Manual Procedure for Obstetric and Gynecological Nursing PDF

Manual Procedure for Obstetric and Gynecological Nursing Department Manual Procedure for Obstetric and Gynecological Nursing Department For third year nursing studentsPrepared by Staff of Obstetrics and Gynecological Nursing,Sohag University 2023-2...

Manual Procedure for Obstetric and Gynecological Nursing Department Manual Procedure for Obstetric and Gynecological Nursing Department For third year nursing studentsPrepared by Staff of Obstetrics and Gynecological Nursing,Sohag University 2023-2024 1  CONTENT P. No. Antenatal Assessment (History, Physical 1-14 Examination, and Testing). Abdominal examination procedure 15-21 Assessment of uterine contraction 20-26 Vaginal examination (P.V) procedure 27-30 Placenta examination 31-32 Immediate baby care procedure 33-42 Post-Partum Abdominal Examination 43-46 Uterine massage procedure 47-49 Perineal care and examination procedure 50-53 Breast self-examination procedure 54-66 Pap smear procedure: 67-68 Partograph 69-78 Fetal monitoring during pregnancy and labor 79-98 Gynecological and obstetric Instruments 99-123 Normal delivery :Handling procedure 124-130 References 131 2  Antenatal Assessment (History, Physical Examination, and Testing) Definition: The first physical examination during pregnancy is an assessment done in a detailed, by systemic order from head to toes order when a pregnant woman attends the antenatal clinic for the first time. Objectives: 1. To assess the woman's overall health status. 2. To assess medical and obstetric conditions this may indicate risk factors. 3. To use the obtained information as a base line for comparison at subsequentexaminations. necessary supplies equipment: Stethoscope, light measuring device thermometer sphygmomanometer, tongue depressor, weighing scale tape measure pinard fetoscope or sonic fetal heart sound device gloves, urine testing and client record 3  preparation: Ensure that the furniture is arranged conveniently for the work of all staff andcomfortable for the work of all staff and comfortable for the client Ensure that the desk is supplied with cards, pencil ….etc. Check the preparation of the following trays:- o Medication tray. o Immunization tray. o Temperature tray. o Treatment and dressing tray. Ensure that the visual displays and posters are arranged. Ensure that waiting area is comfortable for the clients and educational materialsare 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 Use an antiseptic hand rub or wash hands thoroughly with soap and water and drywith clean /dry cloth or allow to air dry. Greet the woman and her companion respectfully and with kindness, introduceyourself, and offer the woman a seat. Tell the woman what you are going to do, encourage her to ask questions, andlisten to what she has to say. Explain the importance, schedule and components of regular antenatal visits. Confirm that woman has undergone quick check. Perform quick check if not done. Instruct her to evacuate the bladder and collect specimen of urine 4  steps History Rational Personal Information (First Visit ) 1 Ask the woman's name, address & available phone number" sothat woman can be traced by home visit if she fails to keep her next appointment". 2 Ask the woman's age, level of education, marital status,duration of marriage, religion, nationality and occupation 3 Ask the woman's housing condition and crowding index.(no. ofpersons/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, 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. 5 7 Ask if she been diagnosed with any chronic illnesses orconditions such as T.B, Heart disease, kidney disease. Sickle cell disease. DM, goiter, or any other chronic illnesses. 8 Ask about current medication. 9 Ask if she has ever been in the hospital or had surgery such as C.S, genital repair………etc. Family History Ask the woman about if she has any family history of 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 Lie Style (First Visit) 1 Ask if she walks long distance, carriers' heavy loads or 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:- 1. Pregnancy hazards such as caffeine, tobacco and drug use, or uses any other possible harmful substance. 2. Violence (any type of violence). 3. Over the counter medication. 4. Exposure to toxin /chemical substance …….etc. 5 Ask who she lives with and who is the decision maker. 6  Obstetrical History "First Visit" 1 Details of previous pregnancies such as:- Length, outcome, numbers. Date of last abortion. Problems of each pregnancy as presence of convulsionduring pregnancy…….etc. 2 Details of previous childbirth:- Number, sex, weight of each newborn "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 teat through sphincterand / or rectum and C.S. 3 Details of previous postpartum such as:- Contraceptive history. Complication such as PPHg. Ask if she has breastfed, ask for how long as crackedripple, mastitis…..etc. Menstrual and Contraceptive History (First Visit). 1 Ask her about age of menarche, duration of menstrual flow,interval of menstruation, amount of menstruation, any menstrual problems. 2 Ask the first day of her last menstrual period (LMP) and 7  calculate her expected date of delivery (EDD). BY Naegele's rule Is a standard way of calculating the due date for a pregnancy. The rule estimates the expected date of Example: delivery (EDD) by adding one year, subtracting three months, and adding seven days to the first LMP = 8May2009 day of a woman's last menstrual period (LMP). The +1 year = 8 May 2010 −3 months = 8 February result is approximately 280 days (40 weeks) from 2010 the startof the last menstrual period. Another +7 days = 15 February method is by adding 9 months and 7 days to the 2010 first day of the last menstrual period. 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 and whether she liked the method. 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. 2 Ask if she has felt the baby move. If she has, ask the womanwhen 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 thispregnancy. 5 Make laboratory investigation 8 Tests during pregnancy (A) Urine analysis for glucose (sugar) using benedict solution Level of sugarmay 1. Wash hands indicate 2. Explain test purpose and procedure to the woman gestational diabetes. 3. Wear gloves 4. Prepare and arrange equipment needed at bed side or else where 5. Ask the woman to void in a special container 6. Pour 5 cc of benedict solution in attest tube 7. Add 8 drops of urine to the solution using a dropper 8. Hold test tube by holder and boil it for 2minutes in a directly flame, moving the tube constantly 9. Allow the test tube to cool spontaneously in air 10. If glucose is not present, the color of benedict solution willnot change and remain blue 11. If glucose is present , the benedict solution will change according to the amount of glucose as follows :green (+) ,yellow (++) ,orange(+++),bricked(++++) 12.Clean and arrange equipment 13. Remove gloves 14.Wash hands 15.Chart the test result Interpret test outcomes and explain it to the woman Urine analysis for glucose (sugar) using clini- test tablets orclini-stix reagent strips 9 1. Wash hands 2. explain test purpose and procedure3- prepare and arrange equipment 4. obtain afresh voided urine specimen in atest container Clini-test tablets: 5. place 5drops of urine in a clean dry test tube 6. add 10 drops of water and one clini-test tablet to the urine7.don’t shake the stand for a few seconds before reading 8.if glucose is present , the color will change as for benedict Test Clini-stix reagent strips: 9. dip the test end of the clini-stix in urine and read againstthe color chart 10. dip the ketone reagent strip in afresh urine and then compare the strip with the control color chart on the container 11. wash and arrange equipment 12.wash hands 13. record test findings 14. interpret test outcomes and explain it to the woman (B) Urine analysis for albumen Using turbid metric method or protein reagent dipstick 1. Wash hands 2. explain test purpose and procedure3- prepare and arrange equipment 4.Ask the woman to void in a special container5.wear gloves 6. collect a random urine sample in a clean container and testit as soon as possible 10  Return Visit Remember that the questions about her present pregnancy should be asked at every ANC visit. 1 Ask if she having a medical, obstetric, social, or personal problem or other concerns. 2 Ask she had any problems or significant changes since her last visit. 3 Ask if she has received care from another caregiver since her lastvisit. 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, and 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. 