تمريض النساء والتوليد (عملي) معهد 2023-2024 PDF

‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ 2023/2024 2023/2024 2023/2024 Prepared by: - Staff Members of Maternal & Neonatal Health Nursing Depa...

‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ 2023/2024 2023/2024 2023/2024 Prepared by: - Staff Members of Maternal & Neonatal Health Nursing Department- Faculty of Nursing – Tanta University For Second Academic Year Students of Technical Institute of Nursing 2024-2025 0  ‫رؤية الكلية‪- :‬‬ ‫الريادة والتميز في إستثمار المعرفة في التمريض وتحقيق التنمية المستدامة‪.‬‬ ‫رسالة الكلية‪- :‬‬ ‫تسعى كلية التمريض بجامعة طنطا إلى بناء بيئة أكاديمية فاعلة تؤدى إلى تخريج كوادر مهنية متميزة في علوم التمريض قادرة على‬ ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ ‫المنافسة في سوق العمل على المستوى المحلى واإلقليمي وتساهم في تقديم الخدمات الصحية للمجتمع ودفع مسيرة البحث العلمي‬ ‫المبتكر في إطار قيم وتقاليد المجتمع وذلك من خالل برامج تعليمية حديثة وفق معايير أكاديمية معتمدة‪.‬‬ ‫رؤية ورسالة قسم تمريض صحة االم وحديثى الوالدة للعام الجامعي‬ ‫‪2025-2024‬‬ ‫رؤية القسم‬ ‫العلمية المتميزة على مستوي الكلية من خالل إعداد ممرض‬ ‫‪2023/2024‬‬ ‫صحة األم وحديثى الوالدة من االقسام‬ ‫‪2023/2024‬‬ ‫التطلع إلى أن يكون قسم تمريض‬ ‫‪2023/2024‬‬ ‫وممرضه متميزين قادرين على المنافسة الفعالة في عصر تكنولوجيا المعلومات‪.‬رسالة القسم‬ ‫يسعي قسم تمريض صحة األم وحديثى الوالدة الي إكساب الطالب المعلومات والمهارات واالتجاهات اإليجابية‬ ‫الالزمة والتي تمكنهم من تقديم رعاية تمريضية متطورة في مجال صحة المرأة وحديثي الوالدة وبذلك يساهم في تطوير مهنة التمريض وخدمة‬ ‫المجتمع وتنمية البيئة كما أن القسم يساعد على تنمية وتشجيع القدرات التعليمية والبحثية المبنية على األدلة والبراهين لدي الطالب وأعضاء‬ ‫هيئة التدريس بما يتواكب مع احتياجات المجتمع‪.‬أهداف القسم‬ ‫▣ يهدف القسم إلى تقديم برامج تعليمية من شأنها إعداد كوادرمن الطالب قادرة على تقديم رعاية تمريضية شاملة للمرأة بمختلف‬ ‫المراحل العمرية وعلى جميع مستويات الصحة والمرض مبنية على تحليل وتحديد‬ ‫اإلحتياجات الجسمانية والنفسية والبيئية للمرأة واألسرة والمجتمع وذلك باستخدام المعلومات والتقنية‬ ‫‪1‬‬  ‫الحديثة وتطبيق نظريات وأبحاث علوم التمريض والعلوم األساسية واالجتماعية واإلنسانية كأساس للممارسة التمريضية‬ ‫المهنية‪.‬‬ ‫‪ ‬تتلخص أهداف القسم فيما يلي‪- :‬‬ ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ ‫دراسة الجوانب الجسدية والنفسية واالجتماعية المؤثرة في حياة المرأة من خالل‪- :‬‬ ‫‪ ‬دراسة محتوي التشريح للجهاز التناسلي الداخلي والخارجي وعلم وظائف األعضاء‪.‬‬ ‫‪ ‬دراسة الحالة الصحية للمرأة خالل فترات اإلنجاب والتي تشتمل على الحمل‪ ،‬الوالدة‪ ،‬النفاس واألمراض النسائية ورعاية حديثي‬ ‫الوالدة ويتم التركيز على الرعاية الصحية من خالل تطبيق العملية التمريضية‪.‬‬ ‫‪ ‬دراسة الجهاز التناسلي والرعاية الطبية للسيدة وأمراض النساء الشائعة من حيث األسباب وطرق العدوى واإلنتشار‪ ،‬األعراض‪،‬‬ ‫العالج والمضاعفات‪.‬‬ ‫‪ ‬دراسة كل ما هو جديد فى تمريض أمراض النساء والتوليد وتطبيقه عند الحاجة إليه‪.‬‬ ‫‪ ‬اإلرتقاء بصحة األم والجنين أثناء الحمل وتقديم العناية التمريضة الكاملة لهم خالل مراحل الحمل المختلفة‪.‬‬ ‫‪2023/2024‬‬ ‫‪2023/2024‬‬ ‫‪2023/2024‬‬ ‫‪ ‬إعطاء التثقيف الصحي الشامل للمقبلين على الزواج‪.‬‬ ‫‪ ‬تقديم العناية التمريضية الشاملة لألم والجنين أثناء الوالدة‪.‬‬ ‫‪ ‬تقييم اإلحتياجات األساسية والضرورية لألم أثناء فترة النفاس وإعطاء الرعاية التمريضية لها‪.‬‬ ‫‪ ‬تقديم المشورة الصحية للسيدات عن وسائل تنظيم األسرة‪.‬‬ ‫تطبييق نتائج األبحاث التمريضية القائمة على الدليل التى تساعد فى تخفيف مضايقات السيدات خالل‬ ‫‪‬‬ ‫الفترة ما حول سن اإلياس‪.‬‬ ‫رئيس القسم‬ ‫أ‪.‬د‪/‬منال عبدهللا جاهين‬ ‫‪2‬‬  Table of Contents ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ NO. Subjects P. 1. Abdominal Examination during Pregnancy. 4 2. Vaginal Examination during Labor. 14 3. Episiotomy Care. 28 4. Baby Cord Dressing. 35 2023/2024 2023/2024 2023/2024 5. Post-Partum Abdominal Examination. 40 6. Pap Smear. 48 7. Breast Examination. 53 8. Breast Care. 66 9. Placental Examination. 71 10. Clinical Procedures Checklist. 78 11. Clinical Records. 102 12. Partograph Paper 133 3  Abdominal Examination during Pregnancy ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ Definition Abdominal examination during pregnancy is inspection, palpation and auscultation of the woman’s abdomen during pregnancy. Objectives 1. Confirm pregnancy. 2. Estimate the gestational period. 3. Determine fetal presentation, lie, position and engagement of the presenting part. 2023/2024 2023/2024 2023/2024 4. Assess fetal well-being by measuring fetal heart rate. Contraindications 1. Placental abruption. 2. Preterm labor. 3. Placenta previa. 4. Severe abdominal pain. Proper time to perform abdominal examination during pregnancy: Not before 12th weeks of gestation. 