Clinical Procedures PDF

By Assist. Prof /Nawal Kamal Abd Elkhalek Assist. Prof /Mervat Mahamed Hassan Faculty of Nursing South Valley University  Clinical Procedures Index 1 The Partograph 2 2 Abdom...

By Assist. Prof /Nawal Kamal Abd Elkhalek Assist. Prof /Mervat Mahamed Hassan Faculty of Nursing South Valley University  Clinical Procedures Index 1 The Partograph 2 2 Abdominal examination 27 3 Immediate Care of the Newborn Baby 36 4 Breast self-Examination 44 5 Examination of the placenta 56 6 IUD insertion 63 7 The fundus and lochia examination 68 8 Pap test 69 9 Perineal care 72 10 Bishop score 75 11 Vaginal Examination 77 1  Clinical Procedures The Partograph Introduction Among the five major causes of maternal mortality in developing countries like Ethiopia (hypertension, haemorrhage, infection, obstructed labour and unsafe abortion), the middle three (haemorrhage, infection, obstructed labour) are highly correlated with prolonged labour. To be specific, postpartum haemorrhage and postpartum sepsis (infection) are very common when the labour gets prolonged beyond 18–24 hours. Obstructed labour is the direct outcome of abnormally prolonged labour; you will learn about this in detail in Study Session 9 of this Module. To avoid such complications, a chart called a partograph will help you to identify the abnormal progress of a labour that is prolonged and which may be obstructed. It will also alert you to signs of fetal distress. In this study session, you will learn about the principles of using the partograph, the interpretation of what it tells you about the labour you are supervising, and what actions you should take when the recordings you make on the partograph deviate from the normal range. When the labour is progressing well, the record on the partograph reassures you and the mother that she and her baby are in good health. When you have studied this session, you should be able to: 1- Define and use correctly all of the key terms printed in bold. 2- Describe the significance and the applications of the partograph in labour progress monitoring. 3- Describe the components of a partograph and state the correct time intervals for recording your observations and measurements. 4- Describe the indicators in a partograph that show good progress of labour, and signs of fetal and maternal wellbeing. 2  Clinical Procedures 5- Identify the indicators in a partograph for immediate referral to a hospital during the labour. 1- The value of using the partograph The partograph is a graphical presentation of the progress of labour, and of fetal and maternal condition during labour. It is the best tool to help you detect whether labour is progressing normally or abnormally, and to warn you as soon as possible if there are signs of fetal distress or if the mother’s vital signs deviate from the normal range. Research studies have shown that maternal and fetal complications due to prolonged labour were less common when the progress of labour was monitored by the birth attendant using a partograph. For this reason, you should always use a partograph while attending a woman in labour, either at her home or in the Health Post. In the study sessions in this Module, you have learned (or will learn) the major reasons why you need to monitor a labouring mother so carefully. Remember that a labour that is progressing well requires your help less than a labour that is progressing abnormally. Documenting your findings on the partograph during the labour enables you to know quickly if something is going wrong, and whether you should refer the mother to the nearest health centre or hospital for further evaluation and intervention. 2- Finding your way around of the partograph The partograph is actually your record chart for the labouring mother (Figure 1). It has an identification section at the top where you write the name and age of the mother, her ‘gravida’ and ‘para’ status, her Health Post or hospital registration number, the date and time when you first attended her for the delivery, and the time the fetal membranes ruptured 3  Clinical Procedures What is the difference between a woman who is a multigravida and one who is a multipara? A multigravida is a woman who has been pregnant at least once before the current pregnancy. A multipara is a woman who has previously given birth to live babies at least twice before now. On the back of the partograph (if you are not using another chart), you can also record some significant facts, such as the woman’s past obstetric history, past and present medical history, any findings from a physical examination and any interventions you initiate (including medications, delivery notes and referral(. a- The graph sections of the partograph The graph sections of the partograph are where you record key features of the fetus or the mother in different areas of the chart. We will describe each feature, starting from the top of Figure 4.1 and travelling down the partograph. Immediately below the patient’s identification details, you record the Fetal Heart Rate initially and then every 30 minutes. The scale for fetal heart rate covers the range from 80 to 200 beats per minute. Below the fetal heart rate, there are two rows close together. The first of these is labelled Liquor – which is the medical term for the amniotic fluid; if the fetal membranes have ruptured, you should record the colour of the fluid initially and every 4 hours. The row below ‘Liquor’ is labelled Moulding; this is the extent to which the bones of the fetal skull are overlapping each other as the baby’s head is forced down the birth canal; you should assess the degree of moulding initially and every 4 hours 4  Clinical Procedures Figure (1) the partograph showing where to enter the patient’s identification details at the top and the graphic component below. 5  Clinical Procedures Below ‘Moulding’ there is an area of the partograph labelled Cervix (cm) (Plot X) for recording cervical dilatation, i.e. the diameter of the mother’s cervix in centimetres. This area of the partograph is also where you record Descent of Head (Plot O), which is how far down the birth canal the baby’s head has progressed. You record these measurements as either X or O, initially and every 4 hours. There are two rows at the bottom of this section of the partograph to write the number of hours since you began monitoring the labour and the time on the clock. The next section of the partograph is for recording Contractions per 10 mins (minutes) initially and every 30 minutes. Below that are two rows for recording administration of Oxytocin during labour and the amount given. (You are NOT supposed to do this – it is for a doctor to decide! However, you will be trained to give oxytocin after the baby has been born if there is a risk of postpartum haemorrhage). The next area is labelled Drugs given and IV fluids given to the mother. Near the bottom of the partograph is where you record the mother’s vital signs; the chart is labelled Pulse and BP (blood pressure) with a possible range from 60 to 180. Below that you record the mother’s Temp °C (temperature). At the very bottom you record the characteristics of the mother’s Urine: protein, acetone, volume. You learned how to use urine dipsticks to test for the presence of a protein (albumin) during antenatal care. You learned about giving IV (intravenous) fluid therapy to women who are haemorrhaging in Study Session 22 of the Antenatal Care Module. What can you tell from the colour of the amniotic fluid? 6  Clinical Procedures If it has fresh bright red blood in it, this is a warning sign that the mother may be haemorrhaging internally; if it has dark green meconium (the baby’s first stool) in it, this is a sign of fetal distress. b- The Alert and Action lines In the section for cervical dilatation and fetal head descent, there are two diagonal lines labelled Alert and Action. The Alert line starts at 4 cm of cervical dilatation and it travels diagonally upwards to the point of expected full dilatation (10 cm) at the rate of 1 cm per hour. The Action line is parallel to the Alert line, and 4 hours to the right of the Alert line. These two lines are designed to warn you to take action quickly if the labour is not progressing normally. You should refer the woman to a health centre or hospital if the marks recording cervical dilatation cross over the Alert line, i.e. indicating that cervical dilation is proceeding too slowly. (The Action line is for making decisions at health-facility level). 3- Recording and interpreting the progress of labour As you learned in Study Session 1 of this Module, a normally progressing labour is characterised by at least 1 cm per hour cervical dilatation, once the labour has entered the active first stage of labour. Another important point is that (unless you detect any maternal or fetal problems), every 30 minutes you will be counting fetal heart beats for one full minute, and uterine contractions for 10 minutes. You should do a digital vaginal examination initially to assess: The extent of cervical effacement (look back at Figure 1.1) and cervical dilatation The presenting part of the fetus The status of the fetal membranes (intact or ruptured) and amniotic fluid 7  Clinical Procedures The relative size of the mother’s pelvis to check if the brim is wide enough for the baby to pass through. Thereafter, in every 4 hours you should check the change in: Cervical dilatation Development of cervical oedema (an initially thin cervix may become thicker if the woman starts to push too early, or if the labour is too prolonged with minimal change in cervical dilatation) Position (of the fetus, if you are able to identify it( Fetal head descent Development of moulding and caput (Study Session 2 in this Module) Amniotic fluid colour (if the fetal membranes have already ruptured). You should record each of your findings on the partograph at the stated time intervals as labour, progresses. The graphs you plot will show you whether everything is going well or one or more of the measurements is a cause for concern. When you record the findings on the partograph, make sure that: You use one partograph form per each labouring mother. (Occasionally, you may make a diagnosis of true labour and start recording on the 8  Clinical Procedures partograph, but then you realise later that it was actually a false labour. You may decide to send the woman home or advise her to continue her normal daily activities. When true labour is finally established, use a new partograph and not the previously started one.