Third Year Maternity & Gynecology Nursing Skills PDF

Third year Maternity & Gynecology Nursing Skills Revised by Dr. Hanan Abd Elmohdy Emara Dr. Faten Ibrahim Elsebeiy  (4) General objectives of clinical guide line At the end of the course, each student should be able...

Third year Maternity & Gynecology Nursing Skills Revised by Dr. Hanan Abd Elmohdy Emara Dr. Faten Ibrahim Elsebeiy  (4) General objectives of clinical guide line At the end of the course, each student should be able to: Perform Antenatal assessment (Take history, physical examination investigation). Demonstrate abdominal examination during pregnancy and labor (abdominal grips). Monitor fetal heart rate. Perform vaginal examination during pregnancy and labor. Perform pitting edema assessment. Provide care of eclamptic patient. Administer magnesium sulfate. Provide care of oxytocin infusion. Monitor the progress of labor and the maternal and fetal condition partograph. Provide perineal care and episiotomy care. Provide immediate care to the new born. Demonstrate fundal and lochia assessment. Record and interpret information of labor on partograph. Identify Intra partum electronic fetal monitoring. Demonstrate Neonatal assessment. Demonstrate Neonatal resuscitation. Use effective communication techniques when counseling patients. Explain how family planning methods prevent pregnancy and their effectiveness. Determine the suitability of patient for each family planning method. Counsel a patient interested in using family planning method to make an informed choice. Provide follow up management for each family planning methods including management of minor side effects and other health problems.  (5) List of contents No learning guide title Page 1 General objectives of clinical guide line:- 4 2 List of contents 5 3 Antenatal Assessment Assist. Lect. Azza Ibrahim 6 4 Caring Eclamptic Patient. Dem. Yasmine Mahmoud 23 5 Administration Of Magnesium Sulphate. Dem. Yasmine Mahmoud 28 6 Management of first stage of labor Dem. Asmaa Mohammed 33 7 Vaginal examination during labor Assist. Lect. Noha Elsayed 45 8 Management of oxytocin infusion Assist. Lect. Fatma Talal 50 9 Intrapartum electronic fetal monitoring Dem. Asmaa Mohammed 56 10 Management of second stage of labor Dr. Hemat Moustafa 68 11 Perineal care Dem. Asmaa Mohammed 73 12 Episiotomy Assist. Lect. Fatma Talal 77 13 Management of third stage of labor Assist. Lect. Noha Elsayed 87 14 Management of fourth stage of labor Dem. Yasmine Mahmoud 93 15 Management of caesarian section Assist. Lect. Fatma Talal 102  (6) Antenatal Assessment Objectives: By the end of this section, the students will be able to: 1. Define the antenatal assessment. 2. List the components of antenatal assessment. 3. Mention the frequency of antenatal visits. 4. Discuss in details investigations done during antenatal visits. 5. Detect the gestational age by measuring the fundal height. 6. Perform leopold's maneuver to detect the presentation and so on. 7. Auscultate FHR and describe FHR abnormalities. Definition of antenatal assessment: It is the routine health evaluation of presumed healthy pregnant women without symptoms (screening), in order to diagnose diseases or complicating obstetric conditions. Purpose of antenatal assessment: 1. Prevention, early detection and treatment of pregnancy related complications as pre-eclampsia, eclampsia and haemorrhage. 2. In late pregnancy, detection of malpresentations, malpositions and disproportion that may influence the decision of labour. 3. Instruct the pregnant woman about hygiene, diet and warning symptoms. 4. Laboratory studies of parameters may affect the foetus as blood group, Rh typing, toxoplasmosis and syphilis. Frequency of antenatal visits: - Every month during the first 28 weeks. - Every 2 weeks from 28 weeks – 36 weeks. - Every week after 36 weeks. N.B: More frequent visits are indicated in high risk pregnancy.  (7) Role of the nurse during antenatal assessment: Steps Rational 1. Arrange the ante natal room by To be convenient for the work of staff Ensuring that the desk is supplied and comfortable for the patients. with cards, pencil,. Etc. Ensuring that the visual displays and posters are arranged. Ensuring that waiting area is comfortable for the clients and educational materials are available. Making sure that all instruments and equipment are available and in working order. Check and balance the scales at the beginning of the clinic. 2. Prepare instruments and To be ready for using it during apparatus required for ante natal antenatal assessment. room. 3. Greet the woman respectfully To gain her cooperation. and with kindness, introduce yourself, and offer the woman a seat. Tell the woman what you are going to do, encourage her to ask questions, and listen to what she has to say. 4. Take complete history for To gather the data about the pregnant pregnant women. women. 5. Perform physical and abdominal Abdominal examination is done to examination for women's during detect the gestational age and subsequent visits. presentation  (8) 6. Record all findings of physical To facilitate the cooperation between and abdominal examination. all the medical staff. 7. Recognize the necessary To detect any abnormality as early as laboratory investigations possible and manage it effectively. required for pregnant women during initial visit. Components of antenatal assessment: 1. Taking complete history from pregnant women. 2. Performing physical examination for women (general, abdominal and vaginal examination). 3. Performing laboratory investigations. Fist component: Taking complete history for pregnant women Steps Rational In the first visit: Consanguinity is very essential to a) Personal information:- determine the liability of hereditary Ask the woman's name, address, phone disease transmission to offspring. number, age, level of education, consanguinity, marital status, duration of marriage, religion sources of income/financial support and occupation also housing condition and crowding index. b) Medical and surgical history:- History of chronic illness is very Ask about important to manage the pregnant The previous blood transfusion. woman effectively, because she is Previous accidents involving considered as high risk woman. injury of the pelvis, tetanus immunization. Allergies from food and drug.  (9) If she has been diagnosed STDS. Chronic illnesses or conditions such as T.B, heart disease, kidney disease, sickle cell disease, DM. Surgical history of any previous operation especially pelvic surgery. c) Family history:- Theses disease run in families and the Ask the woman about any family pregnant woman is liable to have these history of such diseases as D.M, diseases. hypertension, cardiac disease, multiple pregnancy, congenital abnormalities and allergic condition such as asthma. d) Obstetrical History:- To obtain data about GPO Previous pregnancies history such G: gravid. as (length, outcome, numbers, and P: para problems of each pregnancy as O: abortion. presence of convulsion during pregnancy). Previous childbirth such as (number of children, sex, whether live or Stillbirth, problems of each childbirth such as C.S., uterine surgery). Previous postpartum (contraceptive history, complication such P. PHg, puerperal sepsis, breast feeding length and whether she had any problems such as cracked nipple, mastitis).  (10) Date of last abortion, gestational age at abortion and number of abortion. e) Daily Habits and Life Style:- To give her advice to change her daily Ask if she habits to make her pregnancy more Works outside the home, walks long safe. distances, carring heavy loads, does heavy physical labor, hours of sleep and rest. Eats any non-food substances such as dirt or clay, smokes, drinks alcohol, or uses any other possible harmful substance. f) Menstrual and Contraceptive To ask about the first day of last History:- menstrual period (LMP) to determine Ask the woman about the expected date of delivery (EDD). Age of menarche. Duration of menstrual flow, interval, amount of menstruation. Dysmenorrhea. Last menstrual period (LMP). Contraception, method, duration, acceptance or reason for termination. g) Present Pregnancy complaint To identify any pregnancy complaints (First Visit):- and consult the woman about their Ask the woman about relief measures. Symptoms of pregnancy. Quickening is the first sensation of the fetal movement by the mother, occurs at 18-20 weeks in primigravida and at 16-18 weeks in multiparas. Current symptoms, signs and  (11) problems. Environmental hazards (as smoking, radiation ………. etc.). In the return visits: To identify any problems or significant Ask the woman if changes since her last visit A medical, obstetric, social, or other concerns. If there is a change in her daily habits or lifestyle (workload, rest, dietary intake). Second component: Performing physical examination for women. A) General Examination: Steps Rational 1- Observe her general well-being:- Her gait and movement (walks steadily and without a limp). Her facial expression (is alert and responsive). Her general cleanliness (no visible dirt, no odor). Her skin (free from lesions and bruises). 2- Measure accurately woman's weight to obtain baseline for comparing and height weight gain during pregnancy and to give a rough guide to the size of pelvis. 3- Measure blood pressure and pulse. To detect any abnormality and baseline for any elevation. 4- Examine the head: To check the conjunctiva for degree  (12) Check hair for lice and nits. of redness, pallor may indicate Check the face for pallor, edema anemia). and facial expression. To note any pigmentation on Check conjunctiva. forehead and cheeks as evidence for Note any pigmentation on forehead physiological changes during and cheeks. pregnancy (Cholasma gravidarum). 5- Examine mouth for conditions of To assess the gum for any signs of gums and teeth. gingivitis. 6- Examine the neck (Palpate the Palpate the nodes below the posterior nodes below the posterior angle of angle of jawbones (swollen, tender jawbones (swollen, tender nodes). nodes) which my indicate the signs of Check the neck for the thyroid gland). infection or cancer 7- Examine the chest: (Assist with To detect any abnormality in the heart examination of the heart and lungs by or the lung or the breast. preparing the woman. Examine the breasts, nipples and areola). 8- Examine the Genitalia: To look for swelling, discharge, Touch the inside of the woman's tenderness, ulcers, and fistulas. thigh before touching genital area. Separate labia majora with two fingers, check labia minora, clitoris, urethral opening and vaginal opening. Palpate the labia minora for irregularities and nodules. Check Bartholin's glands for discharge and tenderness by inserting index finger into vagina at lower edge of opening and feel at base of each labia majora and palpate each side for swelling or tenderness. Check perineum for scar, lesions,  (13) inflammation or cracks in skin. 9- Examine the extremities: To look for signs of edema and Check the color of the palms and varicose vein. nails. Check swelling of fingers. Examine the legs, ankles and feet for shape and unequal length. Check edema over the tibia, ankle and feet. Observe legs for dilated veins. 10- Check the woman for danger signs To manage any abnormality as early as of pregnancy. possible and avoid any deterioration of N.B: danger signs of pregnancy: the pregnant woman. 1. Vaginal bleeding 2. Gush of fluid per vagina 3. Abdominal pain 4. Persistent headache 5. Blurring of vision 6. Edema of lower limbs or face 7. Persistent vomiting B) Abdominal Examination (which include inspection, palpation and auscultation of FHR): Definition: Examination of the pregnant woman to determine the normalcy of fetal growth in relation to the gestational age, position of the fetus in the uterus and its relation to the maternal pelvis. Purpose: 1. To measure the fundal height and determine the gestational age. 2. To determine the fetal lie, presentation, position and engagement. 3. To determine the possible location of the fetal heart tone.  (14) 4. To observe the signs of pregnancy. 5. To detect any deviation from normal. Steps Rational 1. Preparatory steps: To make her more comfortable 1. Ask her to empty her bladder. during examination. 2. Explain the steps of the physical To gain her cooperation. examination and obtain the woman's consent. 3. Provide her with a drape or cloth To maintain her privacy. to cover the parts of her body that are not being examined & uncover her abdomen. 2. Detection of fundal height: To estimate the period of gestation. Stand at the right of the woman 1- Inspect abdomen for scars, from a caesarean section or other surgery also for hair distribution, skin pigmentation, edema, fetal movement, shape & enlargement of the abdomen. 2- Measure fundal height (Palpate the abdomen). Place the ulnar border of the left hand just below the xiphistemum & move it down the abdomen until the fundus is felt. Measure the number of fingers, which can fit between the fundus & xiphisternum or measure the distance from the symphysis pubis to the fundus using tape measure. 3. Leopold's manuever To determine which part of the fetus  (15) 1-Carry out fundal grip:- is occupying the fundus. Stand at the woman's right side, Head is more firm, hard and round facing her face. that moves independently of the Place the palm of both hands on body. the sides of the fundus at the top Breech is less well defined that of the abdomen. moves only in conjunction with the Using the pads of the fingers. body, irregular and larger than the Apply gentle but firm pressure to head. assess consistency and mobility of the fetal part. 2-Carry out lateral grip:- To identify location of fetal back. To Move hands smoothly down, sides determine position. of uterus to feel for fetal back. Fetal back is smooth, hard, Keep dominant hand steady convex, elongated and against the side of uterus and use resistant surface. palm of other hand to apply gentle Knees and elbows of fetus but deep pressure to explore feel with a number of angular opposite side of uterus. nodulation. Repeat procedure on other side of uterus.  (16) 3-Carry out suprapubic "Pelvic To determine which part of the fetus grip":- is occupying the lower part of the Facing the woman's feet, uterus. Place the palm of both hands on the uterus just below the umbilicus with fingers close together & pointing downwards. Carry out Pawlik grip "done at 9th To determine engagement of month or 36 weeks":- presenting part. Facing the woman's head, The presenting part is not Use the right hand to grasp the engaged if it movable. lower part of uterus between the It is engaged it will become not thumb & fingers. movable.  (17) Ask woman to take deep breathes & breather out gently. Allow fingers to sink gently & deeply above the symphysis pubis to feel the size & mobility & engagement of presenting part. Auscultation of Fetal Heart Rate Intermittent Auscultation:- Intermittent (IA) is a method of fetal surveillance that utilize listening and counting the fetal heart rate for a specified amount of time at specified intervals in relation to uterine contractions. Indications: 1. Labor occurring after 37 weeks, where continuous electronic fetal monitoring is not available. 