A Student Manual of Clinical Skills in Obstetrics and Gynecology

Prepared by Mohamed M. F. Fathalla Lecturer of Obstetrics and Gynecology

Table of Contents
PAGE INTRODUCTION OBSTETRICS 1- History taking in obstetrics 2- Pregnancy monitoring skills Measuring blood pressure in pregnant women Measuring proteinuria using urine strips Antenatal abdominal examination 3- Labor management skills - Abdominal and vaginal examination during labor - management of the first stage of labor - Management of the second stage of labor - Active management of the third stage of labor - Perform and repair episiotomy - Repair 1st and 2nd degree perineal tears - Repair of 3rd degree perineal tears - Repair cervical laceration -Perform bimanual compression of the uterus 4- Postpartum Assessment and Care GYNECOLOGY 1- History taking in gynecology 2- Breast Examination 3- Abdominal examination 4- Genital examination 5- Taking a vaginal swab 6- Cervical inspection with Acetic acid staining 7- Contraception a) Counseling in family planning b) Fundamental concepts in contraception b) Insert and remove Cu-T 380-A intrauterine contraceptive device c) Prescribe oral contraceptive pills d) Prescribing Depot Medroxy progesterone Acetate Injection e) Inserting and removing subdermal contraceptive implants Annexes 1- The WHO medical eligibility criteria for contraceptive use 2- The WHO partograph

References

1. Shaaban M History taking (Gynecology for postgraduates: Theory and Practice)

2. Supreme Council of Universities Obstetrics and Gynecology Clinical Learning

Guides

3. The Perinatal Care Manual: Geneva Foundation for Medical Education and
Research

Introduction This manual is intended to help the students/house officers perform the basic clinical skills required for their practice in the department of Obstetrics and Gynecology. The skills are outlined as sequential steps (called the Clinical learning guide or CLG). Each CLG contains a description of the exact steps or tasks and their proper sequence, needed by the learner to competently perform each skill. These steps and tasks correlate to the consensus of international best practices, are evidence-based and performance-oriented, and have been adapted to the Egyptian context. Clinical Learning Guides are designed to be used primarily in a skill lab or other simulation environment during the early phases of learning (i.e., skill acquisition) when learners are practicing with the appropriate models or in the proper simulation situations. Subsequently, during the practice sessions, CLGs serve as step-by-step guide for the learner as s/he performs the skill. It is important to recognize that the learner is not expected to perform all the steps or tasks correctly the first time s/he practices them. If used consistently, the learning guides enable each learner to chart her/his progress and to identify areas for improvement. From these learning guides, checklists are developed that will form the basis for student/house officer evaluation. However, three points are worth noting. First, some modules needed more elaborate explanation, so, these were provided before the learning guide. Second, for other topics no learning guide was provided because they contain no "manual" skills but they were included as they are being taught in the skill lab. Examples include prescribing oral contraceptive pills. Third, the history taking part is provided here as a model sheet for use by students. It can be copied each time they present a case and just fill it. This saves a lot of their time

and effort trying to memorize history items. It also helps them structure their ideas in the sections of the present, past and family histories.

This manual intentionally draws heavily on the Supreme Counsel of University Clinical learning guides for Obstetrics and Gynecology. The part on abdominal examination is adapted from the learning guides of "Foundation skills". Logistic difficulties stood in the face of using these guides. However, all is not lost. This manual, as it is hoped, will help the students achieve a better and more enjoyable clinical experience.

Obstetrics

Pregnancy management skills

History Taking in Obstetrics

Introduction
History taking is an important skill in obstetric practice. History includes in addition to the usual historical points, specific questions about pregnancy. These peculiarities have to be considered when interviewing an obstetric case. Not all women who present to the obstetrician are ill. This makes the use of terms such as complaint or history of present illness, inappropriate. A complaint of coming for antenatal care is perfectly acceptable. However, the presence of pregnancy and its duration need to be included in the complaint. Some women have medical conditions that antedate pregnancy. The mere presence of these conditions in a pregnant woman makes pregnancy high-risk. In these women, it is important to word the complaint as follows: diabetes since 8 years and pregnant for 5 months, for example. This will allow the student to analyze the medical history in a more comprehensive manner. More peculiarities will be covered during clinical teaching. The obstetric history should include a thorough analysis of previous pregnancies. Any abnormal pregnancy should be treated as a new complaint and thoroughly analyzed regarding where it happened, outcome and possible complications. If the woman has a hospital discharge card, this should provide invaluable information. The menstrual history is also of particular importance. The date of the first day of the last menstrual period is one way of determining the expected date of delivery. The first day of the last menstrual period is considered unreliable for estimating the expected date of delivery if any of the following was present: 1- Irregular cycles precede pregnancy 2- The pregnancy took place less than 3 months after lactational amenorrhea 3- The pregnancy took place while on combined oral contraceptive pills or within 3 months after discontinuation

Case Sheet in Obstetrics

History PERSONAL HISTORY Name: Age: Residence Occupation: Marital status: Parity: Nullipara, primipara, multipara, grandmultipara Special habits: Husband's name: Age: Occupation: Special habits of medical importance Complaint (s) and duration Amenorrhea of pregnancy in months Other complaint (and their duration) MENSTRUAL HISTORY Age of menarche: Regularity: P/C: Inter-menstrual bleeding/discharge: PMS Dysmenorrhea If yes, Type?

1st day of Last menstrual period Expected date of delivery

OBSTETRIC HISTORY Gravid , Para +

Deliveries Normal Abnormal Abortions LD LA

PRESENT HISTORY Analysis of the complaint Onset Course Characters Associated symptoms (to detect causes/complications) Effects on the mother/fetus Therapeutic history PAST HISTORY Past medical history Past surgeries Blood transfusions/drug allergies FAMILY HISTORY Diabetes Hypertension Breast/ovarian cancer Twinning Pre-eclampsia

Examination General Examination: - Pulse: ____/min. Weight:___ Kg height - B.P. ____ mm Hg. - Temp. ____ C -

cm

- Head & Neck: - Breasts: - Chest & Heart: - Lower Limbs:

Abdominal Examination:

- Inspection:

- Fundal Level/Uterine Size:

- Fundal Grip:

- Umbilical Grip:

- Pelvic Grip:

- Uterine Contractions:

- F.H.S.:

Pelvic Examination: - V & V: - Cervical Dilatation: cm - Membranes: - P.P.: - Position: - Effacement:

- Station:

- Bony Pelvis:

Diagnosis:

G ____,

P____, ____ Weeks Pregnant, _______ Presentation,

______ Labor, Associated with:

Learning guide ANTENATAL HISTORY TAKING AND EXAMINATION First visit GETTING READY 1. Make sure that the clinic is ready: clean, tidy, sphygnomanometre, sonicaid and weight scale are available and calibrated. 2. Hand washing and drying. 3. Greet the lady, introduce yourself and offer her a seat. 4. Explain what you are going to do to the client, obtain consent and listen to her carefully. HISTORY Personal History Obtaining the following information from the client:

Name,Age, Occupation, Residence, Marital status, Gavidity, parity, living offspring (males/females), and Special habits of medical importance

(smoking or any other harmful substances) Complaint Major cause of seeking medical advice if she is not coming for her regular antenatal visits. Menstrual and Contraceptive History Date of the first day of the last menstrual period-------expected date of delivery Reliability of the cycle (irregularities before, lactational amenorrhea before or COCs < 2 months before Obstetric History Gravidity, parity (para + ) Each pregnancy (if ended in delivery): pregnancy(duration and any complication), Delivery (type, where, who attended and any complications), newborn (sex, weight, wellbeing, jaundice, congenital anomalies), puerperium (bleeding or pyrexia) and lactation (breast or bottle, duration and any problems) Each pregnancy (if ended in abortion): Duration, spontaneous or induced, followed by surgical evacuation/curettage or not, postabortive period (bleeding or pyrexia) Date of last delivery/last abortion

History of the present pregnancy A-How many (weeks/months) her pregnancy is? When was her +ve pregnancy test (in blood or urine)? Analysis of complaints if any. B-Warning symptoms of pregnancy C- Symptoms of other systems D- Investigations and treatment: Asking about any investigations done during (recently before or related to) her current pregnancy. Asking about any previous medical advice regarding current pregnancy Any medications received during this pregnancy or currently regularly on. Past History Medical disease: (do not forget Hypertension, DM) Previous surgeries: type, date, where and any complications Allergy to medications Family History Medical disease: DM, hypertension Consanguinity Hereditary or congenital disease Twins Examination a- examine the look of the patient, especially the gait b- examine vital signs c- examine the face, neck, chest and heart d- abdominal exam (refer to the learning guide) Tell the woman the date of the next visit

Antenatal history: repeat visit GETTING READY 1. Make sure that the clinic is ready: clean, tidy, sphygmomanometer, sonicaid and weight scale are available and calibrated. 2. Hand washing and drying. 3. Greet the lady, introduce yourself and offer her a seat. 4. Explain what you are going to do to the client, obtain consent and listen to her carefully. HISTORY Note: Flexibility may be used with respect to the order in which the questions are asked. History of the present pregnancy A- Analysis of complaints if any. B-Warning symptoms of pregnancy C- Ask about fetal movements/rate of fetal growth D- Investigations and treatment: Asking about any investigations done during (recently before or related to) her current pregnancy. Asking about any previous medical advice regarding current pregnancy Any medications received during this pregnancy or currently regularly on. Tell the woman the date of the next visit

Measuring blood pressure

MEASURING BLOOD PRESSURE AND PROTEINURIA DURING PREGNANCY

(I) MEASURING BLOOD PRESSURE

A THE STANDARDISED METHOD OF MEASURING BLOOD PRESSURE. The following are important if you want to measure the blood pressure accurately: 1. The right upper arm is used. 2. The arm is better taken out of the sleeve. 3. The patient should sit on a chair or lie to one side. 4. Take the blood pressure after a 5 minute period of rest. 5. The cuff must be applied correctly. If the patient is sitting in a chair, the blood pressure apparatus must be at the same level as her upper arm and the right side of the heart. 6. The systolic blood pressure is taken at Korotkoff phase 1. 7. The diastolic blood pressure is taken at Korotkoff phase 5.

B USE THE RIGHT ARM. The examination couches in most clinics stand with their left side against a wall as it is most convenient for a right handed person to examine the right side of the patient. The lower arm (i.e. the right arm if she is lying on her right side) should be used, as the upper arm will give false low readings as it is above the level of the heart. The arm must be fully undressed so that the cuff can be correctly applied. C THE PATIENT MUST NOT LIE ON HER BACK. The patient should lie down on her side or sit. Lying on her back may cause hypotension, giving a falsely low reading. She should also lie slightly turned onto her side. Lying on her back may cause the uterus to press on the inferior vena cava

resulting in a decreased return of blood to the heart and a drop in blood pressure. A false low blood pressure may, therefore, be recorded.

D ALLOW THE PATIENT TO REST FOR 5 MINUTES BEFORE MEASURING THE BLOOD PRESSURE. Anxiety and the effort of climbing onto the couch often increase the blood pressure. This will usually return to a resting value if the patient can lie down and relax for 5 minutes.

E HOW TO APPLY THE CUFF. A standard size cuff (width of 14.5 cm) is usually used. If the arm is very fat, then use a wide cuff (17.5 cm) to get a correct reading. The cuff must be applied firmly around the arm, not allowing more than 1 finger between the cuff and the patient's arm.

F: LISTENING TO THE PULSE. The cuff should be pumped up with a finger feeling the brachial or radial pulse. Only when the pulse can no longer be felt, should the stethoscope be put over the brachial pulse and the pressure released slowly.

G RECOGNISING THE KOROTKOFF PHASES 1 AND 5. The Kortokoff phases are times when the sound of the pulse changes during the measurement of the blood pressure: PHASE 1 is the first sound which you hear after the cuff pressure is released. This indicates the systolic pressure. PHASE 5 is the time when the sound of the pulse disappears. Usually the sound gets softer before it disappears but sometimes it disappears without first becoming softer.

However, in all cases the diastolic blood pressure must be read when the sound of the pulse disappears. (II) MEASURING PROTEINURIA MEASURING THE AMOUNT OF PROTEINURIA. The amount of protein in a sample of urine is simply and easily measured with a plastic, reagent strip. GRADING THE AMOUNT OF PROTEINURIA. Using a reagent strip the amount of proteinuria is graded as follows: 1+ = 0,3 g/l 2+ = 1,0 g/l 3+ = 3,0 g/l 4+ = 10 g/l Remember that a trace (0.1g/l) of protein is not regarded as significant proteinuria and may occur normally.

THE USE OF A REAGENT STRIP TO MEASURE THE AMOUNT OF PROTEINURIA. 1. Collect a fresh specimen of urine. 2. Remove a reagent strip from the bottle and replace the cap. 3. Dip the strip into the urine so that all the test areas are completely covered, then immediately remove the strip. 4. Wait 60 seconds. 5. Hold the strip horizontally and compare with the color blocks on the side of the bottle. Hold the strip close to the bottle to match the colors but do not rest it on the bottle as the urine will damage the color chart. The darker the color of the reagent strip, the greater is the amount of proteinuria.

Clinical Learning Guide

Measuring Blood Pressure in Adults STEP/TASK Preparing the patient 1. Ask the patient to relax in a supine position (before 12 weeks). After 12 weeks measure the blood pressure in the sitting position. Instruct the patient to support the back; uncross the legs and rest the feet flat on the floor. 2. Wait for 5 minutes. 3. Prepare equipment (stethoscope and mercury or aneroid sphygmomanometer) 4. Measure the radial pulse on both sides, if pulses are equal, use the right arm for blood pressure measurement; if pulses are unequal, use the arm with the stronger pulse. 5. Uncover the identified arm. The arm should be abducted and supinated. 6. Choose the correct cuff size : The cuff-bladder should cover at least 40% of the circumference and 80% of the length of the upper arm 7. Wrap the cuff around the mid arm 8. Align the cuffed arm to the level of the heart Measuring the Blood Pressure 1. Place the cuff around the upper arm with the lower edge of the cuff, with its tubing connections, placed about one inch above the antecubital space across the inner aspect of the elbow. 2. Wrap the cuff snuggly around the inflatable inner bladder centered over the area of the brachial artery 3. Close the valve 4. Inflate the cuff while palpating the radial pulse. Inflate the cuff rapidly to 70 mmHg then 10 mmHg at time till the pulse is no longer felt (The pulse obliteration pressure). This is the approximate systolic blood pressure. 5. Deflate the cuff 6. Add 20-30 mm Hg to that number to know the maximum inflation level (MIL). 7. Place the earpieces of the stethoscope into ears, with the earpiece angles turned forward toward the nose. 8. Palpate the brachial artery.

9. Apply the bell (or diaphragm in obese arm) of the stethoscope over the brachial artery, just below the cuff. (Avoid touching the cuff or tubing) 10. Close the valve. 11. Inflate the cuff rapidly to the MIL while focusing eyes to the level of the midrange of the manometer scale. 12. Open the valve slightly and maintain a constant rate of deflation at approximately 2mm per second. 13. Allow the cuff to deflate 14. Listen throughout the entire range of deflation until 10mm Hg below the level of the diastolic reading. The systolic reading (Korotkov I) will be the first loud sound to be heard. The sudden reduction of sound will be (Korotkov IV).

The diastolic reading (Korotkov V) will be the disappearance* of the sound. 15. Deflate the cuff fully by opening the valve. 16. Remove the stethoscope earpieces from the ears. 17. Record the exact readings in mm Hg.

Antenatal abdominal examination

EXAMINATION OF THE ABDOMEN IN PREGNANCY

OBJECTIVES

1. Determine the gestational age from the size of the uterus. 2. Measure the symphysis-fundus height. 3. Assess the lie and the presentation of the fetus. 4. Assess the amount of liquor present. 5. Listen to the fetal heart. 6. Assess fetal movements. 7. Assess the state of fetal well being.

There are 2 main parts to the examination of the abdomen: 1. General examination of the abdomen. 2. Examination of the uterus and the fetus.

GENERAL EXAMINATION OF THE ABDOMEN

A) PREPARATION OF THE PATIENT FOR EXAMINATION. 1. The patient should have an empty bladder. 2. She should lie comfortably on her back with a pillow under her head. She should not lie slightly turned to the side, as is needed when the blood pressure is being taken.

B) GENERAL APPEARANCE OF THE ABDOMEN.

The following should be specifically looked for and noted: 1. The presence of obesity. 2. The presence or absence of scars. When a scar is seen the reason for it should be specifically asked for (e.g. what operation did you have?), if this has not already become clear from the history. 3. The apparent size and shape of the uterus. 4. Any other abnormalities.

C) PALPATION OF THE ABDOMEN. 1. The liver, spleen and kidneys must be specifically palpated (felt) for. 2. Any other abdominal mass should be noted. The presence of an enlarged organ, or a mass, should be reported to the responsible doctor, and the patient should then be assessed by the doctor.

EXAMINATION OF THE UTERUS AND THE FETUS D PALPATION OF THE UTERUS. 1. Check whether the uterus is lying in the midline of the abdomen. Sometimes it is rotated to either the right or the left. 2. Feel the wall of the uterus for irregularities. An irregular uterine wall suggests either: (i) The presence of myomas (fibroids) which usually enlarge during pregnancy and may become painful. (ii) A congenital abnormality such as a bicornuate uterus.

Figure (1) Determining the fundal height.

E DETERMINING THE SIZE OF THE UTERUS BEFORE 18 WEEKS GESTATION.

1. Anatomical landmarks are used, i.e. the symphysis pubis and the umbilicus. 2. Gently palpate the abdomen with the left hand to determine the height of the fundus of the uterus: (i) If the fundus is palpable just above the symphysis pubis, the gestational age is probably 12 weeks. (ii) If the fundus reaches half way between the symphysis and the umbilicus, the gestational age is probably 16 weeks. (iii) If the fundus is at the same height as the umbilicus, the gestational age is probably 22 weeks (one finger under the umbilicus = 20 weeks and one finger above the umbilicus = 24 weeks).

Figure 2. Determining the uterine size before 24 weeks.

F DETERMINING THE HEIGHT OF THE FUNDUS FROM 18 WEEKS GESTATION. The symphysis-fundus height should be measured as follows: 1. FEEL FOR THE FUNDUS OF THE UTERUS. This is done by starting to gently palpate from the lower end of the sternum. Continue to palpate down the abdomen until the fundus is reached. When the highest part of the fundus has been identified, mark the skin at this point with a pen. If the uterus is rotated away from the midline, the highest point of the uterus will not be in the midline but will be to the left or right of the midline. Therefore, also palpate away from the midline to make sure that you mark the highest point at which the fundus can be palpated. Do not move the fundus into the midline before marking the highest point.

Figure (2) Measuring the symphysis-fundus height.

