Maternal Health Nursing Skills

Maternal Maternal Health Nursing Health Nursing

SkillsSkills

Maternal Maternal Health Nursing Health Nursing

SkillsSkillsMary Lourdes Nacel G. Celeste, RN, MDMary Lourdes Nacel G. Celeste, RN, MD

RESPONSIBLERESPONSIBLEPARENTHOODPARENTHOOD

ReproductReproduct

ive Life ive Life PlanningPlanning

FAMILY PLANNINGFAMILY PLANNING

MLNG CELESTE, RN, MD 4

Reproductive Life Reproductive Life PlanningPlanning

Includes all decisions an individual or Includes all decisions an individual or couple make about having children:couple make about having children:

- If and when to have childrenIf and when to have children- How many children to haveHow many children to have- How children are spacedHow children are spaced- Conception, fertility and counselingConception, fertility and counseling


A responsible person is a man or woman who is A responsible person is a man or woman who is able and willing to give the proper response to the able and willing to give the proper response to the demands of a given situation.demands of a given situation.

With specific reference to marriage and family life, With specific reference to marriage and family life, the responsible spouse is one who gives the proper the responsible spouse is one who gives the proper responses to the needs of his/ her spouse, as well responses to the needs of his/ her spouse, as well as his own, and of their life together. Similarly, as his own, and of their life together. Similarly, responsible parents give proper responses to the responsible parents give proper responses to the needs of their children.needs of their children.

Responsible Responsible ParenthoodParenthood


Although some people object to the idea, we Although some people object to the idea, we tend to equate family planning with tend to equate family planning with responsible parenthood. Family planning responsible parenthood. Family planning refers more specifically to the voluntary and refers more specifically to the voluntary and positive action of a couple to plan and decide positive action of a couple to plan and decide the number of children they want to have and the number of children they want to have and when to have them.when to have them.



The concept of family planning includes these The concept of family planning includes these elements:elements:

Responsibility of parents to themselves and to each Responsibility of parents to themselves and to each otherother

Responsibility to their present and future childrenResponsibility to their present and future children

Responsibility to their community and countryResponsibility to their community and country



Purposes of Family PlanningPurposes of Family Planningimprovement of healthimprovement of healthpromotion of human right to determine promotion of human right to determine reproductive performancereproductive performancerelation of demographic change to relation of demographic change to economic developmenteconomic development



The ultimate goal of family planning is directed The ultimate goal of family planning is directed towards:towards:

Birth spacing, to allow the mothers time to rest and Birth spacing, to allow the mothers time to rest and regain their health before the next pregnancyregain their health before the next pregnancy

Birth limitation, when the desired number of children Birth limitation, when the desired number of children is reachedis reached

Helping those who do not have children to have Helping those who do not have children to have childrenchildren



Advantages of family planningAdvantages of family planning

To the mother:To the mother:enables the mother to regain her health after the deliveryenables the mother to regain her health after the deliverygives mother enough time and opportunity to love and gives mother enough time and opportunity to love and provide attention to her husband and childrenprovide attention to her husband and childrenprovides mother who has chronic illness enough time for provides mother who has chronic illness enough time for treatment and recovery without further exposure to the treatment and recovery without further exposure to the physiologic burden of pregnancyphysiologic burden of pregnancyprevents high risk pregnancyprevents high risk pregnancygives mother more time to herself, family and communitygives mother more time to herself, family and community



To the children,the practice of family To the children,the practice of family planning will make themplanning will make them

healthierhealthier

happierhappier

feel wanted and satisfiedfeel wanted and satisfied

securesecure



To the fathersTo the fatherslightens his burden and responsibility in supporting lightens his burden and responsibility in supporting his familyhis familyenables him to give his children a good home, good enables him to give his children a good home, good education and better futureeducation and better futureenables him to give his family a happy and contented enables him to give his family a happy and contented lifelifegives him time for his personal advancementgives him time for his personal advancementprovides a father who has chronic illness enough provides a father who has chronic illness enough time for treatment and recovery from his illnesstime for treatment and recovery from his illness



To the familyTo the family

gives the family members more opportunity to gives the family members more opportunity to enjoy each other’s company with love and enjoy each other’s company with love and affectionaffection

enables the family to save some amount for enables the family to save some amount for improvement of standard of living, and for improvement of standard of living, and for emergenciesemergencies



To the communityTo the communityimproves the economic and social status of the improves the economic and social status of the communitycommunitybetter job opportunitiesbetter job opportunitieshealth status will improvehealth status will improveextra resources in the community (less congestion, extra resources in the community (less congestion, less pollution, potable water supply, etc)less pollution, potable water supply, etc)members will have more time to socialize with each members will have more time to socialize with each other; to participate in socio-civic activitiesother; to participate in socio-civic activities



ContraceptiveContraceptive

Any device used to prevent Any device used to prevent fertilization of an eggfertilization of an egg


Considerations:Considerations:

Personal valuesPersonal valuesAbility to use method correctlyAbility to use method correctlyHow method will affect sexual enjoymentHow method will affect sexual enjoymentFinancial factorsFinancial factorsStatus of couple’s relationshipStatus of couple’s relationshipPrior experiencesPrior experiencesFuture plansFuture plansContraindicationsContraindications


CONTRAINDICATIONS OF CONTRAINDICATIONS OF CONTRACEPTIVE USECONTRACEPTIVE USE


ContraceptivesContraceptives

40 million women in United States 40 million women in United States use some form of contraceptionuse some form of contraception

65% of women of childbearing age65% of women of childbearing age

? PHILIPPINES? PHILIPPINES



1. 1. AbstinenceAbstinence

0% failure rate0% failure rate

Most effective method to prevent Most effective method to prevent STDsSTDs

Difficult to comply withDifficult to comply with



2. Natural Family Planning 2. Natural Family Planning

No chemical or foreign material into No chemical or foreign material into the bodythe body

Failure rate of approximately 25%Failure rate of approximately 25%


ContraceptivesContraceptivesFertility Awareness MethodsFertility Awareness Methods

Calendar (rhythm) methodCalendar (rhythm) methodBasal body temperatureBasal body temperatureCervical mucus (Billings) methodCervical mucus (Billings) methodSymptothermal methodSymptothermal methodOvulation awarenessOvulation awarenessLactation amenorrhea methodLactation amenorrhea method

Coitus interruptusCoitus interruptus


Calendar/ Rhythm Calendar/ Rhythm (Natural Family (Natural Family

Planning)Planning)Action – periodic abstinence from Action – periodic abstinence from intercourse during fertile period; intercourse during fertile period; based on the regularity of ovulation; based on the regularity of ovulation; variable effectivenessvariable effectiveness


Teaching – fertile period may be Teaching – fertile period may be determined by a drop in the basal body determined by a drop in the basal body temperature before and a slight rise temperature before and a slight rise aftre ovulation and/ or by a change in aftre ovulation and/ or by a change in cervical mucus from thick, cloudy and cervical mucus from thick, cloudy and sticky during nonfertile period to more sticky during nonfertile period to more abundant, clear, thin, stretchy and abundant, clear, thin, stretchy and slippery as ovulation occursslippery as ovulation occurs

Calendar/ Rhythm Calendar/ Rhythm (Natural Family (Natural Family

Planning)Planning)


Entails keeping a day-by-day record of Entails keeping a day-by-day record of your cycle for your cycle for 6 consecutive months6 consecutive months

noting the onset of bleeding as day 1 and noting the onset of bleeding as day 1 and the last day before your next menstrual the last day before your next menstrual bleeding as the final day of your cyclebleeding as the final day of your cycle

This 6 month record will show you your This 6 month record will show you your longest and shortest cycles- from which longest and shortest cycles- from which you can calculate your FERTILE daysyou can calculate your FERTILE days

1. Calendar (rhythm) method1. Calendar (rhythm) method


The first day of menstrual bleeding The first day of menstrual bleeding (day 1 of your period) counts as the (day 1 of your period) counts as the first day of the cycle.first day of the cycle.

Approximately Approximately 14 days (or 12 to 16 14 days (or 12 to 16 days) before days) before the start of the next the start of the next period, an egg will be released by period, an egg will be released by one of the ovaries.one of the ovaries.

1. Calendar (rhythm) 1. Calendar (rhythm) methodmethod


While the egg from the woman lives While the egg from the woman lives for only around 24 hours, sperm for only around 24 hours, sperm from the man can survive for up to 3 from the man can survive for up to 3 days, possibly longer.days, possibly longer.

1. Calendar (rhythm) 1. Calendar (rhythm) methodmethod


First unsafe day: subtract 18 from the First unsafe day: subtract 18 from the number of days in your shortest cyclenumber of days in your shortest cycleLast unsafe day: subtract 11 from the Last unsafe day: subtract 11 from the number of days in your longest cyclenumber of days in your longest cycleEx: shortest: 26 – 18 = day 8Ex: shortest: 26 – 18 = day 8 longest: 31 – 11 = day 20longest: 31 – 11 = day 20

UNSAFE PERIOD!! Days 8 -20UNSAFE PERIOD!! Days 8 -20-avoid coitus or use a contraceptive-avoid coitus or use a contraceptive



LONGEST CYCLE

11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616 1717 1818 1919 2020 2121 2222 2323 2424 2525 2626 2727 2828 2929 3030 3131

11 DAYS11 DAYS

SHORTEST CYCLE

1122 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616 1717 1818 1919 2020 2121 2222 2323 2424 2525 2626

18 DAYS18 DAYS

UNSAFE TIME

11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616 1717 1818 1919 2020 2121 2222 2323 2424 2525 2626 2727 2828 2929 3030 3131

UNSAFE TIMEUNSAFE TIME


2. Basal Body 2. Basal Body TemperatureTemperature

Involves taking the temperature every Involves taking the temperature every morning BEFORE the woman gets out of bed morning BEFORE the woman gets out of bed and recording itand recording it

The temperature drops slightly 24 hours The temperature drops slightly 24 hours before ovulation, then rises to about half a before ovulation, then rises to about half a degree higher than normal and remains thus degree higher than normal and remains thus for up to three days: UNSAFE period!for up to three days: UNSAFE period!

Not a very efficient method unless combines Not a very efficient method unless combines with calendar and mucus methodswith calendar and mucus methods


3. Cervical Mucus 3. Cervical Mucus (Billings) Method(Billings) Method

Involves becoming aware of the Involves becoming aware of the normal changes in the cervical normal changes in the cervical secretions that occur throughout secretions that occur throughout your cycle by inserting the forefinger your cycle by inserting the forefinger into the vagina first thing in the into the vagina first thing in the morningmorning


A few days after menstrual bleeding: little A few days after menstrual bleeding: little secretion, vagina is drysecretion, vagina is dry

Gradually, secretion increases and Gradually, secretion increases and becomes thicker, cloudy white and stickybecomes thicker, cloudy white and sticky

As ovulation approaches, this secretion or As ovulation approaches, this secretion or mucus becomes copious, clear, thin, less mucus becomes copious, clear, thin, less viscous, more liquid, slippery or stringy; viscous, more liquid, slippery or stringy; as soon as this change begins and for as soon as this change begins and for 3 full days later: UNSAFE PERIOD!! 3 full days later: UNSAFE PERIOD!!

3. Cervical Mucus 3. Cervical Mucus (Billings) Method(Billings) Method


3. Cervical 3. Cervical ChangesChanges

Spinnbarkeit testSpinnbarkeit test

Cervical mucus is Cervical mucus is thin, watery and thin, watery and can be stretched can be stretched into long strandsinto long strands

high level of high level of estrogen: estrogen: ovulation is about ovulation is about to occurto occur


3. Cervical 3. Cervical ChangesChanges

Ferning or Ferning or arborization of arborization of cervical mucus cervical mucus At the height of At the height of estrogen stimulation estrogen stimulation just before ovulationjust before ovulationFerning- due to Ferning- due to crystallization of crystallization of sodium chloride on sodium chloride on mucus fibersmucus fibers


Symptothermal methodSymptothermal method

Combines BBT and cervical mucus Combines BBT and cervical mucus methodsmethods


Ovulation awarenessOvulation awareness

Use of over-the-counter OTC Use of over-the-counter OTC ovulation test kit which detects the ovulation test kit which detects the midcycle LH (luteinizing hormone) midcycle LH (luteinizing hormone) surge in the urine 12 to 24 hours surge in the urine 12 to 24 hours before ovulationbefore ovulation

98 to 100% accurate98 to 100% accurate


Lactation amenorrhea Lactation amenorrhea methodmethod

As long as a woman is breastfeeding As long as a woman is breastfeeding an infant, there is some natural an infant, there is some natural suppression of ovulationsuppression of ovulationNot dependable- woman may be Not dependable- woman may be fertile even if she has not had a fertile even if she has not had a period since childbirthperiod since childbirthAfter 6 months, she should another After 6 months, she should another method of contraceptionmethod of contraception


Coitus interruptusCoitus interruptusOldest methodOldest methodCouple proceeds with coitus until the Couple proceeds with coitus until the moment of ejaculation, then the man moment of ejaculation, then the man withdraws and spermatozoa are emitted withdraws and spermatozoa are emitted outside the vaginaoutside the vaginaOffers little protection because Offers little protection because ejaculation may occur before withdrawal ejaculation may occur before withdrawal is co mplete and despite the care used, is co mplete and despite the care used, spermatozoa may be deposited spermatozoa may be deposited in the vagina in the vagina



3. Oral Contraceptives3. Oral Contraceptives

Composed of varying amounts of Composed of varying amounts of estrogen combined with small estrogen combined with small amount of progesteroneamount of progesterone

99.5% effective99.5% effective



Estrogen Estrogen suppresses FSH suppresses FSH and LH, thereby and LH, thereby suppressing suppressing ovulationovulation

Progesterone Progesterone decreases the decreases the permeability of permeability of cervical mucuscervical mucus


Monophasic - Fixed doses of estrogen Monophasic - Fixed doses of estrogen and progesterone ; 21-28 day cycleand progesterone ; 21-28 day cycle

Biphasic - Constant amount of Biphasic - Constant amount of estrogen with increased progesterone estrogen with increased progesterone

Triphasic - Varying levels of estrogen Triphasic - Varying levels of estrogen and progesteroneand progesterone

3. Oral Contraceptives 3. Oral Contraceptives


3. Oral Contraceptives3. Oral ContraceptivesBenefits of OC’s: Benefits of OC’s: DECREASED incidences of:DECREASED incidences of:

DysmenorrheaDysmenorrheaPremenstrual dysphoric syndromePremenstrual dysphoric syndromeIron deficiency anemiaIron deficiency anemiaAcute PID with tubal scarringAcute PID with tubal scarringEndometrial and ovarian cancer and Endometrial and ovarian cancer and ovarian cystsovarian cystsFibrocystic breast diseaseFibrocystic breast disease


Side EffectsSide EffectsNauseaNauseaWeight gainWeight gainHeadacheHeadacheBreast tendernessBreast tendernessBreakthrough bleedingBreakthrough bleedingMonilial vaginal infectionsMonilial vaginal infectionsMild hypertensionMild hypertensionDepressionDepression



Absolute Contraindications to OC’sAbsolute Contraindications to OC’s

BreastfeedingBreastfeeding

Family history of CVA or CADFamily history of CVA or CAD

History of thromboembolic diseaseHistory of thromboembolic disease

History of liver diseaseHistory of liver disease

Undiagnosed vaginal bleedingUndiagnosed vaginal bleeding

3. Oral Contraceptives


Possible Contraindications to OC’sPossible Contraindications to OC’sAge 40+Age 40+Breast or reproductive tract malignancyBreast or reproductive tract malignancyDiabetes MellitusDiabetes MellitusElevated cholesterol or triglyceridesElevated cholesterol or triglyceridesHigh blood pressureHigh blood pressureMental depressionMental depression

3. Oral Contraceptives


Migraine or other vascular type headachesMigraine or other vascular type headaches

ObesityObesity

PregnancyPregnancy

Seizure disordersSeizure disorders

Sickle cell or other hemoglobinopathiesSickle cell or other hemoglobinopathies

SmokingSmoking

Use of drug with interaction effectUse of drug with interaction effect


Other ContraceptivesOther Contraceptives

Continuous or extended regimen Continuous or extended regimen pillspills

Mini-pillsMini-pills

Estrogen-progesterone patchEstrogen-progesterone patch

Vaginal rings Vaginal rings


Estrogen-progesterone Estrogen-progesterone patchpatch


Highly effective, weekly hormonal birth Highly effective, weekly hormonal birth control patch that’s worn on the skincontrol patch that’s worn on the skinCombination of estrogen and progestinCombination of estrogen and progestinAbsorbed on the skin and then transferred Absorbed on the skin and then transferred into the bloodstreaminto the bloodstreamCan be worn on the upper outer arm, Can be worn on the upper outer arm, buttocks, upper torso or abdomenbuttocks, upper torso or abdomenWorn for 1 week, replaced on the same Worn for 1 week, replaced on the same day of the week for 3 consecutive weeks. day of the week for 3 consecutive weeks. No patch-4No patch-4thth week week


Emergency Postcoital Emergency Postcoital ContraceptivesContraceptives

““Morning-after pills”Morning-after pills”

