Obstetric and gynecological care for the rural population

The peculiarities 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 (agriculture, animal husbandry, poultry farming), the large front of these works, their seasonality, determine the features of the organization of all medical care in the rural area, in including obstetric and gynecological. Obstetric and gynecological assistance to the rural population is provided by a complex of medical and preventive institutions. Depending on the degree of approach 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 providing obstetric and gynecological care. The first stage: the implementation of pre-medical and first medical aid. This stage is the rural medical area. It includes a rural district hospital with an outpatient clinic and a hospital, feldsher-obstetric points (FAP), and maternity hospitals. The location of the first stage is the periphery of the district.
The second stage: the implementation of qualified medical care. It includes district (numbered) and central district hospitals, which include obstetric and gynecological departments and women's clinics. The location of the second stage is the regional center.
The third stage: providing the rural population with highly qualified (specialized) obstetric and gynecological care. It includes a regional (regional, republican) hospital, which includes obstetric and gynecological departments and an antenatal clinic or an independent maternity hospital with an antenatal clinic. The location of the third stage is the regional (regional, republican) center.

Medical obstetric and gynecological care in a rural medical district is carried out by a general doctor - the chief doctor of a rural district hospital (if there are two doctors in a district hospital, one of them). Under his direct supervision, the midwife of the district hospital works, 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, a gradual reduction in the number of maternity beds in rural district hospitals and an increase in the number of beds in district and central district hospitals are being carried out. However, in a number of districts 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 has increased to eight, and the post 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 hospitalized in a local hospital (in the absence of a specialist obstetrician-gynecologist on the staff). Despite the presence on the periphery of the district of a medical hospital - a rural district hospital, the bulk of obstetric and gynecological care in a rural medical area refers to first aid, and it is carried out by midwives of the feldsher-obstetric station and the 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 the staff of the district hospital, the latter provides all medical and consultative assistance at the feldsher-obstetric station and in the collective farm maternity hospital.

FAP: structure of work

Feldsher-obstetric points (FAP) are provided for by the nomenclature of medical institutions. FAP is organized in a village with a population of 300 to 800 inhabitants in cases where there is no rural district hospital or outpatient clinic within a radius of 4–5 km. All FAP work is provided by a paramedic-midwife, midwife, nurse. The number of service personnel is determined by the capacity of the FAP and the size of the population served by it. The FAP provides for the following positions:
medical assistant - 1 position with a population of 900 to 1300 people; 1 position with a population of 1300 to 1800 people; 1.5 positions with a population of 1,800 to 2,400 people. and 2 positions with a population of 2400 to 3000 people;
nurse - 0.5 positions with a population of up to 900 people and 1 position with a population of over 900 people.

Depending on local conditions, the FAP may only have outpatient appointments or have maternity beds. In the latter case, along with outpatient care, inpatient care is also provided at the FAP. Due to the fact that the FAP provides medical assistance to the entire rural population, and not only to women, the premises in which it is located should consist of two halves: paramedic and obstetric.

Obstetric unit of FAP. The obstetric part of the feldsher-obstetric station (FAP) should have the following set of premises: an entrance hall, a waiting room and a midwife's office. FAPs with maternity beds, in addition to these premises, must have an examination room, delivery and postnatal wards. The FAP midwife carries out all the work on the organization and provision of obstetric and gynecological care to rural women within the radius of the service 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 the necessary medical and preventive measures, patronage of pregnant women, postpartum women and children under the age of 1 year; conducting health education among women; providing medical care for normal childbirth; identifying gynecological patients, referring them to a doctor and providing them with medical assistance as prescribed by a doctor. Significant assistance in the early detection of pregnant women is provided by household rounds of the population, carried out by a FAP midwife. In the observation of pregnant women, the midwife performs the entire bulk of the necessary research. So, at the first visit of a pregnant woman, the midwife collects a detailed history, general (heredity, past diseases, etc.) and special obstetric (menstrual, sexual, generative, lactation functions, gynecological diseases, etc.). From the anamnesis, the midwife finds out the features 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 of internal organs: cardiac activity, blood pressure measurement (on both hands), pulse analysis, urine for protein (by boiling). The midwife is currently studying the state of health of pregnant women on the basis of measuring height, body weight (in dynamics), the presence of edema, pigmentation, the state of the mammary glands and nipples, and the state of the abdominal press. Conducting a special obstetric examination, the midwife measures the external dimensions of the pelvis, by means of a vaginal examination, sets the gestational age and the internal dimensions of the pelvis. In the second half of pregnancy, it measures the height of the fundus of the uterus above the bosom, 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, general urine analysis, the pregnant woman is sent to the nearest laboratory. Here, a bacteriological study of the vaginal flora is carried out for the degree of purity, the discharge of the urethra, cervix and vagina for gonococcus, the reaction of vaginal secretions. X-ray examinations in pregnant women (fluoroscopy 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 allocated to high-risk groups and require the most close attention to them during pregnancy; in childbirth and the postpartum period, groups of increased risk are distinguished for cardiac pathology, bleeding in the postpartum and early successive periods, inflammatory-septic complications after childbirth, endocrinopathies - diabetes mellitus, obesity, adrenal insufficiency and other types of obstetric and somatic pathology. All individual cards of pregnant women belonging to the risk group 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 studies of gynecological patients also includes the collection of general and special gynecological anamnesis. The study of the state of health of women is currently carried out on the basis of a general clinical examination, similar to the examination of pregnant women. Special gynecological examination includes two-handed and instrumental (examination in mirrors) examination. A bacterioscopic examination of the discharge of the urethra, cervix and vagina for gonococcus is carried out using methods of provocation, according to indications - the Borde-Zhangu reaction; examination of a vaginal smear for cell atypia; research on tests of functional diagnostics.

If a woman needs a biochemical blood test for cholesterol, bilirubin, sugar, residual nitrogen and urine tests for acetone, urobilin, bile pigments, she is sent to the nearest multidisciplinary laboratory. Women and married couples with a history of hereditary diseases or children with deformities of the central nervous system, Down's disease, cardiovascular defects are sent for examination, including for the determination of sex chromatin, to specialized medical genetic centers. While monitoring pregnant women, the FAP midwife is obliged to show each of them to the doctor. If a woman's pregnancy is proceeding normally, then her meeting with a doctor is carried out at her first scheduled visit to the FAP. All pregnant women who show 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 re-examinations. In the second half of pregnancy, it is especially necessary to carefully monitor the possible development of late toxicosis, for which it is necessary to pay attention to the presence of edema, the dynamics of blood pressure and the presence of protein in the urine. It is very important to monitor the dynamics of the weight of the pregnant woman.

Organization of patronage work. An obligatory section of the midwife's work in monitoring pregnant women should be conducting classes on psycho-preventive preparation for childbirth. In organizing monitoring of pregnant women in the countryside, as well as in the city, patronage work is very responsible. Patronage of pregnant women 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 sets a specific goal. First of all, it is an acquaintance with the living conditions of a woman. Knowing the peculiarities of the life of each family (housing conditions, family composition, level of material security, degree of culture, including health literacy), it is easier for a midwife to monitor the health of the population. The purpose of patronage is the need to find out the state of health of a pregnant woman who does not appear at the 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, draws attention to the presence of edema, and measures blood pressure. With long periods of pregnancy, it measures the circumference of the abdomen and the height of the uterine fundus, determines the position of the fetus. After making sure that there are no deviations from the normal development of pregnancy, the midwife appoints the woman a deadline for the next examination. In the presence of the slightest signs of complications of pregnancy, the midwife invites the pregnant woman to an appointment with the doctor or informs the doctor about it, who decides on the possibility of treating the pregnant woman at home or the need for her hospitalization. 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 the patronage may be the desire to make sure that the woman fulfills the doctor's prescriptions correctly, the need to conduct additional research (laboratory, measure blood pressure).