2. MEASURE THE SYMPHYSIS-FUNDUS (S-F) HEIGHT. Having marked the fundal height, hold the end of the tape measure at the top of the symphysis pubis. Lay the tape measure over the curve of the uterus to the point marking the top of the uterus. The tape measure must not be stretched while doing the measurement. Measure this distance in centimetres from the symphysis pubis to the top of the fundus. This is the symphysis-fundus height. 3. If the uterus does not lie in the midline but, for example, lies to the right, then the distance to the highest point of the uterus must still be measured WITHOUT moving the uterus into the midline. Having determined the height of the fundus, you need to assess whether the height of the fundus corresponds to the patient's dates, and to the size of the fetus. From 18 weeks, the S-F height must be plotted on the SF growth curve to determine the gestational age. This method is, therefore, only used once the fundal height has reached 18 weeks. In other words when the S-F height has reached two fingers width under the umbilicus.

G PALPATION OF THE FETUS. The lie and presenting part of the fetus only becomes important when the gestational age reaches 34 weeks. The following must be determined:

1. THE LIE OF THE FETUS. This is the relationship of the long axis of the fetus to that of the mother. The lie may be longitudinal, transverse, or oblique. 2. THE PRESENTATION OF THE FETUS. This is determined by the presenting part: (i) If there is a breech, it is a breech presentation. (ii) If there is a head, it is a cephalic presentation or a transverse lie. 3. THE POSITION OF THE BACK OF THE FETUS. This refers to whether the back of the fetus is on the left or right side of the uterus, and will assist in determining the position of the presenting part.

H) METHODS OF PALPATION. There are 4 specific steps for palpating the fetus. These are performed

systematically. With the mother lying comfortably on her back, the examiner faces the patient for the first 3 steps, and faces towards her feet for the fourth. 1. FIRST STEP: Having established the height of the fundus, the fundus itself is gently palpated with the fingers of both hands, in order to discover which pole of the fetus (breech or head) is present. The head feels hard and round, and is easily movable and ballotable. The breech feels soft, triangular and continuous with the body. 2. SECOND STEP. The hands are now placed on the sides of the abdomen. On one side there is the smooth, firm curve of the back of the fetus, and on the other side the rather knobby feel of the fetal limbs. It is often difficult to feel the fetus well when the patient is obese, when there is a lot of liquor or when the uterus is tight, as in some primigravidas. 3. THIRD STEP. The examiner grasps the lower portion of the abdomen, just above the symphysis pubis, between the thumb and fingers of one hand. The objective is to feel for the presenting part of the fetus and to decide whether the presenting part is loose above the pelvis or fixed in the pelvis. If the head is loose above the pelvis, it

can be easily moved and balloted. The head and breech are differentiated in the same way as in the first step. 4. FOURTH STEP. The objective of the step is to determine the amount of head palpable above the pelvic brim, if there is a cephalic presentation. The examiner faces the patient's feet, and with the tips of the middle 3 fingers palpates deeply in the pelvic inlet. In this way the head can usually be readily palpated, unless it is already deeply in the pelvis. The amount of the head palpable above the pelvic brim can also be determined.

Figure (3) The 4 steps in palpating the fetus.

I) SPECIAL POINTS ABOUT THE PALPATION OF THE FETUS. 1. When you are palpating the fetus, always try to assess the size of the fetus itself. Does the fetus fill the whole uterus, or does it seem to be smaller than you would expect for the size of the uterus, and the duration of pregnancy? A fetus which feels smaller than you would expect for the duration of pregnancy, suggests intra-uterine growth restriction, while a fetus which feels smaller than expected for the size of the uterus, suggests the presence of a multiple pregnancy. 2. If you find an abnormal lie when you palpate the fetus, you should always consider the possibility of a multiple pregnancy. When you suspect that a patient might have a multiple pregnancy, she should have an ultrasound examination.

J) SPECIAL POINTS ABOUT THE PALPATION OF THE FETAL HEAD. 1. DOES THE HEAD FEEL TOO SMALL FOR THE SIZE OF THE UTERUS? You should always try to relate the size of the head to the size of the uterus and the duration of pregnancy. If it feels smaller than you would have expected, consider the possibility of a multiple pregnancy. 2. DOES THE HEAD FEEL TOO HARD FOR THE SIZE OF THE FETUS? The fetal head feels harder as the pregnancy gets closer to term. A relatively small fetus with a hard head suggests the presence of intra-uterine growth retardation.

K) ASSESSMENT OF THE AMOUNT OF LIQUOR PRESENT. This is not always easy to feel. The amount of liquor decreases as the pregnancy nears term. The amount of liquor is assessed clinically by feeling the way that the fetus can be moved (balloted) while being palpated. 1. If the liquor volume is reduced (oligohydramnios), it suggests that: (i) There may be intra-uterine growth retardation.

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(ii) There may be a urinary tract obstruction or some other urinary tract abnormality in the fetus. This is uncommon. 2. If the liquor volume is increased (polyhydramnios), it suggests that one of the following conditions may be present: (i) Multiple pregnancy. (ii) Maternal diabetes. (iii) A fetal abnormality such as spina bifida, anencephaly or oesophageal atresia. In many cases, however, the cause of polyhydramnios is unknown. All of these can be serious problems, and the patient should be referred to a hospital where the fetus can be carefully assessed. The patient needs an ultrasound examination by a trained person to exclude multiple pregnancy, or a congenital abnormality in the fetus.

L) ASSESSMENT OF UTERINE IRRITABILITY. This means that the uterus feels tight, or has a contraction, while being palpated. Uterine irritability normally only occurs after 36 weeks of pregnancy, i.e. near term. If there is an irritable uterus before this time, it suggests either that there is intra-uterine growth retardation or that the patient may be in, or is likely to go into, preterm labor.

M) LISTENING TO THE FETAL HEART. 1. WHERE SHOULD YOU LISTEN? The fetal heart is most easily heard, by listening over the back of the fetus. This means that the lie and position of the fetus must be established by palpation before listening for the fetal heart. 2. WHEN SHOULD YOU LISTEN TO THE FETAL HEART? You need only listen to the fetal heart if a patient has not felt any fetal movements during the day. Listening to the fetal heart is, therefore, done to rule out an intra-uterine death. 3. HOW LONG SHOULD YOU LISTEN FOR? You should listen long enough to be sure that what you are hearing is the fetal heart and not the mother's heart.

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When you are listening to the fetal heart, you should, at the same time, also feel the mother's pulse.

N) ASSESSMENT OF FETAL MOVEMENTS. The fetus makes 2 types of movement: 1. KICKING movements, which are caused by movement of the limbs. These are usually quick movements. 2. ROLLING movements, which are caused by the fetus changing position. When you ask a patient to count her fetal movements, she must count both types of movement. If there is a reason for the patient to count fetal movements and to record them on a fetal movement chart it should be done as follows: 1. TIME OF DAY: Most patients find that the late morning is a convenient time to record fetal movements. However, she should be encouraged to choose the time which suits her best. She will need to rest for an hour. It is best that she use the same time every day. 2. LENGTH OF TIME: This should be for 1 hour per day, and the patient should be able to rest and not be disturbed for this period of time. Sometimes the patient may be asked to rest and count fetal movements for 2 or more half hour periods a day. The patient must have access to a watch or clock, and know how to measure half and one hour periods. 3. POSITION OF THE PATIENT: She may either sit or lie down. If she lies down, she should lie on her side. In either position she should be relaxed and comfortable.

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Clinical learning guide Abdominal examination in a pregnant woman STEP / TASK Getting Ready Ask the patient to empty her bladder. Ask the woman to lie on her back on the examination table with her knees slightly flexed to relax her abdominal muscles and uncover her abdomen.

1. 2.

3. Stand on the right side of the patient. 4. Warm your hands if cold by rubbing them together.
The Procedure

1. Inspect the abdomen (visually) for size, contour, scars of previous

operations, skin pigmentation (linea nigra), stretch marks (stria gravidara), divercation of the recti, hernia (umbilical, inguinal or femoral), fetal movements, grooves (above or below the umbilicus). 2. Palpate the whole abdomen gently with the palmer surface of your fingers for tenderness, rigidity or contractility of the uterus while keeping eye contact with your patient. Check for any other abdominal mass. 3. Palpate specifically for the liver, spleen and kidneys. 1. Palpate the uterus gently. Check whether the uterus is lying in the midline of the abdomen. Sometimes it is rotated to either the right or the left. Feel the wall of the uterus for irregularities. An irregular uterine wall suggests either; the presence of myomas or a congenital abnormality such as bicornuate uterus. 2. Fundal Height Determination

Before 20 weeks gestation; by gently palpating the abdomen with the ulnar border of the left hand to determine the height of the fundus of the uterus. Anatomical landmarks are used, i.e. the symphysis pubis and the umbilicus.

After 20 weeks gestation; determine the fundal level by gently palpating the abdomen with the left hand to determine the height of the fundus of the uterus starting from the xiphisternum and determine how many fingerbreadth is the fundus below the xiphisternum. Alternatively, determine the symphysis-fundus height. Gently palpate for the fundus of the uterus by

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STEP / TASK the ulnar side of left hand starting from the lower end of the sternum and moving down the abdomen until the highest part of the fundus is reached and mark this point. If the uterus is dextro-posed, centralize the uterus before estimating the S_P height. Hold the end of the tape measure at the top of the symphysis pubis and lay it over the curve of the uterus to the point marking the top of the uterus.

3. Palpation of the fetus (to determine the lie, presentation and position)
becomes important when the gestational age reaches 32-34 weeks. There are 4 specific steps for palpating the fetus (historically known as Leopolds Maneuvers). These are performed systematically. With the mother lying comfortably on her back, the examiner faces the patient for the first three

steps and faces toward her feet for the fourth. First step (maneuver) Fundal Grip: The objective is to identify the fetal pole which occupies the fundus. Having established the height of the fundus, place both hands on the sides of the fundus and palpate its content. The head feels hard and round and is easily movable and ballotable. The breech feels

soft, triangular and continuous with the body. Second step (maneuver) Lateral or Umbilical Grip: The objective is to identify the position of the fetal back. The hands are now placed on the sides of the abdomen (uterus) at about the level of the umbilicus. Keep one hand steady against one side of the uterus while using palm of the other hand to palpate the opposite side of uterus. Repeat the procedure by alternating hands. On one side there is the smooth firm curve of the back of the fetus,

and on the other side the rather knobby feel of the fetal limbs. Third step (maneuver) First Pelvic Grip or Pawlick Grip: The objective is to feel the presenting part of the fetus and to decide whether the presenting part is loose above the pelvis or fixed in the pelvis. Grasp the lower portion of the abdomen, just above the symphysis pubis, between the thumb and fingers of the right hand. The head and breech are differentiated in the same way as in the first step.

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STEP / TASK Fourth step (maneuver) Second Pelvic Grip: The objective is to determine the amount of head palpable above the pelvic brim if there is a cephalic presentation and to detect any deflexion of the head. Face the womans feet, and with the tips of the middle three fingers of both hands palpate deeply in the pelvic inlet (try to insert your fingers between the presenting part and the symphysis pubis).

4. Auscultation of Fetal Heart Sounds Place the transducer of the doppler vertically on the abdomen below the
umbilicus in cephalic presentation on the side you palpated the fetal back. Listen at or above the level of the umbilicus on the side of the fetal back in breech presentation. Rotate the handle of the transducer slowly in a circular motion, while widening the circle until you hear the fetal heart tone. If you are using a fetal stethoscope Pinard Stethoscope, place the opening of the cone vertically on the abdomen as in the previous step and place your good ear on the other end of the stethoscope. Take your hand off the stethoscope so that it is only held in place by your head. Move your head slowly in a circular manner until you can hear the fetal heart. Listen to fetal heart for a full minute, counting beats against the seconds hand of your watch to determine the heart rate. Feel the woman's pulse simultaneously to ensure that what you are hearing is the fetal and not the maternal heart. Post-procedure Wash your hand Explain the findings to the woman and record them in her antenatal card or your records

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Labor management skills

38

Abdominal and vaginal examination during labor

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Introduction Management of the first stage of labor is an extremely important skill for the obstetrician. However, this is not a single procedure. This does not enable the application of a single learning guide. The role of the obstetrician during labor is to monitor the progress of labor, maternal condition, and fetal condition, ensure the well-being of the mother and fetus and take decision as to when, where (by referral if in a primary facility) and how the delivery should take place. Covering all skills is beyond the scope of this book but some of the basic skills will be covered, namely examination during labor and oxytocin augmentation and amniotomy.

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I) EXAMINATION OF THE ABDOMEN IN LABOUR

OBJECTIVES When you have completed this, you should be able to: 1. Assess the size of the fetus. 2. Determine the fetal lie and presentation. 3. Determine the descent of the head. 4. Grade the uterine contractions.

A WHEN SHOULD YOU EXAMINE THE ABDOMEN OF A PATIENT WHO IS IN LABOUR? The abdominal examination forms an important part of every complete physical examination in labor. The examination is done: 1. On admission. 2. Before EVERY vaginal examination. 3. At any other time when it is considered NECESSARY.

B WHAT IS TO BE ASSESSED ON EXAMINATION OF THE ABDOMEN OF A PATIENT WHO IS IN LABOUR? 1. The shape of the abdomen. 2. The height of the fundus. 3. The size of the fetus. 4. The lie of the fetus. 5. The presentation of the fetus 6. The fetal heart rate pattern. 7. The descent and engagement of the head. 8. The presence or absence of hardness and tenderness of the uterus. 9. The contractions.

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C SHAPE OF THE ABDOMEN. It is helpful to look at the shape and contour of the abdomen. 1. The shape of the uterus will be oval with a singleton pregnancy and a longitudinal lie. 2. The shape of the uterus will be round with a multiple pregnancy or polyhydramnios. 3. A "flattened" lower abdomen suggests a vertex presentation with an occipito-posterior position (ROP or LOP). 4. A suprapubic bulge suggests a full bladder. D HEIGHT OF THE FUNDUS. Check if the height of the fundus is in keeping with the patient's dates and the findings at previous antenatal attendances. E SIZE OF THE FETUS. This is best done by feeling the size of the fetal head. Is the size of the fetus in keeping with the patient's dates and the size of the uterus? A fetus whose head feels smaller than expected may be due to: 1. Incorrect dates. 2. Intra-uterine growth retardation. 3. Multiple gestation.

F LIE AND PRESENTATION OF THE FETUS. It is important to know whether the lie is longitudinal (cephalic or breech presentation), oblique, or transverse. With an abnormal lie, there is an increased risk of umbilical cord prolapse. An abnormal lie may suggest that there is a multiple pregnancy or a placenta previa. It is also important to know the presentation of the fetus. If a breech presentation is present, it must be decided whether a vaginal delivery is possible. With breech presentation, there is an increased risk of cord prolapse or a placenta previa.

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G PRESENTATION OF THE FETUS. If the presentation is cephalic, it is sometimes possible when palpating the abdomen to determine the presenting part of the fetal head (vertex, face or brow). The following figure indicates some features that can assist you in determining the presentation:

Figure (1) differentiating Vertex, face and brow presentations. H FETAL HEART RATE PATTERN.

I DESCENT AND ENGAGEMENT OF THE HEAD This assessment is an essential part of EVERY examination of a patient in labor. The descent and engagement of the head is an important part of assessing the progress of labor and must be assessed before each vaginal examination. The amount of descent and engagement of the head is assessed by feeling how many fifths of the head are palpable ABOVE the brim of the pelvis: 1. 5/5 of the head palpable mean that the whole head is above the brim of the pelvis. 2. 4/5 of the head palpable means that a small part of the head is below the brim of the pelvis and can be lifted out of the pelvis with the deep pelvic grip. 3. 3/5 of the head palpable means that the head cannot be lifted out of the pelvis. On doing the deep pelvic grip, your fingers will move outwards from the neck of the fetus, then inwards before reaching the pelvic brim.

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4. 2/5 of the head palpable means that most of the head is below the pelvic brim, and on doing the deep pelvic grip, your fingers only splay outwards from the fetal neck to the pelvic brim. 5. 1/5 of the head palpable means that only the tip of the fetal head can be felt above the pelvic brim. It is very important to be able to distinguish between 3/5 and 2/5 head palpable above the pelvic brim. If only 2/5 of the head is palpable, then engagement has taken place and the possibility of disproportion at the pelvic inlet can be ruled out.

Figure (2) determining the head station abdominally

J HARDNESS AND TENDERNESS OF THE UTERUS. A uterus may be regarded as abnormally hard: 1. When it is difficult to palpate fetal parts. 2. When the uterus feels harder than usual. This may occur: 1. In some primigravidas. 2. During a contraction. 3. When there is abruptio placentae.

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4. When the uterus has ruptured. When there is both hardness and tenderness of the uterus, without period of relaxation during which the uterus is not tender, the commonest causes are: 1. An abruptio placentae. 2. A ruptured uterus. Therefore, there is likely to be a serious problem if the uterus is harder than normal AND there is also tenderness without periods of relaxation. Hardness or tenderness of the uterus must be reported immediately.

K CONTRACTIONS. Contractions can be felt by placing a hand on the abdomen and feeling when the uterus becomes hard, and when it relaxes. It is, therefore, possible to assess the length of the contractions by taking the time at the beginning and end of the contraction. The strength of contractions is assessed by measuring their duration, and also the frequency with which they occur in a period of 10 minutes.

L GRADING THE DURATION OF CONTRACTIONS. 1. Contraction lasting less than 20 seconds ("weak contractions"). 2. Contractions lasting 20-40 seconds ("moderate contractions") 3. Contractions lasting more than 40 seconds ("strong contractions").

Figure (3) Method of grading the duration of uterine contractions for recording on the partogram.

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II) VAGINAL EXAMINATION IN LABOUR

OBJECTIVES 1. Perform a complete vaginal examination during labor. 2. Assess the state of the cervix. 3. Assess the presenting part. 4. Assess the size of the pelvis.

PREPARATION FOR A VAGINAL EXAMINATION IN LABOUR 2A EQUIPMENT FOR A STERILE VAGINAL EXAMINATION. A sterile tray is needed. This should contain: 1. Swabs. 2. Tap water for swabbing. 3. Sterile gloves. 4. A suitable instrument for rupturing the membranes. 5. An antiseptic vaginal cream or sterile lubricant. An ordinary surgical glove can be used and the patient does not need to be swabbed, if the membranes have not ruptured yet and are not going to be ruptured during the examination.

2 B PREPARING THE PATIENT FOR A STERILE VAGINAL EXAMINATION. 1. Explain to the patient what examination is to be done, and why it is going to be done. 2. The patient needs to know that it will be an uncomfortable examination, and sometimes even a little painful. 3. The patient should lie on her back, with her legs flexed and knees apart. Do not expose the patient until you are ready to examine her. It is sometimes necessary to examine the patient in the lithotomy position.

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4. The patient's vulva and perineum are swabbed with tap water. This is done by first swabbing the labia majora and groin on both sides and then swabbing the introitus while keeping the labia majora apart with your thumb and forefinger.

2 C PREPARATION NEEDED BY THE EXAMINER. 1. The person to do the vaginal examination must have either scrubbed or thoroughly washed his/her hands. 2. Sterile gloves must be worn. 3. The examiner must THINK about the findings and their significance for the patient and the management of her labor. PROCEDURE OF EXAMINATION A vaginal examination in labor is a systematic examination, and the following should be assessed: 1. Vulva and vagina. 2. Cervix. 3. Membranes. 4. Liquor. 5. Presenting part. 6. Pelvis.