11  Physical Examination (General Examination) 1 Observe her general well-being:- Her gait and movement (walks steadily and without a limp). Her facial expression (is alert and responsive). Her general cleanliness (no visible dirt, no odor). Her skin (free from lesions and bruises). 2 Measure accurately woman's weight without shoes. -To obtain baseline for comparing weightgainduring pregnancy. 3 Measure accurately her height without shoes. - To give arough guide tothe size of pelvis. 4 Measure blood pressure while the woman is seated or lying downwith the knees slightly bent and relaxed:-If diastolic BP is>90 mmHg, ask the woman if she has sever 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 stand the right side of the woman. To provide privacy. 12 8 Examine the head:- -Pallor mayindicate Check hair for lice and nits. anemia. Check the face for pallor, edema and facial expression. -Evidence for Check conjunctiva for degree for redness. physiological Note any pigmentation on forehead and cheeks. changes during Examine mouth for condition of gums and teeth. pregnancy. 9 Examine the neck:- -Swollen, tender Palpate the nodes below the posterior angle of jawbones. nodesmay indicate Check the neck for the thyroid gland. infection or cancer. 10 Examine the chest:- Assist with examination of the heart and lungs by preparingthe woman. Examine the breasts, nipples, and areola. 11 Examine the Genitalia:- Touch the inside of the woman's thigh before touching genitalarea. 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 fistulas. Check Bartholin's glands for discharge and tenderness by inserting index finger into vagina at lower edge of openingand feel at base of each labia majora and palpate each 13  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 unequallength. Check edema over the tibia, ankle and feet. Observe legs for dilated veins. 13 Check the woman for danger signs of pregnancy. 14  Abdominal Examination Purpose of Abdominal examination: (1) To observe signs of pregnancy. (2) To assess fetal size & growth. (3) To identify the location of fetal parts. (4) To auscultate the fetal heart sound. (5) To detect any abnormality from normal. Equipment: - Pinard stethoscope. - Measuring tape. - Pen and watch. - Pillows. The procedure: Performed in three different examinations:I- Inspection II- Palpation. III- Auscultation 15 Nursing action Rational (1) Explain procedure to the * To obtain verbal consent and women. cooperation. (2) Ensure woman's bladder is * A Full bladder will cause discomfort during empty. the procedure and make the measurement of the fundal height less accurate. (3) Provide privacy * Shows respect & feelings of self-value. (4) Ask the woman to lie in * The abdominal muscles are more supine position with relaxed in this position. thighs slightly flexed, and place a pillow under her head and upper shoulders. (5) Expose the abdomen fully * To maintain privacy, and enable from below the breasts to visualization of the whole abdomen. the symphysis pupis, leaving legs and pubic area covered I- Inspection: - Stand on right side of the * It is good practice to work from thisside woman ifyou are right handed. − Observe the abdomen for * To get a rough idea of the uterine size& fetal size. size: I-Proper with period of amenorrhea. - Size in relation to period of amenorrhea - causes - AS I- Normal size pregnant uterus 1- Wrong calculation. 2- Full bladder, distended colon or obesity. 16 II- oversized pregnant - AS uterus 1- Large fetus. A- give false impression of fetal size 2- Fetal malformation as hydrocephalus (Hydrocephalus is an abnormal expansion of cavities (ventricles) within the brain that is causedby B- give true impression of the accumulation of cerebrospinal fluid). fetal size 3- Multiple pregnancy. 4- Hydatidiform mole. 5- Polyhydraminios. 6- Uterine fibroids and closely attached adrenal mass as ovarian cyst. 7-Placenta abruption with concealed hemorrhage. 17  III-undersized pregnant uterus - causes A-give false impression of fetal size - AS 1- Wrong calculation. 2- Pregnancy during aperiod of amenorrhea as lactation. - AS B-give true impression of fetal size 1- Small fetus. 2- Intra uterine fetal death 3- Oligohydraminos. 4- Malpresentation as transverse lie orbreech with extended legs. * The shape and contour of * Shape and contour usually a well- theabdomen defined longitudinal oval (sung The fetal lie usually affects the shape. ovoid) in primi gravida, in some multi gravida, contour is ovoid with fullness at the sides of completelyround(pendulous abdomen). (O.P.P)Occiput posterior position the fetus has a saucer-like depression * skin change * to confirm reason for significant Stria- gravidarium, Lina- nigra Scars ; may indicate previous surgery andScars. especially C. S. that indicate for induced C.S. II-Palpation: * To compare size of uterus with - Assessment of fundal height. period of amenorrhea. And to confirm normal or oversize or undersize of pregnant uterus. 18 - Palpation (Leopold’s Maneuver) is Leopold’s Maneuver which are done in 4 special movements with systematic way to evaluate the warm relaxed hands and arms using, maternal abdomen the pads of the fingers movements * To avoid discomfort to the woman over the abdomen should be smooth. and causing contractions. - The maneuvers consist of four each maneuver helping to determine distinct actions, the position and presentation of the Classifications of Leopold's Maneuver fetus, which in conjunction with 1. First Maneuver [Fundal Grip] correct assessment of the shape of the dividedinto: - maternal pelvis can indicate whether or not the delivery is goingto be a- Estimation of the fundal level. complicated, or whether or nota b- Fundal Grip cesarean section is necessary. 2. Second Maneuvers- (Lateral Grip) 3. Third maneuver: Pawlik”s grib. 4. Fourth maneuver: pelvic grib. *First maneuver: * To determine the height of the a- Estimation of the fundal level. fundusto estimate the weeks of Place the ulnar border of the left hand gestation. just below the xiphisternum, press gently down the abdomen till curve of fundus is felt, Measurements can be recorded by using a " Symphysis – fundal height chart " which determine the relationship between the fundus and gestational age. 19  *Confirm the condition which makes *See causes above the fundal level higher than the *See causes above expected. * Confirm the condition which makes the fundal level lower than the expected. b- Fundal Grip: *To determine which part occupies the Face the woman's head. Place hands fundus (head or breech) to diagnoselie and presentation of the fetus. palm down wards, with fingers close * Helps to diagnose the lie &presentation. together on the fundus, gently feel * Usually the buttocks are in thefundus. withthe finger tips. They feel softer, bulky, symmetrical and has small bony prominences, it moves with the trunk. * The head feels firm, hard, round & moves dependently of the trunk. * Second maneuver : * To locate the fetal back & determine [Lateral Grip]. the position. - Place one hand on each side of the * The side occupies the back is felt abdomen at the level of the Firm, straight, curved. umbilicus. * The side opposite to the back will - Use one hand to steady the uterus & feel irregular. Limb parts and the other to palpate. Alternate hands movements may be felt. and walk the handover the abdomen to feel the back. 20  *.Third maneuver: Powlik’s grib * To judge the mobility of the head Faces the mother and Grasp the in order to determine the lower part of the uterus between amount of engagement of the index and thumb, spread wide presenting part. enough to fit the head, don't put * Sometimes useful to judge the much pressure. sizeand mobility of the head. - Mobile head means unengaged head - Fixed head meansengaged head * This movement causes discomfort ifdone carelessly. * Fourth maneuver: Pelvic grib : 1 - Turn to face the woman's feet. 1- To determine which part of the 2- Ask the woman to bend her knees fetusoccupies the pelvis so, slightly and breathe steadily with determining theposition and hermouth open. presentation of the fetus. 3- Hold the sides of the uterus just 2- To aid relaxation and avoid causing below the umbilicus with fingers discomfort to woman. close together, pointing 3- If the fetal head is presenting a firm, downwards& in wards. hard and rounded mass is fell onboth sides. If buttocks are in the lower part of the uterus the presentation is breech. 21  Auscultation The fetal heart sounds are heard by the fetal pinard stethoscope. They can be heard all over the abdomen with a point of maximum intensity over the anterior shoulder and there for this point varies according to the position of the fetus. They are usually heard at the 24th week by the fetal stethoscope. Objectives Of Auscultating Fetal Heart Sounds: fetal position FHR heard on maternal abdomen (1) In cephalic presentation * Best heard in the lower quadrant of thematernal abdomen. (2) In breech presentation. * is heard at or above the level ofumbilicus. 