Government College of Nursing Somajiguda,

Hyderabad, T.S

Procedure Manual for Obstetrics and

Gynecological Nursing
 INDEX
S.no Procedure P.no.
01 Female Pelvis 1-3
02 Fetal Skull 4-6
03 Antenatal Assessment 7-14
04 Pervaginal Examination 15-20
05 Artificial Rupture Of Membranes 21-23
06 Conducting Normal Delivery 24-30
07 Partograph 31-35
08 Episiotomy Giving And Repairing 36-41
09 Management of Third Stage Labour 42-45
10 Placental Examination & Cord Abnormalities 46-49
11 Assisted Breech Delivery 50-56
12 Assisting for LSCS 57-60
13 Assisted Forceps Delivery 61-62
14 Assisted Vaccum Delivery 63-65
15 Post natal Assessment 66-70
16 Perineal Care 71-74
17 Immediate / Essential Newborn Care 75-77
18 Newborn Assessment 78-85
19 Baby Bath 86-90
20 Breastfeeding 91-94
21 Kangaroo Mother Care 95-100
22 Photo Therapy 101-106
23 Newborn Resuscitation 107-113
24 Formulas for Drug Calculation 114-115
25 MTP setup 116-121
26 Insertion and Removal of IUCD 122-131
27 Tubectomy 132-133
28 Pap-smear 134-136
 1.FEMALE PELVIS
Definition:
Pelvis is key to midwifery practice as one of the way to estimate a woman‘s
progress in labour is by assessing the relationship of the fetus to certain pelvic
landmarks from the obstetrical standpoint.
Functions:
 The primary function of the pelvic girdle is to allow movement of the body,
especially walking & running.
 This makes it necessary for the sacroiliac joint to be immensely strong
and virtually immobile.
 The pelvis also takes the weight of the sitting body on to the ischial
tuberosities.
The female bony pelvis is divided into:
• False pelvis: above the pelvic brim and has no obstetric importance.
• True pelvis: below the pelvic brim and related to the child -birth.
1. The Pelvic Inlet (Brim) Boundaries

1. Upper border of the symphysis pubis.

2. Pubic crests
3. Pubic tubercle
4. Upper border of the superior pubic rami,
5. Ilio-pectineal eminences,
6. Ilio-pectineal lines, Figure-1: Bony landmarks for the brim of
7. Sacroiliac joints, pelvis
8. Anterior border of ala of the sacrum,
9. Sacral promontory,
Pelvis is composed of:
- 2 Innominate or hip bones and pubic bone
- 1 Sacrum
- 1 Coccyx
Pelvic joints
1) 1Symphysis pubis (between two pubic bones)
2) 2 Sacroiliac articulation (between sacrum and iliac bones)
3) 1 Sacro-coccygeal joint(between sacrum and coccyx)

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Pelvis Diameter
Anterior -posterior Transverse Oblique
Pelvic inlet 11 13 12
Pelvic cavity 12 12 12
Pelvic outlet 13 11 --

Antero-posterior diameters of inlet is of three types:

1) Obstetric conjugate = 10cm
2) True conjugate= 11cm
3) Diagonal conjugate = 12cm
Extra edge for the viva:
Largest diameter of the fetal skull: Mento-vertex (14cm) and smallest
diameter is bimastoid diameter (7.5)
Diameters of engagement for fetal skull in normal labor are:
- Subocciouto bregmatic (9.5cm)
- Subocciputo fontal (10cm) as anterioposterior diameter.
- Bitemporal (9.5cm) as transvers diameter.
Importance of suture:
 Permits gliding movements of skull bones for its moulding during the
labour.
 Gives an idea of manner engagement by means of digital palpation of
sagittal suture through p/v examination shows degree of rotation of head
shows degree of moulding.
Moulding: It is an alteration of the shape of the fore coming head while passing
through resistant birth canal during labour.
It is disappears within few hours after birth.
Caput succedaneum: it is the formation of swelling due to stagnation of fluid
in the layers of the skull beneath the girdle of contact.
Types of pelvis:
1) Gynaecoid (50%)
2) Android(20%)
3) Anthropoid(25%)
4) Platypelloid( 5%).
Type of pelvis Shape Important features
Gynaecoid Round or - Normal female pelvis.
transversely oval - The transvers diameter of inlet is
slightly AP diameter
- Sacrum is well curved
- Ischial spines are not prominent
- Sacro sciatic notch is wide
- Supra pubic angle is 90o

