Medical assistance to the rural population is provided on a general basis, but the implementation of therapeutic and preventive measures in an optimal volume and at a sufficient level is complicated by a number of circumstances that must be taken into account when organizing it, namely: socio-economic, medical-demographic, medical-social, natural conditions , stages, infrastructure development, a significant part of pre-medical care, the creation of mobile forms of medical and preventive care.

The organization of medical care for the rural population is based on the principles of stages. There are four stages of assistance:

Stage I – the rural medical district provides primary health care.

Stage II – district medical institutions provide mainly secondary (specialized) care.

Stage III – regional hospitals and dispensaries provide highly specialized care.

Stage IV – interregional and state specialized centers.

At each stage, the activities of all medical institutions are interconnected.

I. Rural medical station - organized to provide medical care to residents of settlements remote from the regional center. It includes a local hospital or outpatient clinic and paramedic and obstetric stations.

Tasks of the rural medical station:

• providing medical and preventive care to the population;
• carrying out anti-epidemic measures;
• carrying out activities to protect the health of mothers and children;
• implementation of continuous sanitary supervision of the territory, objects of economic activity, educational and educational institutions;
• study of the health status of the population;
• carrying out activities for hygienic education of the population.

A rural medical district is created to provide primary health care on a local basis for residents of settlements remote from the regional center. The average population in the area is 3800 inhabitants and with an average service radius of 7.2 km. When organizing a site, the population size, the distance between settlements, settlement patterns, and the area of ​​the area are taken into account.

A rural district hospital is located in a so-called point village with a significant population and has an average capacity of 15.7 beds.

The structure of the SMS includes: an outpatient clinic, a clinical laboratory, a hospital, an X-ray room, and a physiotherapeutic room.

The functions of the SMS are: timely detection of diseases, provision of outpatient and inpatient care, carrying out preventive measures, dispensary observation and examination of disability.

Inpatient care, which is provided in a local hospital, is predominantly of a therapeutic profile, although sometimes emergency surgical care is provided, children and infectious patients are hospitalized.

The local hospital includes a rural medical outpatient clinic. It can also exist on its own. The staffing schedule determines the presence of four specialists who provide outpatient care: a therapist (family doctor), a pediatrician, an obstetrician-gynecologist (in settlements with a population of over 1000 people) and a dentist.

The rural outpatient clinic provides timely detection and treatment of diseases in the outpatient clinic and at home: timely hospitalization, referral for consultations with specialists; carries out the selection of persons for dispensary observation; conducts an examination of temporary disability and sends it to MSEC; conducts dynamic monitoring of the health status of pregnant women and children, carries out health-improving and anti-epidemic measures.

A significant number of villages with a small population and their significant distance from health care institutions contribute to the development of mobile forms of medical care (mobile medical outpatient clinics, dental offices, diagnostic fluorography complexes).

Together with the rural outpatient clinic, outpatient and polyclinic care to the population at the pre-medical stage is provided by a paramedic and obstetric station (FAP).

The main tasks of the FAP are: provision of medical and preventive care (first aid, patronage of pregnant women and children, participation in medical examinations) and carrying out sanitary and educational activities (carrying out preventive vaccinations, identifying infectious patients, participating in ongoing sanitary surveillance).

The second stage of providing medical care to the rural population includes the following institutions: central district hospital (CRH), district hospital, district SES, central district pharmacy.

The main institution for providing secondary specialized care is the Central District Hospital. The main functions of which are the provision of outpatient and inpatient specialized treatment and preventive care, as well as ambulance and emergency care, consultations with patients.

The Central District Hospital has specialized departments: therapeutic, surgical, infectious, neurological, pediatric, obstetric and gynecological. Other specialized departments (cardiology, gastroenterology, traumatology, otolaryngology, ophthalmology) can also be created on the basis of the Central District Hospital, which operate as inter-district departments. They carry out consultations with patients from assigned areas and hospitalize them, and also develop measures to improve the quality of specialized care and improve the qualifications of medical personnel.

Structure of the Central District Hospital:

• clinic;
• hospital;
• emergency department;
• pathological and anatomical department;
• information and analytical department.

Tertiary, highly specialized, highly qualified medical care for rural residents is provided by Stage III institutions, which include regional hospitals, dispensaries, regional SES, blood transfusion stations, and forensic bureaus.

The tasks of the regional hospital are: advisory outpatient care, highly specialized inpatient care, organizational and methodological work (assessment of the health status of the region's population, analysis of the activities of all health care facilities in the region and individual services, drawing up an action plan to improve the quality of medical care, advanced training of medical workers).

Structure of the Central District Hospital:

• advisory clinic;
• hospital;
• medical, auxiliary and diagnostic units;
• Center for Medical Statistics;
• departments of emergency and planned advisory care;
• administrative and economic part;
• pension.

Highly specialized medical care for the rural population is also provided by interregional medical institutions and centers that are part of research institutes, universities, regional hospitals or that exist independently (IV stage of medical provision for the rural population).

Unity of principles for providing treatment and preventive care for urban and rural populations: 1) preventive in nature; 2) locality; 3) mass participation; 4) specialization of medical care 5) general availability.

Features of providing medical and preventive care to the rural population:

1) stages of assistance

2) mobile types of medical care (traveling medical teams).

Features of the organization of rural medical care:

1) low population density - the number of rural population in 2004 was 2,803,600, 2005 2,744,200, 2006 2,691,500. Compared to 2002, the rural population decreased by 118 thousand. In 2005, 90,307 people were born, of which 24,205 (26.8%) were born in rural areas. The birth rate in 2005 was 9.2 in the Republic of Belarus, in rural areas – 8.9. The mortality rate in rural areas is 2.2 times higher than in the city. Infant mortality in general is 6.4, in rural areas – 9.3. Life expectancy in rural areas is 64.52 years, in cities 70.53 years.

Crowding is the number of people in a populated area. The average rural population is 200 people.

2) scattered settlements over a large territory - rural settlements 24 thousand. The average population density in the Republic of Belarus is 48 people per km2, in the village - 10 people per km2. Proximity is the distance between settlements; service radius is the distance from a settlement where there are medical institutions to the most remote settlement whose residents are attached to this institution for medical care. This value is manageable and varies depending on the population size.

3) poor quality of roads

4) specifics of agricultural labor: seasonality, dependence on weather

5) conditions, lifestyle, traditions

6) low supply of specialists

Stages of providing medical and preventive care to the rural population and main organizations:

Stage I – previously – rural medical station (VSU), including a complex of medical institutions:

A) a rural district hospital (SUB, provides both outpatient and inpatient care) or a rural medical outpatient clinic (SVA, provides only outpatient care)

B) first aid station (FAP)

C) health centers (if there is an industrial enterprise in the serviced area).

Currently There are no SVUs, SVA and local hospitals are branches of the Central District Hospital, FAPs are branches of the SVU.

Main function of the stage: provision of first aid, first qualified medical care with possible elements of specialized medical care.

FAPs– are created for medical care of 400 people or more at a distance of 2 km or more from the medical institution. When serving more than 400 people. in the staff of the FAP there are: 1 position of a paramedic or midwife or nurse and 0.5 positions of a nurse. Costs for FAPs are 1.5-2.0% of the district budget.

Functions of the FAP:

– provision of pre-medical care and timely implementation of doctor’s prescriptions;

– carrying out preventive work and anti-epidemic work;

– organization of patronage for pregnant women, children,

– carrying out measures to reduce infant and maternal mortality;

– hygienic training and education of the population.

Rural medical station (VU)– served 7-9 thousand people within a radius of 7-9 km.

