule. The visiting team includes an obstetrician-gynecologist, a pediatrician, a therapist, a dentist, a laboratory assistant, a midwife, and a children's nurse. The composition of the visiting team of doctors and paramedical workers is brought to the attention of the heads of medical and obstetric centers.
Carrying out preventive periodic examinations. The paramedic and midwife are required to have in their area a list of women subject to preventive and periodic examinations. Practically healthy women with a good obstetric history and a normal course of pregnancy during the period between team visits are observed by a midwife at a FAP or local hospital, and are sent to the nearest local or regional hospital for childbirth. With a group of women for whom pregnancy is contraindicated, the obstetrician-gynecologist and midwife talk about the dangers of pregnancy to their health, possible complications of pregnancy and childbirth, teach them how to use contraceptives, and recommend intrauterine contraceptives. When visiting the team again, the obstetrician-gynecologist checks the obstetrician-gynecologist's compliance with the prescriptions and recommendations. Significant assistance in the early detection of pregnant women is provided by door-to-door visits conducted by a midwife. All identified pregnant women, starting from the earliest stages of pregnancy (up to 12 weeks), and postpartum women are subject to medical examination.
In the normal course of pregnancy, a healthy woman is recommended to attend a consultation with all tests and doctors’ opinions 7–10 days after the first visit, and then visit the doctor in the first half of pregnancy once a month, after 20 weeks of pregnancy - 2 times a month, after 32 weeks - 3–4 times a month. During pregnancy, a woman should attend a consultation approximately 14–15 times. If a woman is ill or has a pathological course of pregnancy that does not require hospitalization, the frequency of examinations is determined by the doctor on an individual basis. It is important that pregnant women carefully attend consultations during antenatal leave.
Hospitalization of pregnant women in medical hospitals. Very important in the work of a FAP midwife is the timely hospitalization of pregnant women in medical hospitals when initial signs of deviation from the normal course of pregnancy appear, as well as women with a burdened obstetric history. Pregnant women with a narrow pelvis (with an external conjugate of less than 19 cm), abnormal fetal position and breech presentation, immunological incompatibility of the blood of mother and fetus (including a history), extragenital diseases, and the appearance of bloody discharge from the genital tract are subject to prenatal hospitalization in medical hospitals. , edema, the presence of protein in the urine, increased blood pressure, excessive weight gain, when a multiple pregnancy is established, as well as other diseases and complications that threaten the health of a woman or child.
When sending a pregnant woman to an obstetric hospital, it is very important to choose the right method of transportation (medical transport, air ambulance), associated transport, and also correctly decide on the institution where this pregnant woman should be hospitalized. A correct assessment of the health status of a pregnant woman will allow you to avoid multi-stage hospitalization, and immediately assign the patient to the obstetric hospital where there are all the conditions for providing her with full medical care.
Carrying out childbirth at a medical facility. At the paramedic-midwife station, only normal (uncomplicated) births are provided. In cases where one or another complication occurs during childbirth (which cannot always be foreseen), the FAP midwife should immediately call a doctor or (if possible) take the woman in labor to a medical hospital. In this case, it is very important to resolve the issue of means of transportation. It must be remembered that women with unseparated placenta, preeclampsia and eclampsia, as well as with threatening uterine rupture cannot be transported. If a woman with an unseparated placenta needs to be transported due to certain complications of pregnancy, the FAP midwife is obliged, first of all, to manually separate the placenta and transport the woman with a contracted uterus.
If it is impossible to provide the woman with the necessary assistance to such an extent that she is in a state of transportability, a doctor should be called to her and a plan of further action should be outlined with him. When providing emergency pre-medical care to a pregnant and laboring woman, a FAP midwife has the right to perform the following obstetric operations and aids: turning the fetus on its leg when the uterine pharynx is fully open and the waters are intact or have just broken, removing the fetus by the pelvic end, manual separation of the placenta, manual examination of the uterine cavity , restoration of the integrity of the perineum (after a rupture of the perineum or perineotomy). If there is bleeding in the early postpartum period, the midwife must exclude rupture of the birth canal tissue. Complications that arise during childbirth require the midwife, in addition to urgently calling a doctor, to take clear organizational actions, on which the outcome of the birth largely depends. The midwife must be fully proficient in the primary methods of resuscitation of newborns born with asphyxia.
Maintaining documentation for the FAP. It is very important in the work of a FAP midwife to carefully maintain documentation. For each pregnant woman who applies to the FAP, an “Individual Card of a Pregnant Postpartum Woman” (f-111/u) is filled out. If obstetric complications or extragenital diseases are detected, a duplicate of this card is filled out and sent to the district obstetrician-gynecologist.
There are many options for storing individual cards. One of the most convenient options for work, which can be recommended, is as follows: a box for storing individual cards (the width and height of the box must correspond to the size of the card) is divided by transverse partitions into 33 cells. Each partition is marked with a number from 1 to 31. These numbers correspond to the dates of the month. When scheduling a pregnant woman's next appointment, the midwife places her card in a box marked with the corresponding date of the month, i.e., the day on which she needs to attend. Before starting work, the midwife takes out all the individual cards from the box corresponding to the day of the appointment and prepares them for the appointment - they will check the accuracy of the records and the availability of the latest tests. Having completed the appointment with the pregnant woman, he assigns her a day of subsequent appearance and places the card of this pregnant woman in a cell with a mark corresponding to the day of the month for which she is scheduled to appear. At the end of the appointment, based on the number of remaining cards, it is easy to judge about pregnant women who did not show up for the appointment on the day assigned to them. The midwife places these cards in the 32nd cell of the box marked “Patronage”. Then the midwife visits at home (patronizes) all women who do not show up for appointments. All cards of those who have given birth and are subject to dispensary observation until the end of the postpartum period are placed in the 33rd cell marked “Postpartum women”.
For each woman in labor, a “History of Childbirth” is filled out (f-099/u). All women who give birth in a FAP are registered in the birth register (f-098/u). In addition to these documents, the FAP keeps a diary-notebook for recording pregnant women (f-075/u) and a diary (f-039-1/u). When a pregnant woman (after 28 weeks of pregnancy) or a postpartum woman is sent to a medical obstetric hospital, she is given an “Exchange Card” (account no. 113). If a pregnant woman is hospitalized before 28 weeks, she is given an extract from the medical history (account no. 27). When leaving the hospital, she receives an extract from the medical history using the same form, which is given to her by the midwife of the FAP.
Organizing and conducting preventive examinations of rural women. An important section in the work of a midwife at a medical and obstetric station is the organization and conduct of preventive examinations of women. It is advisable to carry out preventive examinations of rural residents in the autumn-winter period in order to complete the recovery of identified patients before the start of spring field work. All work on organizing preventive examinations is led by the district obstetrician-gynecologist and the chief midwife of the district. An inspection plan is drawn up in advance, which indicates the place where the inspection will be carried out and the calendar dates for inspections for each locality. Preventive examinations are carried out by FAP midwives who have undergone special training and instruction. To successfully conduct a preventive examination, the midwife must first make a door-to-door visit, the task of which is to explain to women the purpose of the examination, the method of conducting it, and the place of the examination.
The purpose of preventive examinations is the early detection of pre-tumor, tumor, inflammatory and so-called functional diseases of the genital organs in women and the prescription of appropriate treatment, if necessary. Preventive examinations also make it possible to identify among the organized part of the female population occupational hazards that affect the genital organs, and to develop measures to eliminate them. Direct examination of women consists of two sequential procedures - examination of the external genitalia, vagina and vaginal part of the cervix (using mirrors) and two-handed examinations to determine the condition of the internal genital organs.
During preventive examinations, objective diagnostic methods are used: cytological examination of vaginal discharge, “prints” from the cervix, colposcopic examination. To carry out laboratory research, material is taken from various parts of the woman’s genitourinary system:
smears from the urethra and cervical canal for bacteriological examination of Neisser gonococci and flora. The material obtained from the urethra is applied to a glass slide in the form of a circle, and from the cervical canal - in the form of a streak in the longitudinal direction;
A smear from the posterior vaginal fornix to determine the degree of purity of the vaginal contents is taken after inserting the speculum and using a stick with cotton wool wound at the end. The smear is applied to the glass slide in the longitudinal direction in the form of a line;
A smear from the side wall of the vagina for hormonal cytodiagnosis is also taken after the insertion of speculum and using a stick with cotton wool wound around its end. The stroke is applied in the form of a stroke along the glass;
a scraping smear from the surface of the cervical erosion is obtained using a spatula and applied with a stroke across the glass slide; A scraping smear from the cervical canal is taken using a Volkmann spoon and applied to the glass in the form of a circle (or several circles).
At the slightest suspicion of the presence of a disease, which arises from a midwife performing a preventive examination, the woman should be immediately referred to a doctor. In carrying out preventive examinations, careful registration and accounting of all examined women is very important, for which a list of persons subject to a targeted medical examination for identification is compiled (form No. 048/u). To register and record women who are subject to active dispensary observation, dispensary observation control cards are created for them (form No. 030/u).
Another institution providing pre-hospital obstetric and gynecological care in rural areas is the collective farm maternity hospital. The following premises must be provided in a collective farm maternity hospital: a vestibule, a reception room, a labor room (10–12 sq. m), a postpartum ward (6 sq. m for 1 mother and child bed), a kitchen, and a toilet. Each collective farm maternity hospital has from 2 to 5 beds (at the rate of 1 bed per 1000 population). The collective farm maternity hospital is located at a distance of 6–8 km from the rural medical site to which it is attached. Under good transport conditions, this distance can be increased to 10–15 km. Collective farm maternity hospitals are served by a midwife, whose responsibilities are similar to those of a midwife at a FAP. If in one village near the FAP there is a collective farm maternity hospital and due to the volume of its work there is no need for an independent staff, the service of the latter is entrusted to the midwife of the FAP.