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Android Wedge shaped - Male type of pelvis
Inlet with small - Cavity is funnel shaped
posterior - All diameters of cavity are
segment reduced
- Sacrum is flat
- Side walls convergent
- Ischial spines are prominent
- Supra pubic angle is <90o
Anthropoid Long anterio- - Ape like pelvis
posterior oval - AP diameter of inlet is more than
transverse diameter
Platypelloid Inlet is transvers - Flat bowl like pelvis
oval much - The transverse diameter is more
longer than the than AP diameter
AP - Supra pubic angle is wide

Figure-2: Types of pelvis

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 2.FETAL SKULL
Areas of fetal skull
Fetal skull is formed of twin pliable the bones composing main four areas
of it.
1. Face: Bounded by root of nose and supra-orbital ridges and by the
junction of the floor of mouth with neck.
2. Brow/sinciput: Bounded by anterior fontanelle and coronal sutures and
by root of nose and supra orbital ridges of either side.
3. Vertex: Quadrangular area which is bounded anteriorly by bregma and
coronal sutures, posteriorly by lambda and lamboid sutures and laterally
by parietal lines passing through both parietal eminences.
4. Sinciput: Limited to the occipital bone.

Figure-1: fetal skull

Bones of Fetal Skull:

1. Frontal bones
2. Parietal bones
3. Temporal bones
4. Occiput bone

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Sutures of Fetal Skull:
1. Frontal suture(between two frontal bones)
2. Caronal suture(between two frontal and two parietal bones)
3. Sagittal suture (between two parietal based)
4. Lambdoid suture(between two parietal bones and occiput bone)

Fontanels of Fetal Skull:

Anatomically it contains 6 fontanelles. But two of them are obstetrically
significant
 Anterior fontanella (bregma)
 Posterior fontanella (lambda)

Table shows that features of anterior and posteriorfontenellas

S.no Feature Anterior fontanel Posterior fontanel

Formed by Junction of 4 sutures Junction 3 sutures
1 Frontal 1 Sagittal 1
Sagittal 1 Lambdoid 2
Caronal 2
2 Shape Diamond Triangular
3 measures 3cm x 3cm 1.2 cm x 12cm
4 Ossifies at 1 ½ years of age 6weeks of age
Diameters of the Fetal Skull:
It has: - 4 transfers diameters, 6 anteroposterior diameters
a) Transverse diameters: for memorizing transvers diameters learn a
memotic miss tina so pretty
1. Miss: Bi mastoid diameters = 7.5 cm
2. Tina : bitemporal diameters = 8 cm
3. So: super subparietal diamtera= 8.5cm
4. Pretty: bi parietal diameter= 9.5cm
b) Anteroposterior diameters:
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S.no Diameters Attitude of fetas Presentation
of Head
1 Suboccipito- bregmatic = 9.5cm Complete flexion Vertex
2 Suboccipito-frontal = 10cm Incomplete flexion Vertex
3 Occipito-frontal = 11.5cm Marked deflexion Vertex
4 Mento-vertical = 14cm Partial extension Brow
5 Submento-vertical = 11.5cm Incomplete extension Face
6 Submento-bregmatic = 9.5cm Complete extension Face

Figure: Diameters of fetal skull

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 3.ANTENATAL ASSESSMENT
Definition:
Systemic Supervision of a woman During Pregnancy is called antenatal care or
assessment.
Record of past events and circumstances that are relevant to a patients current
state of health.
Objectives:
General Objective: It is to ensure a normal pregnancy with deliver of healthy baby
from a healthy mother.
Specific Objectives:
- To assess the health status of the mother and the fetus, to formulate the plan of
subsequent management.
- To monitor the growth and development of the fetus.
- To calculate the estimated date of birth.
- To obtain baseline information against which are the subsequent assessed and
which are of importance in the determination of the gestational age.
- To Screen the ―High-Risk‖ cases.
- To prevent or to detect and treat at the earliest any untoward complications.
- To ensure continued medical surveillance and prophylaxis.
Pre requisites:
- Wash hands before and after the procedure to prevent cross infection.
- Explain the procedure to the mother to gain willingness of the mother.
- Ask the mother to empty her bladder.
- Place the mother in a comfortable position (dorsal position with slightly flexed
knees).
- Provide screen to maintain privacy.
- Abdomen should be fully exposed.
- Warm Hands by rubbing them with each other before touching the abdomen
and hands should not be removed until the procedure is over.
- Provide good source of light.
- Collect required articles at bed side.
- Stand at the right side of the mother.
- Record and re[porting to be done