The FAP midwife is obliged to carry out patronage of 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 a 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 - supervision at home - 2 times a month; 6-12 months of life - observation at home - once a month. In addition, a child under 1 year old must be examined by a pediatrician at a FAP at least 1 time per 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 patronage.

The midwife's patronage work is strictly planned. The plan provides for the days of visiting villages and villages. In a special notebook, a record of patronage work is kept, all visits by women and children are recorded. The midwife enters all the advice and recommendations in the home visiting nurse's notebook (patronage sheet) for subsequent verification of their implementation.

Mobile teams from the Central District Hospital. The bulk of women from rural areas give birth in medical obstetric departments of the Central District Hospital. If necessary, inpatient qualified medical care is provided to rural women in large republican, regional, regional maternity hospitals. To bring ambulatory and polyclinic medical care closer to women in rural areas, mobile teams from the Central Regional Hospital are created, which come to the feldsher-obstetric stations according to the approved schedule. The mobile team includes an obstetrician-gynecologist, pediatrician, therapist, dentist, laboratory assistant, midwife, children's nurse. The composition of the mobile team of doctors and paramedical workers is brought to the attention of the heads of the feldsher-obstetric centers.

Carrying out preventive periodic examinations. The paramedic and midwife are required to have a list of women in their area who are subject to preventive and periodic examinations. Practically healthy women with a successful obstetric history, a normal course of pregnancy in the period between team visits are observed by a FAP midwife or a local hospital, and are sent for childbirth to the nearest local or district hospital. With a group of women who are contraindicated in carrying a pregnancy, an obstetrician-gynecologist and a midwife conduct conversations about the harm to their health of pregnancy, possible complications of pregnancy and childbirth, teach them to use contraceptives, and recommend intrauterine contraceptives. The obstetrician-gynecologist of the visiting team, upon re-departure, checks the obstetrician-gynecologist's fulfillment of appointments and recommendations. Household visits by a midwife provide significant assistance in the early detection of pregnant women. 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 visit a consultation with all analyzes and conclusions of doctors 7-10 days after the first visit, and then visit a 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 visit a consultation about 14-15 times. In case of a woman's illness or 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 attend the consultation carefully during prenatal leave.

Hospitalization of pregnant women in medical hospitals. 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, is very important in the work of a FAP midwife. Pregnant women with a narrow pelvis (with external conjugate less than 19 cm), abnormal position of the fetus and breech presentation, immunological incompatibility of the blood of the mother and the fetus (including a history), extragenital diseases, with the appearance of bloody discharge from the genital tract , edema, the presence of protein in the urine, increased blood pressure, excess weight gain, when multiple pregnancies are 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 way of transporting her (ambulance, air ambulance), associated transport, and also correctly decide on the institution where this pregnant woman should be hospitalized. A correct assessment of the state of health of a pregnant woman will allow avoiding multi-stage hospitalization, and immediately identify the patient to that obstetric hospital where there are all conditions for providing her with full medical care.

Delivery at FAP. At the feldsher-obstetric station, only normal (uncomplicated) childbirth is provided. In cases where a complication arises 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 hospital. In this case, it is very important to resolve the issue of means of transportation. It must be remembered that women with an unseparated placenta, preeclampsia and eclampsia, as well as with a threatening rupture of the uterus, cannot be transported. If a woman with an unseparated placenta needs transportation due to certain complications of pregnancy, the FAP midwife is obliged, first of all, to perform manual separation of the placenta and, in case of a contracted uterus, to transport the woman.

If it is impossible to provide a 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 for further action should be drawn up with him. Providing emergency first aid to a pregnant and giving birth woman, the FAP midwife has the right to perform the following obstetric operations and benefits: turning the fetus on the leg with full opening of the uterine pharynx and whole or just released waters, 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 rupture of the perineum or perineotomy). With bleeding in the early postpartum period, the midwife must exclude rupture of the tissues of the birth canal. Complications arising during childbirth require from the midwife, in addition to urgently calling a doctor, clear organizational actions, on which the outcome of childbirth largely depends. The midwife should be fully proficient in the primary methods of resuscitation of newborns born with asphyxiation.

Maintaining documentation for FAP. It is very important in the work of a FAP midwife to maintain thorough documentation. For each pregnant woman who applies to the FAP, an “Individual card of a pregnant woman in childbirth” is filled in (f-111 / y). When obstetric complications or extragenital diseases are detected, a duplicate of this card is filled in, which is transferred 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 match 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 assigning a next visit to a pregnant woman, the midwife places her card in the box with the corresponding day of the month, that is, the day she needs to come to the appointment. Before starting work, the midwife takes out all individual cards from the cell corresponding to the day of reception and prepares them for reception - they will check the correctness of the records, the presence of the latest tests. Finishing the reception of the pregnant woman, he assigns her the day of the subsequent appearance and places the card of this pregnant woman in the box with a mark corresponding to the day of the month for which she is scheduled to appear. At the end of the appointment, by the number of cards remaining, it is easy to judge about pregnant women who did not show up for an appointment on the day assigned to them. The midwife places these cards in the 32nd cell of the box marked "Patronage". The midwife then visits (patronizes) all women who do not attend. All cards of those who have given birth and who are subject to dispensary observation until the end of the postpartum period are placed in the 33rd cell with the mark "Postpartum women".

For each woman in labor, the "History of childbirth" is filled in (f-099 / y). All women who gave birth in the FAP are registered in the birth register (f-098 / y). In addition to these documents, the FAP keeps a diary-notebook of records of pregnant women (f-075 / y) and a diary (f-039-1 / y). When a pregnant woman (after 28 weeks of pregnancy) or a postpartum woman is sent to a medical obstetric hospital, she will be given an "Exchange card" (account number 113). If a pregnant woman is hospitalized before 28 weeks, she will be given an extract from the medical history (study f. No. 27). When she is discharged from the hospital, she receives an extract from the medical history in the same form, which is given to her by the FAP midwife.

Organization and conduct of preventive examinations of rural women. An important section in the work of a midwife of a feldsher-obstetric station is the organization and conduct of preventive examinations of women. It is advisable to carry out preventive examinations of rural women in the autumn-winter period in order to complete the rehabilitation of the identified patients before the start of spring field work. All work on the organization of preventive examinations is supervised by the district obstetrician-gynecologist and the chief midwife of the district. A preliminary plan for conducting inspections is drawn up, which indicates the place where the inspection will be carried out, the calendar dates of inspections for each locality. Preventive examinations are carried out by FAP midwives who have undergone special training and instruction. For a successful preventive examination, the midwife must first make a home visit, the tasks of which are to explain to women the purpose of the examination, the method for conducting it, and the place of examination.

The purpose of preventive examinations is the early detection of precancerous, neoplastic, inflammatory and so-called functional diseases of the genital organs in women and the appointment, if necessary, of appropriate treatment. Preventive examinations also make it possible to identify among the organized part of the female population occupational hazards that affect the organs of the genital area, and to develop measures to eliminate them. Direct examination of women consists of two sequentially conducted procedures - examination of the external genitalia, the vagina and the vaginal part of the cervix (using mirrors) and two-handed examinations in order to find out the state of the internal genital organs.