THE VULVA AND VAGINA

IMPORTANT ASPECTS OF THE EXAMINATION OF THE VULVA AND VAGINA. This examination is particularly important when the patient is first admitted: 1. When you examine the vulva you should look for ulceration, varices and any perineal scarring or rigidity. 2. When you examine the vagina, the presence or absence of the following features should be noted:

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(i) A vaginal discharge. (ii) A full rectum. (iii) A vaginal stricture or septum. (iv) Presentation or prolapse of the umbilical cord. 3. A speculum examination, NOT a digital examination, must be done if it is thought that the patient has preterm or prelabor rupture of the membranes.

THE CERVIX When you examine the cervix you should observe: 1. Length. 2. Dilatation. E MEASURING CERVICAL LENGTH. The cervix becomes progressively shorter in early labor. The length of the cervix is measured by assessing the length of the endocervical canal. This is the distance between the internal os and the external os on digital examination. The endocervical canal of an uneffaced cervix is approximately 3 cm long, but when the cervix is fully effaced there will be no endocervical canal, only a ring of thin cervix. The length of the cervix is measured in centimeters. In the past the term "cervical effacement" was used and this was measured as a percentage.

F- DILATATION. Dilatation must be assessed in centimeters, and is best measured by comparing the degree of separation of the fingers on vaginal examination, with the set of circles in the labor ward. In assessing the dilatation of the cervix, it is easy to make 2 mistakes: 1. If the cervix is very thin, it may be difficult to feel, and the patient may be said to be fully dilated, when in fact she is not.

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2. When feeling the rim of the cervix, it is easy to stretch it, or pass the fingers through the cervix and feel the rim with the side of the fingers. Both of these methods cause the recording of dilatation to be more than it really is. The correct method is to place the tips of the fingers on the edges of the cervix.

Figure (4) The correct method of measuring cervical dilatation.

THE MEMBRANES AND LIQUOR G ASSESSMENT OF THE MEMBRANES. Rupture of the membranes may be obvious if there is liquor draining. However, one should always feel for the presence of membranes overlying the presenting part. If the presenting part is high, it is usually quite easy to feel intact membranes. It may be difficult to feel them if the presenting part is well applied to the cervix. In this case, one should wait for a contraction, when some liquor often comes in front of the presenting part, allowing the membranes to be felt. Sometimes the umbilical cord can be felt in front of the presenting part (a cord presentation). THE PRESENTING PART An abdominal examination must have been done before the vaginal examination to determine the lie of the fetus and the presenting part. If the presenting part is

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the fetal head, the number of fifths palpable above the pelvic brim must first be determined. When palpating the presenting part on vaginal examination, there are 4 important questions that you must ask yourself: 1. What is the PRESENTING PART, e.g. head, breech or shoulder? 2. If the head is presenting, what is the PRESENTATION, e.g. vertex, brow or face presentation? 3. What is the POSITION of the presenting part in relation to the mother's pelvis? 4. If the presentation is vertex brow, is MOULDING present?

The presenting part is usually the head but may be the breech, the arm, or the shoulder. 1. FEATURES OF A VERTEX PRESENTATION. The posterior fontanel is normally felt. It is a small triangular space. In contrast, the anterior fontanel is diamond shaped. If the head is well flexed, the anterior fontanel will not be felt. If the anterior fontanel can be easily felt, the head is deflexed.

Figure 5. Features of a vertex presentation.

2. FEATURES OF A FACE PRESENTATION. On abdominal examination the presenting part is the head. However, on vaginal examination: (i) Instead of a firm skull, something soft is felt.

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(ii) The gum margins distinguish the mouth from the anus. (iii) The cheek bones and the mouth form a triangle. (iv) The orbital ridges above the eyes can be felt. (v) The ears may be felt.

Figure 6 Features of a face presentation.

3. FEATURES OF A BROW PRESENTATION. The presenting part is high. The anterior fontanels felt is on one side of the pelvis, the root of the nose on the other side, and the orbital ridges may be felt laterally. Figure 7. Features of a brow presentation.

If the presenting part is not the head, it could be either a breech or a shoulder.

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NOTE THAT IN A FACE OR BROW PRESENTATION, THE PRESENTING PART LOOKS MUCH LOWER THAN ITS ACTUAL STATION. ALWAYS PALPATE THE BONY LANDMARKS NOT THE SOFT TISSUE 4. FEATURES OF A BREECH PRESENTATION. On abdominal examination the presenting part is the breech. (Soft and triangular). On vaginal examination: (i) Instead of a firm skull, something soft is felt. (ii) The anus does not have gum margins. (iii) The anus and the ischial tuberosities form a straight line. Figure (8) Features of a breech presentation.

5. FEATURES OF A SHOULDER PRESENTATION. On abdominal examination the lie will be transverse or oblique. Features of a shoulder presentation on vaginal examination will be quite easy if the arm has prolapsed. The shoulder is not always that easy to identify, unless the arm can be felt. The presenting part is usually high. DETERMINING THE POSITION OF THE PRESENTING PART. Position means the relationship of a fixed point on the presenting part (i.e. the point of reference or the denominator) to the mother's pelvis. The position is determined on vaginal examination. 1. In a vertex presentation the point of reference is the posterior fontanel (i.e. the occiput). 2. In a face presentation the point of reference is the chin (i.e. the mentum). 3. In a breech presentation the point of reference is the sacrum of the fetus.

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Figure 9. Examples of the position of the presenting part with the patient lying on her back.

DETERMINING THE DESCENT AND ENGAGEMENT OF THE HEAD. Descent and engagement of the head is assessed on abdominal and not on vaginal examination. The head station vaginally is determined by the relation of the lowermost part to the ischial spines. When the lowermost part is at the ischial spine, it is said that the head is station zero, 1 cm above minus one, 2 cm above minus two and so on. If the lowermost part is 1 cm below the presenting part, the head is said to be at station plus one, 2 cm plus two and so on. The head is on the perineum when it is 5 cm below the ischial spine. Understanding this system is of vital importance in understanding the classification of operative vaginal delivery procedures.

MOLDING

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Molding is the overlapping of the fetal skull bones at a suture which may occur during labor due to head compression as it passes through the pelvis of the mother. THE DIAGNOSIS OF MOLDING. In a cephalic (head) presentation, molding is diagnosed by feeling overlapping of the sutures of the skull on vaginal examination, and assessing whether or not the overlap can be reduced (corrected) by pressing gently with the examining finger. The presence of caput succedaneum can also be felt as a soft, boggy swelling, which may make it difficult to identify the presenting part of the fetal head clearly. With severe caput the sutures may be impossible to feel. GRADING THE DEGREE OF MOLDING. The occipito-parietal and the sagittal sutures are palpated and the relationship or closeness of the two adjacent bones assessed. The amount of molding recorded on the partogram should be the most severe degree found in any of the sutures palpated. The degree of molding is assessed according to the following scale: 0 = Normal separation of the bones with open sutures. 1+ = Bones touching each other. 2+ = Bones overlapping, but can be separated with gentle digital pressure. 3+ (severe) = Bones overlapping, but cannot be separated with gentle digital pressure. This is a serious degree (called pathological molding). Delivery should not be allowed to continue beyond this point and the baby should be immediately delivered. ASSESSING THE PELVIS. When assessing the pelvis, the size and shape of the pelvic inlet, the mid-pelvis and the pelvic outlet must be determined: 1. To assess the size of the PELVIC INLET, the sacral promontory and the retropubic area are palpated.

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2. To assess the size of the MID-PELVIS, the curve of the sacrum, the sacrospinous ligaments and the ischial spines are palpated. 3. To assess the size of the PELVIC OUTLET, the subpubic angle, intertuberous diameter and mobility of the coccyx are determined. It is important to use a step-by-step method to assess the pelvis:

STEP 1. THE SACRUM. Start with the sacral promontory and follow the curve of the sacrum down the midline: 1. An adequate pelvis: The promontory cannot be easily palpated, the sacrum is well curved and the coccyx cannot be felt. 2. A small pelvis: The promontory is easily palpated and prominent, the sacrum is straight and the coccyx is prominent and/or fixed. Figure (10) Lateral view of the pelvis, showing the examining fingers just reaching the sacral promontory.

STEP 2. THE ISCHIAL SPINES AND SACROSPINOUS LIGAMENTS. Lateral to the midsacrum, the sacrospinous ligaments can be felt. If these ligaments are followed laterally, the ischial spines can be palpated.

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1. An adequate pelvis: Two fingers can be placed on the sacrospinous ligaments (i.e. they are 3 cm or longer) and the spines are small and round. 2. A small pelvis: The ligaments allow less than 2 fingers and the spines are prominent and sharp.

Figure 11. The brim of the pelvis.

STEP 3. RETROPUBIC AREA. Put 2 examining fingers, with the palm of the hand facing upwards, behind the symphysis pubis and then move them laterally to both sides: 1. An adequate pelvis: The retropubic area is flat. 2. A small pelvis: The retropubic area is angulated.

Figure 12 The pelvic outlet

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STEP 4. THE SUBPUBIC ANGLE AND INTERTUBEROUS DIAMETER.

To measure the subpubic angle, the examining fingers are turned so that the palm of the hand faces upward, a third finger is held at the entrance of the vagina (introitus) and the angle under the pubis felt. The intertuberous diameter is measured with the knuckles of a closed fist placed between the ischial tuberosities. 1. An adequate pelvis: The subpubic angle allows 3 fingers (i.e. an angle of about 90 degrees) and the intertuberous diameter allows 4 knuckles. 2. A small pelvis: The subpubic angle allows only 2 fingers (i.e. an angle of about 60 degrees) and the intertuberous diameter allows only 3 knuckles

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LEARNING GUIDE

Vaginal Examination during Labor

Getting ready 1. Prepare the necessary equipment (Pre-packed vaginal examination set Sterile gloves - Lubricant K-Y Sterile pad). 2. 3. 4. 5. Ask the patient to empty her bladder before examination. Tell her in terms she can understand what you will be doing Help the patient to lie on her back. Ask the patient to lie on her back with knees flexed, heels together and legs apart outwards. Put a pillow under her head and ask that she can rest her hands across her abdomen or other sides. 6. Drape her legs to avoid unnecessary exposure. Make sure that you can see her face during the examination. The procedure 1. 2. 3. 4. Wash your hands and put on gloves: If ruptured membranes are suspected always use sterile gloves. If membranes are intact clean or sterile gloves can be used. Ask the patient to separate or spread her legs. Do not try to use force. Ask the patient if you may proceed now. Generously lubricate the index and middle fingers of your examining hand with K-Y lubricating Jelly. 5. Separate the labia with your gloved fingers. Inspect the general area of introitus (Vaginal opening). And look for: Amount of show (Labor is advanced). Wet, glistening perineum. (i.e. membranes have ruptured) Meconium. Any scars indicating episiotomy or prior perineal surgery. Insert the first finger of the other sterile gloved hand then the second finger gently into the vagina. The hand should be turned sideways in this initial step. Keep downward pressure as you insert the fingers to avoid pressing on the anterior vaginal wall or urethera. The thumb and fore finger on one hand separate the labia widely to expose the vaginal opening and prevent the examining fingers from touching the labia.

6.

7.

Move your fingers the full length of the vagina (usually 7.5-10 cm.).

During the examination, the fourth and fifth fingers should not touch the rectal area.

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8.

Note the following:

State of the vagina. State of cervix, effacement, and dilatation. Membranes. Presenting part. Position. Degree of molding. Caput succedaneum or any abnormalities.

State of cervix: degree of cervical dilatation is measured in centimeter. One finger represents approximately 1.5-2Cm. dilatations. Measurement of dilatation can be from 0-10Cm. in diameter.

Effacement is measured in percentages the uneffaced cervix is approximately 1 inch thick and would be described as uneffaced or 0%. A cervix that inch thick is 50% effaced. (25%, 50%,75% and full or 100%)

Palpate for the presenting part. If you feel

The hard skull with the sagittal suture and follow it to the anterior or posterior fontanel. It is a cephalic presentation. The soft buttocks. It is a breech presentation. Irregular knobby parts like facial features. It is a face presentation.

Station: Locate the portion of the presenting part, and then sweep the fingers deeply to one side of the pelvis to feel for ischial spines. To determine station, estimate how far (in centimeters) the tip of the presenting part is above or below ischial spine

Postprocedural tasks 1. 2. 3. Record your findings on the partogram. Clear away the equipments and clean it. Wash hands.

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LEARNING GUIDE: amniotomy and oxytocin augmentation of labor STEP/TASK Getting ready 1. Prepare the necessary equipment. 2. Tell the woman (and her support person) what is going to be done, listen to her and respond attentively to her questions and concerns. 3. Provide continual emotional support and reassurance, as feasible. 4. Review the partograph to ensure that there is a need to correct slow progress of labor. Amniotomy 1. Listen to the fetal heart. 2. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry. 3. Put high-level disinfected or sterile surgical gloves on both hands. 4. Clean the vulva with antiseptic solution. 5. Use one hand to examine the cervix and note consistency, position, effacement and dilation. 6. Use the other hand to insert an amniotic hook or a Kocher clamp into the vagina. 7. Guide the hook or clamp along the fingers of the examining hand in the vagina toward the membranes. 8. Place two fingers of the examining hand against the membranes and gently rupture the membranes, between rather than during a contraction, with the hook or clamp in the other hand. 9. Remove the hook or clamp from the vagina. 10.Allow the amniotic fluid to drain away slowly around the fingers of the examining hand. 11.Note the color of the fluid (e.g., clear, greenish, bloody). 12.Remove the examining hand from the vagina. Post-procedure 1. Before removing gloves, dispose of waste materials in a leak60

proof container or plastic bag. 2. Place all instruments in 0.5% chlorine solution for 10 minutes for decontamination. 3. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out and place them in a leak-proof container or plastic bag. Oxytocin infusion 1. Continue to monitor progress of labor using the partograph. 2. Start an IV infusion of dextrose or normal saline. 3. Infuse oxytocin 10 units in 1000 mL of dextrose or normal saline at 15 drops/ minute:

Increase the infusion rate by 15 drops/minute every 30 minutes until there are three contractions in 10 minutes, each lasting more than 40 seconds.

4.

Maintain the rate until the birth is completed. If any contraction lasts longer than 60 seconds or if there are more than four contractions in 10 minutes:

Stop the infusion. Relax the uterus by giving terbutaline 250 g IV slowly over 5 minutes, OR

Give salbutimol 10 mg in 1 L IV fluid (normal saline or

Ringers lactate) at 10 drops/minute. 5. If there are not three contractions in 10 minutes, each lasting more than 40 seconds with the infusion at 60 drops/minute:

Adjust the infusion rate to 30 drops/minute. Increase the infusion rate by 15 drops/minute every 30 minutes until a satisfactory contraction pattern or the maximum rate of 60 drops/minute is reached.

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6.

Consider induction to have failed if labor is still not well established, using the higher concentration of oxytocin, in

multigravida and arrange for delivery by cesarean section. 7. In primigravida, if labor is still not well established using the higher concentration of oxytocin:

Increase the infusion rate by 15 drops/minute every 30 minutes until good contractions are established.

If good contractions are not established at 60 drops/minute, arrange for delivery by cesarean section.

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Management of the second stage of labor

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Clinical Learning Guide Management of Second Stage of Labor

STEP / TASK Getting Ready 1. Prepare the necessary equipments. 2. Check beginning of second stage. 3. Encourage woman to adopt dorsal position or the position of choice &start bearing down effort. 4. Tell the woman what is going to be done, answer her questions. 5. Provide continuous support &reassurance. Assisting the Birth 1. Wash hands thoroughly with soap and water & dry with clean cloth. 2. Put on sterile gloves and gown. 3. Place sterile drape over the abdomen, the thighs, under the buttocks and keep one to receive the baby. 4. Clean the woman's perineum with a cloth or compress, wet with antiseptic solution or soap and water, wiping from front to back. 5. PV examination to confirm diagnosis of the presenting part, rupture of membranes & to exclude cord prolapse. 1. Ask the woman to push with contractions & to relax in between. 2. Wait until the perineum bulges & the scalp of the fetus appears through the vaginal opening. 3. The palm of one hand is used to support the perineum and the second hand applies pressure to the occiput to prevent premature extension. 4. Do episiotomy with local infiltration of anesthesia if indicated. 5. After crowning of the head exert forward pressure on the chin with one hand & gradually release the pressure on the occiput to allow gradual extension on the head. 6. Wipe the mucous from the babys mouth and nose with a clean cloth or soft rubber catheter with a bulb. 7. Feel around the babys neck to ensure that the cord is not around the neck. If the coils around the neck are loose it is slipped around the head. If it is coiled tightly, two clamps are applied and the cord is cut between

them. 8. Allow the babys head to turn spontaneously.

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STEP / TASK 9. Place a hand on each side of the babys head and apply gentle pressure downward (toward the mothers spine) until the anterior shoulder slips under the pubic bone. 10. When the axilla is seen, guide the head upward toward the mothers abdomen as the posterior shoulder is born over the perineum.

11. Move the top most hand from the head to support the rest of the babys body
as it slides out using the other hand on the upper side of the baby. 12. Clamp the cord (if immediate cord clamping is indicated). 13. Place the baby on the mothers abdomen (if the mother is unable to hold the baby, ask an assistant to care for the baby). 14. Thoroughly dry the baby and cover with clean dry cloth. 15. Assist breathing, if it does not breathe immediately, begin resuscitative measures. Cord clamping 16. Clamp and cut the umbilical cord (clamp at 3 cm & 5 cm from the umbilicus and cut between the clamps). 17. Keep the baby warm by skin to skin contact with the mother and cover the baby with a blanket, including the head. 18. Palpate the mothers abdomen to exclude the presence of additional baby/ies.

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Third stage of labor

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1 WHAT IS THE THIRD STAGE OF LABOUR? The third stage of labor starts immediately after the delivery of the infant and ends with the delivery of the placenta and membranes. 2 HOW LONG DOES THE NORMAL THIRD STAGE OF LABOUR LAST? The normal duration of the third stage of labor depends on the method used to deliver the placenta. It usually lasts less than 30 minutes, and mostly only 2-5 minutes. 3 WHAT HAPPENS DURING THE THIRD STAGE OF LABOUR? 1. Uterine contractions continue, although less frequently than in the second stage. 2. The uterus contracts and becomes smaller and, as a result, the placenta separates. 3. The placenta is squeezed out of the upper uterine segment into the lower uterine segment and vagina. The placenta is then delivered. 4. The contraction of the uterine muscle compresses the uterine blood vessels and this prevents bleeding. Thereafter, clotting (coagulation) takes place in the uterine blood vessels due to the normal clotting mechanism.

4 WHY IS THE THIRD STAGE OF LABOUR IMPORTANT? Excessive bleeding is a common complication during the third stage of labor. Therefore, the third stage, if not correctly managed, can be an extremely dangerous time for the patient. Postpartum hemorrhage is the commonest cause of maternal death in some developing countries.

5 HOW SHOULD THE THIRD STAGE OF LABOUR BE MANAGED? There are 2 ways of managing the third stage of labor: 1. The active method. 2. The passive method.