( You start recording on the partograph when the labour is in active first stage (cervical dilation of 4 cm and above). Your recordings should be clearly visible so that anybody who knows about the partograph can understand and interpret the marks you have made. If you have to refer the mother to a higher level health facility, you should send the partograph with your referral note and record your interpretation of the partograph in the note. Without looking back over the previous sections, quickly write down the partograph measurements that you must make in order to monitor the progress of labour. Compare your list with the partograph in Figure ( 1). If you are at all uncertain about any of the measurements, then re-read Sections 2. and 3. 9  Clinical Procedures 4- Cervical dilatation As you learned in Study Session 1 of this Module, the first stage of labour is divided into the latent and the active phases. The latent phase at the onset of labour lasts until cervical dilatation is 4 cm and is accompanied by effacement of the cervix (as shown in Figure 1 previously). The latent phase may last up to 8 hours, although it is usually completed more quickly than this. Although regular assessments of maternal and fetal wellbeing and a record of all findings should be made, these are not plotted on the partograph until labour enters the active phase. Vaginal examinations are carried out approximately every 4 hours from this point until the baby is born. The active phase of the first stage of labour starts when the cervix is 4 cm dilated and it is completed at full dilatation, i.e. 10 cm. Progress in cervical dilatation during the active phase is at least 1 cm per hour (often quicker in multigravida mothers.) In the cervical dilatation section of the partograph, down the left side, are the numbers 0–10. Each number/square represents 1 cm dilatation. Along 10  Clinical Procedures the bottom of this section are 24 squares, each representing 1 hour. The dilatation of the cervix is estimated by vaginal examination and recorded on the partograph with an X mark every 4 hours. Cervical dilatation in multipara women may need to be checked more frequently than every 4 hours in advanced labour, because their progress is likely to be faster than that of women who are giving birth for the first time. In the example in Figure (2), what change in cervical dilatation has been recorded over what time period? View larger image Figure (2) an example of how to record cervical dilatation (marked by Xs) and fetal head descent (marked by 0s) using a partograph. The cervical dilatation was about 5 cm at 1 hour after the monitoring of this labour began; after another four hours, the mother’s cervix was fully dilated at 10 cm. If progress of labour is satisfactory, the recording of cervical dilatation will remain on, or to the left, of the alert line. If the membranes have ruptured and the woman has no contractions, do not perform a digital vaginal examination, as it does not help to establish the diagnosis and there is a risk of introducing infection. (PROM, premature rupture of membranes, was the subject of Study Session 17 of the Antenatal Care Module). 5- Descent of the fetal head For labour to progress well, dilatation of the cervix should be accompanied by descent of the fetal head, which is plotted on the same section of the partograph, but using O as the symbol. But before you can do that, you must learn to estimate the progress of fetal descent by 11  Clinical Procedures measuring the station of the fetal head, as shown in Figure 4.3. The station can only be determined by examination of the woman’s vagina with your gloved fingers, and by reference to the position of the presenting part of the fetal skull relative to the ischial spines in the mother’s pelvic brim. View larger image Figure (3) assessing the station (descent) of the fetal head by vaginal examination, relative to the ischial spines in the mother’s pelvic brim. (Source: WHO, 2008, Midwifery Education Module: Managing Prolonged and Obstructed Labour, Figure 7.28, page 132) As you can see from Figure (3), when the fetal head is at the same level as the ischial spines, this is called station 0. If the head is higher up the birth canal than the ischial spines, the station is given a negative number. At station –4 or –3 the fetal head is still ‘floating’ and not yet engaged; at station –2 or –1 it is descending closer to the ischial spines. If the fetal head is lower down the birth canal than the ischial spines, the station is given a positive number. At station +1 and even more at station +2, you will be able to see the presenting part of baby’s head bulging forward during labour contractions. At station +3 the baby’s head is crowning, i.e. visible at the vaginal opening even between contractions. The cervix should be fully dilated at this point. Now that you have learned about the different stations of fetal descent, there is a complication about recording these positions on the partograph. In the section of the partograph where cervical dilatation and descent of head are recorded, the scale to the left has the values from 0 to 10. By tradition, the values 0 to 5 are used to record the level of fetal descent. Table 4.1 shows you how to convert the station of the fetal head (as 12  Clinical Procedures shown in Figure (3) to the corresponding mark you place on the partograph by writing O. (Remember, you mark fetal descent with Os and cervical dilatation with Xs, so the two are not confused( When the baby’s head starts crowning (station +3), you may not have time to record the O mark on the partograph! Table (1) corresponding positions of the station of the fetal head (determined by vaginal examination) and the record of fetal descent on the partograph. Station of fetal head Corresponding mark on the (Figure 4.3) partograph –3 5 –2 4 1- 3 0 2 +1 1 +2 0 Crowning means that the presenting part of the baby’s head remains visible between contractions; this indicates that the cervix is fully dilated. 6- Assessing moulding and caput formation Figure (4 ) Sutures and fontanels in the newborn’s skull. 13  Clinical Procedures The five separate bones of the fetal skull are joined together by sutures, which are quite flexible during the birth, and there are also two larger soft areas called fontanels (Figure4). Movement in the sutures and fontanels allows the skull bones to overlap each other to some extent as the head is forced down the birth canal by the contractions of the uterus. The extent of overlapping of fetal skull bones is called moulding, and it can produce a pointed or flattened shape to the baby’s head when it is born (Figure 5). Figure (5) normal variations in moulding of the newborn skull, which usually disappears within 1–3 days after the birth. Some baby’s skulls have a swelling called a caput in the area that was pressed against the cervix during labour and delivery (Figure 6); this is common even in a labour that is progressing normally. Whenever you detect moulding or caput formation in the fetal skull as the baby is moving down the birth canal, you have to be more careful in evaluating the mother for possible disproportion between her pelvic opening and the size of the baby’s head. Make sure that the pelvic opening is large enough for the baby to pass through. A small pelvis is common in women who were malnourished as children, and is a frequent cause of prolonged and obstructed labour. 14  Clinical Procedures Figure (6) A caput (swelling) of the fetal skull is normal if it develops centrally, but not if it is displaced to one side. A swelling on one side of the newborn’s head is a danger sign and should be referred urgently; blood or other fluid may be building up in the baby’s skull. a- Recording moulding on the partograph To identify moulding, first palpate the suture lines on the fetal head (look back at Figure1) and appreciate whether the following conditions apply. The skull bones that are most likely to overlap are the parietal bones, which are joined by the sagittal suture, and have the anterior and posterior fontanels to the front and back. Sutures apposed: This is when adjacent skull bones are touching each other, but are not overlapping. This is called degree 1 moulding (+1). Sutures overlapped but reducible: This is when you feel that one skull bone is overlapping another, but when you gently push the overlapped bone it goes back easily. This is called degree 2 moulding (+2). Sutures overlapped and not reducible: This is when you feel that one skull bone is overlapping another, but when you try to push the overlapped bone, it does not go back. This is called degree 3 moulding (+3). If you 15  Clinical Procedures find +3 moulding with poor progress of labour, this may indicate that the labour is at increased risk of becoming obstructed. You need to refer the mother urgently to a health facility if you identify signs of an obstructed labour. You will learn more about this in Study Session 9. When you document the degree of moulding on the partograph, use a scale from 0 (no moulding) to +3, and write them in the row of boxes provided: 0 Bones are separated and the sutures can be felt easily. +1 Bones are just touching each other. +2 Bones are overlapping but can be separated easily with pressure by your finger. +3 Bones are overlapping but cannot be separated easily with pressure by your finger. In the partograph, there is no specific space to document caput formation. However, caput detection should be part of your assessment during each vaginal examination. Like moulding, you grade the degree of caput as 0, +1, +2 or +3. Because of its subjective nature, grading the caput as +1 or +3 simply indicates a ‘small’ and a ‘large’ caput respectively. You can document the degree of caput either on the back of the partograph, or on the mother’s health record (if you have it). Imagine that you are assessing the degree of moulding of a fetal skull. What finding would make you refer the woman in labour most urgently, and why? 16  Clinical Procedures If you found +3 moulding and the labour was progressing poorly, it may mean there is uterine obstruction. 