District hospital- This is the main institution at the VU, consisting of a hospital and an outpatient clinic. Depending on the number of beds, there may be category I - 75-100 beds, category II - 50-75 beds, category III - 35-50, IV - 25-35 beds. At the local hospital All types of qualified medical and preventive care are provided. Medical assistance to the population during field work is of great importance. Significant work is being done to protect the health of women and children, to introduce modern methods of prevention, diagnosis, and treatment.

Provides all types of medical and preventive care to pregnant women, mothers and children Local hospital doctor. If there are several doctors, then one of them is responsible for the health of children and women in a given area.

At Unprofitable activities of local hospitals, they are closed or converted into branches Rehabilitation of district hospitals, and for medical care of the population they open Independent rural medical outpatient clinics(SVA), whose staff should include: a general practitioner, a dentist, an obstetrician-gynecologist, and a pediatrician. Medical care for patients with dental diseases in a local hospital or in a rural outpatient clinic is provided by a dentist (dentist).

From the staffing standards for medical personnel at local hospitals:

1. The positions of doctors for providing outpatient care to the population are established per 10,000 population:

2. The positions of doctors in hospital departments are established at the rate of 1 position:

– general practitioner – for 25 beds;

– pediatrician – for 20 beds;

– surgeon – for 25 beds;

– dentist – for 20 beds.

The bed capacity of the rural district hospital is 27-29 beds.

Organization of work of the SMS:

– provision of medical and preventive care to the population

– introduction into practice of modern methods of prevention, diagnosis and treatment of patients

– development and improvement of organizational forms and methods of medical care for the population, improving the quality and efficiency of medical and preventive care

– organization and implementation of a set of preventive measures among the population of the site

– carrying out therapeutic and preventive measures to protect the health of mothers and children

– study of the causes of general morbidity and morbidity with temporary disability and development of measures to reduce it

– organization and implementation of medical examination of the population, especially children and adolescents

– implementation of anti-epidemic measures (vaccinations, identification of infectious patients, dynamic monitoring of persons who were in contact with them, etc.)

– implementation of current sanitary supervision of the condition of industrial and communal premises, water supply sources, children's institutions, public catering establishments;

– carrying out treatment and preventive measures to combat tuberculosis, skin and venereal diseases, malignant neoplasms

– organization and implementation of events for sanitary and hygienic education of the population, promotion of a healthy lifestyle, including rational nutrition, and strengthening physical activity; combating alcohol consumption, smoking and other bad habits

– widespread public involvement in the development and implementation of measures to protect public health

Stage II – territorial medical association (TMO).

Managed by TMO Chief physician of TMO(he is also the chief physician of the Central District Hospital) and his deputies:

– deputy for medical services to the population (also head of the organizational and methodological office);

– deputy for medical affairs (if the number of beds is 100 or more);

– deputy for medical and social examination and rehabilitation (with a population of at least 30,000 people served);

– deputy for obstetrics and childhood (with a population of at least 70,000 people served);

– Deputy for Economic Affairs;

– Deputy for administrative and economic affairs.

The medical council includes: the chief physician, his deputies, the chief physician of the Center for Hygiene and Epidemiology, the head of the central district pharmacy, leading specialists of the district, the chairman of the district committee of the trade union of medical workers, the chairman of the Red Cross and Red Crescent Society.

The decision to create a TMO is made by a higher health authority. In small towns and rural areas, the TMO usually unites all medical and preventive institutions and replaces the city health department and the central district hospital. In large cities with a population of more than 100,000 people, there may be several TMOs, one of them is the main one.

TMO is a complex of health care facilities that are functionally and organizationally interconnected. TMO may include:

clinics (adults, children, dental);

antenatal clinics, dispensaries, hospitals, maternity hospitals;

ambulance stations;

children's sanatoriums and other institutions.

Merging institutions should be expedient, not mandatory. Institutions that are not included in the TMO act independently. As a rule, these are health centers and hygiene and epidemiology centers, forensic medical examination bureaus, and blood transfusion stations.

Principles of formation of TMO:

1. A certain population size - the optimal size of the TMO - 100-150 thousand people.

2. Organizational and financial separation of outpatient and inpatient facilities.

3. Coincidence of the boundaries of the TMO service area with the administrative boundaries of the district (city).

4. Rational unification of institutions - unification of institutions providing medical care to adults and children.

TMO tasks– providing accessible and qualified treatment and preventive care to the population.

TMO functions:

1. Organization of medical and preventive care for the attached population, as well as for any citizen who seeks medical help.

2. Carrying out preventive measures.

3. Providing emergency care to patients.

4. Timely provision of medical care at the reception, at home.

5. Timely hospitalization.

6. Medical examination of the population.

7. Conducting a medical and social examination.

8. Conducting hygienic training and education.

9. Analysis of the activities of health care facilities.

Main treatment and preventive institutions Stage II includes the central district hospital (CRH) and other district institutions (see question 102).

For the organization Treatment and preventive care for women and children At this stage, the district pediatrician and the district obstetrician-gynecologist are responsible. If the population of the district is more than 70,000 people, the position of deputy chief physician for childhood and obstetrics is appointed - an experienced pediatrician or obstetrician-gynecologist.

Outpatient dental care at stage II it can be provided in dental clinics and dental departments of the clinic of the Central District Hospital. Inpatient dental care in the dental department of a hospital hospital or on special beds for dental patients in the surgical department.

Stage III – regional hospital and regional medical institutions.

Regional Hospital is a large multidisciplinary medical and preventive institution that provides full, highly qualified, highly specialized care to residents of the region. This is a center for organizational and methodological management of medical institutions located in the region, a base for specialization and advanced training of doctors and nursing staff.

Structure of the regional hospital:

1. Hospital.

2. Advisory clinic.

3. Other departments (kitchen, pharmacy, morgue).

4. Organizational and methodological department with a medical statistics department.

5. Department of emergency and planned advisory care, etc. (see question 104).

The bed capacity of the regional hospital for adults is 1000-1100 beds, for children – 400 beds.

Advisory clinic provides the population with highly qualified, highly specialized medical care, provides on-site consultations, correspondence consultations by telephone, analyzes the activities of medical institutions, discrepancies between the diagnoses of the referring institutions and the clinic, the diagnoses of the clinic and the hospital, and error analysis. Does not have the right to issue sick leave.

The children's and women's population of the region receives all types of qualified specialized medical care at the advisory clinic. Inpatient care for women is provided in regional maternity hospitals, regional dispensaries and other medical institutions in the region.

Outpatient qualified specialized dental care patients receive treatment in regional dental clinics, inpatient care is provided in the dental departments of regional hospitals.

The number of hospital organizations in rural areas in 2005 was 274, of which there were 184 district hospitals, nursing hospitals – 90. The number of outpatient clinics was 3326. There were 253 independent medical outpatient clinics in 2005, and 336 general practitioner outpatient clinics in 2005. FAPs in 2005 – 2524.

IVstage: republican level(RSPC, republican hospitals).

Obstetric and gynecological care for the rural population

Features of the living and working conditions of the rural population, expressed in the dispersion of settlements, the difference in the forms of organization of agricultural production, the variety of types of agricultural work (farming, livestock farming, poultry farming), the large scope of these works, their seasonality, determine the features of the organization of all medical care in a rural area, in including obstetrics and gynecology. Obstetric and gynecological care is provided to the rural population by a complex of medical and preventive institutions. Depending on the degree of proximity to the rural population, on the specialization and qualifications of medical care, the level of material and technical equipment in the system of providing obstetric and gynecological care, it is customary to distinguish three stages.