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Whenever possible, the active method should be used. However, a midwife working on her own may need to use the passive method.

6 WHAT IS THE ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR? 1. Immediately after the delivery of the infant, an abdominal examination is done to exclude a second twin. 2. An oxytocic drug is given if no second twin is present. 3. When the uterus contracts CONTROLLED CORD TRACTION must be applied: (i) Keep steady tension on the umbilical cord with one hand. (ii) Place the other hand just above the symphysis pubis and push the uterus upwards. 4. Placental separation will take place when the uterus contracts. When controlled cord traction is applied the placenta will be delivered from the upper segment of the uterus. 5. Once this occurs, continuous light traction on the umbilical cord will now deliver the placenta from the lower uterine segment or vagina. 6. If placental separation does not take place during the first uterine contraction after giving the oxytocic drug, wait until the next contraction occurs and then repeat the maneuver. 7 WHICH OXYTOCIC DRUG IS USUALLY GIVEN DURING THE THIRD STAGE OF LABOUR? One of the following two drugs is generally given: 1. Syntometrine. This is given by intramuscular injection after the delivery of the infant. Syntometrine is supplied in a 1 ml ampoule which contains a mixture of 5 units oxytocin and 0,5 mg ergometrine maleate. The drug must be protected from direct light at all times and must be kept in a refrigerator. At all times the ampoules must, therefore, be kept in an opaque container in the refrigerator.

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2. Oxytocin (Syntocinon) 5 units. This is given intramuscularly. It is not necessary to protect this drug against direct light. Although the drug must also be kept in a refrigerator, it has a shelf life of one month at room temperature. 8 WHAT ARE THE ACTIONS OF THE 2 COMPONENTS OF SYNTOMETRINE? 1. Oxytocin causes physiological uterine contractions which start 3 to 5 minutes after an intramuscular injection and continue for approximately 1 to 3 hours. 2. Ergometrine causes a tonic contraction of the uterus which starts 2 to 5 minutes after an intramuscular injection and continues for about 3 hours.

WHAT

ARE

THE

CONTRA-INDICATIONS

TO

THE

USE

OF

SYNTOMETRINE? Syntometrine contains ergometrine and, therefore, should not be used if: 1. The patient is hypertensive. Ergometrine causes vasospasm which may result in a severe increase in the blood pressure. 2. The patient has heart valve disease. Tonic contraction of the uterus pushes a large volume of blood into the patient's circulation, which may cause heart failure with pulmonary edema.

10 WHAT OXYTOCIC DRUG SHOULD BE USED IF THERE IS A CONTRAINDICATION TO THE USE OF SYNTOMETRINE? Oxytocin (Syntocinon) should be used. An intravenous infusion of 10 units oxytocin in 200 ml normal saline is given at a rate of 30 drops per minute or 5 units oxytocin are given by intramuscular injection.

11 WHAT IS THE PASSIVE METHOD OF MANAGING THE THIRD STAGE OF LABOUR? 1. After delivery of the infant the signs of placental separation are waited for. 2. When the signs of placental separation appear, the patient is asked to bear down and the placenta is delivered spontaneously, by maternal effort only.

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3. Only after the placenta has been delivered is an oxytocic drug given.

12 WHAT ARE THE SIGNS OF PLACENTAL SEPARATION? 1. Uterine contraction. 2. The fundus of the uterus rises in the abdomen, when the placenta moves from the upper segment of the uterus to the lower segment and vagina. 3. Lengthening of the umbilical cord. This sign is most easily seen if the cord is clamped with forceps at the vulva. Any lengthening of the umbilical cord above the forceps is then easily noticed. 4. An amount of blood suddenly escapes from the vagina 5. The placenta has definitely separated if the umbilical cord does not shorten when the uterus is pushed up (no cord retraction).

13 WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF THE ACTIVE METHOD OF MANAGING THE THIRD STAGE OF LABOUR? ADVANTAGES: 1. Blood loss is less than when the passive method is used. 2. Everyone who conducts deliveries must be trained in the active method, as the latter must be used if there is excessive bleeding before delivery of the placenta or if the placenta does not spontaneously separate when the passive method is used. 3. There is less possibility that oxytocin will be needed to contract the uterus following the third stage of labor. DISADVANTAGES: 1. The person actively managing the third stage of labor must not leave the patient. Therefore, an assistant is needed to give the oxytocic drug and examine the newborn infant, while the person conducting the delivery continues with the management of the third stage of labor.

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2. The risk of a retained placenta is increased if the active method is not carried out correctly, especially if the first 2 contractions after the delivery of the infant are not used to deliver the placenta. 3. Excessive traction on the umbilical cord can result in inversion of the uterus, especially if the fundus of the uterus is not supported by placing a hand above the bladder on the abdomen. 14 WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF THE PASSIVE METHOD OF MANAGING THE THIRD STAGE OF LABOUR? ADVANTAGES: 1. No assistant is needed. 2. A retained placenta is less common than with the active method. DISADVANTAGES: 1. Blood loss is greater than with the active method. 2. The active method may be needed anyway, if: (i) There is excessive bleeding before delivery of the placenta. (ii) The placenta does not separate spontaneously.

15 HOW LONG CAN YOU SAFELY WAIT FOR SIGNS OF PLACENTAL SEPARATION, IF THE PASSIVE METHOD OF MANAGING THE THIRD STAGE IS USED? If the signs of placental separation have still not appeared 30 minutes after the start of the third stage of labor, then an oxytocic drug must be given and the active management of the third stage must be used.

16 SHOULD THE UMBILICAL CORD BE ALLOWED TO BLEED BEFORE THE PLACENTA IS DELIVERED OR SHOULD THE FORCEPS BE LEFT IN PLACE ON THE UMBILICAL CORD? 1. The umbilical cord must NOT be allowed to bleed after the delivery of the first infant in a multiple pregnancy. In identical twins with a single placenta

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(monochorionic placenta), the undelivered second twin may bleed to death if the umbilical cord of the first born infant is allowed to bleed. 2. The umbilical cord should be allowed to bleed if the patient's blood group is Rhesus negative (Rh-negative) with a single fetus. This will reduce the risk of fetal blood crossing the placenta to the mother's circulation and, thereby, sensitizing the patient. Nevertheless, anti-D immunoglobulin must always be given to these patients. 3. Allowing the umbilical cord to bleed during the third stage of labor, reduces the placental volume and, thereby, speeds up the separation of the placenta. As a general rule, the umbilical cord should be allowed to bleed once a multiple pregnancy has been excluded.

17 HOW SHOULD YOU EXAMINE THE PLACENTA AFTER ADELIVERY? Every placenta must be examined for: 1. COMPLETENESS: Make sure that both the placenta and the membranes are complete after the delivery of the placenta: (i) The membranes are examined for completeness by holding the placenta up by the umbilical cord so that the membranes hang down. You will see the round hole through which the infant was delivered. Examine the membranes carefully to determine whether they are complete. (ii) The placenta is now held in both hands and the maternal surface is inspected after the membranes are folded away. A missing part of the placenta, or cotyledon, is thus easily noticed. 2. ABNORMALITIES: (i) Cloudy membranes, or membranes that smell offensive, suggest the presence of chorioamnionitis. (ii) Clots of blood which adhere to the maternal surface suggest that abruptio placentae has occurred.

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3. SIZE: The weight of the placenta increases with gestational age and is usually 1/6 the weight of the infant, i.e. 450-650 g at term. If the placenta is abnormally large, the following possibilities must be considered: (i) A heavy, edematous placenta is suggestive of congenital syphilis. (ii) A heavy, pale placenta is suggestive of Rhesus hemolytic disease. (iii) A placenta which is heavier than would be expected for the weight of the infant, but with a normal appearance, is suggestive of maternal diabetes. A placenta which is lighter than would be expected for the weight of the infant, is suggestive of fetal intra-uterine growth restriction (IUGR). 4. UMBILICAL CORD: Two arteries and a 1 vein should be seen on the cut end of the umbilical cord. If only 1 umbilical artery is present, the infant must be carefully examined for other congenital abnormalities. *** Infarcts can be recognized as firm, pale areas on the maternal surface of the placenta. Calcification on the maternal surface is normal.

18 WHAT RECORDINGS MUST ALWAYS BE MADE DURING AND AFTER THE THIRD STAGE OF LABOUR? 1. Recordings made about the third stage of labor: (i) Duration of the third stage. (ii) The amount of blood lost. (iii) Medication given. (iv) The condition of the perineum and the presence of any tears. 2. Recordings made immediately after the delivery of the placenta: (i) Whether the uterus is well contracted or not. (ii) Any excessive vaginal bleeding. (iii) A short note on the suturing of an episiotomy or perineal tear. (iv) The patient's pulse rate, blood pressure and temperature.

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(v) The completeness of the placenta and membranes, and any placental abnormality. 3. Recordings made during the first hour after the delivery of the placenta: (i) During this time (sometimes called the fourth stage of labor) it is important to record whether the uterus is well contracted and whether there is any excessive bleeding. During the first hour after the completion of the third stage of labor, there is a high risk of postpartum hemorrhage. (iii) If the third stage of labor was not normal, the observations must be repeated every 15 minutes, until the patient's condition is normal. Thereafter, the observations should be repeated every hour for 4 hours

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Clinical Learning Guide Active Management of the Third Stage of Labor

STEP / TASK GETTING READY 1. Palpate the fundus of the uterus to exclude presence of additional baby(ies) & to feel the consistency of the uterus. 2. Put a suitable receptacle under the buttocks to receive all blood passed which can be watched for clotting. 1. Give 10 units of Oxytocin IM (Check first the content and the expiry date of the vial). 2. Ensure that the uterus has become contracted (The fundus gets hard and globular). 3. Hold the clamped cord close to the perineum by one hand. 4. Place the other hand just above the pubic bone and gently apply counter traction (push upward on the uterus to stabilize the uterus and prevent uterine inversion

(Modified Brandt Andrews Method). 5. Do cord traction in a downward direction following the birth canal direction. 6. Keep the cord tightly tense and wait 2-3 minutes for a strong uterine contraction (Avoid overtraction that might snap the cord controlled traction). 1. When the uterus becomes firm (contracted), with a contraction very gently pull downward on the cord to deliver the placenta. 2. Continue to apply counter traction with the other hand. 3. If the placenta wasnt delivered during 30-40 seconds of controlled traction, relax the tension and repeat with the next contraction. 4. As the placenta delivers, hold it with both hands and twist slowly so the membranes are expelled intact:

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STEP / TASK 5. If the membranes dont slip out spontaneously, gently twist them into a rope and move up and down to assist separation without tearing them. 6. Slowly pull to complete delivery. EXAMINATION OF THE PLACENTA 1. Hold placenta in palms of hands with maternal side facing upwards. Check whether all lobules are present and fit together. 2. Hold placenta in palms of hands with fetal side facing upwards. Check for torn vessels near the margin of placenta (indicating retention of an accessory lobe). Note position of cord insertion. 3. Hold the cord with one hand and allow placenta and membranes to hang down: Insert fingers of other hand inside membranes, with fingers spread out, and inspect the membranes for completeness. 4. Inspect cut end of cord for presence of two arteries and one vein. 1. Immediately massage the uterus through the abdomen until it is contracted. Show the woman how to massage her fundus to maintain contraction.

2. Repeat uterine massage every 10-15 minutes for the 1st

two hours. 3. Ensure that the uterus doesnt become relaxed after you stop. 1. Inspect the perineum for lacerations / tears. 2. Gently separate the labia and inspect lower vagina for lacerations / tears. 3. Gently explore the cervix and upper vagina for lacerations / tears. 4. Gently clean the perineum with warm water and antiseptic

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STEP / TASK solution. 5. Apply a clean pad to the vulva. 1. Place any contaminated items in plastic bags or leakproof, covered waste container. 2. Decontaminate instruments by placing in a container filled with 0.5% chlorine solution for 10 minutes. 3. Decontaminate needles and syringes: Hold the needle under the surface of 0.5 % chlorine

solution, flush 3 times; then place in a sharps container. 4. Immerse both gloved hands briefly in a container filled with 0.5% chlorine, then remove gloves by turning them inside out. 5. Dispose in plastic bag or leak-proof covered waste container. 6. Wash hands thoroughly with soap and water and dry with clean cloth or air dry.

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Vaginal and cervical inspection after birth

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Introduction Vaginal/cervical inspection after delivery is routine practice in most institutions. The aim is to detect early trauma to the vagina and or cervix. The examination has to be done both carefully and gently. The examination is a must in postpartum hemorrhage even if it seems that uterine atony is the cause of bleeding. Anesthesia may be necessary if repair is contemplated especially in uncooperative women and women with inadequate exposure necessitating a posterior vaginal wall speculum (Auvards) such as infabulated women and some primigravidas. The presence of a good light source, assistants and adequate number of retractors is paramount to the success of lower genital exploration after delivery.

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Clinical Learning Guide

Vaginal and cervical inspection after birth

STEP / TASK Getting Ready Have your assistant ready to help you and prepare the necessary equipment (Including 2 Sims vaginal specula, 2 ring or sponge forceps, and gauze swabs). Make sure that the patient is properly covered , gowned and Tell the woman (and her support person) what is going to be done, listen to her and respond attentively to her questions and concerns. Provide continual support and reassurance, as feasible. Wash hands thoroughly with soap and water and dry with a clean dry cloth or air dry. Put high-level disinfected or sterile surgical gloves on both hands. Vaginal inspection Separate the womans labia with one hand. Have an assistant shine a light into the vagina. Look carefully for any tears or hematomas. Press firmly on the back wall of the vagina with the fingers of the other hand and look for bleeding points in the vagina. Continue to press firmly on the wall of the vagina: Move fingers up the side of the wall of the vagina to the cervix, looking for bleeding points. Repeat on the opposite wall of the vagina. Cervical inspection Have an assistant place one hand on the womans abdomen and press firmly on her uterus to move the cervix lower into the vagina. Insert two high-level disinfected Sims specula into the vagina: Place one speculum in the anterior position. Place the second speculum in the posterior position. Have your assistant or the nurse to hold the specula in position. If no specula are available, use one hand to press firmly on the back wall of the vagina to expose the cervix.

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STEP / TASK Insert a ring forceps and catch the anterior lip of the cervix at the 12 oclock position. Insert a second ring or sponge forceps and catch the cervix at the 3 oclock position. Inspect the cervix between the two forceps for bleeding points, using a gauze swab to wipe blood away, if necessary, for better inspection. Remove the forceps from the anterior lip of the cervix (the 12 oclock position). Catch the cervix at the 6 oclock position. Inspect the cervix between the forceps at the 3 oclock and the 6 oclock positions for bleeding points, using a gauze swab to wipe blood away, if necessary, for better inspection. Remove the forceps at the 3 oclock position. Catch the forceps on the cervix at the 9 oclock position. Inspect the cervix between the forceps at the 6 oclock and the 9 oclock positions for bleeding points, using a gauze swab to wipe blood away, if necessary, for better inspection. Remove the forceps at the 6 oclock position. Catch the cervix at the 12 oclock position. Inspect the cervix between the forceps at the 9 oclock and the 12 oclock positions for bleeding points, using a gauze swab to wipe blood away, if necessary, for better inspection. Remove the forceps at the 9 oclock position and remove. Remove the forceps at the 12 oclock position and remove. Remove the vaginal specula (if used). Make sure that the patients perineum and legs are cleaned from any blood remnants and that she is decently covered before transfer to the ward. Take and record patients vital signs, amount of blood lost and summary of any performed procedure in the patients chart immediately. Post Procedural tasks Before removing gloves, dispose of waste materials in a leak-proof container or plastic bag. Place all instruments in 0.5% chlorine solution for 10 minutes for decontamination.

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STEP / TASK Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out and place them in a leak-proof container or plastic bag. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry.

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Performing and repairing episiotomy

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PERFORMING AN EPISIOTOMY Introduction .A THE PURPOSE OF AN EPISIOTOMY-9 To aid the delivery of the presenting part when the perineum is tight and .1 .causing poor progress in the second stage of labour .To prevent the perineum from tearing .2 To allow more space for operative or manipulative deliveries, e.g. forceps or .3 .breech deliveries .To shorten the second stage of labour, e.g. with fetal distress .4 .To reduce pressure on the fetal head when delivering a preterm infant .5 .B PREPARATION FOR AN EPISIOTOMY-9 If you anticipate that an episiotomy may be needed, you should inject local anaesthetic into the perineum. An episiotomy should not be done without adequate analgesia. Usually 10-15 ml 1% lignocaine (Xylotox) supplies adequate analgesia for performing an episiotomy. Be very careful that the local anaesthetic .is not injected into the presenting part of the fetus .C TYPES OF EPISIOTOMY-9 :There are 3 methods of performing an episiotomy .Mediolateral or oblique .1 .J-shaped .2 .Midline .3 The midline episiotomy has the danger that it can extend into the rectum to become a third degree tear while the mediolateral episiotomy often results in more bleeding. This skills workshop will only deal with the mediolateral episiotomy because it is used most frequently, is safe and requires the least .experience .D PERFORMING A MEDIOLATERAL EPISIOTOMY-9 The incision should only be started during a contraction when the presenting part is stretching the perineum. Doing the episiotomy too early may cause severe bleeding and will not immediately assist the delivery. The incision is started in the midline with the scissors pointed 450 away from the anus. It is usually directed to the patient's left but can also be to the right. Two fingers of the left hand are slipped between the perineum and the presenting part when performing a .mediolateral episiotomy .Figure 9-A. The method of performing a left mediolateral episiotomy

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.E PROBLEMS WITH EPISIOTOMIES-9 The episiotomy is done TOO SOON: This can result in excessive bleeding as the .1 presenting part is not pressing on the perineum. An episiotomy will not help the .descent of a high head Extension of the episiotomy by TEARING: This is not only a problem in a .2 midline episiotomy. Both mediolateral and J-shaped episiotomies may also tear through the anal sphincter into the rectum. However, extension of mediolateral .and J-shaped episiotomies are less likely to occur than a midline episiotomy :Excessive BLEEDING may occur .3 .i) When the episiotomy is done too early( .ii) From a mediolateral episiotomy( .iii) After the delivery( Arterial bleeders may have to be temporarily clamped, while venous bleeding is easily stopped by packing a swab into the wound. Suturing the episiotomy usually .stops the venous bleeding but arterial bleeders need to be tired off REPAIRING AN EPISIOTOMY .F PREPARATIONS FOR REPAIRING AN EPISIOTOMY-9 This is an uncomfortable procedure for the patient. Therefore, it is essential to .1 .explain to her what is going to be done .The patient should be put into the lithotomy position if possible .2 It is essential to have a good light that must be able to shine into the vagina. A .3 .normal ceiling light usually is not adequate Good analgesia is essential and is usually provided by local anaesthesia which .4 is given before the episiotomy is performed. As 20 ml of 1% lignocaine may be safely infiltrated, 5-10 ml usually remains to be given in sensitive areas. An .episiotomy should not be sutured until there is good analgesia of the site In order to prevent blood which drains out of the uterus from obscuring the .5 episiotomy site, a rolled pad or tampon should be carefully inserted into the vagina above the episiotomy wound. As this is uncomfortable for the patient, she .should be reassured while this is being done

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Absorbable suture material should be used for the repair. Two packets of .6 chromic 0 are required. One on a round (taper) needle for the vaginal epithelium and muscles, and 1 on a cutting needle for the skin. With larger episiotomies 2 packets on a round needle may be needed. Non-absorbable suture material such as nylon and dermalon are very uncomfortable and should not be used. .Remember that the patient has to sit on her wound G THE FOLLOWING IMPORTANT PRINCIPLES APPLY TO THE SUTURING-9 .OF AN EPISIOTOMY .The apex of the episiotomy must be visualised and a suture put in at the apex .1 .Dead space must be closed .2 Tissues must be brought together but not strangulated by excessive tension on .3 .the sutures .Haemostasis must be obtained .4 The needles must be handled with a pair of forceps and not by hand, and .5 .should be removed from the operating field as soon as possible .Figure 9-B. The method of safely handling a needle

.H THE METHOD OF SUTURING AN EPISIOTOMY-9 :Three layers have to be repaired .The vaginal epithelium .1 .The muscles .2 .The perineal skin .3 .Figure 9-C. An episiotomy wound

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.There are 4 important steps in the repair of an episiotomy wound :STEP 1 Place a suture (stitch) at the apex (the highest point) of the incision in the vaginal epithelium. Then insert 1 or 2 more continuous sutures in the vaginal epithelium. Do not complete suturing the vaginal epithelium when the episiotomy is large or deeply cut but leave this suture and do not cut it. When placing the suture at the .apex be very careful not to prick your finger with the needle .Figure 9-D. Suturing the vaginal epithelium

:STEP 2 Insert interrupted sutures in the muscles. Start at the apex of the wound. The aim is to bring the muscles together firmly and to eliminate any "dead space", i.e.