Issues of labor protection in the work of obstetrics and gynecology services. In the work of obstetric and gynecological services in rural areas at all stages, a lot of space is occupied by the issues of labor protection of female agricultural workers. Agricultural work has its own characteristics, the main of which are seasonality, the implementation of various production operations in a short time under any weather conditions. This requires significant effort and tension from a person, which inevitably leads to violations of the work and rest regime. Female agricultural workers experience additional adverse effects from production factors such as noise, vibration, dust, contact with pesticides (pesticides) and mineral fertilizers. The main work on implementing measures aimed at protecting the labor of rural residents is carried out by hygienists. But the obstetrics and gynecology service should also take part in this work, since unfavorable production factors also have a negative impact on the specific functions of the female body.
To improve the health of women employed in agriculture, it is necessary to carry out a number of organizational measures aimed at protecting the female body from the effects of adverse factors in agricultural production. This is achieved by introducing mechanization and automation of labor-intensive processes, removing women from night work and work with pesticides, from working in highly dusty conditions, reducing vibration and sound pressure to a minimum, rational alternation of work and rest, organizing sanitary facilities, ensuring timely and rational nutrition, widespread use of dispensaries, etc. Work on labor protection of female agricultural workers is carried out and controlled by special commissions, which include an obstetrician-gynecologist, a representative of the SES, a representative of a trade union organization, and a safety engineer. In monitoring compliance with all labor protection requirements for collective farmers, great responsibility lies with paramedical workers (the senior midwife of the district and the midwife of the FAP).
Equipping the midwife's office at the FAP. The midwife performs a significant amount of work at the paramedic-midwife station, so the midwife’s office must be equipped with scales, a gynecological chair, mirrors, sterilizers, a centimeter tape, an obstetric stethoscope, a pelvis, everything necessary for taking smears for cytological examination. To provide emergency obstetric care, the feldsher-midwife station must have a midwife bag equipped with everything necessary for delivery and treatment of the newborn.
Obstetric bag equipment. 1. Instruments, care items and dressings.
Scalpel - 1
Mouth retractor - 1
Anatomical tweezers - 1
Kocher clamps - 2
Scissors - 1
Metal spatula - 1
10 ml syringe - 1
2 ml syringe - 1
Medical needles - 6
Medical gloves - 1 pair
Urethral metal catheter - 1
Sterile catgut - 2 amp.
Obstetric stethoscope - 1
Medical thermometer - 1
Medical scarf - 1
Sterile linen (set) - 1
Towel - 2
Sterile sheets - 2
Bedding - 2
Underlay oilcloths - 2
Blankets:
children's - 1
adults - 1
Cold baby diapers - 2
Iodine sticks - 10 pcs.
Compress cotton wool - 50 g
Bandages 7 m x 5 cm - 2 pcs.
Bandages 10 m x 5 cm - 3 pcs.
Sterile bags - 4
Absorbent cotton wool - 25 g
Warm baby diapers - 2
Adhesive plaster - 1 pc.
Gray cotton wool - 50 g
Packages for processing umbilical cord residues (“umbilical bags”) - 2
Fabric centimeter - 1
Package for childbirth ("birth package") - 1
Soap - 1
Surgical gloves - 1 pair
Surgical sterile silk in ampoules No. 8 - 1 amp.
Medical gowns - 2 pcs.
Harness - 1
Tonometer - 1
Eye dropper - 1
Beaker - 1
Esmarch rubber mug - 1
Medicines.
Atropine sulfate (9.1% solution in ampoules of 1 ml) - 1 amp.
Platyphylline hydrotartrate (0.2% solution in ampoules of 1 ml) - 1
Analgin (50% solution in ampoules of 2 ml) - 2
Dibazol (1% solution in ampoules of 1 ml) - 6
Papaverine hydrochloride (2% solution in ampoules of 2 ml) - 2
Cordiamine (in ampoules of 2 ml) - 3
Caffeine sodium benzoate (10% solution in ampoules of 1 ml) - 3
Calcium gluconate (10% solution in ampoules of 10 ml) - 1
Calcium chloride (10% solution in ampoules of 10 ml) - 2
Lobeline (1% solution in ampoules of 1 ml) - 1
Glucose (40% solution in ampoules of 20 ml) - 2
Adrenaline (0.1% solution in ampoules of 1 ml) - 2
Ephedrine (5% solution in ampoules of 1 ml) - 1
Diphenhydramine (1% solution in ampoules of 1 ml) - 2
Eufillin (2.4% solution in ampoules of 10 ml) - 1
Novocaine (0.5% solution in ampoules of 5 ml) - 2
Pituitrin for injection in ampoules of 1 ml - 2
Validol 0.06 g - 10 tubes.
Nitroglycerin 0.5 mg - 1 tube
Valerian tincture 30 ml - 1 fl.
Alcohol iodine solution (5%) - 1
Hydrogen peroxide (3% solution, 50 ml) - 1
Ammonia solution (10% 40 ml) - 1
Ethyl alcohol 95% - 25 ml
Boiled water - 30 ml
Isotonic sodium chloride solution for injection (0.9% solution per 20 ml)
Benzylpenicillin sodium salt 1,000,000 units - 2 fl.
Pregnancy prevention, anti-abortion propaganda. Midwives in rural areas are faced with the task of instilling in women a negative attitude towards abortion as an operation that can cause trauma to the woman, often leading to gynecological and other diseases. In addition, for older women with Rh-negative blood and signs of infantilism, it is necessary to especially persistently explain the importance of maintaining the first pregnancy. FAP midwives independently conduct anti-abortion propaganda in the territory of the service area, receiving appropriate organizational and methodological instructions from obstetrician-gynecologists of central district and regional hospitals.
Of great importance in promoting the prevention of abortion is the issue of modern means of contraception, the features of their action, and their effective use. It is necessary to explain which means are the most effective and harmless, and to warn against the use of harmful and ineffective means and methods. When conducting interviews, the FAP midwife must identify the following groups of women: those wishing to terminate the pregnancy; who came to the consultation after an abortion; postpartum women after discharge from the obstetric hospital; those who applied for a preventive examination; getting married.
Particular attention is paid to the use of oral contraceptives, since, provided they are taken correctly, they are among the most effective. Hormonal contraceptives are synthetic analogues of the female sex hormones estrogen and progesterone and their derivatives. When they are introduced, a state of pregnancy is created in a woman’s body, the so-called “pseudo-pregnancy”, which ensures sterility. The main mechanism for ensuring sterility with the help of oral contraceptives is to suppress ovulation, that is, the maturation and release of a mature egg from the ovary.
Advantages of using oral medications. The midwife should explain to women the positive aspects of taking hormonal contraceptives:
softening premenstrual tension;
beneficial effect on women with irregular menstrual cycles, which become more regular and menstrual bleeding often decreases; there is evidence of improvement in the condition of women suffering from iron deficiency anemia;
reducing the risk of pelvic inflammation among women using oral contraceptives;
improvement of the condition in diseases of the sebaceous glands - pimples and blackheads disappear;
relief of pain in the middle of the cycle;
providing a protective effect against rheumatoid arthritis;
there may be a decrease or increase in libido;
protective effect against the development of benign breast tumors.
However, when taking oral contraceptives, undesirable effects occur in the form of breast tenderness, weight gain of no more than 2 kg, headaches (migraines), vaginal discharge, menstrual irregularities, and sometimes spontaneous bleeding or intermenstrual uterine bleeding is observed. Contraindications to taking hormonal contraceptives are: breast cancer; all types of genital cancer; liver dysfunction; recent liver disease or jaundice; deep vein thrombosis; pulmonary embolism; cerebral vascular injury; rheumatic heart disease; phlebeurysm; cardiovascular diseases, including hypertension and diabetes with complications (in history or in the form of clinical manifestations); undiagnosed abnormal uterine bleeding; congenital hyperlipidemia. As contraindications, it is necessary to take into account age over 40 years; smoking and age over 35 years; history of acute preeclampsia during pregnancy; in nulliparous women - rare, irregular menstruation, amenorrhea, later menarche; lactation lasting less than 6 months; planned surgery; bouts of depression. The following diseases also need to be taken into account: mild hypertension (diastolic pressure above 90, but below 105 mm Hg); chronic kidney disease not accompanied by hypertension; epilepsy; migraine; diabetes mellitus without vascular complications; gallbladder diseases.
Intrauterine method of contraception. To others effective method protection against pregnancy is intrauterine contraception, which is based on the introduction into the uterine cavity of an intrauterine device that prevents pregnancy. There are the following types of IUDs: non-medicated (Lippes loop, Margulis spiral, double helix); medicinal (basic) - copper-containing (TCi 200, etc.) and hormone-releasing agents. The mechanism of the contraceptive action of the IUD is to disrupt the implantation of the fertilized egg, accelerate the migration of the latter, as a result of which it prematurely ends up in the uterine cavity when the endometrium is not yet prepared for implantation; the effect of medicated IUDs on the endometrium. In this case, a process like chronic endometritis occurs in the endometrium with symptoms of local endometrial atrophy, swelling, increased vascularization and, possibly, disturbances in hormonal secretion.