4  Steps / Task Rational ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ A. Pre- procedure tasks I- Preparation of the equipment  Prepare equipment:- -To save time and facilitate - Non-stretching tape measure. task. (Figure 1) - To promote efficiency. - Pinard fetoscope (Figure 2) or ultrasonic fetal heart sound device (Doppler fetal monitor) 2023/2024 (Figure 3). 2023/2024 2023/2024 - Woman’s record. Fig1http:///www.mazon.com/eBoot-Measure- Sewing-Tailor-Cloth/dp/B01D9RCHDI - Clean gloves. - Watch with second hand. - Soap & tissue paper. Fig2https://www.pregnancy.com.au/product/pi nard-stethoscope-small-17cm/ Fig3https://en.wikipedia.org/wiki/Doppler_fetal_monitor II- Preparation of the environment Close door & windows. - To provide privacy & avoid air draft. Provide adequate light. 5  III- Preparation of the woman  Greet the woman respectfully and with kindness.  Listen to her attentively, and respond to her -Help to get all required ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ questions and explain the procedure to her information.  Ask the woman to empty her bladder. -To prevent wrong fundal height estimation and the interruption during the procedure as well as promote woman's comfort.  Put the woman on her back with knees - To estimate fundal height flexed and slightly separated. correctly. 2023/2024 2023/2024 -To relax the 2023/2024 abdominal muscles. IV- Preparation of the nurse  Wash hands with antiseptic solution & wear - To maintain aseptic clean gloves. technique.  Stand at the right side of the woman's bed. -Proper position allows easier examination. B. Procedure steps Inspection of the abdomen 1. Inspect woman's abdomen for; -To determine the type of the - Suprapubic hair distribution. pelvis which may suggest 6  type of delivery.  Feminine with an upper straight border suggests gynecoid pelvis.(Figure 4)  Masculine with a convex ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ upper border which suggests android pelvis. Fig4https://medicalictionary.thefreedictionary.com/escutcheon (Figure 4) - Pigmentation: o Linea nigra: Dark brown line from umbilicus to symphysis pupis.(Figure 5) 2023/2024 o Striae gravidarm: Pink 2023/2024 lines or 2023/2024 stretching marks in the skin around the umbilicus. It becomes white in color and called "Striae albicans" after Fig5https://uomustansiriyah.edu.iq/media/lect ures/2/2_2017_09_08!11_31_52_PM.pdf delivery. (Figure 5) - Edema: It may be due to toxemia. (Figure 6) - Scars of previous operation. - Size and shape: It may be affected by obesity, lax abdominal muscles, multiple pregnancy, poly-& oligohydramnios, Fig6https://www.researchgate.net/F igure/Skin-over-the-lower-abdomen-showing- fetal size and lie. 7  - Hernia: By asking woman to cough (Figure 7) ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ Fig7https://www.google.com/search?q=hernia &sxsrf=ALeKk0029dLOSg_jsJk7TGiLF3gw9C Palpation during pregnancy 2. Fundal Level Palpate the abdomen to estimate the period of gestation: - A fundal height is - Place the ulnar border of the left hand inconsistent with gestational just below the xiphisternum and move it age may indicate: 2023/2024 2023/2024 2023/2024 down the abdomen until the fundus is - Wrong date or felt. calculation. - Measure the number of fingers, which - Fetus is larger or smaller can fit between the fundus and for gestational age. xiphisternum, or measure the distance - Poly- or from the symphysis pubis to the fundus oligohydramnios. using a tape measure.(Figure 8) - Multiple pregnancy. - Abnormal fetal lie. - Uterine fibroid. - Intrauterine fetal death. - Fetal malformation. - Hydatidiform mole. - Intrauterine growth 8  restriction (IUGR). ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ (Fig 8) https://www.google.com.eg/search?q=fundal+height+measurement&safe=stric t&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiV4KuFtL7VAhVMXRQK Hc 3. Fundal Grip (First maneuver) Still on the right side of the woman's bed & -To determine which part of 2023/2024 looking to her face. 2023/2024 the fetus2023/2024 occupies the upper Palpate the uterine fundus (Figure 9): uterine segment. - The breech is felt softer and more -Distinguishes between a irregular than the head. cephalic and a breech - The head is harder, with a round, presentation: uniform shape. (First maneuver) Fig 9 https://www.studyblue.com/notes/note/n/exam-3/deck/21373924 4. Umbilical or Lateral Grip (Second maneuver) 9  Hold the left hand steady on one side of the -To determine which side of uterus while palpating the opposite side of the uterus is occupied by the uterus with the right hand. (Figure 10) fetal back, and which side - The fetal back is a smooth convex the uterus is occupied by surface. fetal extremities. - The fetal arms and legs are felt ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ nodular and the fetus will often move them during palpation. 