7- Uterine contractions You already know that good uterine contractions are necessary for good progress of labour (Study Session 2). Normally, contractions become more frequent and last longer as labour progresses. Contractions are recorded every 30 minutes on the partograph in their own section, which is below the hour/time rows. At the left hand side is written ‘Contractions per 10 mins’ and the scale is numbered from 1–5. Each square represents one contraction, so that if two contractions are felt in 10 minutes, you should shade two squares. On each shaded square, you will also indicate the duration of each contraction by using the symbols shown in Figure 4.7. Figure (7) Different shading on the squares you draw on the partograph indicates the strength and duration of contractions. 8- Assessment and recording of fetal wellbeing How do you know that the fetus is in good health during labour and delivery? The methods open to you are limited, but you can assess fetal condition: 17  Clinical Procedures By counting the fetal heart beat every 30 minutes; If the fetal membranes have ruptured, by checking the colour of the amniotic fluid. a- Fetal heart rate as an indicator of fetal distress The normal fetal heart rate at term (37 weeks and more) is in the range of 120–160 beats/minute. If the fetal heart rate counted at any time in labour is either below 120 beats/minute or above 160 beats/minute, it is a warning for you to count it more frequently until it has stabilised within the normal range. It is common for the fetal heart rate to be a bit out of the normal range for a short while and then return to normal. However, fetal distress during labour and delivery can be expressed as: Fetal heart beat persistently (for 10 minutes or more) remains below 120 beats/minute (doctors call this persistent fetal bradycardia). Fetal heart beat persistently (for 10 minutes or more) remains above 160 beats/minute (doctors call this persistent fetal tachycardia.) b- Causes of fetal distress There are many factors that can affect fetal wellbeing during labour and delivery. You learned in the Antenatal Care Module. The fetus is dependent on good functioning of the placenta and good supply of nutrients and oxygen from the maternal blood circulation. Whenever there is inadequacy in maternal supply or placental function, the fetus will be at risk of asphyxia, which is going to be manifested by the fetal heart beat deviating from the normal range. Other factors that will affect fetal wellbeing, which may be indicated by abnormal fetal heart rate, are shown in Box 1. 18  Clinical Procedures You learned about hypertensive disorders of pregnancy, maternal anaemia and placental abruption in Study Sessions of the Antenatal Care Module. Box 1 Reasons for fetal heart rate deviating from the normal range Placental blood flow to the fetus is compromised, which commonly occurs when there is: Hypertensive disorder of pregnancy Maternal anaemia Decreased maternal blood volume (hypovolemia) due to blood loss, or body fluid loss through vomiting and diarrhoea Maternal hypoxia (shortage of oxygen) due to maternal heart or lung disease, or living in a very high altitude A placenta which is ‘aged’ Amniotic fluid becomes scanty, which prevents the fetus from moving easily; the umbilical cord may become compressed against the uterine wall by the baby’s body Umbilical cord is compressed because of prolapsed (coming down the birth canal ahead of the fetus), or is entangled around the baby’s neck Placenta prematurely separates from the uterine wall (placental abruption). With that background in mind, counting the fetal heart beat every 30 minutes and recording it on the partograph, may help you to detect the first sign of any deviation for the normal range. Once you detect any fetal heart rate abnormality, you shouldn’t wait for another 30 minutes; count it as frequently as possible and arrange referral quickly if persists for more than 10 minutes. 19  Clinical Procedures c- Recording fetal heart rate on the partograph The fetal heart rate is recorded at the top of the partograph every half hour in the first stage of labour (if every count is within the normal range), and every 5 minutes in the second stage. Count the fetal heart rate: As frequently as possible for about 10 minutes and decide what to do thereafter. Count every five minutes if the amniotic fluid (called liquor on the partograph) contains thick green or black meconium. Whenever the fetal membranes rupture, because occasionally there may be cord prolapse and compression, or placental abruption as the amniotic fluid gushes out. Each square for the fetal heart on the partograph represents 30 minutes. When the fetal heart rate is in the normal range and the amniotic fluid is clear or only lightly blood-stained, you can record the results on the partograph, as in the example in Figure 4.8. When you count the fetal heart rate at less than 30 minute intervals, use the back of the partograph to record each measurement. Prepare a column for the time and fetal heart rate. Figure (8) Example of normal fetal heart rate recorded on the partograph at 30 minute intervals. 20  Clinical Procedures d- Amniotic fluid as an indicator of fetal distress Another indicator of fetal distress which has already been mentioned is meconium-stained amniotic fluid (greenish or blackish liquor). Lightly stained amniotic fluid may not necessarily indicate fetal distress, unless it is accompanied by persistent fetal heart rate deviations outside the normal range. The following observations are made at each vaginal examination and recorded on the partograph, immediately below the fetal heart rate recordings. If the fetal membranes are intact, write the letter ‘I’ (for ‘intact.)’ If the membranes are ruptured and: Liquor is absent, write ‘A’ (for ‘absent’) Liquor is clear, write ‘C’ (for ‘clear’) Liquor is blood-stained, record ‘B’ Liquor is meconium-stained, record ‘M1’ for lightly stained, ‘M2’ for a little bit thick and ‘M3’ for very thick liquor which is like soup Box (2) Extent of meconium staining Refer the woman in labour to a higher health facility as early as possible if you see: M1 liquor in latent first stage of labour, even with normal fetal heart rate. M2 liquor in early active first stage of labour, even with normal fetal heart rate. M3 liquor in any stage of labour, unless progressing fast. 9- Assessment of maternal wellbeing During labour and delivery, after your thorough initial evaluation, maternal wellbeing is followed by measuring the mother’s vital signs: blood pressure, pulse, temperature, and urine output. Blood pressure is 21  Clinical Procedures measured every four hours. Pulse is recorded every 30 minutes. Temperature is recorded every 2 hours. Urine output is recorded every time urine is passed. If you identify persistent deviations from the normal range of any of these measurements, refer the mother to a higher health facility. Summary of the study session In this study session, you have learned that: The partograph is a valuable tool to help you detect abnormal progress of labour, fetal distress and signs that the mother is in difficulty. The partograph is designed for recording maternal identification, fetal heart rate, colour of the amniotic fluid, moulding of the fetal skull, cervical dilatation, fetal descent, uterine contractions, whether oxytocin was administered or intravenous fluids were given, maternal vital signs and urine output. Start recording on the partograph when the labour is in active first stage (4 cm or above). Cervical dilatation, descent of the fetal head and uterine contractions are used in assessing the progress of labour. About 1 cm/hour cervical dilatation and 1 cm descent in four hours indicate good progress in the active first stage. Fetal heart rate and uterine contractions are recorded every 30 minutes if they are in the normal range. Assess cervical dilatation, fetal descent, the colour of amniotic fluid (if fetal membranes have ruptured), and the degree of moulding or caput every four hours. 22  Clinical Procedures Do a digital vaginal examination immediately if the membranes rupture and a gush of amniotic fluid comes out while the woman is in any stage of labour. Refer the woman to health centre or hospital if the cervical dilatation mark crosses the Alert line on the partograph. When you identify +3 moulding of the fetal skull with poor progress of labour, this indicates labour obstruction, so refer the mother urgently. Fetal heart rate below 120/min or above 160/min for more than 10 minutes is an urgent indication to refer the mother, unless the labour is progressing too fast. Even with a normal fetal heart rate, refer if you see amniotic fluid (liquor) lightly stained with meconium in latent first stage of labour, or moderately stained in early active first stage of labour, or thick amniotic fluid in all stages of labour, unless the labour is progressing too fast. Self-Assessment Questions (SAQs) for Study Session 4 Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module. Read Case Study 4.1 and then answer the questions that follow it. Case Study 4.1 Bekelech’s story Bekelech is a gravida 5, para 4 mother, whose current pregnancy has reached the gestational age of 40 weeks and 4 days. When you arrive at 23  Clinical Procedures her house, she is already in labour. During your first assessment, she had four contractions in 10 minutes, each lasting 35–40 seconds. On vaginal examination, the fetal head was at –3 station and Bekelech’s cervix was dilated to 5 cm. The fetal heart rate at the first count was 144 beats/min. SAQ 1 (tests Learning Outcomes 1, 2 and 3) a.What does it mean to say that Bekelech is a ‘gravida 5, para 4 mother?’ b.How would you describe the gestational age of Bekelech’s baby? c.Which stage of labour has she reached and is the baby’s head engaged yet? d.Is the fetal heart rate normal or abnormal? e.What would you do to monitor the progress of Bekelech’s labour? f.How often would you do a vaginal examination in Bekelech’s case and why? Answer a.As a gravida 5, para 4 mother you know that Bekelech has had 5 pregnancies of which 1 has not resulted in a live birth. b.At 40 weeks and 4 days the gestation is term (or full term). c.Bekelch’s cervix has dilated to 5 cm and she is having four contractions in 10 minutes of 35-40 seconds each, so she has entered the active phase of first stage labour. At -3 station, the fetal head is not yet engaged. d.The fetal heart rate is within the normal range of 120-160 beats/minute. e.As Bekelech’s labour is in the active phase and her cervix has dilated to more than 4 cm, you immediately begin regular monitoring of the 24  Clinical Procedures progress of her labour, her vital signs, and indicators of fetal wellbeing distress. You record of all these key measurements on the partograph f.You decide to do vaginal examinations more frequently than the advisory four hours, because Bekelech’s labour may progress quite quickly as she is a multigravida/multipara mother. And you keep alert to the possibility of something going wrong, because Bekelech has already lost one baby before it was born. SAQ 2 (tests Learning Outcome 2( Give two reasons for using a partograph. Answer Two key reasons for using a partograph are because: a.If used correctly it is a very useful tool for detecting whether or not labour is progressing normally, and therefore whether a referral is needed. When the labour is progressing well, the record on the partograph reassures you and the mother that she and her baby are in good health. b.Research has shown that fetal complications of prolonged labour are less common when the birth attendant uses a partograph to monitor the progress of labour. SAQ 3 (tests Learning Outcomes 1, 3, 4 and 5) a.What indicators of good progress of labour would you record on the partograph? b.What indicators of fetal wellbeing would you record on the partograph? c.How often should you measure the vital signs of the mother and record them on the partograph in a normally progressing labour? 25  Clinical Procedures d.What are the key indicators for immediate referral? Answer a.Good progress of labour is indicated by: a rate of dilation of the cervix that keeps it on or to the left of the alert line; evidence of fetal descent coinciding with cervical dilation; and contractions which show a steady increase in duration and the number in 10 minutes. b.Fetal wellbeing is indicated by: a fetal heart rate between 120-160 beats/minute (except for slight changes lasting less than 10 minutes); moulding (overlapping of fetal skull bones) of not more than +2; and clear or only slightly stained liquor (C or M1). c.In a normally progressing labour, you would measure the mother’s blood pressure (every 4 hours), pulse (every 30 minutes), temperature (every 2 hours) and urine (every time it is passed), and record them on the partograph. d.Indicators for immediate referral include: slow rate of cervical dilation (to the right of the Alert line on the partograph); poor progress of labour, together with +3 moulding of the fetal skull; fetal heartbeat persistently below 120 or above 160 beats/minute; liquor (amniotic fluid) stained with meconium, depending on the stage of labour, even with normal fetal heart rate: (refer M1 liquor in latent first stage; M2 liquor in early active first stage, and M3 liquor in any stage, unless labour is progressing fast 26  Clinical Procedures Abdominal Examination Outlines:- 1- Definition 2- Objectives 3- Equipment 4- Preparation of the mother 5- Methods of abdominal examination  Inspection.  Palpation  Auscultation 27  Clinical Procedures Definition:- It is a visual, tactile and or audible examination of the woman's abdomen. Objectives: 1. To confirm pregnancy 2. To assess fetal size and groth 3. To identify the location of fetal partes 4. To auscultate the fetal heart sounds. 5. To detect any deviation from normal Equipment 1- Pinard fetoscope or sonic fetal heart sound device. 2- Client record. Preparation of the mother:- 1- Instruct the woman to empty her bladder because a full bladder will make the examination uncomfortable and also make the measurements of fundal height less accurate. 2- Instruct the woman to lie on “supine position” on her back to relax the abdominal muscles 3- It is important that the midwife exposes only that area of the abdomen she needs to palpate; and covers the remainder of the woman. 4- Maintain privacy to aid in relaxation of the abdominal wall , the shoulders should be raised slightly on a pillow and the knees drawn up a little Methods of abdominal examination 1- Inspection. 2- Palpation 3- Auscultation 28  Clinical Procedures Steps Rational -Welcome the woman and Explain To obtain verbal consent and the procedure Co-operation -Ensure an empty bladder A Full bladder will cause discomfort and cause wrong fundal height. - provide privacy - Show respect and feeling of self value. -Position her on the examination - To relax abdominal muscles and reduce couch on her back with knees the risk of supine hypotension. slightly flexed and seperated.put pillow under her head and put arms down on her side. -Expose the abdomen fully, To maintain privacy leaving legs and pubic area covered. Inspection -Observe the abdomen for:- -shape and size in relation to the - To get a rough idea about utrine size and period of amenorrhea. muscles tone,fetal lie affects the shape ,also Indicate living fetus and his position. -Skin coditiions are three:- -Inddicate previous surgery specially C.S. I-Scars It is adark brown line from the umblica to the symphsis pubis. 2-Linea-negra It is silver or red patches or lines due to 3- striae-gravidarum found in over stretching of the skin ,found (abdomen,breasts,thighs,and buttocks. -Fetal movements 29  Clinical Procedures Note:- Palpation is done in 3 special Move:ment with warm relaxed hands and arms, using the pads of fingers in smooth movements over the abdomen To avoide discomfort to the woman and causing contraction. *Palpated using four Leopold's - To determine which part of fetus is manoeuvres occupying the fundus. First Maneuver:-Fundal Papation (foetal poles): Facing the woman,s head. Place hands palm and fingers close together on the fundus, using fingers pads palpate the fundus.-A hard smooth, round pole indicates a fetal head. -A softer triangular pole continuous with the fetal body is the fetal buttocks(breech). · Second Maneuver The lateral grip(Fetal lie): -Move both hands in a downward -To determine fetal lie. direction from the fundus along the sides of the uterus. -"Lie" is the relationship between the longitudinal axis of the foetus and the longitudinal axis of the mother. -The "lie" is usually longitudinal, hence baby is lying length- wise in the same direction as mother's longitudinal axis. -Other "lies" are transverse lie (fetus lies across the long. axis of mother) and oblique 30  Clinical Procedures lie (foetus lies at an oblique angle to the mother's long. axis). third Maneuver( Pawlik's grip): -The thumb and middle fingers of -to determine the presenting part. the right hand are placed wide apart over the suprapubic area. -Presenting part of fetus is the lowest most part of the fetus at the inlet of the pelvis(the lower fetal pole as opposed to the fetal pole in the fundus). -Cephalic or breech presentation distinguished from each other. Fourth maneuver (pelvic grip): Determines two points about the fetus 1)The attitude of the fetal head -turn around to face patients feet. -Each hand placed on either side of the fetal trunk lower down. -To detem1ine which fetal part is -The hands moved downwards occupying the lower part of the uterus(the towards the fetal head. presenting part). -Note made as to which hand first touches the fetal head (This point called cephalic prominence). -Cephalic prominence helps 31  Clinical Procedures determine the attitude (i.e. flexion, deflexed or extended) of fetal head. -If cephalic prominence is on the opposite side of fetal back, fetal head is well flexed (normal position). -If cephalic prominence on the same side as fetal back, fetal head is extended (abnormal position). -If examiners hands reach the fetal head equally on both sides, fetal head is deflexed ('Military position, indicating mal-position) 2)Engagement of the fetal head: - Continue moving both hands down around the fetal head, determine how far around the head you can get. - Engagement of the fetal head defined as having occurred once the widest transverse diameter of the fetal head has passed through the pelvic inlet into the true pelvis. - still in the lower abdomen (also called the 'false' pelvis but cannot palpate the part of fetal head in the true pelvis. - If you divide the fetal head into five-fifths, you estimate how many fifths of the fetal head can be felt. - If 5,4 or 3 fifths can still be palpated, most of the head is still up, hence the widest part of the head has not engaged into the pelvis. 32  Clinical Procedures - If only 2,1 or 0 fifths of fetal head felt, the widest part of the head has engaged into the pelvis. Leopold's manoeuvres Auscultation of the foetal heart: - Auscultated with a foetal stethoscope( Pinard's foetal stethoscope) or with a - doptone machine. - Best place to listen is over the foetal back, closer to the cephalic pole. The normal foetal heart rate is btw 110 to 160 beats per minute 33  Clinical Procedures Procedure Checklist: Leopold's Maneuver No. STEPS 2 1 0 1. Define the procedure: It is an assessment done in a detailed systemic order when a pregnant woman attended the antenatal clinic (Inspection-palpation and auscultation). 2. Identify Objective: 1) To determine the presentation and position of the fetus. 2) To determine whether lightening and engagement has occurred. 3) To identify the maximum impulse for auscultation of fetal heart beat. 4) To determine if the fetus is in normal state of flexion. 5) To determine the presence of multiple pregnancy. 6) To estimate fetal size and locate fetal parts. 3. Prepare equipment and Wash hands with warm water. 4. Prepare the woman by: Explain the procedure and Instruct to empty her bladder then instruct the woman to lie on her back, with knees flexed slightly (dorsal recumbent position) Place a small pillow or rolled towel under client's right hip. 5. Close the door or close the curtains. Properly drape the patient. 6. Perform abdominal palpation (Determine fundal level) Stand at the foot of the bed facing the face of the woman and measured in centimeters from the top of pubic bone to the top of fundus, correllates with the current weeks of pregnancy. 