Before inserting the IUD, the midwife should collect instruments and devices; brief women and inform them necessary information; collect anamnestic data by filling out a questionnaire; reassure the woman, and also make sure that she is fully aware of the meaning of the IUD, including the advantages and disadvantages of the method, understands the procedure for inserting the IUD and the need for clinical monitoring while wearing the IUD. After insertion of the IUD, the woman must be examined for the first time after 1 month, then after 3 months. In the future, the woman should attend consultations at intervals of 6 months, appearing for examination in the period between menstruation.
List of instruments, devices and sterilization products:
Navy;
conductor (without IUD);
gloves;
Cusco mirror;
lift;
bullet forceps;
uterine probe;
scissors;
bullet irons;
metal trays;
weak aqueous solution of iodine (for sterilization);
tampons for the vulva;
a light source commonly used in consultation.
Instruments must be sterile and ready before insertion of the IUD. Sterilization of instruments is carried out in a dry-heat oven or by boiling at general rules according to instructions. Sterilization of IUDs is carried out by washing them in soapy water and then placing them in a 2% chloramine solution for 3 days (with a daily change of solution). Before use, the IUD is placed in 96% ethyl alcohol for 2 hours. Leaving the IUD in alcohol for long term promotes compaction, which can cause their fragility.
Before intrauterine contraception, women undergo a bacterioscopic examination of smears from the cervical canal, vagina and urethra for flora and degree of purity, a clinical blood test, and, if indicated, a urine test. The IUD is inserted only if the hemogram is normal, I–II - the degree of purity of the vaginal contents. The IUD is inserted on the 5th–7th day of the menstrual cycle, immediately after an uncomplicated abortion or 4–6 months after an uncomplicated birth. Sometimes it is permissible to insert an IUD on the 5th–6th day after an uncomplicated birth, provided that the postpartum period is normal. The introduction of an IUD to women who have been treated for inflammatory diseases of the uterus and appendages is possible only after 6–10 months, in the absence of exacerbation of the process.
Contraindications for IUD insertion:
Acute, subacute and chronic inflammatory diseases of the female genital organs with frequent exacerbations, including inflammatory diseases of the cervix.
Presence of pregnancy or at least suspicion of it.
Infectious and septic diseases and fever of any etiology.
Isthmic-cervical insufficiency.
History of septic (or infected) miscarriage within 3 months before the proposed IUD insertion.
Postpartum pelvic infection within 3 months before the intended insertion of the IUD.
Benign tumors and neoplasms of the female genital organs.
Polyposis of the cervical canal, leukoplakia, cervical erosion.
Polyposis, endometrial hyperplasia.
Tuberculosis of the genitals.
Menstrual irregularities (menorrhagia, metrorrhagia).
Anemia.
Disorders of the blood coagulation system (diathesis, thrombocytopathy, etc.).
Congenital or acquired anomalies of the uterus (fibromatous submucous nodes), incompatible with the design or shape of the IUD, the size of the uterine cavity not corresponding to the size and shape of the IUD.
Stenosis or obstruction of the cervical canal (danger of perforation).
Dysmenorrhea or menorrhagia with disability (history) - for hormonal IUDs.
Repeated expulsions of IUDs (especially large ones).
Allergy to substances released by the IUD (copper, antifibrinolytic substances, hormones).
No history of childbirth.
Observations on women using IUDs. Immediately after insertion of the IUD, dizziness, weakness, nausea, and pain in the lower abdomen may occur. In such cases, it is advisable to rest, administer painkillers, antispasmodics, and inhale ammonia vapors. After insertion of the IUD, slight bleeding may occur for 3–5 days or nagging pain in the lower abdomen that does not require specific therapy. Sexual abstinence is required for the first 7–10 days after insertion of the IUD.
The maximum period of stay of the IUD in the uterine cavity should not exceed 4 years, since with prolonged use the properties of the material from which the IUD is made changes; its contraceptive ability decreases. Indications for removal of the IUD: prolonged pain, bleeding such as menopause or metrorrhagia, exacerbation of the inflammatory process in the genitals, partial expulsion of the IUD, a woman’s desire to become pregnant, expiration of the IUD use period. The positive aspects of IUDs are their high efficiency, duration of use, the possibility of removal at any time, the permissibility of use during breastfeeding, and the absence of unwanted sensations during sexual intercourse.
Clinical examination of the rural population and preventive examinations. The most important section of the work of FAP medical workers is preventive medical examinations of the population, which are carried out in order to identify diseases in the initial stages and carry out the necessary therapeutic and health measures. Preventive medical examinations of the population are the initial stage of the dispensary observation system. The objectives of medical examinations are: active identification of persons with general and occupational diseases in their early stages; dynamic monitoring of the health status of persons exposed to adverse factors; identification of diseases that occur unfavorably under the influence of certain factors, as well as pathologies that may contribute to the development of an occupational disease; determination of deviations in indicators characterizing physical development and ability to work; development of recommendations aimed at improving working conditions, eliminating or significantly reducing unfavorable production factors; carrying out individual treatment and preventive measures based on the results of a medical examination in order to restore impaired body functions and the ability to work of the sick.
According to the classification of G.A. Novogorodtsev and co-authors, all medical examinations are divided into preliminary, periodic and targeted. Children are subject to preliminary medical examinations when they are admitted to a nursery, kindergarten, or school; pupils or students upon admission to technical schools and universities; teenagers getting a job, as well as all persons entering work in certain sectors of industry, agriculture, construction, transport, public catering, etc. Periodic medical examinations are carried out for the above groups of persons throughout their working career for dynamic monitoring their health, maintaining their ability to work and ensuring creative longevity.
Targeted medical examinations provide for the identification of diseases that are the most common and pose a danger to ability to work and life: tuberculosis, cancer, cardiovascular diseases. In carrying out mass medical examinations, two stages are conventionally distinguished: preparatory and actual working. During the preparatory period, the contingent of persons subject to preventive examinations, the timing and place of examinations are determined, teams of doctors and paramedical workers are created and instructional and methodological meetings and seminars are held with them.
The contingents of workers and employees subject to preliminary and periodic examinations indicating occupational hazards are established by the SES, and it, in writing, in an approved form, requests lists of these persons from the heads of rural settlements and enterprises. The lists are compiled in 3 copies (for the chief physician of the Central District Hospital, SES and the head of the agricultural enterprise); The head of the personnel department, with the participation of an occupational health and safety engineer, endorses the documents, signs them with the head of the agricultural enterprise, and they are certified with a seal. The SES develops a schedule for carrying out preventive examinations, indicating the composition of the medical team and the scope of laboratory examinations. The inspection schedule must be coordinated and approved with the leadership of rural settlements and agricultural enterprises and communicated to each medical institution.
The second, or actual working, period consists of the direct organization and conduct of medical examinations, and, as a rule, it begins in December in order to complete all health-improving activities by the start of mass field work. The Central District Hospital issues an order indicating the specific tasks facing the team of doctors, and a senior doctor (usually a therapist) is appointed. Preventive examinations can be carried out at the central district hospital, local hospital, or outpatient clinic. Teams of doctors can directly travel to populated areas, located at the first aid station, in premises specially adapted for examinations. The order, timing and those responsible for attending the inspection are determined by order of the head of the rural locality.
When doctors visit sites, paramedics and midwives prepare premises, appropriate equipment, instruments, clarify lists of persons to be examined, which helps doctors reduce the loss of working time and study in more detail the working conditions of specific professional groups. To attract the population to participate in inspections, radio broadcasts, publications in local newspapers, lectures, conversations, as well as individual invitations to apartments by sanitary activists and paramedics can be organized according to a set schedule. Responsibility for attendance at inspections of workers rests with the heads of agricultural enterprises and trade union organizations. At the end of the preventive inspections, a final report is drawn up for each enterprise.
Clinical examination. One of the most important types of preventive work of a paramedic is medical examination of the population. Medical examination of the population includes:
annual examinations of the population by doctors with the participation of paramedical workers and conducting the necessary laboratory diagnostic and functional studies;
additional examination of those in need using modern diagnostic methods;
carrying out the necessary medical and recreational activities;
dispensary observation of patients and persons with risk factors. The objectives of the medical examination are:
determination and assessment of the health status of each person;
ensuring an increase in the level and quality of annual examinations and clinical supervision with the required volume of research;
expanding the participation of various specialists and nursing staff in medical examinations with the leading role of the local (shop) doctor;
improving the technical support for annual examinations and dynamic monitoring of public health using automated systems;
ensuring the necessary statistical recording and reporting, transfer of information about the examinations and health-improving activities carried out for each person at the place of his observation.
The annual medical examination of the entire population is envisaged in 2 stages. During the period of preparation for the introduction of annual medical examination, the entire population living in the service area of the FAP is personally taken into account in accordance with the “Instructions on the procedure for recording the annual medical examination of the entire population.” In rural areas, police lists of residents are compiled by paramedics of the FAP during door-to-door visits, they are clarified in village and township administrations and transferred to the local hospital (outpatient clinic). For personal registration of each resident, nursing staff fill out the “Minary Medical Examination Record Card” and number it in accordance with the outpatient medical record number (form No. 025/u). After clarifying the composition of the population, all “Medical examination cards” are transferred to the card index.