During preventive examinations, objective diagnostic methods are used: cytological examination of the vaginal discharge, "prints" from the cervix, colposcopic examination. To carry out laboratory studies, material is taken from various departments of the woman's urogenital apparatus:
smears from the urethra and cervical canal for bacteriological examination for Neisser's gonococci and flora. The material obtained from the urethra is applied to the glass slide in the form of a circle, and from the cervical canal - in the form of a stroke in the longitudinal direction;
a smear from the posterior fornix of the vagina to determine the degree of purity of the vaginal contents is taken after the introduction of the speculum and using a stick with cotton wound at the end. The smear is applied to the slide in the longitudinal direction in the form of a stroke;
a smear from the lateral wall of the vagina for hormonal cytodiagnostics is also taken after the introduction of the speculum and using a stick with cotton wool wrapped around its end. The smear is applied in the form of a stroke along the glass;
a scraping smear from the erosion surface of the cervix is ​​obtained with a spatula and applied with a stroke across the slide; a scraping swab from the cervical canal is taken with a Volkmann spoon and applied to the glass in the form of a circle (or several circles).

At the slightest suspicion of a disease that has arisen in a midwife performing a routine examination, a woman should be immediately referred to a doctor. In carrying out preventive examinations, it is very important to carefully register and record all examined women, for which a list of persons subject to targeted medical examination for identification is drawn up (form No. 048 / y). For registration and accounting of women subject to active dispensary observation, dispensary observation control cards (form No. 030 / y) are entered on them.

Another institution that provides pre-medical obstetric and gynecological care in rural areas is the collective farm maternity hospital. In a collective farm maternity hospital, the following premises must be provided: a vestibule, a reception room, a delivery room (10–12 sq. M.), A postnatal ward (6 sq. M. For 1 mother's and children's bed), a kitchen, and a toilet. Each kolkhoz maternity hospital has 2 to 5 beds (at the rate of 1 bed per 1000 population). A collective farm maternity hospital is located at a distance of 6–8 km from the rural medical area to which it is attached. With good transport conditions, this distance can be increased to 10-15 km. Collective farm maternity hospitals are served by a midwife, whose duties are similar to those of a FAP midwife. If in one village near the FAP there is a collective farm maternity hospital and there is no need for an independent staff in terms of the volume of its work, the service of the latter is entrusted to the FAP midwife.

Occupational safety issues in the work of obstetric and gynecological service. In the work of the obstetric and gynecological service in the countryside, at all its stages, a lot of space is occupied by issues of labor protection of female workers in agricultural production. Agricultural work has its own characteristics, the main of which are seasonality, the implementation of various production operations in a short time in any weather conditions. This requires considerable effort and stress from a person, which inevitably leads to violations of the regime of work and rest. Agricultural workers experience additional adverse effects of such industrial factors as noise, vibration, dust, contact with pesticides (pesticides) and mineral fertilizers. The main work on the implementation of measures aimed at protecting the labor of rural residents is carried out by hygienists. But the obstetric and gynecological service should also take part in this work, since unfavorable production factors 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 unfavorable factors of agricultural production. This is achieved by introducing mechanization and automation of labor-intensive processes, removing women from night work and work with pesticides, from work in high dust 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 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, a safety engineer. In exercising control over the observance of all requirements for labor protection of collective farmers, a great responsibility lies with the nursing staff (the senior midwife of the district and the midwife of the FAP).

Equipping a FAP midwife's office. The midwife performs a significant amount of work at the feldsher-obstetric station, so the midwife's office must be equipped with scales, a gynecological chair, mirrors, sterilizers, a measuring tape, an obstetric stethoscope, a pelvis meter, everything necessary for taking smears for cytological examination. To provide emergency obstetric care at the feldsher-obstetric station, there must be an obstetric bag equipped with everything necessary for delivering and handling a newborn.

Equipping an obstetric bag. 1. Instrumentation, care items and dressings.
Scalpel - 1
Mouth dilator - 1
Anatomical forceps - 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
Litter - 2
Lining oilcloths - 2
Blankets:
children - 1
adults - 1
Cold baby diapers - 2
Iodine sticks - 10 pcs.
Compressed cotton wool - 50 g
Bandages 7 mx 5 cm - 2 pcs.
Bandages 10 mx 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
Bags for processing umbilical cord remains ("umbilical bags") - 2
Cloth centimeter - 1
Delivery package ("generic package") - 1
Soap - 1
Surgical gloves - 1 pair
Sterile surgical silk in ampoules No. 8 - 1 amp.
Medical gowns - 2 pcs.
Harness - 1
Tonometer - 1
Eye pipette - 1
Beaker - 1
Esmarch's rubber mug - 1

Medicines.
Atropine sulfate (9.1% solution in 1 ml ampoules) - 1 amp.
Platyphyllina hydrotartrate (0.2% solution in 1 ml ampoules) - 1
Analgin (50% solution in ampoules of 2 ml) - 2
Dibazol (1% solution in 1 ml ampoules) - 6
Papaverine hydrochloride (2% solution in 2 ml ampoules) - 2
Cordiamin (in ampoules of 2 ml) - 3
Caffeine-sodium benzoate (10% solution in 1 ml ampoules) - 3
Calcium gluconate (10% solution in 10 ml ampoules) - 1
Calcium chloride (10% solution in 10 ml ampoules) - 2
Lobelin (1% solution in 1 ml ampoules) - 1
Glucose (40% solution in ampoules of 20 ml) - 2
Epinephrine (0.1% solution in 1 ml ampoules) - 2
Ephedrine (5% solution in 1 ml ampoules) - 1
Diphenhydramine (1% solution in 1 ml ampoules) - 2
Eufillin (2.4% solution in 10 ml ampoules) - 1
Novocaine (0.5% solution in ampoules of 5 ml) - 2
Pituitrin for injection in 1 ml ampoules - 2
Validol 0.06 g - 10 tubes.
Nitroglycerin 0.5 mg - 1 tube
Valerian tincture 30 ml - 1 fl.
Alcohol solution of iodine (5%) - 1
Hydrogen peroxide (3% solution of 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 U - 2 fl.

Prevention of pregnancy, anti-abortion propaganda. Midwives in rural areas are faced with the task of fostering in women a negative attitude towards abortion as an operation that can injure a woman, often entailing gynecological and other diseases. In addition, for older women in the presence of Rh-negative blood, signs of infantilism, it is necessary to especially persistently explain the importance of maintaining the first pregnancy. FAP midwives independently conduct anti-abortion propaganda on the territory of the serviced area, receiving appropriate organizational and methodological instructions from obstetricians-gynecologists of central regional and district hospitals.

Of great importance in the promotion of abortion prevention is the question of modern contraceptives, the peculiarities 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 should identify the following groups of women: those who want to terminate a pregnancy; those who came to the consultation after an abortion; postpartum women after discharge from the obstetric hospital; who applied for a preventive examination; getting married.

Of particular importance is the use of oral contraceptives, since, provided they are taken correctly, they are among the most effective. Hormonal contraceptives are synthetic analogs of the female sex hormones estrogen and progesterone and their derivatives. When they are introduced into the woman's body, a state of pregnancy is created, the so-called "pseudopregnancy", which ensures sterility. The main mechanism for ensuring sterility using oral contraceptives is to suppress ovulation, that is, the maturation and release of a mature egg from the ovary.