High level of estrogenHigh level of estrogen

Must be initiated within 72 hours of Must be initiated within 72 hours of unprotected intercourseunprotected intercourse


4. Other 4. Other ContraceptivesContraceptives

Subcutaneous implants (eg, Norplant)Subcutaneous implants (eg, Norplant)6 nonbiodegradable Silastic implants with 6 nonbiodegradable Silastic implants with synthetic progesterone embedded under the skin synthetic progesterone embedded under the skin on the inside of the upper armon the inside of the upper armSlowly release the hormone over the next 5 yearsSlowly release the hormone over the next 5 yearsSuppress ovulation, stimulating thick cervical Suppress ovulation, stimulating thick cervical mucus and changing the endometrium so mucus and changing the endometrium so implantation is difficultimplantation is difficult


4. Other 4. Other ContraceptivesContraceptives

Intramuscular injectionsIntramuscular injections

-administered every 12 weeks-administered every 12 weeks

Medroxyprogesterone (depo-provera)Medroxyprogesterone (depo-provera)

-100% effective-100% effective


ContraceptivesContraceptives5.5. INTRAUTERINE DEVICESINTRAUTERINE DEVICES

T-shaped plastic device with copperT-shaped plastic device with copperWith progesteroneWith progesteroneMechanism of action not fully understoodMechanism of action not fully understoodMust be fitted by physician, nurse practitioner Must be fitted by physician, nurse practitioner or midwifeor midwifeInsertion performed in ambulatory setting after Insertion performed in ambulatory setting after pelvic examination and pap smearpelvic examination and pap smearDevice is contained within uterus – string Device is contained within uterus – string protrudes into vaginaprotrudes into vaginaEffective for 5-7 years (mirena type) or 8 years Effective for 5-7 years (mirena type) or 8 years (Copper T380)(Copper T380)


INTRAUTERINE INTRAUTERINE DEVICEDEVICE


5. INTRAUTERINE 5. INTRAUTERINE DEVICEDEVICE

Side Effects:Side Effects:

Spotting or uterine crampingSpotting or uterine cramping

Increased risk for PIDIncreased risk for PID

Heavier menstrual flowHeavier menstrual flow

DysmenorrheaDysmenorrhea

Ectopic pregnancyEctopic pregnancy


6. Barrier Methods6. Barrier Methods

Vaginally inserted spermicidal Vaginally inserted spermicidal productsproducts

DiaphragmsDiaphragms

Cervical capsCervical caps

CondomsCondoms


6. BARRIER METHODS6. BARRIER METHODSSPERMICIDAL AGENTSPERMICIDAL AGENT

goal: to kill the goal: to kill the sperm before the sperm before the sperm enters the sperm enters the cervixcervix

-Nonoxynol-9-Nonoxynol-9

-gel, creams, -gel, creams, films,foams, films,foams, suppositoriessuppositories


6. BARRIER METHODS6. BARRIER METHODSDIAPHRAGMDIAPHRAGM

-mechanically blocks sperm -mechanically blocks sperm from entering the cervixfrom entering the cervix

-soft latex dome supported -soft latex dome supported by a metal rimby a metal rim-can be inserted 2 hours -can be inserted 2 hours before intercourse; before intercourse; removed at least 6 hours removed at least 6 hours after coitus or within 24 after coitus or within 24 hourshours-size must fit the individual-size must fit the individual-washable, may be used -washable, may be used for 2-3 years for 2-3 years


6. BARRIER METHODS6. BARRIER METHODS

CERVICAL CAPCERVICAL CAP-similar to -similar to diaphragm but diaphragm but smallersmaller

-thimble-shaped -thimble-shaped rubber cap held rubber cap held onto the cervix by onto the cervix by suctionsuction


6. BARRIER METHODS6. BARRIER METHODS

MALE CONDOMMALE CONDOM FEMALE CONDOMFEMALE CONDOM


MALE CONDOMMALE CONDOMAction – prevents the ejaculate and sperm from Action – prevents the ejaculate and sperm from entering the vagina; help prevent venereal entering the vagina; help prevent venereal disease; effective if properly used; OTCdisease; effective if properly used; OTC

Teaching – apply to erect penis with room at the Teaching – apply to erect penis with room at the tip every time before vaginal penetration; use tip every time before vaginal penetration; use water-based lubricant, e.g., K-Y jelly, never water-based lubricant, e.g., K-Y jelly, never petroleum-based lubricant; hold rim when petroleum-based lubricant; hold rim when withdrawing the penis from the vagina; if condom withdrawing the penis from the vagina; if condom breaks, partner should use contraceptive foam or breaks, partner should use contraceptive foam or cream immediatelycream immediately


7. Surgical Methods7. Surgical MethodsTubal LigationTubal Ligation-28% of all women in -28% of all women in USUS-fallopian tubes are -fallopian tubes are cut,tied/ cauterized to cut,tied/ cauterized to block passage of ova block passage of ova and spermand spermABDOMINAL INCISIONABDOMINAL INCISION

MINILAPAROTOMYMINILAPAROTOMY

LAPAROSCOPY LAPAROSCOPY

FOR TUBAL FOR TUBAL

STERILIZATIONSTERILIZATION


7. Surgical Methods7. Surgical MethodsVasectomy Vasectomy - 11% of all men in US- 11% of all men in US-incisions are made in -incisions are made in the sides of scrotum; the sides of scrotum; vas deferens is cut vas deferens is cut and tied, then plugged and tied, then plugged or cauterizedor cauterized-blocks passage of -blocks passage of spermsperm-viable sperm for 6 -viable sperm for 6 months post opmonths post op-reversible 95%-reversible 95%


8. Elective Termination of 8. Elective Termination of PregnancyPregnancy

Procedure to deliberately end a Procedure to deliberately end a pregnancy before fetal viabilitypregnancy before fetal viabilityInducedInduced(mifepristone-progesterone (mifepristone-progesterone antagonist; misoprostol-antagonist; misoprostol-prostaglandin analogprostaglandin analogMedically inducedMedically inducedD&C, D&E, saline induction, D&C, D&E, saline induction, hysterotomyhysterotomy

Physical AssessmentPhysical Assessmentof a Pregnant Womanof a Pregnant Woman

Mary Lourdes Nacel G. Celeste, RN, MDMary Lourdes Nacel G. Celeste, RN, MD


Genital & Pelvic Genital & Pelvic ExaminationExamination

the most intimate examination that a woman may the most intimate examination that a woman may be ever subjected tobe ever subjected tomust never be performed without:must never be performed without:

1. a careful explanation to the patient about the 1. a careful explanation to the patient about the examinationexamination

2. asking permission from the patient to perform the 2. asking permission from the patient to perform the examinationexamination

3. valid reason for performing the examination3. valid reason for performing the examination


IndicationsIndicationsAT THE FIRST VISIT:AT THE FIRST VISIT:

1.1. The diagnosis of pregnancy during the first trimesterThe diagnosis of pregnancy during the first trimester2.2. Assessment of the gestational ageAssessment of the gestational age3.3. Detection of abnormalities in the genital tractDetection of abnormalities in the genital tract4.4. Investigation of a vaginal dischargeInvestigation of a vaginal discharge5.5. Examination of the cervixExamination of the cervix6.6. Taking a cervical (Papanicolaou) smearTaking a cervical (Papanicolaou) smear


IndicationsIndicationsAT SUBSEQUENT ANTENATAL VISITS:AT SUBSEQUENT ANTENATAL VISITS:

1.1. Investigation of a threatened abortionInvestigation of a threatened abortion2.2. Confirmation of PROM with a sterile speculumConfirmation of PROM with a sterile speculum3.3. To confirm the diagnosis of preterm laborTo confirm the diagnosis of preterm labor4.4. Detection of cervical effacement and/ or dilatation in a patient with Detection of cervical effacement and/ or dilatation in a patient with

a risk for preterm labora risk for preterm labor5.5. Assessment of the ripeness of the cervix prior to induction of Assessment of the ripeness of the cervix prior to induction of

laborlabor6.6. Identification of the presenting part in the pelvisIdentification of the presenting part in the pelvis7.7. Performance of a pelvic assessmentPerformance of a pelvic assessment

IMMEDIATELY BEFORE LABORIMMEDIATELY BEFORE LABOR1. 1. Performance of artificial rupture of the membranes to induce laborPerformance of artificial rupture of the membranes to induce labor


PreparationPreparationThe bladder must be empty.The bladder must be empty.The procedure must be carefully explained to the patient.The procedure must be carefully explained to the patient.The patient is put in lithotomy (or dorsal) position.The patient is put in lithotomy (or dorsal) position.*The lithotomy position provides better access to the genital *The lithotomy position provides better access to the genital tract. Lithotomy poles and stirrups are required.tract. Lithotomy poles and stirrups are required.Provide good lighting.Provide good lighting.Drape properly.Drape properly.Let the support person stay at the head of the bed.Let the support person stay at the head of the bed.Instruct woman not to hold or squeeze your hands, hold her Instruct woman not to hold or squeeze your hands, hold her breath, close eyes tightly, clench fist and contract perineal breath, close eyes tightly, clench fist and contract perineal muscles.muscles.Explain that the procedure may be slightly uncomfortable.Explain that the procedure may be slightly uncomfortable.After the procedure, provide tissue to wipe perineum of After the procedure, provide tissue to wipe perineum of lubricant.lubricant.


TO THE FEMALE CLIENT TO THE FEMALE CLIENT

You will be asked to place your feet in the footrests at the You will be asked to place your feet in the footrests at the end of the table. end of the table.

Slide your hips down to the edge of the table. Let your Slide your hips down to the edge of the table. Let your knees spread wide apart, and relax as much as possible. knees spread wide apart, and relax as much as possible.

If your buttocks and abdominal and vaginal muscles are If your buttocks and abdominal and vaginal muscles are relaxed, you will be more comfortable, and the exam will be relaxed, you will be more comfortable, and the exam will be more complete. more complete.

You can cover your lower abdomen and thighs with the You can cover your lower abdomen and thighs with the drape sheet to feel less exposed and more comfortable drape sheet to feel less exposed and more comfortable during the procedure.during the procedure.



You'll feel less tense if youYou'll feel less tense if you

Breathe slowly and deeply with your mouth open.Breathe slowly and deeply with your mouth open.

Let your stomach muscles go soft.Let your stomach muscles go soft.

Relax your shoulders.Relax your shoulders.

Relax the muscles between your legs.Relax the muscles between your legs.

Ask the clinician to describe what is being done as it Ask the clinician to describe what is being done as it is happening.is happening.



Remember that the exam is not emotional or sexual for your Remember that the exam is not emotional or sexual for your clinician. Talk with your clinician aboutclinician. Talk with your clinician aboutyour fearsyour fearsany pelvic pain you may haveany pelvic pain you may haveyour experience of abuseyour experience of abuse

Talking with your clinician about your experience will help your Talking with your clinician about your experience will help your cliniciancliniciantailor the exam to your special needstailor the exam to your special needshelp you feel as comfortable as possiblehelp you feel as comfortable as possibleunderstand how your physical and emotional health may be understand how your physical and emotional health may be affectedaffected


Sexual Abuse and Other Sexual Abuse and Other ConcernsConcerns

Some women are very anxious about Some women are very anxious about having a pelvic exam because of difficult having a pelvic exam because of difficult experiences that may include sexual experiences that may include sexual abuse. The client may have more pelvic abuse. The client may have more pelvic pain, fear, and discomfort during the pain, fear, and discomfort during the pelvic exam if she has pelvic exam if she has been sexually abused in the pastbeen sexually abused in the pastheard alarming stories about GYN examsheard alarming stories about GYN examshad other negative sexual experiences had other negative sexual experiences


If the clinician is a man, the client may request to If the clinician is a man, the client may request to have another woman in the room. Her presence have another woman in the room. Her presence may help the client to feel more relaxed. She may may help the client to feel more relaxed. She may hold the client’s hand or just talk to her to ease hold the client’s hand or just talk to her to ease her tension. If the client wants to see what's her tension. If the client wants to see what's going on and/or know what the vagina and cervix going on and/or know what the vagina and cervix look like, a mirror may be requested.look like, a mirror may be requested.

It is also okay to have a trusted friend or relative It is also okay to have a trusted friend or relative with the client during the exam. with the client during the exam.


Four StepsFour Steps

Usually, the exam lasts just a few Usually, the exam lasts just a few minutes. There are four steps:minutes. There are four steps:

The External Genital ExamThe External Genital Exam

The Speculum ExamThe Speculum Exam

The Bimanual ExamThe Bimanual Exam

The Rectovaginal ExamThe Rectovaginal Exam


Step 1. The External Step 1. The External Genital Exam Genital Exam

The clinician visually examines the soft folds of The clinician visually examines the soft folds of the vulva and the opening of the vagina to check the vulva and the opening of the vagina to check for signs of irritation, discoloration, discharge, for signs of irritation, discoloration, discharge, swelling and other abnormalities. She will gently swelling and other abnormalities. She will gently feel for glands, cysts, genital warts, or other feel for glands, cysts, genital warts, or other conditions.conditions.


Step 2. The Speculum Step 2. The Speculum ExamExam

The clinician inserts a metal or plastic speculum into the The clinician inserts a metal or plastic speculum into the vagina. When opened, it separates the walls of the vagina, vagina. When opened, it separates the walls of the vagina, which normally are closed and touch each other, so that which normally are closed and touch each other, so that the cervix can be seen.the cervix can be seen.

The client may feel some degree of pressure or mild The client may feel some degree of pressure or mild discomfort when the speculum is inserted and opened. She discomfort when the speculum is inserted and opened. She will likely feel more discomfort if she is tense or if the will likely feel more discomfort if she is tense or if the vagina or pelvic organs are infected. The position of the vagina or pelvic organs are infected. The position of the cervix or uterus may affect comfort as well. If a metal cervix or uterus may affect comfort as well. If a metal speculum is used, the client may feel the chill of the metal. speculum is used, the client may feel the chill of the metal. Most clinicians lubricate the speculum and warm it to body Most clinicians lubricate the speculum and warm it to body temperature for more comfort. temperature for more comfort.


Step 2. The Speculum Step 2. The Speculum ExamExam

Once the speculum is in place, the clinician Once the speculum is in place, the clinician checks for any irritation, growth, or abnormal checks for any irritation, growth, or abnormal discharge from the cervix. Tests for gonorrhea, discharge from the cervix. Tests for gonorrhea, human papilloma virus, chlamydia, or other human papilloma virus, chlamydia, or other sexually transmitted infections may be taken by sexually transmitted infections may be taken by collecting cervical mucus on a cotton swab. collecting cervical mucus on a cotton swab.

These tests may not be done unless the client These tests may not be done unless the client has concerns about infections and/or asks for has concerns about infections and/or asks for testing. The client should talk with her clinician if testing. The client should talk with her clinician if she has symptoms or concerns about her she has symptoms or concerns about her partner(s).partner(s).


The Speculum ExamThe Speculum Exam


Insertion of a Speculum Insertion of a Speculum


Pap SmearPap SmearUsually a small spatula or tiny brush is used to Usually a small spatula or tiny brush is used to gently collect cells from the cervix for a Pap test. gently collect cells from the cervix for a Pap test. The cells are tested for abnormalities — The cells are tested for abnormalities — the the presence of precancerous or cancerous cellspresence of precancerous or cancerous cells. . You may have some staining or bleeding after the You may have some staining or bleeding after the sample is taken.sample is taken.

As the clinician removes the speculum, the As the clinician removes the speculum, the vaginal walls that were covered by it are also vaginal walls that were covered by it are also checked for irritation, injury, and any other checked for irritation, injury, and any other problems.problems.


Pap SmearPap SmearPap tests can detectPap tests can detect

the presence of abnormal cells in the cervixthe presence of abnormal cells in the cervixinfections and inflammations of the cervixinfections and inflammations of the cervixsymptoms of sexually transmitted infections symptoms of sexually transmitted infections (With the exception of trichomoniasis, Pap tests cannot (With the exception of trichomoniasis, Pap tests cannot identify specific sexually transmitted infections, but theyidentify specific sexually transmitted infections, but theymay detect symptoms.)may detect symptoms.)

thinning of the vaginal lining from lack of estrogen thinning of the vaginal lining from lack of estrogen commonly related to menopausecommonly related to menopauseThe cell sample will be sent to a laboratory. The results will The cell sample will be sent to a laboratory. The results will be sent back to the clinician within a few days/ weeks. Pap be sent back to the clinician within a few days/ weeks. Pap tests need to be repeated if there is too much blood present tests need to be repeated if there is too much blood present for an accurate reading or if there are not enough cells to for an accurate reading or if there are not enough cells to be examined.be examined.


Pap SmearPap SmearIf the results are abnormal, the clinician will advise the client on follow-If the results are abnormal, the clinician will advise the client on follow-up care:up care:If noncancerous abnormalities and infections are found, the client If noncancerous abnormalities and infections are found, the client needs to complete the prescribed treatment and repeat the tests as needs to complete the prescribed treatment and repeat the tests as advised. advised. If early precancerous or suspicious growths are found, she will need If early precancerous or suspicious growths are found, she will need careful follow-up and may also be advised to careful follow-up and may also be advised to Repeat the Pap test in a few weeks or have them at more frequent Repeat the Pap test in a few weeks or have them at more frequent

intervals.intervals. Have other tests.Have other tests. Have a colposcopy and biopsy.Have a colposcopy and biopsy.