7. First Maneuver or fundal grip:( determine the fetal lie and presentation) Stand at the foot of the bed, facing the patient and gently place both hands flat on the abdomen palpate upper abdomen with both hands (Use palms not fingertips). Palpate gently but with firm motions ,determine if the mass palpated is the head or buttocks by observing the relative consistency ,shape ,and mobility 34  Clinical Procedures 8 Second maneuver: Umbilical Grip After the upper abdomen has been palpated and the form that is found is identified, the individual performing the maneuver attempts to determine the location of the fetal back. Still facing the woman, the health care provider palpates the abdomen with gentle but also deep pressure using the palm of the hands. First the right hand remains steady on one side of the abdomen while the left hand explores the right side of the woman's uterus. This is then repeated using the opposite side and hands. The fetal back will feel firm and smooth while fetal extremities (arms, legs, etc.) should feel like small irregularities and protrusions. The fetal back, once determined, should connect with the form found in the upper abdomen and also a mass in the maternal inlet, lower abdomen. 9 Third maneuver: Pawlick's Grip In the third maneuver the health care provider attempts to determine what fetal part is lying above the inlet, or lower abdomen. The individual performing the maneuver first grasps the lower portion of the abdomen just above the pubic symphysis with the thumb and fingers of the right hand. This maneuver should yield the opposite information and validate the findings of the first maneuver. If the woman enters labor, this is the part which will most likely come first in a vaginal birth. If it is the head and is not actively engaged in the birthing process, it may be gently pushed back and forth. The Pawlick's Grip, although still used by some obstetricians, is not recommended as it is more uncomfortable for the woman. Instead, a two-handed approach is favored by placing the fingers of both hands laterally on either side of the presenting part. 10 Fourth maneuver: Pelvic Grip The last maneuver requires that the health care provider face the woman's feet, as he or she will attempt to locate the fetus' brow. The fingers of both hands are moved gently down the sides of the uterus toward the pubis. The side where there is resistance to the descent of the fingers toward the pubis is greatest is where the brow is located. If the head of the fetus is well-flexed, it should be on the opposite side from the fetal back. If the fetal head is extended though, the occiput is instead felt and is located on the same side as the back. 35  Clinical Procedures Immediate Care of the Newborn Baby Outlines  Introduction  Immediate care of new born baby 1. clearing the air way 2. Assessment of baby's condition using Apgar score 3. Clamping and cutting the cord 4. Thermal adaptation 5. Identification 6. Care of the eyes 7. Vitamin K 36  Clinical Procedures Introduction Definition of neonatal period: The time from birth though the twenty eight day of life. During this time the neonate must make many adjustments to extra - uterine life. The following measures are designed to assist the infant in accomplishing the adaptations to extra uterine life. 1- Clearing the air way As soon as the head is born, and before the baby takes its first breath, the pharynx (mouth) and Nasopharynx (nose) must be suctioned to prevent aspiration of mucous, blood and meconium and debris into the trachea when breathing begins. This should be done using mechanical suction to minimize the risk of virus transmission. Once the baby is born it should be held down for a few moments to promote drainage of mucous and to facilitate the drainage of liquid material from pharynx by gravity. Then, the infant is transferred to a warmed bassinet. 37  Clinical Procedures 2-Assessment of baby's condition using Apgar score Apgar score is scoring system used to assess cardiopulmonary function of newborn baby Assessment by Apgar scoring is carried out at 1 minute and at 5 minute after birth for rapid evaluation of early cardiopulmonary adaptation. A score of 7 to10 is normal, 3 to 6 indicates mild to moderate distress, 0 to 2 sever distress and the infant needs resuscitation and I.C.U The infant is assigned a score of 0 to 2 in each of the five items and the scores are totaled. A Appearance (color) P Pulse (Heart rate) G Grimes (Reflexes) A Activity (muscle tone) R Respiration 38  Clinical Procedures Sign 0 1 2 Heart rate Absent < 100 b.p.m ≥ 100 b.p.m Weak cry, Respiratory effort Absent Good, crying hypoventilation Cry or active Reflex irritability No response Grimace withdrawal Some flexion of Muscle tone Limp Active motion extremities Body pink, Color Blue, pale Completely pink extremities blue NOTE:- Bradypnea: less than 15 breath /min Tachypnea: more than 60 breath /min 3-Clamping and cutting the cord The cord consists of 2 arteries and one vein, covered by substance called Wharton’s jell. The length of cord is about 50 cm. Separation of the infant from the placenta is achieved by dividing the umbilical cord between two clamps which should be applied approximately 8-10 cm from the umbilicus of the fetus. The cord is clamped and divided, as soon as pulsations have ceased. If ligation is done carelessly the baby may loss a great deal of blood very quickly. The cord ligation is applied 2-2.5 cm from the umbilicus. The cord is ligated with a special clamp or rubber bands or tapes. The blood volume of a term newborn infant is 80-100ml per kg body weight. 39  Clinical Procedures 4-Thermal adaptation Characteristics of newborns that predispose them to loss heat. The skin is thin. The blood vessels are close to the surface. Heat is readily transferred from the warmer internal areas of the surrounding air. To conserve heat, the healthy full- term infant remains in apposition of flexion. This reduces the amount of skin surface exposed to the surrounding temperatures and decreases heat loss. Methods of heat loss in the neonate:- A-Evaporation Occurs when wet surfaces are exposed to air At birth the infant loses heat when amniotic fluid on the skin evaporates. 40  Clinical Procedures Evaporation also occurs during bathing. Thus drying the infant as quickly as possible at birth and after bathing helps prevent excessive heat loss. B-Conduction Occurs when new born come in direct contact with objects that are cooler than their skin. Placing infants on cold surfaces such as (scales or touching them with cold hands or a cold stethoscope causes this type of heat loss). The reverse is also true, that is wrapping newborns in warm blankets or placing them against the mother's skin can protect them against heat loss. C-Conviction Occurs when heat is transferred to air surrounding the infant by currents of cool air passing over the surface of this body. Maintaining warm environmental temperatures help to prevent this type of heat loss. Oxygen should be warmed before administration. Newborns are often placed in incubators for a short time after birth so that the surrounding temperature can be controlled to prevent convective heat loss. D-Radiation Is the transfer of heat to cooler objects that are not in direct contact with the infant. For examples:- Infants placed near cold windows loss heat by radiation. 41  Clinical Procedures Infants should be kept away from windows and outside walls to minimize radiant heat loss. Small amounts of heat are lost through respiration and in urine and faces. It is important for the midwives to ensure that they employ measures to minimize heat loss at delivery by ensuring that the delivery room temperature is 21-24 C and encouraging skin to skin contact with the mother to promote heat gain. Covering the baby head is of particular importance 5-Identification When babies are in hospital, it is necessary that they are readily identifiable one from another. Various methods of indicating identity can be employed. e.g.:- Name bands are applied usually one on the infant's wrist and one on the ankle. Each contain the family name, sex of the infant, 42  Clinical Procedures and date and time of birth.name bands should remain on the baby until his discharge from hospital. 6-Care of the eyes Before the baby is transferred to the nursery the eyes must be receive prophylactic treatment to prevent ophthalmic neonatorum. The most common medication for eye prophylaxis is: tetracycline and erthromycin ointment. 7-Vitamin K Hemorrhagic disease of the new born is acumination which results from a deficiency of vit-K one dose of vit-K prevents bleeding problems until the infant is able to produce it on his her own. Vitamin K is given to the neonate within the first hour after birth intramuscularly injection of 0.5 mg to 1 mg of water soluble vit.K. This can be prevent hemorrhagic disease. Note: Post natal bleeding tendency occurs as a result of: In ability of synthesize vit. K Immaturity of liver in terms of production of prothrombin and other clotting factors 43  Clinical Procedures Breast self Examination Introduction:- Monthly breast self-exams should always include: visual inspection (with and without a mirror) to note any changes in contour or texture; and manual inspection in standing and reclining positions to note any unusual lumps or thicknesses. The best reason for performing monthly breast self examinations is the fact that 90 percent for all lumps and Just under half of all breast cancers are actually discovered by women or by their partners. As with all tumors, early detection leading to early treatment is the single most important factor in successful tumor removal and preservation of the breast. As in all types of cancer, early detection and treatment saves lives. Definition:- Is a method of finding abnormalities of the breast, for early detection of breast cancer? The method involves the women herself looking at and feeling each breast for possible lumps, or swelling. Breast self examination is the only non invasive procedure that can be regularly performed between internal breast imaging and clinical breast examination (CBE). The purpose of a Breast Self-Exam  To learn the topography of the breasts.  Knowing how the breasts normally feel will allow you to notice changes in the future. 44  Clinical Procedures  There is a three-pronged attack one can make in order to detect breast cancer: o Breast Self-Examination: Feeling your breasts. o Mammography: An X-ray of your breast. o Clinical Breast Examination (CBE): When an experienced doctor examines the breasts. Time of performing Breast Self-Examination Women older than 20 years should perform it on a regular monthly basis about 1 week after the onset of each menstrual period, when the breasts are typically not tender or swollen. BSE is most effective when it uses a dual approach incorporating both inspection and palpation. After menopause, BSE should be performed on the same day each month (chosen by the woman for ease of remembrance). Time required: 15 minutes a month Equipments:-  A mirror which lets you see both breasts.  