Maternity and Newborn Health Nursing PDF

Manual of Maternity and Newborn Health Nursing BY : Maternity and Newborn Health Nursing Staff members Revision Edition Clinical Learning Guides and Checklists to Facilitate Learning and Assessment of Core Competencies This document was produced by Health Workforce Deve...

Manual of Maternity and Newborn Health Nursing BY : Maternity and Newborn Health Nursing Staff members Revision Edition Clinical Learning Guides and Checklists to Facilitate Learning and Assessment of Core Competencies This document was produced by Health Workforce Development (HWD) Project. The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. Egypt Health Workforce Development Project Contract No. TASC2 IQC NO. GHS-I-00-03-00025, TASK ORDER NO. GHS-I-03-03-00025-00 Clinical Learning Guides and Checklists to Facilitate Learning and Assessment of Core Competencies Introduction Use of Clinical Learning Guides (CLGs) and Clinical Skill Checklists (CCLs) is an internationally accepted best practice now adapted to the Egyptian context. CLGs provide a step-by-step description of all steps in their proper sequence to perform a defined skill, task or activity. Learners use CLGs to facilitate their acquisition of clinical skills. Clinical trainers use CCLs, which are derived from CLGs to assess progress of learners in achieving clinical competency. CLGs and CCLs are valuable tools for use in both simulation environments (e.g., skill labs) and clinical practice learning environments; and their use is widely recognized internationally as an effective tool for learning and assessment of clinical skills. When used to support learner practice in a skill lab (or a clinical practice site) CLGs have several advantages. Skill acquisition and competency development facilitated by CLGs is results in competency faster than traditional approaches to clinical training and is more humanistic by reducing potential risk of harm to patients and learners. CLGs are effective primarily because they are consistent with sound learning theory, including that they are: (i) based upon adult learning principles, (ii) employ behavior modeling, and (iii) are competency-based. A particularly useful feature of CLGs is that they can be used to support peer-to-peer as wel asself learning opportunities. The CLGs and CCLs found in this volume are consistent with the recently revised core medical and nursing curricula released in September 2004 throughout Egypt, including core course curricula for:  Medical undergraduates and house officers in obstetrics and gynecology, pediatrics, and community health; and  Nursing undergraduates and nurse interns in maternity and gynecologic nursing, pediatric nursing and community health nursing. In preparing these instructional and assessment materials, care has been taken to ensure their consistency with Egyptian national quality assurance and accreditation standards, Egyptian Ministry of Health and Population clinical protocols, and international best practices in medical and nursing education. With the conclusion of the effort to produce these CLGs and CCLs, it is apparent to the team that has undertaken this task that there now exists for Egypt a model for instructional materials design and development that can be applied to all other specialty areas of medical and nursing education in Egypt.  Contents No. LEARNING GUIDE TITLE PAGE ANTENATAL Antenatal Assessment 1 1 (History, Physical Examination & Testing). 2 Auscultation Fetal Heart Rate. 15 3 Pitting Edema Assessment. 18 4 Deep Tendon Reflex Assessment 20 LABOUR 5 Management of first stage of labor 24 6 Vaginal examination during labor 32 7 The Partogram 38 8 Management of second stage of labor 43 9 Instrumental tray of normal labor 45 10 Perineal care 54 11 Episiotomy 56 12 Management of third stage of labor 60 13 Examination of the placenta 62 14 Newborn assessment 66 15 Immediate care of the newborn 77 16 Neonatal resuscitation 81 17 Management of fourth stage of labor 86 18 Fundus and lochia assessment 89 19 Perineal care &assessment 93 20 Routine episiotomy care 96 21 The first two weeks routine neonate’s care 100 Nursing Responsibilities in Various Gynecological 22 Examinations in Gynecological Clinic. 106 23 Breast Examination 113 24 Assisting In IUD Insertion 122 25 Administer Contraceptive Hormonal Injection 124 26 Assisting In Insertion And Removal Of Norplant Implants 126  Learning Guide 1: Antenatal Assessment (History, Physical Examination, Testing) (To be completed by Participants) Rate the performance of each step or task observed using the following rating scale: 1. Needs Improvement: Step or task is performed incorrectly or out of sequence (if sequence necessary) or is omitted 2. Competently Performed: Step or task is performed correctly and in proper sequence (if sequence necessary) but participant does not progress from step to step efficiently 3. Proficiently Performed: Step or task is performed efficiently and precisely and in the proper sequence (if sequence necessary) LEARNING GUIDE FOR ANTENATAL ASSESSMENT (HISTORY, PHYSICAL EXAMINATION, TESTING) (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Getting Ready 1. Prepare the client care area, necessary supplies and 1 2 3 4 5 equipment: Stethoscope, light measuring device , thermometer , sphygmomanometer , tongue depressor, weighing scale ,tape measure, pinardfetoscope or sonic fetal heart sound device, gloves, urine testing facility & client record.  Ensure that the furniture is arranged conveniently for the work of all staff and comfortable for the client.  Ensure that the desk is supplied with cards, pencil, ….etc. 1  LEARNING GUIDE FOR ANTENATAL ASSESSMENT (HISTORY, PHYSICAL EXAMINATION, TESTING) (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES  Check the preparation of the following trays. - Medication tray. - Immunization kit. - Temperature tray. - Treatment and dressing tray.  Ensure that the visual displays and posters are arranged.  Ensure that waiting area is comfortable for the clients and educational material are available.  Make sure that all instruments and equipment are available and in working order.  Check and balance the scales at the beginning of the clinic. 2. Use an antiseptic hand rub or wash hands thoroughly with soap and water and dry with clean/dry cloth or allow to air dry. 3. Greet the woman and her companion respectfully and with kindness, introduce yourself, and offer the woman a seat. 4. Tell the woman what you are going to do, encourage her to ask questions, and listen to what she has to say. 5. Explain the importance, schedule and components of regular antenatal visits. 6. Confirm that woman has undergone quick check. Perform quick check if not done. 7. Instruct her to evacuate the bladder and collect specimen of urine. History Note: Flexibility may be used with respect to the order in which the questions are asked. For example, it may be better to link some questions with particular aspects of the woman’s physical examination. In performing the ANC history and physical examination learners should ask appropriate following questions as needed. Personal Information (First Visit) 1. Ask the woman’s name, address & available phone number 1 2 3 4 5 “so that woman can be traced by home visit if she fails to keep her next appointment.” 2  LEARNING GUIDE FOR ANTENATAL ASSESSMENT (HISTORY, PHYSICAL EXAMINATION, TESTING) (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 2. Ask the woman’s age, level of education, consanguinity, marital status, duration of marriage, religion, nationality and occupation. 3. Ask the woman’s housing condition and crowding index. (no. of persons/no. of rooms) 4. Ask what are her family’s sources of income/financial support. 5. Ask if she has received care from another caregiver during this pregnancy. 6. Ask if she has access to reliable transportation. Medical and Surgical History 1. Ask about the previous blood transfusion “frequency, 1 2 3 4 5 last date and cause” 2. Ask about previous accidents involving injury of the pelvis. 3. Ask about tetanus immunization. 4. Ask if she has any allergies from food or/and drug “what’s the name?” 5. Ask if she has been diagnosed with anemia in the last 3 months 6. Ask if she has been diagnosed with syphilis/STDs. 7. Ask if she been diagnosed with any chronic illnesses or conditions such as T.B, Heart disease, kidney disease, sickle cell disease, DM, goiter, or any other chronic illnesses. 8. Ask about current medication if any 9. Ask if she has ever been in the hospital or had surgery such as C.S, genital repair… etc. 3  LEARNING GUIDE FOR ANTENATAL ASSESSMENT (HISTORY, PHYSICAL EXAMINATION, TESTING) (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Family History 1. Ask the woman about if she has any family history of 1 2 3 4 5 such diseases as D.M, hypertension, cardiac disease, multiple pregnancy, congenital abnormalities and allergic condition such as asthma, eczema “specify relation & disease”. Daily Habits and Life Style (First Visit) 1. Ask if she walks long distances, carriers heavy loads or 1 2 3 4 5 does heavy physical labor. 