2023/2024 2023/2024 2023/2024 (Second maneuver) Fig 10 https://demo.oppia-mobile.org/media/courses/ldc-all/02_12185_en.html 5. The First Pelvic or Pawlick Grip (Third maneuver) - Palpate the suprapubic area. If a - Confirms the presentation breech is palpated in the fundus, that is determined in the expect a hard, rounded head in this first maneuver. area. - Determines whether the - Attempt to grasp the presenting part presenting part is engaged gently between the thumb and fingers. in the maternal pelvis. 10  If the presenting part is not engaged, the grasping movement of the fingers will easily move it upward in the uterus.(Figure 11) ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ (Third maneuver) Fig11 https://www.slideshare.net/rosechellebsiupan/pre-natal-care-78592993 6. The Second Pelvic Grip (Fourth maneuver) 2023/2024 2023/2024 2023/2024 - Omit the fourth maneuver if the fetus is -Is done only in cephalic in a breech presentation. presentations to determine whether the fetal head is flexed. - Turn so that face the woman's feet. -It is proper position to perform the steps. - Place hands on each side of the uterus with fingers pointed toward the pelvic inlet. On one side, fingers will easily slide to the upper edge of the symphysis. On the other side, fingers will meet an obstruction, the cephalic prominence. (Figure 12) 11 ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ (Fourth maneuver) Fig 12 https://www.fotosearch.com/LIF139/nu113015/ Auscultation Auscultation:It is important to identify maternal To avoid mixing between pulse before locating the fetal heart. maternal and fetal heart sounds (FHS). 7. Place the pinard fetal stethoscope at the -FHS can't be audible before right angles;(Figure 13 &14) 22nd week & sometimes it's 2023/2024 2023/2024 difficult2023/2024 to hear till the 28 th  In vertex presentations: week of gestation. - Left-occipito-anterior(L.O.A.) -Keep the ear in firm contact position, the FHS are best heard at with the pinard, and don't touch it while listening. mid-way along the line joining the -Fetal heart rate ranges umbilicus to the left anterior superior between 110 - 160 b / m. , iliac spine( ASIS). listen carefully and count for 30 – 60 second. - Right-occipito-anterior(R.O.A.) position, the FHS are best heard at mid-way along the line joining the umbilicus to the right anterior superior iliac spine.{In some cases FHS are heard along middle line of Fig 16 the abdomen below the umbilicus}. https://www.verywellfamily.com/hearing-babys- heartbeat-2752812 12  - Right-occipito-posterior(R.O.P.) position, the FHS are best heard a little above & lateral to their site in R.O.A. position. - Left-occipito-posterior(L.O.P.) position, the FHS are heard with ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ some difficulty above & lateral to their site in L.O.A. position. Fig 17: https://www.pinterest.com/pin/6255788229881894 2/ C. Post-Procedure tasks. I Woman 2023/2024 2023/2024 2023/2024  Drape the exposed abdomen.  Assist the woman to get down from examination table. II Equipment  Remove equipment and clean as usual. -To be ready for another use. III Nurse  Remove gloves, wash your hands and dry -To prevent cross- contamination after the procedure. IV Documentation - Documentation provides a means of evaluation.  Inform the woman about the procedure 13  findings. ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ Vaginal Examination during Labor Definition 2023/2024 2023/2024 2023/2024 It is a procedure performed to determine progress of labor by internal vaginal examination of the cervix. Fig(1)https://www.google.com/url?sa=i&url=https%3A%2F%2Fm.facebook.com%2FMidwifeSally Objectives 1. To assess degree of cervical dilatation & percentage of cervical effacement. 2. To determine station, position & presentation of the fetus. 3. To assess status of fetal membrane (intact or ruptured). 14  4. To exclude cord prolapse following spontaneous or artificial rupture of membrane. 5. To perform artificial rupture of membrane (Amniotomy). Contraindications 1. Placenta previa. 2. Placenta abruption. ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ 3. Unknown placental location with bleeding. 