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any spaces between the muscles where blood can collect. Remember that the .sutures must be inserted at 90 degrees to the line of the wound .Figure 9-E. Suturing the muscles

point of the needle is seen when crossing from the one side to the other of the deepest part of the wound, the stitch will not be too deep. Figure 8 stitches (double stitches) are used to suture the muscle layer. When the muscles have been correctly sutured the cut edges of the vaginal epithelium and the skin :should be lying close together. The markers for correct alignment are .The remains of the hymen .1 The junction of the skin and the vaginal epithelium. The skin is recognized by .2 .the darker pigmentation .Figure 9-F. The correct position of the skin and vaginal epithelium

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:STEP 3 Return to the vaginal epithelium and complete the continuous catgut suture, ending at the junction with the skin. Do not pull the sutures tight as they only .need to bring the edges of the vaginal epithelium together :STEP 4 Use interrupted sutures with an absorbable suture material to repair the perineal skin. Mattress sutures may be used. Do not pull the sutures tight as they only need to bring the edges of the skin together. Sutures that are too tight become .uncomfortable for the patient .Figure 9-G. The repair of the skin

:When the suturing is complete Remove the pad from the vagina. Be gentle as this will be uncomfortable for .1 .the patient Put a finger into the rectum and feel if a suture has been placed through the .2 .rectal wall by mistake .Make sure that the uterus is well contracted .3

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Get the patient out of the lithotomy position and make sure that she is .4 .comfortable

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Clinical Learning Guide Performing and repairing episiotomy

STEP / TASK Getting Ready 1. Prepare the necessary equipment. 2. Tell the woman (and her support person) what is going to be done, listen to her and respond attentively to her questions and concerns. 3. Provide continual support and reassurance, as feasible. 4. Ask about allergies to antiseptics and anesthetics. 5. Put on personal protective barriers. The Procedure 1. Wash hands thoroughly with soap and water and dry with a clean, dry 2. 3. 4. 5. 6. cloth or air dry. Put high-level disinfected or sterile surgical gloves on both hands. Clean the perineum with antiseptic solution. Draw 10 ml of 0.5% Lignocaine into a syringe. Place two fingers into the vagina along the proposed incision line. Insert the needle beneath the skin for 45 cm following the same line and aspirate by drawing the plunger back slightly to make certain the needle is not penetrating a blood vessel. 7. Inject the Lignocaine solution slowly while withdrawing the needle towards a more superficial level to ensure an even distribution of the anesthetic substance to all layers and over the whole length to the anticipated cut (wound), this should include the vaginal mucosa, beneath the skin of the perineum and into the perineal muscle. 8. Wait 2 minutes and then pinch the incision site with forceps. (If the woman feels the pinch, wait 2 more minutes and then retest). 1. Wait to perform episiotomy until crowning where the head distending the vulva and does not recede back in contractions and the perineum is fully stretched over the head. 2. Insert two fingers into the vagina, palmer side downward, between the babys head and the perineum. 3. Insert the open blade with the blunt tip of the episiotomy scissors between the perineum and the two fingers. 4. Make a single cut 34 cm long in a mediolateral direction (45 angle to the midline toward a point midway between the ischial tuberosity and the anus).

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STEP / TASK 5. If delivery of the head does not follow immediately, apply pressure to the episiotomy site between contractions, using a piece of gauze, to minimize bleeding. 6. Control delivery of the head to avoid extension of the episiotomy. Repair of episiotomy 1. Ask the woman to position her buttocks toward the lower end of the bed or table (use stirrups if available). 2. Ask an assistant to direct a strong light onto the womans perineum. 3. Clean the womans perineum with antiseptic solution. 4. If it is necessary to repeat local anesthetic, draw 10 ml of 0.5% Lignocaine into a syringe. 5. Insert the needle along one side of the vaginal incision and inject the Lignocaine solution while slowly withdrawing the needle. 6. Repeat on the other side of the vaginal incision and on each side of the perineal incision. 7. Wait 2 minutes to allow the Lignocaine solution to take effect. 8. Using 2/0 chromic catgut, insert the suture needle just above (1 cm) the vaginal incision. 9. Use a continuous suture from the apex downward to repair the vaginal incision. 10. Continue the suture to the level of the vaginal opening. 11. At the opening of the vagina, bring together the cut edges. 12. Bring the needle under the vaginal opening and out through the incision and tie. Use interrupted inverted sutures to repair the perineal muscle, working from the top of the perineal incision downward (in 2 layers if deep incision). 14. Use interrupted or subcuticular sutures to bring the skin edges together. 15. Clean with a disinfectant then place a clean pad on the womans perineum. Post Procedure 1. Before removing gloves, dispose waste materials in a leak-proof container or plastic bag. 2. Place all instruments in 0.5% chlorine solution for 10 minutes for decontamination. 3. Decontaminate or dispose of syringe and needle: If reusing needle or syringe, fill syringe (with needle attached) with

13.

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STEP / TASK 0.5% chlorine solution and submerge in solution for 10 minutes for decontamination. If disposing of needle and syringe, flush needle and syringe with 0.5% chlorine solution three times, and then place in a sharps container. 4. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out. If disposing of gloves, place them in a leak-proof container or a plastic

bag. 5. Wash hands thoroughly with soap and water and dry with a clean dry cloth or air dry. 6. Record the procedure in the record.

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Repair of lower genital lacerations

Introduction A) Repair of cervical tears Anaesthesia is not required for most cervical tears. For tears that are high and extensive, give pethidine and diazepam IV slowly (do not mix in the same syringe) or use ketamine. Ask an assistant to massage the uterus and provide fundal pressure. Gently grasp the cervix with ring or sponge forceps. Apply the forceps on both sides of the tear and gently pull in various directions to see the entire cervix. There may be several tears. Close the cervical tears with continuous 0 chromic catgut (or polyglycolic) suture starting at the apex (upper edge of tear), which is often the source of bleeding. If a long section of the rim of the cervix is tattered, under-run it with continuous 0 chromic catgut (or polyglycolic) suture. If the apex is difficult to reach and ligate, it may be possible to grasp it with artery or ring forceps. Leave the forceps in place for 4 hours. Do not persist in attempts to ligate the bleeding points as such attempts may increase the bleeding. Then:After 4 hours, open the forceps partially but do not remove; After another 4 hours, remove the forceps completely. A laparotomy may be required to repair a cervical tear that has extended deep beyond the vaginal vault.

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B) Repair of vaginal and perineal tears There are four degrees of tears that can occur during delivery: First degree tears involve the vaginal mucosa and connective tissue. Second degree tears involve the vaginal mucosa, connective tissue and underlying muscles. Third degree tears involve complete transection of the anal sphincter.

Fourth degree tears involve the rectal mucosa. REPAIR OF FIRST AND SECOND DEGREE TEARS Most first degree tears close spontaneously without sutures. Use local infiltration with lignocaine. Ask an assistant to massage the uterus and. Carefully examine the vagina, perineum and cervix.

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Apply antiseptic solution to the area around the tear. Infiltrate beneath the vaginal mucosa, beneath the skin of the perineum and deeply into the perineal muscle using about 10 mL 0.5% lignocaine solution.

Note: Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated. If blood is returned in the syringe with aspiration, remove the needle. Recheck the position carefully and try again. Never inject if blood is aspirated. The woman can suffer convulsions and death if IV injection of lignocaine occurs.

At the conclusion of the set of injections, wait 2 minutes and then pinch the area with forceps. If the woman feels the pinch, wait 2 more minutes and then retest.

Repair the vaginal mucosa using a continuous 2-0 suture:Start the repair about 1 cm above the apex (top) of the vaginal tear. Continue the suture to the level of the vaginal opening;

At the opening of the vagina, bring together the cut edges of the vaginal opening;

Bring the needle under the vaginal opening and out through the perineal tear and tie.

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Repair the perineal muscles using interrupted 2-0 suture. If the tear is deep, place a second layer of the same stitch to close the space.

Repair the skin using interrupted (or subcuticular) 2-0 sutures starting at the vaginal opening.

If the tear was deep, perform a rectal examination. Make sure no stitches are in the rectum.

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REPAIR OF THIRD AND FOURTH DEGREE PERINEAL TEARS Note: The woman may suffer loss of control over bowel movements and gas if a torn anal sphincter is not repaired correctly. If a tear in the rectum is not repaired, the woman can suffer from infection and rectovaginal fistula (passage of stool through the vagina). Repair the tear in the operating room. Provide emotional support and encouragement. Use general anesthesia. Ask an assistant to massage the uterus and provide fundal pressure. Examine the vagina, cervix, perineum and rectum. To see if the anal sphincter is torn:

- Place a gloved finger in the anus and lift slightly; - Identify the sphincter, or lack of it; - Feel the surface of the rectum and look carefully for a tear. Change to clean, high-level disinfected gloves. Apply antiseptic solution to the tear and remove any faecal material, if

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present. Repair the rectum using interrupted 2-0 or 3-0 sutures 0.5 cm apart to bring together the mucosa. Continuous sutures can also be used. Remember: Place the suture through the muscularis (not all the way through the mucosa). Cover the muscularis layer by bringing together the fascial layer with interrupted sutures; Apply antiseptic solution to the area frequently.

If the sphincter is torn: Grasp each end of the sphincter with an Allis clamp (the sphincter retracts when torn). The sphincter is strong and will not tear when pulling with the clamp;

Repair the sphincter with two or three interrupted stitches of 2-0 suture.

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Apply antiseptic solution to the area again. Examine the anus with a gloved finger to ensure the correct repair of the rectum and sphincter. Then change to clean, high-level disinfected gloves.

Repair the vaginal mucosa, perineal muscles and skin.

POST-PROCEDURE CARE o o If there is a fourth degree tear, give a single dose of prophylactic antibiotics:Ampicillin 500 mg by mouth; PLUS metronidazole 500 mg by mouth. Follow up closely for signs of wound infection. Avoid giving enemas or rectal examinations for 2 weeks. Give stool softener by mouth for 1 week.

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Clinical Learning Guide Repair of First and Second Degree Perineal Tear

STEP / TASK Getting Ready 1. Prepare the necessary equipment. 2. Tell the woman (and her companion) what is going to be done, listen to her and respond attentively to her questions and concerns. 3. Provide continual support and reassurance, as feasible. 4. Ask about allergies to antiseptics and anesthetics. 5. Ask the woman to empty her bladder or insert a catheter, if necessary. 6. Put on personal protective barriers. 7. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry. 8. Put high-level disinfected or sterile surgical gloves on both hands. 9. Have an assistant massage the uterus. Assessment of the degree of the tear 1. Examine the tear, if the tear is long and deep through the perineum, inspect to be sure there is no third or fourth degree tear: Place a gloved finger in the anus. Gently lift the finger to identify the

sphincter. Feel the tone or tightness of the sphincter. If the sphincter is injured, this is a 3rd Degree Perineal

Tear. 2. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out and place them in leak-proof container or plastic bag. 3. Put another pair of high-level disinfected or sterile surgical gloves on both hands.

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STEP / TASK 4. Apply antiseptic solution to the areas around the tear. Injecting local anesthetics 1. Draw 10 ml of 0.5% Lignocaine (Bupivacaine) solution into a syringe (after checking the content and the expiry date of the vial).

2. Insert the needle beneath the vaginal mucosa and

aspirate by drawing the plunger back slightly to make sure the needle is not penetrating a blood vessel. Inject only if there is no blood in the syringe. 3. Inject the Lignocaine solution into the vaginal mucosa, beneath the skin of the perineum and deep into the perineal muscle. Repair 1. Place the first suture about 1 cm above the top (the apex) of the vaginal tear. Use a continuous suture (Chromic Catgut 00), working down to the level of the vaginal opening. Take a widerspaced bite in the longer edge if the tear is not midline (an oblique tear will lead to one edge being longer than the other thus requires the uneven bites) 3. Bring the torn edges of the vaginal opening together: Place the needle under the vaginal opening and out

2.

through the perineal tear and tie the suture. 4. Repair the perineal muscle using interrupted sutures: If the tear is deep, place a second layer of stitches to

close the space. 5. Repair the skin using interrupted (or subcuticular) sutures starting at the vaginal opening: If the tear is deep, perform a rectal examination and

make sure there are no stitches in the rectum. 6. Wash the perineum with soap and water and put a clean pad on the womans perineum. After the procedure

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STEP / TASK 1. Before removing gloves, dispose waste materials in a leak-proof container or plastic bag. 2. Place all instruments in 0.5% chlorine solution for 10 minutes for decontamination. 3. Decontaminate or dispose of needle or syringe by flushing needle and syringe with 0.5% chlorine solution three times, then place in a sharps container. 4. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out and place them in a leak-proof container or plastic bag. 5. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry. 6. Record the procedure in the patient's file.

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Repair of a third and fourth degree perineal tear

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LEARNING GUIDE REPAIR OF THIRD AND FOURTH DEGREE PERINEAL TEARS

STEP/TASK Getting ready 1. Prepare the necessary equipment. 2. Tell the woman (and support person) what is going to be done, listen to her and respond attentively to her questions and concerns. 3. Provide continual emotional support and reassurance, as feasible. 4. Ask about allergies to antiseptics and anesthetics.

5. Have the woman empty her bladder or insert a catheter, if

necessary. 6. Put on personal protective barriers. Repair the tear 1. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry. 2. Put high-level disinfected or sterile surgical gloves on both hands. 3. To see if the anal sphincter is torn:

Place a gloved finger in the anus and lift slightly. Identify the sphincter or lack of it. Feel the surface of the rectum and look carefully for a tear.

Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out and submerge them in 0.5% chlorine solution for 10 minutes for decontamination.

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STEP/TASK 4. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry. 5. Put another pair of high-level disinfected or sterile surgical gloves on both hands. 6. Apply antiseptic solution to the areas around the tear and remove any fecal material, if present. 8. Bring the rectal mucosa together using interrupted sutures 0.5 cm apart:

Place the suture through the muscularis, not all the way through the mucosa.

Cover the muscularis layer by bringing together the fascial layer with interrupted sutures.

Apply antiseptic solution to the area frequently while working.

9. If the sphincter is torn:

Grasp each end of the sphincter with an Allis clamp. Repair the sphincter with two or three interrupted sutures.

14. Apply antiseptic solution to the area again. 15. Examine the anus with a gloved finger to ensure correct repair of the rectum and sphincter. 16. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out then place them in a leakproof container or plastic bag. 17. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry. 18. Put another pair of high-level disinfected surgical gloves on both hands.

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STEP/TASK

19. Repair the vaginal mucosa, perineal muscles and skin (see
Learning Guide: Repair of First and Second Degree Perineal Tears). Post-procedural tasks 1. Before removing gloves, dispose of waste materials in a leakproof container or plastic bag. 2. Place all instruments in 0.5% chlorine solution for 10 minutes for decontamination.

3. Decontaminate or dispose of needle or syringe by flushing the

needle and syringe with 0.5% chlorine solution three times, then place in a puncture-proof container.

4. Immerse both gloved hands in 0.5% chlorine solution. Remove

gloves by turning them inside out and submerge them in 0.5% chlorine solution for 10 minutes for decontamination. 5. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry.

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Repair of a cervical tear

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LEARNING GUIDE: REPAIR OF CERVICAL TEARS

STEP/TASK Getting ready 1. Prepare the necessary equipment. 2. Tell the woman (and her support person) what is going to be done, listen to her and respond attentively to her questions and concerns. 3. Provide continual emotional support and reassurance, as feasible. 4. Have the woman empty her bladder or insert a catheter, if necessary. 5. Give anesthesia (IV pethidine and diazepam, or ketamine), if necessary. 6. Put on personal protective barriers. Repairing cervical laceration 1. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry. 2. Put high-level disinfected or sterile surgical gloves on both hands. 3. Have an assistant shine a light into the vagina. 4. Clean the vagina and cervix with antiseptic solution. 5. Have the assistant massage the uterus and provide fundal pressure. 6. Insert a ring or sponge forceps into the vagina and grasp the cervix on one side of the tear. 7. Insert a second ring or sponge forceps and grasp the cervix on other side of the tear. 8. Place the handles of both forceps in one hand:

Hold the cervix steady by gently pulling the forceps toward you.

9. Place the first suture at the top (the apex) of the tear.

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STEP/TASK 10. Close the tear with a continuous suture:

Be sure to include the whole thickness of the cervix each time the suture needle is inserted.

11. If a long section of the rim of the cervix is tattered, under-run it with a continuous suture. 12. If the apex is difficult to reach and ligate:

Grasp it with artery or ring forceps. Leave the forceps in place for 4 hours. After 4 hours, open the forceps partially but do not remove.

After another 4 hours, remove the forceps completely.

Post-procedure 1. Before removing gloves, dispose of waste materials in a leak proof container or plastic bag. 2. Place all instruments in 0.5% chlorine solution for 10 minutes for decontamination.

3. Immerse both gloved hands in 0.5% chlorine solution.

Remove gloves by turning them inside out and place them in a leakproof container or plastic bag. 4. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry.

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Bimanual compression of the Uterus

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Introduction This procedure is required in women who have atonic hemorrhage. The benefits of the procedure are many. First, it temporarily arrests blood loss acting as an effective first aid measure. Second, it is a therapeutic for uterine atony not responding to uterotonics. Third, it maybe used as a therapeutic test before applying compression sutures.