After conducting a personal census of the entire population, the following groups are distinguished:
newborns;
children 1 and 2 years of age;
preschool children in organized groups;
schoolchildren under 15 years of age;
teenagers (schoolchildren, students of vocational schools and secondary specialized educational institutions, working teenagers aged 15–17 years);
disabled people and participants of the Great Patriotic War, participants in the war in Afghanistan, liquidators of the consequences of the accident at the Chernobyl nuclear power plant;
pregnant women; workers in industry, construction, transport, communications;
workers of municipal, medical and preventive, children's and other enterprises, organizations and institutions;
machine operators, livestock breeders, field farmers, greenhouse workers and other agricultural workers;
students of higher educational institutions and students of secondary specialized educational institutions;
personal pensioners receiving medical care in a given healthcare institution;
persons under medical supervision;
other population groups not included in the above list.
Scope of research at the first stage of medical examination. In rural areas (except for district centers and assigned areas), the following scope of examinations is recommended at the first stage of medical examination.
Children's population: Annual examinations by a pediatrician (in the absence of a pediatrician - a therapist), a dentist (dentist). A pediatrician must examine children of the 1st and 2nd year of life, and before entering school - a pediatrician, neurologist and surgeon.
Nursing staff conducts: anthropometric measurements; determination of visual acuity; determination of hearing acuity; preliminary assessment of physical and neuropsychic development; tuberculin tests.
The following laboratory, diagnostic and instrumental studies: blood test (ESR, hemoglobin, leukocytes, erythrocytes); general urine analysis; stool analysis for worm eggs; blood pressure measurement from 7 years; fluorography of the chest organs from 13 years of age.
Adult population: Annual examinations by a therapist, dentist, obstetrician-gynecologist (in his absence, a midwife), and other specialists - as indicated.
Nursing staff, including FAPs, collect anamnestic data using a specially designed questionnaire; anthropometric measurement; blood pressure measurement; gynecological examination of women with taking smears (for cytological examination); determination of visual acuity; tonometry (persons over 40 years old); determination of hearing acuity, tuberculin tests (adolescents 15–17 years old).
Laboratory, diagnostic and instrumental studies: blood test (ESR, hemoglobin); urine test for sugar, urine test for protein (express method); ECG (after 40 years); fluorography (x-ray) annually; smear cytology from 18 years of age in women; mammography (fluoromammography) once every 2 years in women over 35 years of age.
The scope of research carried out during the annual medical examination of agricultural workers in the main professions includes the following groups:
machine operators;
repair shop workers (mechanics, turners, electric welders, battery workers, blacksmiths);
livestock breeders (milkmaids, cattlemen, pig farmers, calf farmers);
poultry farmers (poultry workers, operators, egg sorters, slaughterhouse workers, etc.);
plant protection agronomists, pesticide storekeepers, greenhouse workers, plant protection workers;
greenhouse workers (greenhouses, agronomists).
For each profession, the order provides for the identification of an etiological factor, examination by specialists (mandatory, according to indications) and laboratory tests, mandatory and according to indications.
Stages of dispensary work. In dispensary work, it is necessary to stage dispensary observation, and there are 3 stages: planning work in connection with annual examinations of the organized and unorganized population (stage I); identification of populations subject to dispensary observation (stage II); carrying out active dynamic observation, treatment, health and rehabilitation measures (stage III). The scope of medical examinations and diagnostic studies during pregnancy and the postpartum period includes the following nosological forms: physiological pregnancy in a healthy woman, as well as a normal postpartum period. The frequency of observation by an obstetrician-gynecologist, examinations by doctors of other specialties, the name and frequency of laboratory and other diagnostic tests, basic treatment and health measures, and hospitalization were established.
Medical care for the rural population is based on the same principles as for the urban population, but the peculiarities of life of the rural population (nature of settlement, low population density, specific conditions of the labor process, economic activities and everyday life, poor quality or lack of roads) require the creation of a special system organization of treatment and preventive care. The organization of medical care in rural areas, its volume and quality depend on the distance of medical institutions from the place of residence of patients, the staffing of healthcare facilities with qualified personnel and equipment, and the possibility of receiving specialized medical care. A feature of medical care for the rural population is the staged nature of medical care. There are three stages of providing medical care to rural residents:
1. Rural medical district - unites a rural district hospital, a medical outpatient clinic, paramedic and obstetric stations, paramedic stations, preschool institutions, paramedic health centers at enterprises, and a dispensary. At this stage, the rural population can receive qualified medical care. Qualified medical care is medical medical care provided to citizens for diseases that do not require specialized methods of diagnosis, treatment and the use of complex medical technologies.
2. District medical institutions - central district hospitals, district hospitals, district centers of state sanitary and epidemiological surveillance. At this stage, rural residents receive specialized medical care.
3. Republican (territorial, regional) medical institutions: Republican (territorial, regional) - hospitals, dispensaries, clinics, centers of state sanitary and epidemiological surveillance. At this stage, highly qualified and highly specialized medical care is provided.
102 First stage. Rural medical station includes the following medical institutions: a local hospital with an outpatient clinic (polyclinic) or an independent hospital (medical outpatient clinic, FAP, state farm (collective farm) medical dispensaries, pharmacy points, dairy kitchens. All medical and preventive institutions that are part of the rural medical district are close primary health care to the rural population and contribute to the successful solution of the tasks of providing this care in conditions of significant remoteness of settlements from district and central district hospitals.
The first stage is a rural medical station, where patients receive qualified medical care; the second stage - district medical institutions and the leading institution at this stage is the central district hospital, providing specialized medical care for its main types; the third stage - regional institutions and, in particular, the regional hospital, which provides highly qualified specialized medical care in almost all specialties.
A rural medical district is the first link in the system of medical care for the rural population. The composition of a rural medical district, in addition to a rural district hospital or an independent medical outpatient clinic, includes paramedic stations, seasonal and permanent nurseries, paramedic health centers at industrial enterprises and trades. The network of these institutions is built depending on the location and size of settlements, service radius, the economy of the area and the condition of roads. The average population in a medical area ranges from 5-7 thousand inhabitants with an optimal radius of the area being 7-10 km (the distance from the point village in which the SMS is located to the most remote settlement of the rural medical area). Depending on natural and economic-geographical factors, the size of medical districts and their population may vary.
All medical institutions that are part of the medical district are organizationally united and operate according to a single plan under the leadership of the chief physician of the local hospital.
The nearest medical institution to which rural residents turn for medical care is a paramedic-midwife station (FAP). The presence of paramedic-midwife stations is one of the features of rural healthcare, due to the need to bring medical care closer to the population in conditions of a large service radius of the local hospital and low density rural residents.
The recommended standard for the number of residents when organizing a FAP is 700 or more at a distance to the nearest medical facility of at least 5 km. If the distance to the nearest medical facility exceeds 7 km, then the FAP is organized in settlements with a population of 300-500.
The main tasks of the FAP are:
Providing first aid;
Carrying out sanitary and anti-epidemic measures to prevent and reduce morbidity and injury;
Timely and full implementation of doctor’s prescriptions;
Organization of patronage for children and pregnant women;
Systematic monitoring of the health status of war invalids and leading agricultural specialists;
Implementation of measures to reduce infant and maternal mortality.
The main medical institution in a rural medical district is a local hospital or an independent medical outpatient clinic (polyclinic).
Regardless of the capacity, any local hospital should provide outpatient and inpatient care to therapeutic and infectious patients, assistance during childbirth, medical and preventive care for children, emergency surgical and trauma care, and dental care.
There are four categories of rural district hospitals: I - 75-100 beds, II - 50-75 beds, III - 35-50 beds, IV - 25-35 beds. The specialization of beds in the SUB depends on their number. Thus, category I hospitals (75-100 beds) should have specialized beds for therapy, surgery, obstetrics, pediatrics, infectious diseases, and tuberculosis. As a rule, such hospitals are equipped with clinical diagnostic equipment. Category IV hospitals (25-35 beds) should have beds for therapy, surgery and obstetrics.
At a rural district hospital, as a department, there should be a mobile outpatient clinic to bring medical care closer.
The main functions of a rural medical station are:
Providing treatment and preventive care to the population;
Carrying out sanitary and anti-epidemic work.
Outpatient medical care is provided to the population of the rural medical district in the local hospital and at first aid stations. SUB doctors provide outpatient care to adults and children, provide home care and emergency care. A doctor in a village must be a general practitioner (family doctor); he must continue the traditions of the zemstvo doctor.
The following features can be highlighted in the organization of medical care in the SMS:
There is no clear time limit for outpatient appointments;
Visiting hours for patients should be scheduled at the most productive time for the population, taking into account the seasonality of agricultural work;
The ability to see a patient by a paramedic in the absence of a doctor for one reason or another;
House calls are made by a doctor only in the village, house calls in another locality of the rural medical station are carried out by a paramedic;
Duty in a hospital with the right to stay at home and mandatory information to staff about their location in case of emergency assistance.
103 Second stage. District medical institutions : central district and so-called zonal district hospitals located within the district with clinics and emergency departments, district dispensaries and other medical institutions
The second stage of medical care for rural residents:
District health care institutions: central district hospital, numbered district hospitals, district center of state sanitary inspection, dispensaries, medical units, etc.
The main link in the system of organizing medical care for rural residents is the central district hospital (CRH), which provides specialized care for its main types to residents of the entire region, respectively, of all rural medical districts.
The main tasks of the Central District Hospital:
Providing the population of the district and regional center with qualified specialized medical care;
Operational and organizational methodological management of healthcare institutions in the region;
Planning, financing and organization of material and technical supply of health care institutions in the region;
Development and implementation of measures to improve the quality of medical care and improve public health.