Have growths removed with cryotherapy, laser surgery, or Have growths removed with cryotherapy, laser surgery, or electrocautery.electrocautery.If cancerous growths are foundIf cancerous growths are found Discuss options with clinician.Discuss options with clinician. See another provider or specialist.See another provider or specialist.


Pap SmearPap SmearRemember — Remember —

Most abnormalities that are detected are not Most abnormalities that are detected are not cancer.cancer.

Early treatment of precancerous growths can Early treatment of precancerous growths can prevent cancer from developing.prevent cancer from developing.

Follow-up examinations are necessary if an Follow-up examinations are necessary if an abnormal condition is found.abnormal condition is found.


Pap SmearPap Smear


Pap SmearPap SmearFindings of Pap’s SmearFindings of Pap’s Smear

Class I – Normal findingsClass I – Normal findingsClass II – Normal with atypical cells present Class II – Normal with atypical cells present (inflammatory reaction)(inflammatory reaction)Class III – Suggestive of malignancy, with benign and Class III – Suggestive of malignancy, with benign and malignant cellsmalignant cellsClass IV – Probably malignant, with signs of malignancy Class IV – Probably malignant, with signs of malignancy presentpresentClass V – Definitely malignant cellsClass V – Definitely malignant cells


Step 3. The Bimanual Step 3. The Bimanual ExamExam

Wearing an examination glove, the clinician Wearing an examination glove, the clinician inserts one or two lubricated fingers into the inserts one or two lubricated fingers into the vagina. The other hand presses down on the vagina. The other hand presses down on the lower abdomen.lower abdomen.

The clinician can then feel the internal organs of The clinician can then feel the internal organs of the pelvis between the two fingers in the vagina the pelvis between the two fingers in the vagina and the fingers on the abdomen.and the fingers on the abdomen.



The clinician examines the internal organs with both The clinician examines the internal organs with both hands to check forhands to check forsize, shape, and position of the uterussize, shape, and position of the uterusan enlarged uterus, which could indicate a pregnancy an enlarged uterus, which could indicate a pregnancy or fibroidsor fibroidstenderness or pain, which might indicate infectiontenderness or pain, which might indicate infectionswelling of the fallopian tubesswelling of the fallopian tubesenlarged ovaries, cysts, or tumorsenlarged ovaries, cysts, or tumors



The bimanual part of the exam causes a The bimanual part of the exam causes a sensation of pressure. The client may find it sensation of pressure. The client may find it somewhat uncomfortable. Deep breathing somewhat uncomfortable. Deep breathing through the mouth helps. The client should tell through the mouth helps. The client should tell the clinician if she feels pain.the clinician if she feels pain.


Step 4. Rectovaginal Step 4. Rectovaginal Exam Exam

Many clinicians complete the bimanual exam by Many clinicians complete the bimanual exam by inserting a gloved finger into the rectum to check inserting a gloved finger into the rectum to check the condition of muscles that separate the vagina the condition of muscles that separate the vagina and rectum. They also check for possible tumors and rectum. They also check for possible tumors located behind the uterus, on the lower wall of located behind the uterus, on the lower wall of the vagina, and in the rectum. Some clinicians the vagina, and in the rectum. Some clinicians insert one finger in the anus and another in the insert one finger in the anus and another in the vagina for a more thorough examination of the vagina for a more thorough examination of the tissue in between.tissue in between.During this procedure, the client may feel as During this procedure, the client may feel as though she needs to have a bowel movement. though she needs to have a bowel movement. This is normal and lasts only a few seconds.This is normal and lasts only a few seconds.

Perinatal Perinatal ExercisesExercises



Perinatal ExercisesPerinatal ExercisesPurposes:Purposes:

Help prevent the need for cesarean sectionHelp prevent the need for cesarean section

Help strengthen pelvic and abdominal muscles Help strengthen pelvic and abdominal muscles

Help reduce discomfortHelp reduce discomfort

Help hasten recoveryHelp hasten recovery

ExercisesExercises – should be done in moderation and – should be done in moderation and must be individualizedmust be individualized


PRE-EXERCISE POINTERSPRE-EXERCISE POINTERS

1. Always let breath flow freely. Let abdomen and ribcage 1. Always let breath flow freely. Let abdomen and ribcage expand and compress naturally as you inhale and exhale.expand and compress naturally as you inhale and exhale.

2. Warm up with gentle stretching before exercise program - 2. Warm up with gentle stretching before exercise program - increase blood flow to muscles and loosen them up.increase blood flow to muscles and loosen them up.

3. When you finish, take time to relax fully; lie in comfortable 3. When you finish, take time to relax fully; lie in comfortable position on floor for 10 minutes with eyes closed; let position on floor for 10 minutes with eyes closed; let breathing slow down.breathing slow down.

4. As strength improves, add one repetition of each exercise 4. As strength improves, add one repetition of each exercise until you’re up to 10; also, try holding positions from 3 to 5 until you’re up to 10; also, try holding positions from 3 to 5 counts.counts.

5. Do each exercise slowly and thoroughly. Allow rest 5. Do each exercise slowly and thoroughly. Allow rest between each exercise.between each exercise.


PRE-EXERCISE POINTERSPRE-EXERCISE POINTERS

6. Avoid extreme motions like deep lunges or twisting 6. Avoid extreme motions like deep lunges or twisting movements.movements.

7. Avoid lying flat on your back for prolonged periods; it may 7. Avoid lying flat on your back for prolonged periods; it may become uncomfortable and the position allows less blood become uncomfortable and the position allows less blood flow to the uterus. Lying on your side increases blood flow.flow to the uterus. Lying on your side increases blood flow.

8. Think of opportunities for exercises during day; Kegel’s 8. Think of opportunities for exercises during day; Kegel’s while standing in line at grocery store, squatting while while standing in line at grocery store, squatting while peeling potatoes, talking on the phone, watching television, peeling potatoes, talking on the phone, watching television, etc.etc.

9. If there is a prenatal exercise class in your area, join it. It is 9. If there is a prenatal exercise class in your area, join it. It is fun to get into shape with other pregnant women. fun to get into shape with other pregnant women.


A. Tailor SittingA. Tailor Sitting

1. It strengthens the thigh 1. It strengthens the thigh and stretches the perineal and stretches the perineal musclesmuscles

2. Done at least 15 min/day2. Done at least 15 min/daySit on floor with thighs Sit on floor with thighs apart, knees bent, legs apart, knees bent, legs parallel to each other, one parallel to each other, one ankle should NOT be on ankle should NOT be on top of the other, push top of the other, push knees gently towards the knees gently towards the floor until you feel the floor until you feel the perineum stretch. Use this perineum stretch. Use this when watching TV, reading when watching TV, reading or entertaining friends. Do or entertaining friends. Do this for 15 minutes daily.this for 15 minutes daily.


B. Squatting B. Squatting

1. Helps to stretch muscle of 1. Helps to stretch muscle of the pelvic floor.the pelvic floor.

2. Done at least 15min/day2. Done at least 15min/dayWhen lifting something When lifting something from the floor, bend knees from the floor, bend knees rather than the back; do rather than the back; do not squat on tiptoes but not squat on tiptoes but keep feet flat on the floor; keep feet flat on the floor; incorporate this into daily incorporate this into daily activities; practice for 15 activities; practice for 15 minutes dailyminutes daily


C. Pelvic Floor C. Pelvic Floor Contractions (Kegel’s Contractions (Kegel’s

Exercise)Exercise) It is designed to strengthen pubococcygeus It is designed to strengthen pubococcygeus

muscle. muscle. It may lead to increased sexual enjoyment.It may lead to increased sexual enjoyment. Each is a separate exercise and should be done 3x a Each is a separate exercise and should be done 3x a day.day.

1.1. Squeeze the muscle surrounding the vagina as if Squeeze the muscle surrounding the vagina as if stopping the flow of urine, hold for 3 seconds then stopping the flow of urine, hold for 3 seconds then relax. (10x)relax. (10x)

2.2. Contract and relax the muscles surrounding the Contract and relax the muscles surrounding the vagina as rapidly as possible 10 – 25xvagina as rapidly as possible 10 – 25x

3. Imagine that you are sitting in the bath tub of water 3. Imagine that you are sitting in the bath tub of water and squeeze muscles as if sucking water into the and squeeze muscles as if sucking water into the vagina. Hold for 3 seconds then relax. 10x vagina. Hold for 3 seconds then relax. 10x


D. Abdominal Muscle ContractionsD. Abdominal Muscle Contractions

1. strengthen the abdominal muscles1. strengthen the abdominal muscles2. help prevent constipation 2. help prevent constipation 3. may be done as often as she wishes3. may be done as often as she wishes

Tighten abdominal muscles, then relax and Tighten abdominal muscles, then relax and repeat as often as you can; can be done on lying repeat as often as you can; can be done on lying or standing position along with pelvic floor or standing position along with pelvic floor contractions.contractions.


E. Pelvic RockingE. Pelvic Rocking

1. Helps to relieve backache during 1. Helps to relieve backache during pregnancy and early labor pregnancy and early labor

2. Makes the lumbar spine more flexible2. Makes the lumbar spine more flexible3. Can be done on a variety of positions3. Can be done on a variety of positions

The woman arches her back, trying to The woman arches her back, trying to lengthen or stretch her spine. She holds lengthen or stretch her spine. She holds the position for 1 minute, and then hollows the position for 1 minute, and then hollows her back.her back.

- do this at the end of the day (5x)- do this at the end of the day (5x)


F. Pelvic TiltF. Pelvic Tilt1.1. PELVIC TILT – SUPINEPELVIC TILT – SUPINE

Do daily and after delivery.Do daily and after delivery.

Position: Backlying, knees bent.Position: Backlying, knees bent.

Exercise: Press small of back against floor by tightening Exercise: Press small of back against floor by tightening abdominal muscles and buttocks abdominal muscles and buttocks

muscles.muscles.


F. Pelvic TiltF. Pelvic Tilt2. PELVIC TILT – STANDING2. PELVIC TILT – STANDING

Position: Stand with back to wall, Position: Stand with back to wall, feet about three inches from feet about three inches from base of wall.base of wall.

Exercise: Tighten stomach and Exercise: Tighten stomach and buttocks and press low back buttocks and press low back against the wall so that your against the wall so that your back is touching the wall. Your back is touching the wall. Your knees must be relaxed or knees must be relaxed or slightly bent to do this.slightly bent to do this.


F. Pelvic TiltF. Pelvic Tilt3. PELVIC TILT - ALL FOURS3. PELVIC TILT - ALL FOURS

Position: On hands and knees.Position: On hands and knees.

Exercise:Tighten stomach Exercise:Tighten stomach muscles and arch backmuscles and arch backtoward the ceiling. Hold. toward the ceiling. Hold. Tighten buttocks, pelvic floor Tighten buttocks, pelvic floor and back muscles and archand back muscles and archback to produce hollow. Hold.back to produce hollow. Hold.


G. Sit ups G. Sit ups 1. SIT-UPS - Modified1. SIT-UPS - ModifiedPurpose: Strengthen abdominal Purpose: Strengthen abdominal

muscles. Good muscle tone is muscles. Good muscle tone is important for maintaining good important for maintaining good posture, for effective pushing, and posture, for effective pushing, and for early return of figure for early return of figure postpartum.postpartum.

Position: Backlying, knees bent, low Position: Backlying, knees bent, low backbackflat (pelvic tilt).flat (pelvic tilt).

Exercise: Lift head and shoulders off Exercise: Lift head and shoulders off floor, reaching hands toward knees floor, reaching hands toward knees (lift trunk to about 45° angle). (lift trunk to about 45° angle). Slowly return to starting position; Slowly return to starting position; do not drop back.do not drop back.


G. Sit ups G. Sit ups 2. OBLIQUE (DIAGONAL) 2. OBLIQUE (DIAGONAL)

SIT-UPS - ModifiedSIT-UPS - ModifiedPurpose: Strengthen oblique Purpose: Strengthen oblique

abdominal muscles.abdominal muscles.

Position: Backlying, knees bent, Position: Backlying, knees bent, low back flat.low back flat.

Exercise: As above, but reach up Exercise: As above, but reach up and across to the outside of and across to the outside of the the opposite knee.opposite knee.


H. GLUTEAL / PELVIC FLOOR H. GLUTEAL / PELVIC FLOOR SETTINGSETTING

Position: Backlying, legs straight, ankles crossed, arms at sides.Position: Backlying, legs straight, ankles crossed, arms at sides.

Exercise: Pinch buttocks, squeeze pelvic floor muscles, squeeze Exercise: Pinch buttocks, squeeze pelvic floor muscles, squeeze thighs together, raise head off floor.thighs together, raise head off floor.


I. ADDUCTOR I. ADDUCTOR LENGTHENINGLENGTHENING

Position: Sit on floor with legs straight and slightly apart.Position: Sit on floor with legs straight and slightly apart.Roll knees outward.Roll knees outward.

Exercise: Slowly lean body forward towards the floor with Exercise: Slowly lean body forward towards the floor with arms stretched out in front of you. Your knees may bend arms stretched out in front of you. Your knees may bend slightly. Do not jerk or bounce. Hold forward for 3 to 5 slightly. Do not jerk or bounce. Hold forward for 3 to 5 seconds.seconds.


SPECIFIC ACTIVITIESSPECIFIC ACTIVITIES

1. Jogging:1. Jogging:Wear good shoes; supportive bra. Keep pelvic floor muscles strong withWear good shoes; supportive bra. Keep pelvic floor muscles strong withKegel exercises. Jog at a slower pace, shorter distances, less frequently.Kegel exercises. Jog at a slower pace, shorter distances, less frequently.

Remember: increased weight and laxity of ligaments means more strainRemember: increased weight and laxity of ligaments means more strainon lower body (lower spine, hip joints, knees, ankles and feet). Do noton lower body (lower spine, hip joints, knees, ankles and feet). Do notoverexert yourself.overexert yourself.

2. Bicycling and Swimming:2. Bicycling and Swimming:Excellent activities with reasonable limitations. Don’t push yourself!Excellent activities with reasonable limitations. Don’t push yourself!

3. Tennis, Basketball, other “sudden stop and start” Activities. 3. Tennis, Basketball, other “sudden stop and start” Activities. More awkward as bulk increases; listen to your body and slow down whenMore awkward as bulk increases; listen to your body and slow down whennecessary.necessary.


4. Skating, Horseback Riding:4. Skating, Horseback Riding:Danger of falling! Advise against. Consult your obstetrician or nurseDanger of falling! Advise against. Consult your obstetrician or nursepractitioner as needed.practitioner as needed.

5. Walking:5. Walking:Most highly recommended for the pregnant woman; ideal alternative to more Most highly recommended for the pregnant woman; ideal alternative to more strenuous exercise. Walk uphill, downhill, and at different speeds.strenuous exercise. Walk uphill, downhill, and at different speeds.

Patient Teaching: Consult your obstetrician or nurse practitioner early in yourPatient Teaching: Consult your obstetrician or nurse practitioner early in yourpregnancy. In general, you can continue your pre-pregnant routine of pregnancy. In general, you can continue your pre-pregnant routine of exercising. Stop when something hurts, or when you become fatigued. Know exercising. Stop when something hurts, or when you become fatigued. Know your limits, and avoid exercising to the point of exhaustion. It is generally your limits, and avoid exercising to the point of exhaustion. It is generally advised that you not begin any new sport or activity during pregnancy. You may advised that you not begin any new sport or activity during pregnancy. You may want to taper off your sports participation during the last few months, but you want to taper off your sports participation during the last few months, but you may still continue to exercise gently. Avoid exercising in very hot or humid may still continue to exercise gently. Avoid exercising in very hot or humid weather, or at high altitudes if you’re not used to it.weather, or at high altitudes if you’re not used to it.

Leopold’s ManeuversLeopold’s ManeuversMary Lourdes Nacel G. Celeste, RN, MDMary Lourdes Nacel G. Celeste, RN, MD


LEOPOLD’S LEOPOLD’S MANEUVERsMANEUVERs

systematic method of observation systematic method of observation and palpation to determine fetal and palpation to determine fetal positionposition

woman empties her bladder; lies woman empties her bladder; lies supine with her knees flexed slightlysupine with her knees flexed slightly

examiner warms hands to avoid examiner warms hands to avoid contraction of abdominal musclescontraction of abdominal muscles

gentle but firm touch gentle but firm touch


LEOPOLDS LEOPOLDS MANEUVERsMANEUVERs

First Maneuver First Maneuver Palpation of the Uterine Fundus Palpation of the Uterine Fundus Will usually indicate the fetal part situated in the fundus; Will usually indicate the fetal part situated in the fundus; usually a fetal head; infrequently a fetal breech.usually a fetal head; infrequently a fetal breech.Place hands on either side of the fundal area so that the Place hands on either side of the fundal area so that the fingers of both hands almost touch each other (face the fingers of both hands almost touch each other (face the woman's head).woman's head).A somewhat hard and roundish shape, which when moved A somewhat hard and roundish shape, which when moved back and forth between the finger pads, also moves the back and forth between the finger pads, also moves the entire fetus usually indicates a fetal breech. entire fetus usually indicates a fetal breech. Press gently and firmly with finger pads.Press gently and firmly with finger pads.A very hard round well-defined shape that can be moved A very hard round well-defined shape that can be moved back and forth (balloted) usually indicates a fetal head.back and forth (balloted) usually indicates a fetal head.