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Learning Guide Bimanual compression of the Uterus

STEP / TASK Getting Ready 1. Tell the woman (and her support person) what is going to be done, listen to her and respond attentively to her questions and concerns. 2. Provide continual support and reassurance, as feasible. 3. Put on personal protective barriers. Bimanual Compression 1. Wash hands thoroughly with soap and water and dry with a clean dry 2. 3. 4. 5. cloth or air dry. Put high-level disinfected or sterile surgical gloves on both hands. Clean the vulva and perineum with antiseptic solution. Insert one hand into the vagina and form a fist. Place the fist into the anterior vaginal fornix and apply pressure against

the anterior wall of the uterus. 6. Place the other hand on the abdomen behind the uterus. 7. Press the abdominal hand deeply into the abdomen and apply pressure against the posterior wall of the uterus and compress the uterus between both hands. 8. Maintain compression until bleeding is controlled and the uterus contracts. Post Procedure 1. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out 2. Place the gloves in a leak-proof container or plastic bag. 3. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry. 4. Monitor vaginal bleeding and take the womans vital signs: Every 15 minutes for 1 hour.

Then every 30 minutes for 2 hours. 5. Make sure that the uterus is firmly contracted.

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Postpartum assessment and care

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Clinical Learning Guide Posrpartum assessment and care (the day 6 visit)

STEP / TASK Getting Ready 1. Make sure that the clinic is ready: clean, tidy and equipment is ready. 2. Wash and dry your hands. 3. Greet the lady, introduce yourself and offer her a seat. 4. Explain what you are going to do to your client, obtain consent and listen to her carefully. History relevant to the last delivery Place and mode of delivery Complications of delivery (convulsions, pre-eclampsia, cesarean section, episiotomy or repair of lacerations Neonatal outcome

Breast feeding or not Analyze current complaints if any (onset, course, severity and associated therapy and whether previous treatment was given). Ask about the warning symptoms Bleeding Fever Color of discharge Abdominal pain Pain at episiotomy site Involuntary leakage or difficulty of micturition and defecation Breast tenderness

Swelling or pain in the calves Menstrual history 1. Regularity of the cycle 2. Was menstruation resumed (in late checks) Obstetric history 1. Gravidity, parity (obstetric 4 digital code), date of last (abortion, and delivery)

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STEP / TASK 2. Each pregnancy (if ended in delivery) No, date, pregnancy(duration and any complication), Delivery (type, where, who attended and any complications), newborn (sex, weight, wellbeing, jaundice, congenital anomalies), puerperium (bleeding or pyrexia) and lactation (breast or bottle, duration and any problems) 3. Each pregnancy (if ended in abortion). Duration, spontaneous or induced, followed by surgical evacuation/curettage or not, postabortive period (bleeding or pyrexia) Past history 1. Medical disease: Hypertension (If PIH previously), DM, Jaundice, cardiac, chest or renal problems. 2. Previous surgeries: type, date, where and any complications 3. Allergy to medications General examination 1. Observe abnormal gait e.g. limping, facial expression, and abnormal behavior 2. Take pulse, blood pressure and temperature 3. Examine the head and neck for pallor 4. Breast examination for

Visible lumps. Redness, hotness, and tenderness. Abnormal discharge.

Inverted nipples, cracks or fissures. 5. Abdominal examination Inspect the abdomen for old and new incisions.

Palpate for the size of the uterus and tenderness over it. 6. Vaginal examination Inspect the vulva looking for swellings, lacerations, episiotomy line, and urine or stool leaking from the vagina. Notice the amount, color and odor of any discharge. Order Investigations Order Hemoglobin if you suspect anemia Other investigations are dictated by the condition Provide Advise Nutrition

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STEP / TASK Advise her about general personal hygiene, perineal hygiene and warn against early resumption of sexual activity Provide information on the following Exclusive breastfeeding Positions Need for adequate rest and sleep Increased fluid intake

Breast cleaning and care Counsel about family planning (refer to the learning guide of Counseling) Return visits 1. Ask her to return for the 6 weeks' visit. 2. Ask her to return if the following occur: Bleeding Fever Color of discharge Abdominal pain Pain at episiotomy site Involuntary leakage or difficulty of micturition and defecation Breast tenderness

Swelling or pain in the calves Record the findings in the woman's file and her postpartum card.

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Gynecology

118

CASE SHEET IN GYNECOLOGY

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Introduction Nnnnnnnnnnnnnnnn 8.7.08

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Case sheet in gynecology

History
PERSONAL HISTORY Name: Age: Residence Occupation: Marital status: Parity: Nullipara, primipara, multipara, grandmultipara Special habits:

Husband's name: Age: Occupation: Special habits of medical importance Complaint (s) and duration

MENSTRUAL HISTORY Age of menarche: Regularity: P/C: Inter-menstrual bleeding/discharge: PMS Dysmenorrhea If yes, Type?

1st day of Last menstrual period

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OBSTETRIC HISTORY Gravid , Para + Abnormal

Deliveries Normal Abortions LD LA

PRESENT HISTORY Analysis of the complaint Onset Course Characters Associated symptoms (to detect causes/complications) Effects on the patient (complications of the possible causing condition) Therapeutic history

PAST HISTORY Past medical history

Past surgeries

Blood transfusions/drug allergies

FAMILY HISTORY Diabetes Hypertension Breast/ovarian cancer

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Examination

General Examination:
- Pulse: ____/min. - B.P. ____ mmHg

- Temp. ____ C - Weight:___ Kg - Head & Neck: - Breasts: - Chest & Heart: - Lower Limbs:

Abdominal Examination:
Inspection:

Superficial palpation Deep palpation Percussion Auscultation

Pelvic Examination:
1- Inspection - Vulva:

Labia majora Labia minora Clitoris Urethra

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Skene glands Bartholin glands

Special comments

2- Palpation - Vagina - Cervix

3- Bimanual Palpation - Uterus - Adnexa

4- Speculum examination 5- Uterine sounding .. cm

Rectal examination

Other special tests

Diagnosis:

G ____,

P____,

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Clinical learning guide Gynecologic History

STEP / TASK Getting Ready 1. Prepare the client care area, necessary supplies and equipment. 2. Wash and dry hands. 3. Greet the woman and her companion respectfully and with kindness, introduce yourself, and offer them seats. 4. Tell the woman what you are going to do. Encourage her to ask

questions, and listen to what she has to say. Personal history 1. Full Name, Date of birth and calculate age, Residence, Occupation, Marital status and duration, Parity (Nullipara, primipara, multipara, or grandmultipara) 2. Special habits: including dietary habits, Exercise, Hygienic, recreational habits. 3. Husband's name, Age, Occupation and Special habits of medical importance Complaint and duration 1. Record in the patient's own words and arrange in a chronological order. Menstrual history 1. Age of menarche. 2. Rhythm: Days/Cycle Inter-menstrual bleeding (amount and timing) Discharge (amount, color, and odor) PMS Dysmenorrhea (before, after, or during menses).

3. 1st day of Last menstrual period (ensure that she mentioned it

accurately). Obstetric history 1. Gravidity and parity. 2. Record each pregnancy separately and analyze it. 3. Record each abnormal delivery separately and analyze it. 4. Record the date of last delivery/last abortion. 5. Record number of living children. 6. Record if there were dead children & cause of death. Present history Analysis of the complaint: This is variable according to each case but it

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STEP / TASK follows the general rules below 1. Onset. 2. Course, duration. 3. Characters, severity. 4. Associated symptoms (to detect causes / complications). 5. Effects on the patient (complications and quality of life). 6. Symptoms of other systems related to her condition specially urinary symptoms, bowel habits, change in body weight, etc. 7. Therapeutic history including all types of medications and food supplements. 8. Investigations done for the patient and their results and the treatments received and the response to these treatments. Past history 1. Record past medical conditions of clinical significance. 2. Past surgeries (If present, the operation, indication, where it was done and the outcome should be recorded). 3. Record whether there were any blood transfusions / drug allergies, and endemic diseases. Contraceptive history 1. Including recent methods. 2. Duration of use. 3. Cause of discontinuation if any. Family history 1. Record if there is a family history of diabetes mellitus or Hypertension. 2. Record if there is a family history of similar condition. 3. Record if there is a family history of Breast / ovarian cancer.

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127

Breast examination

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Clinical learning guide Breast Examination

STEP/TASK Getting ready 1. Greet the woman respectfully and with kindness 2. Tell the woman you are going to examine her breasts and explain the procedure to her.

3. Ask the woman to undress from her waist up. Have her sit on the
examining table with her arms at her side.

4. Wash the hands thoroughly and dry them. Warm hands by rubbing
them together if cold. Examination 1. Inspect the breasts with patient sitting and her arms at her side and note any differences in: Shape Size Nipple or skin puckering

Dimpling or bulging 2. Inspect the nipples and note size, shape and direction in which they point. Check for rashes or sores and nipple discharge. 3. Inspect the breasts while the woman has her hands over her head, presses her hands on her hips or the palms together in front of the forehead. Check to see if breast hang evenly.

4. Have the patient lie down on the examining table. 5. Inspect the left breast and note any differences from the right breast. 6. Place pillow under womans left shoulder and place her ipsilateral arm
over her head. 7. Palpate the entire breast by small circular movements with the palmer surface of the index, middle and ring fingers using light medium and deep pressure, moving systematically in a small circular pattern from the nipple to the outer edge (the spiral technique),. Note any lumps or increased warmth or tenderness.

8. Squeeze the nipple gently and note any discharge.

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9. Repeat steps 4 to 8 for the right breast. If necessary repeat

procedure with the woman is sitting up or standing and with her arms at her sides. This may disclose a lesion not palpated in the supine position.

10.The tail of the breast, the axillary and supraclavicular lymph nodes
are most easily examined while the woman is seated or standing. Supporting the ipsilateral arm of the side being examined allows full relaxation so that the nodes deep within the axilla can be palpated. Check for enlarged lymph nodes or tenderness. 11.Repeat the procedure for the right side. 12. After completing the examination, have the woman cover. Explain any abnormal findings and what needs to be done. If the examination is normal, tell the woman everything is normal and healthy and when she should return for a repeat examination. 13.Instruct the woman on the frequency, timing and the procedure of breast self examination.

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Abdominal examination in Gynecology

131

Clinical learning guide Abdominal examination

STEP/TASK 1. Greet the patient respectfully and with kindness. 2. Explain the procedure to the patient. 3. Ask the patient to undress from the nipple line to the mid-thigh. Allow the patient to cover with a clean sheet. 4. Wash hands thoroughly and dry them. If necessary, put on new examination or high-level disinfected surgical gloves on both hands.

5. Exposure: uncover the patient from the nipple line to just below 6.
the symphysis pubis The patient's position: ask the patient to lie flat on her back with the legs extended. You may also ask the patient to flex the hips to 45 and the knees to 90 in order to relax the abdominal muscles. Inspection 1. Look from both ends of the bed 2. Look from both sides 3. Look tangentially (get down to your knees to have the eyes at the same level with the abdomen) 4. observe Breasts Abdominal movements with respiration (Type of breathing) Pulsations (Epigastric pulsations) Any bulges that are elicited by coughing (Hernia) Any bulge elicited by flexion of the trunk (Divercation of recti) Palpation 1. Stand by the right side of the patient (unless you are left handed) 2. Make sure that your hand is warm

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3. Instruct the patient to: a. Flex the hips and knees in order to relax the abdominal muscles b. Open the mouth and breathe quietly in and out. 4. Ask the patient whether there is a painful area or a mass. Always start palpation in the region diagonally opposite to any lesion or pain, and proceed systematically to other regions approaching the affected area last of all.

5. Proceed with palpation in a predetermined sequence (S or G

sequence); so as not to miss any of the nine abdominal quadrants. Light palpation (superficial palpation) Tenderness:

Ask the patient to locate the site of tenderness. Ask the patient to take a deep breath or to cough to confirm the site of maximum tenderness.

Rigidity: Differentiate it from guarding which is voluntary and disappears on expiration Swelling:

Ask the patient to contract the abdominal wall muscles by raising the head (to determine whether the swelling is intra or extra abdominal)

Notice the swelling mobility with respiration (determines the relation of the swelling to the diaphragm)

Try to reach the lower border of the mass , if you can insinuate your fingers between the mass and the symphysis pubis it is an abdominal mass , if not, it is a pelviabdominal mass Hernia orifices: Examine the anatomical sites of hernia for swelling and any expansile impulse with cough.

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Dilated veins: Determine the direction of the flow by placing two fingers on the vein, sliding one finger along the vein to empty it and then releasing one finger and watching to see which way the empty segment fills. Deep palpation: Start palpation of the normal solid viscera (the liver, the spleen and the kidneys): Liver Place your right hand on the right iliac fossa in one of the following positions: o o Resting transversely parallel to the costal margin Placed with fingers pointing towards the head of the patient Place the other hand in the right loin. Ask the patient to take a deep breath. Keep your hand still during inspiration As the patient to expire, slide the hand a little nearer to the right costal margin till you palpate lower border of the right lobe of the liver. Put your hand in the midline and repeat the above steps till you palpate the lower border of the left lobe of the liver. If the liver is enlarged, put one hand on the liver anteriorly and the other hand at the back. Ask the patient to hold her breath and feel for pulsation The standard method or bimanual examination: Start palpation from the right iliac fossa with the tips of the examining hand directed towards the left axilla. The left hand is placed over the lateral aspect of the left costal margin, exerting a certain amount of compression.

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Follow the rules of palpation moving toward the left hypochondrium until you feel the spleen.

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Spleen The right lateral position method: Ask the patient to turn to the right side Insinuate the hand below the costal margin Ask the patient to take a deep breath Press till you feel the lower edge of the spleen

The hooking method: Ask the patient to place the fist of the left hand under the lower ribs in order to push the spleen forward. Stand on the left side of the patients head Place the fingers of both hands over the costal margin. Instruct the patient to take deep breath.

To feel the right kidney: Put your left hand behind the patient's right loin (between the last rib and the iliac crest) Lift the loin and the kidney forward. Put the right hand on the right lumbar region just above the anterior superior iliac spine and ask the patient to take a deep breath. During expiration push your right hand deeply but gently and keep it still during inspiration

Repeat as the patient takes her breath. To feel the left kidney: Repeat the same procedure on the left side by either standing on the patient's left side or by leaning across the patient Put the right hand in the left loin and feeling the kidney with

the left hand. D. Palpate for other Abdominal Swellings:

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Parietal swellings:

Swellings of the anterior abdominal wall are differentiated from intraabdominal swellings by the following signs: o o Relation to the costal margin. Behavior on contraction of the abdomen.

PERCUSSION Percuss for ascites and over any masses. In the abdomen only light percussion is necessary. Start from resonant to dull in the midline Determine the upper border of the liver by heavy percussion starting from the 2nd intercostal space opposite the sternocostal junction Percuss down along each inter-costal space in the MCL and when you reach the dullness ask the patient to take a deep breath and hold it Percuss again, (tidal percussion), if it became resonant this will denote infra diaphragmatic cause (liver). If it remain dull, this will denote supra diaphragmatic cause(pleural effusion) Measure the distance between the upper border (by percussion) and lower border (by palpation) in the right midclavicular line; this is the span of the liver. Percussion of the Traube space: Area defined by the anatomical apex (5th ICS in MCL), left sixth and eighth ribs superiorly, the left midaxillary line (9th, 10th&11th ICS) laterally, and the left costal margin inferiorly. o o If Traube space is dull, the spleen is enlarged. Instruct the patient to lie in the supine position Percussion for the upper border of the fluid

Place the hand transversely above the umbilicus and below the hepatic dullness, move towards the symphysis pubis till you elicit a dull tone.

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 o o

Percussion for the lateral edge of the fluid Place your fingers parallel to the flanks Start percussion from the region of the umbilicus down to the flank till you elicit a dull tone.

Percussion for the shifting dullness: On detecting dullness, ask the patient to turn to the opposite side, while keeping the examining hand over the exact site of dullness.

Keep your hand in position till the patient rests on the opposite side,

o Repeat percussion; if the flank returns a resonant note

and percussion at the umbilicus return a dull note; this indicates the presence of moderate free ascites. Testing for ascites in the knee elbow position: (If shifting dullness is negative) o In case of minimal ascites, percuss around the umbilicus while the patient is kneeling in the knee-elbow position AUSCULTATION : Intestinal sounds Bruits Venous hum Rub Succession splash

Scratch sign EXAMINATION OF THE BACK

Ask the patient to sit Inspect for any swellings, deformities or scars Palpate for edema over the sacrum Palpate for the tenderness in the renal angels

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Palpate for tenderness over vertebrae Auscultate the renal angles for bruit Percuss the renal angle (posterior).

EXAMINATION OF THE TENSE ABDOMEN In case of tense ascites, start percussion after inspection. Instruct the patient to lie in the supine position Percuss the upper border of the fluid, placing your hand transversely in the epigastrium (resonant) and move towards the symphysis pubis till you find dullness Percuss the lateral edge of the fluid, placing your fingers parallel to the flanks and start percussion from the region of dullness If most of the abdomen is dull, detect ascites by fluid thrill. DETECTION OF ASCITES BY FLUID THRILL Instruct the patient to lie in the supine position Place one hand flat over the lumbar region on one side Get the patient (or assistant) to put the hand in the midline of the abdomen Tap or flick the opposite lumbar region A thrill will be felt in the other hand PALPATION IN THE PRESENCE OF TENSE ASCITES: THE DIPPING METHOD Place your hand in the right hypochondrium and push the abdominal wall downwards by a quick pushing movement from the wrist. An enlarged liver will rebound and hit your hand Place your hand in the left hypochondrium and push the abdominal wall downwards by quick pushing movement from the wrist. An enlarged spleen will rebound and hit your hand.

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140

Female Genital Examination

141

Examination of the female genitalia

General The examination should take place in a well lit environment, a wall or floor mounted direct light source will be required The room should be warm and the couch should have a sheet for lying on The examination should take place in the presence of a chaperone The procedure should be fully explained to the patient, who should be asked to empty her bladder before proceeding Only expose as much of the patient as is needed and cover the lower abdomen to the mons pubis The patient should be in a supine position with the hips and knees flexed and the ankles close together Abduction of the thighs reveals the external genitalia

Steps I) Inspection Mons pubis, pubic hair distribution and labia majora Gently separate the labia minora Inspect the clitoris, urethra and vaginal orifice Ask the patient to strain down and observe for any bulging or prolapse Ask the patient to cough and observe for any leakage of urine

II) Palpation Internal examination Check Bartholins glands for discharge and tenderness:

Insert index finger into the vagina at the lower edge and feel at base of each labia majora.

Using finger and thumb, palpate each side for swelling or tenderness.