4. Vasa previa. Steps / Task Rational A. Pre- procedure tasks 2023/2024 2023/2024 2023/2024 I- Preparation of the equipment  Wash hands.  Prepare equipment & ensure that -To save time and facilitate task. all instruments & equipment are -To promote efficiency. available and in working order. o Clean or sterile gloves o Lubricant K-Y gel o Sterile pad  Bring all necessary equipment beside the woman. II- Preparation of the woman 15   Identify the woman.  Greet the woman respectfully and - Reduce anxiety and elicit cooperation. with kindness.  Introduce yourself to the woman. ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬  Explain the procedure to the woman and her support person.  Listen to her attentively and - To get required information. respond to her questions.  Take complete history.  Take consent from the woman. 2023/2024 2023/2024 2023/2024  Ask the woman to empty her -To prevent interruption during the bladder. procedure and promote comfort. III Preparation of the environment  Ensure that the environment is - To promote comfort. calm, clean and tidy.  Ensure that the desk is supplied with cards, pencil ….etc.  Ensure that educational materials, - To facilitate health teaching. visual display& posters are available& arranged.  Close door & windows. - To provide privacy & avoid air draft. 16   Provide adequate light source. It should be no glares or shadow.  Elevate bed to the suitable level. - To maintain body mechanics. IV Preparation of the nurse  Wash hands with antiseptic - To maintain aseptic technique. ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ solution &dry them and wear gloves.  Stand at the right side of the -Proper position allows easier woman's bed. examination. B. Procedure Steps / Tasks Rational 1. Put women in dorsal recumbent position.(figure 2) 2023/2024 2023/2024 2023/2024 Fig2https://slideplayer.com/slide/10827679/38/images/27/Figure+18-6%3A+Dorsal+recumbent+position.jpg 2. Ask the women to separate or spread her -This is an intrusive procedure. It legs. Do not try to use force. should be carried out when the women is ready for it. 3. Prepare the area with antiseptic solution. -This help prevention of ascending 17  infection during examination. 4. Assist the woman to relax by -If the woman is anxious, she may encouraging her to breathe naturally. tense her abdominal, pelvic and thigh muscles closing her thighs, this makes vaginal examination difficult. ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ 5. Lubricate the index and middle fingers of your dominant hand with K-Y lubricating Jelly. As you squeeze the tube, let the lubricant drop on to your outstretched fingers. (figure 3) 2023/2024 2023/2024 2023/2024 Fig3https://geekymedics.com/wp-content/uploads/2010/10/LubricateFingers.jpg 6. Using thumb & fore finger of non- dominant hand to spread the labia.  During the examination, the fourth and fifth fingers should not 18  touch the rectal area.  Keep the thumb straight up and stretched out.  Keep the fourth and fifth fingers bent inward and touching the palm of your hand. (figure 4) ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ 7. Inspect the general area of introitus (Vaginal opening), and look for:-  Amount of bloody show (Labor is advanced).  Wet, glistening perineum, (i.e. Membranes have ruptured).  Deep yellow or greenish brown 2023/2024 2023/2024 2023/2024 discharge.  The presence of a greenish brown fluid indicates fresh meconium. In cephalic presentation, it means fetal distress.  Any scars indicating episiotomy or prior perineal surgery. 19 ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ Fig 4 https://geekymedics.com/bimanual-vaginal- examination/ 8. Insert the well lubricated index & middle fingers of dominant hand gently into the vagina. The hand should be 2023/2024 2023/2024 2023/2024 turned sideways in this initial step. Keep downward pressure to avoid pressing on the anterior vaginal wall or urethra. (figure 5) 20  Fig5https://geekymedics.com/bimanual-vaginal-examination/ 9. Move the fingers into the full length of the vagina (usually 7.5-10 cm.) until they touch the cervix. this help to determine:-  The state of cervix, effacement, ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ and dilatation.  Membranes.  Presenting part.  Position.  Station and engagement. 1- the State of cervix: 2023/2024 2023/2024 2023/2024 *Dilatation is measured in centimeters & refers to the opening or the enlargement of the external cervical os.  External cervical os closed: 0 cm dilated.  External cervical os half open: 5 cm dilated.  