Articles preparation:
Articles Purpose
Bed linen To cover the mother
TPR tray To measure the vital signs
Measuring tape and scale To measure the abdominal girth, fundal
height and height of the mother
Weighing machine To take weight of the mother
Fetoscope / stethoscope To auscultate fetal heart sound
Cotton swab To clean the secretions
Paper bag To collect soiled cotton swab
Watch To count pulse rate and fetal heart rate.

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History Taking:
I. Identification Data:
a. Name:
b. Age(years):
c. Address:
d. Education:
e. Occupation:
f. Monthly income:
g. Religion:
h. Marital status:
i. Marital life in Years:
j. Blood group
Husband‘s identification data:
a. Age:
b. Education:
c. Occupation:
d. Monthly income:
e. Blood group:
II. Chief complaints:
The geneses of the complaints are to be noted stating the mode of onset,
progress and duration. Even if there is no complaints, enquiry is to be made
about the sleep, appetite, bowel habit and urination
III. Gynecological History:
a. Menstrual History:
Age at menarche:
Duration of menstrual cycle:
Duration of cycles in days:
Regularity:
Amount of flow:
Associated symptoms:
b. Contraceptive history (Knowledge, practice, type, onset and time of
withdraw, complications / side effects and effects of various temporary
and permanent methods of contraception):
c. Any history of Infertility (type, duration and treatment):
d. Gynecologic anomalies (type and treatment):
e. History of any sexually transmitted diseases (type, duration and
treatment):
f. Sexual History:

IV. Obstetric History

Gravida: Para:
Abortion: Living:

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 a. Past Obstetric History
S. Year Type of Nature of Child Birth PNC condition Remarks
N delivery labour weight
o.
PT FT A and Age sex Mother Baby
delivery
Mention
about the
breast
feeding
and
immunizat
ion status
of the
child.

b. Present pregnancy:
First day of last menstrual period (LMP): Expected date of
delivery(EDD):
Period of Gestation:
Date of Booking:
No. of Antenatal Visits:

c. Any history of minor aliments:

Minor aliments Yes No Do not know
Morning sickness
Back ache
Acidity / heart burn
Constipation
Leg cramps
Varicose veins
Ankle edema
Vaginal discharge
Any other(specify)

d. Date of quickening:
e. H/ O drugs /radiation: Yes / No if yes, Specify: ………….
f. Weight:
Pre pregnant weight: ………kg
Present weight: ……………kg
Total weight gain: …………kg
g. Number of TT injection: TT1___________TT2________
(Tick in the specific dose with the date).

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V. Past medical / surgical history:
Medical Yes No Do not know
conditions
Heart disease
Hypertension
Tuberculosis
Diabetes mellitus
Urinary tract
infection
Drug sensitivity
Allergic reactions
Any other specify
Surgery
(specify if any and
mention the year)
Pelvic
Abdominal

VI. Family History and Social History:

Conditions Yes No Do not know
Twins
Congenital
malformations
Hypertension
Cardiac diseases
Any other
conditions

VII. Dietetic History:

Vegetarian / Non-vegetarian:
Frequency of meal per day:
Pattern of meal: (write about the type of food in detail)