The advantage of using oral medications. The midwife should explain to women the positive aspects of taking hormonal contraception:
mitigation of premenstrual tension;
beneficial effect on women with an irregular menstrual cycle that becomes more regular, and menstrual bleeding often decreases; there is information about the improvement in the condition of women suffering from iron deficiency anemia;
reducing the risk of pelvic inflammatory disease among women using oral contraceptives;
improvement of the condition in diseases of the sebaceous glands - acne and acne 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, there are undesirable phenomena in the form of breast tenderness, an increase in body weight of no more than 2 kg, headaches (migraine), vaginal discharge, menstrual irregularities, spontaneous bleeding or intermenstrual uterine bleeding are sometimes observed. Contraindications for taking hormonal contraceptives are: breast cancer; all types of genital cancer; liver dysfunctions; recent liver disease or jaundice; deep vein thrombosis; pulmonary embolism; trauma to the vessels of the brain; 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 the age over 40 years; smoking and age over 35; a history of acute preeclampsia of pregnancy; nulliparous women - rare, irregular menstruation, amenorrhea, later menarche; lactation lasting less than 6 months; elective surgery; bouts of depression. The following diseases should also 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; diseases of the gallbladder.

Intrauterine contraception. Another effective method of preventing pregnancy is intrauterine contraception, which is based on the introduction of an intrauterine device into the uterine cavity, which prevents pregnancy. There are the following types of IUDs: non-drug (Lippes loop, Margulis spiral, double helix); medicinal (basic) - copper-containing (T-Si 200, etc.) and hormone-releasing agents. The mechanism of contraceptive action of the IUD is to disrupt the implantation of a fertilized egg, the accelerated migration of the latter, as a result of which it prematurely finds itself in the uterine cavity, when the endometrium is not yet prepared for implantation; the effect of drug-induced IUDs on the endometrium. In this case, a process such as chronic endometritis occurs in the endometrium with symptoms of local atrophy of the endometrium, its edema, increased vascularization and, possibly, hormonal secretion disorders.

Before the insertion of the IUD, the midwife should collect the instruments and supplies; instruct women and provide them with the information they need; collect anamnestic data by filling out a questionnaire; reassure a woman, as well as make sure that she is fully aware of the value of the IUD, including the advantages and disadvantages of the method, understands the procedure for inserting the IUD and the need for dispensary observation while wearing the IUD. After the introduction of the IUD, the woman must be examined for the first time after 1 month, then after 3 months. In the future, a woman should visit a consultation with an interval of 6 months, being for an examination in the period between menstruation.

List of instruments, devices and means of sterilization:
Navy;
conductor (without IUD);
gloves;
the mirror of Cuzco;
lift;
bullet forceps;
uterine probe;
scissors;
bullet clothes tongs;
metal trays;
weak aqueous solution of iodine (for sterilization);
vulva tampons;
a light source commonly used in consultation.

Instruments must be sterile and ready before the IUD is inserted. Sterilization of instruments is carried out in a dry heat cabinet or by boiling according to the general rules according to the instructions. Sterilization of IUDs is carried out by washing them in soapy water, followed by placement for 3 days in a 2% chloramine solution (with a daily change of solution). Before use, the IUD is placed in 96% ethyl alcohol for 2 hours. Leaving the IUDs in alcohol for a long time promotes compaction, which can lead to their fragility.

Before intrauterine contraception, women undergo a bacterioscopic examination of smears from the cervical canal, vagina and urethra for flora and purity, a clinical blood test, and, if indicated, a urine test. The IUD is inserted only with normal hemogram parameters, I – II - the degree of purity of the vaginal contents. The IUD is inserted on the 5-7th day of the menstrual cycle, immediately after uncomplicated artificial termination of pregnancy or 4-6 months after uncomplicated childbirth. Sometimes it is permissible to insert an IUD on the 5-6th day after uncomplicated labor, 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 an exacerbation of the process.

Contraindications to IUD insertion:
Acute, subacute and chronic with frequent exacerbations, inflammatory diseases of the female genital organs, including inflammatory diseases of the cervix.
Pregnancy, or at least suspicion of it.
Infectious-septic diseases and febrile conditions of any etiology.
Isthmico-cervical insufficiency.
History of septic (or infected) miscarriage within 3 months prior to the intended insertion of the IUD.
Postpartum infection of the pelvic organs 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 (menstrual, 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, which does not correspond 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 hormone-containing IUDs.
Repeated expulsion of the IUD (especially of a large size).
Allergy to substances secreted by the IUD (copper, antifibrinolytic substances, hormones).
History of no labor.

Observations of women using IUDs. Immediately after the introduction of the IUD, dizziness, weakness, nausea, and pain in the lower abdomen may appear. In such cases, it is advisable to rest, the introduction of painkillers, antispasmodics, inhalation of ammonia vapors. After the introduction of the IUD, minor bloody discharge may appear within 3-5 days or pulling pain in the lower abdomen that does not require specific therapy. Sexual abstinence is necessary for the first 7-10 days after the 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 property of the material from which the IUD is made changes; its conception ability decreases. Indications for removal of the IUD: prolonged pain, bloody discharge such as meno- or metrorrhagia, exacerbation of the inflammatory process in the genitals, partial expulsion of the IUD, the woman's desire to have a pregnancy, the expiration of the use of the IUD. The positive aspects of the IUD are their high efficiency, the duration of use, the possibility of removal at any time, the admissibility of use during the period of breastfeeding, the absence of undesirable sensations during 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 to carry out the necessary medical and recreational 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 state of health of persons exposed to adverse factors; identification of diseases that occur unfavorably under the influence of certain factors, as well as pathology that can contribute to the development of an occupational disease; determination of deviations in indicators characterizing physical development and working capacity; development of recommendations aimed at improving working conditions, eliminating or significantly reducing unfavorable production factors; carrying out individual therapeutic and prophylactic measures based on the results of a medical examination in order to restore the impaired functions of the body and the working capacity of the sick.

According to the classification of G.A. Novogorodtsev et al., All medical examinations are subdivided into preliminary, periodic and targeted. Children are subject to preliminary medical examinations when they are admitted to a nursery, kindergarten, school; pupils or students upon admission to technical schools and universities; adolescents applying for work, as well as all persons applying for work in certain industries, agriculture, construction projects, transport, catering networks, etc. their health, preservation of working capacity and ensuring creative longevity.

Targeted medical examinations provide for the identification of diseases that are most common and pose a threat to working capacity and life: tuberculosis, oncological, cardiovascular. In conducting mass medical examinations, 2 stages are conditionally distinguished: preparatory and actually working. In 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 instructive and methodological meetings and seminars are held with them.

The SES establishes the contingents of workers and employees subject to preliminary and periodic inspections with an indication of occupational hazard, and it requests lists of these persons from the heads of rural settlements and enterprises in writing according to the approved form. The lists are made in 3 copies (for the chief physician of the Central Regional Hospital, SES and the head of an agricultural enterprise); the head of the personnel department, with the participation of an occupational health and safety engineer, endorses the documents, the head of the agricultural enterprise signs them, and they are stamped. At the SES, a schedule is being developed for conducting preventive examinations with an indication of the composition of the medical team and the volume of laboratory examinations. The schedule of examinations must be coordinated and approved with the leadership of rural settlements and agricultural enterprises and communicated to each medical institution.

The second, or actually working, period consists in 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 beginning of mass field work. For the CRH, an order is issued indicating the specific tasks facing the team of doctors, and a senior doctor (usually a therapist) is appointed. Preventive examinations can be carried out on the basis of the Central Regional Hospital, a local hospital, a medical outpatient clinic. Teams of doctors can go directly to settlements, located at the FAP, in rooms specially adapted for examinations. The sequence, time and those responsible for the appearance for inspection are determined by the order of the head of the rural settlement.

Feldshers and midwives, when doctors go to the sites, prepare premises, appropriate equipment, tools, specify the 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 schedule. Responsibility for the attendance at inspections of workers is assigned to the heads of agricultural enterprises and trade union organizations. At the end of preventive examinations, a final act is drawn up for each enterprise.