22 (3) In Transverse Lie * may be heard just above or just belowthe umbilicus. *During labor , FHR tends to descends and move toward the midline *through a contraction, FHR Listening may be difficult because of maternal movement or a muffling of a FHR sounds. 1. It is a sure signs of pregnancy. 2. To diagnosis intrauterine fetal death. 3. To know position and presentation of the fetus. 4. Diagnosis of twin’s pregnancy. 5. Diagnosis of fetal distress. 6. To follow up the progress of labor under normal\abnormal condition of fetal heart (Normal fetal heart rate between 120-160 beats per minute under normal condition: when a- Over 160 b/min indicates tachycardia. b-Below 120 b/min indicates bradycardia. The exact point on maternal abdomen can heard FHR according to the fetal position Denominator: Denominator means to give a name to the part of the presentation. In vertex presentation: it is the occiput. "O" In breech presentation: it is the sacrum "S" In face presentation: it is the mentum "M" 23  Uterine contraction assessment procedure Uterine contraction: - The tightening and shortening of the uterine muscles. During labor, contractions accomplish two things: (1) They cause the cervix to thin and dilate (open) (2) They help the baby to descend into the birth canal. * Objectives: 1. To determine whether a contraction pattern typical of true labor. 2. To identify abnormal contraction 3. To detect, diagnose & provide proper management as early aspossible to prevent health hazards *Equipment: Watch or Stop watch 24 Procedure: Nursing action Rational 1Wash hands. - To provide cleanliness. 2. Warm hand - To provide comfort and relaxation. 3. Explain procedure & its purpose. - To obtain verbal consent to reduce anxiety & promote cooperation. 4. Prepare equipment &take to bedside. 5. Put the mother in dorsal recumbent - This position promotes accuracy of position & screen the mother bed. evaluation. 6. Close windows if open & drafty. - To provide privacy and feeling of Self -value. 7. Assess at least three contractions in - To promote accuracy of evaluation. row but preferably more. 8. Guidelines for minimum - Observation is closed with progressof frequencyof assessment are; labor. − Hourly during latent phase. − Every 30 minutes during active phase. − Every 15 minutes during 2nd stage. 9. Assess more frequently if - For early detection. abnormalities. 10. Place fingertips of one hand on - To promote accuracy of evaluation. uterine fundus, keep fingertips relatively still rather than moving them over uterus. 11. Note time when each contraction - To determine criteria of each begins & ends. contraction. − Determine frequency by calculation 25  average time that elapses from beginning of one contraction until beginning of next one − Determine duration by noting average − time in seconds from beginning to end of each contraction. − Determine interval by noting average − time between end of one contraction& beginning of the next one. 12. Estimate the average intensity of - To facilitate evaluation of contraction contractions by noting how easily the and intensity. uterus can be indented during the peak of the contraction as follow; − Mild contractions are easily indented with fingertips. They feel similar to the tip of the nose. − Moderate contractions can be indented with more difficulty. Theyfeel similar to chin. − Firm contractions are feel woody & cannot be ready indented. They feel similar to the forehead. 13. Chart the average - For documentation. frequency (inminutes & fraction), duration (in seconds) & intensity. 14. Report hypertonic - For early detection of any contraction abnormalities. − Duration longer than 120 seconds. − Incomplete relaxation between contraction. − Contraction Frequency numbering more than five in 10-minute time frame 15. Remove equipment and wash hands. - Keep place clean & to be ready for another use. 26  Vaginal Examination * Objectives: Allows greater accuracy in determining the following: 1- Condition & Dilatation of the cervix. 2- Station & position of the presenting part. 3- Relationship of the fetus to the pelvis. 4- Early diagnosis of abnormal presentation. * Equipment: − Sterile or disposable gloves. − Lubricant (K. y gel). 27  Vaginal Examination The procedure: Nursing action Rational (1) Explain procedure to the * Obtain verbal consent to women. reduce anxiety and promote cooperation. (2) Instruct woman to empty her * This promotes comfort and Bladder before beginning accuracy of evaluation. examination. (3) Provide privacy * Shows respect & feelings of selfvalue. (4) Assist woman into supine * This position promotes position on exam table with accuracy of evaluation lower extremities flexed and rotated outward, her heels should be supported in stirrup which are level with the table about 1 - 2 Ft in front of her buttocks [Lithotomy position]. 5- Assist the woman to relax by * If the woman is anxious, she encouraging her to breathe may tense her abdominal, naturally. pelvic and thigh muscles closing her thighs, this makes vaginal examination difficult. 28 6 - Expose the area for examination. * promote accuracy of evaluation. 7 - Prepare the area with antiseptic * This help prevention of solution. ascending infection during examination. Nursing action Rational 8 - Put on gloves, from standing * To wide the area and facilitate position using thumb & fore insertion of the index & finger of non dominant hand to middle fingers of dominant spread the libia. hand. 9 - Insert the well lubricated index * This help determines the & middle fingers of dominant condition of cervix, hand into the vagina until they membrans, presenting part and touch the cervix, using downward position after palpation. & upward direction and keep thumb of dominant hand upward and supported on vulva. 10 - Provide care with antiseptic * Promotes comfort & prevent solution & put on sterile pad after infection. care. 11 - Remove the equipment& * Keep place clean & prevent gloves. spread of infection. 12 - Wash hands. * Provide cleanliness. 29  Vaginal Examination Fully cervical dilatation 5 finger 10 cm Pelvic brim Cervical dilation 1 finger 2 finger 3 finger 4 finger 2cm 4 cm 6 cm 8 cm 30  Placenta Examination *The objectives: 1. Identify the size, shape, consistency and completeness of the placenta. 2. Determine the presence of accessory lobes, placental infarcts, hemorrhage and tumors. 3. Assess the umbilical cord for length, insertion, number of vessels, thrombosis, knots and the presence of Wharton’s jelly. 4. Evaluate the color and the odor of the fetal membranes. *The clinical characteristics of normal placenta: 1. Diameter:17.5- 20 cm at term. 2. Thickness: 2.5 cm. 3. Weight: 470 g. (approximately one – sixth of the baby's birth weight at full term) 4. The Maternal surface: Dark red in color, it should be divided in cotyledons. The structure should be complete, with no missing cotyledons. 5. The Fetal surface of the placenta should be shiny, gray and translucent enough to see the color of the underlying villous tissues. 6. The umbilical cord: - length: 50 to 60 cm at term. - Diameter: 2 to 2.5 cm - The structure should have 2 arteries and 1 vein. - Normal cord contains Wharton's Jelly. 31 *signs of placenta separation: - Gushing of blood per vagina. Elongation the umbilical cord. The uterus becomes smaller, harder, higher, more globular. A supra-pubic bulge appears due to presence of the placenta in the lower uterine segment. Loss of pulsation in the cord. *Procedures Steps Rational Delivery of the placenta: To prevent retention of 1-As the placenta delivers, hold it in both placenta or membrane hands and gently turn it until the membranes parts are twisted 2-Slowly pull to complete the delivery. Move membranes up and down until they deliver. 3- If the membranes tear, gently examine the To remove any remaining upper vagina and cervix wearing sterile gloves pieces of membrane. and use a sponge forceps. Examining the placenta: 4- Hold the placenta in the palms of the hands, with maternal side facing upwards. 5- Check whether all of the lobules are present and fit together. 6-Hold the cord with one hand and allow the placenta and membranes to hang down. 7-Insert the other hand inside the membranes, with fingers spread out. 8-Inspect the membranes for completeness. 