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Gently introduce the lubricated right index finger, followed by the middle finger Pass downwards and backwards in line with the vagina Cervix will be felt as a semi-hard dome with a dimple in the middle (the external os) The normal cervix is mobile and movement does not cause pain. Assess the fornices III) Bi-manual examination 1 Apply upward pressure on the cervix and uterus by pressing in either the anterior or posterior fornices Fingers of abdominal hand are applied flat to abdominal wall below umbilicus and gradually moved towards pubic bone Estimate distance between fundus and pubic symphysis Use lateral surface of the index finger of the abdominal hand to detect the fundus of uterus A normal uterus may be palpable just above the pubic symphysis. To palpate this you may have to place your finger tips above the pubis and gently push down The uterus should be assessed for size, shape, mobility and consistency as well as for any masses or irregularities Ovaries are not always palpable in patients unless enlarged or patient is thin Ovaries are firm, ovoid in shape (like an olive) and approximately 2-3cms in length. Fallopian tubes are not palpable in health Place the fingers of your abdominal hand over the iliac fossa whilst readjusting the vaginal fingers into the lateral fornix Position the finger pulps to face the abdominal fingers Gently but firmly appose the fingers of either hand by pressing the abdominal hand inward and downward, and the vaginal fingers upward and laterally

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Feel for adnexal structures as the interposed tissues slip between your fingers. The movement should be relatively painless, although palpation of the ovaries might elicit some tenderness, If adnexal structures are felt describe the Size, shape, consistency, mobility and tenderness Completing the examination Rotate your examining hand back to the midline before removing your fingers gently from the vagina Inspect your fingers for signs of blood or mucus etc. Offer the patient tissues to wipe any excess lubricant etc. away. (If patient unable to, ensure you explain what you are doing before you are doing this for the patient) Remove gloves from at least one hand before covering the patient up (to avoid contaminating bedding or clothing). Dispose of your gloves in clinical waste Tell the patient your findings and offer reassurance/management plan.

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Learning guide Vaginal Examination

Getting ready 1. ask her if the bladder is empty 2. Adjust the position of the patient so that she lies in the full dorsal position with her buttocks at the edge of the examination table 3. Adjust the side-lamp so as to have good illumination of the vulval area 4. Put on gloves 5. Explain the procedure to the patient Inspection Separate the labia majora gently with the index finger and thumb of one gloved hand Inspect and comment on the mons pubis, clitoris, labia majora, labia minora, vestibule, urethral orifice, perineum, anal and peri-anal area Instruct the patient to strain and cough to demonstrate any relaxation of the vaginal walls or incontinence of urine Palpation Palpate the vulva and vagina for masses Place the index finger of the right gloved hand within the outer vagina and the thumb on the perineum at about 5 and 7 oclock and gently massage the intervening tissue. The Bartholin gland will frequently be identified as a pea-sized nodule Outward massage the anterior vaginal wall and urethra to detect urethral discharge found in chronic urethritis and for detection of suburethral diverticulum (done if necessary) Speculum examination Select a suitable sized speculum by careful appraisal of the vaginal introitus Hold the closed blades of the bivalve speculum between the index and middle fingers of the right hand and place the thumb on the upper posterior rim of the speculum Separate the labia majora with the index finger and thumb of the leftgloved hand to expose the vaginal introitus

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Place the tip of the speculum at the vaginal introitus and gently advance the blades of the speculum into the vagina bearing in mind its upward and backwards direction Open the blades of the speculum and fix it open Inspect and comment on the vaginal walls and cervix for relaxation (descent), growth, inflammation, unusual discharge or discoloration (A Pap smear or samples of cervical mucous or vaginal discharge may be taken at this stage) Close the blades of the speculum and gently withdraw it from the vagina Bimanual palpation Apply a water soluble jelly to the index and middle fingers of the right gloved hand Separate the labia majora with the index finger and thumb of the left gloved hand to expose the vaginal introitus Insert the index finger of the right gloved hand into the vagina first; only insert the middle finger as the patient relaxes the muscles around the vagina and when it is clear that a two finger examination is possible without causing pain. Move the fingers around inside the vagina to palpate the vaginal walls and cervix look for any unusual growths, the size, position, direction, consistency, mobility and pain or tenderness on pressure or movement of the cervix (the position and direction of the cervix indicates whether the uterus is anteverted or retroverted) Place the vaginal fingers in front of the cervix in the anterior fornix and move the cervix as far backwards to rotate the fundus downwards and forwards Place the palmer surface of the fingers of the left hand (abdominal hand) just below the umbilicus and gradually move it lower until the fundus is caught and pressed against the fingers in the anterior fornix To palpate the uterus gently move the fingers of the abdominal hand around its surface Determine and comment on the uterine size, shape, position, consistency symmetry and mobility

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Palpate the right and left adnexa by placing the vaginal fingers in the respective lateral fornix and gradually lower the abdominal hand toward the respective lower abdominal quadrant (normal tubes are never palpable). Palpation of the ovaries is a matter of chance but if not felt you can be reasonably certain they are not enlarged) If a mass is felt comment on its size, shape, consistency, mobility, relation to the uterus and the presence of pain or tenderness on pressure or movement Place the fingers of the vaginal (right) hand in the posterior fornix and palpate the pouch of Douglas, uterosacral ligaments and the parametrium and comment on any abnormalities. When normal should be soft, pliable and without any significant bulk. (better evaluated during bimanual rectal examination) Slowly and gently withdraw the fingers from the vagina. Rectovaginal examination Insert the index or middle fingers of the right gloved hand into the anal canal and the left hand on the lower abdomen and proceed as in the bimanual vaginal examination. Insert the index finger of the right hand in the vagina and the middle finger of the same hand in the rectum and palpate the intervening tissue. Inspect glove for blood or abnormal discharge Take off glove and properly dispose of it Wash the hands thoroughly with soap and water and dry with clean towel Enter the results of the examination into the patients record N.B. Left handed examiners may switch hands

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VAGINAL EXAMINATION: PICTURES

BARTHOLIN GLAND EXAMINATION

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Preparing and interpreting a vaginal smear

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Clinical Learning Guide Preparation and Interpretation of Wet Vaginal Smear

STEP / TASK Client Assessment 1. Greet the woman respectfully and with kindness. 2. Explain why the vaginal smear is recommended and describe the procedure. 3. Tell her the findings might be and what follow up or treatment might be necessary. Ask about compliance with prerequisites 1. Patient is not menstruating. 2. No sexual intercourse for 24 hours prior to the test. 3. No vaginal douches for 24 hours prior to the test. 4. No use of tampons, vaginal creams, or vaginal medications for at least 24 hours prior to the test. Getting ready 1. Check that the instruments and supplies are available. 2. Ensure that the light source is available and ready to use. 3. Check that the woman has emptied her bladder and washed and rinsed her genital area if necessary. 4. Ask her to undress from the waist down. 5. Help her onto the examining table and drape her. 6. Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry. 7. Palpate the abdomen. 8. Put one pair of new examination or high-level disinfected surgical gloves on both hands. Arrange instruments and supplies on high-level disinfected

9.

tray or container, if not already done. The procedure 1. Inspect external genitalia and check urethral opening for discharge. 2. Palpate Skene's and Bartholin's glands. 3. Insert dry sterile speculum according to its specific learning guide and adjust it so that the entire cervix can be seen. 4. Fix the speculum blades in the open position so that the speculum will remain in place with the cervix in view.

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STEP / TASK 5. Move the light source so that you can see the cervix and vagina clearly. 6. Samples of fluid inside the vagina are then collected with a swab or wooden spatula. 7. This sample is spread on a slide for testing. Wet mount Put sample of the vaginal discharge on a glass microscope slide and mix it with normal saline solution. Examine the prepared slide under a microscope for bacteria, yeast cells, trichomoniasis organisms, and white blood cells. Clue cells indicate bacterial vaginosis (BV). KOH Slide. Put sample of vaginal discharge on a slide. Mixed it with a solution of potassium hydroxide (KOH) 10 %. Examine the slide under a microscope for yeast hyphae and spores. Vaginal pH. Put sample of vaginal discharge on a slide. Test the normal vaginal pH (3.8 to 4.5) by litmus paper. Bacterial vaginosis , trichomoniasis, and atrophic vaginitis often cause vaginal pH greater than 4.5. Whiff test. Add several drops of a potassium hydroxide (KOH) solution to a sample of vaginal discharge. A strong fishy odor from the mixture suggests the presence of bacterial vaginosis (BV). 8. Perform the bimanual examination and rectovaginal examination (if indicated). Post Procedure 1. Wipe light source with 0.5% chlorine solution or alcohol 2. Immerse both gloved hands in 0 5% chlorine solution Remove gloves by turning inside out. Place gloves in leakpoof container or plastic bag.

3. Wash hands thoroughly with soap and water and dry

with clean dry cloth or air dry. 4. Record the test results and other findings in woman's record. Discuss the results with the woman and answer any questions.

5.

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6.

STEP / TASK If the test is negative, tell her when to return for repeat

the testing. 7. After counseling, provide treatment or refer if the test is positive discuss recommended next steps. 8. After counseling, provide treatment or refer

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Visual inspection of the cervix using Acetic acid

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Clinical Learning Guide Visual inspection of the cervix using Acetic acid
CLIENT ASSESSMENT 1. Greet the woman respectfully and with kindness. 2. Explain why the VIA test is recommended and describe the procedure. 3. Tell her what the findings might be and why follow-up or treatment might be necessary. GETTING READY 1. Check that the instruments and supplies are available. 2. Ensure that the light source is available and ready to use. 3. Check that the woman has emptied her bladder and washed and rinsed her genital area if necessary. 4. Ask her to undress from the waist down. 5. Help her onto the examining table, adjust the position of the patient to lie in full dorsal position with her buttocks at the edge of examination table and drape her. 6. Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry. Palpate the abdomen. 7. Put one pair of new examination or high-level disinfected surgical gloves on both hands. If available, put a second glove on one hand. 8. Arrange instruments and supplies on high-level disinfected tray or container, if not already done. VISUAL INSPECTION WITH ACETIC ACID 1. Inspect external genitalia and check urethral opening for discharge. 2. Palpate Skenes and Bartholins glands. 3. Insert speculum and adjust it so that the entire cervix can be seen. 4. Fix the speculum blades in the open position so that the speculum will remain in place with the cervix in view. If using outer glove, immerse this hand in 0.5% chlorine solution and remove the glove by turning it inside out. Place it in a leakproof container or plastic bag. 5. Move the light source so that you can see the cervix clearly. 6. Examine the cervix for cervicitis, ectropion, tumors, Nabothian cysts or ulcers. 7. Use a clean cotton swab to remove any discharge, blood or mucus from the cervix. Dispose of swab in a leak-proof container or plastic bag. 8. Identify the cervical os, squamocolumnar junction (SCJ) and transformation zone.

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9. Soak a clean swab in dilute acetic acid and apply it to the cervix. Dispose of swab in a leak-proof container or plastic bag. 10. Wait at least 1 minute for the acetic acid to be absorbed and any acetowhite change to appear. 11. Inspect the SCJ carefully.

Check whether cervix bleeds easily.

Look for any raised and thickened white plaques or aceto-white epithelium. 12. As needed, reapply acetic acid or swab the cervix with a clean swab to remove mucus, blood or debris. Dispose of swab in a leakproof container or plastic bag. 13. When visual inspection has been completed, use a fresh swab to remove any remaining acetic acid from the cervix and vagina. Dispose of swab in a leakproof container of plastic bag. 14. Remove the speculum.

If VIA test was negative, place in 0.5% chlorine solution for 10 minutes for decontamination.

If the VIA test was positive, place speculum on high-level disinfected tray or

container. 15. Perform the bimanual examination and rectovaginal examination (if indicated). POST-VIA TASKS 1. Wipe light source with 0.5% chlorine solution or alcohol. 2. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning inside out. Place them in leak-proof container or plastic bag. 3. Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry. 4. If VIA test is negative, ask woman to sit up, get down from the examining table and get dressed. 5. Record the VIA test results and other findings in womans record. 6. Discuss the results of the VIA test and pelvic examination with the woman and answer any questions.

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Contraception

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Contraceptive counseling

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The Elements of Counseling

GATHER describes the 6 elements of counseling about family planning and other reproductive health matters.

G: Greet Patients Give patients your full attention as soon as you meet them. Be polite, friendly, and respectful: greet patients, introduce yourself, and offer them seats. Tell patients that you will not tell others what they say. Explain what will happen during the visit. Conduct counseling where no one else can hear.

A: Ask Patients about Themselves Ask patients about their reasons for coming and how you can help. Help patients decide what decisions they face. Help patients express their feelings, needs, and wants, as well as any doubts, concerns, or questions. Ask patients about their experience with the reproductive health matter that concerns them. Keep questions open, simple, and brief. Look at your client as you speak. Ask patients what they want to do. Listen actively to what the client says. Follow where the client leads the discussion. Show your interest and understanding at all times. Express empathy and avoid judgments and opinions. Ask for any information needed to complete client records.

T: Tell Patients about Their Choices

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 Help patients to understand their possible choices. Tailor information appropriately for the clients decision. Personalize information in terms of the clients own life. If patients are choosing a family planning method: o Ask which methods interest them. If no medical reason prevents it, patients should get the methods they want. o If a client has important information wrong, gently correct the mistake. o Briefly describe the clients preferred method. Be sure to discuss: Effectiveness as commonly used How to use the method Advantages and disadvantages Possible side effects and complications o Mention other available methods that might interest the client now or later. o Ask whether the client wants to learn more. o Use samples and other audiovisual materials if possible.

H: Help Patients Choose Tell patients that the choice is theirs. Offer advice as a health expert, but avoid making patients decisions for them. To help patients choose, ask them to think about their plans, family situations, and the results of each possible choice. For family planning methods, some key questions may be: o Are you breastfeeding? o Do you and your partner want (more) children? o Do you or your partner have sex with anyone else? (To gauge STD risk) Ask what the clients sexual partner might want. Ask whether the client wants anything made clearer, and reword and repeat information as needed.

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 Explain that some family planning methods may not be safe for patients with certain medical conditions. Once a client states a choice, ask about these conditions. If a method would not be safe, clearly explain why. Then help the client choose another method. Check whether the client has made a clear decision. Specifically ask, What have you decided to do? Wait for the client to answer.

E: Explain What to Do Give supplies, if appropriate. If the method or services cannot be given at once, tell the client how, when, and where they will be provided. For sterilization, the client may have to sign a consent form. Help the client to understand the consent form before she/he signs it. Explain how to use the method or how to follow other instructions. As much as possible, show how. Describe possible side effects and what to do if they occur. Explain when to come back for routine follow-up or more supplies, if needed. Explain any medical reasons to return. Ask the client to repeat instructions. Make sure the client remembers and understands. If possible, give the client printed material to take home. Mention emergency contraception. Tell patients to come back whenever they wish, if side effects bother them, or if there are medical reasons to return.

R: Return for Follow-Up

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 Ask whether the client has any questions or anything to discuss. Treat all concerns seriously. Ask whether the client is satisfied. Help the client to handle any problems. Ask whether any health problems have come up since the last visit. Determine whether these problems make another method or treatment more appropriate. Refer patients who need care for health problems. Determine whether the client is using the method or treatment correctly. Determine whether the client might need STD protection now. If a client is not satisfied with a temporary family planning method, ask whether she/he wants to try another method. Help the client choose, and explain how to use, the method. Changing methods is normal. If a woman plans pregnancy, suggest where to get prenatal care.

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Clinical Learning Guide Contraceptive counseling

Getting Ready 1. Greet the woman respectfully and with kindness. Assure Necessary Privacy

Introduce yourself to the woman / patient. The Procedure 1. Ask the woman about herself: Ask the woman about her needs/ problems and refer to a previously taken history. Ask the women about her goals / preferences. 2. Tell the woman what is suitable for her. Use paraphrasing (saying the sentence in many forms) 3. Help the woman to take a decision: Provide the woman with a shortlist of the suitable options [including the characteristics, benefits, limitations and side effects of each]. Give her the chance to express her needs, preferences and concerns. Respond to her concerns as needed.

Do not decide for her but rather help her to express herself. 4. Explain the procedure / method in full details. 5. Repeat the instructions: Ask the woman to repeat the instructions. Summarize what you have said to the woman. Discuss the need for return and follow up either routine or if she had one of the warning symptoms or anytime she likes.

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Medical eligibility checklists for contraceptive use

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Checklist of questions asked to women who want to use Combined Oral Contraceptive Pills

Ask the client the questions below. If she answers NO to ALL of the questions, then she CAN use low-dose combined oral contraceptives if she wants. If she answers YES to a question below, follow the instructions.

1. Do you smoke cigarettes and are you age 35 or older? No Yes _Urge her to stop smoking. If she is 35 or older and will not stop smoking, do not provide COCs. Help her choose a method without estrogen.

2. Do you have high blood pressure? No Yes _If you cannot check blood pressure (BP) and she reports high BP, do not provide COCs. Refer for BP check if feasible or help her choose a method without estrogen. If no report of high BP, you can provide COCs. Check BP: If BP was below 140/90, give COCs without further BP readings. If systolic BP 140 or higher or diastolic BP 90 or higher, do not provide COCs. Help her choose another method. (One BP reading in the range of 140 159/9099 is not enough to diagnose high BP. Offer condoms or spermicide for use until she can return for another BP check, or help her choose another method if she prefers. If BP reading at next check is below 140/90, she can use COCs and further BP readings are not necessary.) If systolic BP 160 or higher or diastolic BP 100 or higher, she also should not use DMPA or NET EN.

3. Are you breastfeeding a baby less than 6 months old?

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No Yes _Can provide COCs now with instruction to start when she stops breastfeeding or 6 months after childbirthwhichever comes first. If she is not fully or almost fully breastfeeding, also give her condoms or spermicide to use until her baby is 6 months old. Other effective methods are better choices than COCs when a woman is breastfeeding, whatever her babys age.

4. Do you have serious problems with your heart or blood vessels? Have you ever had such problems? If so, what problems? No Yes _Do not provide COCs if she reports heart attack or heart disease due to blocked arteries, stroke, blood clots (except superficial clots), severe chest pain with unusual shortness of breath, diabetes for more than 20 years, or damage to vision, kidneys, or nervous system caused by diabetes. Help her choose another effective method.

5. Do you have or have you ever had breast cancer? No Yes _ Do not provide COCs. Help her choose a method without hormones.

6. Do you have jaundice, cirrhosis of the liver, a liver infection or tumor? (Are her eyes or skin unusually yellow?) No Yes _Perform physical exam or refer. If she has serious active liver disease (jaundice, painful or enlarged liver, active viral hepatitis, liver tumor), do not provide COCs. Help her choose a method without hormones.

7. Do you often get severe headaches, perhaps on one side or pulsating, that cause nausea and are made worse by light and noise or moving about (migraine headaches)?

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No Yes _If she is 35 or older, do not provide COCs. Help her choose another method. If she is under age 35, but her vision is distorted or she has trouble speaking or moving before or during these headaches, do not provide COCs. Help her choose another method. If she is under age 35 and has migraine headaches without distortion of vision or trouble speaking or moving, she can use COCs.

8. Are you taking medicine for seizures? Are you taking rifampin (rifampicin) or griseofulvin? No Yes _If she is taking phenytoin, carbamezapine, barbiturates, or primidone for seizures or rifampin or griseofulvin, provide condoms or spermicide to use along with COCs or, if she prefers, help her choose another effective method if she is on long-term treatment.