Clinical examination. One of the most important types of preventive work of a paramedic is clinical examination of the population. Dispensary examination of the population includes:
annual examinations of the population by doctors with the participation of paramedical workers and carrying out the necessary laboratory diagnostic and functional studies;
additional examination of those in need with modern diagnostic methods;
carrying out the necessary medical and recreational activities;
dispensary observation of patients and persons with risk factors. The tasks of the clinical examination are:
determination and assessment of the state of health of each person;
ensuring an increase in the level and quality of annual examinations and dispensary observation with the necessary volume of research;
expanding the participation of various specialists and nurses in clinical examination with the leading role of the district (shop) doctor;
improvement of technical support for annual examinations and dynamic monitoring of public health using automated systems;
ensuring the necessary statistical accounting and reporting, transferring information about the examinations and health-improving activities to each person at the place of his observation.

The implementation of the annual prophylactic medical examination of the entire population is envisaged in 2 stages. In the period of preparation for the introduction of the annual medical examination, the entire population living in the FAP service area is personally taken into account, in accordance with the "Instruction on the procedure for accounting for the annual medical examination of the entire population." In rural areas, the police lists of residents are compiled by the average medical staff of the FAP during door-to-door rounds, they are clarified in the village and settlement administrations and transferred to the local hospital (outpatient clinic). For personal accounting of each resident, paramedical workers fill out the "Clinical examination record card" and number it in accordance with the number of the outpatient's medical card (form No. 025 / y). After clarifying the composition of the population, all "Dispensary registration cards" are transferred to the card index.

After conducting a personal registration of the entire population, the following groups are distinguished:
newborns;
children of the 1st and 2nd year of life;
preschool children in organized groups;
schoolchildren under 15;
adolescents (schoolchildren, students of vocational schools and secondary specialized educational institutions, working adolescents aged 15–17 years);
invalids 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 communal, medical and prophylactic, children's and other enterprises, organizations and institutions;
machine operators, livestock breeders, field breeders, indoor workers and other agricultural workers;
students of higher educational institutions and students of secondary specialized educational institutions;
personal retirees who receive medical care in this health care institution;
persons who are under dispensary supervision;
other population groups not included in the above list.

The volume of research at the first stage of clinical examination. In rural areas (except for regional centers and assigned areas), at the first stage of clinical examination, the following volume of examinations is recommended.

Child population: Annual examinations by a pediatrician (in the absence of a pediatrician - a general practitioner), a dentist (dentist). A pediatrician must examine children 1 and 2 years of age, before entering school - a pediatrician, neuropathologist and surgeon.
The nursing staff carries out: anthropometric measurement; 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; analysis of feces for eggs of worms; blood pressure measurement from 7 years old; fluorography of the chest organs from the age of 13.

Adults: Annual examinations by a therapist, dentist, obstetrician-gynecologist (in his absence - by a midwife), other specialists - according to indications.
Nursing staff, including FAP, collects anamnestic data using a specially developed questionnaire; anthropometric measurement; blood pressure measurement; gynecological examination of women with taking smears (for cytological examination); determination of visual acuity; tonometry (persons over 40); 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 in women; mammography (fluoromammography) once every 2 years in women from 35 years old.

The volume 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 (locksmiths, turners, electric welders, accumulators, blacksmiths);
livestock breeders (milkmaids, cattle breeders, pigsties, calves);
poultry farmers (poultry, operators, egg sorters, slaughterhouse workers, etc.);
plant protection agronomists, storekeepers of pesticide warehouses, greenhouses, plant protection workers;
indoor workers (greenhouses, agronomists).

For each profession, the order provides for the identification of the etiological factor, examination by specialists (mandatory, according to indications) and laboratory tests, mandatory and according to indications.

Stages of dispensary work. In dispensary work, a phased dispensary observation is necessary, and there are 3 stages of it: planning of work in connection with annual examinations of the organized and unorganized population (stage I); identification of contingents subject to dispensary observation (stage II); carrying out active dynamic observation, medical and recreational and rehabilitation measures (stage III). The scope of medical examinations and diagnostic studies during pregnancy and in the postpartum period includes the following nosological forms: physiological pregnancy in a healthy woman, as well as the 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, the main therapeutic and recreational activities, and hospitalization were established.

Medical and pharmaceutical care for the rural population is based on the same principles as for the urban population, but the peculiarities of the life of the rural population (the nature of settlement, low population density, specific conditions of the labor process, household activities and everyday life, poor quality or lack of roads) require the creation of a special system for organizing assistance. The organization of medical and pharmaceutical care in the countryside, its volume and quality depend on the remoteness of medical and pharmaceutical organizations from the place of residence of patients, staffing with qualified personnel and equipment, and the possibility of obtaining specialized medical care. The provision of medical and drug assistance to the rural population takes place in medical and preventive institutions (LPI).

Primary health care for the population of the Stavropol Territory is provided by 28 independent outpatient clinics, 146 outpatient clinics, 72 district hospitals, 2 district hospitals, 25 central district hospitals (CRH), 15 city hospitals. There are about 300 feldsher-obstetric points (FAP) in the region, which have the right to provide the population in rural areas with the necessary drugs (MP).

District medical institutions provide qualified and specialized care with consultative appointments of specialist doctors in 10–12 specialties. Rural residents apply to the polyclinic of the central district hospital (CRH) on referral from medical institutions of rural medical districts for functional examination, consultation and treatment with specialist doctors. District medical institutions are difficult to access for the elderly population living in remote rural settlements, which complicates consultation and treatment with specialist doctors.

Rural medical district (SVU) - unites a rural district hospital, a medical outpatient clinic, feldsher-obstetric points (FAPs), feldsher points, households. The IED is a complex of medical institutions that provide the population of a certain territory with qualified medical care, provided according to a single plan under the leadership of the chief physician of a local hospital. Qualified medical care - medical medical care provided to citizens for diseases that do not require specialized diagnostic methods, treatment and the use of complex medical technologies. The number of IEDs in a district is determined by the size of the population and the distance to the district hospital. The average population in one rural medical area varies from 7 to 9 thousand inhabitants, with the optimal radius of the site being 7-10 km. The territory of a rural medical area includes, as a rule, 3-4 settlements. The structure of the institutions that make up the rural medical area is determined depending on the location and size of settlements, the radius of service, the economic state of the region, the state of the roads.

The rural district hospital (SUB) provides outpatient medical appointments in the main specialties (therapy, surgery, dentistry, obstetrics, gynecology, etc.). Paramedics are also involved in outpatient appointments in some cases (absence of a doctor, his illness, vacation, a large number of visits). The doctor or paramedic is obliged to provide a systematic (active) visit to the patient at home. In recent years, the need for medical care at home has increased due to the increase in the proportion of elderly and senile people in the structure of the rural population, while the organization of patient care plays a special role. Local hospitals are the leading medical institution in the rural medical area. In the structure of rural district hospitals, there is a hospital and an outpatient clinic. The capacity of a rural district hospital is determined by the number of hospital beds. Subs 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. At present, rural district hospitals, mainly of the 3rd and 4th categories, constitute the basis for rendering medical care to the rural population. Depending on the capacity, local hospitals have a certain number of departments. The hospital of the 1st category has six departments: therapeutic, surgical, obstetric-gynecological, pediatric, infectious, anti-tuberculosis. In each subsequent category - 1 compartment less. In the hospital of the 2nd category there is no anti-tuberculosis department, in the 3rd category there is no anti-tuberculosis and pediatric department, in the 4th category there is a therapeutic, surgical and obstetric-gynecological department. The medical staff in the hospital is established on the basis of the standard - one medical position for 20 - 25 beds, thus, in the hospital of the fourth category, 3 departments are allocated

1 medical position. The medical staff for outpatient care is determined based on the recommended number of posts per 1000 rural residents (adults and children).