2. Ask if she gets enough sleep and rest. 3. Ask what she normally eats in a day, and ask if she eats any non-food substances such as dirt or clay. 4. Ask if she is exposed to: a- Pregnancy hazards such as caffeine, tobacco and drug use, or uses any other possible harmful substance. b- Violence ( any type of violence) c- Over the counter medication d- Exposure to toxin/ chemical substance….etc. 5. Ask who she lives with and who is the decision maker. Obstetrical History “First Visit” 1. Details of previous pregnancies such as: 1 2 3 4 5  Length, outcome, numbers.  Date of last abortion.  Problems of each pregnancy as presence of convulsion during pregnancy … etc. 2. Details of previous childbirth: 1 2 3 4 5  Number, sex, weight of each newborn t “preterm, L.B.W”.  Whether stillborn babies died before 1 month of age.  Problems of each childbirth/ modes of delivery such as., uterine surgery during labor and tear through sphincter and/or rectum and C.S. 4  LEARNING GUIDE FOR ANTENATAL ASSESSMENT (HISTORY, PHYSICAL EXAMINATION, TESTING) (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 3. Details of previous postpartum such as:  Contraceptive history.  Complication such P PHg.  Ask if she has breastfed. If she has, ask for how long she breast fed and whether she had any problems such as cracked ripple, mastitis…etc. Menstrual and Contraceptive History (First Visit) 1. Ask her about age of menarche., duration of menstrual 1 2 3 4 5 flow, interval of menstruation, amount of menstruation, any menstrual problems. 2. Ask the first day of her last menstrual period (LMP) and calculate her expected date of delivery (EDD). 3. Ask how many more children she plans to have. 4. Ask if she has used a family planning method before. If she has, ask which method (S) and whether she liked the method (S). 5. Ask if she plans on using a family planning method after this baby is born. If so, ask which method. Present Pregnancy (First Visit) 1. Ask woman about symptoms of pregnancy. 1 2 3 4 5 2. Ask if she has felt the baby move. If she has, ask the woman when the baby first moved and whether she has felt it move in the last day. 3. Ask what her feelings are about this pregnancy. 4. Ask what are the feelings of her partner or family about this pregnancy. Interim history (Return Visit) Remember that the questions about her present pregnancy should be asked at every ANC visit 1. Ask if she is having a medical, obstetric, social, or 1 2 3 4 5 personal problem or other concerns. 5  LEARNING GUIDE FOR ANTENATAL ASSESSMENT (HISTORY, PHYSICAL EXAMINATION, TESTING) (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 2. Ask if she had any problems or significant changes since her last visit. 3. Ask if she has received care from another caregiver since her last visit. If so, ask who provided the care, what care was provided and what the outcome of care was. 4. Ask if any her personal information has changed since last visit. 5. Ask if her daily habits or lifestyle (workload, rest, dietary intake) changed. 6. Ask if there has been a change in her medical history since her last visit. 7. Ask if she has taken drugs/medication prescribed and followed the advice/recommendations provided at her last visit. 8. Ask if she has had any reaction to or side effects from immunizations or drugs/Medications given at her last visit. Physical Examination (General Examination) Assessment of General Well Being 1. Observe her general well-being: 1 2 3 4 5  Her gait and movement [walks steadily and without a limp].  Her facial expression [is alert and responsive].  Her general cleanliness [no visible dirt, no odor].  Her skin [free from lesions and bruises]. 2. Measure accurately woman’s weight without shoes to 1 2 3 4 5 obtain baseline for comparing weight gain during pregnancy. 3. Measure accurately her height without shoes. To give a rough guide to the size of pelvis. 6  LEARNING GUIDE FOR ANTENATAL ASSESSMENT (HISTORY, PHYSICAL EXAMINATION, TESTING) (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 4. Measure blood pressure while the woman is seated or lying down with the knees slightly bent and relaxed: If diastolic P is > 90 mm Hg, ask the woman if she has severe headache, blurred vision or epigastric pain, and check her urine for protein. 5. Measure correctly her pulse. 6. Place the woman on the examination couch. 7. Drape her and provide privacy. Stand the right side of the woman. 8. Examine the head:  Check hair for lice and nits.  Check the face for pallor, edema and facial expression.  Check conjunctiva for degree of redness (pallor may indicate anemia).  Note any pigmentation on forehead and cheeks, evidence for physiological changes during pregnancy.  Examine mouth for conditions of gums and teeth. 9. Examine the neck:  Palpate the nodes below the posterior angle of jawbones (swollen, tender nodes my indicate infection or cancer.  Check the neck for the thyroid gland. 7  LEARNING GUIDE FOR ANTENATAL ASSESSMENT (HISTORY, PHYSICAL EXAMINATION, TESTING) (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 10. Examine the chest:  Assist with examination of the heart and lungs by preparing the woman.  Examine the breasts, nipples and areola. 11. Examine the Genitalia:  Touch the inside of the woman’s thigh before touching genital area.  Separate labia majora with two fingers, check labia minora, clitoris, urethral opening and vaginal opening.  Palpate the labia minora for irregularities and nodules.  Look for swelling, discharge, tenderness, ulcers, and 8  LEARNING GUIDE FOR ANTENATAL ASSESSMENT (HISTORY, PHYSICAL EXAMINATION, TESTING) (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES fistulas.  Check Bartholin’s glands for discharge and tenderness by inserting index finger into vagina at lower edge of opening and feel at base of each labia majora and palpate each side for swelling or tenderness.  Check perineum for scar, lesions, inflammation or cracks in skin. 12. Examine the extremities:  Check the color of the palms and nails.  Check swelling of fingers.  Examine the legs, ankles and feet for shape and unequal length.  Check edema over the tibia, ankle and feet.  Observe legs for dilated veins. 13. Check the woman for danger signs of pregnancy. Physical Examination (Local Examination) Preparing for Examination 1. Explain the steps of the physical examination and 1 2 3 4 5 obtain the woman’s consent. 2. Ask her to empty her bladder. Have her provide a urine sample if indicate and if urine testing is available. 3. Have the woman undress in private. Ask her to remove only enough clothing to complete the examination. 4. Position the woman on the examination couch, on her back with knees flexed and slightly separated. 5. Provide her with a drape or cloth to cover the parts of her body that are not being examined & uncover her abdomen. Abdominal Examination (Every Visit) 1. Stand at the right side of the woman. 1 2 3 4 5 9  LEARNING GUIDE FOR ANTENATAL ASSESSMENT (HISTORY, PHYSICAL EXAMINATION, TESTING) (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 2. Inspect abdomen for scars;  If there is a scar, ask if it is from a caesarean section or other surgery also for hair distribution, skin pigmentation, edema, fetal movement, shape & enlargement of the abdomen. Fig(2) Palpation of the abdomen to estimate the period of gestation 3. Measure fundal height (Palpate the abdomen to estimate the period of gestation).  Place the palmer border of the left hand just below the xiphisternum& move it down the abdomen until the fundus is felt.  Measure the number of fingers, which can fit between the fundus &xiphisternum or measure the distance from the symphysis pubis to the fundus using tape measure (Fig2). 4. Carry out fundal palpation  Stand at the woman’s right side, facing her hand.  Place both hands on the sides of the fundus at the top of the abdomen.  Using the pads of the fingers, apply gentle but firm pressure to assess consistency and mobility of the fetal part & to determine which part of the fetus is occupying the fundus. 11  LEARNING GUIDE FOR ANTENATAL ASSESSMENT (HISTORY, PHYSICAL EXAMINATION, TESTING) (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 5. Carry out lateral palpation  Move hands smoothly down, sides of uterus to feel for fetal back.  Keep dominant hand steady against the side of uterus and use palm of other hand to apply gentle but deep pressure to explore opposite side of uterus.  Repeat procedure on other side of uterus. 6. Carry out suprapubic “Pelvic palpation”  Facing the woman’s feet, place both hands on the uterus just below the umbilicus with fingers close together & pointing downwards to determine which part of the fetus is occupying the lower part of the uterus. 7. Carry out Pawlik grip “done at 9th month or 36 weeks”  Facing the woman’s head, use the right hand to grasp the lower part of uterus between the thumb & fingers.  Ask woman to take deep breathes & breathes out gently.  Allow fingers to sink gently & deeply above the symphysis pubis to feel the size & mobility & engagement of presenting part. Fetal Heart Rate Evaluation 1. Listen to the fetal heart rate 1 2 3 4 5  Determine position of the fetus and place fetal stethoscope on abdomen on the same side that you palpated the fetal back.  Place your ear in close, firm contact with fetal stethoscope.  Remove hands from fetal stethoscope and listen to fetal heart for a full minute, counting beats against the second hand of a clock.  