9-If membranes or placenta are not complete, take immediate action 10-Document the findings in the delivery room report 32  Immediate baby Care * Objectives: (1) Ensure an air way & maintain respiration. (2) Prevent cold stress (hypothermia). (3) Provide a time for complete observation. (4) Stimulate circulation as adequate to maintain health. (5) Keep the skin of the baby clean & in good condition. * Equipment: (1) Vacuum suction e sterile.catheter & oxygen. (2) Cord ligature or clamp. (3) Sterile scissor & artery. (4) Warn sterile towel. (5) Rectal thermometer (6) Warm sterile towel. (7) Cotton balls. (8) Bath of water at 37TC (9) Alcohol 70%. (10) Gauze (11) Birth record (12) Eye drop. − The neonatal period includes the time from birth though the twenty eight day of life.During this time the neonate must make many adjustments to extra – uterine life. − The following measures are designed to assist the infant in accomplishing the adaptations to extra uterine life) 33 Procedure: Nursing action Rational 1) Suctioning : (1) Wash hands & wear gloves. (2) Receive newborn in warmed blanket - To avoid hyposthenia - of towel & place under radiant warmer. (3) Place newborn in trend lenburg position ( - To open airway. extend head) (4) Do suction of oropharyngeal canal. - To ensure patent airway. (5) Oxygen may be given. - For central cyanosis. (6) Continue reinserting tube & provide suction as fluid is aspirated. (7) Avoid deep suction during early - Can stimulate the vagus nerve minute following delivery. to cause decreasing in HR. (8) Do minimum - Can traumatize mucous nasopharyngealsuctioning. membrane causing edema & respiratory distress. (2) General physical examination: - For assessment of baby. (1) Complete 1- minute Apgar score & complete the 5-minute Apgar score. 34  Head 33-35.5 cm in circumference. May be covered with lanugo (fetal hair) which Length 51 cm will. Weight 3.5 kg. Eyes dry. The newbornbaby seldom weeps. Sclera ill often blue atbirth. Respirations 30-40 minute, mostly Pulse (apex beat) 120-140/minute. Skin temperature36.4- 37.0°C. Stump of umbilical cordtied or clamped. It should obliterate in 3-4 days, and separate in 6- Abdomen convex. The 9 days. liver is usually palpable 1-2 cm blow rib margin. Kidneys are often In the male testes should have just palpable. descendedinto the scrotum by term. limbs are warm andwell- rounded. The whole skin The baby is covered in utero with a sebacous secretion called „vernix caseosa‟(L., a cheese-like coating). This protects the skin against maceration while in the liquor amine and has antibacterial properties 35  CLAMPING AND LIGATING THE CORD S t The cord is clamped and e divided as soon as pulsations r i have ceased. If ligation is done l carelessly, the baby may lose a e great deal of blood very Artery quickly. The cord is ligated s c with a special clamp or rubber forceps i bands or tapes.The blood s volume of a term newborn s o r s infant is 80-100 ml per kg body weight. Hollisterclamp Hollister clampin position All mucus, blood and meconium must besucked out before the baby has a chance to inhale them. This should be done using mechanical suction (preferably) to minimize the risk of virus transmission. 36  (Apgar Score Chart) Mother name: Date of admission: Time of delivery: Procedure Steps Zero 1 2 1min 5min - Respiratory Absent Slow Good cry irregular effort - Heart Rate Absent Below 100 Over 100 B/M B/M - Muscle tone Flaccid Some Well flexed flexion of limbs - Reflex No response Grimace Cough or sneeze - Color Blue or pale Body pink, All pink limbs blue Total Apgar Score Risk: 1-4 H.R High Risk. 5-7 M.R Moderate Risk. 7-8 S.R Small Risk. 10 Normal 37  Nursing action Rational (3) Vital signs: - * Apical pulse * Auscultate chest for heart beats with stethoscope for1 min (put stethoscope under its nipple) N. B: Temporal area is the most popular for newborn. * Respiration. * Observe respiratory movement rate, depth, pattern & sound) & count the rate for one minute. (Count chest & abdominal movement with eachinspiration * Expiration). * Rectal temperature * Shake down thermometer below 35ْ˚ C -To identify any anal * Remove the new born towel. Abnormality. * Grasp the new born ankle firmly, placing your indexfinger between the ankle bones. - To prevent skin trauma * Place the bulb of the thermometer in the anus &hold it securely in place for minute. * Remove thermometer & wipe it e tissue & recordtemperature. (4) Growth measurement: - include a - Length b. weight c. Head circumference. d. Chest circumference. For accurate height. a. Length: * Remove the newborn towel 38  Nursing action Rational * place the newborn in the supine position. − Grasp the knee together gently. − Push down on the knee until the legs are fully extended & hold legs firmly − To give accurate height. − Measure the length e tape measure & record it. N. B. Average length 40-51 cm. − Weight: - − Is between 2500-4500 gm − Check to see that scale is balance by setting it at zero. − Place new born on the scale without cloth. − Keep hand over new born without touching in. − For accurate weight. N. B. Average weight 3500 gm. − Head circumference − To support the infant & (at its great circumference) for safety. Normal is between(33-35,5) d. Chest circumference (Place the tape across the nipple line). Normal is between(31-33) (5) Assess for any growth abnormalities, congenital defects in head, eyes, ears, chest, spine, face, nose, - For complete observation. abdomen, anus …. etc. 3- Cord Care: (1) Wash hands before manipulating cord. 39  Nursing action Rational (2) Use sterile plastic clamp or ligature, the first ligature is placed about 2 inch from the abdomen &second ligature is placed about 1 cm from the first ligature. (3) Press between the two ligatures. - To assure that there is no oozing blood. (4) Cut the cord by blunt sterile scissor after the second knot. (5) Examine umbilical cord structure. (6) Paint the end of the stump with alcohol. - To observe any bleeding. (4) Eye Care: (1) Wash hands (2) Eye lids should be clean e sterile cotton ballmoistened e sterile warm water. (3) Wipe from the nose outward. (4) Install of one drop of solution of isophenicol (lower lid should be pulled down), solution droppedinto lower conjuctival sac. (5) Lid is released 2 min awaiting period, then wipe - To prevent eye infection. the excess of solution by sterile cotton. (5) Identification of the new born which place on wrist or ankle (mother name, hospital number, sex, weight of new born). (6) Wrape the baby & give to parent. - To encourage attachment. (7) Assist mother to breast feed if she desire. - To encourage breast feeding. 40  (8) Complete charting, reporting & recording. (9) Replace equipment after use & care for it. (10) Wash hands. Neurological Examination : Reflex Name Evoking Stimulus Response Blinking reflex Light flash Eyelids close Pupillary reflex Light flash Pupil constricts. Rooting reflex Light touch of finger on Head rotates toward stimulation; cheek close to mouth mouth opens and attempts to suck finger. Disappears by about 4 months of age. Sucking reflex Finger (or nipple) Rhythmic sucking occurs. inserted into mouth Moro reflex Infant lying on back: Arms are extended, head is slightly raised head thrown back, fingers are suddenly released; spread wide; arms are then infant held brought backto center horizontally, lowered convulsively with hands quickly about 6 inch, clenched; spine and lower and extremities are extended. stopped abruptly Disappears by about 6 months of age. Startle reflex Loud noise Similar to Moro reflex flex ion in arms; fists are clenched. Grasping reflex Finger placed in Infant's fingers close around and palm of Hand grasp object. 41  Reflex Name Evoking Stimulus Response Tonic neck reflex Head turned to one side arm and leg are extended on while infant lies on back theside the infant faces Opposite arm and leg are flexed Abdominal reflex Tactile stimulation or abdominal muscles contract. Tickling Withdrawal reflex Slight pinprick to the sole Leg flexes. of the infant's fool Walking reflex Infant supported in an Rhythmicstepping movement. upright position with Disappears at about 4 months. feetlightly touching a Of age. flat Surface Babinski reflex Gentle stroking onthe Fanning and extension of sole of each foot thetoes (adults respond to this stimulation with flexion of toes). Plantar or toe- Pressure applied with the A plantar flex ion of all grasping,reflex finger against the balls of toes.Disappears by the end the infant's feet of the first year of life. 42  Post-Partum Abdominal Examination Definition -It is the tactile examination of the women abdomen (abdominal palpation) during puerperium to assess the uterine involution Objectives 1. To determine location and firmness of the uterus. Steps / Task Rational 1 Greet the mother, talk to her in a -Reduce anxiety and elicits sympathetic cooperation. manner, explain the procedure, the information it provides, what it might feel like and rationale for each step before beginning the procedure. 2 Ask the woman to void. -A distended bladder lifts and displaces the uterus. -Fullbladder can cause uterine atony. 