A pillow for your head and shoulders.  Privacy. The Seven Ps methods:- Similar method of self-examination is known as the seven' Ps of BSE:- 1. Position: Inspect breasts visually and palpate in the mirror with arms at with various positions. Then perform the examination lying 45  Clinical Procedures down, first pillow under one shoulder, then with a pillow under the other shoulder, and finally lying flat. 2. Perimeter: Examine the entire breast, including the nipple, the axillary's tail that extends into the armpit, and nearby lymph nodes. 3. Palpation: palpate with the pads of the fingers, without lifting the fingers as they move across the breast.. 4. Pressure: First palpate with light pressure, then palpate with moderate pressure, and finally palpate with firm pressure. 5. pattern: There are several examination patterns, and each woman should use the one which is most comfortable for her.the vertical strip pattern involves moving the fingers up and down over the 46  Clinical Procedures breast.the pie-wedge pattern starts at the nipple and moves outward.the circular pattern involves moving fingers in concentric circles from the nipple outward.don't forget to palpate into the axilla. 6. Practice: practice the breast self exam and become familiar with the feel of the breast tissue, so you can recognize changes. A health care practitioner can provide feedback on your method. 1. Plan: know what to do if you suspect change in your breast tissue.know your family history of breast cancer.have mammography done as often as health care provider recommends. Instructions before doing breast self- examination:- a. Start checking your breasts when you are at 20 years or older. b. Mark your calendar to help you remember to do BSE on a regular schedule. One easy way to remember to do BSE is to do the exam on the same day of each month. 47  Clinical Procedures c. Do your BSE one week after your monthly period. This is the time when your breasts may be the least swollen, lumpy, or tender. d. If you are pregnant or have gone through menopause (change of life), do a BSE on the same day of each month. e. Use your fingertip pads to do the exam. Fingertip pads are the top parts of your fingers. f. Use three types of pressure while you do your BSE. First, press lightly. Second, press with medium pressure to feel a little deeper into the breast. Last, use firm pressure to feel deep within your breast. g. Use small circles to feel your breast tissue. Use your fingertip pads to make overlapping circles on your breast and armpits. h. Examine your entire breast area using up and down lines. Talk to your caregiver and make your own personal decision about doing BSE. (Fig.1). BSE involves the following:-  General Visual Exam (looking) 48  Clinical Procedures 1. Look for changes in symmetry, contour, shape, and overall texture of the breasts. 2. Look for dimpling, scaling, redness, sores, and enlarged pores in the skin. 3. Look for discharge, scaling, sores, puckering, and inversion of the nipples. Change color, size or texture Skin dimpling Nipple discharge  General Touch Exam (Palpation and feelling) Feel for unusual lumps, bumps, thickenings, and tender or enlarged lymph nodes in the breasts, under the arms, along the collarbone, and in center of chest between the breasts. The Five Steps of a Breast Self-Exam Step 1: Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips. Breast Self-Exam – Step 1 49  Clinical Procedures Here's what you should look for:  Breasts that are their usual size, shape, and color  Breasts that are evenly shaped without visible distortion or swelling If you see any of the following changes, bring them to your doctor's attention:  Dimpling, puckering, or bulging of the skin  A nipple that has changed position or an inverted nipple (pushed inward instead of sticking out)  Redness, soreness, rash, or swelling Step 2: Now, raise your arms and look for the same changes. Breast Self-Exam - Steps 2 and 3 Step 3: While you're at the mirror, look for any signs of fluid coming out of one or both nipples (this could be a watery, milky, or yellow fluid or blood). Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few finger pads of your hand, keeping 50  Clinical Procedures the fingers flat and together. Use a circular motion, about the size of a quarter. Cover the entire breast from top to bottom, side to side — from your collarbone to the top of your abdomen, and from your armpit to your cleavage. Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were mowing a lawn. This up-and-down approach seems to work best for most women. Be sure to feel all the tissue from the front to the back of your breasts: for the skin and tissue just beneath, use light pressure; use medium pressure for tissue in the middle of your breasts; use firm pressure for the deep tissue in the back. When you've reached the deep tissue, you should be able to feel down to your ribcage. Breast Self-Exam - Step 4 Step 5: Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your 51  Clinical Procedures entire breast, using the same hand movements described in Step 4.and press on nipple between fingers Breast Self-Exam - Step 5 Tips for Doing Your BSE 1. Mark your calendar to remind yourself to do your BSE regularly. This is a good way to prevent worry if find a normal cyclic change. 2. Stay relaxed and breathe normally as you do your BSE. Becoming tense will produce some knots that you may mistake for something worrisome. 3. Report any changes or unusual pain to your doctor or nurse practitioner. Keep a log of changes, if that helps you remember. 4. Remember to have an annual clinical exam and a mammogram. 52  Clinical Procedures Procedure Checklist: Breast Exam No. STEPS 2 1 0 1. Welcome the woman and, introduce yourself. 2. Define the procedure: It is a technique by which a thorough inspection and palpation of the breast is made during antenatal and postnatal period in order to collect data about the breast condition of the mother. 3. Identify the Objectives:  To discover any abnormalities that causes harm or problem as early as possible.  To detect early any breast lesion.  To learn how to examine breast for self and for others.  To encourage BSE practice.  To reinforce the woman's confidence in BSE ability.  To assess the breast size, shape, contour, elasticity and symmetry. (in antenatal period)  To assess the nipple for type, size and secretions.  To examine the areola and nipple for evidence of blisters, cracks or fissures  To assess the breast for signs of engorgement, mastitis or abscess (in postpartum period)  To check the beast tissue for presence of lump or cyst that may require further medical evaluation.  To detect and treat early any abnormalities or complication. 4. Place the woman on the examination couch and Explain the procedure to her. 5. Drape the woman and keep the doors and curtain closed. 6. Wash your hands. 53  Clinical Procedures 7. Inspection: a) On sitting position: Ask the client to sit in comfortable position facing the examiner  With arm relaxed at sides.  With arms held over head.  With hands on hips ,pressing in to contract the chest muscles b) On the supine position: Ask the client to assume the supine position and put her right arm over her head and inspect the right breast (Reverse this step for the left breast). 8. Palpation :examine the right breast on the supine position:  Put right hand behind head. Use pads of fingers of left hand, held flat together, gently press on the breast tissue using small circular motion, imagine the breast as a face of a clock. Beginnings at the top (12 O' clock position) make a circle around the outer area of the breast.  Move in one finger width, continue in smaller and smaller circles until you have reached the nipple (cover all areas including the breast tissues leading to the axilla)  Reverse the procedure to the left breast. Underarm Examination: 9.  Examine the left under arm area with arm held loosely at side. Cup the finger of the opposite hand and insert them high into the underarm area. Draw finger down slowly, pressing in circular pattern, covering all areas.  Reverse the procedure for the right underarm 10. Nipple Examination Gently squeeze the nipple of each breast between the thumb and index finger to check for discharge. 54  Clinical Procedures 11. Assist the woman to get down from examination table and redress her clothes, then wash hands 12. Report abnormality. 13. Record findings and woman's reaction. Total mark 55  Clinical Procedures Examination of the placenta Outlines:- 1- Definition 2- Mature placenta 3- The objectives 4- The clinical characteristics of normal placenta 5- Structure of the placenta 6- Surface of the placenta: 7- Functions of Placenta 8- The steps of placental examination: 56  Clinical Procedures Definition: Is a flat organ measuring about 17.5- 20 cm in diameter, and 2.5 cm thickness, it weight about one-six of the body birth weight at full term and formed by the 12th weeks of pregnancy. OR: Is a complex organ that originate from trophoblastic layer of the fertilized ovum. Mature placenta:  Placenta is completely formed and functioning 10-12 wks after fertilization  12-20 weeks, it weight more than the fetus because fetal organs are insufficiently developed to cope with metabolic process of nutrition.  Later in pregnancy: organs begin to function as liver, so (cytotrophoblast and syncytiotrophoblast) placenta gradually degenerate The objectives:  Identify the size, shape, consistency and completeness of the placenta.  Determine the presence of accessory lobes, placental infarcts, haemorrhage and tumors.  Assess the umbilical cord for length, insertion, number of vessels, thrombosis, knots and the presence of wharton's jelly.  Evaluate the colour and the odour of the fetal membranes The clinical characteristics of normal placenta: Diameter: 22cm at term. 57  Clinical Procedures Thickness: 2 to 2.5 cm. Weight: 470 g The umbilical cord: length: 55 to 60 cm at term Diameter: 2 to 2.5 cm. The structure: should have 2 arteries and one vein. Normal cord contains Wharton's Jelly. Surface of the placenta:  The maternal surface: dark red in colour, it should be divided in cotyledons. The structure should be complete, with no missing cotyledons.  