Feel the woman’s pulse at wrist, simultaneously to ensure that fetal heart tones, and not maternal pulse, are being measured (see LG auscultation of fetal heart). 11  LEARNING GUIDE FOR ANTENATAL ASSESSMENT (HISTORY, PHYSICAL EXAMINATION, TESTING) (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES After the Examination 1. Drape the exposed abdomen. 1 2 3 4 5 2. Remove gloves by turning them inside out. 3. If disposing gloves, place in leak proof container or plastic bag. 4. Help the woman off the examination table. 5. Share your findings with the woman. 6. Record the findings & woman’s reaction. Lab Studies Urine Analysis For Sugar And Albumin Preparing for Testing 1. Explain the steps in the procedure and obtain the 1 2 3 4 5 woman’s consent. 2. Ask her to empty bladder and have her provide a urine sample. 3. Emerge the clinistix strips in the specimen of urine then remove it. 4. Wait 30-60+ second for reaction. 5. Compare the color or reaction of urine with the color guide on the test boxes. 6. Clean the equipment used. 7. Record the finding. Routine Tests 1. Hemoglobin test (1st visit, at about 28 weeks, and 1 2 3 4 5 based on signs and symptoms).  If hemoglobin is less than 7 g/dl, refer woman to hospital.  If hemoglobin is 7-11 g/dl iron/foliate 1 table twice daily as ordered. 2. Test for blood group and Rh, if negative, woman is candidate for anti-D immune globulin. 12  LEARNING GUIDE FOR ANTENATAL ASSESSMENT (HISTORY, PHYSICAL EXAMINATION, TESTING) (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 3. The routine tests done during prenatal visits include:  Urine or blood test for pregnancy at your first visit.  Blood tests to check for diabetes when you are 28 weeks pregnant.  Blood tests for sexually transmitted infections  Cultures of cells from cervix to test for infection if needed.  Skin test for tuberculosis.  Cultures of swabs of the vagina and rectum to test for group B streptococcus in the 35-37 weeks of pregnancy. Optional Tests 1. That are often done only if there are medically 1 2 3 4 5 necessary. They include:  Amniocentesis for testing of fluid from around the baby for chromosome information.  Serum Alpha-Fetoprotein measurement to screen for certain birth defects.  Ultrasound, scans as needed to look at the baby and the uterus, amniotic sac, placenta, ovaries and pelvis.  Non stress tests to check the health of the baby (check the baby’s heart rate when the baby moves. 2. RPR test (first visit/as needed)  If result is positive, refer woman for treatment of syphilis.  Plan to treat newborn.  Encourage woman to bring sexual partner for treatment.  Advise on correct and consistent use of condom to prevent reinfection Post Procedure Task 1. Remove gloves by turning them inside out. 1 2 3 4 5 2. Replace equipment. 3. Use antiseptic hand rub or wash hands thoroughly with soap and water and dry with clean, dry cloth or allow to air dry. 13  LEARNING GUIDE FOR ANTENATAL ASSESSMENT (HISTORY, PHYSICAL EXAMINATION, TESTING) (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 4. Share your findings with the woman. 5. Give the woman the necessary instruction and date of next visit. 6. Record findings and woman’s reaction. 7. Refer abnormal case. 14  Learning Guide 2: Auscultation of Fetal Heart Rate )To be completed by Participants( Rate the performance of each step or task observed using the following rating scale: 1. Needs Improvement: Step or task is performed incorrectly or out of sequence (if sequence necessary) or is omitted 2. Competently Performed: Step or task is performed correctly and in proper sequence (if sequence necessary) but participant does not progress from step to step efficiently 3. Proficiently Performed: Step or task is performed efficiently and precisely and in the proper sequence (if sequence necessary) LEARNING GUIDE FOR AUSCULTATION FETAL HEART RATE (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Getting Ready 1. Prepare the equipment: 1 2 3 4 5  Pinard or Sonicad- fetoscope- ultrasonic gel- cotton. 2. Use an antiseptic hand wash thoroughly with soap and water and dry with clean/dry cloth or allow to air dry and wear gloves. 3. Greet the woman, introduce yourself, and offer the woman a seat. 4. Tell the woman what you are going to do, encourage her to ask questions, and listen to what she has to say. Auscultation Fetal Heart Rate Steps 1. Explain the procedure to the woman and this will include 1 2 3 4 5 the reasons for, the frequency of the procedure and obtain woman consent. 2. Ask her to empty her bladder. 3. Have the woman undress in private. Ask her to remove only enough clothing to complete procedure. 15  LEARNING GUIDE FOR AUSCULTATION FETAL HEART RATE (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 4. Ask the woman to lie on her back on the bed, with pillows under her head.  Place a wedge under her right or left hip to maintain a slight lateral tiltduring the procedure. N.B: Proper position facilitates location of fetal heart tones. 5. Provide her with a drape or cloth to cover the parts of her body that are not being examined. 6. Perform Leopold’s maneuvers to locate the fetal back. (See the procedure of Leopold’s maneuvers). 7. Listen to the fetal heart rate  Place fetal stethoscope on abdomen on the same side that you palpated the fetal back.  Place your ear in close, firm contact with fetal stethoscope.  Remove hands from fetal stethoscope and listen to fetal heart for a full minute, counting beats against the second hand of a clock.  Feel the woman pulse at wrist, simultaneously to ensure that fetal heart tones, and not maternal pulse, are being measured. 8. Auscultate fetal heart rate at regular intervals. For antenatal period:  Each visit. For low risk woman:  First stage: latent phase: every 60 min; active phase: every 30 min.  Second stage: every 15 min. For high risk woman:  First stage: latent phase: every 30 min; active phase: every 15min.  Second stage: every 5 min. 16  LEARNING GUIDE FOR AUSCULTATION FETAL HEART RATE (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Fig (3) Auscultation of the fetal heart Post Procedure Task 1. Drape the exposed abdomen. 1 2 3 4 5 2. Remove gloves by turning them inside out. 3. If disposing gloves, place in leak proof container or plastic bag. 4. Use antiseptic hand rub or wash hands thoroughly with soap and water and dry with clean cloth or air. 5. Record the baseline rate, rhythm and fetal response to uterine contractions. 6. Remove the equipments 17  Learning Guide 3: Pitting Edema Assessment )To be completed by Participants( Rate the performance of each step or task observed using the following rating scale: 1. Needs Improvement: Step or task is performed incorrectly or out of sequence (if sequence necessary) or is omitted 2. Competently Performed: Step or task is performed correctly and in proper sequence (if sequence necessary) but participant does not progress from step to step efficiently 3. Proficiently Performed: Step or task is performed efficiently and precisely and in the proper sequence (if sequence necessary) LEARNING GUIDE FOR PITTING EDEMA ASSESSMENT (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Getting Ready 1. Greet the mother. 1 2 3 4 5 2. Explain the procedure. 3. Edema should be assessed routinely at each prenatal visit after 20 weeks' gestation. 4. Ask the woman and/or family members if the woman face or hands appear swollen (non pitting edema may be found in the patient's fingers, face, and eyelids). 5. Position the mother flat in the bed. 6. Wash hands. Edema Assessment Steps 1. Observe for general appearance (skin texture, swelling). 1 2 3 4 5 2. Inspect the woman face, extremities, and sacral area for signs of pitting edema. 3. Press each area firmly with the thumb or index finger for several seconds and release. 4. Evaluate the extensiveness of the edema, the depth of the depression, and the length of time it takes to clear (pitting edema leaves a depression after finger pressure 18  LEARNING GUIDE FOR PITTING EDEMA ASSESSMENT (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES has been applied to an affected area). 5. Grade the pitting edema according to the following scale:  1+ = Minimal edema of the lower extremities.  2+ = Marked edema of the lower extremities.  3+= edema of the lower extremities, face, and hands.  4+ = Generalized, massive edema. Fig4: PITTING EDEMA ASSESSMENT Post Procedure Task 1. Record and. Compare the finding with those previously 1 2 3 4 5 recorded. 2. Cover the woman and keep her in comfortable position. 19  Learning Guide 4 : Deep Tendon Reflex Assessment )To be completed by Participants( Rate the performance of each step or task observed using the following rating scale: 1. Needs Improvement: Step or task is performed incorrectly or out of sequence (if sequence necessary) or is omitted 2. Competently Performed: Step or task is performed correctly and in proper sequence (if sequence necessary) but participant does not progress from step to step efficiently 3. Proficiently Performed: Step or task is performed efficiently and precisely and in the proper sequence (if sequence necessary) LEARNING GUIDE FOR DEEP TENDON REFLEX ASSESSMENT (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Getting Ready 1. Prepare the necessary equipment (reflex hammer). 1 2 3 4 5 2. Greet the mother. 