In a remote rural area, FAP is a health care institution with a greater prophylactic focus. It may be entrusted with the functions of a pharmacy for the sale of drugs and other pharmaceutical goods to the population.

A feldsher-obstetric station is a medical and preventive institution that is part of a rural medical district and carries out, under the leadership of a district hospital (outpatient clinic), a complex of medical and preventive and sanitary and anti-epidemic measures in a certain area. It is the primary (pre-medical) health care unit in rural areas. As a rule, the FAP is located in the settlements farthest from the district hospital, which brings medical care closer to the rural population. Serves part of the territory of the rural medical district, subordinating to the local hospital or outpatient clinic on medical issues (when there are no such institutions in the area - to the central regional hospital). On the staff of the FAP: the head is a paramedic (who has the right to sell medicinal products); midwife (patronage nurse) and nurse. The FAP staff provides patients with first aid (within the competence and rights of a paramedic and midwife) at outpatient appointments and at home, consults them with a doctor, and fulfills medical prescriptions. The health care institutions of the rural settlement are part of the complex therapeutic area. At this stage, rural residents receive first aid, as well as basic types of medical care (therapeutic, pediatric, surgical, obstetric, gynecological, dental), but it is more problematic with drug provision. The territorial availability of pharmaceutical care in the Stavropol Territory is provided by 910 pharmacies, 468 pharmacy points and 17 pharmacy kiosks. FAPs licensed for drug provision are not always available to rural residents of remote settlements. Households located in remote settlements do not have the conditions and powers for the implementation of drug supply. The first medical institution to which a villager applies is FAPs, which are advisable to organize in settlements with a population of 700 or more with a distance of more than 2 km to the nearest medical institution, and if the distance exceeds 7 km, then in settlements with a number of inhabitants up to 700 people. This makes it difficult to provide drugs in sparsely populated areas where FAPs are not available.

The main problems of health care in rural areas are the predominance of low-power health care facilities in its structure, staff shortages, which, with insufficient funding and an extremely worn out material and technical base of rural health care, makes it difficult to provide the rural population with medical care. The critical state of the material and technical base of rural health care facilities is clearly confirmed by the following data: wear and tear of medical and technical equipment in rural health care facilities is 58%, wear and tear of transport - 62%, about 90% of FAPs and 70% of medical outpatient clinics do not have central heating, water supply and sewerage, in 25 % Of FAPs have no telephone connection, only 0.1% of FAPs are provided with transport. More than half of rural health care facilities are in need of major repairs.

At the present time, the process of consolidation of rural district hospitals is underway, mainly hospitals of the 1st and 2nd categories are being built. Hospitals of the 3rd and 4th categories are transformed into medical outpatient clinics or into departments of the Central District Hospital. Category 1 and 2 hospitals are better equipped with equipment and doctors. The negative side of the enlargement is the separation of medical care from the rural population.

The ongoing restructuring of rural health care is proceeding slowly and has not only its advantages, but also disadvantages, including the growing remoteness of medical and medical care for rural residents, which reduces its availability.

The availability of specialized medical care to rural residents is decreasing. High-tech (expensive) types of medical care are also inaccessible for rural patients. Medicines are a significant problem for the villagers. Defects in the provision of primary medical care, practically the cessation of work on the prevention of diseases, medical examination of the population lead to an increase in cases of diagnosis of severe diseases at 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 is 3.4 and 1.6 times less than the urban population, respectively. In rural areas, the development of general medical practice seems to be the most promising. Securing qualified medical personnel and nursing staff is constrained by the low quality of life in the countryside, low wages, and insufficient social support.

To bring the specialized medical and pharmaceutical care to rural residents closer, it is necessary to organize teams of outpatient and medical aid. The mobile team must work according to the 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, medical specialists - neuropathologists, ophthalmologists, otolaryngologists, allergists, phthisiatricians, oncologists, rheumatologists - can be included in the visiting teams in accordance with geographically widespread diseases. Traveling teams must be provided with 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 the settlements of the Stavropol Territory with a population of less than 100 people who do not have FAPs, 19 households equipped with dressings, immobilization materials and telephone communications have been organized, which are entrusted with the functions of providing first aid. But, the question remains open, requiring the improvement of drug provision. The problem of drug supply in remote rural settlements can be solved by the distribution form of selling drugs, which should mainly be designed for the delivery of drugs to remote places where the opening of a permanently functioning pharmacy organization is impractical. For the supply of medicines (MP) to residents of areas remote from pharmacy organizations and FAPs for considerable distances, it is necessary to organize mobile pharmacy kiosks. The kiosk may have two rooms: for storing and selling medicines and for personnel. Separate the room for storing medicines with a showcase. In the kiosk, create optimal conditions for the correct storage of medicines thanks to a special system for maintaining a constant air temperature inside the body, regardless of fluctuations in the external temperature. Also, create conditions for staff to stay in a mobile kiosk for a long time - install a bed and a bedside table for sleeping clothes and personal belongings in the room, which can be used as a table and washbasin.

For each exit, select the appropriate assortment of medicinal products. To practice mobile teams of doctors and specialists of pharmacy organizations, providing at the same time medical and drug assistance to the rural population. The range and quantity of drugs for a mobile pharmacy should be coordinated with the doctors who are part of the mobile team. With this approach to drug provision for the population of remote areas, savings on rent and other costs associated with organizing trade are possible. Equipped vehicles for pharmacies are 4-6 times cheaper than setting up and equipping one pharmacy organization. That is why it is important to deliver medicines to remote rural settlements in sufficient quantity and guaranteed quality. The assortment of medicinal products can include about 1200 items sold both without a doctor's prescription and by prescription sold under the ONLS program, as well as medical and hygiene products. The assortment of medicinal products must be formed taking into account the provision of the necessary drugs to privileged categories of the population, also taking into account the epidemic situation in rural settlements, the chronic diseases among residents of a particular village, predicting seasonal diseases, the age category of patients, etc. Provision of the process is possible with the help of regional regulatory authorities of the health care 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 the opportunity for young specialists to provide pharmaceutical support to the rural population, while living in urban areas. The working hours of the exit point can be 8 hours (from 9 to 17 hours). A pharmacist can choose a route, taking into account the needs of rural residents in pharmaceutical services and set the time of arrival and the period of stay in a specific rural settlement. The 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 served area. In order to organize the distribution of drugs and pharmaceutical products, it is necessary to develop guidelines. Undoubtedly, this is an opportunity to improve the availability of medicines and medical products for the population 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 treatment 02/23/2016).

2. Voschanova Yu. A. Analysis of the availability of preferential drug care in the context of the municipalities of the Stavropol Territory. / 785-788s. / Scientific journal "Fundamental Research No. 12 Part 4" ./ Moscow, 2011.

The main feature of medical care rural population lies in its stages. Conventionally, there are three stages to the organization of medical care for the rural population.

Tab. 3. Stages of providing medical care to the rural population

The first stage is the health care institutions of the rural settlement, which are part of the integrated therapeutic area. At this stage, rural residents receive first aid, as well as the main types of medical care (therapeutic, pediatric, surgical, obstetric, gynecological, dental).

The first medical institution to which, as a rule, a villager turns, is the feldsher-midwife point (FAP). It functions as a structural subdivision 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 institution over 2 km, and if the distance exceeds 7 km, then in settlements with a population of up to 700 people.