3 Place the mother in a supine -The supine position prevents falsely position with her knees slightly high assessment of fundal height. flexed. Flexing the legs relaxes the abdominal muscles and permits accurate location of the fundus. 4 Wash hands and prepare the equipments:- A clean glove. A clean perineal pad. Put on clean gloves, screen the -Gloves are recommended anytime bed, drape the mother, expose there is the possibility of coming into her abdomen only and lower the contact with body fluids. 43  perineal pads to observe lochia To provide privacy and gain her as the fundus is palpated. cooperation. 6 Place the non-dominant -Supports and anchors the lower handabove the symphysis uterine segment during palpation or pubis. massage of the fundus. 7 Use the flat part of the fingers -The larger surface provides more (not the finger tips) for comfort; palpation is essential, but it palpation. may be painful, particularly for the mother who had a cesarean birth; locating the fundus is more difficult if the woman is obese or if the abdomen is distended. 8 Begin palpation at the -A firm fundus indicates that the uterine umbilicus, and palpate gently muscles are contracted and bleeding until the fundus is located. will not occur. Determine whether the fundus is firm. If it is, it will feel like a hard round object in the abdomen. 9 Measure thetop of the -Fundal height gives information fundus in fingerbreadths about the progress of involution. above, belowor at the Umbilicus 10 Determine the position of the -The fundus may deviate from the fundus in relation to the midline midline when the bladder is full because of the body. the enlarged bladder pushes the uterus aside. 44 11 If the fundus is difficult to locate or is soft -The non – dominant hand or boggy keep the non-dominant hand anchors the lower segment above the symphysis pubis and massage of the uterus and prevents the fundus with the dominant hand until trauma while the uterus is the fundus is firm. massaged. The uterus contraction is essential to control excessive bleeding. 12 Assess the lochia. Release the perineal pad so that you can clearly assess the amount, color and consistency of the lochia. 45 13 Provide the woman with a clean perineal pad. 14 Drape the exposed abdomen. 15 Assist the mother to lie comfortably. -Promotes accurate communication and identifies deviations from expected so that potential problems can be identified early. Document the consistency, level, and location of the fundus. Consistency is recorded as “ fundus firm”,” firm with massage”, or “ boggy”. Fundal height is recorded in fingerbreadths above or below the umbilicus. For example, “fundus firm midline, U-2 (two fingerbreadths below umbilicus). As another example, “Fundus firm with light massage, U+2” (to fingerbreadths above umbilicus), displaced to right. Notify for any abnormalities. 46  Uterine Massage * Objectives: -To assess the level of uterine fundus. -To determine firmness of the uterus -To promote contractility of the uterus. To assess lochial characteristics. -To minimize the post -partum bleeding -To prevent health hazards which mother may be exposed. -To detect, diagnoses & provide management of any abnormality as early as possible * Equipment: 1- Clean gloves. 2- Sterile pad. 3- Rubber sheet. 4- Screen. 47 Procedure: Nursing action Rational 1- Explain the procedure & its purpose - To reduce anxiety 2- Prepare equipment & take to bed side. - To save the time. 3- Screen the mother's bed - To maintain privacy. 4- Close window if open & drafty - To maintain warm environment 5 - Wash hands - To prevent infection. 6-Instruct woman to empty her bladder -to obtain accurate information. 7-Place mother in a supine position. -Proper position to enhance visualization and effectiveness ofprocedure 8-Put on clean gloves &lower the - To observe amount of perineal saturation & pad. characteristic of lochia. 9-Place the non-dominant hand above the - To support the lower uterine symphysis pubis. segment. 10-Use the flate part of the finger for palpation. 11-Begin palpation at the umbilicus & - To determine the level of the palpate gently. uterus. 12-Note firmness &location the of the The fundus should be fundus. firm, in midline and approximately at the level of umbilicus 48  Nursing action Rational 13- If the fundus is difficult to locate or is soft or - To prevent post- atonic, keep the non-dominant hand above the partumbleeding symphysis pubis & massage the fundus with the dominant hand untill the fundus is firm. B 14- Observe the vulva for passage of blood clots & for development of hematoma or bleeding from lacerations. 15-Remove bloody pads, clean perineum and - To minimize the infection. apply sterile perineal pad. 16- help the client to find a comfortable position. 17-record consistency &location of the fundus - Documentation & provide a Bleeding means of evaluation. 18- report the condition of the fundus. - To detect any abnormality. 19- Wash hands after care away of equipment - To prevent the infection 49  Perineal Care and examination Definition It is an external irrigation, cleansing and /or swabbing of the vulva andperineum. * Objectives 1. To clean the vulva and perineum. 2. To promote rapid healing of episiotomy, tear or laceration. 3. To prevent infection. 4. To eliminate bad odor. 5. To promote comfort. 6. To stimulate voiding. 7. To observe the condition of the perineum, episiotomy, hemorrhoid, lochia and orany vaginal discharge. 8. To instruct the mother about self perineal care. 9. To promote normal delivery without infection. Indications of perineal care 1. After abortion. 2. On admission and every 6hours during first stage of labor. 3. Before vaginal examination and catheterization. 4. After enema during labor. 5. After each urination and or defection. 6. Before episiotomy care. 7. Before and after surgery on the perineum, vagina and or anus. 8. In case of excessive vaginal discharge. 50  Equipment: 1. Rubber gloves. 2. Rubber sheet. 3. Paper bag. 4. Clean Perineal Pad.5- Tissue Forceps. 5. Antiseptic solution. 6. Light source *Procedure: Nursing action Rational 1- Explain the procedure to the mother. * Obtain verbal consent to reduce anxiety and promote co-operation. 2- Prepare equipment & take to bedside. * To save the time. 3- Screen the mother's bed. * To keep privacy. 4- Close the windows. * To maintain warm environment & to maintain the privacy. 5- Wash hands and wear gloves. * To minimize infection. 6-Position the mother in dorsal * This position provides easy access to recumbent position. genitalia. 7- Place rubber sheet under mother's hips. * To minimize the transmission of microorganism. 8- Remove soiled pad from front to back. * To minimize the infection. 9- Observe color &amount and odor. * To detect any abnormality. 10- Wrap soiled pad &throw it in paper * To minimize infection. bag. 51 11- Test the temperature of the * To prevent bums to perineum. antiseptic solution. 12-Use antiseptic solution for cleaning * The cleansing method reduces the according to the following direction: transfer of microorganism to the urinary 1- Clean the mons pubis from the level meatus. of clitoris upward to the lower abdomen in azigzag line. 2- Clean two thigh from medial to lateral in a zigzag line. 3- Clean two labia majora from upward todownward in a single motion. 4- Clean the introitus from upward to downward in a single motion. 13-dry the perineum using the same * Retained moisture harbors technique and put clean perineal pad. microorganisms. 14-Remove and clean equipment. * Keep place clean &prevent spread of infection. 15-Wash hands. * Provide cleanliness. 16-Record and report any abnormalities. * To provide early management. 17-Give health teaching about self-care * To encourage mother to do it. and genital hygiene. 52  Cleansing the perineum prior to delivery the nurse follows the numbered diagram, using a new sponge for each area. The woman in this drawing is in dorsal recumbent position to demonstrate the cleaning. The perineal scrub may be accomplished in any material 53  Breast Examination Definition It is the technique by which a thorough inspection and palpation of the breast is in order to collect data about the breast condition. Breast self examination (BSE) Means the regular examination of the breast performed by a woman in a systemic manner for the purpose of early detection of cancer breast. It should be done every month from puberty to menopause and after. The best time is 7-10 days from the first day of the last menstrual period (because breasts are least likely to be swollen or tender). It can be performed at any fixed time of the month after menopause or following hysterectomy (e.g. the 1st day of every month). Objectives 1. To assess the breast size, shape, contour, elasticity and symmetry. 2. To assess the nipples for its type, size and secretions. 3. To examine the areola and nipple for evidence of blisters, cracks or fissures. 