In addition to the central district hospital, located in the district center, there may be other district hospitals in the district, so-called “numbered” hospitals, which can serve as a branch of the central district hospital or specialize in one or another type of medical care. In the so-called assigned area, i.e. in the area located around the central district hospital, there is no rural district hospital; its functions are performed by the central district hospital itself.
The chief physician of the Central District Hospital is also the chief physician of the district. In his work on managing the health care of the district and the central district hospital, the chief physician of the Central District Hospital relies on his deputies;
For organizational and methodological work (usually he heads the organizational and methodological office of the Central District Hospital);
On childhood and obstetrics;
On the medical side;
Organizational forms of leadership:
1. Work of the Medical Council under the chief physician of the Central District Hospital.
2. Activities of the organizational and methodological office of the Central District Hospital.
3. Activities of district specialists.
The chief physician uses the organizational and methodological office and specialist doctors of the Central District Hospital for organizational and methodological management of healthcare institutions in the district, which is carried out by:
Organization of scheduled visits of specialist doctors to rural district hospitals for consultation and provision of practical assistance to doctors of these institutions on issues of treatment, diagnostic and preventive work;
Systematic study by employees of the organizational and methodological department of the main quality indicators of the work of medical institutions in the region - development on this basis of measures to improve the qualifications of medical personnel.
To improve the qualifications of doctors, clinical and analytical conferences, seminars, meetings, lectures and reports are organized and conducted on the basis of the central district hospital by district and regional specialists, at which doctors become acquainted with new methods of work of the best medical institutions in the region. Specialization and advanced training of paramedical workers of the FAP also takes place on the basis of the Central District Hospital.
Currently, the priority direction in the development of rural healthcare is to strengthen and improve outpatient care: new assigned therapeutic and pediatric areas are being organized, various types of mobile medical care are being developed, in particular, mobile medical teams, mobile dental offices and prosthetic laboratories. Much attention is paid to ambulance and emergency medical care in rural areas, staffing them with doctors and paramedical personnel, and equipping them with modern diagnostic and treatment equipment.
104 Third stage. Regional medical institutions : regional hospital with a consultative clinic and air ambulance department, dispensaries, dental clinic, psychiatric hospital, etc.
Third stage medical assistance to rural residents - regional health care institutions located in the regional center. The regional hospital is the main institution at this stage. It is a medical, scientific, organizational, methodological and educational center for healthcare in the region. The regional hospital performs the following main functions:
Providing the population of the region with a full range of highly qualified specialized advisory outpatient and inpatient medical care;
Organizational and methodological assistance to medical and diagnostic institutions of the region in their activities;
Coordination of treatment, preventive, organizational and methodological work carried out by all specialized medical institutions in the region;
Providing emergency medical care by means of air ambulance and ground transport with the involvement of medical specialists from various institutions;
Management and control of statistical accounting and reporting of health care facilities in the region;
Analysis and management of the quality of medical care provided in the regional hospital itself and in all medical institutions in the region;
Study and analysis of morbidity, disability, general and infant mortality of the region's population;
Participation in the development of measures aimed at reducing them;
Generalization and dissemination of best practices in the work of medical and preventive institutions in the region in the introduction of new organizational forms of providing medical care to the population, the use of modern methods of diagnosis and treatment;
Carrying out activities for the specialization and improvement of doctors and nursing staff of treatment and preventive institutions in the region;
Structural departments of the regional hospital: inpatient department, advisory clinic, treatment and diagnostic departments, offices and laboratories, organizational and methodological department with a department of medical statistics, department of emergency and planned advisory care.
The regional hospital should have a boarding house for patients coming from the regions, and a hostel for medical workers coming for various types of specialization.
Department of emergency and planned advisory medical care:
Provides emergency and planned advisory assistance on site on calls from the districts;
Provides transportation of patients to specialized medical institutions in the region and outside the region, urgent delivery of various medications and means necessary to save the lives of patients, as well as for carrying out urgent anti-epidemic measures;
Maintains constant contact with teams sent to provide medical assistance;
Organizational and methodological work is an integral part of the activities of all departments of the hospital. Each department serves as an organizational and methodological center for medical and preventive institutions in the region. This work is coordinated by the regional organizational and methodological department. hospital, which performs the functions:
Studies the volume and nature of the activities of medical institutions in the region;
Provides organizational, methodological, treatment and advisory assistance to regional health authorities and institutions;
Studies the health indicators of the region's population;
Organizes staff training;
Specialization and improvement of medical personnel is carried out in the regional hospital:
At regional seminars, conferences, ten-day events;
In workplaces with complete separation from work;
On intermittent courses with partial separation from work;
With the participation of specialists from the regional hospital on the basis of city and central district hospitals.
Currently, the following tasks of rural healthcare and ways to solve them can be identified:
1. Moving closer to urban health care facilities and improving the quality of outpatient care by:
Construction of rural medical outpatient clinics, work of general practitioners, family doctors;
Development of a network of assigned therapeutic and pediatric sites;
Expansion of mobile types of medical care.
2. Approaching specialized care by:
Strengthening the central district hospital;
Creation of inter-district specialized departments;
Creation of mobile dental offices and dental prosthetic laboratories.
105 MATERNAL AND CHILDHOOD PROTECTION system. state program “birth certificates” (see question 106)
Maternal and Child Health Care (MCCH) is a system of state public and medical measures that ensure the birth of a healthy child, the correct and comprehensive development of the younger generation, and the prevention and treatment of diseases of women and children. Objectives: rational nutrition and physical development. Group 6 - school age. objectives are to accustom children to health procedures, conduct sanitary and hygienic training, and promote a healthy lifestyle. Principles of organizing medical care for mothers and children. 1. The principle of a single pediatrician - that is, one doctor serves children from 0 to 14 years 11 months. 29 days. Since 1993, the child population can be served by two pediatricians under a contract. 2. The principle of locality. Pediatric area size 800 children. The central figure of the outpatient clinic network is the local pediatrician; Now the responsibility of the local pediatrician is increasing within the framework of compulsory health insurance (CHI) and criteria for individual responsibility (or personification) are being sought. 3. Dispensary method of work. All children, regardless of age, health status, place of residence and attendance at organized preschool and school institutions, must be examined as part of preventive examinations, which, like vaccination, is carried out free of charge. 4. The principle of unification, that is, antenatal clinics are united with maternity hospitals, children's clinics are united with hospitals. 5. The principle of alternating medical care: at home, in a clinic, in a day hospital. Only healthy children or convalescents come to the clinic for outpatient appointments; patients are served at home. 6. The principle of continuity. Carried out between the antenatal clinic, maternity hospital and children's clinic in the form of · prenatal care · visits to the newborn within 3 days after discharge from the maternity hospital · monthly examinations of the baby in the children's clinic for 1 year of life 7. for the antenatal clinic - the principle of early registration at the dispensary ( up to 12 months) 8. the principle of social and legal assistance, that is, there is a lawyer’s office in the children’s clinic and antenatal clinic 3.OMID institutions. Child welfare institutions. 1. Outpatient clinics: · children's clinic · children's dental clinic · children's consultation 2. inpatient: · children's somatic hospital · children's infectious diseases hospital · children's department in the structure of general somatic adult hospitals 3. Specialized · children's homes · children's sanatoriums · nurseries · children's dairy kitchens for developmentally retarded children Maternity protection· antenatal clinics · maternity hospitals · obstetric and gynecological departments of somatic hospitals · pathology departments of pregnant women of general somatic hospitals. All OMID institutions are divided into categories and types. Let's look at this using the example of categories of maternity hospitals. 1st category (high) 150 - 200 beds 2nd category - 101 - 150 beds 3rd category 81 - 100 beds 4th category - 60-80 beds
106 Maternity clinic, maternity hospital: their tasks, structure, performance indicators, state program “birth certificates”
Women's consultation. Objectives: 1. carrying out preventive measures to reduce complications in pregnancy 2. conducting preventive examinations of all women 3. dispensary registration of pregnant women, as well as patients with chronic gynecological diseases. 4. Organizational and methodological work 5. sanitary and hygienic education, promotion of a healthy lifestyle. Structure of the antenatal clinic: · registry · offices of district specialists (size of district 3400-3800 women aged 15 years and older). 6. Treatment room. 7. Room for psychopreparation for childbirth. 8. Lawyer’s office 9. dentist’s office 10. venereologist’s office Registration documentation for the antenatal clinic 1. individual card pregnant and parturient women 2. static card 3. certificate of incapacity for work 4. exchange card 5. emergency notice 6. control card of dispensary observations 7. diary of a clinic doctor Reporting forms for antenatal clinic. · Form 30 · Form 16 VN · report on pregnant women and women in labor (form No. 32, insurance indicators work of antenatal clinic). Quantitative indicators - see Adult clinic. Qualitative: 1. Share of late registration for dispensary registration 2. share of pathology in pregnant women 3. share of premature babies 4. maternal mortality (per 1000 population) 5. ante- and intranatal mortality 6. perinatal mortality 7. screening indicators for Rh- factor 8. incidence of gynecological diseases (general and with VUT)
A maternity hospital is a stationary institution that provides medical care to women in labor, and can be independent or combined with a antenatal clinic. Structural units maternity hospital: 1. Reception and access block, operating like a sanitary inspection room, examination room, sanitary treatment 2. physiological department 3. observation department 4. pregnancy pathology department The main measure of the activity of a maternity hospital is a bed-day - 1 day spent by one patient in one bed , this is both a reporting and a planning indicator. Maternity hospital registration documents:· history of childbirth · card of termination of pregnancy · card of those leaving the hospital · history of the development of the newborn · medical certificate of perinatal mortality Reporting documents of the maternity hospital: · form No. 14 (hospital report), according to it the following indicators are calculated: 1. bed turnover - the number of patients treated in one bed in 1 year 2. average bed occupancy - the average number of days that a bed was occupied (the ratio of the total number of bed days to the total number of beds. For a maternity hospital, this figure is 310 days. 3. Average length of stay of a patient in a bed (6 days in the physiological department) 4. maternal mortality 5. stillbirth rate 6. Perinatal mortality 7. frequency of caesarean section cases 8. expert analysis of each case of maternal mortality
Birth certificate program
The birth certificate program has been in effect since January 1, 2006 in all regions of Russia as part of the priority national project “Health,” which provides for a number of measures to improve the demographic situation. This program is aimed at increasing the interest of medical organizations in providing quality medical care. The main goal of birth certificates is to improve the quality of medical care for women during pregnancy, during childbirth and the postpartum period, as well as during preventive medical examinations of the child during the first year of life in medical organizations.