External cervical os fully open: 10 cm dilated. (figure 6) Fig6https://www.google.com/url?sa=i&url=https%3 A%2F%2Fblog.pregistry.com%2Fdilating-cervix 21  *Effacement: is measured in percentages & refers to shortening and thinning of the cervix.  Cervical canal equal to 2cm in length would be described as 0% ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ effaced.  Cervical canal equal to 1cm in length would be described as 50% effaced.  Cervical canal equal to 0cm in length would be described as100% effaced. (figure 7) 2023/2024 2023/2024 2023/2024 Fig7https://cdn-prod.medicalnewstoday.com/content/images/articles/326/326380/a-diagram-showing-the-different-stages-of-cervical- effacement-image-credit-logika600-s-shutterstock-com.jpg 2. Membranes:. intact or ruptured  If the membrane intact it will be felt as a soft bulge that is more prominent during uterine 22  contraction. 3. The presenting part Fetal presentation refers to the first body part of the fetus that enters the pelvic inlet. ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ The three main fetal presentation are:- 1. Cephalic presentation (96%): when the fetal head enters the maternal pelvis first 2. Breech presentation (3.5%): when the fetal buttock or feet enter the maternal pelvis first. 3. Shoulder presentation (0.5%): 2023/2024 when 2023/2024 2023/2024 the fetal scapula enters the maternal pelvis first. (figure 8) 23 ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ Fig8https://i.pinimg.com/originals/cd/8e/65/cd8e65367f40e4652f093863500c365d.jpg 4. Position: 2023/2024 Fetal position describes the2023/2024 relationship 2023/2024 of a given point on the presenting part of the fetus to a designated point of the maternal pelvis. *The position is indicated three letter abbreviation as follows:- 1. The first letter defines whether the presenting part is tilted toward the left (L) or the right (R) side of the maternal pelvis. 2. The second letter represents the landmark of the fetal presenting part:-  (O) for occipital bone which 24  designates vertex presentation.  (M) for mentum (chin) which designates face presentation.  (S) for sacrum which designates breech presentation.  (A) for acromion process which ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ designates shoulder presentation. 3. The third letter defines the location of the presenting part in relation to the anterior portion (A) of the maternal pelvis or the posterior portion (P) of the maternal pelvis (figure 9) *For example: 2023/2024 2023/2024 2023/2024 LOA means left occipitoanterior. RMP means right mentopoasterior. 25 ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ 2023/2024 2023/2024 2023/2024 Fig9https://i.pinimg.com/736x/fe/29/11/fe29113de7da34caccd0af4a6e6c5f02.jpg 26  5. Station: Station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines (the narrowest part of the pelvis). ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ The three main fetal station are:- 1. Minus station (-5:-1): when the presenting part above the ischial spines. 2. Zero station: when the presenting part is at the ischial spines. 3. Plus station (+1:+5): when the 2023/2024 2023/2024 2023/2024 presenting part is below the ischial spines. (figure 10) 5. Engagement: Occurs when the widest part of the fetal head has entered the inlet of the pelvis. Commonly, this occurs when the tip of the presenting part has reached the level of the ischial spine i.e. station = 0. 27 ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ Fig10https://www.ontarioprenataleducation.ca/wp-content/uploads/2016/01/StationsOfDescent.jpg C. Post-Procedure tasks. I For the woman:  Readdress her clothes.  Assume the woman in comfortable position. II For the equipment: 2023/2024 2023/2024 2023/2024  Remove &clean the equipment. -To be ready for another use. III For the nurse:  Remove the gloves and wash hands. To prevent cross-contamination. IV Documentation:  Record time and findings of the Documentation provides a means of evaluation. procedure. 28  Routine Episiotomy Care Definition Episiotomy is a deliberate surgical incision made in the perineum during the second stage of labor (at crowning) to enlarge the vaginal opening and enhance the passage of the fetus. (Figure 1) ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ 2023/2024 2023/2024 2023/2024 Fig 1:https://emedicine.medscape.com/article/2047173-overview Objectives: 1. Observe the condition of the perineum, episiotomy, lochia and or any vaginal discharge. 2. Promote rapid healing of episiotomy. 3. Prevent infection. 4. Eliminate bad odor. 5. Promote comfort. 