3. Explain the procedure to the mother and reassure her overall the procedure. 4. Position the mother so that her arms and legs are flexed or semi flexed and her muscles are relaxed (relaxation of the muscles is required in order to elect the DTR response successfully). Woman's legs hanging freely over the end of the examination table, or with the woman lying on her side with the knee slightly flexed. 5. A blow with a percussion hammer is dealt directly to the patellar tendon, inferior to the patella. 6. Deep tendon reflex is evaluated especially if the woman is being treated with MgSo4; absence of DTRs is an early indication of impending MgSo4 toxicity. Deep Tendon Reflex Assessment Steps 7. Locate the tendon and corresponding muscle of the reflex to 1 2 3 4 5 be tested. For example, prior to assessing the patellar reflex (knee jerk), locate the ligamentum patellae tendon at the base of the patella. Before eliciting the biceps reflex, reflex 21  LEARNING GUIDE FOR DEEP TENDON REFLEX ASSESSMENT (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES the woman's elbow and place your thumb across the tendon in the antecubital space. (identifying the correct tendon is essential to eliciting a reflex response). 8. Tap the tendon directly using the reflex hammer or, in the case of the biceps reflex, firmly tap your thumb, which is pressing on the tendon. 9. Rate the reflex response according to the following scale:  0 = Reflex absent  +1 = Reflex hypoactive (diminished)  +2 = Normal reflex (extension or kicking out of the leg)  +3 = Reflex hyperactive (Brisk i.e the foot is sharply dorsiflexed and the position maintained for a moment, the foot is then released)  +4 = Clonus - Normal (negative clonus) response is elicited when no rhythmic oscillations (jerking) are felt while the foot is held in dorsiflexion. When the foot is released, no oscillations are seen as the foot drops to the planter flexed position. - Abnormal (positive clonus) response is recognized by rhythmic oscillations of one or more beats felt when the foot is in dorsiflexion and seen as the foot drops to the plantar flexed position. 21  LEARNING GUIDE FOR DEEP TENDON REFLEX ASSESSMENT (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Fig(5) DEEP TENDON REFLEX ASSESSMENT 10.Repeat the procedure if you are unable to elicit the reflex or to confirm the response as absent or diminished. To confirm absent diminished reflexes, instruct the woman to contract a group of muscles different from those being evaluated. For example, while testing reflexes in the lower extremities, ask the woman to interlock her fingers and pull her arms outward, contracting the muscles in her arms. 11.Assess each reflex symmetrically, comparing the reflex response on one side with the reflex response on the other side. The reflex response for a tendon should be the same on both the right and left sides. 12.When checking for Clonus, explain the procedure to the woman at first. Position the woman so that her knee is semi- flexed. Support her leg by placing one hand or your arm under her knee. 13.Using your other hand, sharply dorsiflex the woman's foot, maintaining slight pressure on her foot after dorsiflexion. Release her foot and observe its movement. 14.Count the beats of Clonus present as you observe for rhythmic contraction and relaxation of the gastrocnemius and soleus muscles. (clonus is evaluated by counting the number of times the muscle contracts and relaxes after it has been sharply stretched). 22  LEARNING GUIDE FOR DEEP TENDON REFLEX ASSESSMENT (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Post Procedure Task 1. Record and compare your findings with those previously 1 2 3 4 5 recorded. 2. Remove equipment 3. Wash hand. 4. Reassure mother about findings. 23  Learning Guide 7: Management of First Stage of Labor )To be completed by Participants( Rate the performance of each step or task observed using the following rating scale: 1. Needs Improvement: Step or task is performed incorrectly or out of sequence (if sequence necessary) or is omitted 2. Competently Performed: Step or task is performed correctly and in proper sequence (if sequence necessary) but participant does not progress from step to step efficiently 3. Proficiently Performed: Step or task is performed efficiently and precisely and in the proper sequence (if sequence necessary) LEARNING GUIDE FOR MANAGEMENT OF FIRST STAGE OF LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Getting Ready 1. Prepare the needed equipment: 1 2 3 4 5  Vital signs set: (Sphygmomanometer – thermometer – stethoscope – watch).  F.H.R. monitoring set: (pinard or sonicaid – C.T.G).  P.V. set: (K.Y gel – sterile or disposable gloves).  Supplies: (syringes – I.V. sets – Cannulas with different sizes – sterile dressings – plaster – cotton – antiseptics solution – folly or nelton catheter – urinary bags).  Solutions: (Ringer – Ringer Lactate – Saline – Glucose).  Linens – gowns – towels.  Enema set: (clean well functioning enema with clamp).  Medication set: analgesics e.g. valium – antibiotics- antiemetics – uterotonicc Drugs 24  LEARNING GUIDE FOR MANAGEMENT OF FIRST STAGE OF LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 2. Admission:  Welcome and great the woman in a kind way to initiate a trust relationship and gain full cooperation, because it may be her first admission to hospital and she may be apprehensive about it.  Explain all procedures performed to her.  Seek informed consent.  Help her undress and get into bed if there are any complications as bleeding, PROM with high head, PIH, cardiac disease, or any other medical problems.  Ensure privacy and confidentiality.  Wash hands before each procedure. Nursing Management Steps Of The First Stage Assessment 1. Take complete history in relation to: 1 2 3 4 5  Medical history: (presence of chronic diseases as cardiac, diabetes mellitus, etc..).  Family history: some families have genetic pre- dispositions to certain diseases especially if the parents are close relatives such as diabetes mellitus, essential hypertension, multiple pregnancy, congenital abnormalities and allergic conditions as asthma, eczema and hay fever.  Obstetric history: as previous pregnancies, deliveries, and postpartum complications; menstrual history: as age at menarche, regularity, nature of flow, date of LMP and calculate EDD; contraceptive history: as type, duration, and complications if present. 2. Determine whether the woman is in labor or not through the presence of the following:  Uterine contractions: ask the woman when true contraction began and assess its frequency, intensity, and duration within 10 minutes every 30 minutes.  Show: ask the woman if she had a blood stained mucous discharge. 25  LEARNING GUIDE FOR MANAGEMENT OF FIRST STAGE OF LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES  Membranes: ask the woman if she had a gush of fluid or not, if she is not, if she is not sure, use litmus paper and smell it to exclude urine. If membranes are ruptured record the time of rupture.  Frequency of micturation: it occurs as a result of engagement. The pressure of the presenting part on the urinary bladder decreases its capacity.  Cervical changes: shortening and dilating of the cervix. Through per vaginal examination. - In the Latent phase: cervical dilatation is less than 3 cm (slow cervical effacement). - In the Active phase: cervical dilatation is from 3-10 cm (progressive cervical dilatation). - Primigravida: cervix dilates at less than 1-2 cm/hour. - Multigravida: cervix dilates at less than 1.5 cm/hour.  Formation of the bag of water. 3. Examination of the woman in labor:  Explain all the procedures to the woman to gain full cooperation.  Inform her of the procedures results.  General examination - Observe the woman general condition such as: body built and stature; limbs for edema and varicose veins, deformity and general appearance as presence of pallor may indicate infection and dehydration. - Measure vital signs accurately and should be taken between contractions and recorded, if temperature is high (more than 38 degrees) isolate the woman as indicates to presence of infection. - Test urine for protein and sugar (take the mid- void sample) after vaginal swapping with antiseptic solution and before enema. 26 LEARNING GUIDE FOR MANAGEMENT OF FIRST STAGE OF LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES  Local examination - Examination of the abdomen (abdominal maneuver). 1. Palpate the abdomen gently for the height of fundus, lie, presentation, position, attitude and station of the fetus and record them. 2. Observe and record the frequency, duration and intensity of the uterine contractions/30 min. 3. Auscultate and record the FHS for one min. using pinard 's stethoscope, or sonicaid. Also, a cardiograph machine gives information about fetal condition. The normal range of fetal heart rate is 120-160 b/m. - Examination of the vulva: 1. Inspect for gapping of introitus. 2. Observe color and odor of liquor amnion and presence of meconuim or blood (in cephalic presentation). The presence of offensive odor indicates infection. 3. Check for vulval edema, if present it indicates preeclampsia. - Vaginal Examination: it is done by the midwives or doctor to: 1. Ensure a positive diagnosis of labor. 