3 levels of medical care. Inpatient obstetric care. Levels of care

Ilevel – healthcare institutions – legal entities providingspecialized medical care, including high-tech specialized care:

1. City Clinical Hospital No.: 1 named after N.I. Pirogov, 4, 7, 12, 13, 15 named after O.M. Filatova, 19, 20, 23 named after Medsantrud, 24, 29 named after N.E. Bauman, 31, 36, 40, 50, 52, 57, 59, 64, 67, 68, 70, 81, State Clinical Hospital named after S.P. Botkin, GKUB No. 47, MGOB No. 62, OKB.
2. GVV No.: 1, 2, 3, Maxillofacial Hospital for War Veterans.
3. Moscow city scientific and research center for the fight against tuberculosis.
4. Moscow Scientific and Practical Center of Otorhinolaryngology.
5. Research Institute of Emergency Medicine named after N.V. Sklifosovsky.
6. Scientific and Practical Center for Interventional Cardioangiology.
7. Center for Speech Pathology and Neurorehabilitation.
8. Center for Family Planning and Reproduction.
9. Central Research Institute of Gastroenterology.
10. Scientific and practical center for medical care for children with developmental defects of the craniofacial region and congenital diseases of the nervous system.
11. Research Institute of Emergency Pediatric Surgery and Traumatology.
12. Children's City Clinical Hospital No. 9 named after G.N. Speransky.
13. Morozov Children's City Clinical Hospital.
14. Tushino Children's City Hospital.
15. Children's City Clinical Hospital of St. Vladimir.
16. Izmailovo Children's City Clinical Hospital.
17. Children's Psychoneurological Hospital No. 18.
18. Children's City Clinical Hospital No. 13 named after N.F. Filatov.
19. Children's Infectious Diseases Hospital No. 6 UZ Northern Administrative District of Moscow.

II level – healthcare institutions – legal entities providing specialized medical care (without high-tech medical care):

1. City Clinical Hospital No.: 6, 11, 14 named after. V.G. Korolenko, 45, 51, 53, 55, 60, 61, 63, 71, 79;
   GB No.: 3, 9, 17, 43, 49, 54, 56, 72;
2. IKB No.: 1, 2, 3.
3. TKB No.: 3 im. prof. G.A. Zakharyina, 7; TB No.: 6, 11.
4. PKB No.: 1 named. ON THE. Alekseeva, 4 named after. P.B. Gannushkina, 12, 15;
   PB No.: 2 named. O.V. Kerbikova, 3 im. V.A. Gilyarovsky, 5, 7, 9, 10, 13, 14, 16;
   SKB No. 8 named after. Z.P. Solovyova (Clinic of Neuroses).
5. NKB No. 17.
6. Moscow Scientific and Practical Center for Narcology.
7. Center for medical and social rehabilitation with a department for permanent residence of adolescents and adults with disabilities with severe forms of cerebral palsy who cannot move independently and do not care for themselves.
8. Moscow Scientific and Practical Center for Sports Medicine.
9. Center for Regenerative Medicine and Rehabilitation.
10. Diagnostic Center (Women's Health Clinic).
11. Children's psychiatric hospitals No.: 6, 11.
12. Children's City Hospital for Rehabilitation No. 3.
13. Children's City Hospital No. 19 named after. T.S. Zatsepina.
14. Children's cardio-rheumatological sanatorium No. 20 "Krasnaya Pakhra".
15. Children's pulmonary sanatorium No. 39.
16. Children's tuberculosis sanatorium No. 64.
17. Children's bronchopulmonary sanatorium No. 23.
18. Children's sanatoriums No.: 44, 68.
19. Maternity hospitals No.: 1, 2, 3, 4, 5, 6 named after A.A. Abrikosova, 8, 10, 11, 14, 15, 16, 17, 18, 20, 25, 26, 27, 32.

III level – healthcare institutions – legal entities providing specialized and primary health care (institutions on which there are single- and multi-disciplinary specialized intermunicipal centers):

1. Ambulance and emergency medical care station named after A.S. Puchkov.
2. Scientific and Production Center for Emergency Medical Care.
3. City Hospital No. 8.
4. Gynecological hospitals No.: 1, 5, 11.
5. City clinic No. 25.
6. City consultative and diagnostic center for specific immunoprophylaxis.
7. Moscow City Center for Rehabilitation of Patients with Spinal Injury and Consequences of Cerebral Palsy.
8. Manual Therapy Center.
9. Family planning and reproduction centers No.: 2.
10. Diagnostic Clinical Center No. 1; Diagnostic centers No.: 2, 3, 4, 5, 6.
11. MSCh No.: 2, 6, 8, 13, 14, 15, 17, 18, 23, 26, 32, 33, 34, 42, 45, 48, 51, 56, 60, 63, 66, 67, 68.
12. Rehabilitation clinics No.: 1, 2, 3, 4, 6, 7.
13. HDPE No.: 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24.
14. Narcological Clinical Dispensary No. 5;
15. Anti-tuberculosis clinical dispensaries No.: 4, 12, 21;
    PTD No.: 2, 5, 6, 7, 8, 10, 13, 14, 15, 16, 17, 18, 20.
16. Oncological clinical dispensary No. 1,
    OD No.: 4.
17. Endocrinological dispensary.
18. Cardiological clinic No. 2.
19. Medical and physical education clinics No.: 4, 5, 6, 11, 13, 16, 17, 19, 27.
20. First Moscow hospice.
21. Hospices No.: 2, 3, 4, 5, 6, 7, 8.
22. Children's infectious diseases hospitals No.: 4, 5, 8, 12, 21.
23. Children's homes specialized for children with organic damage to the central nervous system and mental disorders No. 6, 9, 12.
24. Specialized children's homes No.: 20, 21, 23.
25. Tuberculosis sanatoriums No.: 5, 58.
26. Children's nephrological sanatorium No. 6.
27. Children's bronchopulmonary sanatoriums No. 8, 15, 29.
28. Children's tuberculosis sanatorium No. 17.
29. Children's cardio-rheumatological sanatoriums: No. 20 “Krasnaya Pakhra”, 42.
30. Children's psychoneurological sanatorium No. 30, 65, 66.