2. As an adjunct to ecobolics, where continuous electronic fetal monitoring is not available. 3. Assess FHR before: a. Initiation of labor-enhancing procedures, eg. amniotomy (rupture of membranes) b. Administration of medications c. Administration or initiation of analgesia/anesthesia d. Transfer or discharge of patient  (18) 4. Assess FHR after: a. Admission of patient b. Artificial or spontaneous rupture of membranes c. Vaginal examinations d. Abnormal uterine activity patterns, eg. increased basal tone or increased frequency of contractions e. Any abnormal event during labor, eg. maternal hypotension f. Initiation of epidural anesthesia (frequency of monitoring should be increased, to be determined by treating physician) Equipments: Pinard or Sonicad – fetoscope – ultrasonic gel – cotton.  (19) Procedure Rational 1 -Wash your hands; explain procedure 1-Hand washing helps prevent spread to client. Provide privacy of microorganisms; explanation ensure client cooperation and compliance. Privacy enhance self-esteem 2-Prepare the needed equipment. Ask 2-Organization and planning improve the women to turn onto her back with efficiency. The dorsal position is more knees flexed (a dorsal recumbent comfortable. position). 3-performing Leopold's maneuvers 3-to identify the fetal presentation and position, 4-Assess uterine contraction by 4-to listen in between contraction palpation. 5-Determine the maternal pulse rate 5-Feel the woman's pulse at wrist, simultaneously to ensure that fetal heart tones, and not maternal pulse, are being measured. 6-Place the fetoscope or Doppler over 6-as this is where the heart rate will the fetal thorax or back. usually be heard most clearly. 7-Determine the baseline fetal heart 7-As deceleration of FHR occur during rate by listening between contractions uterine contraction and return to and when the fetus is not moving. normal after it passes off Verify maternal pulse rate if necessary. 8-Note accelerations or decelerations 8- To manage non reassuring patterns from the baseline rate by counting and recording the fetal heart rate using a multiple-count strategy agreed upon by practice protocol.  (20) Interpretation: a. Reassuring i. Normal baseline FHR (110 to 160 bpm) ii. Presence of accelerations (transient increase in fetal heart rate) b. Non-reassuring i. Abnormal baseline FHR ii. Tachycardia (FHR > 160 bpm) iii. Bradycardia (FHR 180 bpm  (62) Variability : Fluctuations in the fetal heart rate Baseline variability refers to the variation of fetal heart rate from one beat to the next. Reassuring feature: ≥ 5 bpm Non reassuring feature: < 5 bpm for ≥ 40 minutes but < 90 minutes Abnormal feature: < 5 bpm for > 90 minutes Accelerations: Accelerations are an abrupt increase in the baseline fetal heart rate of greater than15 bpm for greaterthan15 seconds. The presence of accelerations is reassuring.  (63) Decelerations: Decelerations are an abrupt decrease in the baseline fetal heart rate of greaterthan15bpm for greaterthan15seconds. There are a number of different types of decelerations, each with varying significance. Early deceleration: Early decelerations start when the uterine contraction begins and recover when uterine contraction stops. This is due to increased fetal intracranial pressure causing increased vagal tone Late deceleration: Late decelerations begin at the peak of the uterine contraction and recover after the contraction ends. This type of deceleration indicates there is insufficient blood flow to the uterus and placenta.  (64) Variable deceleration: Variable decelerations are observed as a rapid fall in baseline fetal heart rate with a variable recovery phase. They are variable in their duration –depth and time may not have any relationship to uterine contractions Variable deceleration indicate fetal cord compression.  (65) Significance: Reassuring: -Baseline fetal heart rate: 120 to 160 bpm -Baseline variability: 5 to 25 bpm -Decelerations: none or early Non-reassuring: -Baseline heart rate: either of the below would be classed as non-reassuring: 100 to 109 bpm 161 to 180 bpm -Baseline variability: either of the below would be classed as non- reassuring: Less than 5 for 30 to 50 minutes More than 25 for 15 to 25 minutes -Decelerations: Variable deceleration Late decelerations for 30 minutes  (66) c. If cervical dilatation reaches or crosses the action line, this may indicate augmentation, termination of labor, or supportive therapy. d. Prolonged latent phase (8 hours of observed latent phase): review by medical staff (67)  (68) Management of Second Stage of Labor Objectives : At the end of this session, the student will be able to: 1- Define second stage of labor. 2- List the equipment required for delivery of baby. 3- Perform Ritigen maneuver of delivery of the fetal head. Definition: It is the stage of the fetal expulsion. It begins with full cervical dilatation and end with expulsion of the fetus throw the birth canal. Duration: In primigravida: it lasts from one to two hours. In multipara :it lasts 10-30 minutes. Purposes: 1-To ensure successful and uncomplicated birth of the fetus. 2-To prevent perineal laceration. Equipments: 1-For mother: Sterile gown, leggings and towel to cover the perineum during ritigen maneuver. 2-Episiotomy pack: Episiotomy scissors, local anesthesia, syringe and needle for infiltration and 4x4 gauze pieces. 3-For newborn: Scissors for cutting the cord, cord clamp, cotton balls for wipe the baby face and bulb syringe for nasal and oropharyngeal suction for the newborn. 4-Other equipments: Bowl for antiseptic solution, antiseptic solution, gown, gloves, apron, mask. The needed drugs (methergin – oxytocin – xylocaine).  (69) Normal birthing process:  (70) Management the Second Stage of Labor: STEP RATIONAL 1- Transfer mother to the delivery room once the onset of labor has been As labor progress is faster in multipara confirmed. than primipara. -Primigravida women are transferred when the cervix is completely effaced and dilated and the presenting part is pulging the perineum. -Multipara women are transferred when the cervix is 8-9 cm dilated. 1-Open the delivery pack and arrange For easy use of the equipment and the equipments and pour the cleansing timely use. solution in the bowl. 2-Place the woman in lithotomy This position gives good exposure of position - the woman lies on her back, the perineum and assess the progress legs flexed on the hips, knees flexed clearly and spread wide apart. 3-Make careful scrubing then gowning To prevent the spread of infection. and gloving. 4-Record the maternal pulse and blood To detect any abnormalities. pressure also count and record the fetal heart rate every 5 minutes and after every contraction 5-Cleansing of the vulva and the To prevent cross the infection to the surrounding parts with sterile solutions fetus during delivery (perineal care).  (71) 6-Drape the mother as following: That obtains a sterile field for delivery -put two legging on her leg. -put one towel under the mother back. -put one towel above the mother abdomen 7-Insert urinary catheter to evacuate Full bladder impeding fetal descent. the bladder if the woman cannot pass Empty bladder is important to prevent urine in first stage. bladder injury 8-Encourage the woman to bear down -Bearing down with uterine during uterine contraction. contraction help in descending the presenting part 9-Encourage the woman to take a To ensure more oxygen supply to the deep breath in between uterine fetus. contractions. 