Stages of obstetric and gynecological care. First stage: implementation of pre-medical and first medical aid. This stage is a rural medical site. It includes a rural district hospital with an outpatient clinic and a hospital, paramedic and obstetric stations (FAP), and maternity hospitals. The location of the first stage is the periphery of the area.
The second stage: provision of qualified medical care. It includes district (registered) and central district hospitals, which include obstetrics and gynecology departments and antenatal clinics. The location of the second stage is the regional center.
Third stage: providing the rural population with highly qualified (specialized) obstetric and gynecological care. It includes a regional (territorial, republican) hospital, which includes obstetrics and gynecology departments and a antenatal clinic or an independent maternity hospital with a antenatal clinic. The location of the third stage is the regional (territorial, republican) center.

Medical obstetric and gynecological care at a rural medical site is carried out by a general practitioner - the chief physician of the rural district hospital (if there are two doctors in the district hospital - one of them). Under his direct supervision, a midwife works at the local hospital, who helps the doctor both in the hospital (takes part in the management of childbirth) and in the outpatient clinic (takes part in monitoring pregnant women, postpartum women and treating gynecological patients). The number of maternity beds in a rural district hospital usually does not exceed 3–5. To bring qualified medical care closer to rural residents, there is a gradual reduction in the number of maternity beds in rural district hospitals and an expansion of the number of beds in district and central district hospitals. However, in a number of areas where, due to local conditions, it is not possible to provide the population with obstetric and gynecological care in district and central hospitals, rural district hospitals are being consolidated, and in accordance with this, the number of maternity beds is being expanded to eight, and the position of an obstetrician-gynecologist is provided.

Pregnant women and women in labor with a pathological course of pregnancy and childbirth and a burdened obstetric history should not be admitted to a local hospital (if there is no obstetrician-gynecologist on staff). Despite the presence of a medical hospital on the periphery of the region - a rural district hospital, the bulk of obstetric and gynecological care in a rural medical district relates to pre-medical care, and is carried out by midwives from a medical and obstetric station and a collective farm (inter-collective farm) maternity hospital. The work of these institutions is carried out under the direct supervision of the chief physician of the rural district hospital. If there is an obstetrician-gynecologist on staff at the local hospital, the latter provides all medical and advisory assistance at the medical assistant station and in the collective farm maternity hospital.

FAP: work structure

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

Depending on local conditions, the FAP may provide only outpatient care or have maternity beds. In the latter case, the FAP provides inpatient care along with outpatient care. Due to the fact that the FAP provides medical care to the entire rural population, and not just women, the room in which it is located should consist of two halves: a paramedic and an obstetrician.

Obstetric part of the FAP. The obstetric part of the paramedic-midwife station (FAP) should have the following set of premises: an entrance hall, a waiting room and a midwife's office. FAPs that have maternity beds, in addition to these premises, must have an examination room, delivery and postpartum wards. The FAP midwife carries out all the work on organizing and providing obstetric and gynecological care to rural residents within the service radius of the point. The responsibilities of the FAP midwife include: identifying all pregnant women in the service area as early as possible, ensuring dispensary observation of them, including carrying out the necessary treatment and preventive measures, patronage of pregnant women, postpartum women and children under the age of 1 year; carrying out health education work among women; provision of medical care during normal childbirth; identifying gynecological patients, referring them to a doctor and providing them with medical care as prescribed by the doctor. Significant assistance in the early detection of pregnant women is provided by door-to-door visits conducted by the FAP midwife. When monitoring pregnant women, the midwife performs the bulk of the necessary research. So, at the first visit of a pregnant woman, the midwife collects a detailed history, general (heredity, previous diseases, etc.) and special obstetric (menstrual, sexual, generative, lactation functions, gynecological diseases, etc.). From the medical history, the midwife finds out the peculiarities of the course of previous pregnancies, the presence of extragenital diseases and other abnormalities in the woman’s health that can affect the course of pregnancy and childbirth.

The midwife begins the examination of each pregnant woman with an examination of the internal organs: cardiac activity, measuring blood pressure (in both arms), examining the pulse, examining urine for protein (by boiling). The midwife currently studies the health status of pregnant women based on measuring height, body weight (over time), the presence of edema, pigmentation, the condition of the mammary glands and nipples, and the condition of the abdominals. Carrying out a special obstetric examination, the midwife measures the external dimensions of the pelvis and, through a vaginal examination, determines the gestational age and internal dimensions of the pelvis. In the second half of pregnancy, measures the height of the uterine fundus above the womb, determines the position and presentation of the fetus, and listens to its heartbeat.

For a general blood test, group affiliation, determination of the Rh factor, antibody titer, Wasserman reaction, and a general urine test, the pregnant woman is sent to the nearest laboratory. Here, a bacteriological study of the vaginal flora is carried out to determine the degree of purity, the discharge of the urethra, cervix and vagina for gonococcus, and the reaction of vaginal secretions. X-ray examinations in pregnant women (x-ray of the chest, fetus, pelviography) are performed only if there are strict indications.

A thorough examination of pregnant women makes it possible to identify various pathological conditions, on the basis of which these pregnant women are identified as high-risk groups and require the closest attention to them during pregnancy; during childbirth and the postpartum period, high-risk groups are distinguished for cardiac pathology, bleeding in the postpartum and early afterbirth periods, inflammatory and septic complications after childbirth, endocrinopathies - diabetes mellitus, obesity, adrenal insufficiency and other types of obstetric and somatic pathologies. All individual cards of pregnant women at risk are usually marked with the appropriate color marking, indicating in a certain color the risk of a particular pathology (red - bleeding, blue - toxicosis, green - sepsis). The scope of research in gynecological patients also includes the collection of general and special gynecological history. The study of women's health is currently carried out on the basis of a general clinical examination, similar to the examination of pregnant women. A special gynecological examination includes two-manual and instrumental (examination in mirrors) examination. A bacterioscopic examination of the discharge of the urethra, cervix and vagina for gonococcus is carried out using provocation methods, according to indications - the Bordet-Gengou reaction; examination of a vaginal smear for cell atypia; research on functional diagnostic tests.

If a woman needs a biochemical blood test for cholesterol, bilirubin, sugar, residual nitrogen and a urine test for acetone, urobilin, bile pigments, she is sent to the nearest multidisciplinary laboratory. Women and couples who have a history of hereditary diseases or children with deformities of the central nervous system, Down's disease, or defects of the cardiovascular system are sent for examination, including to determine sex chromatin, to specialized medical genetic centers. When monitoring pregnant women, the FAP midwife is obliged to show each of them to the doctor. If a woman’s pregnancy is progressing normally, then she will meet with a doctor at her first scheduled visit to the FAP. All pregnant women who exhibit the slightest deviation from the normal development of pregnancy should be immediately referred to a doctor.

At each subsequent visit to the FAP, the pregnant woman undergoes the necessary repeated examinations. In the second half of pregnancy, you need to especially carefully monitor the possible development of late toxicosis, for which you need to pay attention to the presence of edema, blood pressure dynamics and the presence of protein in the urine. It is very important to monitor the dynamics of a pregnant woman’s weight.