IVlevel – health care institutions – legal entities providing primary health care:

1. GP No.: 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 64, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, KDP No. 121, 122, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140, 141, 142, 143, 144, 145, 146, 147, 148, 149, 150, 151, 152, 153, 154, 155 , 156, 157, 158, 159, 160, 162, 163, 164, 165, 166, 167, 168, 169, 170, 171, 172, 173, 174, 175, 176, 177, 179, 180, 181, 182 , 183, 185, 186, 187, 188, 189, 190, 191, 192, 193, 194, 195, 196, 197, 198, 199, 201, 202, 203, 204, 205, 206, 207, 208, 209 , 210, 211, 212, 213, 214, 215, 217, 218, 219, 220, 221, 222, GPTP No. 223, 224, 225, 226, 227, 229, 230.
2. DGP No.: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42 (teen center), 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140, 141, 142, 143, 144, 145, 146, 147 , 148, 149, 150.
3. SP No.: 2, 3, 4, 5, 7, 8, 9, 11, 12, 13, 14, 15, 19, 20, 22, 23, 24, 27, 31, 32, 33, 34, 35, 48, 49, 50, 51, 53, 55, 56, 57, 60, 61, 62, 64, 65, 66, 67.
4. Chipboard No.: 1, 6, 10, 16, 21, 25, 26, 28, 29, 30, 36, 37, 38, 39, 41, 43, 44, 45, 46, 47, 52, 54, 58, 59, 63.
5. Residential complex No.: 9.
6. Children's sanatoriums No.: 9, 12, 13, 18, 19, 24, 25, 27, 33, 34, 45, 47, 48, 51, 56, 62, 67, 70.
7. Children's home no.: 2, 3, 4, 5, 13, 14, 15, 17, 19, 24, 25.
8. Rehabilitation treatment centers for children No.: 1, 3, 4, 5, 6, 7, 9.
9. Center for rehabilitation treatment for children with bronchopulmonary pathology.
10. Center for organizing rehabilitation treatment of specialized psychoneurological care for children No. 2.

January 22, 2020, Radio electronics. Microelectronics. Supercomputer technologies. Photonics The Development Strategy of the electronics industry of the Russian Federation for the period until 2030 has been approved Order No. 20-r dated January 17, 2020. The goal of the Strategy is to create a competitive industry based on the development of scientific, technical and human resources potential, optimization and technical re-equipment of production facilities, creation and development of new industrial technologies, as well as improvement of the regulatory framework to meet the needs for modern electronic products.

October 8, 2019, Relocation of emergency housing The government has submitted to the State Duma a bill on improving mechanisms for relocating citizens from dilapidated housing Order of October 7, 2019 No. 2292-r. Prepared in pursuance of the instructions of the President of Russia following a meeting with members of the Government on the issue of relocating citizens from emergency housing stock.

September 21, 2019, Emergency situations and liquidation of their consequences A program for the restoration of housing and infrastructure facilities damaged as a result of flooding in the Irkutsk region has been approved Order No. 2126-r dated September 18, 2019. The program for the restoration of housing, communication facilities, social, communal, energy and transport infrastructure, hydraulic structures, administrative buildings damaged or lost as a result of floods in the Irkutsk region includes 211 activities.

September 5, 2019, Quality of regional and municipal governance The Federal Statistical Work Plan has been supplemented with information on the effectiveness of the activities of senior officials and executive authorities of the constituent entities of the Federation Order of August 27, 2019 No. 1873-r. The Federal Statistical Work Plan includes 15 indicators for assessing the effectiveness of the activities of senior officials and executive authorities of the constituent entities of the Federation. The collection of statistical data on these indicators will make it possible to obtain a reliable assessment of the effectiveness of the activities of senior officials and executive authorities of the constituent entities of the Federation.

August 23, 2019, Social innovation. Non-profit organizations. Volunteering and volunteering. Charity Rules for the functioning of a unified information system in the field of volunteer development were approved Resolution of August 17, 2019 No. 1067. The decisions made are aimed at providing information and analytical support for volunteer activities and will allow the formation of a single platform for interaction between institutions of volunteer activity.

August 15, 2019, Plant growing The long-term strategy for the development of the Russian grain complex until 2035 has been approved Order No. 1796-r dated August 10, 2019. The goal of the Strategy is the formation of a highly efficient, scientifically and innovation-oriented, competitive and investment-attractive balanced system of production, processing, storage and sale of basic grains and leguminous crops, their processed products, guaranteeing food security in Russia, fully meeting the country’s internal needs and creating significant export potential.

August 14, 2019, Circulation of medicines, medical devices and substances A decision was made to conduct an experiment on the labeling of wheelchairs related to medical devices Resolution of August 7, 2019 No. 1028. From September 1, 2019 to June 1, 2021, an experiment will be conducted on labeling wheelchairs related to medical devices with identification means. The purpose of the experiment is to study the issues of the operation of the wheelchair marking system and monitor their turnover, organize effective interaction between government bodies, including control bodies, and participants in the turnover of wheelchairs.