10-Delivery of the fetal head: 1-Apply upward pressure on the -Ritgen maneuver maintain perineum and downword pressure on flexion of the fetal head. the occiput (Ritgen maneuver) once and allow slow gradual the biparietal diameter (BPD) passage extension with suboccipito through the vulval ring during frontal (10cm) instead of rapid contraction and does not receed in extension with occipito between(Crowning). frontal(11.5) 2-Instruct the woman to avoid To avoid rapid extension which lead to straining after crowning perineal laceration. 3-Once the head is delivered, Swab To facilitate breathing and prevent gently the eye lid- nose and suction the aspiration of the fluid. oral and nasal passage.  (72) 4-try to slip the loop of cord around To avoid tightening around the fetal the fetal neck if present if several neck. loops apply two clamp and cut the cord in between. 11-Delivery of the shoulders: 1-Lift the fetal head upward to deliver To allow safe delivery of the shoulders the anterior shoulder then downward without vigorous traction on the fetal to deliver the posterior shoulder. neck 12-Delivery the rest of the body 13-Place two clamps on the cord about To prevent spraying the delivery field 8-10cm from the umbilicus and cut in with blood between while covering with agauze 14-Discard the disposable equipments. 15-Record the result –date and time 16-Arrange and clean the equipment  (73) Perineal care Objective: At the end of this procedure, the student nurse should be able to: Identify the purposes of perineal care. List the equipment required for perineal care. Perform an appropriate tequnique of perineal care. The perineum is the anatomic area between the urethra, the tube that carries urine from the bladder, and the anus. In women, the perineum includes the vaginal opening. This area undergoes a lot of stress and change during pregnancy and delivery, and it needs special care afterward. Perineal care is bathing the genitalia and surrounding area. Proper assessment and care of the perineal area will need professional clinical judgment. Purposes of perineal care: Perineal care is usually called “peri care” It means washing the genitals and anal area. Peri care can be done during a bath or as a separate procedure. Peri care prevents skin breakdown of perineal area, itching, burning, odor, and infections. Perineal care is very important in maintaining the clients' comfort. More frequent care is required for clients who are incontinent or for those who have an indwelling catheter. Make every effort to respect the modesty of clients and be gentle when cleansing this sensitive area. Equipment's required: 1. Gloves (non- sterile) (1 pair) 2. Sponge cloth (1) 3. Basin with warm water (1) 4. Waterproof pad or gauze 5. Towels (1) 6. Mackintosh (1) 7. Soap with soap dish (1)(or other authorized cleansing agent)  (74) 8. Toilet paper 9. Bed pan (1): as required Indications of perineal care:- 1- Patient who are unable to do self- care 2- Patient with genitor –urinary tract infection 3- Patient with incontinence of urine and stool 4- Patient with indwelling catheters 5- Postpartum women 6- Patient after surgery on the genitor-urinary system 7- Patient with injury, ulcer or surgery on perineal area Preliminary Assessment:- 1- Assess the condition of perineal skin –any itching irritation, ulcers, edema, drainage etc 2- Assess the need and frequency of perineal care 3- Assess whether perineal care should be done under an aseptic technique or clean technique 4- Assess the patient ability for self -care 5- Check the articles available in patient unit 6- Screen the bed to keep mother's privacy. 7- Place her in dorsal position and ask her to bend her knees and separate her legs. 8- Put mackintosh and towel under buttocks. Put bed pan. 9- Remove the soiled pad or dressing from above to down ward using disposable glove Procedure: For general case (without urinary catheter) STEP Rational 1.Gather all required equipment's Organization facilitates accurate skill performance 2. Explain the procedure to the client. Providing information fosters  (75) cooperation. 3. Perform hand hygiene and wear on To prevent the spread of infection gloves if available. 4. Close the door to the room and place To protect the client's privacy the screen. 5.Raise the bed to a comfortable height if Proper positioning prevents back strain. possible 6. Preparation the position: A towel or pad protects the bed. You can 1) Uncover the client's perineal area. use the towel to dry the client's perineal 2) Place a mackintosh and towel (or and rectal area. waterproof pad) under the client's hips. 7. Cleanse the thighs and groin: 1) Make a mitt with the sponge cloth. 2) Cleanse the client's upper thighs and groin area with soap and water. 3) Rinse and dry. 4) Wash the genital area next. 1.Use a separate portion of the sponge Cleanse from the pubis toward the anus towel for each stroke to wash from a clean to a dirty area. 2.Change sponge towel as necessary. Prevent contaminating the vaginal area 3.Separate the labia and cleanse and urinary meatus with organisms from downward from the pubic to anal area. the anus. 4.Wash between the labia including the urethral meatus and vaginal area. 5.Rinse well and pat dry. 8.Assist the client to turn on the side. Removing fecal material provides for Separate the client's buttocks and use easier cleaning. toilet paper, if necessary, to remove fecal  (76) materials. 9.Cleanse the anal area, rinse thoroughly, Keep the anal area clean to minimize the and dry with a towel. Change sponge risk of skin irritation and breakdown. towel as necessary. 10.Apply skin care products to the area Lotions may be prescribed to treat skin according to need or doctor's order. irritation. 11. Return the client to a comfortable To provide for comfort and safety position. 12. Remove gloves and perform hand To prevent the spread of infection hygiene. 13. Document the procedure, describing To provide continuity of care the client's skin condition. Sign the chart. Giving signature maintains professional accountability  (77) Episiotomy Objectives: At the end of this procedure, the student nurse should be able to: Define episiotomy. List the advantages of episiotomy. Identify the indications and types complications of episiotomy. List complications of episiotomy. List the equipment required for episiotomy performance. Perform an appropriate technique of episiotomy Definition: Episiotomy is surgical incision into the perineum to widen the vaginal opening. Advantages: 1. It shortens the second stage of labor. 2. It prevents perineal lacerations. The episiotomy wound is easily repaired and heals better than aperineal tear which is irregular. 3. It prevents damage of the fetus during a face or breech presentation, or during instrumental delivery. 4. It avoids compression of the fetal head andintracranial hemorrhage in case of breech delivery and preterm baby.  (78) 5. It prevents prolonged or overstretching of the pelvic floor which predisposes to genital prolapsed and stress urinary incontennce. muscles. Indications: (A)- Maternal indications:- 1. Primigravida. 2. A rigid perineum which is thick&resistant to distention as irigid perineum in elderly primigravida. 3. Soft edematous perineum and vulva. 4. Prior to an assisted delivery such as forceps & vacuum extraction. 5. After repair of genital prolapsed and recto vaginal fistula. (B)- Fetal indications:- 1. Large size baby as macrosomic baby for diabetic mother. 2. Preterm and premature fetusor small for gestational age baby. 3. Fetal malpositionas occipito-posterior position. 4. Malpresentation as breech presentation. 5. Fetal distress. Types of episiotomy: There are 3 methods of performing anepisiotomy but only two are commonly used. These are mediolateral and the median or midline technique. Types of episiotomy: 1. Medline or median 2. Mediolateral or oblique. 