2. Assess the progress of labor in terms of determining the extent of effacement and degree of dilatation of the cervix and assessing progress of uterine contractions. 3. Assess the condition of membranes 4. Determine fetal position, presentation, and degree of fetal head descent in the pelvis in relation to ischial spines (station). 5. Observe the presence of cord prolapse (umbilical cord beside the head). 6. Check the presence of Moulding, caput succedaneum and /or abnormalities 7. Evaluate pelvic capacity and condition of the vagina. 27  LEARNING GUIDE FOR MANAGEMENT OF FIRST STAGE OF LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Active Management Partograph: Nurse uses partograph to record all important information 1 2 3 4 5 about woman and fetus during labor. The nurse can see at a glance the condition of the woman and fetus and the progress of labor. A. Maternal Assessment Includes 1. Vital signs. 1 2 3 4 5 2. Progress of labor (cervical changes, and uterine contractions). 3. Nutrition and Hydration  During labor, there is an excessive loss of fluids and increased the tendency to exhaustion and dehydration due to strong muscles contraction  Women's need for energy is met through nourishing oral fluid at frequent intervals to maintain the fluid balance.  I.V. fluids are given to provide energy and prevent dehydration in case of vomiting, ketosis and possible use of anesthesia.  During early labor, the woman should receive about 75ml of fluid per hour in the form of juices, soups, or tea with sugar and digestive biscuits.  Maintain an intake and output chart.  Diet should be nutritious, easily digestible and small in amount.  Sold food is usually avoided during the active labor since gastric empting is prolonged and in anticipation of anesthesia may cause aspiration of vomitus. 4. Rest and Sleep (comfort measures)  Anxiety and uterine contractions produce sleeplessness. So, it is important for the nurse to be with the woman to reassure her and help her to sleep by use hypnotics if she is in latent phase.  The nurse helps the woman to sleep by providing a warm, nourishing drink, maintain a quite room with dim lighting and comfortable bed.  Ambulation may decrease the need for analgesics, shorten labor and decrease incidence of fetal heart rate 28  LEARNING GUIDE FOR MANAGEMENT OF FIRST STAGE OF LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES abnormalities.  The woman is allowed to ambulate if there is no contraindications as bleeding, PROM, and medical problems.  Massage the back if she complaints of backache.  Relieve pain by encouraging deep breathing during contraction and use of analgesics.  Make dorsiflexion if cramps of her legs occurred. 5. Apply Measures of infection control  Follow the aseptic techniques in each procedure to prevent infection.  Provide dry and clean clothes and bed linen for the woman.  Change the pad frequently if there is excessive vaginal discharge.  Trimming of hair to clean and disinfect the vulva to prevent infection. While shaving is not advisable for fear of lacerations and infection.  Bath is given following an enema and trimming of hair if needed and then instruct the woman to wear a clean night dress or gown and avoid using cosmetics.  Cut and clean nails.  Swab the perineum on admission then every six hours before and after vaginal examination. before delivery and catheterization. Then cover the vulva with sterile pad. 6. Posture of woman in labor:  The nurse should allow the woman to assume any comfortable position, except the dorsal recumbent which may result in supine hypotension and leads to fetal distress.  Encourage the woman to walk in the room if she is not in active labor and to lie down towards the end of first stage of labor. 7. Care of bladder:  Encourage the woman to pass urine every 2-3 hours during labor because a full bladder causes poor uterine contractions, P.P. hemorrhage and injury or vesico-vaginal fistula when the bladder is nipped 29  LEARNING GUIDE FOR MANAGEMENT OF FIRST STAGE OF LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES between fetal head and the pelvis.  N.B: retention of urine occurs frequently in labor due to; lack of muscle tone of the urinary bladder, uncomfortable use of bedpan, pressure on the urethra, and elongation of the urethra, which inhibits relaxation the urethral sphincter. 8. Observe signs of maternal distress:  Increased pulse rate over 100b/min.  Elevated temperature more than 38C.  Decreased blood pressure.  Sweating and pale face.  Signs of dehydration.  Dark vomitus.  Ketone bodies in urine.  Irritability and restlessness.  Anxious and depression. 9. Observe for complication:  Power: hypotonic or hypertonic uterine contraction.  Passengers: big infant, mal-position, and malpresentation.  Passages: CPD/ cephalopelvic disproportion, contracted pelvis and rigid cervix. B. Fetal Assessment Includes 1. Monitor and record fetal heart rate to recognize fetal 1 2 3 4 5 distress or abnormalities. It should be heard every 4 hours until rupture of membranes, then every 30 minutes. 2. Observe and record signs of fetal distress:  Excessive fetal movement.  Excessive molding of fetal head.  Excessive formation of caput succedaneum.  Increase fetal heart rate to more than 160 b/min, or decrease to less than 100 b/min, or become irregular.  Passage of meconium in cephalic presentation. 31  LEARNING GUIDE FOR MANAGEMENT OF FIRST STAGE OF LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Post Procedure Tasks 1. Record all the results and findings of each procedure 1 2 3 4 5 utilizing partograph. 2. Report for any maternal or fetal complications. 3. Clean, repack, and sterilize all the used equipment. 4. Restore and return all the stock. 5. Transfer woman to the delivery room:  Primiparous: when the presenting part pulging the perineum.  Multiparous: when the cervix is 8-9cm dilated. 6. Wash hands. 31  Learning Guide 8: Vaginal Examination During Labor )To be completed by Participants( Rate the performance of each step or task observed using the following rating scale: 1. Needs Improvement: Step or task is performed incorrectly or out of sequence (if sequence necessary) or is omitted 2. Competently Performed: Step or task is performed correctly and in proper sequence (if sequence necessary) but participant does not progress from step to step efficiently 3. Proficiently Performed: Step or task is performed efficiently and precisely and in the proper sequence (if sequence necessary) LEARNING GUIDE FOR VAGINAL EXAMINATION DURING LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Getting Ready 1. Prepare the necessary equipment ( Pre-packed vaginal 1 2 3 4 5 examination set – Sterile gloves - Lubricant K-Y – Sterile pad). 2. Ask the patient to empty her bladder before examination. 3. Tell her in terms she can understand what you will be doing and share your findings with her throughout the examination to gain her cooperation throughout the procedure. 4. Screen the bed. 5. Help the patient to lie on her back. 6. Perform an abdominal examination to determine the lie, presenting part, position and auscultate the fetal heart sound. 7. Using your left hand swab the labia majora, labia minora and vestibule using one swab for each part (i.e.: 5 swabs in all) inspecting vulva as you do so. 32  LEARNING GUIDE FOR VAGINAL EXAMINATION DURING LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 8. Ask the patient to lie on her back with knees flexed, heels together and legs apart outwards. Put a pillow under her head and ask that she can rest her hands across her abdomen or other sides. This increases her comfort and relaxation. Sometimes women put their hands over their heads during vaginal examination which lightens abdominal muscles and makes the examination more difficult or uncomfortable. 9. Drape her legs to avoid unnecessary exposure. Make sure that you can see her face during the examination. The message given to the patient is that you respect her modesty and privacy. This will help her relax. Making sure that you can see her face at all times might reassure her and enable you to note expressions of fear, discomfort, or embarrassment. Vaginal Examination Steps 1. Wash your hands and put on gloves: 1 2 3 4 5  If ruptured membranes are suspected always use sterile gloves.  If membranes are intact clean or sterile gloves can be used. 2. Ask the patient to separate or spread her legs. Do not try to use force. This is an intrusive procedure. It should be carried out when the patient is ready for it. 3. Tell the patient how to relax. Have her do slow, deep, relaxed breathing. 4. Ask the patient if you may proceed now. This appropriately gives her some control and is empowering. 5. Generously lubricate the index and middle fingers of your examining hand with K-Y lubricating Jelly. As you squeeze the tube, let the lubricant drop on to your outstretched fingers. Do not wipe your fingers against the mouth of the tube to obtain the lubricant. The lubricant should be considered clean only- not sterile. 33  LEARNING GUIDE FOR VAGINAL EXAMINATION DURING LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 6. Separate the labia with your gloved fingers. 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 discharge. The presence of a greenish brown fluid indicates fresh meconium. In cephalic presentation, it means fetal distress.  