4. To assess the breast for signs of engorgement, mastitis or abscess (in postpartum period). 5. To check the breast tissues for presence of lump or cyst that may require further medical evaluation. 6. To detect and treat early any abnormalities or complications. 54  Indications Breast examination is indicated in the following conditions 1. At puberty at a regular basis for early detection of cancer breast. 2. In antenatal period for breast appraisal. 3. In post partum period for detecting signs of engorgement or other breast complications in lactating mothers (after all milk has been expressed). 4. After menopause or following hysterectomy for early detection of cancer breast. 5. Breast examination is also indicated for women who may potentially develop cancer breast e.g. early menarche, over 40 years of age, family history of cancer breast, nulliparous women whose first parity occurred after the age of 34 exposure to carcinogens, presence of other cancers such as endometrial, colon rectum, salivary gland and ovary. procedure Steps / Task Rational Getting Ready 1 Prepare the necessary equipment and assemble it on the tray to bedside: Large Mirror. Good lamp. Sterile gloves. 2 Greet the woman respectfully and with kindness 3 Explain procedure to the woman, what is going to -To gain her cooperation examine her breasts, listen to her attentively, and and relief anxiety. respond to her questions and concerns. 55 4 Discuss advantages of regular breast self examination. 5 Ask client to empty bladder prior to procedure. -For comfort. 6 Close windows and keep privacy of the client to undress. 7 Raise the bed to the best level for good body mechanics. 8 Obtain detailed history from the client regard: -To identify possible risk factors for cancer Age, menstrual history, parity. breast. Development of the breast. Breast-feeding. Changes in size, shape or color of breast. Medications and any breast surgery. Soreness of breasts or nipples, particularly in relation to the menstrual cycle pain. Any discharge or secretions (describe color and consistency). Any lumps, masses, cysts or tumors (when noticed, how detected, how treated). Family history of breast cancer or breast disease. Any previous mammogram results. Knowledge of breast self examination. 56 9 Make sure you have good lightening. There should -Good lighting is be no glares or shadows. necessary if you are going to be able to see slight changes in breast contour, color, retraction signs, and the nipple epithelium. 10 Wash hands thoroughly, dry them and, put both -To prevent cross hands on new sterile surgical gloves. infection. Breast examination steps by the nurse 1 Ask the woman to undress from her waist up. Have -Exposure of only the her sit on the examining table with her arms at her area necessary protects sides and facing the examiner to detect a symmetry the woman's sense of in size and observe color of skin, thickening or modesty edema 2 Look at the breasts and note any differences in: shape size nipple Check for swelling, increased warmth or tenderness in either breast. 57 3 Look at the nipples and note size, shape and direction in which they point. Check for rashes or sores and nipple discharge. 4 Repeat inspection in sitting position with arms -This helps in raised over the head. contradiction of the pectoral muscles and does not alter the contour of the breast normally. 5 Examine the clavicular and axillary regions through palpation the tail of the breast and check for enlarged lymph nodes, tenderness, discoloration, swelling or lesions. 58 6 Ask the client to assume the supine position and put her right arm over her head and inspect & palpate the right breast using the spiral technique. Note any lumps or tenderness. 7 Repeat with the left breast and note any differences from the right breast. 8 Make imaginary division of breast into 4 quarters. 9 Palpate the breast tissue starting from outer edge of the upper quadrant at 12 O'clock wise use circular manner toward the nipple. 10 Use the palms of the hand: the flat surface or flat - The fingertips tend to pads of the three middle fingers, rather than the push a lump away. finger tips to feel large areas of the breast against Nodules caused by the chest wall. occluded milk ducts during puerperium can be palpated most frequently in the upper outer quadrants 11 If the breast is pendulous, examine it between two hands. 12 Inspect and palpate the areola and nipples. Gently -To demonstrate the spread the areola and squeeze the nipple between presence of cracks, fingers. fissures and secretion. 59 13 Record normal and abnormal findings and date of -To refer the client to next examination. physician if abnormalities are present. Breast Self Examination Steps Motivate the client to perform her own breast Regular examination examination regularly following the directions will show what is below because regular examination will show what normal for the client is normal for the client and will give her confidence and will give her in performing the procedure. confidence in performing the procedure. In Front of A Mirror 1 Stand in front of a mirror. -To detect any visual changes in size, shape, skin color. 60 2 Inspect your breasts looking for changes in contour and shape, color , texture of the skin , nipple and evidence of discharge from the nipples. 3 Inspect your breasts with arms relaxed at your sides then with arms bending forward to detect any visual changes in size, shape, skin color. 4 Lift your arms over your head to look for any change in the contour of each breast, swilling, dimpling of skin or changes in the nipple. 5 Rest the palm on hips and press down firmly to flex the chest muscles so that both breasts will hang evenly. 61 6 Gently squeeze the nipple (Right and Left) to look for any unusual discharge particularly pinkish or reddish discoloration. 7 If you detect abnormal discharge, report immediately to your doctor. In the shower 1 Examine your breast during bath or shower by -Hands glide easily raising your left arm over your head to examine the over wet skin. left breast with your right hand (the right breast with the left hand). 62 2 Be sure to use the flat pads of the three middle fingers rather than finger tips. 3 Move gently and smoothly over every part of each To be sure you cover breast using superficial and deep pressure of fingers your whole breast, take with circular motion to check for any lump, hard your time and follow a knot, or thickening. definite pattern: lines, circles, or wedges. 4 Be especially careful to check under the armpit and -Cancers of the breast near the collarbone. may occur in the surrounding lymph node tissue. 5 If you have heavy or pendulous breasts, support one breast with one hand while using the other to do the examination. 6 Repeat for the other breast. Lying Down 1 Place a folded towel or a pillow under your mid-back -To help distribute the while you are lying down. breast tissue more evenly on the chest wall. 63 2 Rub a little lotion on your breast to make examination easier. 3 Press gently around an imaginary clock face with -To make examination your left hand. You should advance an inch toward easier. the nipple until the entire breast has been examined. 4 Gently repeat for other side with fingertips close To look for any together in one of three patterns. unusual discharge particularly pinkish or reddish discoloration. 64 5 Squeeze the nipple of each breast gently between -To detect any thumb and index finger. discharge, clear or bloody. 6 Use the calendar to keep a record of when she perform breast self examination. 7 Perform breast self examination at the same time each month. 8 If you notice a lump, discharge, or any other change during the month whether or not it is during breast self examination contact your physician as soon as possible. Post Procedure Tasks 1 Ask woman to dress her clothes after completing the examination. 3 Wash hands and dry them. 65 3 If the examination is normal, tell the woman everything is normal, healthy and when she should return for a repeat examination. 4 Give the woman health education about breast self- examination. 5 Record and report the following: Size, shape and symmetry of breasts. Color (e.g. persistent patches of redness or inflammation). Skin texture (e.g. dimpling or puckering of the skin, 'orange-peel' skin, prominent blood vessels). Retraction or inversion of the nipples. Any spontaneous discharge from the nipples. Persistent sores, lesions, rashes or ulcerations. Any swelling, redness, inflammation, lesions or masses of the upper arm or axillae. Any other observation or abnormal findings. 