The birth certificate is an additional document financial support activities of medical organizations, giving the right to payment for medical care services provided by medical organizations to women during pregnancy, childbirth and the postpartum period, as well as during preventive medical examinations of the child during the first year of life. The certificate is issued to a pregnant woman registered for pregnancy starting from 30 weeks for a single pregnancy and from 28 weeks for a multiple pregnancy.
The birth certificate consists of six parts: registration (spoof), four coupons and the certificate itself:
· The spine of the birth certificate is intended to confirm its issue and remains in the medical institution that issued the certificate.
· Coupon No. 1 of the birth certificate is intended to pay for medical services provided by the antenatal clinic during pregnancy (3 thousand rubles for each woman who received the corresponding services). Transferred from consultation to the regional office of the Fund social insurance for payment.
· Coupon No. 2 of the birth certificate is used to pay for medical care provided to women during childbirth in maternity care institutions (6 thousand rubles for each woman who received the appropriate services). Transferred from the maternity hospital or maternity ward to the regional office of the Social Insurance Fund for payment.
· Coupon No. 3 consists of two parts. Coupon No. 3-1 of the birth certificate is intended for payment to health care institutions for services for the first six months of dispensary observation of a child (1 thousand rubles for each child registered during the first year of life at the age of up to 3 months and received during the next 6 months from the date of registration of the relevant services). Coupon No. 3-2 of the birth certificate is intended to pay health care institutions for services for the second six months of dispensary observation of the child (1 thousand rubles for each child who received the appropriate services). Coupons No. 3 are transferred from children's clinics to the regional branch of the Social Insurance Fund for payment.
· The birth certificate serves as confirmation of the provision of medical care to a woman during pregnancy and childbirth by health care institutions. A birth certificate (without coupons), which records the date of birth, weight and height of the baby, is issued to a woman upon discharge from the maternity hospital. The birth certificate is accompanied by a leaflet containing information about the rights and responsibilities of a woman within the framework of the implementation of the “Birth Certificate” program.
The regional branch of the Social Insurance Fund of the Russian Federation transfers funds to pay for the services of a medical organization on the basis of a concluded contract and submitted birth certificate coupons confirming the provision of services for medical care for women during pregnancy (coupon No. 1), medical care for women and newborns during childbirth and postpartum period (coupon No. 2), as well as dispensary (preventive) observation of the child during the first year of life (coupons No. 3-1 and 3-2);
107 Family Planning Center: tasks of structure functions
The Center for Family Planning and Reproduction provides specialized advisory, treatment and diagnostic assistance for reproductive health disorders associated with endocrinopathies in various age and sex groups ranging from 14 to 60 years old through an integrated approach, clear specialization, and standardization modern technologies, prevention, diagnosis and treatment of reproductive disorders.
The main objectives of the Family Planning Reproduction Center are:
· provision public policy in the field of reproductive health protection of the population of Omsk;
· carrying out a set of measures to prevent reproductive health disorders of the population of Omsk;
· reducing the time required to restore lost health by introducing modern technologies, prevention, diagnosis and treatment into practice;
· provision of a set of measures to protect the reproductive health of adolescents in Omsk.
The main function is to provide specialized outpatient treatment, diagnostic and advisory assistance on a wide range of problems related to the protection of reproductive health of the population:
· preconception preparation of pregnancy in women with endocrinopathies;
· provision of advisory assistance on family planning, contraception, prevention of unwanted pregnancy in women of fertile age suffering from endocrinopathies;
· medical, psychological and psychotherapeutic assistance to adolescents with developmental disorders of reproductive function;
· diagnosis and treatment of infertile marriage;
· providing assistance to women and men of transitional age in order to preserve and prolong their social functioning and improve the quality of life;
· detection of breast pathology;
· organizational and methodological work with antenatal clinics on reproductive health issues, analysis of the prevalence of abortion and contraception, development of proposals for improving this work;
· advanced training of specialists in health care facilities and health education on reproductive health issues.
work organization
In accordance with the tasks and functions, the Center for Family Planning and Reproduction provides the following specialized procedures:
1. "Gynecological endocrinology"
· provides consultative and diagnostic assistance in the direction of endocrinologists for patients with endocrinopathies;
· diagnosis of mammary gland pathology and referral to specialized hospitals; prevention of unwanted pregnancy, contraception in women with endocrine pathology.
2. "Pathological development of reproductive function in adolescents"(2 positions of gynecologists-juvenologists) provides consultation, diagnosis, treatment and rehabilitation for:
· delayed sexual development;
· premature puberty;
· obesity;
diseases of the thyroid gland;
· hyperandrogenemia;
· hypothalamic syndrome;
diabetes mellitus, anorexia nervosa
3. "Adolescent Reproductive Health"- carry out prevention, diagnosis, treatment and rehabilitation of inflammatory diseases of the pelvic organs, STIs, psychosomatic and psychological problems, unwanted pregnancy; selection of contraception, early gestation abortion, comprehensive preparation for termination of pregnancy for medical reasons and referral to a specialized hospital, health education on reproductive health issues.
4. "Andrology and Reproduction" carries out reception, diagnosis and treatment of puberty disorders in young men, prognosis of male fertility, male infertility, incl. with endocrinopathies, consultations with men of adolescence with diseases of the endocrine system (according to indications, consultations with specialists - a sexologist, psychotherapist, psychologist), a complex of examinations tions of men during IVF.
5. �Female infertility� provides consultation, diagnosis and treatment of female infertility, consultations on the prognosis of a woman’s reproductive function, preconception preparation of pregnancy in women with endocrinopathies, comprehensive preparation of women for IVF.
6. "Woman's health after 40" carries out reception, diagnosis, treatment and consultations of women in the pre- and postmenopausal periods and after oophorectomy.
7. Appointment with a psychotherapist
8. Reception of a psychologist
9. Appointment with a sexologist- specialized assistance is provided on issues of violations of sexual relations both in a married couple and individually.
108. Reproductive losses. Measures to prevent maternal and perinatal mortality and newborn morbidity. Improving perinatal services within the framework of the national project “Health”.
Reproductive losses are cases of maternal and perinatal mortality, as well as loss of products of conception due to abortion and ectopic pregnancy.
Reproductive health protection - methods, technologies and services that contribute to the formation, preservation and strengthening of reproductive health by preventing the elimination of disorders in the reproductive sphere throughout a person’s life;
Mortality refers to the process of population extinction, characterized by the statistically recorded number of deaths in a specific population over a certain period of time.
Maternal mortality is an indicator characterizing the number of women who died during pregnancy, regardless of its duration and location, or within 42 days after its end from any cause related to pregnancy, aggravated by it or its management, but not from an accident or sudden cause, correlated with the number of live births
The perinatal period is considered to be the period of time starting from 28 weeks of pregnancy and ending with the 7th day of life of the newborn. In turn, it is divided into antenatal (intrauterine), intranatal (childbirth) and postnatal (1st week of life). The perinatal mortality rate is calculated as the ratio of the sum of the number of stillbirths and the number of children who died in the first 168 hours of life to the number of live and stillborns, multiplied by 1000.
INFANT MORTALITY This is the number of children who died before one year old per 1000 live births. There are 2 ways to calculate infant mortality. The lowest infant mortality rate is in Japan (5 ppm), in the Scandinavian countries 6-7 ppm, in the USA - 10 ppm. The infant mortality rate is considered as an operational criterion for assessing the sanitary well-being of the population, the level and quality of medical and social care, and the effectiveness of obstetric and pediatric services. It is IMPORTANT to unify the concepts of “live birth”, “stillborn”, “fetus” (late abortion). calculate indicators such as: - early neonatal mortality (the ratio of the number of children who died in the 1st week of life in a given year to the number of live births in a given year, multiplied by 1000) (in Russia - 6-9‰); - late neonatal mortality (the ratio of the number of children who died at 2-4 weeks of life in a given year to the number of live births in a given year, multiplied by 1000); - neonatal mortality (the ratio of the number of children who died in the first 28 days of life in a given year to the number of those born alive in a given year, multiplied by 1000) (in Russia - 9-11‰); - postneonatal mortality (the ratio of the number of children who died between the ages of 29 days and 1 year to the difference between the number of live births and the number of deaths in the first 28 days of life, multiplied by 1000) (in Russia - 7-8‰). The perinatal period from 28 weeks of pregnancy to the 7th day of the newborn’s life. DIVIDED INTO antenatal (intrauterine), intranatal (childbirth) and postnatal (1st week of life). Factors influencing infant mortality: 1. Gender of the child: boys die more often than girls. Infant mortality is higher in premature babies. 2. Mother's age: the lowest infant mortality rate is for children born to mothers aged 20-30 years. The highest mortality among children is observed in firstborns and after 6-7 children. The healthiest 4th child. 3. Socio-ethnic factors (countries with high birth rates have high infant mortality).