Organization of patronage work. A mandatory part of a midwife’s work in monitoring pregnant women should be conducting classes on psychoprophylactic preparation for childbirth. In organizing monitoring of pregnant women in rural areas, as well as in the city, patronage work is very responsible. Patronage of pregnant and gynecological patients is an element of the active dispensary method. The goals of patronage are very diverse, so each patronage visit to a woman has a specific goal. First of all, this is an acquaintance with the living conditions of a woman. Knowing the peculiarities of the life of each family (living conditions, family composition, level of material security, degree of culture, including health literacy), it is easier for the midwife to monitor the health status of the population. The purpose of patronage is the need to find out the health status of a pregnant woman who did not show up for an appointment at the appointed time. In this case, the midwife, in a conversation with the pregnant woman, finds out the general condition of the woman, performs a thorough examination, pays attention to the presence of edema, and measures blood pressure. During long periods of pregnancy, she measures the circumference of the abdomen and the height of the uterine fundus, and determines the position of the fetus. Having made sure that there are no deviations from the normal development of pregnancy, the midwife sets a date for the woman to appear for the next examination. If there is the slightest sign of pregnancy complications, the midwife invites the pregnant woman to see a doctor or informs the doctor about this, who decides whether the pregnant woman can be treated at home or whether she needs to be hospitalized. In the latter case, the midwife monitors the timeliness of the woman’s admission to the hospital and continues active monitoring after she is discharged home. The reason for patronage may be the desire to make sure that the woman is following the doctor’s orders correctly, or the need to conduct additional tests (laboratory tests, measure blood pressure).

The FAP midwife is obliged to provide patronage to children, especially the first 3 years of life. In this case, it is necessary to observe the frequency of observations of children of the 1st year of life by the midwife (paramedic) of the FAP: 1st month of life - observation only at home - 5 times; 2nd month of life - observation at home - 3 times; 3–5 months of life - observation at home - 2 times a month; 6–12th months of life - observation at home - once a month. In addition, a child under 1 year of age must be examined by a pediatrician at the FAP at least once a month. Thus, the midwife sees the child during the 1st year of life 12 times during preventive examinations by a doctor and 20 times during home visiting.

The midwife's patronage work is strictly planned. The plan provides for days of visiting villages and hamlets. A special notebook keeps records of patronage work and records all visits to women and children. The midwife enters all advice and recommendations into the home visiting nurse’s work notebook (patronage sheet) for subsequent verification of their implementation.

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

Carrying out preventive periodic examinations. The paramedic and midwife are required to have in their area a list of women subject to preventive and periodic examinations. Practically healthy women with a good obstetric history and a normal course of pregnancy during the period between team visits are observed by a midwife at a FAP or local hospital, and are sent to the nearest local or regional hospital for childbirth. With a group of women for whom pregnancy is contraindicated, the obstetrician-gynecologist and midwife talk about the dangers of pregnancy to their health, possible complications of pregnancy and childbirth, teach them how to use contraceptives, and recommend intrauterine contraceptives. When visiting the team again, the obstetrician-gynecologist checks the obstetrician-gynecologist's compliance with the prescriptions and recommendations. Significant assistance in the early detection of pregnant women is provided by door-to-door visits conducted by a midwife. All identified pregnant women, starting from the earliest stages of pregnancy (up to 12 weeks), and postpartum women are subject to medical examination.

In the normal course of pregnancy, a healthy woman is recommended to attend a consultation with all tests and doctors’ opinions 7–10 days after the first visit, and then visit the doctor in the first half of pregnancy once a month, after 20 weeks of pregnancy - 2 times a month, after 32 weeks - 3–4 times a month. During pregnancy, a woman should attend a consultation approximately 14–15 times. If a woman is ill or has a pathological course of pregnancy that does not require hospitalization, the frequency of examinations is determined by the doctor on an individual basis. It is important that pregnant women carefully attend consultations during antenatal leave.

Hospitalization of pregnant women in medical hospitals. Very important in the work of a FAP midwife is the timely hospitalization of pregnant women in medical hospitals when initial signs of deviation from the normal course of pregnancy appear, as well as women with a burdened obstetric history. Pregnant women with a narrow pelvis (with an external conjugate of less than 19 cm), abnormal fetal position and breech presentation, immunological incompatibility of the blood of mother and fetus (including a history), extragenital diseases, and the appearance of bloody discharge from the genital tract are subject to prenatal hospitalization in medical hospitals. , edema, the presence of protein in the urine, increased blood pressure, excessive weight gain, when a multiple pregnancy is established, as well as other diseases and complications that threaten the health of a woman or child.

When sending a pregnant woman to an obstetric hospital, it is very important to choose the right method of transportation (medical transport, air ambulance), associated transport, and also correctly decide on the institution where this pregnant woman should be hospitalized. A correct assessment of the health status of a pregnant woman will allow you to avoid multi-stage hospitalization, and immediately assign the patient to the obstetric hospital where there are all the conditions for providing her with full medical care.

Carrying out childbirth at a medical facility. At the paramedic-midwife station, only normal (uncomplicated) births are provided. In cases where one or another complication occurs during childbirth (which cannot always be foreseen), the FAP midwife should immediately call a doctor or (if possible) take the woman in labor to a medical hospital. In this case, it is very important to resolve the issue of means of transportation. It must be remembered that women with unseparated placenta, preeclampsia and eclampsia, as well as with threatening uterine rupture cannot be transported. If a woman with an unseparated placenta needs to be transported due to certain complications of pregnancy, the FAP midwife is obliged, first of all, to manually separate the placenta and transport the woman with a contracted uterus.

If it is impossible to provide the woman with the necessary assistance to such an extent that she is in a state of transportability, a doctor should be called to her and a plan of further action should be outlined with him. When providing emergency pre-medical care to a pregnant and laboring woman, a FAP midwife has the right to perform the following obstetric operations and aids: turning the fetus on its leg when the uterine pharynx is fully open and the waters are intact or have just broken, removing the fetus by the pelvic end, manual separation of the placenta, manual examination of the uterine cavity , restoration of the integrity of the perineum (after a rupture of the perineum or perineotomy). If there is bleeding in the early postpartum period, the midwife must exclude rupture of the birth canal tissue. Complications that arise during childbirth require the midwife, in addition to urgently calling a doctor, to take clear organizational actions, on which the outcome of the birth largely depends. The midwife must be fully proficient in the primary methods of resuscitation of newborns born with asphyxia.

Maintaining documentation for the FAP. It is very important in the work of a FAP midwife to carefully maintain documentation. For each pregnant woman who applies to the FAP, an “Individual Card of a Pregnant Postpartum Woman” (f-111/u) is filled out. If obstetric complications or extragenital diseases are detected, a duplicate of this card is filled out and sent to the district obstetrician-gynecologist.

There are many options for storing individual cards. One of the most convenient options for work, which can be recommended, is as follows: a box for storing individual cards (the width and height of the box must correspond to the size of the card) is divided by transverse partitions into 33 cells. Each partition is marked with a number from 1 to 31. These numbers correspond to the dates of the month. When scheduling a pregnant woman's next appointment, the midwife places her card in a box marked with the corresponding date of the month, i.e., the day on which she needs to attend. Before starting work, the midwife takes out all the individual cards from the box corresponding to the day of the appointment and prepares them for the appointment - they will check the accuracy of the records and the availability of the latest tests. Having completed the appointment with the pregnant woman, he assigns her a day of subsequent appearance and places the card of this pregnant woman in a cell with a mark corresponding to the day of the month for which she is scheduled to appear. At the end of the appointment, it is easy to judge by the number of remaining cards about pregnant women who did not show up for the appointment on the day assigned to them. The midwife places these cards in the 32nd cell of the box marked “Patronage”. Then the midwife visits at home (patronizes) all women who do not show up for appointments. All cards of those who have given birth and are subject to dispensary observation until the end of the postpartum period are placed in the 33rd cell marked “Postpartum women”.

For each woman in labor, a “History of Childbirth” is filled out (f-099/u). All women who give birth in a FAP are registered in the birth register (f-098/u). In addition to these documents, the FAP keeps a diary-notebook for recording pregnant women (f-075/u) and a diary (f-039-1/u). When a pregnant woman (after 28 weeks of pregnancy) or a postpartum woman is sent to a medical obstetric hospital, she is given an “Exchange Card” (account no. 113). If a pregnant woman is hospitalized before 28 weeks, she is given an extract from the medical history (account no. 27). When leaving the hospital, she receives an extract from the medical history using the same form, which is given to her by the midwife of the FAP.