First Maneuver First Maneuver Palpation of the Uterine Palpation of the Uterine

Fundus Fundus


Second ManeuverSecond Maneuver Determines small parts and back of Determines small parts and back of

fetus along the sides of maternal fetus along the sides of maternal abdomenabdomen

Lateral Palpation of the Uterus Lateral Palpation of the Uterus Examiner faces woman's head Examiner faces woman's head Palpate with one hand on each side of abdomenPalpate with one hand on each side of abdomenPalpate fetus between two hands Palpate fetus between two hands Assess on which side is the fetal back or spine Assess on which side is the fetal back or spine and which side has small parts or extremitiesand which side has small parts or extremities


Generally provides information regarding the Generally provides information regarding the location of the fetal back and the fetal small parts location of the fetal back and the fetal small parts consisting of arms and legs.consisting of arms and legs.Hands should alternately apply pressure against Hands should alternately apply pressure against the opposite hand.the opposite hand.Directing alternating pressure against each hand Directing alternating pressure against each hand is the technique.is the technique.Alternating hands using firm resistance while the Alternating hands using firm resistance while the other hand gently and firmly applies pressure and other hand gently and firmly applies pressure and rotates in a circular fashion.rotates in a circular fashion.This technique can be used up and down the This technique can be used up and down the entire length of the uterus. entire length of the uterus.


Second ManeuverSecond Maneuver Determines small parts and back of Determines small parts and back of

fetus along the sides of maternal fetus along the sides of maternal abdomenabdomen


Third ManeuverThird Maneuver (Lower uterine segment or uterine (Lower uterine segment or uterine

pole)pole)

Face the woman's head and spread your hands Face the woman's head and spread your hands widely apart.widely apart.Grasp the uterine contents just above the Grasp the uterine contents just above the symphysis pubis (firmly but gently).symphysis pubis (firmly but gently).Hold presenting part between index finger and Hold presenting part between index finger and thumb.thumb.Assess for cephalic versus Breech Presentation Assess for cephalic versus Breech Presentation Move the fetal presenting part gently back and Move the fetal presenting part gently back and forth in your hand Fetal head will shift more forth in your hand Fetal head will shift more easily back and forth Fetal breech will move the easily back and forth Fetal breech will move the whole body.whole body.


The 3rd Leopold's Maneuver The 3rd Leopold's Maneuver (Pawlick's grip) will provide either (Pawlick's grip) will provide either initial information or confirm prior initial information or confirm prior data gained from the previous steps data gained from the previous steps of Leopold's maneuvers. of Leopold's maneuvers. Anchoring the uterine fundus with Anchoring the uterine fundus with the non-dominant hand assistthe non-dominant hand assistin identifying the location of the fetal in identifying the location of the fetal back and small parts.back and small parts.


Third ManeuverThird Maneuver (Lower uterine segment or uterine (Lower uterine segment or uterine

pole)pole)


Fourth Maneuver Fourth Maneuver (pelvic palpation of the uterus (pelvic palpation of the uterus

- assess the presenting part) - assess the presenting part)

Provides information about the presenting part: Provides information about the presenting part: breech or head, attitude (flexion or extension), breech or head, attitude (flexion or extension), and station (level of descent of the presenting and station (level of descent of the presenting part).part).Examiner faces woman's feet .Examiner faces woman's feet .Place hands on either side of the lower abdomen Place hands on either side of the lower abdomen with finger pads at the lower uterine pole (bikini with finger pads at the lower uterine pole (bikini line) and thumbs directed toward the umbilicus. line) and thumbs directed toward the umbilicus. Carefully move fingers of each hand towards Carefully move fingers of each hand towards each other in a downward and inward manner each other in a downward and inward manner using gentle pressure.using gentle pressure.


The nurse's thumbs should point towards the The nurse's thumbs should point towards the woman's umbilicus.woman's umbilicus.If there is a head palpated in the pelvis, the fetal If there is a head palpated in the pelvis, the fetal presentation is referred to as a cephalic or vertex presentation is referred to as a cephalic or vertex presentation. Assess if a prominence on one side presentation. Assess if a prominence on one side of the abdomen can be palpated higher than a of the abdomen can be palpated higher than a prominence on the other side. The first prominence on the other side. The first prominence felt indicates the sinciput (forehead) prominence felt indicates the sinciput (forehead) of the infant and is on the same side as the fetal of the infant and is on the same side as the fetal small parts. Therefore, the sinciput is on the side small parts. Therefore, the sinciput is on the side opposite the fetal back. The prominence felt opposite the fetal back. The prominence felt further down the pelvis is the fetal occiput back further down the pelvis is the fetal occiput back of the head) and is on the same side as the fetal of the head) and is on the same side as the fetal back.back.


Fourth Maneuver Fourth Maneuver (pelvic palpation of the uterus (pelvic palpation of the uterus

- assess the presenting part) - assess the presenting part)

1st MANEUVER

What is at the uterine fundus? Head is more firm, hard and round that moves independently of the body. Breech is less well defined that moves only in conjunction with the body.

2nd MANEUVER

Where is the fetal back? Fetal back is smooth, hard, resistant surface. Knees and elbows of fetus feel with a number of angular nodulation.

3rd MANEVER

What is at the inlet of the pelvis? By grasping the lower portion of the abdomen (just above the symphisis pubis. Not engaged (not firmly settled in the pelvis) if the presenting part moves upward so an examiner’s hands can be pressed together.

4th MANEUVER

What is the fetal attitude? (degree of flexion) Fingers on both sides of the uterus (2 inches above inguinal ligaments) pressing down and inwards. The fingers of the hand that do not meet obstruction above the ligament palpates the fetal brow. Good attitude if brow corresponds to the side (2nd maneuver) that contained the elbows and knees. Poor attitude if examining fingers will meet an obstruction on the same side as fetal back (hyperextended head). Also palpates infant’s anteroposterior position. If brow is very easily palpated, fetus is at posterior position (occiput pointing towards woman’s back).

Taking Taking FHTFHTMary Lourdes Nacel G. Celeste, RN, MDMary Lourdes Nacel G. Celeste, RN, MD


Fetal heart rateFetal heart rateFHR should be 120-160FHR should be 120-160

beats per minutebeats per minute

Can be heard with a Can be heard with a Doppler : 10 – 11Doppler : 10 – 11thth week of week of pregnancypregnancy

Fetoscope: 18-20 weeksFetoscope: 18-20 weeks


Fetal heart rateFetal heart rateAssist the patient to a supine position.Assist the patient to a supine position.Drape her with a blanket to minimize exposure.Drape her with a blanket to minimize exposure.Apply water soluble lubricant to her abdomen or the monitoring Apply water soluble lubricant to her abdomen or the monitoring device.device.To assess FHR in a fetus 20 weeks or younger, position To assess FHR in a fetus 20 weeks or younger, position Doppler/Stethoscope/ fetoscope on the abdominal midline above the Doppler/Stethoscope/ fetoscope on the abdominal midline above the symphysis pubis. After 20 weeks AOG, when you can palpate fetal symphysis pubis. After 20 weeks AOG, when you can palpate fetal position, use Leopold’s maneuvers and position the listening position, use Leopold’s maneuvers and position the listening instrument over the fetal back.instrument over the fetal back.Place the earpieces in your ears and press gently on the patient’s Place the earpieces in your ears and press gently on the patient’s abdomen. If there are no earpieces, turn the device on and adjust the abdomen. If there are no earpieces, turn the device on and adjust the volume. As needed. Start listening at the midline, midway between volume. As needed. Start listening at the midline, midway between the umbilicus and the symphysis pubis. the umbilicus and the symphysis pubis. Move the instrument from side to side to locate the loudest heart Move the instrument from side to side to locate the loudest heart tones then palpate the maternal pulse.tones then palpate the maternal pulse.


Fetal heart rateFetal heart rateIf the maternal radial pulse and FHR are the same, try to locate the If the maternal radial pulse and FHR are the same, try to locate the fetal thorax/ back by Leopold’s maneuver, then reassess FHR for fetal thorax/ back by Leopold’s maneuver, then reassess FHR for 60 seconds. Record FHR.60 seconds. Record FHR.During labor, monitor FHR during the relaxation period between During labor, monitor FHR during the relaxation period between the contractions to determine baseline.the contractions to determine baseline.In a low-risk labor, assess FHR every 60 minutes during the latent In a low-risk labor, assess FHR every 60 minutes during the latent phase, every 30 minutes during the active phase and then every 15 phase, every 30 minutes during the active phase and then every 15 minutes during the 2nd stage of labor. In high risk labor, assess minutes during the 2nd stage of labor. In high risk labor, assess FHR every 30 minutes during the latent phase, every 15 minutes FHR every 30 minutes during the latent phase, every 15 minutes during the active phase, and every 5 minutes during the 2nd stage during the active phase, and every 5 minutes during the 2nd stage of labor.of labor.Auscultate FHR during a contraction and for 30 seconds afterward Auscultate FHR during a contraction and for 30 seconds afterward to identify the response to the contraction.to identify the response to the contraction.Auscultate FHR before administration of medications, ambulation, Auscultate FHR before administration of medications, ambulation, and artificial rupture of membranes, changes in the and artificial rupture of membranes, changes in the characteristics of contractions, vaginal examinations and characteristics of contractions, vaginal examinations and medications.medications.


LOCATING FETAL HEART SOUNDS BY LOCATING FETAL HEART SOUNDS BY FETAL POSITIONFETAL POSITION

FHT – heard best at the FETAL BACKFHT – heard best at the FETAL BACK

Fetal Heart Rate PatternsFetal Heart Rate Patterns Indicative of…Indicative of… InterventionIntervention

Tachycardia (>160 bpm)Tachycardia (>160 bpm) Maternal or fetal infectionMaternal or fetal infection

Fetal hypoxia (ominous sign)Fetal hypoxia (ominous sign)

Depends on the causeDepends on the cause

Bradycardia (<120 bpm)Bradycardia (<120 bpm) Fetal hypoxia or stressFetal hypoxia or stress

Maternal hypotension after Maternal hypotension after epidural initiationepidural initiation

Place client on her left sidePlace client on her left side

Increase fluids to counteract Increase fluids to counteract hypotensionhypotension

Stop oxytocin (Pitocin) if in Stop oxytocin (Pitocin) if in useuse

Early decelerationEarly deceleration

(deceleration begins and ends (deceleration begins and ends with uterine contraction)with uterine contraction)

Head compressionHead compression :not :not ominousominous

Vagal stimulationVagal stimulation

None requiredNone required

Late decelerationLate deceleration

(HR decreases after peak of (HR decreases after peak of contraction and recovers after contraction and recovers after contraction ends)contraction ends)

Fetal stress and hypoxiaFetal stress and hypoxia

Deficient placental perfusionDeficient placental perfusion

Supine positionSupine position

Maternal hypotensionMaternal hypotension

Uterine hyperstimulationUterine hyperstimulation

Change maternal positionChange maternal position

Correct hypotensionCorrect hypotension

Increase IV fluid rate as Increase IV fluid rate as orderedordered

Discontinue oxytocinDiscontinue oxytocin

Administer oxygen as Administer oxygen as orderedordered

Variable decelerationVariable deceleration

(transient decrease in HR (transient decrease in HR anytime during contractionanytime during contraction

Cord compressionCord compression

HypoxiaHypoxia or hypercarbia or hypercarbia

Change maternal positionChange maternal position

Administer OxygenAdminister Oxygen

Decreased variabilityDecreased variability Fetal sleep cycleFetal sleep cycle

Depressant drugsDepressant drugs

HypoxiaHypoxia

CNS anomaliesCNS anomalies

Depends on the causeDepends on the cause

Measuring Fundic Measuring Fundic HeightHeight



Fundic HeightFundic HeightMcDonald’s Rule – determines during McDonald’s Rule – determines during midpregnancy, that the fetus is growing in midpregnancy, that the fetus is growing in utero by measuring the fundal (uterine) utero by measuring the fundal (uterine) heightheight

Typically, the distance from the fundus to Typically, the distance from the fundus to the symphysis in centimeters is equal to the symphysis in centimeters is equal to the week of gestation between the 20the week of gestation between the 20thth and and 3131stst weeks of pregnancy. weeks of pregnancy.


Fundic HeightFundic HeightMeasure from the notch of the symphysis Measure from the notch of the symphysis pubis to over the top of the uterine fundus as pubis to over the top of the uterine fundus as the woman lies supine.the woman lies supine.Place the zero line of the tape measure on the Place the zero line of the tape measure on the anterior border of the symphysis pubis and anterior border of the symphysis pubis and stretch tape over midline of abdomen to top of stretch tape over midline of abdomen to top of fundus.fundus.The tape should be brought over the curve of The tape should be brought over the curve of the fundus.the fundus.The height of the fundus in centimeters equals The height of the fundus in centimeters equals the number of weeks gestation plus or minus the number of weeks gestation plus or minus 2. (inaccurate in the 32. (inaccurate in the 3rdrd trimester esp after 32 trimester esp after 32 wks)wks)

Typical measurementsTypical measurements- Over the symphysis pubis: 12 wks Over the symphysis pubis: 12 wks - At the umbilicus: 20 wksAt the umbilicus: 20 wks- At the xiphoid process: 36 wksAt the xiphoid process: 36 wks

Rises about 1cm per week; after which it Rises about 1cm per week; after which it variesvaries


Fundic HeightFundic Height


Location of the fundus:12 weeks at the level of the symphysis pubis16 weeks halfway between symphysis pubis and umbilicus20weeks at the level of the umbilicus24 weeks two fingers above umbilicus30 weeks midway between umbilicus and xiphoid process36 weeks at the level of xiphoid process40 weeks two fingers below umbilicus,

drops at 34 weeks level because of lightening

Computation of Computation of EDC & AOG based on EDC & AOG based on

LMPLMPObstetrical NumberObstetrical Number



EDCEDCLAST MENSTRUAL PERIOD – first day of the last menses


AOGAOGCOMPUTATION OF AGE OF GESTATIONCOMPUTATION OF AGE OF GESTATIONExample: LMP: January 1, 2009Example: LMP: January 1, 2009 Date of consult: August 31, 2009 Date of consult: August 31, 2009

AOG: AOG: Total # of days from LMP up to date of consult Total # of days from LMP up to date of consult 77

JanuaryJanuary 30 days30 daysFebruaryFebruary 2828 Total = 242 daysTotal = 242 daysMarchMarch 3131 AOG = AOG = 242242AprilApril 3030 77MayMay 3131 34 to 35 weeks 34 to 35 weeks JuneJune 3030JulyJuly 3131AugustAugust 3131


Obstetrical History/ Obstetrical History/ NumberNumber

G__ P__ (T, P, A, L)G__ P__ (T, P, A, L)Gravida – the total number of pregnancies regardless of duration Gravida – the total number of pregnancies regardless of duration (includes present pregnancy)(includes present pregnancy)Para – number of past pregnancies that have gone beyond the Para – number of past pregnancies that have gone beyond the period of viability (capability of the fetus to survive the outside of period of viability (capability of the fetus to survive the outside of the uterus; currently considered any time after 20-wk gestation), the uterus; currently considered any time after 20-wk gestation), regardless of the number of fetuses or whether the infant was regardless of the number of fetuses or whether the infant was born alive or dead born alive or dead Term infant – an infant born between 38 and 42 weeks of gestationTerm infant – an infant born between 38 and 42 weeks of gestationPreterm – an infant born before 38 weeksPreterm – an infant born before 38 weeksPost term – an infant born after 42 weeksPost term – an infant born after 42 weeksAbortion – pregnancy that terminates before the period of viability Abortion – pregnancy that terminates before the period of viability (20 wks)(20 wks)Live birth – a live birth is recorded when an infant born shows Live birth – a live birth is recorded when an infant born shows sign of lifesign of life

Fetal Presentation, Fetal Presentation, Attitude, Lie & PositionAttitude, Lie & Position

StationStationMary Lourdes Nacel G. Celeste, RN, MDMary Lourdes Nacel G. Celeste, RN, MD


PresentationPresentation

part of fetus that presents to part of fetus that presents to (enters) maternal pelvic inlet(enters) maternal pelvic inlet

Cephalic/vertex – head presentation Cephalic/vertex – head presentation (>95% of labors)(>95% of labors)

BreechBreech


Breech presentationBreech presentation

Complete – flexion of hips and kneesComplete – flexion of hips and knees

Frank (most common) – flexion of Frank (most common) – flexion of hips and extension of kneeships and extension of knees

Footling/incomplete – extension of Footling/incomplete – extension of hips and kneeships and knees


Attitude/ habitus Attitude/ habitus

relationship of fetal parts to each other; relationship of fetal parts to each other; usually flexion of head and extremities usually flexion of head and extremities on chest and abdomen to accommodate on chest and abdomen to accommodate to shape of uterine cavityto shape of uterine cavity

VertexVertex – head is maximally flexed – head is maximally flexed

MilitaryMilitary – head is partially flexed – head is partially flexed

BrowBrow – head is maximally extended – head is maximally extended

FaceFace – head is partially extended – head is partially extended


LieLie

Lie Lie – – relationship of spine of fetus to relationship of spine of fetus to spine of mother; spine of mother;

longitudinal (parallel)longitudinal (parallel)

transverse (right angles)transverse (right angles)

oblique (slight angle off a true oblique (slight angle off a true transverse lie)transverse lie)


PositionPosition relationship of fetal reference point to mother’s relationship of fetal reference point to mother’s pelvispelvis

Fetal reference pointFetal reference pointVertex presentationVertex presentation – dependent upon degree of – dependent upon degree of flexion of fetal head on chest; full flexion–occiput flexion of fetal head on chest; full flexion–occiput (O); full extension–chin (M); moderate extension–(O); full extension–chin (M); moderate extension–brow (B)brow (B)Breech presentationBreech presentation – sacrum (S) / Sa – sacrum (S) / SaShoulder presentationShoulder presentation – scapula (SC) / A (acromion) – scapula (SC) / A (acromion)


PositionPosition

Relation of the presenting part to a specific Relation of the presenting part to a specific quadrant of a woman’s pelvisquadrant of a woman’s pelvisRight anteriorRight anteriorLeft anteriorLeft anteriorRight posteriorRight posteriorLeft posteriorLeft posterior


Maternal pelvis is designated per her Maternal pelvis is designated per her right/left and anterior/posteriorright/left and anterior/posterior Expressed as standard three letter Expressed as standard three letter

abbreviation; e.g., LOA = left occiput anterior, abbreviation; e.g., LOA = left occiput anterior, indicating vertex presentation with fetal indicating vertex presentation with fetal occiput on mother’s left side toward the front occiput on mother’s left side toward the front of her pelvisof her pelvis

Fetal position reflects the orientation of the Fetal position reflects the orientation of the fetal head or butt within the birth canal. fetal head or butt within the birth canal.