The feldsher-obstetric 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, especially infant, maternal, working age;

Providing the population with pre-hospital medical care;

Participation in the current sanitary supervision of preschool and school educational institutions, utilities, food, industrial and other facilities, water supply and cleaning of populated areas;

Carrying out door-to-door rounds for epidemiological indications in order to identify infectious patients, persons in contact with them and persons with suspected infectious diseases;

Improving the sanitary and hygienic culture of the population.

Thus, the FAP is a health care institution with a greater prophylactic focus. It may be entrusted with the functions of a pharmacy selling finished dosage forms and other pharmaceutical goods to the population.
The work of the FAP is directly headed by the head. In addition to him, a midwife and a visiting nurse work in the FAP.

Despite the important role of FAPs, the leading medical institution at the first stage of providing medical care to the villagers is the district hospital, which may include a hospital and an outpatient clinic. The types and volume of medical care in the district hospital, its capacity, equipment, staffing with medical personnel largely depend on the profile and capacity of other medical institutions that are part of the health care system of the municipal district (rural settlement). The main task of the district hospital is to provide the population with primary health care.



Outpatient and polyclinic care for the population is the most important section of the work of the district hospital. It can be an outpatient clinic as part of the structure of the hospital, 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 clinical examination of patients.

Doctors of the outpatient clinic provide appointments for adults and children, make home calls and emergency care. Paramedics can also take part in the reception of patients, however, medical care in an outpatient clinic should mainly be provided by doctors. In the local hospital, an examination of temporary disability is carried out and, if necessary, patients are referred to the ITU.

In order to bring the specialized medical care closer to the villagers, the doctors of the central regional hospital, according to a certain schedule, go to the outpatient clinic to receive patients and select them, if necessary, for hospitalization in specialized institutions. Recently, in many constituent entities of the Russian Federation, there is a process of reorganization of district hospitals and outpatient clinics into centers of general medical (family) practice.


WHAT ARE THE CITIZENS OF? Demography Efficiency of resource use Public opinion Increasing the competitiveness of the region (okrug) Salary Professional development Career growth Working conditions High living standards Quality of medical services Payable Queues Insecurity Priorities WHAT ARE THE MINISTRY OF HEALTH CARE? WHAT ARE WORKERS OF HEALTHCARE?


Medical assistance to the rural population is provided on general principles, however, the implementation of therapeutic and preventive measures in the optimal volume and at a sufficient level is complicated by a number of circumstances that must be taken into account when organizing it: socio-economic conditions; medical and demographic characteristics; the state of morbidity and disability; natural conditions; development of infrastructure in general and the network of medical institutions


DEVELOPMENT OF RURAL HEALTH IN UKRAINE CHARACTERISTICS DEMOGRAPHIC INDICATORS OF RURAL POPULATION RURAL POPULATION Mortality from external causes of death on 43.6% higher than the urban mortality rural population 19.3% higher than the birth rate URBAN RURAL POPULATION BY 16.7% HIGHER THAN URBAN POPULATION RURAL POPULATION MORTALITY FROM NEW ROCATIONS IS 11.9% LOWER THAN URBAN POPULATION INFANT RURAL POPULATION MORTALITY IS 31.9% HIGHER THAN URBAN POPULATION MORTALITY IS 31.9% ABOVE OVER THE CITY POPULATION. THAN THE URBAN POPULATION MORTALITY OF THE RURAL POPULATION FROM DISEASES OF THE DIGESTIVE ORGANS IS 4.5% LOWER THAN IN THE URBAN POPULATION THE MORTALITY OF THE RURAL POPULATION FROM DISEASES OF THE RESPIRATORY POPULATION IS 56.1% HIGHER


Stages of providing medical care to the rural population: Stage II (regional medical institutions - CRH, RB, NRB) Stage I (SVU, AOPSM, FAP) Stage III (regional medical institutions - regional hospital, specialized dispensary) Stage IV (state specialized centers, clinics Research Institute)



Gradually, to the extent of the restructuring of the network and the increase in the provision of medical personnel, the principle of stages entered into its formation: Stage I - the rural medical section provides primary health care. Stage II - regional medical institutions provide mainly secondary (specialized) care (primary care at this stage is provided only to residents of the regional center and adjacent villages - the assigned area). Stage III - regional hospitals and dispensaries provide highly specialized care. In modern conditions, stage IV has also formed, which is represented by interregional and state specialized centers. In addition, urban health care facilities are also significantly involved in the provision of medical care to the rural population.







The main tasks of the district hospital: providing the population of the district with outpatient and inpatient medical care; implementation of medical and preventive and general health-improving measures for the health care of mothers and children; organization and implementation of measures to prevent and reduce morbidity and injuries; introduction of modern methods of prevention, diagnosis and treatment; organizational and methodological guidance and control of the activities of health care institutions of the medical area.




The rural outpatient clinic carries out: early detection of diseases and risk factors; timely treatment of patients in the outpatient clinic and at home; selection of persons who need dispensary observation, their timely examination, treatment and recovery; organization of ambulance and emergency care; referral for consultations and preparation for examination by doctors-specialists of regional institutions during their planned visit to a rural medical area; timely hospitalization of patients; examination of temporary disability; referral to the medical and social expert commission (MSEC) of patients with signs of persistent disability; dynamic monitoring of the health status of women and children; scheduling and conducting consultative appointments of patients in the territory of FAPs; carrying out health-improving and anti-epidemic measures.




Responsibilities of the head of the FAP conduct outpatient reception and service calls; fulfilling the appointment of doctors, carrying out certain physiotherapeutic procedures and laboratory tests; participation in the organization of preventive medical examinations, in the selection of persons for dispensary observation; organization of transportation of patients to the appropriate medical institutions, while accompanying sick children under the age of one year; early detection of infectious patients; provision of isolation, and, if necessary, hospitalization of these patients; the implementation of patronage of patients with tuberculosis, mental disorders; participating in their outpatient care;


Vaccinations; anti-epidemic measures in the cells of infectious diseases; carrying out the current sanitary supervision over the proper facilities and the territory of the settlement; carrying out measures for the prevention of agricultural injuries; implementation of medical and hygienic education of the population; drawing up FAP work plans; filling out accounting documents and drawing up a report of the feldsher-obstetric station (form 024); issuance of certificates of incapacity for work (in accordance with the relevant order of the regional department (department) of health).



Responsibilities of the FAP midwife: annual census of children under 15 years of age; outpatient reception of children, pregnant women, gynecological patients and the provision of medical care at home; organization of consultations with a local doctor (pediatrician) in case of diseases of children (especially young children), timely admission to the appropriate hospital; conducting preventive examinations of all women; patronage of pregnant women and children;


Referral, if necessary, of women to an obstetrician-gynecologist; fulfillment of doctors' prescriptions for children, pregnant women and gynecological patients; conducting certain physiotherapy procedures and laboratory tests; provision of emergency care for acute illnesses and accidents; vaccinations; medical and hygienic study of women and children.