66  Pap Smear Definition : A Pap smear (also known as the Pap test) is a medical procedure in which a sample of cells from a woman's cervix uterus that is collected and spread on a microscope slide in order to look for pre-malignant (before-cancer) or malignant (cancer) changes. * Objectives: (1) Inspect vagina & cervix. (2) Obtain a specimen of cervical cells for cancer screening. * Equipment: 1- Light Source. 2-Vaginal speculum. 3- Gloves. 4- Cotton balls. 5- Slides. 6- Specimen collection. *Procedure: Nursing action Rational 1- Wash hands. 2- Prepare equipment beside exam table. 3- Explain procedure to woman. To relieve anxiety. 4- Instruct mother to empty bladder. To relieve discomfort. 5- Assist woman into lithotomy position. 6- With gloved hands inspect, palpate the external - For any abnormality. genitalia. 7 - Insert sterile speculum into the vagina: - Prevent tissue injury a - Open the introitus. b - Oblique insertion of speculum. c - Final insertion of speculum. d - Opening the blades of speculum. 8- Excess mucus is removed from the cervix with a The removal of excess dry cotton.. mucus allows for a more accurate specimen sample. 9- A saline moistened Dacron applicator is - A specimen of cells introduced into the endocervical canal & rotated 360 is obtained distributes 67 C & rolled on slide. the cells on a slide. 10- A Wooden or plastic spatula is used to obtain the - This action scrapes ectocervical sample. The longer end is introduced the tissue of the into the cervical os, pressed & turned in a full circle sqaomo columnar junction. This is the area where most malignancies arise & can be seen as a color change of cervical epithelium.. 11- The specimen is smeared on a glass slide & - This prevents the immersed in 95% alcohol. specimen from drying, which distorts the cells. 12- Clean the equipment. 13- wash hands. cervical scrape of secretions for cytology is obtained by using a wooden. Ayre spatula. A. Shows the speculum in place: the spatula is inserted so that the longer end is placed snugly in the os. B. A representative sample of secretions is obtained by rotating the spatula. C. Cervical secretions are gently smeared on a glass slide in a single circularmotion. The slide is placed in the appropriate laxative. Using a cotton tipped applicator, also obtain a smear from the floor of the vagina below the cervix and preserve in the same manner. 68  The partograph Definition: The partograph is a graphical presentation of the progress of labor, fetal and maternal condition during labor. Aims: 1- Prevent of prolonged and obstructed labor 2- Assessing the labor progress 3- Improve outcome in case of prolonged or obstructed labor 4- Recognize the need for action at the proper time. Components of the partograph: ❖ Patient information: as name, gravida, para, date & time of admission and time of ruptured membrane. ❖ Part I : fetal condition ( at top ) ❖ Part II : progress of labor ( at middle ) ❖ Part III : maternal condition ( at bottom ) Obstetric history: Definition: - Is a shorthand notation for woman's history. As G P A (Gravida/ Para/Abortion) or only G P, (Gravida/ Para). Gravida: - Meaning the number of pregnant, regardless of whether these pregnancies were carried to term. Current pregnancy is included in this count. Para: - Meaning the number of births > 20 wks. (Including viable and non- viable fetus i.e. stillbirths). Also included pregnancies consisting of multiples, such as twins or triplets (count as ONE birth for the purpose of this notation) Abortion: - Is the number of pregnancies that were lost < 20 wks. For any reason, including induced abortions. For examples: 1- The history of a woman who had two pregnancies (both of which resulted in live births) what would be noted as? G2P2 69 2- The obstetrical history of a woman who had four pregnancies, one of which was a miscarriage before 20 weeks, what would be noted as? G4P3+1 3- That of a woman who had one pregnancy of twins with successful outcomes what would be noted as? G1P1 70  Part I: fetal condition: This part of the graph is used to monitor and assess fetal condition: 1 - Fetal heart rate 2 - Membranes OR liquor 3 - Moulding the fetal skull bones - Fetal HR: Is recorded every half an hour to know the fetus is well. The fetal heart rate is recorded at the top of the partograph as a dot (. ) 120 -160 beats/ min = Normal pattern > 160 beats/ min = Tachycardia ˂ 120 beats/ min = Bradycardia ˂ 100 beats/ min = Severe bradycardia - Liquor: The state of liquor or amniotic fluid can assist in assessing the fetal condition. The following observations are recorded on the partograph immediately below the fetal heart rate recordings. The observations are made at each vaginal examination. They are: 71  a) Intact recorded as “I” b) Ruptured recorded as - “C” for clear fluid - ”B” for blood-stained fluid - ”M” for meconium - stained fluid - ”A” for absent liquor. - Moulding of the skull bones: Moulding is an important indication of how adequate the pelvis can accommodate the fetal head. Increasing moulding with the head high in the pelvis is an ominous sign of cephalopelvic disproportion. ”O” bones are separated ”+” bones are just touch each other ”++” bones are overlapping & can be separated easily ”+++” bones are overlapping & cannot be separated easily Part II: progress of labor: 1- Cervical dilatation Note: Time of admission recorded at zero time. 2- Descent of the fetal head 3- Uterine contractions 72 Note: The progress is assessed by vaginal examination on admission and every two hours afterwards during the first stage of labor. - CX dilatation (first stage): recorded as “X”. Note: Cervical dilatation is the most important information and the surest way to assess progress of labor, even though other findings discovered on vaginal examination are also important. When progress of labor is normal and satisfactory, plotting of cervical dilation remains on the Alert line or 73 to left of it. Active phase: ✓ Starts from 4 cm cervical dilatation till 10 cm (Full cervical dilatation). ✓ Contractions at least 2/10 min. each lasting > 20 seconds. ✓ The active phase (Faster period of cervical dilatation) the cervix should dilate at a rate 1 cm/ hour or faster. Alert line: ✓ The Alert line drawn from 4 cm- 10 cm dilation. ✓ Represents the rate of dilatation of 1 cm/ hour. ✓ Moving to the right of Alert line means referral to hospital for extra vigilance. Action line: ✓ The Action line is drawn 4 hours to the right of the Alert line and parallel to it. ✓ This is the critical line at which specific management decisions must be made at the hospital. 2- Descent of the fetal head: ✓ -The station of the head is plotted on the 0-5 gradation of the partograph. ✓ -Descent of the fetal head is plotted with an (O) ✓ -Descent of the fetal head can be assessed by two methods: 74 A- Abdominal examination (Rule of Fifths) Rule of Fifths: means the palpable fifths of the fetal head are felt by abdominal examination to be above the level of symphysis pubis. When 2/5 or less of the fetal head is felt above the level symphysis pubis, this means the head is engaged (at the level of ischial spine). 75 B- Vaginal examination: Descent is also recorded by assessing the level of the presenting part above or below the level of the ischial spines and marked as -1, -2, and -3 when it is above the spines and +1, +2 if it is below the spines. 0 stations vaginally equal to 2/5 abdominally equal the level of ischial spines. 3- Uterine contractions: - Observations of the contractions are made every half an hour in the active phase. - Felt through 10 minutes, to determine its frequency & duration as (40 seconds). Frequency: The number of contractions in a 10 minutes period. Duration: Measured in seconds from the time the contraction is first felt abdominally, to the time the contraction ceases. The nature and frequency of the uterine contractions are recorded on the chart by shading in the number of contractions per 10 minutes. 76  Part III: maternal condition: According the space provided as should be recorded the following item: 1- Drugs, IV fluids, and oxytocin if labor is augmented. 2- Maternal pulse, blood pressure and temperature. Take the pulse every hour. 3- Urine volume, analysis for protein and acetone. Abnormal progress of labor: ❖ Prolonged active phase: In the active phase of labor, cervical dilation will normally remain on or to left of the Alert line. But some cases will move to the right of the Alert line and this warns that the labor may be prolonged. This will happen if the rate of cervical dilation in the active phase of labor is not 1 cm/ hour or faster. ❖ Secondary Arrest of cervical dilation: occur in cases with normal progress of cervical dilation when followed by secondary arrest of dilatation. 