6. Early detection and treatment of the complications of episiotomy. 29  Steps / Task Rational A) Pre-procedure tasks I- Preparation of the equipment:  Prepare the equipment & ensure -To save time and facilitate task. that all instruments & equipment -To promotes efficiency. ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ are available and in working order: o Sterile and clean gloves. o Mackintosh. o Bed pan. o Kidney basin. o Anti-septic solution (Betadine) o Cotton gauze. 2023/2024 o Towels, and light source. 2023/2024 2023/2024  Bring all necessary equipment beside the woman. II- Preparation of the woman:  Identify the woman.  Greet the woman respectfully and with  Reduce anxiety and gain her cooperation. kindness.  Introduce yourself.  Explain procedure to the woman.  Listen to her attentively and respond  Help me to get required to her questions. information.  Take consent from woman. 30   Ask the woman to empty her bladder. To prevent interruption of the procedure and promote comfort. III Preparation of the environment:  Ensure that the environment is - To promote comfort calm, clean and tidy. ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬  Ensure that the desk is supplied with cards, pencil ….etc.  Ensure that educational materials, - To facilitate health teaching. visual display & posters are available & arranged.  Close door & windows. - To provide privacy & avoid air draft. 2023/2024  Provide adequate light and avoid 2023/2024 2023/2024 glares or shadow.  Elevate the bed to suitable level. - To maintain good body mechanics. IV- Preparation of the nurse  Wash hands with antiseptic solution - To maintain aseptic technique. & dry them and wear gloves.  Stand at the right side of the -Proper position that allows easier woman's bed. examination. B) Procedure Steps / Tasks 31  1. Ask the woman to lie on the dorsal recumbent position with her knees slightly bent and legs separated and foot flat on the bed. (Figure 2) ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ Fig 2: http://www.piecesof me 08.com 2. Place large mackintosh under the woman's hips. 3. Place the woman on the bedpan correctly. (Figure 3) 2023/2024 2023/2024 2023/2024 Fig 3: http://www.corbisimages.com 4. Remove the soiled perineal pad from front to back and discard it. Assess the episiotomy and suture during the procedure according to REEDA: (Figure 4 & 5).  R: Redness indicates inflammatory response, if accompanied by pain or tenderness it indicates localized infection. 32   E: Ecchymosis indicates soft tissue damage.  E: Edema and tenderness indicates localized infection.  Discharge indicates localized infection. ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬  A: Approximation of the edges, it assess the healing process. Note also the number and size of hemorrhoids if present 6. Do perineal care according to the -To identify any abnorm alities procedure. and provide early treatment. 2023/2024 2023/2024 2023/2024 Fig (4 & 5): https://www.google.episiotomy&gs 7. Wipe the episiotomy site with -To prevent cross of infection. antiseptic solution (betadine) and gauze.  Use gentle pressure technique and avoid fraction to episiotomy stitches.  Start from inside the vagina to 33  its outside then from the outside vaginal opening suture down to the rectum direction. (Figure 6) ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ Fig 6: https://www.google.com.eg/imgres?imgu 8. Instruct the woman to turn on the side away from you to remove the bed pan. 9. Dry woman's buttocks and thighs with 2023/2024 2023/2024 2023/2024 cotton. 10. Apply clean perineal pad. C) Post procedure Steps / Tasks I- For the woman:  Redress her clothes.  Help woman to be in comfortable position. II- For the equipment:  Remove &clean the equipment.  To be ready for another use. III- For the nurse:  Remove the gloves and wash hands.  To prevent cross infection. 34  IV- Documentation:  Record time and findings of the  Documentation provides a means of evaluation. procedure. V- Health Education about:  Episiotomy self-care.  To prevent rupture of stitches  Prevention of infection. ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ and minimizing infection.  Avoiding sitz bath and constipation.  Pain relieving measures for perineal discomfort as paracetamol suppositories.  Rest in the lateral position with a pillow between thighs, and avoid lifting heavy object. 2023/2024 2023/2024 2023/2024  Avoid sexual activity until complete healing of the episiotomy (4 weeks).  Use K-Y gel when starts the sexual activity.  