OBSTETRICAL EXAMINATION
General Head to toe examination:
1. General examination:
a. Height: …………….cm, Weight: …………Kg
b. Temperature: ……….oF, Pulse: ………./ min
c. Respiration: ……/min, B/P: ………..mmHg
General appearance:
Built: average/ thin / obese
Gait: Normal/ lordosis/ scoliosis/ pregnancy walk
Nutritional status: good/ average/ poor
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Head and Scalp:
Face: Chloasma- present/ not present
Eyes: palpebral conjunctiva
Pallor present/ absent
Ears:
Nose:
Mouth: Holitosis - yes/ no
Dental carriers – yes/ no
Gums: healthy/ bleeding – yes/ no
Lips: pallor- present/ absent
Neck: glands enlarged / not enlarged
Breast: soft/ engorged
Primary areola - yes/ no
Secondary areola- yes/ no
Visible veins – yes/ no
Montgomery‘s tubercles – yes/ no
Nipples: well formed- yes/ no
Normal/ cracked/ retracted
Secretion present/ absent
Heart:
Lungs:
Liver and Spleen:
Perineum:
Limbs: pedal edema present/ absent
Type of edema- pitting/ Non-pitting
2. Abdominal examination
a. Inspection
Shape -
Size -
Presence of any incision, scar or herniation
Skin condition - striae gravidarum – yes/ no
Striae albicans - yes / no
Linea nigra present / absent
Any infection
Flanks - full/ not full
Umbilicus - everted / not everted
Fetal movements - seen/ not seen Figure:1
b. Measurements: Fundal height measurements
Abdominal girth (in centimeters and inches)
________cm, _______inches
Fundal height (in centimeters and inches)
________cm, _______inches
c. Palpations: ( figure-2)

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 Fundal palpation:
Right lateral:
Left lateral:
Pelvic grip:
Pawlick grip
d. Auscultation:
Location of FHS
FHR:________/min (regular)
e. Inferences
Lie:
Attitude:
Presentation:
Position:
Presenting part: Engaged/ Not engaged

Fundal palpation Lateral palpation

Pelvic palpation
Pawlick grip

Figure: 2 Different types of palpations.

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After care of the mother and articles:
- Make mother comfortable.
- Inform her about findings.
- Ask for any discomfort and record it.
- Replace all articles properly.
Recording and reporting:
a. Record all the findings in the history taking and assessment file.
b. Inform any abnormalities to the superior and take prompt action.
c. Record any other information that mother gives on the last page.

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 4.PER VAGINAL EXAMINATION IN LABOUR

Definition:
Per vaginal examination is an internal examination of the cervix and
vagina.
Indications:
1. To make a positive diagnosis of labour.
2. To make a positive identification of presentation.
3. To determine whether the head is engaged in case of doubt.
4. To ascertain whether the fore waters have ruptured or to rupture them
artificially.
5. To exclude especially if there is any ill-fitting presenting part.
6. To assess progress or delay in labour.
7. To apply a fetal monitoring in labour.
8. To confirm dilation of the cervix.
9. In multiple pregnancies, to confirm the lie and presentation of the second
twin and to puncture the second amniotic sac.
Purpose of a pelvic examination
- Assess the pelvic adequacy.
- Confirm the onset of labour.
- Assess the progress of labour.
- Descent of the presenting part.
- Effacement and dilatation of cervix.
- Presentation and position of the fetus.
- Detect cord prolapse following rupture of membranes in case of mal
presentation.
- Confirm the onset of second stage of labour.
- Assess the cause of delay in prolonged second stage of labour.
Preparation of environment
 Maintain privacy.
 Provide comfortable bed or examination table.
 Use good source of light.
 Maintain sterile field.
Preparation of the mother
Physical preparation:
- Shave the perineum / trim the hair as per the policy of the hospital during
first stage of labour.
- Provide privacy and drape the woman for vaginal examination.
- Give extra pillows to raise the head and place mackintosh under the
buttocks.
- Ask the woman to flex the knees.
- Pelvic examination is done with the women in dorsal position taking
aseptic precautions.