The fetal surface: of the placenta should be shiny, gray and translucent enough to see the colour of the underlying villous tissues. Functions of Placenta 1- Respiration: No pulmonary exchange of gases can take place, so fetus must obtain oxygen and excrete carbon dioxide through placenta. Oxygen from the mother's hemoglobin passes into fetal blood by simple diffusion, for co2 also 2- Nutrition : Fetus needs nutrition for growth and development. Such as protein, carbohydrates, calcium and phosphorus, iron and minerals, these nutrients are actively transferred from the maternal to the fetal blood through wall of villi. 58  Clinical Procedures 3- Storage: The placenta metabolizes glucose, store it in the form of glycogen and reconvert it into glucose as required. It also stores iron and fat-soluble vitamins. 4- Excretion: The main substances excreted from the fetus is co2 , bilirubin excreted as red blood cells and very amount of urea and uric acid. 5- Protection: Placenta provide limited barriers to infection, some substances as alcohol, chemical of smoking cigarettes , Some virus as cytomegalovirus, and rubella are not filtered out causing congenital anomalies. 6- Endocrine : Secretes hormones such as:  Human chorionic gonadotrphin (HCG(  Oestrogen  Progestrone.  Human placental lactogen (HPL) The steps of placental examination: 1- Delivery of the placenta  As the placenta delivers, hold it in both hands and gently turn it until the membranes are twisted.  Slowly pull to complete the delivery. move membranes up and down until they deliver 59  Clinical Procedures  If the membranes tear, gently examine the upper vagina and cervix wearing sterile gloves and use a sponge forceps to remove any remaining pieces of membrane.  Place the placenta in the receptacle provided (for later examination). 2- Examination the placenta: Step 1:- Wash hands; wear an apron and gloves. Step 2: - Explain the procedure to the parents and ask if they want to observe. Step 3: - Ensure that there is adequate lighting to check the placenta. Step 4: - Prepare a flat surface with protection to avoid blood spillage. Step 5:- Prepare syringe and needle if cord samples are required. Step 6:- Lay out the placenta with the fetal surface uppermost - noting shape, size, colour and smell. Step 7: - Examine the cord, noting the length, insertion point and presence of true knots or thrombi. Step 8: - Inspect the umbilical cord vessels at the cut end at the furthest point from the placenta as the arteries can be fused around the insertion site making it difficult to differentiate them. Step 9: - Count the vessels in the cut end of the cord; the absence of one of the arteries can be associated with renal agenesis. 60  Clinical Procedures Step 10 -Observe the fetal side for irregularities such as succenturate lobes, missing cotyledons, fatty deposits or infarctions Step 11 -observe the membranes and inspect for completeness. There should be a single hole present where the baby has passed through the membranes. Step 12 -Separate the amnion from the chorion by pulling the amnion back over the base of the umbilical cord to ensure both are present. Step 13 -Turn the placenta over to inspect the maternal side. Step 14 -Examine the cotyledons, ensuring all are present, noting the size and any areas of infarction, blood clots or calcification. Retain the clots to make an accurate assessment of blood loss. The lobes of a complete placenta fit neatly together without any gaps with the edges forming a uniform circle. Broken fragments of cotyledon should be carefully replaced before making an accurate assessment, e.g. succenturate lobes, missing cotyledons, fatty deposits or infarctions. Step 15 -Take cord blood samples if required. Step 16 -Weigh, swab or take samples if indicated. Step 17 -Where there is suspicion that the placenta and/or membranes are incomplete, they should kbe kept for further inspection and referred to the duty obstetrician. Step 18 -Clean away equipment. 61  Clinical Procedures Step 19 -Wash hands. -Referral of placenta for examination may be DESIRABLE for: Prematurity (30-36 weeks) Placental abruption Fetal congenital malformation Rhesus (and other) isoimmunisation Morbidly adherent placenta Twins or other multiple pregnancy (uncomplicated) Abnormal placental shape (if clinically relevant) Two vessel cord, etc. Prolonged rupture of the membranes (more than 36 hours) Gestational diabetes Maternal group B streptococcus Pre-eclampsia/maternal hypertension Maternal coagulopathy Maternal substance abuse. Disposal of Placenta -The placenta should be placed in a yellow placenta bag then into a yellow placenta pot. -If the woman wishes to take her placenta home to bury or Encapsulate 62  Clinical Procedures IUD insertion Definition: Introduction of a specially device into the uterine cavity of a fertile woman who desires to prevent conception / pregnancy for a specific period of a time. Purposes: 1- To avoid unwanted pregnancy. 2- To space pregnancies. Contraindications: Absolute: 1-suspected pregnancy. 2-pelvic inflammatory disease. 3- Vaginal bleeding of undiagnosed etiology. 4- Cancer of cervix, uterus or adnexae and other pelvic tumors. 5- Previous ectopic pregnancy. Relative: 1- Anemia. 2- Menorrhagia. 3- History of pelvic inflammatory disease. 4- Purulent cervical discharge. 5- Distortions of the uterine cavity due to congenital malformations, fibroids. Advantages of IUCD: 1- Simplicity- no complex procedures are involved in insertion. 2- Hospitalization is not required. 63  Clinical Procedures 3- IUCD stays in place as long as required (different types of IUCDs) have varying durations recommended for replacement depending on the amount of impregnated medication. 4- Inexpensive. 5- Contraceptive effect is reversible by removal of IUCD. 6- Free from systemic metabolic side effects associated with hormonal pills. 7- There is no need for continual motivation Articles: 1- IUCD pre- sterilized insertion package. 2- Sterile tray containing.  Vaginal speculum(cuscos)  Vulsellum.  Uterine sound  Sponge holding forceps.  Bowel containing cotton swab.  Sterile gloves.  Scissors.  Disinfectant solution.  Kidney tray. Procedure: 1- Explain the procedure including advantages, dis advantages, effectiveness and side effects of IUCD. 2- Arrange the equipment's on examination table. 3- Instruct woman to empty her bladder. 4- Position woman on her back with knees flexed and buttocks at the edge of the table. 64  Clinical Procedures 5- Provide privacy and drape patient appropriately. 6- Wash hands and don sterile gloves. 7- Load IUCD inside applicator as per manufacturer's instruction. 8- Inspect external genitalia, urethra and vagina for signs of infection, lesions or discharge. 9- Explain to the women that there will be slight discomfort during speculum insertion. 10- Insert the speculum gently and observe the cervix for signs of infection and erosion. 11- Clean the external cervical os with an antiseptic soaked swab by using sponge holding forceps. 12- Instruct the patient that there will be discomfort (pinching pain) when applying the vulsellum. Apply vulsellum at the 120 clock position on the cervix; grasp the lip of the cervix. 13- Pass the uterine sound into the cervical canal and insert carefully into the uterine cavity while pulling steadily downward and outward on the vulsellum. (a slight resistance indicates that the top of the uterine sound has reached the fundus), and remove the uterine sound. 14- Measure the length of the device to be inserted into the uterine cavity. The depth of gauge on the inserter-tube is used to mark the depth of the uterus. Pull the loaded inserter tube gently until the distance between the top of the folded "T" and edge of the depth gauge closest to the "T" is equal to the depth of the uterus as measured on uterine sound. 65  Clinical Procedures 15- Carefully peel the clean plastic cover of the package away from the white packing. Lift the loaded inserter keeping it horizontal os that neither the "T" nor the white rod falls out.be careful not to push the white rod towards the "T" 16- Grasp the vulsellum and pull firmly downwards and outwards to align the uterine cavity and cervical canal with the vaginal canal. 17- Gently introduce the loaded inserter assembly through the cervical canal. keeping the depth gauge into a horizontal position 18- According to the position and direction of the uterine cavity gently and carefully advance the loaded inserter assembly until the depth gauge comes in contact with the cervix or resistance of the uterine fundus is felt. 19- Hold the vulsellum and the white rod in one hand. 20- Gently and carefully push the inserter tube upwards, towards resistance. 21- Remove the while rod while holding the inserter tube stationary. 22- Gently and slowly withdraw the inserter tube from the cervical canal and check for the strings protruding from the uterus.cut the strings shorter so that they protrude only 3 cm outside the cervix. 23- Remove the vulsellum. If there is excessive bleeding from the vulsellum site, press a sterile cotton ball to the site using forceps until the bleeding stops. 24- Remove speculum and drapes. 25- Instruct patient to stay in bed for some time. 26- Wash perineum with soap and water speculum and drapes. 27- Remove gloves and discard. 28- Instruct the woman on follow-up measures 66  Clinical Procedures 1- To confirm presence of IUCD periodically by feeling the presence of threads in vagina. 2- instruct patient to visit clinic whenever she experiences the warning signs of problems related to IUCD such as: PAINS P: delayed periods, spotting, bleeding or missing period. A: abnormal pain or pain during coitus. I: infection, any vaginal discharge. N: not feeling well, fever, or pelvic pain. S: strings in vagina (feeling the device in vagina). Side effects and complications: 1- Excessive bleeding. 2- Low back pain during menstruation. 3- Pain during menstruation. 4- Pelvic infection. 5- Uterine perforation. 6- Ectopic pregnancy. 7- Expulsion of device. 67  Clinical Procedures The fundus and lochia examination Procedure: 1- Hand washing 2- Prepare the necessary equipment and taken to the bed side table (clean gloves, sterile pad, and antiseptic solution) 3- Great the woman, and explain the procedure to obtain her consent. 4-ask the woman to empty her bladder before the procedure. 5- Maintain privacy through the procedure. A- Fundus and Lochia Assessment Steps. 6- Wash hands and wear the clean examination gloves. 