Organizing and conducting preventive examinations of rural women. An important section in the work of a midwife at a medical and obstetric station is the organization and conduct of preventive examinations of women. It is advisable to carry out preventive examinations of rural residents in the autumn-winter period in order to complete the recovery of identified patients before the start of spring field work. All work on organizing preventive examinations is led by the district obstetrician-gynecologist and the chief midwife of the district. An inspection plan is drawn up in advance, which indicates the place where the inspection will be carried out and the calendar dates for inspections for each locality. Preventive examinations are carried out by FAP midwives who have undergone special training and instruction. To successfully conduct a preventive examination, the midwife must first make a door-to-door visit, the task of which is to explain to women the purpose of the examination, the method of conducting it, and the place of the examination.

The purpose of preventive examinations is the early detection of pre-tumor, tumor, inflammatory and so-called functional diseases of the genital organs in women and the prescription of appropriate treatment if necessary. Preventive examinations also make it possible to identify among the organized part of the female population occupational hazards that affect the genital organs, and to develop measures to eliminate them. Direct examination of women consists of two sequential procedures - examination of the external genitalia, vagina and vaginal part of the cervix (using mirrors) and two-handed examinations to determine the condition of the internal genital organs.

During preventive examinations, objective diagnostic methods are used: cytological examination of vaginal discharge, “prints” from the cervix, colposcopic examination. To carry out laboratory research, material is taken from various parts of the woman’s genitourinary system:
smears from the urethra and cervical canal for bacteriological examination of Neisser gonococci and flora. The material obtained from the urethra is applied to a glass slide in the form of a circle, and from the cervical canal - in the form of a streak in the longitudinal direction;
A smear from the posterior vaginal fornix to determine the degree of purity of the vaginal contents is taken after inserting the speculum and using a stick with cotton wool wound at the end. A smear is applied to a glass slide in the longitudinal direction in the form of a line;
A smear from the side wall of the vagina for hormonal cytodiagnosis is also taken after the insertion of speculum and using a stick with cotton wool wound around its end. The stroke is applied in the form of a stroke along the glass;
a scraping smear from the surface of the cervical erosion is obtained using a spatula and applied with a stroke across the glass slide; A scraping smear from the cervical canal is taken using a Volkmann spoon and applied to the glass in the form of a circle (or several circles).

At the slightest suspicion of the presence of a disease, which arises from a midwife performing a preventive examination, the woman should be immediately referred to a doctor. In carrying out preventive examinations, it is very important to carefully register and record all women examined, for which a list of persons subject to a targeted medical examination for identification is compiled (form No. 048/u). To register and record women who are subject to active dispensary observation, dispensary observation control cards are created for them (form No. 030/u).

Another institution providing pre-hospital obstetric and gynecological care in rural areas is the collective farm maternity hospital. The following premises must be provided in a collective farm maternity hospital: a vestibule, a reception room, a labor room (10–12 sq. m), a postpartum ward (6 sq. m for 1 mother and child bed), a kitchen, and a toilet. Each collective farm maternity hospital has from 2 to 5 beds (at the rate of 1 bed per 1000 population). The collective farm maternity hospital is located at a distance of 6–8 km from the rural medical site to which it is attached. Under good transport conditions, this distance can be increased to 10–15 km. Collective farm maternity hospitals are served by a midwife, whose responsibilities are similar to those of a midwife at a FAP. If in one village near the FAP there is a collective farm maternity hospital and due to the volume of its work there is no need for an independent staff, the service of the latter is entrusted to the midwife of the FAP.

Issues of labor protection in the work of obstetrics and gynecology services. In the work of obstetric and gynecological services in rural areas at all stages, a lot of space is occupied by the issues of labor protection of female agricultural workers. Agricultural work has its own characteristics, the main of which are seasonality, the implementation of various production operations in a short time under any weather conditions. This requires significant effort and tension from a person, which inevitably leads to violations of the work and rest regime. Female agricultural workers experience additional adverse effects from production factors such as noise, vibration, dust, contact with pesticides (pesticides) and mineral fertilizers. The main work on implementing measures aimed at protecting the labor of rural residents is carried out by hygienists. But the obstetrics and gynecology service should also take part in this work, since unfavorable production factors also have a negative impact on the specific functions of the female body.

To improve the health of women employed in agriculture, it is necessary to carry out a number of organizational measures aimed at protecting the female body from the effects of adverse factors in agricultural production. This is achieved by introducing mechanization and automation of labor-intensive processes, removing women from night work and work with pesticides, from working in highly dusty conditions, reducing vibration and sound pressure to a minimum, rational alternation of work and rest, organizing sanitary facilities, ensuring timely and rational nutrition, widespread use of dispensaries, etc. Work on labor protection of female agricultural workers is carried out and controlled by special commissions, which include an obstetrician-gynecologist, a representative of the SES, a representative of a trade union organization, and a safety engineer. In monitoring compliance with all labor protection requirements for collective farmers, great responsibility lies with paramedical workers (the senior midwife of the district and the midwife of the FAP).

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

Obstetric bag equipment. 1. Instruments, care items and dressings.
Scalpel - 1
Mouth retractor - 1
Anatomical tweezers - 1
Kocher clamps - 2
Scissors - 1
Metal spatula - 1
10 ml syringe - 1
2 ml syringe - 1
Medical needles - 6
Medical gloves - 1 pair
Urethral metal catheter - 1
Sterile catgut - 2 amp.
Obstetric stethoscope - 1
Medical thermometer - 1
Medical scarf - 1
Sterile linen (set) - 1
Towel - 2
Sterile sheets - 2
Bedding - 2
Underlay oilcloths - 2
Blankets:
children's - 1
adults - 1
Cold baby diapers - 2
Iodine sticks - 10 pcs.
Compress cotton wool - 50 g
Bandages 7 m x 5 cm - 2 pcs.
Bandages 10 m x 5 cm - 3 pcs.
Sterile bags - 4
Absorbent cotton wool - 25 g
Warm baby diapers - 2
Adhesive plaster - 1 pc.
Gray cotton wool - 50 g
Packages for processing umbilical cord residues (“umbilical bags”) - 2
Fabric centimeter - 1
Package for childbirth ("birth package") - 1
Soap - 1
Surgical gloves - 1 pair
Surgical sterile silk in ampoules No. 8 - 1 amp.
Medical gowns - 2 pcs.
Harness - 1
Tonometer - 1
Eye dropper - 1
Beaker - 1
Esmarch rubber mug - 1

Medicines.
Atropine sulfate (9.1% solution in ampoules of 1 ml) - 1 amp.
Platyphylline hydrotartrate (0.2% solution in ampoules of 1 ml) - 1
Analgin (50% solution in ampoules of 2 ml) - 2
Dibazol (1% solution in ampoules of 1 ml) - 6
Papaverine hydrochloride (2% solution in ampoules of 2 ml) - 2
Cordiamine (in ampoules of 2 ml) - 3
Caffeine sodium benzoate (10% solution in ampoules of 1 ml) - 3
Calcium gluconate (10% solution in ampoules of 10 ml) - 1
Calcium chloride (10% solution in ampoules of 10 ml) - 2
Lobeline (1% solution in ampoules of 1 ml) - 1
Glucose (40% solution in ampoules of 20 ml) - 2
Adrenaline (0.1% solution in ampoules of 1 ml) - 2
Ephedrine (5% solution in ampoules of 1 ml) - 1
Diphenhydramine (1% solution in ampoules of 1 ml) - 2
Eufillin (2.4% solution in ampoules of 10 ml) - 1
Novocaine (0.5% solution in ampoules of 5 ml) - 2
Pituitrin for injection in ampoules of 1 ml - 2
Validol 0.06 g - 10 tubes.
Nitroglycerin 0.5 mg - 1 tube
Valerian tincture 30 ml - 1 fl.
Alcohol iodine solution (5%) - 1
Hydrogen peroxide (3% solution, 50 ml) - 1
Ammonia solution (10% 40 ml) - 1
Ethyl alcohol 95% - 25 ml
Boiled water - 30 ml
Isotonic sodium chloride solution for injection (0.9% solution per 20 ml)
Benzylpenicillin sodium salt 1,000,000 units - 2 fl.