Life expectancy for Russians reached 72 years this year, and infant and maternal mortality rates fell to historic lows. In many ways, these results were obtained due to the fact that the Ministry of Health changed its approach to the medical care system. The effectiveness of healthcare is no longer determined by the number of hospital beds, but by real indicators of population health.

Russian Health Minister Veronika Skvortsova, in her report at the final board of the ministry, said that over the past year, the life expectancy of Russians has increased by six months, reaching 72 years for the first time. “We managed to save 17.5 thousand more lives than in 2015. This became possible thanks to a decrease in mortality from all major causes,” the minister emphasized.

Another important achievement in 2016 was that infant and maternal mortality rates reached historic lows. In many ways, this became possible thanks to the transition to a three-level system of maternal and child health care and the formation of the third level of this system - a network of perinatal centers.

Today, all domestic healthcare is moving to a three-level system of medical care. This is not just another administrative reform, but a necessity caused by changes in medical technology over the past decades. Firstly, during this time, new treatment methods have emerged that make it possible to provide effective assistance to patients in severe, life-threatening conditions, and not to hope that “the body will cope” while the patient is under the supervision of doctors in a hospital bed. For example, diagnoses of “vascular accidents”: heart attack and stroke no longer sound like a death sentence. Nowadays, these are serious and dangerous diseases, but in most cases they are treatable. Secondly, modern technologies require modern equipment and qualified doctors who have a permanent practice of treating patients in their specialization. Therefore, to apply highly effective medical technologies, it is necessary to create specialized medical centers. Thirdly, the ability to diagnose and prevent diseases has significantly expanded, as a result of which the very philosophy of medical care has changed: the focus has shifted towards maintaining health and preventing disease.

A three-tier system of medical care is an adequate way to organize modern medicine. Each level solves its own problems. The first level is focused on primary admission, prevention and outpatient treatment. The second one works with more complex problems, often requiring inpatient treatment. The third is medical care, which is effective in the most difficult cases, many of which were previously considered hopeless.

The most important characteristic of primary health care is its territorial accessibility. For the first time since Soviet times, the Ministry of Health has approved mandatory requirements for the accessibility of medical organizations and monitors their implementation using a special geographic information system. For each region, tasks have been identified to create the missing primary level medical resources. The corresponding regional programs must be completed within the next two years. Already last year, 418 new FAPs (feldsher-midwife stations) and 55 offices of general practitioners were built and commissioned in small settlements.

The reform will have a beneficial effect on the Russian healthcare sector, Roman Alekhin, the founder of the OrthoDoctor federal network, is confident. According to the doctor, the three-tier system will allow “dividing the competencies” of medical institutions, which will lead to increased efficiency. This will be of particular importance for primary outpatient care, since it bears a very large burden and separating it from other stages will be beneficial for both doctors and patients.

The intensification of diagnostic and preventive measures is already yielding results. Thus, mass vaccination of the population made it possible to reduce the incidence of influenza tenfold. Vaccination of children and adults at risk against pneumococcal infection in 2016 covered more than 2.2 million people, including 1.8 million children. “This led to a significant reduction in the population’s mortality from pneumonia (by 10.6%), and in young children by 30%,” the minister said. Thanks to medical examination of the population in 2016, 55% of malignant neoplasms were detected at the first and second stages.

Essential hospital beds are now moving to the second tier of the health system. The consolidation of medical hospitals, of course, makes it possible to more effectively use and optimize available resources. But the main goal is to create the necessary conditions for the introduction of modern treatment methods into mass medical practice. Thus, the country is creating an emergency specialized medical care service for life-threatening conditions. Now it includes more than 590 vascular centers and 1.5 thousand trauma centers. The location of such centers allows patients to be delivered to them during the “therapeutic window”, when medical care is most effective. To ensure these deadlines, a unified centralized ambulance dispatch service must be created in all regions by the end of 2018. Using the GLONASS system, it will optimize the routing of patients and reduce the time of patient delivery to the hospital.

As for assistance to patients with cerebrovascular accidents, ten years ago we provided some kind of acceptable assistance only in separate centers and only at the expense of the personal qualities of individual people. There was no system,” Moscow’s chief neurologist, Professor Nikolai Shamalov, explains the situation. - Thanks to the vascular program, a unified network of specialized stroke departments has now been created throughout the country. Substantial money was allocated - both federal and regional - for repairs, purchase of equipment, personnel training, etc. As a result, we now widely use many modern diagnostic and treatment methods, and our stroke system is recognized by the World Stroke Organization as the best in the world.

The launch of specialized medical centers made it possible to reduce mortality from strokes by more than 34% over five years, and from injuries sustained in road accidents by 20%.

The third level of medical care is, for example, the already mentioned perinatal centers. These are large clinics, equipped with everything necessary according to modern standards, in which teams of specialists are created who are capable of providing medical care in the most difficult situations: heart defects, premature birth, developmental pathologies, etc. And they are not intended for the “elite categories”, but for everyone patients at high risk of complications. The active creation of perinatal centers began ten years ago. As part of the priority national project “Health,” 23 regional and two federal centers were created. The current program to organize 32 new perinatal centers should be completed by the end of this year.

The third level also includes the most modern - high-tech medical care (HTMC): angioplasty and stenting of arteries, technologically complex types of microsurgical operations, IVF, etc. Just 10-15 years ago, HTMC was a monopoly of the leading metropolitan research institutes. In 2013, 505 thousand patients already received it, and in 2016, 932 medical organizations across the country provided it to more than 963 thousand patients. According to the plans of the Ministry of Health, in 2018, over 1 million patients will receive VMP, which is close to the real needs of the population in this type of care.