3. J or L-shaped. 1. Medline or median episiotomy:- The episiotomy incision is given in the midline, extending from the vaginal opening towards the anus. Advantages: Less blood loss. Less pain and dyspareunia.  (79) An easier to perform procedure. Wound repair is done easily. Better cosmetic results due to less scarring. Disadvantages: A higher incidence of damage to the anal sphincter. 2. Mediolateral episiotomy:- In a mediolateral episiotomy, the incision begins the incision begins at the midpoint of the fourchette to avoid damage to the Bartholin’sgland. It is then directed at a 45° angle to the midline towards a point between the ischial tuberosity and the anus. Advantage of a mediolateral episiotomy is that the risk for anal muscle tears is much lower. Disadvantages:- Increased blood loss More severe pain Difficult repair and is associated with more bleeding. Higher risk of long-term discomfort, especially dysparunia. 3. J or L-shaped: A midline episiotomy is done. If the wound is going to extend, the incision is carried postero-laterally.  (80) Contraindication of episiotomy: Episiotomy is contraindicated when there is a high head. In these circumstances, descent will not be assisted. Complications of episiotomy: 1. Excessive Blood Loss: This can occur either at the time of the episiotomy or after the repair. 2. Extension of the wound: The wound may extend beyond its intended limits. It may also include the anal region resulting in fecal incontinence 3. Perineal Infections: Infections are very rare, but can nevertheless occur. Necrotizing fasciitis is a rare but potentially fatal complication of episiotomy. Moreover, methicillin-resistant Staphylococcus aureus infection arising from the episiotomy site has also been reported. 4. Postpartum Perineal Pain: Excessive perineal pain after childbirth can be a sign of the formation of a hematoma, a blood clot in the wound. 5. Wound Dehiscence: Wound dehiscence is the rupture of the stitched-up wound along the line of incision that can occur after an episiotomy. However, dehiscence of an episiotomy usually occurs less than 2% of the time. 6. Dyspareunia: This is commonly known as painful sexual intercourse. It can last anywhere up to 18 months postpartum. Episiotomy during first birth and scarring of the perineum during the procedure are major risk- factors for long-term dyspareunia. 7. Perineal tears:- 1. First Degree: The tear only penetrates the vaginal lining. 2. Second Degree: The tear penetrates the vaginal lining and the underlying vaginal tissues.  (81) 3. Third Degree: T he tear extends through the vaginal lining, vaginal tissues and part of the anal sphincter. 4. Fourth Degree: The tear extends through the vaginal lining, vaginal tissues, anal sphincter and the rectal lining Equipments: Tray of anesthesia (xylocaine). Blunt-tipped scissors and two arteries. Two needles: on cutting and one round. One needle holder, four rings. Chromic catgut suture. Two gowns, two gloves and two masks. Four towels. Gauze and dressing. General instructions: The following instructions should be observed regardless of which types of episiotomy is cut:- 1. The presenting part of fetus is protected from injury. 2. A single cut in any direction is preferable to repeated snipping as the latter will have jagged ends. 3. The episiotomy should be large enough to meet the purpose.  (82) 4. The timing should be such that lacerations are prevented & unnecessary blood loss avoided. Procedure: No Items Rational Getting Ready 1 Explain what will happen to the Explanation ensures client cooperation and compliance. mother to reassure her. 2 Follow up mother s' labor To ensures the proper time for making episiotomy. progress by per vaginal examination (p.v). 3 Prepare the needed equipment Organization and planning improve efficiency. Steps of episiotomy A- Making Incision. 1 Infiltrate the local anesthesia into perineum as the following: - When the presenting part is When the presenting part distending the vulva during a is distending the vulva contraction to decrease pain. during a contraction put - Putting the first two fingers of the the first two fingers of left hand between the fetal presenting the left hand between the part and Perineum. to prevent fetal presenting part and injuring the fetal scalp. Perineum. Hold the syringe in the right hand, introduce the needle under the skin in the midline and at angle of 20% to the perineal skin.  (83) Insert the needle for a distance of about 3 cm. withdraw the plunger to ensure that the needle is not in vein, then slowly depress it while injecting 1-3 ml. of the solution. Then slowly withdraw the needle but don't remove it completely from the skin. Redirect it, still within the perineum (the needle point is 1 cm. to the right and inject a further 1-3 ml. Redirect the needle a third time to the left of the original site and infiltrate the remaining solution midline and at angle of 20% to the perineal skin. 2 Allow time for the local To make anesthesia be effective. anesthesia (7 min.)  (84) 3 Place two fingers between the Because muscles are stretched so fetal presenting part and the pain will be less. perineum when the fetal head is distending the vulva and perineum is stretched and is not retracting during contractions. 4 Single clean cut (approximately 3 cm in length) is made in a mediolateral direction, commencing at the fourchette in the midline and directing the scissors to the right at an angle of 45degree. 5 Replace the gloves with another sterile one. 6 Remove all clots from perineum. B - Repair of episiotomy 1 Locate the apex of the episiotomy.  (85) 2 Insert a roll of swabs or a pack To absolves and remove any into the vagina. remaining parts and to guard against bleeding 3 Start suturing at the apex of the wound, close the vaginal tear with a continuous No. 1 or zero catgut then suturing the muscles. 4 Close the skin over the muscles with interrupted sutures (No. 2or 3 catgut). 5 Inspect the wound, remove the To guard against any tears. vaginal pack. 6 Insert a finger into the rectum. To exclude any involvement. 7 Clean the wound and cover it To prevent spread of infection. with a sterile pad.  (86) After procedure 1 Make perineal care. To prevent spread of infection. 2 Swab with betadine on the To promote cleanliness on the episiotomy site. episiotomy site. 3 Put a sterile dressing on the To prevent spread of infection. perineal area. 4 Remove all towels from the mother. 5 Wash hands after cleaning all Hand washing helps prevent instruments. spreadof microorganisms. 6 Lift down the mother's legs and make her comfortable. 7 Clean, dry and repack the instrument. 8 Rearrange the delivery trolley and the surrounding environment  (87) Management of third stage of labor Objectives:- At the end of this procedure, the student nurse should be able to: Define 3rd stage & examination of placenta Observe signs and symptoms of placental separation. Differentiate between Duncan's and Schultz's mechanisms of placental separation. Palpate uterine firmness and assess amount of blood loss. Check size, shape, consistency & weight of the placenta. Perform fundal massage gently with adequate support of the lower uterine segment to prevent PPHge. Definition:- The third stage of labor: is the stage of placental delivery and it is the shortest stage of labor. The duration ranges from 5-30 minutes irrespective to parity. It begins with delivery of fetus & ends with delivery of placenta and fetal membranes. Mechanism of placental separation:-.  (88) (A) Schultz's mechanism (B) Duncan's mechanism ( centeral separation) (marginal separation) - Most common (80%) - Less common (20%) -Separation starts centrally. - Separation starts at lower pole. - The placenta it is delivered like - It is delivered side away presenting inverted umbrella with the fetal by its lower edge first. surface presenting first followed by the membranes with small retr-oplacental clot. - There is more liability to bleeding & -There is less liability to blood loss & retained placental part or fragments. retained placental part or fragments. Equipments:- 1. Bowel 2. A weighing machine 3. Measuring tape 4. Kidney tray 5. Gloves 6. Arteries & ringes 7. Sterile dressing & gauze Procedure:- Nursing action Rational Preparation:- 1.Maintain careful scrubbing. - To protect against any contamination. 2. Maintain privacy & explain the - To reassure mother & decrease her procedure to the mother fear & anxiety.  (89) 3.Teach mother to push during - To help in separation and contraction and take deep breathing in expulsion of placenta. between. 4.Swab the perineum & make perineal - To clean vulva & prevent care. infection. I. Conservative (physiological) management : - To ensure that the uterus well 1. Put the ulnar border of the left hand contracted or not. just above the fundus and don’t - To prevent any irregular uterine massage of the uterus contraction & to allow complete separation of the placenta. 2. Observe signs of placental separation: - To ensure separation & descent of ▪ Elongation of the umbilical cord placenta. outside vagina ▪ The uterus becomes firm, hard and globular ▪ The uterus rises in the abdomen ▪ Sudden gush of blood from the vagina ▪ Suprapubic bulging due to presence of the placenta in the lower uterine segment ▪ Loss of the cord pulsation 3. Massage the uterus - To help it to contract to stop any bleeding (as soon as the signs of placental separation & descent are detected). 4. Hold the placenta between both - To allow the sliding out of hands and rotates it as a rope. placenta & membranes with no  (90) retained parts or fragments. 5. Invert the placenta, expose maternal - To ensure that no parts of the surface and remove any clots. placenta or membranes is retained inside the uterus ( Maternal surface of the placenta red in color and consist of around 15-20 cotyledons, which are divided by septa) - To assess the presence of abnormalities such as infarctions….etc 6. Examine the 2 membranes amnion For completeness and presence of & chorion. abnormal vessels (Fetal surface of the placenta should be shiny, grey in color & attached by the umbilical cord ) 7. Inspect the cut end of the umbilical - Two arteries and one vein should cord for the presence of 3 umbilical normally be seen. Absence of an vessels & measure the umbilical artery may be associated with renal cord. abnormalities. - Average length of the cord is 55- 60cm. The cord is usually inserted in the centre of the fetal surface with blood vessels branching outwards. 8. Weigh the placenta by placing it on - A fresh, term, healthy placenta the weighing scale then discard. weighs approximately 500-600gms (1/6 of the baby’s birth weight). 9. Give ergometrin (1/2 mg) IM or - To maintain uterine contraction & synticynon (5 units) with IV prevent PPHge.  (91) infusion after the delivery of the placenta. II. Active management (Brandt-Andrews method) : 1. Give ergometrin (1/2 mg) IM or - To maintain uterine contraction & synticynon (5 units) with IV help in placental separation & infusion with crowning or with the descent. delivery of the anterior shoulder. 2. With the contraction of the uterus the placenta is delivered by controlled cord traction with as the - To support uterus and prevent following:- uterine inversion. ▪ Place the left hand above the - To help in descent and delivery of symphysis pubis pushing the placenta. uterus upward. ▪ By the right hand do gentle downwards & backwards traction of the umbilical cord. 3. The same steps (4-8) in conservative management. Post procedure:- - To remove any blood. 1. Swab the vulva then examine the - To detect & repair any tears, cervix, vagina and perineum. lacerations or episiotomy wound if present. 2. Perform perineal care and apply - To clean vulva & prevent sterile pad over vulva. infection. 3. Remove equipments, hand washing - To allow communications between & record all the findings of staff members. placental examination, umbilical  (92) cord, membranes and any complications. 4. Observe the woman carefully for (1- 2 hours) after delivery of the placenta (4th stage of labor)  (93) Magement of Fourth Stage of Labor Objectives:- At the end of this procedure, the student nurse should be able to: 1. Define fourth stage of labor. 2. Identify aim and purpose of caring woman during 4th stage of labor 3. List equipments needed in 4th stage of labor. 4. Apply nursing care during the fourth stage of labor: Definition: It is period of two hours immediately following the delivery of the fetus, placenta and membranes. Aim: 1- Examine placenta and membranes for any missed parts and abnormalities. 2- Ensure safety and comfort for the woman. 3- Prevention of P.PHge. 4- Explain to the mother to initiate breast feeding. 5- Examine the newborn for any congenital anomalies. 6- Give health teaching & implement the discharge plane. Equipments:- Prepare I.V. set and I.V. stand. 500 cc saline or ringer lactate. Equipments that needed for vital signs (stesoscope, sphygmomanometer, thermometer). Cannula, dry cotton. Antiseptic solution. Rubber sheet. Cotton and cotton with alcohol. Clean pads or dressing  (94) Plaster. Handle forceps. Procedure: Step Rationale Getting Ready : 1-Wash hands thoroughly with soap Decrease spread &transmission of and water and wear gloves infection. 2- Prepare necessary equipments Arrange the supplies make it easily reached. 3- Transfer the patient from the To ensure comfort for the woman and delivery table and remove the drapes allow for monitoring the condition. and soiled linen. 4- Remove both legs from the stirrups To prevent cramping to the legs. at the same time and then lower both leg down at the same time. 5- Provide care of the perineum with Decrease spread &transmission of antiseptic solution. infection 6-Apply ice pack to the perineum. To reduce swelling from episiotomy reduce swelling from manual manipulation during labor from all the exams 7- Apply a clean perineal pad between To keep area clean and estimate the legs. amount of blood. 8-Transfer the patient to the recovery To monitor the maternal condition in room. post delivery room and ensure comfort. 9- Ensure emergency equipment is To be ready for possible complication. available in the recovery room:  (95) a) Suction and oxygen b) Pitocin and emergency medication c) Endotracheal tube d) IV remains patent 10-Monitor vital signs and general condition: Close monitoring of vital signs is 1.Take BP, P, and R every 15 minutes important indicator for general for an hour, then every 30 minutes for condition after delivery and to detect an hour, and then every hour as long as any problem. the patient is stable. Take the patient's temperature every hour 2. Observe for any untoward effects from anesthesia. 3. Encourage the patient to drink fluids and take adequate rest. 11- Check the fundus : 1) Ensure the fundus remains firm. Monitoring fundus is important Massage the fundus until it is firm if indicator for uterine condition to avoid the uterus relax. occurrence of P.PHge. 2) Massage the fundus every 15 A boggy uterus many indicate uterine minutes during the first hour, atony or retained placental fragments. every 30 minutes during the next hour, and then, every hour.  (96) 3) Chart fundal height. Evaluate This is recorded as two fingers below from the umbilicus using the umbilicus (U/2), one finger above fingerbreadths. the umbilicus (1/U). 4) The fundus should remain in the If fundus deviated from the middle, midline. indicates distended bladder. To take appropriate action. 5) Inform the charge nurse or physician if the fundus remains boggy after being massaged 12-Monitor lochia flow: 1) Keep a pad count. &record the 1) To estimate amount to avoid post- number of pads soaked with lo chia partum hemorrhage. during recovery. 2) Identify presence of constant Bright red bleeding indicate perineal trickle of bright red bleeding or tear. blood clots. Blood clots indicate severity of bleeding or presence of missed parts. 3) Document thick, foul-smelling 3)foul-smelling lochia indicate lochia. infection 4) Document lochia flow when the fundus is massaged. (a) Every fifteen (15) minutes times one hour. (b) Every thirty (30) minutes times one hour. (c) Every hour until ready for transfer.  (97) 13- Observe the mother for chills: Occur as the result of circulatory Cover the mother with a warm changes after delivery. blanket. 14 Initiate the I.V line: To maintain state of dehydration for 1. Insert cannula using then fix it first four hours postpartum. with suitable size of plaster. 2. Prepare 500cc solution of ringer lactate. 3. Insert the I.V. set in the bottle. 4. Connect the I.V. set with the cannula. 5. Justify the rate of I.V. fluids by 30 drops / minutes. 15- Observe urinary bladder for Because it affect uterine contraction distention: and make fundus boggy and may (1) Characteristics of a full bladder. actually cause postpartum hemorrhage. (a) Bulging of the lower abdomen. (b) Spongy feeling mass between the fundus and the pubis. (c) Displaced uterus from the midline, usually to the right. (d) Increased lochia flow. 16-Monitor urine output every 1 If urinary output less than 300cc on hour: initial void after birth suggest urinary retention. 1) Document the fundal height and bladder status before the patient urinates. 2) Reevaluate and document the fundal  (98) height and bladder status after the patient urinates to accurately document an empty bladder. 17- Evaluate the perineal area for signs of edema:It may be due to: prolonged second stage, delivery of a large infant, rapid delivery and fourth degree laceration. 1) Apply an ice pack to the perineum To decrease the amount of developing as soon as possible. edema. 2) Stress the importance of peri-care and use of "sitz-baths" on the postpartum ward. 3) Assess for urinary distention which is due to edema of the urethra. 18- Assessment for perineal hematoma : 1) Look for discoloration of the perineum. perineal hematoma may indicate 2) Listen for the patient's complaints presence of perineal laceration under or expression of severe perineal pain. the skin so be aware of the condition 3) Observe for edema of the area. of the skin and how to differentiate between edema and hematoma 4) Observe / listen for patient's feeling the need to defecate if forming hematoma is creating rectal pressure. 5) Observe for patient's sensitivity of the area by touch (by sterile glove). 6) Observe for signs of hemorrhage.  (99) 19- Initiate & establish maternal The emotional and physical attachment infant bonding: between infant and mother that is initiated in the first hour or two after 1) Show the mother her baby. delivery to create positive relationship between mother and newborn. 2) Encourage woman to put her baby on her breast as soon as possible 3) Observe the mother – infant interaction during lactation and Putting baby on mother breast because woman's response toward her baby's the infant is very alert and sucking crying which indicate her acceptance reflex is very strong at this time. to her baby and stable psychological state. 20- Assess for ambulatory stability: (1) The patient should be Because patient is at risk of fainting accompanied on the first on initial ambulation after delivery ambulation and observed for due to hypovolemia from blood loss at stability. delivery and hypoglycemia from prolonged nothing by mouth (NPO) (2)The patient should be closely status. monitored while in the bathroom to prevent injury if fainting does occur. (3)The patient who received regional Most C-section patients are still anesthesia at deliver (that is, pudendal initially recovered in the recovery block) should be assessed for possible room. If not, monitor the patient as loss of sensation in the lower you would any patient in a recovery extremities. room immediately post delivery  (100) 21- Observe C-section patients: 1) monitor the fundus and lochia flow 2) Times are consistent with the normal vaginal delivery patient. Post procedure: 1- Discontinue IV line on a normal patient once she is stable and the physician has ordered removal. 2- Complete the record for woman and infant. 3-Complete note and transfer the stable patient to the ward (on normal vaginal delivery – others require physician clearance). Post-partum discharge instruction: 1- Instruct to postpone vaginal intercourse until the perineum is well healed, usually 2 to 4 weeks, or longer if significant perineal trauma occurred. 2- Continue perineal care and the use of topical agents until the perineum is healed. 3- Teach about Exercises to strengthen the abdominal muscles and goodposture and body mechanics may reduce musculoskeletaldiscomfort. 4- Stress about importance of breast feeding. 5- Instruct her to take suitable contraceptive methods. 6- Instruct woman about adequate rest. 7- Teach woman how to care incision site with aseptic technique. 8- Instruct her about nutrition and suitable food.  (101) 9- Stress about importance of drinking a lot of water to compensate loss and increase breast milk. 10- Instruct her to take fiber diet to avoid post-partum constipation 11- Teaching about signs and symptoms that should be reported physician: Fever Localized area of redness, swelling, or pain in either breast Persistent abdominal tenderness Feelings of pelvic fullness or pelvic pressure Persistent perineal pain Frequency, urgency, or burning on urination Abnormal change in character of lochia (increased amount, resumption of bright red color, passage of clots, foul odor).  (102) Management of Cesarean Section Objectives:- At the end of this procedure, the student nurse should be able to: 1.Define cesarean section. 2.Identify classification & indications of cesarean section. 3. Discuss complications of cesarean section. 4. Explain procedure of cesarean section to the women. 5. Provide care to women with cesarean section. Definition: Cesarean section is the surgical removal of the infant from the uterus through an incision made in the abdominal wall and the uterus. Classification of caesarean sections: According to the site of uterine incision 1. Upper segment caesarean section (classical C.S.): The incision is done in the upper uterine segment and it is always vertical. 