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

Of great importance in promoting the prevention of abortion is the issue of modern means of contraception, the features of their action, and their effective use. It is necessary to explain which means are the most effective and harmless, and to warn against the use of harmful and ineffective means and methods. When conducting interviews, the FAP midwife must identify the following groups of women: those wishing to terminate the pregnancy; who came to the consultation after an abortion; postpartum women after discharge from the obstetric hospital; those who applied for a preventive examination; getting married.

Particular attention is paid to the use of oral contraceptives, since, provided they are taken correctly, they are among the most effective. Hormonal contraceptives are synthetic analogues of the female sex hormones estrogen and progesterone and their derivatives. When they are introduced, a state of pregnancy is created in a woman’s body, the so-called “pseudo-pregnancy”, which ensures sterility. The main mechanism for ensuring sterility with the help of oral contraceptives is to suppress ovulation, that is, the maturation and release of a mature egg from the ovary.

Advantages of using oral medications. The midwife should explain to women the positive aspects of taking hormonal contraceptives:
softening premenstrual tension;
beneficial effect on women with irregular menstrual cycles, which become more regular and menstrual bleeding often decreases; there is evidence of improvement in the condition of women suffering from iron deficiency anemia;
reducing the risk of pelvic inflammation among women using oral contraceptives;
improvement of the condition in diseases of the sebaceous glands - pimples and blackheads disappear;
relief of pain in the middle of the cycle;
providing a protective effect against rheumatoid arthritis;
there may be a decrease or increase in libido;
protective effect against the development of benign breast tumors.

However, when taking oral contraceptives, undesirable effects occur in the form of breast tenderness, weight gain of no more than 2 kg, headaches (migraines), vaginal discharge, menstrual irregularities, and sometimes spontaneous bleeding or intermenstrual uterine bleeding is observed. Contraindications to taking hormonal contraceptives are: breast cancer; all types of genital cancer; liver dysfunction; recent liver disease or jaundice; deep vein thrombosis; pulmonary embolism; cerebral vascular injury; rheumatic heart disease; phlebeurysm; cardiovascular diseases, including hypertension and diabetes with complications (in history or in the form of clinical manifestations); undiagnosed abnormal uterine bleeding; congenital hyperlipidemia. As contraindications, it is necessary to take into account age over 40 years; smoking and age over 35 years; history of acute preeclampsia during pregnancy; in nulliparous women - rare, irregular menstruation, amenorrhea, later menarche; lactation lasting less than 6 months; planned surgery; bouts of depression. The following diseases also need to be taken into account: mild hypertension (diastolic pressure above 90, but below 105 mm Hg); chronic kidney disease not accompanied by hypertension; epilepsy; migraine; diabetes mellitus without vascular complications; gallbladder diseases.

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

Before inserting the IUD, the midwife should collect instruments and devices; brief women and provide them with the necessary information; collect anamnestic data by filling out a questionnaire; reassure the woman, and also make sure that she is fully aware of the meaning of the IUD, including the advantages and disadvantages of the method, understands the procedure for inserting the IUD and the need for clinical monitoring while wearing the IUD. After insertion of the IUD, the woman must be examined for the first time after 1 month, then after 3 months. In the future, the woman should attend consultations at intervals of 6 months, appearing for examination in the period between menstruation.

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

Instruments must be sterile and ready before insertion of the IUD. Sterilization of instruments is carried out in a dry-heat oven or by boiling according to general rules according to the instructions. Sterilization of IUDs is carried out by washing them in soapy water and then placing them in a 2% chloramine solution for 3 days (with a daily change of solution). Before use, the IUD is placed in 96% ethyl alcohol for 2 hours. Leaving IUDs in alcohol for a long period of time promotes hardening, which can cause them to become brittle.

Before intrauterine contraception, women undergo a bacterioscopic examination of smears from the cervical canal, vagina and urethra for flora and degree of purity, a clinical blood test, and, if indicated, a urine test. The IUD is inserted only if the hemogram is normal, I–II - the degree of purity of the vaginal contents. The IUD is inserted on the 5th–7th day of the menstrual cycle, immediately after an uncomplicated abortion or 4–6 months after an uncomplicated birth. Sometimes it is permissible to insert an IUD on the 5th–6th day after an uncomplicated birth, provided that the postpartum period is normal. The introduction of an IUD to women who have been treated for inflammatory diseases of the uterus and appendages is possible only after 6–10 months, in the absence of exacerbation of the process.

Contraindications for IUD insertion:
Acute, subacute and chronic inflammatory diseases of the female genital organs with frequent exacerbations, including inflammatory diseases of the cervix.
Presence of pregnancy or at least suspicion of it.
Infectious and septic diseases and fever of any etiology.
Isthmic-cervical insufficiency.
History of septic (or infected) miscarriage within 3 months before the proposed IUD insertion.
Postpartum pelvic infection within 3 months before the intended insertion of the IUD.
Benign tumors and neoplasms of the female genital organs.
Polyposis of the cervical canal, leukoplakia, cervical erosion.
Polyposis, endometrial hyperplasia.
Tuberculosis of the genitals.
Menstrual irregularities (menorrhagia, metrorrhagia).
Anemia.
Disorders of the blood coagulation system (diathesis, thrombocytopathy, etc.).
Congenital or acquired anomalies of the uterus (fibromatous submucous nodes), incompatible with the design or shape of the IUD, the size of the uterine cavity not corresponding to the size and shape of the IUD.
Stenosis or obstruction of the cervical canal (danger of perforation).
Dysmenorrhea or menorrhagia with disability (history) - for hormonal IUDs.
Repeated expulsions of IUDs (especially large ones).
Allergy to substances released by the IUD (copper, antifibrinolytic substances, hormones).
No history of childbirth.

Observations on women using IUDs. Immediately after insertion of the IUD, dizziness, weakness, nausea, and pain in the lower abdomen may occur. In such cases, it is advisable to rest, administer painkillers, antispasmodics, and inhale ammonia vapors. After insertion of the IUD, minor bleeding may appear for 3–5 days or nagging pain in the lower abdomen that does not require specific therapy. Sexual abstinence is required for the first 7–10 days after insertion of the IUD.

The maximum period of stay of the IUD in the uterine cavity should not exceed 4 years, since with prolonged use the properties of the material from which the IUD is made changes; its contraceptive ability decreases. Indications for removal of the IUD: prolonged pain, bleeding such as menopause or metrorrhagia, exacerbation of the inflammatory process in the genitals, partial expulsion of the IUD, a woman’s desire to become pregnant, expiration of the IUD use period. The positive aspects of IUDs are their high efficiency, duration of use, the possibility of removal at any time, the permissibility of use during breastfeeding, and the absence of unwanted sensations during sexual intercourse.