Signs of inflammation or infection.  Any scars indicating episiotomy or prior perineal surgery. 7. Insert the first finger of the other sterile gloved hand then the second finger gently into the vagina. The hand should be turned sideways in this initial step. Keep downward pressure as you insert the fingers to avoid pressing on the anterior vaginal wall or urethera. The thumb and fore finger on one hand separate the labia widely to expose the vaginal opening and prevent the examining fingers from touching the labia. 34  LEARNING GUIDE FOR VAGINAL EXAMINATION DURING LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 8. Move your fingers the full length of the vagina (usually 7.5-10 cm.).  During the examination, the fourth and fifth fingers should not 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. 9. Note the following:  State of the vagina.  State of cervix, effacement, and dilatation.  Membranes.  Presenting part.  Position.  Degree of moulding. 35 LEARNING GUIDE FOR VAGINAL EXAMINATION DURING LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES  Caput succedaneum or any abnormalities.  State of cervix: degree of cervical dilatation is measured in centimeter. One finger represents approximately 1.5- 2Cm. dilatations. Measurement of dilatation can be from 0-10Cm. in diameter.  Effacement is measured in percentages the uneffaced cervix is approximately 1 inch thick and would be described as uneffaced or 0%. A cervix that ½ inch thick is 50% effaced.  Palpate for the presenting part. If you feel - The hard skull with the sagittal suture and follow it to the anterior or posterior fontanel. It is a cephalic presentation. - The soft buttocks. It is a breech presentation. - Irregular knobby parts like facial features. It is a face presentation.  Station: has engagement occurred. Locate the lowest portion of the presenting part, and then sweep the fingers deeply to one side of the pelvis to feel for ischial spines. To determine station, estimate how far (in centimeters) the tip of the presenting part is above or below ischial spine e.g if fetal head is approximately 1Cm below ischial spines, it is at +1 station.  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. 36  LEARNING GUIDE FOR VAGINAL EXAMINATION DURING LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Post Procedure Tasks 1. Swab the vulva orifice to dry it. It is swabbed in the 1 2 3 4 5 reverse order this time, commencing with vaginal opening then the vestibule and finishing with labia majora. If the membranes have ruptured place a sterile pad over the vulva. Turn the patient on to her left side, dry the anal region and pull through the sanitary towel. You may change the bed linen. 2. Make patient comfortable. 3. Auscultate the fetal heart and let the patient know how things are progressing. 4. Record your findings on the partogram. 5. Clear away the equipments and clean it. 6. Wash hands. 37  Learning Guide 11 : The Partogram )To be completed by Participants( Rate the performance of each step or task observed using the following rating scale: 1. Needs Improvement: Step or task is performed incorrectly or out of sequence (if sequence necessary) or is omitted 2. Competently Performed: Step or task is performed correctly and in proper sequence (if sequence necessary) but participant does not progress from step to step efficiently 3. Proficiently Performed: Step or task is performed efficiently and precisely and in the proper sequence (if sequence necessary) LEARNING GUIDE FOR THE PARTOGRAM (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Getting Ready 1. Prepare the equipment: 1 2 3 4 5  Partogram sheet  Sphingomanometer,stethoscope and thermometer  Gloves (disposable)  Sonicade or pinardTocotransducer. 2. Explain the procedure and way of assessment to the woman to reassure her. 3. Wash hands. Steps Of Recording On The Partogram 1. Record the mother s’ admission data: 1 2 3 4 5  Name, age, gravida, para, date and time of admission, condition of membranes, first day of last menstrual period and expected date of delivery and gestational age. 38  LEARNING GUIDE FOR THE PARTOGRAM (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 2. Assess and record the fetal condition:  fetal heart rate  Membranes condition: - I-intact - R-ruptured ,if membranes are ruptured ,assess the color of the amnioticfluid as the following: C- Clear. M- Meconium stained. B- Bloody.  Moulding: record as the following: - Zero: if sutures are separate. - + : if sutures are touching but not overlapping - ++ : if sutures are overlapping but with gentle pressure is reduced. - +++: if sutures are overlapping and can not be reduced. 39  LEARNING GUIDE FOR THE PARTOGRAM (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 3. Assess and record labor progress as the following:  Cervical dilation: - Record the cervical dilatation on vaginal examination measured by fingers (one finger equals one centimeter). - the vertical line is numbered 0-10 and represents cervical dilatation in centimeters. - Bottom of the graph are numbers (0-24), each square represents one hour. - Plot with symbol 'x' to differentiate it from the descent of the fetal head.  Descent of the fetal head: - Assessed on abdominal palpation (rule of fifth) by assessing number offingers above pelvic brim. The figures 0-5 on the same line represent the amount of head which is palpable above the pelvic brim. - if the head is mobile above the brim, it will accommodate the full width of five fingers. - As the head descends, the portion of the head remaining above the brim will be represented by fewer fingers (3/5, 4/5…) - The head is engaged when the portion above the brim is represented bytwo fingers width. - Plot on the left hand side of the graph is the word “descent” with linesgoing from (5-0) - Descent is plotted with “o” on the partograph N.B: Cervical dilatation will appear on the graph as arising oblique line and the descent of the fetal head will be a falling oblique line. N.B:-Alert line : is a straight line from (3-10 cm) - When a women is admitted in the active phase, dilatation of the cervix is plotted on the alert line, clock time written directly under the “x” in the space for time - If the progress is satisfactory ,the plotting of cervical dilatation will remain on or to the left of the alert line - Action line : is 4 hours to the right of the alert line , 41  LEARNING GUIDE FOR THE PARTOGRAM (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES if a woman s’ labor reaches this line ,appropriate action should be taken. 4. Uterine contractions:  Assess frequency of contractions by determining how many contractions in an interval of 10 minutes.  Calculate the duration of contractions when you feel the contraction over the fundus up till relaxation of the fundus.  There are three ways of shading the duration of contractions: - less than 20 seconds. - from 20-40 seconds. - more than 40 seconds. 5. Assess and record maternal vital signs:  Assess maternal vital signs according to the phase of labor(refer to management of first stage of labor)  Record the pulse using appropriate sign (!).  Record the blood pressure using appropriate different sign (arrows).  Record the temperature. 6. Record I.V fluids , drugs 41  LEARNING GUIDE FOR THE PARTOGRAM (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 7. Record syntocinon as the following:  Calculate the number of units in 500 ml Dextrose or other IV fluid.  Adjust the rate of infusion per minute. 8. Record urine volume and abnormal constitutes (albumin , acetone and blood ). Post Procedure Tasks 1. Give positive feedback to the mother about progress if 1 2 3 4 5 labor 2. Put the mother in a comfortable position 3. Remove all equipment 4. Report for any deviation from normal and take the needed actions 5. Wash hands 42  Learning Guide 12 : For Management Of Second StageOf Labor )To be completed by Participants( Rate the performance of each step or task observed using the following rating scale: 1. Needs Improvement: Step or task is performed incorrectly or out of sequence (if sequence necessary) or is omitted 2. Competently Performed: Step or task is performed correctly and in proper sequence (if sequence necessary) but participant does not progress from step to step efficiently 3. Proficiently Performed: Step or task is performed efficiently and precisely and in the proper sequence (if sequence necessary) LEARNING GUIDE FOR MANAGEMENT OF SECOND STAGE OF LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Getting Ready 1. Prepare the needed equipment on the delivery trolley: 1 2 3 4 5 A- Top shelf: Delivery Pack contents:  bowel for lotion.  dry swabs, cotton wool.  three sterile towels.  two cord clamps.  one pair of cord scissors  one pair of episiotomy scissors.  sterile sanitary pad.  sterile gloves, sterile dressings.  cord ligatures. B- Lower Shelf:  Antiseptic solution.  The needed drugs (methergin- oxytocin-xylocaine).  Syringe and needles.  Dry linens.  Episiotomy pack.  Put the trolley of equipment within easy reach. 2. Put the women on the delivery bed on lithotomy position. 43  LEARNING GUIDE FOR MANAGEMENT OF SECOND STAGE OF LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 3. Explain what will happen to the mother to reassure her and teach her to push during contraction and take deep breathing in between. 