Anterior FontanelAnterior FontanelThe bones of the fetal scalp are soft and meet at The bones of the fetal scalp are soft and meet at "suture lines." Over the forehead, where the "suture lines." Over the forehead, where the bones meet, is a gap, called the "anterior bones meet, is a gap, called the "anterior fontanel," or "soft spot." This will close as the fontanel," or "soft spot." This will close as the baby grows during the 1st year of life, but at baby grows during the 1st year of life, but at birth, it is open.birth, it is open.The anterior fontanel is an obstetrical landmark The anterior fontanel is an obstetrical landmark because of its' distinctive diamond shape. because of its' distinctive diamond shape. Feeling this fontanel on pelvic exam tells you Feeling this fontanel on pelvic exam tells you that the forehead is just beneath your fingers.that the forehead is just beneath your fingers.Early in labor, it is usually difficult (if not Early in labor, it is usually difficult (if not impossible) to feel the anterior fontanel. After impossible) to feel the anterior fontanel. After the patient is nearly completely dilated, it the patient is nearly completely dilated, it becomes easier to feel the fontanel.becomes easier to feel the fontanel.When attaching a fetal scalp electrode, it is When attaching a fetal scalp electrode, it is better to not attach it to the area of the fontanel.better to not attach it to the area of the fontanel.


Posterior FontanelPosterior FontanelThe occiput of the baby has a similar The occiput of the baby has a similar obstetric landmark, the "posterior fontanel."obstetric landmark, the "posterior fontanel."This junction of suture lines in a Y shape This junction of suture lines in a Y shape that is very different from the anterior that is very different from the anterior fontanel.fontanel.In cases of fetal scalp swelling or In cases of fetal scalp swelling or significant molding, these landmarks may significant molding, these landmarks may become obscured, but in most cases, they become obscured, but in most cases, they can identify the fetal head position as it is can identify the fetal head position as it is engaged in the birth canal. engaged in the birth canal.


Left occiput anterior Left occiput anterior (LOA)(LOA)


Right occiput anteriorRight occiput anterior(ROA)(ROA)


Left occiput transverseLeft occiput transverse(LOT)(LOT)


Right occiput Right occiput transversetransverse

(ROT)(ROT)


Occiput posteriorOcciput posterior(OP)(OP)


Occiput AnteriorOcciput Anterior(OA)(OA)


Left occiput posterior Left occiput posterior (LOP)(LOP)


Right occiput posterior Right occiput posterior (ROP)(ROP)


FETAL POSITION


StationStation

level of presenting part of fetus in level of presenting part of fetus in relation to imaginary line between relation to imaginary line between ischial spines (zero station) in ischial spines (zero station) in midpelvis of mothermidpelvis of mother

––5 to –1 indicates a presenting part 5 to –1 indicates a presenting part above zero station (floating); +1 to +5, above zero station (floating); +1 to +5, a presenting part below zero stationa presenting part below zero station

Engagement – when the presenting Engagement – when the presenting part is at station zeropart is at station zero


STATION or DEGREE OF ENGAGEMENT

Perinatal CarePerinatal CareMary Lourdes Nacel G. Celeste, RN, MDMary Lourdes Nacel G. Celeste, RN, MD


Monitor vital signs and FHRMonitor vital signs and FHR

Provide comfort measures (ambulate if tolerated Provide comfort measures (ambulate if tolerated and if BOW is not ruptured yet; side lying is and if BOW is not ruptured yet; side lying is usually most comfortable, sacral pressures, back usually most comfortable, sacral pressures, back rubs)rubs)

Breathing techniquesBreathing techniques


Slow-Paced Breathing Slow-Paced Breathing Every woman beginning labor should be taught this simple technique Every woman beginning labor should be taught this simple technique for coping with labor. The use of a specific breathing pattern during for coping with labor. The use of a specific breathing pattern during labor contractions has two objectives: Helping the woman relax by labor contractions has two objectives: Helping the woman relax by distracting her from the intense contraction sensations. Ensuring a distracting her from the intense contraction sensations. Ensuring a steady, adequate intake of oxygen.steady, adequate intake of oxygen.

Begin the Breathing TechniqueBegin the Breathing Technique This technique is done only during contractions. Rest and sleep This technique is done only during contractions. Rest and sleep

between contractions is important. Instruct the laboring woman to do between contractions is important. Instruct the laboring woman to do the following:the following:Assume a comfortable position.Assume a comfortable position.Try to maintain a relaxed state throughout the con traction.Try to maintain a relaxed state throughout the con traction.Close her eyes orClose her eyes orConcentrate on a focal point while doing the breathing (e.g., a pretty Concentrate on a focal point while doing the breathing (e.g., a pretty picture, a button on some one's shirt).picture, a button on some one's shirt).


Cleansing BreathCleansing BreathBegin and end each breathing technique with a cleansing breath. Begin and end each breathing technique with a cleansing breath. This is simply a deep quick breath, like a big sigh. Inhalation is This is simply a deep quick breath, like a big sigh. Inhalation is through the nose; exhalation is through slightly pursed lips.through the nose; exhalation is through slightly pursed lips.

Slow-Paced BreathingSlow-Paced BreathingThis technique can be used in early labor and for as long as the This technique can be used in early labor and for as long as the mother is comfortable with it. For some women, this may last mother is comfortable with it. For some women, this may last throughout the entire first stage of labor.throughout the entire first stage of labor.1. Take a cleansing breath as soon the contraction begins.1. Take a cleansing breath as soon the contraction begins.2. Breathe slowly and deeply in through the nose and out 2. Breathe slowly and deeply in through the nose and out through slightly pursed lips or the nose over the duration of the through slightly pursed lips or the nose over the duration of the contraction.contraction.3. Maintain a steady rate of approximately 6 to 9 breaths during a 3. Maintain a steady rate of approximately 6 to 9 breaths during a 60-second contraction (the cleansing breaths do not count).60-second contraction (the cleansing breaths do not count).


During transition phase: Take a deep breath and exhale During transition phase: Take a deep breath and exhale slowly and completely. At beginning of contraction, take a slowly and completely. At beginning of contraction, take a fairly deep breath. Then engage in shallow breathing. If fairly deep breath. Then engage in shallow breathing. If there is an urge to push, puff out every 3rd, 4th, or 5th there is an urge to push, puff out every 3rd, 4th, or 5th breath. Take deep breath at the end of contraction.breath. Take deep breath at the end of contraction.


Comfort Measures for the Laboring WomanComfort Measures for the Laboring Woman

Do not leave alone in active labor.Do not leave alone in active labor.

Change soiled and damp linen promptly.Change soiled and damp linen promptly.

Provide mouth care.Provide mouth care.

Ice chips, lubricate lips.Ice chips, lubricate lips.

Keep room cool, uncluttered, quiet and privacy.Keep room cool, uncluttered, quiet and privacy.

Promote participation of coach.Promote participation of coach.

Insertion of CatheterInsertion of CatheterMary Lourdes Nacel G. Celeste, RN, MDMary Lourdes Nacel G. Celeste, RN, MD


CatheterizationCatheterization

INSERTION OF CATHETER / CatheterizationINSERTION OF CATHETER / Catheterization

involves the introduction of a catheter through involves the introduction of a catheter through the urethra into the urinary bladderthe urethra into the urinary bladder



Purposes:Purposes:1. To relieve discomfort due to a bladder distention and to provide 1. To relieve discomfort due to a bladder distention and to provide

gradual decompression of a distended bladder.gradual decompression of a distended bladder.2. To access the amount of residual urine if the bladder is to be emptied 2. To access the amount of residual urine if the bladder is to be emptied

completelycompletely3. To obtain a urine specimen to assess the presence of abnormal 3. To obtain a urine specimen to assess the presence of abnormal

constituents and the characteristic of the urineconstituents and the characteristic of the urine4. To empty the bladder completely prior to surgery to prevent 4. To empty the bladder completely prior to surgery to prevent

inadvertent injury to adjacent organ such as to the rectum or the inadvertent injury to adjacent organ such as to the rectum or the vaginavagina

5. To manage incontinence when all other measures have failed5. To manage incontinence when all other measures have failed6. To provide for intermittent or continuous bladder drainage and 6. To provide for intermittent or continuous bladder drainage and

irrigationirrigation7. To prevent urine from contacting an incision after perineal surgery7. To prevent urine from contacting an incision after perineal surgery8. To facilitate accurate measurement of urinary output for critically ill 8. To facilitate accurate measurement of urinary output for critically ill

client whose output needs to be monitored hourlyclient whose output needs to be monitored hourly



Points to consider:Points to consider:1. There are 2 hazards in the process, namely, 1. There are 2 hazards in the process, namely,

sepsis and trauma, hence asepsis technique sepsis and trauma, hence asepsis technique should be maintained and the catheter should be should be maintained and the catheter should be inserted gently.inserted gently.

2. When catheterization is ordered to relieve bladder 2. When catheterization is ordered to relieve bladder distention, gradual decompression of the bladder distention, gradual decompression of the bladder should be done to prevent engorgement of the should be done to prevent engorgement of the vessels as well as improve the muscle tone of the vessels as well as improve the muscle tone of the bladder by adjusting the intravesical pressurebladder by adjusting the intravesical pressure



Types of catheter:Types of catheter:1. Straight or Robinson catheter – a single lumen tube with a 1. Straight or Robinson catheter – a single lumen tube with a

small eye or opening about ½ inch from the insertion tipsmall eye or opening about ½ inch from the insertion tip2. Retention or Foley catheter- contains a second smaller tube 2. Retention or Foley catheter- contains a second smaller tube

throughout its length on the inside. This tube is connected throughout its length on the inside. This tube is connected to a balloon near the insertion tip. After catheter insertion, to a balloon near the insertion tip. After catheter insertion, the balloon is inflated to hold the catheter in place within the balloon is inflated to hold the catheter in place within the bladder.the bladder.

Catheters are sized by the diameter of the lumen and are Catheters are sized by the diameter of the lumen and are graded on French scale numbers. The larger the number, graded on French scale numbers. The larger the number, the larger the lumen size. Small sizes such as French 8 – the larger the lumen size. Small sizes such as French 8 – 10 are used in children. French 14, 16 and 18 are for adults.10 are used in children. French 14, 16 and 18 are for adults.


Straight CatheterStraight Catheter

Equipment:Equipment:lamp or flashlightlamp or flashlightmask, if required by hospitalmask, if required by hospitalblanket/ drapeblanket/ drapesoap, basin of warm water, washcloth, towelsoap, basin of warm water, washcloth, toweldisposable glovesdisposable gloveswater soluble lubricantwater soluble lubricantsterile glovessterile glovessterile drapes (optional)sterile drapes (optional)antiseptic solutionantiseptic solutioncotton balls or gauze squarescotton balls or gauze squaresforcepsforcepsbasin for urinebasin for urinesterile catheter (straight)sterile catheter (straight)specimen container if requiredspecimen container if requiredbag or receptacle for disposal of the cotton ballsbag or receptacle for disposal of the cotton balls



Procedure:Procedure:1. Explain the procedure to the client.1. Explain the procedure to the client.2. Put on a mask, gown or cap if required by agency.2. Put on a mask, gown or cap if required by agency.3. (Percuss and) Palpate the bladder to assess urinary retention.3. (Percuss and) Palpate the bladder to assess urinary retention.4. Assist client to a supine position, with knees flexed and thighs externally 4. Assist client to a supine position, with knees flexed and thighs externally

rotated.rotated.5. Drape the client. Prevent unnecessary exposure.5. Drape the client. Prevent unnecessary exposure.6. Don disposable gloves.6. Don disposable gloves.7. Adjust the light to view the urinary meatus.7. Adjust the light to view the urinary meatus.8. Drape the client with sterile drapes (expose the perineum).8. Drape the client with sterile drapes (expose the perineum).9. Pour antiseptic solution over the cotton balls if they are not already prepared.9. Pour antiseptic solution over the cotton balls if they are not already prepared.10. Lubricate insertion tip of the catheter and place it in a sterile container/ area 10. Lubricate insertion tip of the catheter and place it in a sterile container/ area

ready for use.ready for use.11. Clean the meatus. With the nondominant hand, separate the labia majora 11. Clean the meatus. With the nondominant hand, separate the labia majora

with the thumb and finger and clean the labia minora on each side using with the thumb and finger and clean the labia minora on each side using forceps and cotton balls soaked in antiseptic. Use a new swab for each forceps and cotton balls soaked in antiseptic. Use a new swab for each stroke. Move downward from the pubic area to the anus. (prevents transfer stroke. Move downward from the pubic area to the anus. (prevents transfer of microorganisms)of microorganisms)



12. Expose the urinary meatus by retracting the tissue of the labia minora in an 12. Expose the urinary meatus by retracting the tissue of the labia minora in an upward direction. Clean from the meatus downward on either side, then work upward direction. Clean from the meatus downward on either side, then work outward. Once the meatus is cleaned, do not allow the labia to close over it.outward. Once the meatus is cleaned, do not allow the labia to close over it.

13. Inspect the meatus for any swelling, excoriation, discharge.13. Inspect the meatus for any swelling, excoriation, discharge.14. Insert the catheter gently with the uncontaminated gloved hand into the urinary 14. Insert the catheter gently with the uncontaminated gloved hand into the urinary

meatus until urine flows. Keep the drainage end in the urine receptacle. When meatus until urine flows. Keep the drainage end in the urine receptacle. When the urine flows, transfer the hand from the labia to the catheter to hold it in place the urine flows, transfer the hand from the labia to the catheter to hold it in place and prevent its expulsion by a possible bladder contraction.and prevent its expulsion by a possible bladder contraction.

15. Collect specimen if required (usually 30 ml) by transferring the drainage end 15. Collect specimen if required (usually 30 ml) by transferring the drainage end into a sterile bottle.into a sterile bottle.

16. Empty or partially drain the bladder and then remove the catheter. Limit amount 16. Empty or partially drain the bladder and then remove the catheter. Limit amount of urine drained to 700-1000 ml. rapid removal of large amounts of urine is of urine drained to 700-1000 ml. rapid removal of large amounts of urine is thought to induce engorgement of the pelvic blood vessels and hypovolemic thought to induce engorgement of the pelvic blood vessels and hypovolemic shock.shock.

17. Pinch the catheter. Remove the catheter slowly.17. Pinch the catheter. Remove the catheter slowly.18. Dry the perineum with a towel or drape.18. Dry the perineum with a towel or drape.19. Assess the urine.19. Assess the urine.20. Document the catheterization.20. Document the catheterization.


FOLEY/ INDWELLING/ FOLEY/ INDWELLING/ Retention CatheterRetention Catheter

Additional Equipment: syringe prefilled with fluid (usually 15 ml)Additional Equipment: syringe prefilled with fluid (usually 15 ml)Follow steps as for straight catheterization up to #15.Follow steps as for straight catheterization up to #15.16. Insert the catheter an additional 2.5 – 5 cm (1-2 in) beyond the point at 16. Insert the catheter an additional 2.5 – 5 cm (1-2 in) beyond the point at

which the urine began to flow to ensure that the balloon near the insertion which the urine began to flow to ensure that the balloon near the insertion tip will be inflated inside the bladder and not the urethra, where it could tip will be inflated inside the bladder and not the urethra, where it could produce trauma.produce trauma.