Doctor of Medical Sciences, executive secretary of the Public Council for the Protection of Patients' Rights under Roszdravnadzor Alexey Starchenko is confident that the main contribution of the three-tier system is effective care for pregnant women:

I would positively note the development of a network of perinatal centers. Women with pathologies are provided with highly qualified care in these centers, and even intrauterine surgery is being developed. It is possible to operate in utero. This is a very important achievement.

However, there is still a lot to work on. The main task that the Ministry of Health has to solve, according to Alexey Starchenko, is the availability of medicines for HIV-infected people.

A separate issue is personnel. The Ministry of Health took up this long-standing problem in 2012, when, together with the regions, it developed a whole set of measures that have already borne fruit: the number of doctors, for the first time, slowly but went up, and the number of part-time workers, on the contrary, went down. Rural doctors have increased by 24 thousand. The number of doctors in the most scarce specialties has also increased - for example, oncology or anesthesiology.

At the beginning of the century, the average life expectancy in Russia was 65 years, now it is already 72. Modern medicine makes it possible to extend it to 80 years and longer. For this purpose, the entire domestic healthcare system is being adjusted to new medical technologies.

The organization of work in obstetric hospitals is based on a single principle in accordance with the current regulations of the maternity hospital (department), orders, instructions, instructions and existing methodological recommendations.

The structure of the obstetric hospital must comply with the requirements of building codes and rules of medical institutions; equipment - equipment list of the maternity hospital (department); sanitary and anti-epidemic regime - in accordance with current regulatory documents.

Currently, there are several types of obstetric hospitals that provide medical and preventive care to pregnant women, women in labor, and postpartum women: a) without medical care - collective farm maternity hospitals and first-aid posts with obstetric codes; b) with general medical care - local hospitals with obstetric beds; c) with qualified medical care - obstetric departments of the Republic of Belarus, Central District Hospital, city maternity hospitals; with multidisciplinary qualified and specialized care - obstetric departments of multidisciplinary hospitals, obstetric departments of regional hospitals, interdistrict obstetric departments based on large central district hospitals, specialized obstetric departments based on multidisciplinary hospitals, obstetric hospitals united with the departments of obstetrics and gynecology of medical institutes, departments of specialized research institutes. The variety of types of obstetric hospitals provides for their more rational use to provide qualified care to pregnant women.

Table 1.1. Levels of hospitals depending on the population of pregnant women

The distribution of obstetric hospitals into 3 levels for hospitalization of women depending on the degree of risk of perinatal pathology is presented in table. 1.1 [Serov V.N. et al., 1989].

The hospital of the maternity hospital - the obstetric hospital - has the following main divisions:

• reception and access block;
• physiological (I) obstetric department (50-55% of the total number of obstetric beds);
• department (ward) of pathology of pregnant women (25-30% of the total number of obstetric beds), recommendations: to increase these beds to 40-50%;
• department (wards) for newborns in the I and II obstetric departments;
• observational (II) obstetric department (20-25% of the total number of obstetric beds);
• gynecological department (25-30% of the total number of beds in the maternity hospital).

The structure of the premises of the maternity hospital should ensure the isolation of healthy pregnant women, women in labor, and postpartum women from the sick; compliance with the strictest rules of asepsis and antiseptics, as well as timely isolation of sick people. The reception and access block of the maternity hospital includes a reception area (lobby), a filter and examination rooms, which are created separately for women admitted to the physiological and observational departments. Each examination room must have a special room for sanitary treatment of incoming women, equipped with a toilet and shower. If there is a gynecological department in the maternity hospital, the latter must have an independent reception and access unit. The reception room or lobby is a spacious room, the area of ​​which (like all other rooms) depends on the bed capacity of the maternity hospital.

For the filter, a room with an area of ​​14-15 m2 is allocated, where there is a midwife's table, couches, and chairs for incoming women.

Examination rooms must have an area of ​​at least 18 m2, and each sanitary treatment room (with a shower, a toilet with 1 toilet and a vessel washing facility) must have an area of ​​at least 22 m2.

A pregnant woman or woman in labor, entering the reception area (lobby), takes off her outer clothing and goes into the filter room. In the filter, the doctor on duty decides which department of the maternity hospital (physiological or observational) she should be sent to. To correctly resolve this issue, the doctor collects a detailed medical history, from which he clarifies the epidemic situation in the mother’s home environment (infectious, purulent-septic diseases), the midwife measures body temperature, carefully examines the skin (pustular diseases) and pharynx. Women who do not have any signs of infection and have not had contact with infectious patients at home, as well as the results of testing for RW and AIDS, are sent to the physiological department and the department of pathology of pregnant women.

All pregnant women and women in labor who pose the slightest threat of infection to healthy pregnant women and women in labor are sent to the observation department of the maternity hospital (maternity ward of the hospital). After it has been established which department the pregnant or parturient woman should be sent to, the midwife transfers the woman to the appropriate examination room (I or II obstetric department), entering the necessary data in the “Register of admission of pregnant women in labor and postpartum” and filling out the passport part of the birth history. Then the midwife, together with the doctor on duty, conducts a general and special obstetric examination; weighs, measures height, determines the size of the pelvis, abdominal circumference, height of the uterine fundus above the pubis, position and presentation of the fetus, listens to its heartbeat, prescribes a urine test for blood protein, hemoglobin content and Rh status (if not on the exchange card) .