MEASURES TO PREVENT MATERNAL AND PERINATAL MORTALITY AND INFANT MORTALITY
reducing the influence of risk factors: social-econ (welfare, labor conditions), social-biol (legacy, suffered from illness), social-hygiene (activity, nutrition, work-rest, medical literacy), environmental-hygienic (containing in soil and and water of all kinds), medical and organizational (low level of access to care, low level of qualified personnel, non-compliance of services with standards, low level of medical activity of patients). primary prevention (individual, group , population) - a set of measures aimed at preventing the appearance of certain diseases or deviations in the state of health. secondary prophylaxis - complete medical, social, health care, psychol and other measures, aimed at early detection of the disease and prevention of exacerbations and chronicity. tertiary profile - honey, psychol, pedagogy, social measures aimed at recovery or compensation for violations of physiol, social f org-ma, quality of life and work ability and healthy lifestyle.
National project “Health” (vaccination, diagnosis of congenital metabolic defects, financing of antenatal clinics and perinatal services)
The main goals of the priority national project “Health”:
1. Strengthening the health of the Russian population, reducing the level of morbidity, disability, and mortality;
2. Increasing the availability and quality of medical care;
3. Strengthening primary health care, creating conditions for the provision of effective medical care at the prehospital stage;
4. Development of preventive healthcare;
5. Meeting the population's need for high-tech medical care.
Legal basis medical activities for family planning and planning of human reproductive function.
Artificial insemination of a woman and implantation of an embryo are carried out in institutions that have received a license for this type of activity, with the written consent of the spouses (single woman).
A child born through artificial insemination has the same rights in relation to his parents as children born naturally. A husband who has consented to the artificial insemination of his wife with the help of a donor is registered as the father of the child born by her and cannot challenge paternity in court.
Information about artificial insemination and embryo implantation, as well as the identity of the donor, constitutes a medical secret. In the event of disclosure of information about specific persons participating in this procedure, medical personnel bear responsibility established by law.
A woman’s rights to information provided by a doctor performing medical intervention about the procedure of artificial insemination and embryo implantation, medical and legal aspects its consequences, the data of a medical genetic examination, external data and the nationality of the donor are enshrined in Art. 35 Basics
Artificial termination of pregnancy can be performed at the request of the woman (for up to 12 weeks of pregnancy), as well as for social reasons (for up to 22 weeks of pregnancy). The legislator highlighted one more point - medical indications and the woman’s consent. In this case, termination of pregnancy is carried out regardless of the stage of pregnancy.
The list of social indications has been approved by the Government of the Russian Federation. These may be social and economic living conditions, age, etc.
The list of medical indications for artificial termination of pregnancy is determined by the Ministry of Health of the Russian Federation. These include tuberculosis (all active forms), syphilis, HIV infection, malignant neoplasms of all locations in the present or in the past, acute and chronic leukemia, congenital heart disease, etc.
If a pregnant woman is diagnosed with a disease that is not listed in the list, but it poses a threat to the life or health of the pregnant woman or newborn, the issue of terminating the pregnancy is decided individually. Medical indications for termination of pregnancy are established by a commission consisting of an obstetrician-gynecologist, a doctor of the specialty to which the disease (condition) relates, and the head of a health care facility.
Artificial termination of pregnancy is carried out within the framework of compulsory medical insurance programs in institutions that have received a license for this type of activity, by doctors with special training.
Medical sterilization is permitted by law, i.e. surgical intervention, the result of which is the deprivation of a person’s ability to reproduce offspring. To carry it out, a written application from a citizen, an age of more than 35 years or the presence of at least two children is required, and if there are medical indications and the consent of the citizen, it is performed regardless of age and the presence of children. Medical sterilization is carried out for both men and women.
Medical indications for medical sterilization (determined by the Ministry of Health of the Russian Federation) include chronic ischemic heart disease, epilepsy, mental retardation, etc.
Medical sterilization is carried out in institutions of the state or municipal health care system that have received a license for this type of activity.
Illegal artificial insemination and embryo implantation, artificial termination of pregnancy, as well as medical sterilization entails criminal liability, established by law Russian Federation.
Clinic.
A polyclinic is a highly developed specialized medical and preventive institution that provides medical care to visiting patients, as well as patients at home, and carries out a complex of therapeutic and preventive measures to treat and prevent the development of diseases and their complications .
The main objectives of the clinic are: providing primary health care to the assigned population on a territorial basis, both in the clinic and at home to adults and children; organization and implementation of a set of preventive measures among the assigned population; organization and implementation of dispensary observation of the attached population; organizing and conducting events for sanitary and hygienic education of the attached population and promoting a healthy lifestyle.
Clinic structure
1 Registry
2 Prevention departments
3 Treatment and prevention units
4 Auxiliary diagnostic units
The main goals of the national healthcare project:
Strengthening public health, reducing morbidity, disability, and mortality rates;
Increasing accessibility and quality of medical care;
Strengthening primary health care, creating conditions for the provision of effective medical care at the prehospital stage;
Development of preventive healthcare;
Meeting the population's needs for high-tech types of medical care.
Primary medical and social care for the urban population is provided by outpatient clinics (territorial clinics serving the adult population) and institutions for the protection of motherhood and childhood (children's clinics and antenatal clinics).
The main organizational and methodological principles of the work of polyclinics and territorial medical associations (TMO) are locality (assigning a normative number of residents to a medical position) and the widespread use of the dispensary method (systematic active monitoring of the health status of certain contingents). The main planning and normative indicators regulating the work of polyclinics are: locality standard (1,700 people per 1 position of local therapist); workload norm (5 visits per hour at a clinic appointment and 2 when a therapist serves patients at home); staffing standard for local therapists (5.9 per 10,000 residents over 14 years of age).
The capacity of polyclinics is measured by the number of visits per shift (more than 1200 visits - category I, less than 250 visits - category V). TMOs, to a greater extent than polyclinics and antenatal clinics, meet the new principles of organization and financing of primary health care and social care. They can more effectively organize the work of family doctors (order of the Ministry of Health of the Russian Federation No. 237 of 08.26.92). In a number of TMOs, conditions have been created for family medical care, for example, joint work at the site of a therapist, pediatrician and gynecologist (obstetric-pediatric-therapeutic complex - APTC). In this case, the performance indicator is not the dynamics of attendance, but changes in the health status of the population (decrease in morbidity, disability, infant mortality, number of advanced cancer diseases, health status of patients from dispensary groups, etc.).
The main activities of primary health care institutions are: preventive work, medical examination, hygienic training and education of the population, promotion of a healthy lifestyle; diagnostic and treatment work (including examination of temporary disability); organizational and methodological work (management, planning, statistical recording and reporting, activity analysis, interaction with other health care institutions, advanced training, etc.); organizational and mass work.
The clinic is headed by a chief physician. The structure of the clinic includes: a registry office, a prevention department, treatment and preventive departments and offices, treatment and diagnostic units, an administrative and economic part, rehabilitation treatment departments, etc. The continuity of the work of the clinic and the hospital is assessed by the number of patients prepared for planned hospitalization and the exchange of documentation before and after treatment in the hospital.
Related information.
Medical and medicinal assistance to the rural population is based on the same principles as to the urban population, but the peculiarities of life of the rural population (nature of settlement, low population density, specific conditions of the labor process, economic activities and everyday life, poor quality or lack of roads) require the creation a special system for organizing assistance. The organization of medical and medicinal care in rural areas, its volume and quality depend on the remoteness of medical and pharmacy organizations from the place of residence of patients, the availability of qualified personnel and equipment, and the possibility of receiving specialized medical care. The provision of medical and medicinal assistance to the rural population takes place in medical and preventive institutions (HCI).
Primary health care for the population Stavropol Territory are provided by 28 independent outpatient clinics, 146 medical outpatient clinics, 72 district hospitals, 2 district hospitals, 25 central district hospitals (CRH), 15 city hospitals. There are about 300 paramedic and obstetric stations (FAP) operating in the region, which have the right to provide the population in rural areas with necessary medications (MP).
District treatment and preventive institutions provide qualified and specialized care with consultations with medical specialists in 10–12 specialties. Rural residents come to the clinic of the central district hospital (CRH) on referral from medical institutions of rural medical districts for functional examination, consultation and treatment by medical specialists. Regional medical and preventive institutions are difficult to access for the elderly population living in remote rural settlements, which complicates consultations and treatment with medical specialists.
Rural medical district (VMU) - unites a rural district hospital, a medical outpatient clinic, paramedic and obstetric stations (FAPs), paramedic stations, and households. SVU is a complex of medical institutions that provide the population of a certain territory with qualified medical care, provided according to a unified plan under the leadership of the chief physician of the local hospital. Qualified medical care is medical medical care provided to citizens for diseases that do not require specialized methods of diagnosis, treatment and the use of complex medical technologies. The number of IEDs in an area is determined by population size and distance to the area hospital. The average population in one rural medical area ranges from 7 to 9 thousand inhabitants with an optimal radius of the area being 7-10 km. The territory of a rural medical district usually includes 3-4 settlements. The structure of institutions included in the rural medical district is determined depending on the location and size of settlements, service radius, economic condition of the area, and road conditions.