17. Inflate the balloon by injecting the contents of the prefilled syringe into 17. Inflate the balloon by injecting the contents of the prefilled syringe into the valve of the catheter.the valve of the catheter.

18. Ensure effective balloon inflation applying slight tension on the catheter 18. Ensure effective balloon inflation applying slight tension on the catheter until you feel resistance (well anchored in the bladder).until you feel resistance (well anchored in the bladder).

19. Tape the catheter to the inside of the female’s thigh.19. Tape the catheter to the inside of the female’s thigh.20. Secure drainage bag to the bedframe using its hook. Suspend it off the 20. Secure drainage bag to the bedframe using its hook. Suspend it off the

floor but keep it below the level of the patient’s bladder. Make sure the floor but keep it below the level of the patient’s bladder. Make sure the emptying base of the drainage bag is closed.emptying base of the drainage bag is closed.

21. Document catheterization.21. Document catheterization.


How to insert a catheter (women)How to insert a catheter (women)1. Assemble all equipment: catheter, lubricant, sterile gloves, cleaning supplies, syringe with water 1. Assemble all equipment: catheter, lubricant, sterile gloves, cleaning supplies, syringe with water to inflate the balloon, drainage receptacle.to inflate the balloon, drainage receptacle.

2. Wash your hands. Use betadine or cleansing product to clean the urethral opening. In women 2. Wash your hands. Use betadine or cleansing product to clean the urethral opening. In women clean the labia and urethral meatus using downward strokes. Avoid the anal area.clean the labia and urethral meatus using downward strokes. Avoid the anal area.

3. Apply the sterile gloves. Make sure you do not touch the outside of the gloves with your hands.3. Apply the sterile gloves. Make sure you do not touch the outside of the gloves with your hands.

4. Lubricate the catheter.4. Lubricate the catheter.

5. Spread the labia and locate the meatus (opening which is located below the clitoris and above 5. Spread the labia and locate the meatus (opening which is located below the clitoris and above the the vagina).).

6. Slowly insert the catheter into the meatus.6. Slowly insert the catheter into the meatus.

7. Begin to gently insert and advance the catheter.7. Begin to gently insert and advance the catheter.

8. Once the urine flow starts, advance the catheter another 2 inches. Hold the catheter in place 8. Once the urine flow starts, advance the catheter another 2 inches. Hold the catheter in place while you inflate the balloon. Care must be taken to ensure the catheter is in the bladder. If pain is while you inflate the balloon. Care must be taken to ensure the catheter is in the bladder. If pain is felt which inflating the balloon, stop; deflate the balloon; advance the catheter another 2 inches; felt which inflating the balloon, stop; deflate the balloon; advance the catheter another 2 inches; and attempt to inflate the balloon again.and attempt to inflate the balloon again.

9. Secure the catheter, and attach the drainage bag. 9. Secure the catheter, and attach the drainage bag.

http://health.allrefer.com/health/vagina-info.html

Procedure on Procedure on ChildbirthChildbirth


Vaginal DeliveryVaginal DeliveryMary Lourdes Nacel G. Celeste, RN, MDMary Lourdes Nacel G. Celeste, RN, MD


PROCEDURE ON PROCEDURE ON CHILDBIRTH (Conduct of CHILDBIRTH (Conduct of

Normal Delivery)Normal Delivery)Purpose: To provide safe outcome for the mother and to deliver a Purpose: To provide safe outcome for the mother and to deliver a

healthy babyhealthy baby

Equipment: Standard delivery room equipmentEquipment: Standard delivery room equipmentDelivery table with stirrupsDelivery table with stirrupsInstrument tableInstrument tableAnesthesia machineAnesthesia machineResuscitator with heating machine for infantResuscitator with heating machine for infantSterile pack containing:Sterile pack containing:

DrapesDrapesLeggingsLeggingsTowelsTowelsGownsGownsSpongesSponges



Normal Delivery)Normal Delivery)Sterile instrumentsSterile instruments

2 scissors ( 1 for episiotomy, 1 for cutting 2 scissors ( 1 for episiotomy, 1 for cutting the the umbilical cord)umbilical cord)

2 cord clamps/ kelly forceps2 cord clamps/ kelly forceps4 allis clamps (for episiotomy repair)4 allis clamps (for episiotomy repair)2 needle holders2 needle holders Suture needlesSuture needles2 ring forceps (to aid in the delivery of the 2 ring forceps (to aid in the delivery of the

placenta and membranes) placenta and membranes)1 vaginal retractor (to aid in inspection of the 1 vaginal retractor (to aid in inspection of the

birth canal)birth canal)



Normal Delivery)Normal Delivery)Procedure: Procedure: Nursing Action/ RationaleNursing Action/ Rationale1. Observe strict aseptic technique in gowning and gloving. 1. Observe strict aseptic technique in gowning and gloving.

(To prevent introduction of microorganisms into the uterine (To prevent introduction of microorganisms into the uterine cavity)cavity)

2. Drape and cleanse perineal area. (To maintain asepsis).2. Drape and cleanse perineal area. (To maintain asepsis).


Perineal PreparationPerineal Preparation



Normal Delivery)Normal Delivery)3. Catheterize patient PRN. (To prevent bladder trauma)3. Catheterize patient PRN. (To prevent bladder trauma)4. Instruct patient to push. (This is a technique of using the 4. Instruct patient to push. (This is a technique of using the

abdominal muscles to assist in uterine expulsive efforts during abdominal muscles to assist in uterine expulsive efforts during contractions)contractions)

5. Wipe the perineum with sponges and antiseptic solution using a 5. Wipe the perineum with sponges and antiseptic solution using a downward and backward motion. (To prevent fecal downward and backward motion. (To prevent fecal contamination)contamination)

6. Avoid the use of fundal pressure to hasten delivery. (Fundal 6. Avoid the use of fundal pressure to hasten delivery. (Fundal pressure may cause uterine damage)pressure may cause uterine damage)

7. Avoid too rapid delivery. (To preserve the flexion of the fetal head)7. Avoid too rapid delivery. (To preserve the flexion of the fetal head)8. Assess for leg cramps which may occur when the head crowns. 8. Assess for leg cramps which may occur when the head crowns.

These may be relieved by changing the position of the legs. These may be relieved by changing the position of the legs. (Caused by the pressure of the fetal head on the pelvic nerves)(Caused by the pressure of the fetal head on the pelvic nerves)

9. Assess the necessity for episiotomy when the head crowns 9. Assess the necessity for episiotomy when the head crowns slightly, if a tear seems inevitable, a midline or right or left slightly, if a tear seems inevitable, a midline or right or left mediolateral episiotomy may be performed. (To prevent perineal mediolateral episiotomy may be performed. (To prevent perineal lacerations caused by pressure of the fetal head)lacerations caused by pressure of the fetal head)


Types of EpisiotomyTypes of Episiotomy



Normal Delivery)Normal Delivery)10. 10. Control the delivery by Ritgen’s maneuver. This consists of Control the delivery by Ritgen’s maneuver. This consists of

covering the anus with sterile towel and exerting upward and covering the anus with sterile towel and exerting upward and downward pressure on the area beneath the fetal chin while downward pressure on the area beneath the fetal chin while maintaining pressure against the occiput with the other hand to maintaining pressure against the occiput with the other hand to control the emerging head and to effect delivery between control the emerging head and to effect delivery between contractions. (To prevent injury to the mother and infant)contractions. (To prevent injury to the mother and infant)

11. Feel and look for the cord around the back of the neonate as 11. Feel and look for the cord around the back of the neonate as soon as the head is delivered. Loosen the cord and slip over the soon as the head is delivered. Loosen the cord and slip over the head. If unable to loosen coils, occlude the cord with 2 clamps head. If unable to loosen coils, occlude the cord with 2 clamps and cut between them. (To prevent interference with fetal and cut between them. (To prevent interference with fetal oxygenation)oxygenation)


Ritgen’s maneuverRitgen’s maneuver



Normal Delivery)Normal Delivery)12. Remove mucus and fluid from the neonate’s face and suction 12. Remove mucus and fluid from the neonate’s face and suction

oropharynx. (To prevent aspiration of the mucus when the oropharynx. (To prevent aspiration of the mucus when the newborn gasps during initial respiration)newborn gasps during initial respiration)

13. Do not hasten completion of the delivery. Wait until the head 13. Do not hasten completion of the delivery. Wait until the head rotates externally. (As soon as the head is delivered , there is rotates externally. (As soon as the head is delivered , there is usually a lull in contractions. Rotation of the head is indication usually a lull in contractions. Rotation of the head is indication that the shoulders have rotated externally)that the shoulders have rotated externally)

14. Observe for continued uterine contractions and for the shoulder 14. Observe for continued uterine contractions and for the shoulder to lie directly anterposteriorly . Pull the head gently downward to lie directly anterposteriorly . Pull the head gently downward and backward until the anterior shoulder is behind and against and backward until the anterior shoulder is behind and against the symphysis pubis. Lift the head for delivery of the posterior the symphysis pubis. Lift the head for delivery of the posterior shoulder.shoulder.

15. Clamp the cord at about 2.5 cm (or depending upon the hospital 15. Clamp the cord at about 2.5 cm (or depending upon the hospital policy) from the umbilicus. (Whether sustained benefit is policy) from the umbilicus. (Whether sustained benefit is obtained by waiting for cessation of pulsation before clamping obtained by waiting for cessation of pulsation before clamping the cord has not been established.)the cord has not been established.)


Normal Spontaneous Normal Spontaneous Delivery Delivery


Umbilical cordUmbilical cord


16. Place newborn in a heated crib . (To prevent heat loss and 16. Place newborn in a heated crib . (To prevent heat loss and hypothermia)hypothermia)

17. Circulating nurse should administer oxytocin IM to the patient 17. Circulating nurse should administer oxytocin IM to the patient (To administer effective uterine contractions for the purpose of (To administer effective uterine contractions for the purpose of expelling the placenta and preventing uterine atony)expelling the placenta and preventing uterine atony)

18. Observe for resumption of contraction and for indications that 18. Observe for resumption of contraction and for indications that the placenta has separated from the uterine wall. (There is the placenta has separated from the uterine wall. (There is sudden gush of blood; the uterus rises upward in the sudden gush of blood; the uterus rises upward in the abdomen, changes from discoid to a globular shape and the abdomen, changes from discoid to a globular shape and the cord lengthens outside the vagina )cord lengthens outside the vagina )

19. Express the placenta by pushing downward on the fundus 19. Express the placenta by pushing downward on the fundus with moderate pressure and with slight tension on the cord. If with moderate pressure and with slight tension on the cord. If membranes begin to tear, grasp with clamp and tease out membranes begin to tear, grasp with clamp and tease out slowly. (Excessive pressure on the relaxed uterus may cause slowly. (Excessive pressure on the relaxed uterus may cause inversion)inversion)


20. Examine the placenta carefully. (a. To make certain that 20. Examine the placenta carefully. (a. To make certain that none of the placental membranes have been retained in the none of the placental membranes have been retained in the uterus; b. To identify the gross changes that may have uterus; b. To identify the gross changes that may have pathological significance)pathological significance)

21. Inspect the vaginal canal and cervix for lacerations or 21. Inspect the vaginal canal and cervix for lacerations or injury. (The examination is carried before the episiotomy injury. (The examination is carried before the episiotomy repair, otherwise, if bleeding should occur following repair, repair, otherwise, if bleeding should occur following repair, inspection at that time would cause tension on recently inspection at that time would cause tension on recently placed sutures and could damage the episiotomy wound)placed sutures and could damage the episiotomy wound)

22. Repair the episiotomy.22. Repair the episiotomy.


PlacentaPlacenta


23. Estimate blood loss. (Observe the saturation sponges and 23. Estimate blood loss. (Observe the saturation sponges and towels as well as the amount of bleeding)towels as well as the amount of bleeding)

24. Remove soiled linen, replace end of the delivery table and 24. Remove soiled linen, replace end of the delivery table and lower the patient’s legs from the stirrups simultaneously. lower the patient’s legs from the stirrups simultaneously. (To prevent injury or muscle spasm)(To prevent injury or muscle spasm)

25. Apply a sterile perineal pad, warm gown, and blanket. 25. Apply a sterile perineal pad, warm gown, and blanket. (Chilling accompanied by shaking often occurs (Chilling accompanied by shaking often occurs immediately following delivery.)immediately following delivery.)

26. Help the mother to hold the infant and inspect it if she 26. Help the mother to hold the infant and inspect it if she wishes. (Early contact with the infant assists in the mother-wishes. (Early contact with the infant assists in the mother-infant bonding process. One of the mother’s first needs is infant bonding process. One of the mother’s first needs is to be reassured that her infant is normal)to be reassured that her infant is normal)

Cesarean ChildbirthCesarean ChildbirthMary Lourdes Nacel G. Celeste, RN, MDMary Lourdes Nacel G. Celeste, RN, MD


Scheduled or Scheduled or Unscheduled C/SUnscheduled C/S

Scheduled Cesarean BirthScheduled Cesarean Birth- If it is to be a repeat cesarean birthIf it is to be a repeat cesarean birth

(eg, cephalopelvic disproportion)(eg, cephalopelvic disproportion)- If labor is contraindicated (eg, complete If labor is contraindicated (eg, complete

placenta previa, hydrocephaly)placenta previa, hydrocephaly)- If labor cannot be induced and birth is If labor cannot be induced and birth is

necessarynecessaryClients have some time to prepare for the Clients have some time to prepare for the cesarean birthcesarean birth


Unscheduled/ Emergency Cesarean Unscheduled/ Emergency Cesarean BirthBirth

- Usually a result of some difficulty in the Usually a result of some difficulty in the labor process/ failure to progress in labor process/ failure to progress in laborlabor

- Placenta previaPlacenta previa- Abruptio placentaAbruptio placenta- Fetal distressFetal distress


Vaginal Birth after Cesarean (VBAC)Vaginal Birth after Cesarean (VBAC)- When the reason for the initial cesarean is When the reason for the initial cesarean is

a nonrecurring situation such as placenta a nonrecurring situation such as placenta previa, prolapsed cord, or breech previa, prolapsed cord, or breech presentation, the client may be able to presentation, the client may be able to have a vaginal birth with the next have a vaginal birth with the next pregnancypregnancy

- Low transverse uterine incision: trial of Low transverse uterine incision: trial of labor is recommendedlabor is recommended

- Classic uterine incision: trial of labor is CIClassic uterine incision: trial of labor is CI


POSTPARTUM PERINEAL POSTPARTUM PERINEAL CARECARE

I. Vaginal birth (which stretches and sometimes tears the perineal I. Vaginal birth (which stretches and sometimes tears the perineal tissues) and episiotomy (which may minimize tissue injury) tissues) and episiotomy (which may minimize tissue injury) usually cause perineal edema and tenderness. Postpartum usually cause perineal edema and tenderness. Postpartum perineal care aims to relieve discomfort, promote healing and perineal care aims to relieve discomfort, promote healing and prevent infection.prevent infection.


Cleaning the perineumCleaning the perineum

Typically, you’ll use a water-jet irrigation system or a peribottle to Typically, you’ll use a water-jet irrigation system or a peribottle to clean the perineum. Assist the patient to the bathroom, wash your clean the perineum. Assist the patient to the bathroom, wash your hands and put on gloves.hands and put on gloves.If you’re using a water jet irrigation system, insert the prefilled If you’re using a water jet irrigation system, insert the prefilled cartridge containing the antiseptic or medicated solution into the cartridge containing the antiseptic or medicated solution into the handle, and push the diposable nozzle into the handle until you hear it handle, and push the diposable nozzle into the handle until you hear it click into place. Instruct the patient to sit on the commode. Next, place click into place. Instruct the patient to sit on the commode. Next, place the nozzle parallel to the perineum and turn on the unit. Rinse the the nozzle parallel to the perineum and turn on the unit. Rinse the perineum for at least 2 minutes from front to back. Turn off the unit. perineum for at least 2 minutes from front to back. Turn off the unit. Remove the nozzle. Discard the cartridge. Dry the nozzle and store it Remove the nozzle. Discard the cartridge. Dry the nozzle and store it for later use.for later use.If you’re using a peribottle, fill it with cleaning solution and instruct the If you’re using a peribottle, fill it with cleaning solution and instruct the patient to pour it over the perineal area.patient to pour it over the perineal area.Help the patient to stand up and assist her in applying a new perineal Help the patient to stand up and assist her in applying a new perineal pad before returning to bed.pad before returning to bed.


Assessing healing progressAssessing healing progress

To inspect the perineum, put on gloves, ensue adequate To inspect the perineum, put on gloves, ensue adequate

lighting, and place the patient in the lateral Sims’s position.lighting, and place the patient in the lateral Sims’s position.

When inspecting the wound area, be alert for such signs of When inspecting the wound area, be alert for such signs of infection as unusual swelling, redness and foul-smelling infection as unusual swelling, redness and foul-smelling discharge.discharge.


PERINEAL CAREPERINEAL CARE

Perineal Care- cleansing the vulva and perineal areaPerineal Care- cleansing the vulva and perineal area

Purposes: Purposes: 1. To clean the perineum in the following after a bowel or 1. To clean the perineum in the following after a bowel or

bladder elimination prior to any vaginal examination or bladder elimination prior to any vaginal examination or treatmenttreatment

2. To prevent vaginal or perineal wound infection and 2. To prevent vaginal or perineal wound infection and unpleasant odor.unpleasant odor.