The doctor on duty checks the midwife’s data, gets acquainted with the “Individual Card of the Pregnant and Postpartum Woman,” collects a detailed history and identifies swelling, measures blood pressure in both arms, etc. For women in labor, the doctor determines the presence and nature of labor. The doctor enters all examination data into the appropriate sections of the birth history.

After the examination, the mother in labor is given sanitary treatment. The scope of examinations and sanitary treatment in the examination room is regulated by the general condition of the woman and the period of childbirth. Upon completion of sanitary treatment, the woman in labor (pregnant) receives an individual package with sterile linen: towel, shirt, robe, slippers. From the examination room of the first physiological department, the woman in labor is transferred to the prenatal ward of the same department, and the pregnant woman is transferred to the department of pathology of pregnant women. From the observation room of the observation department, all women are sent only to the observation room.

Pathology departments for pregnant women are organized in maternity hospitals (departments) with a capacity of 100 beds or more. Women are usually admitted to the department of pathology of pregnant women through the examination room of the obstetric department, and if there are signs of infection, through the examination room of the observation department into the isolated wards of this department. The corresponding examination room is led by a doctor (during the daytime, department doctors, from 13.30 - doctors on duty). In maternity hospitals, where it is impossible to organize independent pathology departments, wards are allocated as part of the first obstetric department.

Pregnant women with extragenital diseases (heart, blood vessels, blood, kidneys, liver, endocrine glands, stomach, lungs, etc.), pregnancy complications (preeclampsia, threatened miscarriage, fetoplacental insufficiency, etc.), and abnormal position are hospitalized in the department of pathology of pregnant women. fetus with a burdened obstetric history. In the department, along with an obstetrician-gynecologist (1 doctor for 15 beds), a maternity hospital therapist works. This department usually has a functional diagnostics room, equipped with devices for assessing the condition of the pregnant woman and the fetus (PCG, ECG, ultrasound scanner, etc.). In the absence of their own office, general hospital departments of functional diagnostics are used for examining pregnant women.

Modern medications and barotherapy are used for treatment. It is desirable that women be assigned to the small wards of this department according to their pathology profile. The department must be continuously supplied with oxygen. The organization of rational nutrition and medical and protective regime is of great importance. This department is equipped with an examination room, a small operating room, and a room for physical and psychoprophylactic preparation for childbirth.

The pregnant woman is discharged home from the pathology department or transferred to the maternity ward for delivery.

In a number of obstetric hospitals, pathology departments for pregnant women with a semi-sanatorium regime have been deployed. This is especially true for regions with high birth rates.

The Department of Pathology for Pregnant Women is usually closely associated with sanatoriums for pregnant women.

One of the criteria for discharge for all types of obstetric and extragenital pathology is the normal functional state of the fetus and the pregnant woman herself.

The main types of studies, the average examination time, the basic principles of treatment, the average treatment time, discharge criteria and the average length of hospital stay for pregnant women with the most important nosological forms of obstetric and extragenital pathology are presented in the order of the USSR Ministry of Health No. 55 of 01/09/86.

I (physiological) department. It includes a sanitary checkpoint, which is part of the general admission block, a delivery block, postpartum wards for the joint and separate stay of mother and child, and a discharge room.

The birth block consists of prenatal wards, an intensive observation ward, labor wards (delivery rooms), a manipulation room for newborns, an operating room (large operating room, preoperative anesthesia room, small operating rooms, rooms for storing blood, portable equipment, etc.). The birth block also houses offices for medical personnel, a pantry, sanitary facilities and other utility rooms.

The main wards of the maternity block (prenatal, delivery), as well as small operating rooms, should be in a double set so that their work alternates with thorough sanitary treatment. The rotation of the labor wards (delivery rooms) should be especially strictly observed. For sanitary treatment, they must be closed in accordance with the regulations of the Ministry of Health of the Russian Federation.

It is advisable to create prenatal wards with no more than 2 beds. It is necessary to strive to ensure that each woman gives birth in a separate room. For 1 bed in the prenatal ward, 9 m2 of space should be allocated, for 2 or more - 7 m2 for each. The number of beds in prenatal wards should be 12% of all beds in the physiological obstetric department. However, these beds, as well as the beds in the maternity wards (functional), are not included in the estimated number of beds in the maternity hospital.

Prenatal wards must be equipped with a centralized (or local) supply of oxygen and nitrous oxide and equipped with anesthesia equipment for pain relief during labor.

In the prenatal room (as well as in the delivery wards), the requirements of the sanitary and hygienic regime must be strictly followed - the temperature in the ward must be maintained at a level of +18 to +20 °C.

In the prenatal ward, the doctor and midwife establish careful monitoring of the woman in labor: general condition, frequency and duration of contractions, regular listening to the fetal heartbeat (with full water every 20 minutes, with empty water - every 5 minutes), regular (every 2-2U 2 hours) measurements blood pressure. All data is entered into the birth history.

Psychoprophylactic preparation for childbirth and drug pain relief are carried out by an anesthesiologist-resuscitator or an experienced nurse anesthetist, or a specially trained midwife. Modern anesthetic agents include analgesics, tranquilizers and anesthetics, often prescribed in various combinations, as well as narcotic substances.

When monitoring the birth process, the need arises for a vaginal examination, which must be performed in a small operating room with strict adherence to the rules of asepsis. According to the current situation, a vaginal examination must be carried out twice: upon admission of a woman in labor and immediately after the discharge of amniotic fluid. In other cases, this manipulation should be justified in writing in the birth history.