4. Make careful scrubbing. Then gowning and gloving. Management Of Second Stage Of Labor Steps 1. Check the FHR in between contraction. 1 2 3 4 5 2. Make perineal care (wet). 3. Drape the mother as following :  Put two leggings on her abdomen.  Put 1st towel under the mother s’ back and the 2nd towel on her abdomen. 4. Apply sterile dressing on the perineum with pressure during crowning:  To prevent tear of perineal muscles.  To maintain fetal head flexion 5. Clean and dry the newborn's face immediately after head delivery with sterile dressing to prevent swallowing of any mucous, liquor or stool. 6. Give the drugs as doctor order. 7. Clamp the cord without milking and cut in between the two clamps. Post Procedure Tasks 1. Continue management of third stage of labor and 1 2 3 4 5 immediate baby care. 44  Learning Guide 13: Instrumental tray of normal labor Rate the performance of each step or task observed using the following rating scale: 1. Needs Improvement: Step or task is performed incorrectly or out of sequence (if sequence necessary) or is omitted 2. Competently Performed: Step or task is performed correctly and in proper sequence(if sequence necessary) but participant does not progress from step to step efficiently 3. Proficiently performed: Step or task is performed efficiently and precisely and the proper sequence (if sequence necessary) LEARNING GUIDE FOR INSTRUMENTAL TRAY OF NORMAL LABOR (Some of the following steps/tasks should be performed simultaneously.) Step/Task CASES Getting Ready Instrumental tray of normal labor Clean table consists of 2 shelves: A. Upper shelf contain: 1. 4 sterile towels 2. Dry swabs, cotton wool. 3. handling forceps 4. Sterile sanitary pad. 5. Sterile gloves, sterile dressing, and aprons. 6. One pair of kokher. 7. one pair of artery forceps 8. one pair of cord scissors.(straight) 9. one pair of episiotomy scissors.(curved) 45  10. 4ovums. 11. sim's speculum. 12. Disposable catheter. 13. Antiseptic solution. 14. The needed drugs"methargin- Oxytocin, prophylactic antibiotic" 15. Syringe and needles 16. Episiotomy pack(needle holder, needle, catgut suture, toothed and nontoothed, local anesthesia) B. Lower shelf contain: - Equipments of perineal care - Dry linens. Instruments used in obstetric and gynecology Uses Artery Forceps  Grasp instrument used during repair of episiotomy 46   Clamp of umbilical Kokher forceps cord.  Rupture of membrane Scissors( curved &straight)  Straight Scissors for Cutting of umbilical cord.  Curved scissors for cutting of episiotomy Ovum Forceps & Ring Forceps  Grasp soft cervix during Vaginal evacuation. 47  Explorations of cervix after vaginal delivery Cerclage operation. Repair of cervical laceration after delivery Non Toothed Tissue forceps  Holding internal soft tissue ,fascia and muscle during repair of episiotomy. Toothed Tissue forceps  Holding skin layer during repair of episiotomy Needles(curved & straight ) With Round or  Needles with rounded Cutting End end for suturing of internal soft tissues.  Needles with cutting end for suturing of skin. 48  Needle holder  Hold needle during repair of episiotomy ,tears or laceration. Sims ’s Speculum  Visualization of anterior vaginal wall for diagnosis of vesico-vaginal fistula.  Exploration of vagina and cervix after vaginal delivery.  During surgical repair of fistula.  Routine vaginal Cusco Vaginal Speculum examinations to visualize lateral vaginal wall and cervix.  Exploration of vagina and cervix after vaginal delivery.  Other uses in minor 49  procedures e.g. I.U.D application, Cauterization.   1.Maternal:maternal distress.  2.Fetal:fetal distress  3.Prolonged second stage:  causes in passage e.g. mild degree cephalopelvic disproportion.  causes in power e.g. inertia (no bearing down)  causes in passenger e.g. after coming head of breech The Ventouse( Vacuum Extractor)  1.Maternal:maternal distress.  2.Fetal:fetal distress  3.Prolonged second stage:  causes in passage e.g. mild degree cephalopelvic disproportion.  causes in power e.g. 51  inertia (no bearing down)  causes in passenger e.g. after coming head of breech Allis  AnAllisis used tograsptissue. Availab le in short and long sizes.  Used for dilation of the Cervical Dilator cervix for uterine access, cervical stenosis, placement and removal of intrauterine devices, drainage of the uterine cavity, endometrial biopsy, uterine curettage, etc. Vaginal Retractor  To retract the posterior vaginal wall during: 51  1. Major vaginal operations 2. Minor vaginal operations if done under general anesthesia.  Doyen Retractor to retract bladder down word in lower segment C.S  These sounds are Uterine Sound intended for probing a woman's uterus through the cervix, to measure the length and direction of the cervical canal and uterus, to determine the level of dilation, or to induce further dilation.  Uterine sounding may be performed prior to embryo transfer to determine the uterine depth and how easily an embryo transfer catheter can be passed through the 52  cervix. In this case, it may also be called a trial transfer.  It is performed prior to insertion of an intrauterine device (IUD) in order to measure the length and direction of the cervical canal and uterus. This reduces the risk of perforating the uterus with the IUD. This may occur when the IUD is inserted too deeply or at the wrong angle. 53  Learning Guide 14 : Perinea Care )To be completed by Participants( Rate the performance of each step or task observed using the following rating scale: 1. Needs Improvement: Step or task is performed incorrectly or out of sequence (if sequence necessary) or is omitted 2. Competently Performed: Step or task is performed correctly and in proper sequence (if sequence necessary) but participant does not progress from step to step efficiently 3. Proficiently Performed: Step or task is performed efficiently and precisely and in the proper sequence (if sequence necessary) LEARNING GUIDE FOR PERINEAL CARE (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Getting Ready 1. Prepare the necessary equipment (cotton sponges, sterile 1 2 3 4 5 and disposable gloves, antiseptic solution as Betadine, kidney basin, paper bag, and sterile pad). 2. Explain the procedure to the mother. 3. Screen the bed to keep mother’s privacy. 4. Place her in dorsal position and ask her to bend her knees and separate her legs. 5. Put mackintosh and towel under buttocks. 6. Put bed pan. 7. Remove the soiled pad or dressing from above to down ward using disposable glove. 8. Wash hands. Perineal Care Steps 1. Clean the vulva and perineum using the following 1 2 3 4 5 sequence:  Beginning with mons, the area is cleaned up to the lower abdomen.  The second sponge is used to cleanse the inner groin and 54  LEARNING GUIDE FOR PERINEAL CARE (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES thigh of far side.  The third sponge for the other near side.  The last three sponges are used to clean the labia and vestibule withdown ward sweep each. 2. Use one direction swapping to prevent recontamination of swabbed area. 3. Dry using the same principles and direction. Post Procedure Tasks 1. Apply a sterile perineal pad. 1 2 3 4 5 2. Remove bed pan and dry the buttocks with dressing or wash cloth. 3. Remove and clean the equipments. 4. Wash hand. 5. Documentation: document appropriately all the following:  Time of perineal care.  Color, odor, amount and consistency of lochia.  Condition of vulva and perineum. 55  Learning Guide 15 : Episiotomy )To be completed by Participants( Rate the performance of each step or task observed using the following rating scale: 1. Needs Improvement: Step or task is performed incorrectly or out of sequence (if sequence necessary) or is omitted 2. Competently Performed: Step or task is performed correctly and in proper sequence (if sequence necessary) but participant does not progress from step to step efficiently 3. Proficiently Performed: Step or task is performed efficiently and precisely and in the proper sequence (if sequence necessary) LEARNING GUIDE FOR EPISIOTOMY (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES GETTING READY 1. Prepare the necessary equipment 1 2 3 4 5  Tray of anesthesia (xylocaine).  Blunt-tipped scissors and two arteries.  Two needles: one cutting and one round.  One needle holder, four rings.  Chromic catgut suture.  Two gowns, two gloves and two masks.  Four towels.  Gauze and dressing. 2. Check good light , place and complete equipments. 3. Put mother in lithotomy position. 4. Explain what will happen to the mother to reassure her. 5. Put on mask and over head. 6. Scrubbing , gowning and gloving. 7. Drapping the mother according to procedure. 8. Make perineal care. 56  LEARNING GUIDE FOR EPISIOTOMY (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 9. Follow up mother s' labor progress by per vaginal examination (p.v). EPISIOTOMY STEPS Making Incision 1. Infiltrate the local anesthesia into perineum as the 1 2 3 4 5 following:  When the presenting part is distending the vulva during a contraction putthe first two fingers of the left hand between the fetal presenting part and Perineum to prevent injuring the fetal scalp.  