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 - Keep the mother in lithotomy or dorsal position with thighs flexed and
separated.
Psychological preparation
 Explain the procedure and its uses to the mother to win the confidence;
encourage and reassure her during the procedure.
Articles required
Articles Purpose
Clean linen To provide privacy
A mackintosh To prevent soiling of the bed
A bowl with warm water To flush the perineum
Antiseptic lotion To clean the perineum
Cotton swabs, gauze or rag piece in a To clean the perineum
sterile container
Long artery forceps in a sterile tray To hold the swabs for cleaning
Paper bag To receive the waste
A sterile pair of gloves To maintain the sterility and self-
precaution
Sterile pad To put over the perineum if needed

Steps of procedure:
Steps Rationale
Wash hands thoroughly To prevent infection
Poor water or antiseptic solution over To wash off any discharge from the
the perineum by squeezing the swabs perineal area
Clean the perineum using the wet To prevent the entrance of bacteria
swabs. from the anus into the urinary tract.
 Hold the swabs with forceps and  To prevent recontamination.
clean from above, downwards
towards the anal canal.
 Use one swab for one stroke.  To ensure thorough cleaning.
Clean the perineum from the mid-line
outwards in the following order
- The value
- Labia minora-farthest side.
- Labia minora-nearest side
- Inner side labia mejora farthest
side
- Inner side labia mejora nearest
side
- Outer side labia mejora farthest
side
- Outer side labia mejora nearest

15
 side
- Clean the anus thoroughly in
circular motion
Separate the labia minora with the left To note the progress of labour.
hand, wet two gloved finger of the
right hand and insert into vagina the
following features should be noted
simultaneously.
- Status of the cervix: cervical
dilatation and effacement.
- Position and presentation.
- Feel the sagittal suture to
ascertain the position and station
of presenting part and condition
of membrane.
- Station of the presenting part in
relation to ischial spines.
- Elasticity of the perineal
muscles.
- Character of the discharges if
any
- Pelvic adequacy
Do not remove fingers until
examination is completed
Keep the woman dry To make the woman comfortable

After care of the mother:

- Make the mother for comfortable.
- Explain of findings in simple way to the mother.
- Reassure for further management.

Recording the Findings of pelvic examination

After every vaginal examination, it is important to maintain a record of
the findings. These findings will be different for each woman and in each
examination, which is done for the same woman. The findings of vaginal
examination to be record are as follows:
 Condition of external genitalia and vagina.
 Cervix: Consistency, effacement and dilatation
 Status of the membranes: intact, leaking or ruptured.
 If ruptured, colour of the amniotic fluid.
 Presentation and position of the fetus.

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  Presence of caput.
 Descent of the fetal head in terms of station (figure. 1)
 Ischial spine and ischial tuberosity not prominent / prominent.

Figure-1
Station of the head
Policy
Physicians, Registered Midwives and competency validated Registered
Nurses (RN) perform vaginal / pelvic examinations to assess cervical change.
Applicability:
Vaginal examinations occur in the Diagnostic Ambulatory Program and
in the Antepartum/ Postpartum and Birthing Program areas of the Acute
Perinatal Program.
Procedure
1. Consent: The indication and procedure is discussed with the mother and
consent is obtained prior to a vaginal examination.
2. Criteria: A vaginal exam is only indicated if it will change the mothers
management and care.
Antepartum
A vaginal exam may be indicated:
Prior to an induction (ie, administration of Prostaglandin, Cervidil, Oxytocin)
 When pre-term delivery is IMMINENTLY suspected (contractions,
pelvic/rectal pressure).
 NOTE: If there are no signs/symptoms of imminent delivery a sterile
speculum
Intra partum
A vaginal exam may be indicated to/for:
- Confirm progress in labour/suspected dystocia of labour and confirm full
dilation.
- Confirm presenting part.
- FECG or IUPC application (Fetal Spiral Electrode, Intrauterine Pressure
Catheter)
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  Following spontaneous rupture of membranes (SROM), unless the
presenting part is known to be firmly engaged identify.
 Cord prolapse - for example, where there is brady-cardia or recurrent
variable decelerations of the fetal heart rate (FHR)
 Prior to Analgesia
o Before the initial dose of epidural anesthesia
o Before an epidural top-up, if indicated
o Immediately before the administration of an opioid.
Postpartum
A vaginal exam may be indicated to assess a woman‘s source of bleeding
(retained placenta or clots)
Contraindications: Vaginal examinations are not performed for a woman with
the following conditions:
 Placenta previa
 Vasa previa
 Suspected or known low lying placenta
 Unknown placental location with bleeding
 Women with the following conditions are at higher risk of developing an
infection. Vaginal examinations should be extremely limited and
duplicate exams for learning purposes are not appropriate.
 Group B Strep positive with ruptured membranes
 Prolonged rupture of membranes
Documentation:
Record the results of the vaginal examination