3. To provide for personal cleanliness and comfort3. To provide for personal cleanliness and comfort



Special considerations:Special considerations:

Avoid burning the patient by using the right temperature Avoid burning the patient by using the right temperature of the flushing waterof the flushing water

Observe special care in order to avoid discomfort when a Observe special care in order to avoid discomfort when a patient has a perineal wound or stitches.patient has a perineal wound or stitches.

Avoid unnecessary exposure.Avoid unnecessary exposure.

If the patient defecated, empty the bedpan first before If the patient defecated, empty the bedpan first before giving perineal flushing.giving perineal flushing.



Equipment:Equipment:Bedpan with coverBedpan with coverScreenScreenFlushing tray with the following:Flushing tray with the following:jar with dry cotton ballsjar with dry cotton ballsjar with cotton soaked with cleansing solutionjar with cotton soaked with cleansing solutionflushing pitcher with warm waterflushing pitcher with warm waterpick up forceps in antiseptic solutionpick up forceps in antiseptic solutionemesis basin for soiled cotton ballsemesis basin for soiled cotton ballsbed protectorbed protectorordered medicine or perineal pad (if necessary)ordered medicine or perineal pad (if necessary)drapedrape



Procedure:Procedure:Assemble all your equipment.Assemble all your equipment.Set up screen to cover the patient. Explain Set up screen to cover the patient. Explain procedure.procedure.Wash your hands.Wash your hands.Position the patient in a back lying position with the Position the patient in a back lying position with the knees flexed or (dorsal recumbent position).knees flexed or (dorsal recumbent position).Place rubber protector and bedpan.Place rubber protector and bedpan.Drape exposing only the part to be cleansed.Drape exposing only the part to be cleansed.Flush the perineal area with warm water.Flush the perineal area with warm water.



Using pick up forceps, get cotton balls soaked with Using pick up forceps, get cotton balls soaked with cleansing solution and clean from the midline of symphysis cleansing solution and clean from the midline of symphysis pubis down to anus. Never retrace stroke.pubis down to anus. Never retrace stroke.Get another cotton ball. Clean starting from mons veneris Get another cotton ball. Clean starting from mons veneris by way of external labium towards anus. (To prevent spread by way of external labium towards anus. (To prevent spread of contamination).of contamination).Discard used cotton balls into the emesis basin.Discard used cotton balls into the emesis basin.Do likewise in the opposite side.Do likewise in the opposite side.Clean groin.Clean groin.Flush thoroughly with sterile water.Flush thoroughly with sterile water.Dry using the same stroke as above.Dry using the same stroke as above.Apply medication as ordered or perineal pad as necessary.Apply medication as ordered or perineal pad as necessary.

Sitz BathSitz BathMary Lourdes Nacel G. Celeste, RN, MDMary Lourdes Nacel G. Celeste, RN, MD


SITZ BATH (Kozier)SITZ BATH (Kozier)

A sitz bath, or a hip bath, is used to soak a client’s A sitz bath, or a hip bath, is used to soak a client’s pelvic area. The client sits in a special tub or chair and pelvic area. The client sits in a special tub or chair and is usually immersed from the midthighs to the iliac is usually immersed from the midthighs to the iliac crests or umbilicus. Special tubs or chairs are crests or umbilicus. Special tubs or chairs are preferred because when the legs are also immersed, preferred because when the legs are also immersed, as in a regular bathtub, blood circulation to the as in a regular bathtub, blood circulation to the perineum or pelvic area is decreased. Disposable sitz perineum or pelvic area is decreased. Disposable sitz baths are also available.baths are also available.The temperature of the water should be from 40 to 43 C The temperature of the water should be from 40 to 43 C (105 to 110 F), unless the client is unable to tolerate (105 to 110 F), unless the client is unable to tolerate the heat. Determine hospital protocol. Some sitz tubs the heat. Determine hospital protocol. Some sitz tubs have temperature indicators attached to the water have temperature indicators attached to the water taps. The duration of the bath is generally 15-20 taps. The duration of the bath is generally 15-20 minutes, depending on the client’s health.minutes, depending on the client’s health.


SITZ BATHSITZ BATHTo provide a sitz bath, the nurse carries out the To provide a sitz bath, the nurse carries out the following steps:following steps:Assist the client into the tub, and provide support for Assist the client into the tub, and provide support for comfort. Provide support for the client’s feet; a comfort. Provide support for the client’s feet; a footstool can prevent pressure on the backs of the footstool can prevent pressure on the backs of the thighs.thighs.Provide a bath blanket for the client’s shoulders and Provide a bath blanket for the client’s shoulders and eliminate drafts to prevent chilling.eliminate drafts to prevent chilling.Observe the client closely during the bath for signs of Observe the client closely during the bath for signs of faintness, dizziness, weakness, accelerated pulse rate faintness, dizziness, weakness, accelerated pulse rate and pallor.and pallor.Maintain the water temperature.Maintain the water temperature.Following the sitz bath, assist the client out of the tub. Following the sitz bath, assist the client out of the tub. Help the client to dry.Help the client to dry.


SITZ BATH (Pilliteri)SITZ BATH (Pilliteri)

Purpose: To aid healing of the perineum through application of moist Purpose: To aid healing of the perineum through application of moist heatheat

Procedure: Procedure: 1. Wash your hands, identify client and explain procedure.1. Wash your hands, identify client and explain procedure.2. Assess client’s condition; ascertain whether client is able to 2. Assess client’s condition; ascertain whether client is able to

ambulate to bathroom; assist and modify as necessary.ambulate to bathroom; assist and modify as necessary.3. Assemble equipment, including sitz bath, clean towel, perineal 3. Assemble equipment, including sitz bath, clean towel, perineal

pad.pad.4. Place sitz bath on toilet seat. Fill collecting bag with warm water at 4. Place sitz bath on toilet seat. Fill collecting bag with warm water at

a temperature of 100 F to 105 F (38 C to 41 C). Hang the bag a temperature of 100 F to 105 F (38 C to 41 C). Hang the bag overhead so a steady stream of water will flow from the bag, overhead so a steady stream of water will flow from the bag, through the tubing, and into the basin.through the tubing, and into the basin.

Principle: using correct temperature of water eliminates risk of Principle: using correct temperature of water eliminates risk of thermal injury. Adequate flow of warm water increases circulation thermal injury. Adequate flow of warm water increases circulation to the perineum, thereby reducing inflammation and aiding to the perineum, thereby reducing inflammation and aiding healing.healing.


SITZ BATHSITZ BATH5. Assist client while ambulating to bathroom; help with 5. Assist client while ambulating to bathroom; help with

removal of perineal pad from front to back. Assist client to removal of perineal pad from front to back. Assist client to seat in basin.seat in basin.

6. Instruct client to use clamp on tubing to regulate water flow; 6. Instruct client to use clamp on tubing to regulate water flow; use robe or blankets to prevent chilling and provide for use robe or blankets to prevent chilling and provide for privacy. Have call bell within reach.privacy. Have call bell within reach.

7. After 20 minutes, assist client with drying perineum and 7. After 20 minutes, assist client with drying perineum and applying clean pad (holding pad by the bottom side or ends). applying clean pad (holding pad by the bottom side or ends). After 20 minutes, heat is no longer therapeutic because After 20 minutes, heat is no longer therapeutic because vasoconstriction occurs.vasoconstriction occurs.

8. Assist client with ambulating back to room8. Assist client with ambulating back to room9. Evaluate client’s tolerance and response to procedure; ask 9. Evaluate client’s tolerance and response to procedure; ask

client to report how she feels. Institute health teaching, such client to report how she feels. Institute health teaching, such as continuing sitz baths when at home.as continuing sitz baths when at home.

10. Record completion of procedure, condition of perineum and 10. Record completion of procedure, condition of perineum and client’s condition and response.client’s condition and response.

Perilight Perilight AdministrationAdministrationMary Lourdes Nacel G. Celeste, RN, MDMary Lourdes Nacel G. Celeste, RN, MD


PERILIGHT PERILIGHT ADMINISTRATIONADMINISTRATION

the application of warmth to the perineal area by means of lampthe application of warmth to the perineal area by means of lamp

Rationale: Rationale: a. to provide perineal heat for the comfort of the patienta. to provide perineal heat for the comfort of the patientb. to aid in the healing of the episiotomy or laceration keeping the suture b. to aid in the healing of the episiotomy or laceration keeping the suture

drydry

Nursing objectives:Nursing objectives:Avoid burning the patient by prolonged exposure or too-close proximity Avoid burning the patient by prolonged exposure or too-close proximity

to light.to light.Prevent cross contamination by thorough cleaning of lights between Prevent cross contamination by thorough cleaning of lights between

patients’ use.patients’ use.Facilitate healing by optimal use of light and heat.Facilitate healing by optimal use of light and heat.



Equipment:Equipment:

Perineal lightPerineal light

Padding for stirrupsPadding for stirrups

ScreenScreen

Sterile perineal padSterile perineal pad

Bag for disposal of used perineal padBag for disposal of used perineal pad

Prescribed medicationPrescribed medication



Procedure:Procedure:Explain the procedure to patient. (Importance of the Explain the procedure to patient. (Importance of the procedure: It will make her comfortable and promote procedure: It will make her comfortable and promote healing of the episiotomy).healing of the episiotomy).The patient should empty her bladder prior to the The patient should empty her bladder prior to the procedure. A distended bladder may cause discomfort procedure. A distended bladder may cause discomfort during the procedure.during the procedure.Screen the patient.Screen the patient.Position the patient flat on her back in bed. If the bed Position the patient flat on her back in bed. If the bed has stirrups, they should be padded for comfort.has stirrups, they should be padded for comfort.Plastic and rubber absorb and conduct heat. If a foley Plastic and rubber absorb and conduct heat. If a foley catheter is in place, a clean washcloth should be placed catheter is in place, a clean washcloth should be placed between it and the thigh, to protect the patient from between it and the thigh, to protect the patient from being burned by the heated tubing.being burned by the heated tubing.



Position the perineal light far enough from the perineum to Position the perineal light far enough from the perineum to avoid burning the tender skin; approximately 12 inches is avoid burning the tender skin; approximately 12 inches is considered safe. The lamp should not be left on for more considered safe. The lamp should not be left on for more than 20 minutes. Expose the perineum to perineal light than 20 minutes. Expose the perineum to perineal light several times a day.several times a day.The perineal area must be checked frequently during the The perineal area must be checked frequently during the procedure for redness which would indicate that the light procedure for redness which would indicate that the light was too hot or the time span was too long. Suture should was too hot or the time span was too long. Suture should be observed for proper healing and signs of infection, be observed for proper healing and signs of infection, bleeding or any other problems. Observe patient’s bleeding or any other problems. Observe patient’s reactions.reactions.A bulb over 60 watts must be used.A bulb over 60 watts must be used.Wash the perineal light in a utility room with a germicide.Wash the perineal light in a utility room with a germicide.

Breast CareBreast CareMary Lourdes Nacel G. Celeste, RN, MDMary Lourdes Nacel G. Celeste, RN, MD


Breasts – Breasts – progress from soft filling with potential progress from soft filling with potential for engorgement (vascular congestion related to for engorgement (vascular congestion related to increased blood and lymph supply; breasts are increased blood and lymph supply; breasts are larger, firmer, and painful)larger, firmer, and painful)Non-nursing woman – Non-nursing woman – suppress lactationsuppress lactationMechanical methods – tight-fitting brassiere, ice Mechanical methods – tight-fitting brassiere, ice packs, minimize breast stimulationpacks, minimize breast stimulationNursing woman –Nursing woman – successful lactation is successful lactation is dependent on infant sucking and maternal dependent on infant sucking and maternal production and delivery of milk (letdown/milk production and delivery of milk (letdown/milk ejection reflex); monitor and teach preventive ejection reflex); monitor and teach preventive measures for potential problems measures for potential problems


Nipple – irritation/crackingNipple – irritation/crackingNipple care – clean with water, no soap, Nipple care – clean with water, no soap, and dry thoroughly; absorbent breast and dry thoroughly; absorbent breast pads if leaking occurs; expose to airpads if leaking occurs; expose to airPosition nipple so that infant’s mouth Position nipple so that infant’s mouth covers a large portion of the areola and covers a large portion of the areola and release infant’s mouth from nipple by release infant’s mouth from nipple by inserting finger to break suctioninserting finger to break suctionRotate breastfeeding positionsRotate breastfeeding positions


Engorgement Engorgement nurse frequently (every ½-3 h) and long enough nurse frequently (every ½-3 h) and long enough to empty breasts completely (evidenced by to empty breasts completely (evidenced by sucking without swallowing) sucking without swallowing) warm shower or compresses to stimulate warm shower or compresses to stimulate letdown letdown alternate starting breast at each feeding alternate starting breast at each feeding mild analgesic 20 min before feeding and ice mild analgesic 20 min before feeding and ice packs between feedings for pronounced packs between feedings for pronounced discomfortdiscomfort


Plugged ducts –Plugged ducts – area of tenderness and area of tenderness and lumpiness often associated with engorgement; lumpiness often associated with engorgement; may be relieved by heat and massage prior to may be relieved by heat and massage prior to feedingfeeding

Medications –Medications – most drugs cross into breastmilk; most drugs cross into breastmilk; check with physician before taking any check with physician before taking any medicationmedication


Expression of breast milk Expression of breast milk to collect milk for supplemental feedings to collect milk for supplemental feedings to relieve breast fullness or to build milk supply to relieve breast fullness or to build milk supply may be manually expressed or pumped by a may be manually expressed or pumped by a device and refrigerated for no more than 48 h or device and refrigerated for no more than 48 h or frozen in plastic bottles (to maintain stability of frozen in plastic bottles (to maintain stability of all elements) in refrigerator freezer for 2 wk and all elements) in refrigerator freezer for 2 wk and deep freezer for 2 months (do not thaw in deep freezer for 2 months (do not thaw in microwave or on stove)microwave or on stove)


LACTATION PRINCIPLES

Breast Care – Antepartum and Postpartum

Initiating Breast Feeding

Soap on nipples should be avoided during bathing to prevent dryness

Nipples can be “prepared” antepartum by exposure to sun, air, and by wearing loose clothing

Redness or swelling can indicate infection and should always be investigated

Relaxed position of mother is essential – support dependent arm with pillow

Both breasts should be offered at each feeding

Five minutes on each breast is sufficient at first – teach proper way to break suction

Most of the areola should be infant’s mouth to ensure proper sucking


BREASTFEEDINGBREASTFEEDING BOTTLEFEEDINGBOTTLEFEEDING

Non-allergenicNon-allergenic

Meet infant ‘s specific nutritional Meet infant ‘s specific nutritional needsneeds

Immunologic properties help Immunologic properties help prevent infectionprevent infection

Easily digestedEasily digested

Constipation unlikelyConstipation unlikely

Overfeeding less likelyOverfeeding less likely

No formula or bottles to buyNo formula or bottles to buy

No formula and bottle to prepareNo formula and bottle to prepare

Oxytocin release help involutionOxytocin release help involution

Mother more likely to eat well Mother more likely to eat well balance dietbalance diet

May help with mother’s weight lossMay help with mother’s weight loss

Enhances mother/infant attachment Enhances mother/infant attachment through skin to skin contactthrough skin to skin contact

Frozen -20c (6 mos)Frozen -20c (6 mos)

Refrigerated 4c ( 24 H)Refrigerated 4c ( 24 H)

Father or others may feed Father or others may feed infant day or nightinfant day or night

Feed less frequently (3-Feed less frequently (3-4H)4H)

Amount of milk taken at Amount of milk taken at each feeding knowneach feeding known

ADVANTAGES


BREASTFEEDINGBREASTFEEDING BOTTLEFEEDINGBOTTLEFEEDING

Feed more frequently (2-3 H)Feed more frequently (2-3 H)

More frequent diaper changesMore frequent diaper changes

Amount of milk taken at each Amount of milk taken at each feeding unknownfeeding unknown

Medications taken by mother Medications taken by mother present in milkpresent in milk

Discomfort of som mothers to Discomfort of som mothers to nurse in publicnurse in public

Expense of pumping and storing Expense of pumping and storing milk for periods when mother is milk for periods when mother is unavailable ( such as work)unavailable ( such as work)

Expense of formula, Expense of formula, bottlesbottles

Washing bottlesWashing bottles

Fixing and refrigerating Fixing and refrigerating formulaformula

Carrying bottles on Carrying bottles on outingsoutings

May cause constipationMay cause constipation

DISADVANTAGES


BreastfeedingBreastfeedingPosition for feedingPosition for feeding The infant should be held with head slightly The infant should be held with head slightly

higher than the rest of the bodyhigher than the rest of the body Cradle hold with infant’s head in the bend of Cradle hold with infant’s head in the bend of

the mother’s elbow and arm supporting the the mother’s elbow and arm supporting the infant’s bodyinfant’s body

OTHERS:OTHERS: Football holdFootball hold Side lying positionSide lying position Across lapAcross lap

Cradling


BreastfeedingBreastfeedingLatching onLatching on The mother should use the infant's The mother should use the infant's

rooting reflex to allow positioning of rooting reflex to allow positioning of the nipple in the infant’s mouththe nipple in the infant’s mouth

Brushing the nipple against the Brushing the nipple against the infant’s lower lip will cause the infant infant’s lower lip will cause the infant to open the mouth.to open the mouth.