2. Lower segment caesarean section (LSCS): It is the commoner type. The incision is done in the lower uterine segment and may be transverse (the usual). According to the urgency of cesarean section 1.Emergency cesarean section: Immediate threat to the life of the woman or the fetus, i.e. placental abruption: antepartum; or uterine rupture: intrapartum 2.Urgent cesarean section: No immediate risk to the life of the woman or baby but delivery should be achieved as soon as possible, i.e. three previous cesarean sections, membranes are ruptured with meconium-stained liquor: antepartum; or nonreassuring CTG and FBS is not possible or contraindicated: intrapartum  (103) 3. Nonscheduled: Delivery is needed but can fit in with delivery suite workload and allow for fasting/steroid administration and some degree of planning, i.e. preterm IUGR/PET 4. Scheduled(elective): Also referred to as elective. No urgency whatsoever, and procedure planned to suit woman, staff, delivery suite, etc. and carried out >39 weeks’ gestation during the working day (i.e. not out of hours) Indications:- Maternal indications Fetal Indications ▪ Previous C-section. ▪ Mal-presentation or mal- ▪ Ante partum hemorrhage or bleeding position. disorder. ▪ Transverse lie. ▪ Pelvic or uterine abnormality such as: ▪ Fetal macrosomia CPD,….etc ▪ Failed trial of forceps or ▪ Placental abnormality. Vacuum ▪ Severe hypertension or severe pre- ▪ Fetal distress eclampsia. ▪ Fetal anomalies or very low or ▪ Active maternal herpes simplex very high birth weight genital infection. ▪ Cord prolapse ▪ Maternal HIV infection. ▪ Multiple gestation or twins with ▪ Arrest of descent first being non vertex ▪ Prolonged & obstructed labor. ▪ Post-term gestations. Complications:- 1. Anesthetic complications. 2. Bladder, ureter and bowel injuries. 3. Injury of infant. 4. Wound hematoma. 5. Major puerperal infection, urinary tract infection or respiratory infection.  (104) 6. Pulmonary embolism. 7. Venous thromboembolism. 8. Postpartum cardiac arrest. 9. Uterine atony & postpartum hemorrhage. 10.Delayed return of bowel function 11.Uterine scars which increased risk of uterine rupture in subsequent pregnancies. 12.Potential risks in subsequent pregnancies, such as placenta previa, placenta accrete & the need for hysterectomy. Equipments / supplies:- Supplies Instruments ▪ Sterile drape sheet ▪ Forceps with teeth ▪ Sterile towels ▪ Russian forceps ▪ Sterile sponge ▪ Bonney forceps ▪ Delivery forceps ▪ Straight Mayo scissor ▪ Cord clamp ▪ Curved Mayo scissor ▪ Basin set ▪ Longer, thinner scissors ▪ Neonatal receiving unit ▪ Bandage scissor ▪ ID bands ▪ Snap ▪ Suction catheter ▪ Allis clamp ▪ Solutions ▪ Kelly clamp  (105) ▪ Syringes ▪ Kocher ▪ Sutures ▪ Babcock ▪ Medications ▪ Needle holder ▪ Ring Forceps ▪ McBurney retractor ▪ Bladder blade / doyen retractor ▪ Pratt Clamp ▪ Pennington clamp ▪ Knife handle ▪ Right angle retractor ▪ Smooth forceps (106)  (107) Procedure: STEP Rational Preparation:- - Admit the mother one or two days − To take a complete history before the proposed date for (medical, family, obstetric, Etc). cesarean section. − To carry out a full general examination to exclude factors which may result in complications (vital signs, FHR, uterine contractions & labor progress). − To perform the needed investigation (such as: Hb, CBC, platelet count, Blood grouping, Etc). - Explain the procedure, its − To decrease anxiety, fear, and gain complication to the woman. her cooperation. - Sign in the consent form. - Shave the abdomen from the − To keep incision area clean & umbilicus to the symphysis pubis prevent infection. according to type of operation. - Perform enema on the day − To maintain bowel & bladder preceding operation &Insert a empty. catheter. - Starve the mother for 6 hrs before − To avoid any complication during the operation. anesthesia (such as: aspiration, Etc). - Remove all jewelers or denatures − To avoid suffocation from and nail polish. anesthesia. - Insert cannula & administer  (108) medication as prescribed. - Dress in operating room gown - Notify obstetrician, − All health care team must be ready anesthesiologist, pediatrician and for any emergent conditions. resuscitation team with C-section - Prepare the needed sterile equipments, supplies & make sure that all equipments are present and in good operating condition prior to delivery. During procedure : 1. Position woman with a wedge − To keep the weight of the uterus off under the patient's right hip , this of her large blood vessels. occurs as soon as the patient arrive at the operating room & provide privacy 2. Placing a grounding pad under her − It is important not to place the thigh and attaching the electro grounding pad over a wet surface to cautery unit (the grounding pad or avoid any burns. return electrode for the electro cautery unit must be placed on the patient's thigh and attached to the unit before being turned on). 3. Maintain careful scrubbing & apply aseptic technique. 4. Start the sterilization of the − To prevent infection & maintain abdomen and works outward in a aseptic technique. circular motion, never going back over a previously prepped site with a used applicator.  (109) 5. Drape the woman with sterile towels exposing the site of incision. 6. Handle the needed equipment as − The physician verbally requested and count dressing, acknowledges this information. sponges and sharp instruments These counts occur at the beginning throughout C-section. of the surgery, when a body cavity Is closed, and prior to skin closure; to avoid missing any sponges, dressings or sharps instruments in the uterus or the peritoneal cavity. 7. Assist the obstetrician in cesarean − The seven layers of abdomen are section incision (an incision is the skin, fat, rectus sheath, the made in the skin and is carried rectus abdominis , the parietal through the abdominal wall to enter peritoneum (abdominal the pelvis. The skin incision may be peritoneum) , the loose made vertical (up and down) or peritoneum(pelvic peritoneum) and transverse (from side-to-side). then the layers of uterus. 8. The fetus, placenta is delivered from uterine cavity. 9. Observe carefully the conscious − To avoid any complications. level. 10.The layers of uterus then abdominal wall layers are sutured and then the skin closed with either suture or staples  (110) 11.Disinfect the incision & covered it with sterile dressing. 12.Apply immediate baby care. Post procedure:- 1. Remove the used equipments & hand washing. 2. Assess vital signs and level of − To avoid any deviation from consciousness. normal. 3. Observe and assess the wound or − To exclude postpartum bleeding & dressing site for bleeding. infection. 4. Massage the uterus & observe for − To avoid uterine atony& any excessive bleeding. postpartum hemorrhage. 5. Put the baby to the breast as soon as possible after the mother wakes − To establish maternal infant up. bounding. 6. Administer analgesics, IV fluids, − To relieve pain. uterotonic drugs (Syntocinon, − To maintain fluid balance. Syntometrine, methergine, misotac − To maintain good uterine , etc) & other medications as contraction & avoid uterine atony. ordered. 7. When the bowel sounds are − To maintain gastrointestinal present, discontinues IV fluids and motility. give warm fluids. 8. Remove the urinary catheter after 6 − To prevent urinary tract infection. hrs postoperative. 9. Encourage her to walk as much as − To prevent stasis of circulation that possible after measuring her blood may lead to deep venous  (111) pressure. thrombosis, atelectasis and pneumonia. 10.Give light diet and then a normal diet as soon as she can tolerate it. 11.Give health teaching (discharge − Many patients can be discharged 36 instructions) which include : hours after a cesarean section. ▪ Wound care 13.Keep the wound clean and dry. 14.Notify the physician's office of the following problems: (Pus seeping out of the wound, fever, painful urination, difficulty breathing shortness of breath, or increasing pain). 15.Follow up in the office for a wound check & removal of the sutures as the doctor order (on 9th or 10th day) ▪ Rest 1. Limit activity to walking for the first week, back to full activity by 6weeks 2. No driving for 10 days. 3. Refrain from intercourse for 4 to 6 weeks ▪ Diet ▪ Breast feeding ▪ Clinic visit for postnatal check 12.Family planning & child immunization