Hold the syringe in the right hand; introduce the needle under the skin in the midline and at angle of 20% to the perineal skin.  Insert the needle for a distance of about 3 Cm. withdraw the plunger toensure that the needle is not in vein, then slowly depress it while injecting 1-3 ml. of the solution. Then slowly withdraw the needle but don’t remove it completely from the skin.  Redirect it, still within the perineum (the needle point is 1 Cm. to the right and inject a further 1-3 ml.).  Redirect the needle a third time to the left of the original site and infiltrate theremaining solution midline and at angle of 20% to the perineal skin. 2. Allow time for the local anesthesia (7 min.) to be effective. 3. Place two fingers between the fetal presenting part and the perineum when the fetal head is distending the vulva and perineum is stretched and is not retracting during contractions( because muscles are stretched so pain will be less). 57  LEARNING GUIDE FOR EPISIOTOMY (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 4. Single clean cut (approximately 3 cm in length) is made in one of two directions:  Median : extending directly from the lower vaginal border towards the anus  Mediolateral: extending directly from the lower vaginal border towards the mother s' right or left. Fig (8) 5. If the woman has a previous episiotomy scar it is better to avoid incising the old scar as it doesn’t heal well. 6. Replace the gloves with another sterile one (because the gloves used during second and third stages become desterilized. 7. Remove all clots from perineum. 8. Carefully examine for extensions and other tear and repair. 9. Cover the episiotomy incision with sterile dressing. 10.Make perineal care. 11.Change the towel under the mother. Repair of episiotomy 1. Locate the apex of the episiotomy. 1 2 3 4 5 2. Insert a roll of swabs or a pack into the vagina. 3. Start suturing at the apex of the wound, close the vaginal tear with a continuous No.1 or zero catgut then suturing the muscles. 58  LEARNING GUIDE FOR EPISIOTOMY (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 4. Close the skin over the muscles with interrupted sutures (No. 2 or 3 catgut). 5. Inspect the wound, remove the vaginal pack. 6. Insert a finger into the rectum to exclude any involvement. 7. Clean the wound and cover it with a sterile pad. POST PROCEDURE TASKS 1. Make perineal care. 1 2 3 4 5 2. Swab with Betadine on the episiotomy site 3. Put a sterile dressing on the perineal area. 4. Remove all towels from the mother. 5. Wash hands after cleaning all instruments. 6. Report a complete information about:  Type and site of episiotomy.  Amount of bleeding.  If there is any abnormalities. 7. Lift down the mother’s legs and make her comfortable. 8. Clean, dry and repack the instrument. 9. Rearrange the delivery trolley and the surrounding environment. 10.Give health teaching to the mother about care of episiotomy, diet, signs of infection. 59  Learning Guide16: Management of Third Stage Labor )To be completed by Participants( Rate the performance of each step or task observed using the following rating scale: 1. Needs Improvement: Step or task is performed incorrectly or out of sequence (if sequence necessary) or is omitted 2. Competently Performed: Step or task is performed correctly and in proper sequence (if sequence necessary) but participant does not progress from step to step efficiently 3. Proficiently Performed: Step or task is performed efficiently and precisely and in the proper sequence (if sequence necessary) LEARNING GUIDE FOR MANAGEMENT OF THIRD STAGE OF LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES Getting Ready 1. The same as 2nd stage of labor. 1 2 3 4 5 Management Of Third Stage Of Labor Steps 1. Feel the fundus to see if it is well contracted or not. 2. Active Management of third stage of labor( LG OB GYN) 3. Observe signs of placental separation and then commence controlled cord traction as the following:-  Place the left hand above the symphysis pubis to support uterus and prevent its inversion while the right hand exerts a steady down wards traction of the cord.  Signs of placental separation: 1. Uterus become harder, globular, smaller and increased mobility of the uterine fundus. 2. Lengthening of the cord. 3. Sudden gush of blood. 4. Suprapubic Plug 61  LEARNING GUIDE FOR MANAGEMENT OF THIRD STAGE OF LABOR (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES 4. Support the placenta in both hands after its delivery and rotates it in order to allow the sliding out of the membranes and observe the placental lobes to confirm that nothing is detached or retained. 5. Swab the vulva to remove any blood then examine the vagina and perineum for any laceration or extension of an episiotomy and don't forget to remove theswab after care is completely given 6. Perform perineal care. Post Procedure Tasks 1. Assess maternal vital signs, abdominal counter and blood 1 2 3 4 5 loss. 2. Record the finding and report for any abnormalities. 3. Change the mother gown and put her in a comfortable position. 4. Wash, rinse, dry and repack all equipment. 61  Learning Guide 17 :Examination of the Placenta )To be completed by Participants( Rate the performance of each step or task observed using the following rating scale: 4. Needs Improvement: Step or task is performed incorrectly or out of sequence (if sequence necessary) or is omitted 5. Competently Performed: Step or task is performed correctly and in proper sequence(if sequence necessary) but participant does not progress from step to step efficiently 6. Proficiently performed: Step or task is performed efficiently and precisely and the proper sequence (if sequence necessary) LEARNING GUIDE FOR EXAMINATION OF THE PLACENTA (Some of the following steps/tasks should be performed simultaneously.) Step/Task CASES Getting Ready 17.Greet the mother 18.Explain the procedure 19.The placenta is examined at the third stage of labor 20.Wash hands 21.Wear gloves Placental Examination Steps Examination of the membranes:- I. Had the placenta from the cord allowing the membranes to hang 2. Observe The hole through which the baby was delivered 62 3. Hand spread out inside the membranes to aid inspection 4. After that the placenta should be laid on a flat surface &both placental surfaces carefully examined in a good light 5. The amnion should be peeled from the chorion right up to the umbilical cord, which allows the chorion to be fully viewed. Examination of the Placenta:- The placenta is examined for the following:- - Placental completeness - Placental size - Abnormalities in the shape Placenta bilobata Placenta bipartite Placenta succenturita Placenta circumvalatta 63  Placenta fenestrate - Abnormalities in the weight - Abnormalities in the position Placenta previa - Abnormalities in the adhesion Placenta accrete Placenta increta Placenta percreta - Abnormalities of the maternal placental surface - Abnormalities of the fetal placental surface Examination of the Maternal Surface:- 1. Any clots seen on the maternal surface should be removed &measured; any broken or damaged fragment of cotyledons must be carefully replaced. 2. The maternal surface examined for any infarction ,recent infarctions are bright when old infarction form gray patches but the localized calcification may be seen as white patches 3. The lobes should be carefully examined for its completeness without any gaps. 4. Blood vessels should be radiate beyond the placental edges as this denotessuccenturate lobe which developed fromthe main placenta, &this cause danger ofthe retained lobe of placenta. 64 Examination of the Fetal Surface (Cord):- The cord is examined for the following:- - Abnormalities in the cord insertion Velamentous insertion Marginal insertion - Abnormalities of the cord length Long cord Short cord - Others as: Knots of the cord Torsion of the cord Hematoma Single umbilical artery 1. If it is normal or abnormal (batteldore or velamentous insertion) 2. Three opening should be present (two umbilical arteries &one vein) the absence of one artery may be associated with congenital abnormality particularly renal agenesis 3. After all of this examination the placenta should be weigh ,normal weight is 1/6 of baby weight if clamping of the cord is delayed but if earlier it weigh l/5 of baby weight (approximately 500 gm) Post Procedure Tasks 1. Disposal of the Placenta At the hospital it should be incinerated, in home deliveries the midwives sent it to the nearer hospital to be incinerated. Disposal by burial is not recommended because risk of preying animals. 2. Record the findings 3. Wash hands 65  Learning Guide 18 : Newborn Assessment )To be completed by Participants( Rate the performance of each step or task observed using the following rating scale: 1. Needs Improvement: Step or task is performed incorrectly or out of sequence (if sequence necessary) or is omitted 2. Competently Performed: Step or task is performed correctly and in proper sequence (if sequence necessary) but participant does not progress from step to step efficiently 3. Proficiently Performed: Step or task is performed efficiently and precisely and in the proper sequence (if sequence necessary) LEARNING GUIDE FOR NEWBORN ASSESSMENT (Some of the following steps/tasks should be performed simultaneously.) STEP/TASK CASES