When the mouth is wide open and the When the mouth is wide open and the tongue is down, the mother quickly tongue is down, the mother quickly brings the infant closer to the breast brings the infant closer to the breast so the infant can latch on the nipple so the infant can latch on the nipple and areola.and areola.

Cradling


BreastfeedingBreastfeedingLength of feedingLength of feeding Varies with each mother /infant unitVaries with each mother /infant unit

BURPING- BURPING- ALL INFANTS REQUIRE BURPINGALL INFANTS REQUIRE BURPING TO EXPEL THE AIR SWALLOWED TO EXPEL THE AIR SWALLOWED

WHEN THE INFANT SUCKSWHEN THE INFANT SUCKS SOME INFANT SWALLOW MORE AIR SOME INFANT SWALLOW MORE AIR

THAN OTHERS AND REQUIRE MORE THAN OTHERS AND REQUIRE MORE FREQUENT BURPINGFREQUENT BURPING

Cradling


BREAST CAREBREAST CARE

Rationale:Rationale:

Maintain proper support and cleanlinessMaintain proper support and cleanliness

Prevent trauma and infectionPrevent trauma and infection

Materials:Materials:

Mild soap and waterMild soap and water

Clean wash cloth and towelClean wash cloth and towel


The client should always wash wash her hands The client should always wash wash her hands thoroughly before handling the breasts.thoroughly before handling the breasts.The breasts are washed with warm water and The breasts are washed with warm water and soap on a washcloth, using circular motion from soap on a washcloth, using circular motion from the nipple out.the nipple out.The breasts should be dried well, but gently.The breasts should be dried well, but gently.Postpartum, the woman should wear well-fitting Postpartum, the woman should wear well-fitting brassiere .brassiere .Use nursing pads if nipples leak. Change them Use nursing pads if nipples leak. Change them when they become soiled.when they become soiled.Tender, painful cracked nipples should be Tender, painful cracked nipples should be exposed to air. Medications may be taken as exposed to air. Medications may be taken as ordered.ordered.

Inverted NipplesInverted NipplesMary Lourdes Nacel G. Celeste, RN, MDMary Lourdes Nacel G. Celeste, RN, MD


INVERTED NIPPLEsINVERTED NIPPLEsInverted nipples fold inward instead of pointing out. Women Inverted nipples fold inward instead of pointing out. Women with inverted nipples may have a hard time getting started with inverted nipples may have a hard time getting started with breastfeeding. A breast-feeding baby latches on more with breastfeeding. A breast-feeding baby latches on more easily to a nipple when it is erect.easily to a nipple when it is erect.

To determine whether you have flat or inverted nipples:To determine whether you have flat or inverted nipples:Place your thumb and forefinger on the edges of the areola Place your thumb and forefinger on the edges of the areola (dark area around the nipple) just behind the nipple. (dark area around the nipple) just behind the nipple. Squeeze the tissue gently. Squeeze the tissue gently. If the nipple is flat or inverted, it will flatten or retract into the If the nipple is flat or inverted, it will flatten or retract into the breast instead of pointing out. breast instead of pointing out. Special techniques and breast shells sometimes are Special techniques and breast shells sometimes are recommended to prepare inverted nipples for breast-feeding. recommended to prepare inverted nipples for breast-feeding. However, their effectiveness is questionable. Inverted However, their effectiveness is questionable. Inverted nipples may naturally become more erect after the birth of nipples may naturally become more erect after the birth of your baby. your baby.


INVERTED NIPPLEsINVERTED NIPPLEsTechniques for flat or inverted nipples:Techniques for flat or inverted nipples:

An effective breastfeeding baby usually has little trouble An effective breastfeeding baby usually has little trouble breastfeeding even if his/her mother's nipples appear to be breastfeeding even if his/her mother's nipples appear to be flatter. A less effective breastfeeder may need some time to flatter. A less effective breastfeeder may need some time to figure out how he/she can draw the nipple into the mouth with figure out how he/she can draw the nipple into the mouth with latch-on. Although the benefit of using hard plastic breast shells latch-on. Although the benefit of using hard plastic breast shells is not conclusive, some mothers find it helps to wear them in the is not conclusive, some mothers find it helps to wear them in the bra between feedings. Breast shells exert a small amount of bra between feedings. Breast shells exert a small amount of traction to help draw the nipple outward. Using a breast pump to traction to help draw the nipple outward. Using a breast pump to draw the nipple out just prior to breastfeeding may also help.draw the nipple out just prior to breastfeeding may also help.If nipples invert, or "dent" inward, with stimulation, try the If nipples invert, or "dent" inward, with stimulation, try the interventions mentioned for flat nipples. Nipple eversion devices interventions mentioned for flat nipples. Nipple eversion devices are available. Occasionally, a mother has one or more severely are available. Occasionally, a mother has one or more severely inverted nipples. If one breast is less affected, your baby can inverted nipples. If one breast is less affected, your baby can breastfeed on only one breast. Most women can produce enough breastfeed on only one breast. Most women can produce enough milk in one breast to exclusively breastfeed their babies.milk in one breast to exclusively breastfeed their babies.


Proper breast-feeding Proper breast-feeding technique technique

The infant should be lined up: mouth, chin and The infant should be lined up: mouth, chin and umbilicus. The head is neutral, the mouth wideumbilicus. The head is neutral, the mouth wide. . Bring the infant to the breast. The gum line Bring the infant to the breast. The gum line should overlap the areola as much as possible.should overlap the areola as much as possible.The nipple should be straight back in the mouth, The nipple should be straight back in the mouth, with the tip nestled into the infant's soft palate.with the tip nestled into the infant's soft palate.The tip of the infant's nose and chin should touch The tip of the infant's nose and chin should touch the breast with equal pressurethe breast with equal pressure. . The infant's lips are flanged, with the tongue The infant's lips are flanged, with the tongue protruding over the lower gum.protruding over the lower gum.

Proper breast-feeding technique.


Early Breast-Feeding AttemptsEarly Breast-Feeding AttemptsNew mothers should initiate breast-feeding as New mothers should initiate breast-feeding as soon as possible after giving birth. When soon as possible after giving birth. When mothers initiate breast-feeding within one-half mothers initiate breast-feeding within one-half hour of birth, the baby's suckling reflex is hour of birth, the baby's suckling reflex is strongest, and the baby is more alert.Early strongest, and the baby is more alert.Early breast-feeding is associated with fewer nighttime breast-feeding is associated with fewer nighttime feeding problems and better mother-infant feeding problems and better mother-infant communication.Babies who are put to breast communication.Babies who are put to breast earlier have been shown to have higher core earlier have been shown to have higher core temperatures and less temperature instability. temperatures and less temperature instability.


Nipple ConfusionNipple Confusion

Nipple confusion occurs when a baby has not had the Nipple confusion occurs when a baby has not had the opportunity to establish the correct mouth movements for opportunity to establish the correct mouth movements for proper breast-feeding. Early and subsequent use of proper breast-feeding. Early and subsequent use of pacifiers, water, glucose water and formula pacifiers, water, glucose water and formula supplementation have been shown to promote early supplementation have been shown to promote early weaning and nipple confusion.The frequent use of an weaning and nipple confusion.The frequent use of an artificial nipple early in life has been shown to promote a artificial nipple early in life has been shown to promote a less effective mouth movement; this was demonstrated less effective mouth movement; this was demonstrated with ultrasonography over a decade ago.32 For this reason, with ultrasonography over a decade ago.32 For this reason, the physician should encourage the staff and the patient to the physician should encourage the staff and the patient to address breast-feeding problems first, with direct address breast-feeding problems first, with direct observation of breast-feeding, before considering the use observation of breast-feeding, before considering the use of supplementation.of supplementation.


A woman with normal breasts produces sufficient A woman with normal breasts produces sufficient colostrum during the last trimester and at delivery to colostrum during the last trimester and at delivery to sustain twins or a large term baby until her milk comes in.sustain twins or a large term baby until her milk comes in.

Breast-Feeding on Demand and Rooming-InBreast-Feeding on Demand and Rooming-InRooming-in and breast-feeding on demand should be an Rooming-in and breast-feeding on demand should be an integral part of routine postpartum care. Breast-feeding "on integral part of routine postpartum care. Breast-feeding "on demand" means feeding when the baby shows early signs demand" means feeding when the baby shows early signs of hunger, such as the rooting reflex, or when the baby is of hunger, such as the rooting reflex, or when the baby is awake and his or her hands are coming to the mouth. awake and his or her hands are coming to the mouth. Rooming-in allows mothers to respond to feeding cues Rooming-in allows mothers to respond to feeding cues much more effectively than a busy nurse could. Breast-much more effectively than a busy nurse could. Breast-feeding on demand promotes more frequent feeding, which feeding on demand promotes more frequent feeding, which prevents sore nipples, breast engorgement and early prevents sore nipples, breast engorgement and early weaning.weaning.


The benefits of breast milk:The benefits of breast milk:A mother’s breast milk is the preferred milk for all babies, even the A mother’s breast milk is the preferred milk for all babies, even the most premature babies. Breast milk contains all the nutrients most premature babies. Breast milk contains all the nutrients needed for growth and development. Although commercial milk needed for growth and development. Although commercial milk formulas are designed to be close to breast milk, most are based formulas are designed to be close to breast milk, most are based on cow's milk. The fats in breast milk are more easily digested. on cow's milk. The fats in breast milk are more easily digested. Formula is digested more slowly than breast milk and may not be Formula is digested more slowly than breast milk and may not be as well tolerated. In addition, breast milk contains antibodies from as well tolerated. In addition, breast milk contains antibodies from the mother to help protect babies from infection, something the mother to help protect babies from infection, something commercial formulas do not have. This protection is especially commercial formulas do not have. This protection is especially important when babies are sick or premature and may have higher important when babies are sick or premature and may have higher chances of developing an infection.chances of developing an infection.Very premature babies may need human milk fortifiers added to Very premature babies may need human milk fortifiers added to breast milk to meet their increased needs for protein, calcium, and breast milk to meet their increased needs for protein, calcium, and phosphorus. Even if baby cannot breastfeed, the mother can phosphorus. Even if baby cannot breastfeed, the mother can pump her breast milk and it can be stored for gavage or nipple pump her breast milk and it can be stored for gavage or nipple feedings. Depending on the amount of milk needed for feedings, feedings. Depending on the amount of milk needed for feedings, formula may need to be added to breast milk.formula may need to be added to breast milk.


Benefits of Breast-Benefits of Breast-FeedingFeeding

Promotes mother-infant bondingPromotes mother-infant bondingPromotes uterine involutionPromotes uterine involutionEconomical for family and societyEconomical for family and societyConvenientConvenientBetter cognitive development in childrenBetter cognitive development in childrenLower incidence of premenopausal breast cancerLower incidence of premenopausal breast cancerLower incidence of premenopausal ovarian cancerLower incidence of premenopausal ovarian cancerLower incidence of maternal osteoporosisPerceived Lower incidence of maternal osteoporosisPerceived Barriers to Breast-Feeding Loss of freedomBarriers to Breast-Feeding Loss of freedomEmbarrassmentEmbarrassmentJealousy (paternal and sibling)Jealousy (paternal and sibling)Difficulty returning to work or schoolDifficulty returning to work or schoolPhysical discomfortPhysical discomfortWeaningWeaningLack of confidence (afraid that baby is starving)Lack of confidence (afraid that baby is starving)Perception that formula is equal to breast milkPerception that formula is equal to breast milk


Hospital Discharge Hospital Discharge Breastfeeding Instructions Breastfeeding Instructions

Feed the infant on demand--on "hunger cues.“Feed the infant on demand--on "hunger cues.“Listen and feel for infant's swallowing.Listen and feel for infant's swallowing.Infant should regain birth weight by two weeks of age.Infant should regain birth weight by two weeks of age.Avoid nipple confusion by adopting this policy: three to Avoid nipple confusion by adopting this policy: three to four weeks of exclusive breastfeeding, then no more than four weeks of exclusive breastfeeding, then no more than one bottle a day, using expressed breast milk.one bottle a day, using expressed breast milk.Count wet diapers: one on day 1, two on day 2, three on Count wet diapers: one on day 1, two on day 2, three on day 3, six per day from day 6 on, with three or more stools day 3, six per day from day 6 on, with three or more stools per day.per day.Report any signs and symptoms of dehydration and Report any signs and symptoms of dehydration and jaundice.jaundice.Make use of lactation support telephone numbers.Make use of lactation support telephone numbers.Expect weight loss of <8 percent at the two- to four-day Expect weight loss of <8 percent at the two- to four-day follow-up visit. follow-up visit.


Breast-Milk ExpressionBreast-Milk ExpressionExpressing breast milk is a skill that should be taught to all Expressing breast milk is a skill that should be taught to all new mothers. Mothers should be encouraged to use only new mothers. Mothers should be encouraged to use only breast milk, not formula, when using bottles. breast milk, not formula, when using bottles. If supplementation is necessary, the baby should also be If supplementation is necessary, the baby should also be at the breast so that nipple stimulation occurs and nipple at the breast so that nipple stimulation occurs and nipple confusion is prevented. confusion is prevented. Bottle-feeding should be delayed for three to four weeks to Bottle-feeding should be delayed for three to four weeks to prevent nipple confusion and early weaning. After this time, prevent nipple confusion and early weaning. After this time, nipple confusion and premature weaning seem to be less of nipple confusion and premature weaning seem to be less of a problem if bottles are limited to about one per day. The a problem if bottles are limited to about one per day. The clinician should routinely discuss bottle use and the issue clinician should routinely discuss bottle use and the issue of nipple confusion before discharge.of nipple confusion before discharge.

Chest Thrusts for Chest Thrusts for A Pregnant WomanA Pregnant Woman



CHOKINGCHOKING

If a pregnant woman chokes on a piece of meat or any If a pregnant woman chokes on a piece of meat or any foreign object blocks the airway, attempting to dislodge the foreign object blocks the airway, attempting to dislodge the object with a sudden upward thrust to the upper abdomen object with a sudden upward thrust to the upper abdomen ( a Heimlich maneuver) is difficult. ( a Heimlich maneuver) is difficult. This is because of a lack of space between the uterus and This is because of a lack of space between the uterus and the end of the sternum and because a person cannot reach the end of the sternum and because a person cannot reach from the rear around the woman’s enlarged abdomen.from the rear around the woman’s enlarged abdomen.Late in pregnancy, therefore, therefore a rescuer might use Late in pregnancy, therefore, therefore a rescuer might use successive chest thrusts instead.successive chest thrusts instead.


CHEST THRUSTS FOR CHEST THRUSTS FOR PREGNANT WOMAN OR PREGNANT WOMAN OR

OBESE PERSONOBESE PERSONCONSCIOUSCONSCIOUS1. Stand behind the person, placing your arms under the person's armpits 1. Stand behind the person, placing your arms under the person's armpits

and around his or her chest.and around his or her chest.2. Make a fist with one hand and put the thumb side of the fist against the 2. Make a fist with one hand and put the thumb side of the fist against the

center of the person's breastbone.center of the person's breastbone.3. Make sure your thumb is on the breastbone–not the ribs–and that you are 3. Make sure your thumb is on the breastbone–not the ribs–and that you are

not near the tip of the breastbone.not near the tip of the breastbone.4. Put your other hand over the fist and give quick inward thrusts.4. Put your other hand over the fist and give quick inward thrusts.5. Continue giving thrusts until the object is dislodged.5. Continue giving thrusts until the object is dislodged.If the person becomes unconscious while you’re doing this, use the method If the person becomes unconscious while you’re doing this, use the method

for unconscious people.for unconscious people.

ONCE THE OBJECT IS DISLODGEDONCE THE OBJECT IS DISLODGEDIf the person is not breathing and has a pulse, perform rescue breathing. If If the person is not breathing and has a pulse, perform rescue breathing. If

the person is not breathing and does not have a pulse, give CPR.the person is not breathing and does not have a pulse, give CPR.


UNCONSCIOUSUNCONSCIOUS1. Kneel beside the person, placing one hand on the 1. Kneel beside the person, placing one hand on the center of the person's breastbone and then placing your center of the person's breastbone and then placing your other hand on top of it.other hand on top of it.2. Give 5 quick thrusts, compressing the chest 1 1/2 to 2 2. Give 5 quick thrusts, compressing the chest 1 1/2 to 2 inches.inches.3. Do a finger sweep (see above), open the airway with a 3. Do a finger sweep (see above), open the airway with a head tilt and a chin lift and give 2 slow breaths. If air head tilt and a chin lift and give 2 slow breaths. If air still will not go in, continue giving chest thrusts, finger still will not go in, continue giving chest thrusts, finger sweeps and 2 slow breaths until the object is expelled sweeps and 2 slow breaths until the object is expelled and air goes in.and air goes in.

Thank Thank You.You.

Maternal Health Nursing Skills

Documents

Transcript of Maternal Health Nursing Skills