The rural district hospital (RPH) provides outpatient medical appointments in the main specialties (therapy, surgery, dentistry, obstetrics, gynecology, etc.). In some cases (the absence of a doctor, his illness, vacation, a large number of calls), paramedics are also involved in outpatient appointments. A doctor or paramedic is obliged to provide systematic (active) visits to the patient at home. In recent years, the need for medical care at home has been increasing due to the increase in the proportion of elderly and senile people in the structure of the rural population, while the organization of care for the sick plays a special role. District hospitals are the leading medical institution in the rural medical area. The structure of rural district hospitals includes a hospital and an outpatient clinic. The capacity of a rural district hospital is determined by the number of hospital beds. SUB of the first category are designed for 75 - 100 beds, the second - for 50 - 75 beds, the third for 35 - 50 beds, the fourth for 25 - 35 beds. Currently, the basis for providing medical care to the rural population is rural district hospitals, mainly of categories 3 and 4. Depending on the capacity, local hospitals have a certain number of departments. The 1st category hospital has six departments: therapeutic, surgical, obstetrics and gynecology, pediatrics, infectious diseases, and anti-tuberculosis. In each subsequent category there is 1 less department. In a hospital of category 2 there is no anti-tuberculosis department, in category 3 there is no anti-tuberculosis and pediatric department, in category 4 there are therapeutic, surgical and obstetric-gynecological departments. The medical staff in a hospital is established based on the standard - one medical position for 20 - 25 beds, thus, in a fourth category hospital there are 3 departments
1 medical position. The medical staff for outpatient care is determined based on the recommended number of positions per 1000 rural residents (adults and children).
In remote rural areas, the FAP is a healthcare institution with a more preventive focus. It may be entrusted with the functions of a pharmacy for selling medicines and other pharmaceutical products to the population.
A paramedic-midwife station is a medical and preventive institution that is part of a rural medical district and carries out, under the leadership of a local hospital (outpatient clinic), a complex of therapeutic, preventive and sanitary and anti-epidemic measures in a certain territory. It is the primary (pre-hospital) health care unit in rural areas. As a rule, FAPs are located in the most remote settlements from the local hospital, which brings medical care closer to the rural population. Serves part of the territory of the rural medical district, reporting on medical issues to the local hospital or outpatient clinic (when there are no such institutions in the area - the central district hospital). On the staff of the FAP: the head is a paramedic (with the right to sell medicines); midwife (visiting nurse) and nurse. FAP staff provides patients with pre-medical care (within the competence and rights of a paramedic and midwife) at outpatient appointments and at home, consults them with a doctor, and carries out medical orders. Health care institutions in a rural settlement are part of a complex therapeutic area. At this stage, rural residents receive pre-medical, as well as basic types of medical care (therapeutic, pediatric, surgical, obstetric, gynecological, dental), but it is more problematic to provide medications. Territorial availability of medicinal care in the Stavropol Territory is provided by 910 pharmacies, 468 pharmacy points and 17 pharmacy kiosks. FAPs licensed to provide medicines are not always available to rural residents of remote settlements. Households located in remote settlements do not have the conditions and authority to sell medicines. The first medical institution to which a rural resident turns is FAPs, which are advisable to organize in settlements with a population of 700 or more, with a distance to the nearest medical facility of more than 2 km, and if the distance exceeds 7 km, then in settlements with the number inhabitants up to 700 people. This complicates the provision of medicines in sparsely populated areas where FAPs are not available.
The main problems of healthcare in rural areas are the predominance in its structure of low-power medical institutions, staff shortages, which, with insufficient funding and an extremely worn-out material and technical base of rural healthcare, makes it difficult to provide the rural population with medical care. The critical state of the material and technical base of rural healthcare facilities is clearly confirmed by the following data: the wear and tear of medical and technical equipment in rural healthcare facilities is 58%, the wear and tear of transport is 62%, about 90% of first aid stations and 70% of medical outpatient clinics do not have central heating, water supply and sewerage, in 25 % of FAPs do not have a telephone connection, only 0.1% of FAPs are provided with transport. More than half of rural healthcare facilities are in need of major repairs.
Currently, there is a process of consolidation of rural district hospitals, mainly hospitals of 1 and 2 categories are being built. Hospitals of categories 3 and 4 are being converted into medical outpatient clinics or departments of the central district hospital. Hospitals of categories 1 and 2 are better equipped with equipment and doctors. The negative side of consolidation is the distance of medical care from the rural population.
The ongoing restructuring of rural health care is being carried out slowly and has not only its advantages, but also disadvantages, including the increasing remoteness of rural residents from receiving medical and medicinal care, which reduces its accessibility.
Access to specialized medical care for rural residents is decreasing. High-tech (expensive) types of medical care are also inaccessible to rural patients. A significant problem for village residents is the provision of medicines. Defects in the provision of primary health care, the virtual cessation of work on disease prevention, medical examination of the population lead to an increase in cases of diagnosis of serious diseases in late, advanced stages, which contributes to high disability and mortality among rural residents.
The provision of the rural population with doctors (paramedics) and pharmacy workers compared to the urban population is 3.4 and 1.6 times less, respectively. In rural areas, the most promising is the development of general medical practice. The consolidation of qualified medical personnel and paramedical personnel is hampered by the low quality of life in rural areas, small wages, insufficient social support.
To bring specialized medical and medicinal care closer to rural residents, it is necessary to organize teams of on-site medical, outpatient and medicinal care. The visiting team must work according to a plan and schedule approved in accordance with the established procedure by the chief physician of the central district hospital and the head of the pharmacy organization. The team includes a therapist, pediatrician, dentist, obstetrician-gynecologist, children's nurse, laboratory assistants and pharmacists. If necessary, specialist doctors - neurologists, ophthalmologists, otolaryngologists, allergists, phthisiatricians, oncologists, rheumatologists - can be included in the visiting teams in accordance with territorially widespread diseases. Mobile teams must be provided vehicles equipped with portable equipment and equipment for examining and treating patients. The mobile team plays a significant role in the medical examination of the rural population.
In settlements of the Stavropol Territory with a population of less than 100 people that do not have FAPs, 19 households have been organized, equipped with dressings, immobilization materials and telephone communications, which are entrusted with the functions of providing first aid. But the question remains open, requiring improvement of the drug supply. The problem of drug supply in remote rural settlements can be solved by a delivery form of drug sales, which should mainly be intended for delivery of drugs to remote places where opening a permanently functioning pharmacy is impractical. To supply medicines to residents of areas remote from pharmacies and health centers over considerable distances, it is necessary to organize mobile pharmacy kiosks. The kiosk may have two rooms: for storing and selling medicines and for staff. Separate the storage room for medicines with a display case. The kiosk will create optimal conditions for proper storage of medicines thanks to a special system for maintaining a constant air temperature inside the body, regardless of fluctuations in external temperature. Also create conditions for staff to stay in a mobile kiosk for a long time - install a sleeping place and a cabinet for bed linen and personal belongings in the room, which can be used as a table and washbasin.
For each trip, select the appropriate assortment of medications. To practice mobile teams of doctors and specialists from pharmacy organizations, providing both medical and medicinal care to the rural population. The range and quantity of medications for a mobile pharmacy should be agreed upon with the doctors who are part of the visiting team. With this approach to providing medicines to the population of remote areas, savings on rent and other costs associated with organizing trade are possible. Cars equipped for pharmacies are 4-6 times cheaper than creating and equipping one pharmacy organization. That is why the delivery of medicines to remote rural settlements in sufficient quantity and guaranteed quality is urgent. The assortment of drugs can include about 1,200 items sold both without a doctor’s prescription and with a doctor’s prescription sold under the ONLS program, as well as medical and hygiene products. The range of drugs must be formed taking into account the provision of necessary drugs to benefit categories of the population, also taking into account the epidemic situation in rural settlements, existing chronic diseases among residents of a particular village, forecasting seasonal diseases, the age category of patients, etc. Ensuring the process is possible with the help of district regulatory authorities of the healthcare system. In addition, cooperation between doctors and pharmacists working in rural areas should take place at a fundamentally new, closer collegial level. At the same time, it is possible to solve the personnel problem and allow young specialists to provide pharmaceutical support to the rural population while living in urban areas. The operating hours of the exit point can be 8 hours (from 9 a.m. to 5 p.m.). The pharmacist can choose a route, taking into account the needs of rural residents for pharmaceutical services and set the time of arrival and period of stay in a specific rural locality. A circular route (movement from one settlement to another, with a return to the starting point after the end of the working day) will make it possible to rationally use working time and fuel with optimal provision of the serviced territory. In order to organize the distribution of drugs and pharmaceutical products, it is necessary to develop methodological recommendations. Undoubtedly, this is an opportunity to improve the availability of medicines and medical products for people living in rural and hard-to-reach areas, as well as to stop the supply of medicines to remote regions from non-specialized sources.
Bibliography
1. URL: http:// [email protected](date of access: 02/23/2016).
2. Voschanova Yu. A. Analysis of the availability of preferential drug care in the context of municipalities of the Stavropol Territory. / 785-788 pp. / Scientific journal “Fundamental Research No. 12 part 4”. / Moscow, 2011.