Encourage the woman to do pelvic floor muscle exercises  To improve circulation and (Kegel exercise). increase healing processes. 35  Baby Cord Dressing Definition It is a technique by which the umbilical cord of the newborn is cleaned. Objectives 1. To ensure complete and proper healing of the umbilical cord of the newborn. ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ 2. To observe abnormalities of the cord such as bleeding, infection, hernia and abnormalities in the umbilical vein and arteries. 3. To prevent infection. Time of cord drops off The umbilical cord typically falls off 7 to 14 days after mature baby’s birth. The cord stump will fall off by itself, and in some cases delay to 3 weeks. (Figure1). 2023/2024 2023/2024 2023/2024 Fig1https://maternitynest.com/take-care-babys-umbilical-cord-stump/ 36  Steps / Task Rational A. Pre-procedure tasks I- Preparation of the equipment  Prepare the necessary equipment. -To save time and facilitate - Sterile small iodine bowls. task. ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ - Sterile cotton sponges. - Antiseptic solution, alcohol 70%. - Sterile forceps and /or gloves. - Ordered medicine if required. - Paper bag or dustbin. - Kidney basin. - Clean diaper. - Medication if prescribed. 2023/2024 2023/2024 2023/2024 II- Preparation of the woman  Explain the procedure to the mother. -To gain her cooperation and to teach her how to perform the procedure for her baby after discharge. III- Preparation of the environments  Prepare environment (tidy, clean, avoid air -To be ready to conduct the drafts). procedure. IV- Preparation of the baby  Prepare the baby: - -To provide comfort. - Check the diaper. -Clean the baby before procedure if needed. 37  V- Preparation of the nurse  Wash hands and apply gloves. -To prevent infection. B. Procedure tasks 1. Expose only the required area. (Figure 2) -To avoid unnecessary heat loss. ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ Fig 2 https://www.news-medical.net/health/Caring-for-the-Umbilical-Cord- Postpartum.aspx 2. Observe the condition of the cord. -To detect any abnormalities 3. Hold the umbilical cord away from the skin with one hand. 4. 2023/2024 2023/2024 Wipe the cord with the other hand 2023/2024 using the -To prevent infection and antiseptic solution, alcohol 70% from the promote healing. stump to the bottom (from up to down). 5. Clean the surrounding area with another swab. (Figure 3-4) Fig 4 Fig 3 https://www.fairview.org/patient- https://jaxbabycompany.com/tag/dressing-a-newborn/ education/116657EN 6. Apply medicine if required. 7. Note if the cord drops off, wipe the -To assure complete healing. 38  granulating area (stump) by using antiseptic solution. ( Figure 5) Fig 5 https://raisingchildren.net.au/newborns/health-daily- care/hygiene-keeping-clean/umbilical-care ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ 8. Let the area dry. C. Post-procedure tasks I- Baby Redress the baby. Don’t cover the umbilical stump up inside the diaper where it may come in contact with urine or stool. To prevent this, fold the front of the diaper 2023/2024 down below the cord (Figure2023/2024 6). 2023/2024 Fig6https://www.swaddlesnbottles.com/ho w-to-care-for-your-babys-umbilical-cord/ II- Equipment Remove equipment and clean it as usual. II- Nurse Remove gloves and wash hands III- Record the following: - - Care given. - Observations: - o Signs of bleeding. o Signs of infection. o Other abnormalities as hernia, abnormalities in vein and arteries. - Report abnormalities to doctor. 39  IV- Give health education to the mother about cord care as: - - Keep the cord exposed to air. - Don’t cover the umbilical stump up inside the diaper. - Don’t dress the baby in clothing that ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ is tight across the cord. - Don’t put the baby in bathwater until the cord has fallen off. Instead, bathe the baby with a sponge or damp washcloth. - Tell her to contact with the doctor if notice the following: 2023/2024 o Red or swollen skin around the 2023/2024 2023/2024 umbilical cord. o Significant bleeding. o White or yellow pus drain from the umbilical cord site. o The umbilical cord hasn’t fallen off 4-6 weeks after birth. o High grade fever. o A foul smell around the umbilical cord area. o Cord area pushes or bulges outwards when baby cries. 40  Postpartum Abdominal Examination and Assessment of Lochia Flow Objectives 1. To determine the uterine involution (location, height and consistency or firmness of the uterus). 