9. Do you think you are pregnant? No Yes _Assess whether pregnant (see page 46). If she might be pregnant, also give her condoms or spermicide to use until reasonably certain that she is not pregnant. Then she can start COCs.

10. Do you have gallbladder disease? Ever had jaundice while taking COCs? Planning surgery that will keep you from walking for a week or more? Had a baby in the past 21 days? No Yes _If she has gallbladder disease now or takes medicine for gallbladder disease, or if she has had jaundice while using COCs, do not provide COCs. Help her choose a method without estrogen. If planning surgery or just had a baby, can provide COCs with instruction on when to start them later. Be sure to explain the health benefits and risks and the side effects of the method that the client will

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use. Also, point out any conditions that would make the method inadvisable when relevant to the client.

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Checklist of questions asked to women who want to use Progestin-Only Oral Contraceptives Ask the client the questions below. If she answers NO to ALL of the questions, then she CAN use progestin-only pills (POP) if she wants. If she answers YES to a question below, follow the instructions.

1. Do you have or have you ever had breast cancer? No Yes _ Do not provide POCs. Help her choose a method without hormones.

2. Do you have jaundice, severe cirrhosis of the liver, a liver infection or tumor? (Are her eyes or skin unusually yellow?) No Yes _ Perform physical exam or refer. If she has serious active liver disease (jaundice, painful or enlarged liver, viral hepatitis, liver tumor), do not provide POCs. Refer for care. Help her choose a method without hormones.

3. Are you breastfeeding a baby less than 6 weeks old? No Yes _ Can give her POCs now with instructions on when to startwhen the baby is 6 weeks old (see page 69).

4. Do you have serious problems with your blood vessels? If so, what problems? No Yes _ Do not provide POPs if she reports blood clots (except superficial clots). Help her choose another effective method.

5. Are you taking medicine for seizures? Taking rifampin (rifampicin) or griseofulvin? No Yes _ If she is taking phenytoin, carbamezapine, barbiturates, or primidone for seizures or rifampin or griseofulvin, provide condoms or

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spermicide to use along with POCs. If she prefers, or if she is on long-term treatment, help her choose another effective method.

6. Do you think you are pregnant? No Yes _ Assess whether pregnant. If she might be pregnant, also give her condoms or spermicide to use until reasonably sure that she is not pregnant. Then she can start POCs. Be sure to explain the health benefits and risks and the side effects of the method that the client will use. Also, point out any conditions that would make the method inadvisable when relevant to the client.

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Checklist of questions asked to women who want to use DMPA Injectables

Ask the client the questions below. If she answers NO to ALL of the questions, then she CAN use DMPA. If she answers YES to a question below, follow the instructions.

1. Are you breastfeeding a baby less than 6 weeks old? No Yes _ She can start using DMPA beginning 6 weeks after childbirth. If she is fully or almost fully breastfeeding, however, she is protected from pregnancy for 6 months after childbirth or until her menstrual period returnswhichever comes first. Then she must begin contraception at once to avoid pregnancy. Encourage her to continue breastfeeding.

2. Do you have problems with your heart or blood vessels? Have you ever had such problems? If so, what problems? No Yes _ Do not provide DMPA if she reports heart attack, heart disease due to stroke, blood clots (except superficial clots), severe chest pain with unusual shortness of breath, severe high blood pressure, diabetes for more than 20 years, or damage to vision, kidneys, or nervous system caused by diabetes. Help her choose another effective method.

3. Do you have high blood pressure? No Yes _ Check BP If systolic BP below 160 and diastolic BP below 100, okay to give DMPA. If systolic

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BP over 160 or diastolic BP over 100, do not provide DMPA. Help her choose another method except COCs.

4. Do you have or have you ever had breast cancer? No Yes _ Do not provide DMPA. Help her choose a method without hormones.

5. Do you have severe cirrhosis of the liver, a liver infection or tumor? (Are her eyes or skin unusually yellow?) No Yes _ Perform physical exam or refer. If she has serious active liver disease (jaundice, painful or enlarged liver, viral hepatitis, liver tumor), do not provide DMPA. Refer for care. Help her choose a method without hormones.

6. Do you think you are pregnant? No Yes _ Assess whether pregnant (see page 46). Give her condoms or spermicide to use until reasonably sure that she is not pregnant. Then she can start DMPA.

7. Do you have vaginal bleeding that is unusual for you? No Yes _ If she is not likely to be pregnant but has unexplained vaginal bleeding that suggests an underlying medical condition, can provide DMPA. Assess and treat any underlying condition as appropriate, or refer. Reassess DMPA use based on findings. Be sure to explain the health benefits and risks and the side effects of the method that the client will use. Also, point out any conditions that would make the method inadvisable when relevant to the client.

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Checklist of questions asked to women who want to use Copper-Bearing IUCDs

Ask the client the questions below. If she answers NO to ALL of the questions, then she CAN use an IUD if she wants. If she answers YES to a question below, follow the instructions:

1. Do you think you are pregnant? No Yes _ Assess whether pregnant (see page 46). Do not insert IUD. Give her condoms or spermicide to use until reasonably sure that she is not pregnant.

2. In the last 3 months have you had vaginal bleeding that is unusual for you, particularly between periods or after sex? No Yes _ If she has unexplained vaginal bleeding that suggests an underlying medical condition, do not insert IUD until the problem is diagnosed. Evaluate by history and during pelvic exam. Diagnose and treat as appropriate, or refer.

3. Did you give birth less than 4 weeks ago? No Yes _ Delay inserting an IUD until 4 or more weeks after childbirth. If needed, give her condoms or spermicide to use until then.

4. Do you have an infection following childbirth? No Yes _ If she has puerperal sepsis (genital tract infection during the first 42 days after childbirth), do not insert IUD. Refer for care. Help her choose another effective method.

5- Have you had a sexually transmitted disease (STD) or pelvic inflammatory disease (PID) in the last 3 months? (ask about pain in lower

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abdomen and possibly also abnormal vaginal discharge, fever, or frequent urination with burning.) If she has no tenderness in the abdomen or when the cervix is moved, however, she probably does not have pelvic infection. No Yes _ Do not insert IUD now. Urge her to use condoms for STD protection. Refer or treat client and partner(s). IUD can be inserted 3 months after cure unless re-infection is likely.

6- Do you have any cancer in the female organs or pelvic tuberculosis? No Yes _ Do not insert IUD. Treat or refer for care as appropriate. Help her choose another effective method. Be sure to explain the health benefits and risks and the side effects of the method that the client will use. Also, point out any conditions that would make the method inadvisable when relevant to the client.

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Intrauterine contraceptive Device Insertion and Removal

175

Clinical Learning Guide IUCD insertion

STEP / TASK Pre-Insertion Counseling 1. Greet the woman respectfully and with kindness. 2. Ask woman about her reproductive goals and need for protection against STDs. 3. If IUD counseling not done, arrange for counseling prior to performing procedure. 4. Determine that the woman's contraceptive choice is the IUD. 5. Review the woman Screening Checklist to determine if the IUD is an appropriate choice for the woman. Are you reasonably sure that the lady is not pregnant. Is there any contraindication to insert the IUD for this

lady? 6. Assess woman's knowledge about the IUD's major side effects. Warning signs include: 7. Be responsive to woman's needs and concerns about the IUD. 8. Describe insertion procedure and what to expect.

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STEP / TASK Pre-insertion counseling 1. Obtain or reviews brief reproductive health history. 2. Check that the woman has recently emptied her bladder and washed and rinsed her genital area if necessary. 3. Tell the woman what is going to be done and encourages her to ask questions. 4. Wash hands thoroughly and dry them. 5. Arrange instruments and supplies on high-level disinfected or sterile tray. 6. Put new examination or high-level disinfected surgical gloves on both hands. 7. Perform abdominal, speculum and bimanual examination (refer to the specific clinical learning guide) 8. Load Copper T 380A in sterile package. Insertion 1. Put new examination or high-level disinfected surgical gloves on both hands. 2. Insert vaginal speculum to see cervix. 3. Apply antiseptic solution two times to the cervix, especially the os, and the vagina. 4. Gently grasp cervix with Tenaculum. 5. Sound uterus using no-touch technique: Determine the size and direction of the uterus 6. Adjust the shoulder on the inserter to the size of the uterus.

7. Insert the Copper T 380A IUD using the withdrawal

technique. 8. Cut IUD strings to 3-4 cm in length. 9. Gently remove Tenaculum and speculum and places in 0.5% chlorine solution for 10 minutes for decontamination. Post-procedure tasks 1. Before removing gloves, place all instruments in 0.5% chlorine solution for 10 minutes for decontamination. 2. Dispose of waste materials in leak proof container or plastic bag.

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STEP / TASK Immerse both gloved hands in 0.5% chlorine solution and removes gloves by turning inside out and place them in a

leak-proof container or plastic bag. 3. Wash hands thoroughly and dries them. 4. Complete womans record. Post-insertion counseling 1. Teach the woman how and when to check for strings. Once every month at the end of menstruation. Using only one clean finger.

No attempt to pull on the threads. 2. Discuss what to do if the woman experiences any side effects or problems. 3. Provide follow up visit instructions and answer any questions. 4. Assure the woman that she can have the IUD removed at any time. 5. Observe the woman for at least 15 to 20 minutes before sending her home.

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Clinical Learning Guide IUCD removal

STEP / TASK Pre-Removal Counseling 1. Greet the woman respectfully and with kindness. 2. Ask the woman her reason for removal and answers any questions. 3. Review the woman's reproductive goals and need for protection against STDs. 4. Describe the removal procedure and what to expect. Removal 1. Check to be sure the woman has emptied her bladder and washed and rinsed her genital area if necessary. 2. Tell the woman what is going to be done and encourages her to ask questions. 3. Wash hands thoroughly and dry them. 4. Put new examination or high-level disinfected surgical gloves on both hands. 5. Perform bimanual examination. 6. Insert vaginal speculum to see cervix and IUD strings. 7. Apply antiseptic solution two times to the cervix, especially the os, and vagina. 8. Grasp strings close to cervix and pull slowly but firmly to remove IUD. 9. Show IUD to the woman. 10. Immerse IUD in 0.5% chlorine solution and dispose of in leak-proof container or plastic bag. 11. Gently remove speculum and place in 0.5% chlorine solution for 10 minutes for decontamination. 1. Before removing gloves, place all instruments in 0.5% chlorine solution for 10 minutes for decontamination. 2. Dispose of waste materials in leak proof container or plastic bag. 3. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning inside out.

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STEP / TASK If disposing of gloves, place in leak-proof container or plastic bag.

If reusing surgical gloves, submerge in 0.5% chlorine

solution for 10 minutes for decontamination. 4. Wash hands thoroughly and dries them. 5. Record IUD removal and the cause of discontinuation in the woman record. Post-procedural tasks 1. Discuss what to do if the woman experiences any problems and answers any questions. 2. Counsel the woman regarding new contraceptive method, if desired. 3. Help the woman obtain new contraceptive method or provides temporary (barrier) method until method of choice can be started.

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Implanon insertion and removal

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Clinical Learning Guide Implanon Insertion

Getting ready 1. Greet client respectfully and with kindness. 2. Ask woman about her reproductive goals and need for protection against STDs. 3. If Implanon implant counseling was not done, arrange for counseling prior to performing procedure. 4. Determine that the woman's contraceptive choice is Implanon. 5. Review Client Screening Checklist to determine if Implanon is an appropriate choice for the client. 6. Perform (or refer for) further evaluation, if indicated. 7. Assess woman's knowledge about Implanon's major side effects. 8. Respond to client's needs and concerns about Implanon. 9. Describe insertion procedure and what to expect. Insertion 1. Check to be sure that client has thoroughly washed and rinsed her entire non dominant arm. 2. Tell client what is going to be done and encourages her to ask questions. 3. Make sure that the implant package, sterile gloves, Antiseptic solution, and the sterile cloth (Optional) and marker pen (Optional) are available. 4. Allow the client to lie on her back with the non dominant arm turned outward and bent at the elbow. Place clean, dry cloth under her arm pen (Optional). 5. Mark position on arm for insertion of the implant at the inner side of the upper arm 6-8 cm above the elbow crease. You can use the groove

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between the biceps and triceps. 6. Washes hands thoroughly and dries them. 7. Puts sterile or high-level disinfected gloves on both hands (if powdered, removes powder from glove fingers). 8. Preps insertion site with antiseptic solution. 9. Places sterile or high-level disinfected drape over arm (optional). 10. Injects local anesthetic 2 ml of (1% without epinephrine) just under skin; by advancing the needle about 4 cm under the skin and injects 1-2 ml of local anesthetic along the subdermal tracks. 11. Checks for anesthetic effect before introducing the applicator needle. 12. Remove the sterile disposable applicator carrying the Implanon from its blister 13. Visually Verify the presence of the implant inside the metal part of the cannula. If the implant protrudes from the needle, return it to its original position by tapping against the plastic part of the cannula. Make all effort to keep the implant sterile. 14. Hold the applicator with the needle pointed upward until insertion, to prevent the implant from dropping out. 15. Stretch the skin around the insertion site with thumb and index. Introduce the needle in the space between the biceps and triceps directly under the skin and as superficial as possible, slightly angled and parallel to the skin surface 16. While lifting the skin with the tip of the needle, advance the needle to its full length. 17. While the cannula is kept parallel to the skin surface, break the seal of the applicator and turn the obturator 90 with respect to the cannula. 18. Fix the obturator firmly against the arm. 19. With your free hand slowly pull the cannula out of the arm with the obturator immobilized in place. (The process is opposite to giving an

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injection where the plunger is pushed and the syringe is fixed. And it is similar to IUD insertion using the withdrawal technique). 20. Palpate the implant to check that it has been inserted. 21. Apply sterile gauze with a pressure bandage. 22. Before removing gloves, fill or flush needle and syringe with 0.5% chlorine solution and places all instruments in 0.5% chlorine solution for 10 minutes. 23. Dispose of waste materials by placing in leak proof container or plastic bag. 24. Immerse gloved hands in 0.5% chlorine solution. Removes gloves by turning inside out and place in leak proof container or plastic bag. 25. Wash hands thoroughly and dries them. 26. Complete client record, including the insertion side and any difficulty or complications. Give the client the Implanon ID card if available. Post-insertion care 1. Instruct client regarding wound care. The instruction should emphasis the need to keep the removal area dry for 24 hours, and removal of the covering gauze and bandage after 24 hours. 2. Ask the client to come for return visits 3. Discuss what to do if client experiences any problems following insertion or side effects. 4. Assure client that she can have Implant removed at any time if she desires. 5. Ask client to repeat instructions and answer client's questions. 6. Observe client for at least 15 to 20 minutes before sending her home.

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Clinical Learning Guide Implanon Removal

PREREMOVAL COUNSELING 1. Greet client respectfully and with kindness. 2. Ask client her reason for removal and answers any questions. 3. Review client's present reproductive goals and asks if she wants another set of Norplant implants. 4. Describe the removal procedure and what to expect. REMOVAL OF NORPLANT IMPLANT Getting Ready 1. Check to be sure client has thoroughly washed and rinsed her entire arm. 2. Tell client what is going to be done and encourages her to ask questions. 3. Position woman's arm and palpates Implant to determine point for removal incision. Ask the client to bend her arm to make palpation easier. Do not start the procedure if the implant has not been located and consult a senior physician. 4. Determine that required sterile or high-level disinfected instruments are present. This should include Scalpel, 2 forceps, sterile gloves, syringes, local anesthetic, butterfly closure and antiseptic solution. Pre-removal Tasks 5. Wash hands thoroughly and dry them 6. Put sterile or high-level disinfected gloves on both hands (if gloves are powdered, removes powder from fingers). 7. Prep removal site with antiseptic solution. 8. Places sterile or high-level disinfected drape over arm (optional). 9. Inject 0.5 1ml of local anesthetic (1% without epinephrine) at the incision site which is just under the distal end of the Implant. Application above the implant makes the skin swell, which may cause difficulties in locating the implant.

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10. Check for anesthetic effect before making skin incision. REMOVAL: 1. Make a small (2 mm) skin incision in the longitudinal direction of the arm at the distal end of the implant 2. Push the implant towards the incision until the tip is visible. 3. Grasp the implant with a (mosquito) forceps, and remove it 4. Place the removed implant in bowl containing 0.5% chlorine solution for 10 minutes for decontamination. ALTERNATIVE REMOVAL METHODS A. If the implant is encapsulated, open fibrous sheath over the end with scalpel. Gently squeezes the end of the implant into the incision, till it "pops out" and remove it with a forceps. B. If the tip is not visible, gently insert a forceps into the incision and grasp the implant and uses a second forceps to dissect tissues around the implant till it pops out and removed. Post-removal Tasks 5. Remove drape and wipes client's skin with alcohol 6. Close wound with a butterfly closure, applies pressure dressing snugly. 7. Before removing gloves, fill or flush needle and syringe with 0.5% chlorine solution and place all instruments in 0.5% chlorine solution for 10 minutes for decontamination. 8. Dispose of waste materials by placing in leak proof container or plastic bag. 9. Immerse gloved hands in 0.5% chlorine solution. Remove gloves by turning inside out and place in leak proof container or plastic bag.

10. Wash hands thoroughly and dries them.

11. Complete client record. This should include any difficulty in removal and the total time consumed during the procedure, and reinsertion, if done. POSTREMOVAL COUNSELING

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1. Instruct client regarding wound care. The instruction should emphasis the need to keep the removal area dry for 24 hours, and removal of the covering gauze and bandage after 24 hours. 2. Ask the client to makes return visit appointment, if necessary ( as in case of pain or irritation). 3. Discuses what to do if any problems occur and answers any questions 4. Counsel client regarding new contraceptive method, if desired. Emphasis the rapid return of fertility after removal of the implant. 5. Help client obtain new contraceptive method or provides temporary (barrier) method until method of choice can be started. A new implant can be inserted immediately after removal in the same site using the same removal incision. 6. Observe client for at least 15 to 20 minutes before sending home.

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Annexes

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The WHO partograph

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WHO Medical eligibility Criteria for starting contraception

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Summary table of WHO medical eligibility criteria of FP methods

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CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN) CERVICAL CANCER (awaiting treatment)

2 CONDITION BREAST DISEASE a) Undiagnosed mass b) Benign breast disease c) Family history of cancer d) Cancer (i) current (ii) past and no evidence of current disease for 5 years ENDOMETRIAL CANCER 1 OVARIAN CANCER 1 UTERINE FIBROIDS a) Without distortion of the uterine cavity b) With distortion of the uterine cavity PELVIC INFLAMMATORY DISEASE (PID) a) Past PID (assuming no current risk factors of STIs) (i) with subsequent pregnancy (ii) without subsequent pregnancy b) PID - current or within the last 3 months 1 1 1 1 1 4 3 2 1 1 COCs

2 CICs

1 POPs

2 DMPA NET-EN 2 1 1 4 3

Subdermal Implants 2 1 1 4 3

2 1 1 4 3

2 1 1 4 3

1 1

1 1

1 1

1 1

1 1

1 1

1 1

1 1

1 1 1

1 1 1

1 1 1

1 1 1

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