In the prenatal ward, the woman in labor spends the entire first stage of labor, during which her husband may be present.

The intensive observation and treatment ward is intended for pregnant women and women in labor with the most severe forms of pregnancy complications (preeclampsia, eclampsia) or extragenital diseases. In a ward with 1-2 beds with an area of ​​at least 26 m2 with a vestibule (airlock) to isolate patients from noise and with a special curtain on the windows to darken the room, there must be a centralized oxygen supply. The ward should be equipped with the necessary equipment, instruments, medications, functional beds, the placement of which should not interfere with an easy approach to the patient from all sides.

Personnel working in the intensive care unit should be well trained in emergency management techniques.

Light and spacious labor wards (maternity rooms) should contain 8% of all obstetric beds in the physiological obstetric department. For 1 birth bed (Rakhmanovskaya) 24 m2 of space should be allocated, for 2 beds - 36 m2. Birth beds should be placed with the foot end towards the window in such a way that there is a free approach to each of them. In the delivery rooms, the temperature regime must be observed (optimal temperature is from +20 to +22 °C). The temperature should be determined at the level of the Rakhmanov bed, since the newborn remains at this level for some time. In this regard, thermometers in delivery rooms should be attached to the walls 1.5 m from the floor. The woman in labor is transferred to the delivery room at the beginning of the second stage of labor (expulsion period). Multiparous women with good labor are recommended to be transferred to the delivery room immediately after the (timely) release of amniotic fluid. In the delivery room, the woman in labor puts on a sterile shirt, scarf, and shoe covers.

In maternity hospitals with an obstetrician-gynecologist on duty around the clock, his presence in the delivery room during childbirth is mandatory. During an uncomplicated pregnancy, a normal birth is performed by a midwife (under the supervision of a doctor), and all pathological births, including births with a breech presentation, are performed by a doctor.

The dynamics of the labor process and the outcome of childbirth, in addition to the birth history, are clearly documented in the “Inpatient Birth Recording Journal”, and surgical interventions are clearly documented in the “Inpatient Surgical Interventions Recording Journal”.

The operating unit consists of a large operating room (at least 36 m2) with a preoperative room (at least 22 m2) and an anesthesia room, two small operating rooms and utility rooms (for storing blood, portable equipment, etc.).

The total area of ​​the main premises of the operating unit must be at least 110 m2. The large operating room of the obstetric department is intended for operations involving transection.

Small operating rooms in the delivery block should be placed in rooms with an area of ​​at least 24 m2. In the small operating room, all obstetric aids and operations during childbirth are performed, except for operations accompanied by transection, vaginal examinations of women in labor, the application of obstetric forceps, vacuum extraction of the fetus, examination of the uterine cavity, restoration of the integrity of the cervix and perineum, etc., as well as blood transfusions and blood substitutes.

The maternity hospital should have a clearly developed system for providing emergency care to women in labor in the event of severe complications (bleeding, uterine rupture, etc.) with the distribution of responsibilities for each member of the duty team (doctor, midwife, operating room nurse, nurse). Upon a signal from the doctor on duty, all personnel immediately begin to perform their duties; establishing a transfusion system, calling a consultant (anesthesiologist-resuscitator), etc. A well-developed system for organizing emergency care should be reflected in a special document and periodically reviewed with staff. Experience shows that this greatly reduces the time before intensive care, including surgery.

The mother stays in the delivery room for 2-2 1/2 hours after normal birth (risk of bleeding), then she and the baby are transferred to the postpartum ward for a joint or separate stay.

In organizing emergency care for pregnant women, women in labor and postpartum, the blood service is of great importance. In each maternity hospital, by the corresponding order of the chief physician, a responsible person (doctor) is appointed for the blood service, who is entrusted with full responsibility for the state of the blood service: he monitors the availability and correct storage of the necessary supply of canned blood, blood substitutes, drugs used during blood transfusion therapy, serums to determine blood groups and Rh factor, etc. The responsibilities of the person in charge of the blood service include the selection and constant monitoring of a group of reserve donors from among employees. A large place in the work of the person responsible for the blood service, who in the maternity hospital works in constant contact with the blood transfusion station (city, regional), and in obstetric departments with the blood transfusion department of the hospital, is occupied by the training of personnel to master the technique of blood transfusion therapy.

All hospitals with 150 beds or more must have a blood transfusion department with a requirement for donor blood of at least 120 liters per year. To store canned blood in maternity hospitals, special refrigerators are allocated in the maternity unit, observation department and department of pathology of pregnant women. The temperature regime of the refrigerator must be constant (+4 °C) and be under the control of the senior operating nurse, who daily indicates the thermometer readings in a special notebook. For transfusion of blood and other solutions, the operating nurse should always have sterile systems (preferably disposable) ready. All cases of blood transfusion in the maternity hospital are recorded in a single document - the “Record of Transfusion of Transfusion Media”.

The ward for newborns in the delivery block is usually located between two delivery rooms (delivery rooms).

The area of ​​this room, equipped with everything necessary for the initial treatment of a newborn and providing him with emergency (resuscitation) care, when placing 1 children's bed in it, is 15 m 2.

As soon as the child is born, a “History of the Development of the Newborn” is started on him.

For the initial treatment and toileting of newborns in the maternity room, sterile individual bags must be prepared in advance containing the Rogovin bracket and umbilical cord forceps, a silk ligature and a triangular gauze folded in 4 layers (used for ligating the umbilical cord of newborns born from mothers with rhesus negative blood), Kocher clamps (2 pcs.), scissors, cotton swabs (2-3 pcs.), pipette, gauze balls (4-6 pcs.), measuring tape made of oilcloth 60 cm long, cuffs to indicate the mother’s last name , gender of the child and date of birth (3 pcs.).