Settlement of less than 100 inhabitants Settlement of less than 100 inhabitants Improvement of medical care for the rural population, including first aid Departments of the general public health department Central district hospital Inter-municipal centers Inter-territorial polyclinics (from 100 to 200 thousand inhabitants) Inter-municipal centers Inter-territorial polyclinics (from 100 to 200 thousand inhabitants) Feldsher's FAP stations First aid households Settlement from 100 to 300 inhabitants Settlement from 100 to 300 inhabitants Settlement from 300 to 700 inhabitants Settlement from 300 to 700 inhabitants Settlement of 1500 inhabitants Settlement of 1500 inhabitants Settlement of about 3000 inhabitants and more Settlement facility with about 3000 inhabitants and more Outpatient clinics Complex area Mobile medical teams Developed infrastructure: roads, communications, telephone communications First aid to the population Subdivisions and branches District hospital Settlement 1700 residents Settlement 1700 residents "20






Implementation of modern methods of diagnostics and treatment into the practice of the district's health care facilities; Providing emergency and emergency medical care;


Organization of advisory assistance; organizational and methodological management of the work of all health care facilities of the district, as well as control of their activities; development and implementation of measures aimed at improving the quality of medical care; development, organization and implementation of measures to improve the qualifications of medical personnel and the rational use of medical personnel and material and technical resources; planning, financing and organization of material and technical support of the district health care institutions.



Areas of organizational and methodological work analysis of population health indicators; analysis of performance indicators of health care facilities of the district; study and dissemination of best practices; planning and organizing visits of CRH specialists to rural areas for advice to the population and doctors; planning and ensuring the conduct of preventive medical examinations; planning and organizing advanced training of medical workers of district and district health care facilities; development of measures to improve medical support for the population of the region.


Functions of the district pediatrician consultative assistance to workers of the health care facilities of the district center, rural medical districts on the organization of medical care for children; visiting FAPs and rural hospitals (outpatient clinics), examining healthy children and consulting sick children, checking the timeliness of preventive vaccinations and sanitary and anti-epidemic measures; control over the conduct of dispensary supervision over children, primarily in the first year of life; for carrying out preventive vaccinations for children; drawing up, together with the sanitary-epidemiological station (SES), a plan of anti-epidemic measures aimed at combating childhood infectious diseases, participation in its implementation;


Provision of advanced training in pediatrics for doctors in rural areas, medical workers of preschool institutions and schools, patronage nurses, medical personnel of FAPs; visiting preschool institutions, monitoring their activities; analysis of reports of children's health care institutions, study and assessment of the health status of children in the rural area and the activities of health care facilities, generalization of the data obtained and the development of specific measures to improve the quality of medical care; involvement of representatives of local authorities, public organizations, and Red Cross Society activists in activities aimed at improving medical care for children.


Scheme of financing the levels of medical care to the population in the city hospital 25 of Donetsk 1 LEVEL: Family medical outpatient clinic Family doctor - holder and distributor of finances 2 LEVEL: CRH, RB, NB, Consultative and diagnostic centers 3 LEVEL: Oblast hospital, Specialized inpatient care Budget funding per resident Extra-budgetary funds Funds attracted through insurance companies Payment from the family doctor's fund for each patient on a completed visit costly groups of diseases Finances attracted by insurance companies Anyone good for his sample Scheme of financing the levels of medical care for the rural population Click for larger picture


The main tasks of the regional hospital: providing the population of the region in full with highly specialized inpatient and consultative polyclinic care; organization and provision of emergency and advisory medical care in the region; introduction of modern methods and means of diagnostics, treatment, work experience of the best medical institutions into the practice of the hospital; advanced training of doctors and nurses of medical institutions in the region; organization, management and control of statistical accounting and reporting, preparation of consolidated reports, analysis of performance indicators of medical institutions in the region; development of measures aimed at improving the quality of medical care and improving the health of the population.




Satisfaction of the population with the quality of medical care in 2011 56.3% - upon receiving inpatient medical care 41.8% - upon receiving outpatient and polyclinic care 68.4% - upon receiving inpatient medical care Satisfied with the quality of medical care according to a sociological survey 50.8 % of respondents Satisfied with the quality of medical care according to a sociological survey 50.8% of respondents The number of complaints from the population about: the quality of food in hospitals, the sanitary condition of the premises of medical institutions, drug provision has decreased. The possibilities of making an appointment have been expanded, which gives the patient the right to choose a method that is convenient for him personally


Financial resources for the implementation of the health care modernization program of UKRAINE in years All funds 6.5% of GDP Strengthening the material and technical base of medical institutions Implementation of modern information systems in health care Implementation of medical care standards, increasing the availability of outpatient medical care, including that provided by specialist doctors


Implementation of modern information systems in health care in 81 health care facilities Implementation of 52 standards of medical care, increasing the availability of outpatient medical care, including that provided by medical specialists (63 health care facilities are involved), medical examination of adolescents in 34 health care facilities, opening of 6 centers of medical and social support for pregnant women in base of interdistrict obstetrics and childhood centers Strengthening MTB: - continued construction construction (acquisition) of 15 FAPs - purchase of 233 units of equipment for 32 health care facilities (including 1 CT scan, 1 angiograph, 9 units of vehicles, 2 neonatal resuscitation vehicles, 2 mobile complex) - the creation of an emergency department on the basis of GBUZ JSC "First City Clinical Hospital" - the opening of 55 general medical practices in rural areas - the creation of 47 households III. II. I.I.I.I. Measures to implement the healthcare modernization program


Provision of doctors for residents The industry employs people, doctors of paramedics Provision: -doctors - 40.3 per population; medical staff 93% - Coefficient of combination of doctors - 1.48, -wed. staff - 1.23


City 968 units Village 102 units. City 850 units Village 90 units. Social expectations of students (motivation to work in the countryside) a set of social measures: state support provided in the form of social payments for the construction or purchase of housing, cultural leisure and modern infrastructure, computerization of the village, the possibility of consulting with more experienced colleagues, professional retraining, the availability of medical literature, high salaries , including surcharge for work in rural areas The total number of vacancies for secondary medical. staff 940 units The total number of medical vacancies is 1070. Functions of an advisory polyclinic: Providing highly specialized counseling to patients in the areas of medical and prophylactic institutions of the region; solution of questions about the subsequent treatment of consulted patients with the definition of medical technology and place; involvement of highly qualified doctors-specialists of hospitals and other health care facilities, as well as workers of research institutes and medical universities in consultation; referral to medical institutions that sent patients for consultation, conclusions indicating the diagnosis established in the polyclinic, performed and recommended treatment; development of proposals (leaflets) for the health care facilities of the region on the procedure and indications for referring patients to consultative polyclinics;



Organization and holding (together with the department of emergency and planned consultative care) field consultations of specialist doctors in the regions, as well as correspondence consultations for doctors of regional healthcare facilities; a systematic analysis by rayons of the oblast of cases of disagreement in diagnoses between health care facilities, which sent patients for consultation, and a consultative polyclinic; analysis of mistakes made by doctors of health care facilities during examination and treatment of patients before sending them to an advisory clinic; preparation of reviews and information sheets on the state and level of treatment and diagnostic work in the districts and health care facilities of the region.


DEVELOPMENT OF RURAL HEALTH IN UKRAINE IN THE REGIONAL PROGRAM OF MODERNIZATION OF HEALTH ENTITIES IN UKRAINE IS A COMPLEX OF MEASURES TO IMPROVE THE PROVISION OF HEALTH CARE RURAL POPULATION, INCLUDING: increasing the availability of medicinal aid rural population Intensifying prevention PRIMARY HEALTH NETWORK DEVELOPMENT OF MEDICAL ORGANIZATIONS IN RURAL DEVELOPMENT OF HUMAN RESOURCES POTENTIAL HEALTH INSTITUTIONS IN RURAL AREAS Optimization of hospital beds in rural areas and improving its performance strengthening material-technical base of medical ORGANIZATIONS IN RURAL AREAS IMPLEMENTATION IN THE WORK OF PRIMARY HEALTH MOBILE MEDICAL CENTER (mobile outpatient clinics, MOBILE HEALTH CENTERS)