Clinical examination of the rural population and preventive examinations. The most important section of the work of FAP medical workers is preventive medical examinations of the population, which are carried out in order to identify diseases in the initial stages and carry out the necessary therapeutic and health measures. Preventive medical examinations of the population are the initial stage of the dispensary observation system. The objectives of medical examinations are: active identification of persons with general and occupational diseases in their early stages; dynamic monitoring of the health status of persons exposed to adverse factors; identification of diseases that occur unfavorably under the influence of certain factors, as well as pathologies that may contribute to the development of an occupational disease; determination of deviations in indicators characterizing physical development and ability to work; development of recommendations aimed at improving working conditions, eliminating or significantly reducing adverse production factors; carrying out individual treatment and preventive measures based on the results of a medical examination in order to restore impaired body functions and the ability to work of the sick.

According to the classification of G.A. Novogorodtsev and co-authors, all medical examinations are divided into preliminary, periodic and targeted. Children are subject to preliminary medical examinations when they are admitted to a nursery, kindergarten, or school; pupils or students upon admission to technical schools and universities; teenagers getting a job, as well as all persons entering work in certain sectors of industry, agriculture, construction, transport, public catering, etc. Periodic medical examinations are carried out for the above groups of persons throughout their working career for dynamic monitoring of their health, maintaining their ability to work and ensuring creative longevity.

Targeted medical examinations provide for the identification of diseases that are the most common and pose a danger to ability to work and life: tuberculosis, cancer, cardiovascular diseases. In carrying out mass medical examinations, two stages are conventionally distinguished: preparatory and actual working. During the preparatory period, the contingent of persons subject to preventive examinations, the timing and place of examinations are determined, teams of doctors and paramedical workers are created and instructional and methodological meetings and seminars are held with them.

The contingents of workers and employees subject to preliminary and periodic examinations indicating occupational hazards are established by the SES, and it, in writing, in an approved form, requests lists of these persons from the heads of rural settlements and enterprises. The lists are compiled in 3 copies (for the chief physician of the Central District Hospital, SES and the head of the agricultural enterprise); The head of the personnel department, with the participation of an occupational health and safety engineer, endorses the documents, signs them with the head of the agricultural enterprise, and they are certified with a seal. The SES develops a schedule for carrying out preventive examinations, indicating the composition of the medical team and the scope of laboratory examinations. The inspection schedule must be coordinated and approved with the leadership of rural settlements and agricultural enterprises and brought to each medical institution.

The second, or actual working, period consists of the direct organization and conduct of medical examinations, and, as a rule, it begins in December in order to complete all health-improving activities by the start of mass field work. The Central District Hospital issues an order indicating the specific tasks facing the team of doctors, and a senior doctor (usually a therapist) is appointed. Preventive examinations can be carried out at the central district hospital, local hospital, or outpatient clinic. Teams of doctors can directly travel to populated areas, located at the first aid station, in premises specially adapted for examinations. The order, timing and those responsible for attending the inspection are determined by order of the head of the rural locality.

When doctors visit sites, paramedics and midwives prepare premises, appropriate equipment, instruments, clarify lists of persons to be examined, which helps doctors reduce the loss of working time and study in more detail the working conditions of specific professional groups. To attract the population to participate in inspections, radio broadcasts, publications in local newspapers, lectures, conversations, as well as individual invitations to apartments by sanitary activists and paramedics can be organized according to a set schedule. Responsibility for attendance at inspections of workers rests with the heads of agricultural enterprises and trade union organizations. At the end of the preventive inspections, a final report is drawn up for each enterprise.

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

The annual medical examination of the entire population is envisaged in 2 stages. During the period of preparation for the introduction of annual medical examination, the entire population living in the service area of ​​the FAP is personally taken into account in accordance with the “Instructions on the procedure for recording the annual medical examination of the entire population.” In rural areas, police lists of residents are compiled by paramedics of the FAP during door-to-door visits, they are clarified in village and township administrations and transferred to the local hospital (outpatient clinic). For personal registration of each resident, nursing staff fill out the “Minary Medical Examination Record Card” and number it in accordance with the outpatient medical record number (form No. 025/u). After clarifying the composition of the population, all “Medical Medical Examination Cards” are transferred to the card index.

After conducting a personal census of the entire population, the following groups are distinguished:
newborns;
children 1 and 2 years of age;
preschool children in organized groups;
schoolchildren under 15 years of age;
teenagers (schoolchildren, students of vocational schools and secondary specialized educational institutions, working teenagers aged 15–17 years);
disabled people and participants of the Great Patriotic War, participants in the war in Afghanistan, liquidators of the consequences of the accident at the Chernobyl nuclear power plant;
pregnant women; workers in industry, construction, transport, communications;
workers of communal, medical and preventive, children's and other enterprises, organizations and institutions;
machine operators, livestock breeders, field farmers, greenhouse workers and other agricultural workers;
students of higher educational institutions and students of secondary specialized educational institutions;
personal pensioners receiving medical care in a given healthcare institution;
persons under medical supervision;
other population groups not included in the above list.

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

Children's population: Annual examinations by a pediatrician (in the absence of a pediatrician - a therapist), a dentist (dentist). A pediatrician must examine children of the 1st and 2nd year of life, and before entering school - a pediatrician, neurologist and surgeon.
Nursing staff conducts: anthropometric measurements; determination of visual acuity; determination of hearing acuity; preliminary assessment of physical and neuropsychic development; tuberculin tests.
The following laboratory, diagnostic and instrumental studies: blood test (ESR, hemoglobin, leukocytes, erythrocytes); general urine analysis; stool analysis for worm eggs; blood pressure measurement from 7 years; fluorography of the chest organs from 13 years of age.

Adult population: Annual examinations by a therapist, dentist, obstetrician-gynecologist (in his absence, a midwife), and other specialists - as indicated.
Nursing staff, including FAPs, collect anamnestic data using a specially designed questionnaire; anthropometric measurement; blood pressure measurement; gynecological examination of women with taking smears (for cytological examination); determination of visual acuity; tonometry (persons over 40 years old); determination of hearing acuity, tuberculin tests (adolescents 15–17 years old).
Laboratory, diagnostic and instrumental studies: blood test (ESR, hemoglobin); urine test for sugar, urine test for protein (express method); ECG (after 40 years); fluorography (x-ray) annually; smear cytology from 18 years of age in women; mammography (fluoromammography) once every 2 years in women over 35 years of age.

The scope of research carried out during the annual medical examination of agricultural workers in the main professions includes the following groups:
machine operators;
repair shop workers (mechanics, turners, electric welders, battery workers, blacksmiths);
livestock breeders (milkmaids, cattlemen, pig farmers, calf farmers);
poultry farmers (poultry workers, operators, egg sorters, slaughterhouse workers, etc.);
plant protection agronomists, pesticide storekeepers, greenhouse workers, plant protection workers;
greenhouse workers (greenhouses, agronomists).

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

Stages of dispensary work. In dispensary work, it is necessary to stage dispensary observation, and there are 3 stages: planning work in connection with annual examinations of the organized and unorganized population (stage I); identification of populations subject to dispensary observation (stage II); carrying out active dynamic observation, treatment and rehabilitation measures (stage III). The scope of medical examinations and diagnostic studies during pregnancy and the postpartum period includes the following nosological forms: physiological pregnancy in a healthy woman, as well as a normal postpartum period. The frequency of observation by an obstetrician-gynecologist, examinations by doctors of other specialties, the name and frequency of laboratory and other diagnostic tests, basic treatment and health measures, and hospitalization were established.