The baby's first toilet is performed by the midwife who delivered the baby.

Sanitary rooms in the birth block are designed for processing and disinfection of oilcloth linings and vessels. In the sanitary rooms of the birth block, oilcloths and vessels belonging only to the prenatal and delivery wards are disinfected. It is unacceptable to use these rooms for processing oilcloths and vessels in the postpartum department.

In modern maternity hospitals, instruments are sterilized centrally, so there is no need to allocate a room for sterilization in the maternity unit, as well as in other obstetric departments of the maternity hospital.

Autoclaving of linen and materials is usually carried out centrally. In cases where the maternity ward is part of a multidisciplinary hospital and is located in the same building, autoclaving and sterilization can be carried out in a common autoclave and sterilization hospital.

The postpartum department includes wards for postpartum mothers, rooms for expressing and collecting breast milk, for anti-tuberculosis vaccination, a treatment room, a linen room, a sanitary room, a hygiene room with an ascending shower (bidet), and a toilet.

In the postpartum department, it is desirable to have a dining room and a day care room for postpartum women (hall).

In the postpartum physiological department, it is necessary to deploy 45% of all obstetric beds in the maternity hospital (department). In addition to the estimated number of beds, the department must have reserve (“unloading”) beds, constituting approximately 10% of the department’s bed capacity. The rooms in the postpartum ward should be bright, warm and spacious. Windows with large transoms should be opened at least 2-3 times a day for good and quick ventilation of the room. Each ward should have no more than 4-6 beds. In the postpartum department, small (1-2 beds) wards should be allocated for postpartum women who have undergone operations, with severe extragenital diseases, who have lost a child in childbirth, etc. The area of ​​single-bed wards for postpartum women should be at least 9 m2. To accommodate 2 or more beds in a ward, it is necessary to allocate an area of ​​7 m2 for each bed. If the size of the room area corresponds to the number of beds, the latter must be placed in such a way that the distance between adjacent beds is 0.85-1 m.

In the postpartum department, cyclicity should be observed when filling the wards, i.e., simultaneous filling of the wards with postpartum women of the “one day”, so that on the 5-6th day they can be discharged at the same time. If 1-2 women are detained in the ward for health reasons, they are transferred to “unloading” wards in order to completely vacate and sanitize the ward, which has been functioning for 5-6 days.

Compliance with cyclicity is facilitated by the presence of small wards, as well as the correctness of their profile, i.e. the allocation of wards for postpartum women who, for health reasons (after premature birth, with various extragenital diseases, after severe complications of pregnancy and surgical childbirth) are forced to stay in the maternity hospital for longer period than healthy postpartum women.

Rooms for collecting, pasteurizing and storing breast milk must be equipped with an electric or gas stove, two tables for clean and used dishes, a refrigerator, a medical cabinet, tanks (buckets) for collecting and boiling milk bottles, and breast pumps.

In the postpartum ward, the postpartum woman is placed in a bed covered with clean, sterile linen. Just as in the prenatal ward, an oilcloth lining is laid over the sheet, covered with a sterile large diaper; linen diapers are changed every 4 hours for the first 3 days, and 2 times a day on subsequent days. The oilcloth lining is disinfected before changing the diaper. Each maternity bed has its own number, which is attached to the bed. The same number is used to mark an individual bedpan, which is stored under the mother’s bed, either on a retractable metal bracket (with a socket for the bedpan) or on a special stool.

The temperature in the postpartum wards should be from +18 to +20 °C. Currently, most maternity hospitals in the country have adopted active management of the postpartum period, which consists of early (by the end of the 1st day) getting up of healthy postpartum women after an uncomplicated birth, doing therapeutic exercises and self-performing hygienic procedures by postpartum women (including toileting the external genitalia) . With the introduction of this regime in postpartum departments, the need arose to create personal hygiene rooms equipped with an ascending shower. Under the supervision of a midwife, postpartum women independently wash their external genitalia and receive a sterile padding diaper, which significantly reduces the time midwives and junior medical staff spend on “cleaning” postpartum women.

To conduct therapeutic gymnastics classes, the exercise program is recorded on tape and broadcast to all wards, which allows the exercise therapy methodologist and midwives on duty to observe the correctness of the exercises performed by postpartum women.

The organization of feeding of newborns is very important in the postpartum department. Before each feeding, mothers put on a headscarf and wash their hands with soap. The mammary glands are washed daily with warm water and baby soap or a 0.1% solution of hexachlorophene soap and wiped dry with an individual towel. It is recommended to clean the nipples after each feeding. Regardless of the means used to treat nipples, when caring for the mammary glands, it is necessary to take all precautions to prevent the occurrence or spread of infection, i.e. strictly adhere to the requirements of personal hygiene (keeping the body, hands, underwear, etc. clean). Starting from the 3rd day after birth, healthy postpartum women take a shower daily with a change of underwear (shirt, bra, towel). Bed linen is changed every 3 days.

If the slightest signs of illness appear, postpartum women (including newborns), who can become a source of infection and pose a danger to others, are subject to immediate transfer to the II (observation) obstetric department. After the mother and newborn are transferred to the observation department, the ward is disinfected.

II (observational) obstetric department. It is a miniature independent maternity hospital with an appropriate set of premises, performing all the functions assigned to it. Each observation department has a reception and examination area, prenatal, delivery, postpartum wards, wards for newborns (boxed), operating room, manipulation room, buffet, sanitary facilities, discharge room and other utility rooms.