77 ❖ Secondary Arrest of head descent: occur with normal progress in descent of the head when followed by secondary arrest of descent of the fetal head. Important considerations: 1- Oxytocin: ✓ Oxytocin should be given until contractions are 3 or 4 in 10 minutes, each lasting 40-50 seconds. ✓ It may be maintained at that rate throughout the second stage of labor. ✓ Stop oxytocin infusion if there is evidence of uterine hyperactivity and/ or fetal distress. 2- Membranes: ✓ If membranes have been ruptured for 12 hours or more antibiotics should be given. ✓ Fetal distress: ✓ If a woman is laboring in a health center, transfer her to a hospital with facilities for operative delivery. In the hospital, immediately: ✓ Conduct a vaginal examination to exclude cord prolapse and observe amniotic fluid. ✓ Provide adequate hydration. ✓ Administer oxygen, if available. ✓ Stop oxytocin ✓ Turn the woman in her left side. 78  Fetal monitoring during pregnancy and labor Introduction: The assessment of fetal well-being is a critical tool in ensuring optimal neonatal outcomes from both pregnancy and labor. The assessment of fetal well-being is a broad term that refers to a variety of tests that may be administered during pregnancy and labor in order to evaluate whether or not a baby is thriving in utero. These tests are typically ordered by obstetricians for woman who are experiencing high risk pregnancies, and they are an additional means by which to manage and monitor both the mother’s and baby’s health and well- being. Definition: Fetal monitoring is a series of tests used to assess the health of the fetus in the womb and to detect that the fetus is well oxygenated. Types: 1. Antepartum fetal monitoring 2. Intrapartum fetal monitoring 3. Antepartum fetal monitoring Indications of antepartum fetal monitoring: ✓ Gestational diabetes ✓ Pregnancy-induced hypertension ✓ Decreased fetal movement 79  ✓ Fetal growth restriction ✓ Post- term pregnancy ✓ Premature rupture of membranes Aims of antepartum fetal monitoring: ✓ Prevent and avoid fetal injury and death. ✓ To ensure satisfactory growth and well- being of the fetus. ✓ Avoiding unnecessary interventions such as cesarean delivery or preterm delivery. Technique of antepartum fetal monitoring: 1- Daily fetal movement count (DFMC) 2- Non- stress test (NST) 3- Contraction stress test (CST) or Oxytocin challenge test 4- Biophysical profile (BPP) 1- Daily fetal movement count (DFMC): 80 - It’s the simplest method of fetal monitoring. It’s often called kick counting. It’s done by counting the number of kicks mother feel from her baby in the uterus in a certain time period. - The count should be performed daily starting at 28 weeks of pregnancy. - Most babies tend to be more active about an hour after the mother eats. This is because of the increase in sugar (glucose) in the mother's blood. - Fetal movement is one show of a baby’s health in the womb. Each woman should learn the normal pattern and number of movements for her own baby. - A change in the normal pattern or number of fetal movements may mean the baby is under stress. - It is recommended that women who notice a decrease in fetal movements should undergo further fetal surveillance. Technique: - A woman sits or lies on her side (since the baby will have better circulation) in a comfortable spot during the same time each day to count movements when the baby is usually active. - Count fetal movement one hour each in morning, noon and evening. (Total 1+1+1=3 hours). - Total counts multiplied by four gives daily (12 hours) fetal movement count (DFMC). Results of the test: - Woman should feel at least 3 movements in each hour or at least 10 movements in 12 hours. - If there is diminution of number of ‘kicks’ to less than 10 in 12 hours (or less than 3 in each hour), it indicates fetal compromise. 81 2- Non- stress test (NST) - A non- stress test is a safe, noninvasive test for pregnant women. - This test sometimes called a cardiotocography (CTG). - This test measures a baby’s heart rate and fetal movement over a specific period of time without any external factors being applied. - Normal fetal heart rate between 120- 160 b/m. - In most healthy babies, the heart rate, also known as the fetal heart rate, increases during movement (acceleration). So, Baby’s heart should beat faster when active. - This test is done after 30 weeks of pregnancy and frequency should be twice weekly. - For the NST, the fetal heart rate is monitored externally with a sensor that is attached to a belt and placed on the mother’s abdomen. - The NST can reassure that baby is healthy and getting enough oxygen. 82 Technique: - Woman will lie down with one belt around her abdomen to measure the baby's heartbeat. - When woman feel the baby kick or move, she may press a button so the doctor can see how the baby's heartbeat changed while moving. - The test will take about 20 minutes. - If the baby seems to be sleeping, a nurse may try to wake up the baby by ringing a bell, moving mother abdomen, or by using an acoustic stimulator. Results of the test: - The test result may be reactive (Reassuring) or no- reactive (non-reassuring). Reactive or Reassuring: - Means two accelerations of at least 15 beats per minute baseline lasting for not less than 15 seconds within a 20- minute period. 83 No- reactive or non- reassuring: - Means absence of fetal reactivity. - The baby's heartbeat didn't increase when moving, or the baby wasn't moving much. If test non-reactive or non-reassuring: - Test is repeated later the same day - Or perform another test of fetal monitoring. Note: A non-reactive result doesn't always mean the baby has a health problem. The baby may simply have been asleep and not easily awoken. Non- reactive results may also be caused by certain medicines taken during pregnancy. 84  3- Contraction stress test or Oxytocin challenge test - Contraction stress test or Oxytocin challenge test monitors fetal heart rate and uterine contraction. - Women may get a contraction stress test after 32 weeks of pregnancy. - The test triggers contractions through administration of oxytocin which causes woman’s uterus to contract and registers how the baby’s heart reacts. - CSTs are very uncommon, because it can trigger early labor. Technique: - Woman should stop eating and drinking for four to eight hours before the test. - Woman will lie down with two belts around her abdomen. One measures your baby's heartbeat and the other measures contractions. - To trigger contractions, doctor may give woman a dose of the drug oxytocin through an IV in the arm. - Doctor records baby’s heart rate during and between contractions. 85 - Immediately after the test, doctor observes woman until contractions stop. If contractions don’t stop, doctor may give woman medicine to stop them. The test often takes up to two hours. Results of the test: Normal (negative) results: Means that the baby’s heart rate doesn’t stay slow after a contraction or no late decelerations occur, and that's an excellent sign that the baby will be healthy during labor. 86 Abnormal (positive) results: Means that the baby’s heart rate slows down and stays slow after a contraction or late decelerations occur, and it means the baby may be unable to tolerate the stress of labor contractions. Note: Doctor may recommend additional tests, including another contraction test a week or two later. If woman continue to have positive results, doctor may recommend delivery via cesarean section. 87  4- Biophysical profile (BPP) - The biophysical profile (BPP) combines non- stress test and fetal ultrasound to evaluate fetal well-being. It was originally designed to mimic the Apgar score for postnatal assessment. - This test done after the 28th week of pregnancy. - The test might take 30 minutes or so to complete. - The test is scored with five components; each component that's evaluated during a biophysical profile is given a score of 0 or 2 points, depending on whether specific criteria were met. - The five components are a fetal heart rate, breathing movements (lung expansion), fetal movements, muscle tone and amniotic fluid volume. - The assessment of fetal heart rate is accomplished by performing a non- stress test, whereas the latter 4 variables are observed using real-time fetal ultrasound. 88  Results of the test: - A score of 8 or 10 is reassuring - A score of 6 is suspicious and indicates a need for further evaluation and the biophysical profile test should be repeated within 24 hours if the pregnancy is less than 37 weeks. - And a score of 4 or less is ominous, indicating the need for immediate intervention and delivery may be needed to be induced. 2. Intrapartum fetal monitoring - The fetal intrauterine environment changes dramatically during labour due to uterine contractions which result in compression of the fetal presenting part and the umbilical cord, which cause repeated transient interruptions of fetal oxygenation. Most fetuses tolerate this process well, but some do not. So, it is mandatory that all healthcare profes