2. To determine volume, color, odor, and consistency of lochia that may be ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ discharged during massage. Steps/ Tasks Rational A. Pre procedure Steps I. Prepare the necessary equipment:  Prepare the equipment and ensure -To save time and facilitate that all equipment are available task. 2023/2024 2023/2024 2023/2024 and in working order: - -To promotes efficiency. 1. Clean gloves. 2. Sterile perineal pad. 3. Paper bag. 4. Woman's record 5. Light source. II. Prepare the woman: -Reduce anxiety and gains  Identify the woman. her cooperation.  Greet the woman respectfully and with kindness  Introduce your-self.  Explain the procedure to the woman and her support person. 41   Listen to her attentively and respond to her questions.  Ask the woman to empty her -Help the nurse to get all bladder. required information. -A distended bladder lifts and displaces the uterus ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ upwards and laterally and prevents contraction of the uterus → uterine atony → increases risk of postpartum hemorrhage. (Figure 1). 2023/2024 2023/2024 2023/2024 (Fig1):https://pressbooks.pub/app/uploads/sites/427 2/2022/09/Fundus-225x300.jpg III. Prepare the environment:  Close windows and curtains. -To prevent air drafts and provide privacy.  Provide adequate light. -To good visualization.  Elevate the bed to the suitable -To maintain good body level. mechanics. IV. Prepare the nurse:  Wash hands thoroughly with soap and water and dry them with a clean towel.  Put on clean gloves.  Stand at the right side of the -Proper position allows woman's bed. easier examination. 42  B. Procedure Steps / Tasks 1. Put the woman in a supine position -The supine with her knees slightly flexed and position permits accurate separated and her head on a pillow. location of the fundus. (Figure 2) -Flexing the legs ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ relaxes the abdominal muscles. (Fig 2): https://what-whenhow.com/wp- content/uploads/2012/08/tmp61b652.pn 2. Drape the mother, expose her 2023/2024 2023/2024 2023/2024 abdomen for palpation and lower the perineal pads to observe lochia as the fundus is palpated. 3. Gently place one hand on the lower -Supports the lower uterine uterine segment just above the segment during palpation or symphysis pubis. massage of the fundus to prevent uterine prolapse. 43  4. With the other hand gently palpate -The larger the abdomen at the umbilical level surface provides more until the fundus is located (Figure comfort and more 3). accurate result. Use the flat part of the fingers (not the finger tips) for palpation (Figure ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ 4). 2023/2024 2023/2024 2023/2024 (Fig3):https://obgynkey.com/wpcontent/uploads /2016/07/CPOSTPARTUMFFU1.jpg (Fig4):http://www.glowm.com/resources/glowm/c d/pages/v1/v1c027.html 5. Determine whether the fundus is -A firm fundus indicates that firm. If it is, it will be felt hard and the uterine muscles are round like a firm grapefruit in the contracted and bleeding will abdomen. If the fundus is boggy, not occur. gently massage the fundus in a 44  circular motion while continuing to support the lower uterine segment. 6. Measure the height of the fundus in -Fundal height gives fingerbreadths above, below or at the information about the umbilicus. (Figure 5) progress of uterine ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ involution. NB: Uterine Involution: is the process by which the postpartum uterus returning to its nearly prepregnant state. - 1 to 2 hours after birth, the fundus typically is between 2023/2024 2023/2024 2023/2024 the umbilicus and the symphysis pubis. - Approximately 6 to 12 hours after birth, the fundus usually is at the level of the umbilicus. - The fundus progresses downward at a rate of one (Fig 5): http://quizlet.com/12025672/post-partum- fingerbreadth (or 1cm) per flash-cards/ day after childbirth - One week after birth, the fundus midway between umbilicus and symphysis pupis. 45  - Two weeks after birth, the fundus at the symphysis pubis. (Figure 6). N.B: The uterine fundus is not palpable abdominally by two weeks postpartum, and ‫ﺭﺍﻧﻴﺎ ﻣﺤﻤﺪ ﺳﻌﻴﺪ ﻣﺤﻤﺪ ﺣﻤﺰﺍﻭﻯ‬ reaches its normal non- pregnant size by six to eight weeks postpartum. (Fig 6): https://img2.tfd.com/mk/I/X2604-I- 27.png 7. Determine the location of the fundus -The fundus may deviate from in relation to the midline of the body. the midline when the bladder 2023/2024 2023/2024 is full because 2023/2024the enlarged bladder displacing the uterus upward and laterally. 8. Assess the lochia: Observe lochia on The lochia: is the perineal pads