The observation department provides medical care to pregnant women, women in labor, postpartum women and newborns with diseases that can be sources of infection and pose a danger to others.

The list of diseases that require admission or transfer of pregnant women, women in labor, postpartum women and newborns from other departments of the maternity hospital to the observation department is presented in section 1.2.6.

MINISTRY OF HEALTH OF THE ASTRAKHAN REGION

ORDER

On approval of a three-level system for organizing the provision of medical care

(as amended by Orders of the Ministry of Health of the Astrakhan Region dated December 27, 2016 N 1716r, dated January 20, 2017 N 48r, dated January 27, 2017 N 69r, dated 02/15/2017 N 134r, dated 03/31/2017 N 362r, dated 06/06 .2017 N 551р, from 07/10/2017 N 637r, from 07/28/2017 N 710r, from 08/15/2017 N 759r, from 09/25/2017 N 911r, from 12/29/2017 N 1317r, from 04/19/2018 N 422r, from 3 05/1/2018 N 567r, from 06/15/2018 N 616r, from 06/15/2018 N 617r, from 09/07/2018 N 883r, from 11/01/2018 N 1067r, from 02/01/2019 N 82r)

In order to structure the system of medical care in the Astrakhan region and streamline the activities of medical organizations by types, conditions and forms of medical care within the framework of execution:

1. Approve the attached Regulations on the three-level system for organizing the provision of medical care in the Astrakhan region (hereinafter referred to as the Regulations).

2. The heads of medical organizations subordinate to the Ministry of Health of the Astrakhan Region shall be guided in their work on organizing the provision of medical care by these Regulations.

3. To the director of the state budgetary healthcare institution of the Astrakhan region "Medical Information and Analytical Center" V.N. Shumelenkova. post this Order within three days from the date of signing on the official website of the Ministry of Health of the Astrakhan Region.

4. Entrust control over the implementation of this Order to the First Deputy Minister of Health of the Astrakhan Region S.A. Olkhovskaya.

5. The order comes into force on 01/01/2016.

Minister
P.G.DZHUVALYAKOV

Regulations on a three-level system for organizing the provision of medical care in the Astrakhan region

Approved
By order
Ministry of Health
Astrakhan region
dated December 16, 2015 N 1970 rub.

dated December 27, 2016 N 1716r)

1. In order to implement the recommendations of the Ministry of Health of the Russian Federation on the formation of an effective model of regional healthcare, creating uniformity of the conceptual apparatus and streamlining the application of legal, organizational and economic components in the management of the activities of medical organizations subordinate to the Ministry of Health of the Astrakhan Region within the framework of the implementation of the Federal Law of November 21. 2011 N 323-FZ “On the fundamentals of protecting the health of citizens in the Russian Federation”, a hierarchical system of medical care has been created in the Astrakhan region, according to which medical organizations or their divisions, depending on the main or primary activities and assigned functions, are distributed across three levels.

2. This three-level system for organizing the provision of medical care is integrated into the existing regional healthcare system while maintaining the classification by type, conditions and form of medical care, ensuring the ability to comply with the procedures for providing medical care, meeting the standards of medical care, maintaining the continuity and phasing of treatment measures, and further development patient routing schemes for various diseases and conditions.

3. Medical care, depending on the activities performed by medical organizations, is divided into 3 levels:

1) first level - provision of predominantly primary health care, including primary specialized medical care, as well as specialized medical care and emergency medical care (in central district hospitals, city, district, district hospitals, city clinics, emergency medical care stations) .

First-level medical organizations primarily carry out a set of activities, including primary prevention, early, most common and minimally costly diagnosis, treatment of diseases and conditions without the use of complex and resource-intensive methods, medical rehabilitation, palliative care, monitoring the course of pregnancy, promoting a healthy lifestyle and sanitary -hygienic education of the population.

2) the second level - the provision of predominantly specialized (with the exception of high-tech) medical care in medical organizations that have specialized intermunicipal (interdistrict) departments and (or) centers in their structure, as well as in dispensaries, multidisciplinary and specialized hospitals.

Second-level medical organizations primarily carry out a set of activities, including special diagnosis and treatment of diseases and conditions using common and individual complex resource-intensive, but not high-tech types, techniques, as well as medical rehabilitation.

3) third level - provision of predominantly specialized, including high-tech, medical care in medical organizations that provide high-tech medical care in a hospital setting and a day hospital at a hospital.

Third-level medical organizations use unique complex and resource-intensive methods with scientifically proven effectiveness for diagnosis and treatment, related to high-tech types of medical care.

4. A diagram of the relationship between types, conditions, forms, levels of medical care and medical organizations is presented in Appendix No. 1.

5. The distribution of medical organizations by level of medical care is presented in Appendix No. 2.

Appendix No. 1. Scheme of the relationship between types, conditions, forms, levels of medical care and medical organizations

Appendix No. 1
to the Regulations

Note:

MP - medical assistance

V - the provision of medical care is regulated by legal and regulatory acts

Providing medical assistance is possible only if necessary or if technology is available

Legal and regulatory acts do not regulate the provision of medical services

Appendix No. 2. Distribution of medical organizations by level of medical care

Appendix No. 2
to the Regulations

(as amended by Order of the Ministry of Health of the Astrakhan Region dated 02/01/2019 N 82р)

Abbreviations used:

GBUZ JSC - state budgetary healthcare institution of the Astrakhan region;

IVF - in vitro fertilization