LECTURE: ORGANIZATION OF MEDICAL CARE TO THE RURAL POPULATION Compiled by: senior lecturer, Ph.D. Badoeva Zaira Aslanbekovna Vladikavkaz 2013

Plan 1. Unity of principles for providing medical and 2. preventive care to urban and 3. rural populations. 2. Features of the organization of rural 3. medical care. 3. Stages of providing medical and preventive care to the rural population and the main organizations.

Protecting the health of rural residents is part of the entire healthcare system. Therefore, the basic principles inherent in healthcare in general are also characteristic of rural healthcare.

However, in rural conditions, the concept of accessibility to medical care should not be equated with territorial approximation, since this is not always possible. In this connection, we are talking about a system in which it would be possible to provide or organize the provision of timely, adequate and full medical care.

The unity of the principles of providing medical and preventive care to the urban and rural population: preventive nature, locality, mass character, specialization of medical care, universal accessibility.

Currently, the level of inpatient medical care for rural residents has almost reached the level of city residents. At the same time, the level of outpatient medical care in rural and urban populations differs significantly. The same applies to the quality of medical services.

The existing differences in the organization of medical care for the rural population are due to: the unique system of population settlement; low population density; seasonality of agricultural labor; significant remoteness of settlements from each other; reduction in the proportion of people of working age; an increase in the proportion of elderly and elderly in rural areas; insufficient development of transport links;

The level and quality of medical care for the rural population is also affected by: deterioration of the material and technical base of rural healthcare; high turnover of medical personnel; low level of provision of rural healthcare organizations with modern medical equipment;

One of the main features of providing medical care to the rural population is its staged nature. At the first stage, medical care is provided by a rural medical district. The second stage is district medical institutions: central district hospital, sanitary-epidemiological station and other medical institutions.

Stage I - previously - a rural medical district (VDU), which includes a complex of medical institutions: a) a rural district hospital (RPH, provides both outpatient and inpatient care) or a rural medical outpatient clinic (RVA, provides only outpatient care)

b) first aid station (FAP) c) health centers (if there is an industrial enterprise in the serviced area). At present, there are no emergency medical services; internal medical assistance and local hospitals are branches of the Central District Hospital, and FAPs are branches of the emergency medical service.

The main function of the stage: provision of first pre-medical aid, first qualified medical care with possible elements of specialized medical care.

FAPs - are created for medical care of 400 people or more at a distance of 2 km or more from a medical institution. When serving more than 400 people. in the FAP staff there are: 1 position of paramedic or midwife or nurse and 0.5 positions of nurse. Costs for FAPs are 1.5 -2.0% of the district budget.

Functions of the FAP: - provision of pre-medical care and timely implementation of doctor’s prescriptions; - carrying out preventive and anti-epidemic work; - organizing patronage for pregnant women and children, - carrying out measures to reduce infant and maternal mortality; - hygienic training and education of the population.

The rural medical district (VSU) served 7-9 thousand people within a radius of 7-9 km. The local hospital is the main institution at the VU, consisting of a hospital and an outpatient clinic.

Depending on the number of beds, there may be category I - 75 -100 beds, II - 50 -75 beds, III - 35 -50, IV - 25 -35 beds. The local hospital provides all types of qualified medical and preventive care.

All types of medical and preventive care for pregnant women, mothers and children are provided by the local hospital doctor. If there are several doctors, then one of them is responsible for the health of children and women in a given area.

If district hospitals are unprofitable, they are closed or repurposed into rehabilitation departments of district hospitals, and independent rural medical outpatient clinics (SVA) are opened for medical care of the population, whose staff should include: a general practitioner, a dentist, an obstetrician-gynecologist, and a pediatrician.

From the staffing standards of medical personnel of district hospitals: 1. The positions of doctors for providing outpatient care to the population are established per 10,000 population: Adult Children's population General practitioner 4.0 Pediatrician - Obstetrician-gynecologist 0.6 Surgeon 0.4 - 8.0 - 0.3 2.5 Dentist

2. The positions of doctors in hospital departments are established at the rate of 1 position: - general practitioner – for 25 beds; - pediatrician – for 20 beds; - surgeon – for 25 beds; - dentist – for 20 beds. The bed capacity of the rural district hospital is 27 -29 beds.

Organization of work of the SMS: - provision of medical and preventive assistance to the population; - introduction into practice of modern methods of prevention, diagnosis and treatment of patients; - development and improvement of organizational forms and methods of medical care for the population, improving the quality and efficiency of medical and preventive care.

organizing and carrying out a set of preventive measures among the population of the site - carrying out treatment and preventive measures to protect the health of mothers and children - studying the causes of general morbidity and morbidity with temporary disability and developing measures to reduce it -

- organization and implementation of clinical examination of the population, especially children and adolescents - implementation of anti-epidemic measures (vaccinations, identification of infectious patients, dynamic monitoring of persons who were in contact with them, etc.)

- implementation of current sanitary supervision of the condition of industrial and communal premises, water supply sources, children's institutions, public catering establishments; - carrying out treatment and preventive measures to combat tuberculosis, skin and venereal diseases, malignant neoplasms

- organization and implementation of events for sanitary and hygienic education of the population, promotion of a healthy lifestyle, including rational nutrition, and strengthening physical activity; fight against alcohol consumption, smoking and other bad habits.

Stage II – territorial medical association (TMO). The TMO is led by the Chief Physician of the TMO (he is also the chief physician of the Central District Hospital) and his deputies: - deputy for medical services to the population (he is also the head of the organizational and methodological office); - deputy for medical affairs (if the number of beds is 100 or more);

- deputy for medical and social examination and rehabilitation (with a population of at least 30,000 people served); - deputy for obstetrics and childhood (with a population of at least 70,000 people served); - Deputy for Economic Affairs; - Deputy for administrative affairs.

TMO is a complex of health care facilities that are functionally and organizationally interconnected. The TMO may include: clinics (adults, children, dental); antenatal clinics, dispensaries, hospitals, maternity hospitals; ambulance stations; children's sanatoriums and other institutions.

Principles of formation of TMO: 1. A certain population size – 2. optimal size of TMO – 100 -150 thousand population. 2. Organizational and financial separation of outpatient and inpatient facilities. 3. Coincidence of the boundaries of the TMO service area with the administrative boundaries of the district (city). 4. Rational unification of institutions - unification of institutions providing medical care to adults and children.

Functions of TMO: 1. Organization of medical and preventive care for the attached population, as well as for any citizen who seeks medical help. 2. Carrying out preventive measures. 3. Providing emergency care to patients.

4. Timely provision of medical care at the reception, at home. 5. Timely hospitalization. 6. Medical examination of the population. 7. Conducting a medical and social examination. 8. Conducting hygienic training and education. 9. Analysis of the activities of health care facilities.

At this stage, the district pediatrician and the district obstetrician-gynecologist are responsible for organizing treatment and preventive care for women and children. If the population of the district is more than 70,000 people, the position of deputy chief physician for childhood and obstetrics is appointed - an experienced pediatrician or obstetrician-gynecologist.

Stage III – regional hospital and regional medical institutions. The regional hospital is a large multidisciplinary medical and preventive institution that provides full, highly qualified, highly specialized care to residents of the region. This is a center for organizational and methodological management of medical institutions located in the region, a base for specialization and advanced training of doctors and nursing staff.

Structure of the regional hospital: 1. Hospital. 2. Advisory clinic. 3. Other departments (kitchen, pharmacy, morgue). 4. Organizational and methodological department with a medical statistics department. 5. Department of emergency and planned advisory care, etc. The bed capacity of the regional hospital is 1000-1100 beds for adults, 400 beds for children.

The children's and women's population of the region receives all types of qualified specialized medical care at the advisory clinic. Inpatient care for women is provided in regional maternity hospitals, regional dispensaries and other medical institutions in the region.