7-Ask the woman to lie on her back with her knees slightly bent. 8- Do fundal massage using one hand and the other gloved hand lowered the perineal pad to assess the lochia flow in the bad. 9- Ask the woman since how many hours she changed her perineal pad. 10- Assess the fundal level, position, size and consistency first then massage as needed. 11- Assess the lochia flow in the bad during massage. 12- Support the uterus by cupping one hand against the lower uterine segment (just above the symphysis pubis) 13- Measure by finger breadth how far the fundus from the umbilicus. 14- Use anew-perineal pad to cover the perineum after perineal care. B- Post procedure tasks. 12- Remove and dispose gloves according to procedure. 13- Inform the woman about the findings and document the procedure accurately. 68  Clinical Procedures Pap test Preparing the patient  Introduce yourself  Explain the procedure, ask whether they have ever had a speculum performed before (previous experience can make the difference between this ‘experience’ a good or bad one for both of you!)  Explain that it will be uncomfortable but should not be painful and to tell you if it hurts too much and you will stop  Gain informed consent  Ask if they would like a chaperone present, tell them you will be getting a chaperone  Ask her to empty her bladder if she needs to and remove any sanitary protection she might be wearing Whilst you leave the room to get your chaperone ask her to undress from the waist down, explain that you need her to be in the supine position with her feet facing each other brought as close to her bottom as she can manage and to let her legs ‘flop’ apart and to cover herself up with the modesty sheet provided Ensure all equipment that you need is to hand and in good working order  Gloves, Speculum (warmed), lubricating jelly, examination couch and modesty sheet, good lighting  Wash your hands!!!  Expose the patient and put on your gloves. Inspection of the perineum  Abnormal hair distribution  Vulval skin (e.g. psoriasis, eczema) 69  Clinical Procedures  Perineal scars/tears  Evidence of discharge, prolapse, ulcers, warts  Insertion of Bivalve speculum (Cusco’s speculum)  Warn the patient that you are now going to touch her first with your fingers then the speculum  Part the labia with your left hand to inspect the urethral meatus for evidence of any discharge  Insert the lubricated end of the speculum into the vagina gently and rotate it until the blades are horizontal as you insert in a slightly posterior direction  Open the blades of the speculum until the cervix comes into view, secure speculum at this point Inspection of the cervix  Normal cervix-pink and healthy  Inspect for atrophic vaginitis  Any evidence of discharge, warts, tumours, obvious bleeding or pathology  The cervical os (nulliparous or multiparous?)  Ectropians, Polyps  Threads from IUCD? 70  Clinical Procedures Taking a smear sample  Using your Aylesbury spatula rest the ‘bigger’ end into the cervical os and rotate 360° clockwise then anti-clockwise, ensuring good contact throughout exerting ‘light pencil pressure’  the cells that you have obtained onto your pre-labelled slide (with patient details, name, DOB)  Put in fixative To conclude the procedure  Inform the patient of how long it will be until she obtains the results and how (letter/phone call?)  Explain that she might experience some ‘light spotting’ but if her loss is significant then to see her GP  Thank the patient 71  Clinical Procedures Perineal care The perineum is the part of the woman’s body between her legs, including the vagina (birth canal) and rectum. after having a baby , woman needs to give this area special attention. postpartum perineal care includes all the things need to do to make the area feel better, heal properly , and avoid infection , will need to do this for 1 to 3 weeks. Causes: The perineum is severely stressed as a baby is pushed through the vagina (birth canal).Also, the doctor may have made a small opening called episiotomy so that the vagina wouldn’t tear when the baby was coming out. Although this is sewn back together, it will take time to heal. Objectives: 1- To clean the vulva and perineum 2- To promote healing, prevent infection relieve edema and soreness. 3- To eliminate odour and make woman 4- Comfortable. 5- To stimulate micturition. 6- To observe condition of perineum. Indications: 1- Before vaginal examination and catheterization. 2- Following shaving. 3- On admission and at six hour interval during labour as well as immediately before and after delivery. 4- After urination and or defecation in post-partum period. 5- Before dressing on episiotomy wound. 72  Clinical Procedures 6- Pre and post-operative of perineal and vaginal surgery. 7- In case of leucorrhea. Signs and symptoms which indicate perineal care: 1. There will be pain and swelling around the vagina because of stretching when the baby was born. 2. You will also notice a discharge from the vagina.at first it will be bloody, and then it will turn pink. later it will turn yellow and then go away. 3. Woman may have a tear in her vagina. Procedure: 1- Wash hands. 2- Prepare equipment and take to bedside. 3- Explain the procedure to woman and screen the bed. 4- Drape the woman cover and perineal area only exposed. 5- Put mackintosh and towel under the woman and place the bed pan with the towel ( lithotomy position). 6- Remove the soiled perineal pad from above to downward and wrap in paper and place in paper bag or kidney basin. 7- With forceps and cotton sponges clean as follows:  From symphysis pubis upward to the umbilicus.  The far thigh then, the near thigh.  The far labia from above downward, then the near labia.  Center from clitoris downward to perineum and rectum  Pour the rest of solution over the vulva and rectum. 73  Clinical Procedures  Dry and clean genitalia with cotton sponges by the same technique.  Remove the bed pan and instruct the women turn on her side & dry her buttocks with cotton.  Apply sterile perineal pad.  Rearrange bed & clothes to make women more comfortable.  Conclusion of Procedure:  Remove soiled equipment  Remove gloves  Position patient for comfort and warmth  Wash hands Charting:  Record the time of procedure.  Temperature & type of solution.  Observation of the vulva and perineum.  Report abnormal observation and woman’s complains. 74  Clinical Procedures Bishop score Also Bishop’s score, also known as cervix score is a pre-labor scoring system to assist in predicting whether induction of labor will be required. It has also been used to assess the odds of spontaneous preterm delivery. The Bishop Score was developed by Dr. Edward Bishop and was published in August 1964. 3- Components: The total score is achieved by assessing the following five components on vaginal examination:  Cervical dilation  Cervical effacement  Cervical consistency  Cervical position  Fetal station The Bishop score grades patients who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score; a score that exceeds 8 describes the patient most likely to achieve a successful vaginal birth. Bishop scores of less than 6 usually require that a cervical ripening method be used before other methods. They can be remembered with the mnemonic: Call PEDS For Parturition = Cervical Position, Effacement, Dilation, Softness; Fetal Station. 4- Scoring: Each component is given a score of 0 to 2 or 0 to 3. The highest possible score is 13 75  Clinical Procedures 3 – Interpretation: A score of 5 or less suggests that labour is unlikely to start without induction. A score of 9 or more indicates that labour will most likely commence spontaneously. A low Bishop’s score often indicates that induction is unlikely to be successful. Some sources indicate that only a score of 8 or greater is reliably predictive of a successful induction. Modified Bishop Score: According to the Modified Bishop’s pre-induction cervical scoring system, effacement has been replaced by cervical length in cm, with scores as follows: 0 for >3 cm, 1 for >2 cm, 2 for >1 cm, 3 for >0 cm. Another modification for the Bishop’s score is the modi- fiers. Points are added or subtracted according to special circumstances as follows: 1- One point is added for: a- Existence of pre-eclampsia b- Every previous vaginal delivery 2- One point is subtracted for: a- Postdate pregnancy b- Nulliparity (no previous vaginal deliveries) c- PPROM; preterm premature (prelabor) rupture of membranes. 76  Clinical Procedures Vaginal Examination Indications 1- On admission for baseline data 2- Upon rupture of the membranes in labour - to rule out cord prolapse 3- Before analgesia - to determine progress 4- Before pushing 5- Upon observing or auscultating non-reassuring fetal heart rate 6- Every 2-4 hours to determine labour progress Contraindication: 1. Undiagnosed vaginal bleeding 2. Placenta previa Minimize Number of Exams: 1. PROM - to prevent ascending infection (speculum examination preferred) 2. Active herpes -to prevent ascending infection * An initial digital examination may be performed after the speculum examination for baseline data Assessment Criteria: 1. Cervix - effacement (cervical length measurement, % taken up), dilatation (cm), consistency, position 2. Presenting part (vertex, breech, compound presentation) position 77  Clinical Procedures 3. Status of the membranes 4. Station (relation of presenting part to ischial spines) A vaginal exam is used in conjunction with or preceded by abdominal palpation The Bishops score (pre-induction cervical scoring) assesses dilatation, effacement, consistency, and position of the cervix, and the station of the presenting part. Method Position the woman in a lateral (or with the head of the bed slightly elevated) rather than supine, position to prevent supine hypotension and fetal bradycardia use sterile lubricant encourage the woman to practice her relaxation exercises keep her informed of what you are doing and your findings perform examination between contractions after completing the assessment, provide perineal care and check fetal heart chart findings and plot progress on the partogram notify physician/midwife of progress (dilatation/descent) 78  Clinical Procedures No. Steps 2 1 0 1. Define the Procedure: The vaginal examination reveals information regarding the fetus such as, presentation, position, station, degree of flexion of the fetal head, and presence of caput succedaneum. 2. Identify the objective: > To determine the status of labor progress. > To evaluate cervical dilation and effacement. > To provide information regarding fetal position. > To assess