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 5.ARTIFICIAL RUPTURE OF MEMBRANES
Definition: The membranes below the presenting part overlying the internal os
are ruptured to drain some amount of amniotic fluid.
INDICATIONS CONTRAINDICATIONS
 Chronic Hydramnios  Intrauterine foetal death
 Severe pre-eclampsia/  Maternal AIDS
eclampsia
 Genital active infections.
 In combination with medical
induction
 To place scalp electrode for
electronic foetal monitoring.

Preliminaries:
 It is an outdoor procedure.
 The patient is asked to empty to bladder.
 It is an aseptic procedure.
 The procedure may be conducted in the labour ward or in the operation
theatre if the risk of cord prolapse is high.

Preparation:
 The practitioner first assesses cervical dilation through the performance
of a sterile digital exam.
 At the same time, assessment of the fetal presenting part is made,
ensuring that the presenting part is, in fact, the fetal head and assessing
that the fetal head is well engaged in the pelvis.
 After confirmation of both fetal presentation and engagement, the
practitioner can proceed with artificial rupture of membranes.

Articles Preparation:
A sterile tray containing:

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 Equipment No. Rationale
01 To grab and tear the amniotic
Amniotomy hook or amniotomy
finger cot membranes.
Lubricant 01 To avoid friction and pain
01 To protect from soiling
Personal protective equipment
(gloves, gown, drapes, mask, eye
protection)
01 To avoid soiling
Absorbent pads and mackintosh
01 To assess fetal well-being
Electronic fetal monitor
(Cardiotocography -CTG)
03 To cover the mother
Sterile drapes
01 To disinfect the area
Betadine solution
01 To soak the gauze pieces in betadine
A small bowl
01 To hold and clean the perineal
Sponge holder
region.
04 To prevent infections
Gauze pieces

 Tocolytics should be available

Personnel:
1. Obstetrician
2. Paediatrician
3. Midwife
4. Labour and delivery nurse.

Steps:
1. Assist the mother to rest in lithotomy position.
2. Clean the perineal region by holding a sponge holder with gauze peices
soaked in betadine solution.

20
 3. Drape the mother and expose the perineum.
4. Two fingers are introduced into the vagina smeared with antiseptic
ointment and lubricant.
5. The index finger is passed through the cervical canal beyond the internal
os.
6. The membranes are swept free from the lower segment as far as reached
by the finger.
7. With one or two fingers still in the cervical canal with the palmer surface
upwards, a long Kocher's forceps with the blades closed or an amnion
hook is introduced along the palmer aspect of the fingers up to the
membranes.
8. The blades are opened to seize the membranes and are torn by twisting
movements.
9. Amnion hook is used to scratch over the membranes.
10.Watch for the umbilical cord not to escape out. This is followed by
visible escape of amniotic fluid.
11.Check the colour of the amniotic fluid clear.

After Care of the Patient:

1. Hemodynamic status of the pregnant woman
2. Vital signs
3. Any signs of infection
4. Any signs of cord prolapse
5. Fetal heart rate
6. Colour of the amniotic fluid (liquor).

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 6.CONDUCTING NORMAL DELIVERY
Definition:
labour is called normal if it will fullfills the following criteria:
1. Spontaneous in onset and at term.
2. With vertex presentation.
3. Without undue prolongation.
4. Naturalmpresentation with minimal aids .
5. Without having any complication affecting the health of the mother and / or the
baby.
Objectives:
It is to provide efficient care and to cope with such emergency as amy arise.
Hence a good midwife will try to:
- Give comfort, relieve pain, conserve strenght, prevent exhaustion, injury and
blood loss.
- Maintain cleanlyness, asepsis, antisepsis throughout the labour.
- Carryout careful observation. Here, it is very essential that nurse has sufficiant
knowledge and experience to enable her to recognise normal progress.
- Detect decviations from the natural course.
- Prevent complications where possible.
- Recognise, complications early and releive promptly and compitanty untill the
arraival of the obstetritian.
Purposes:
 To have the child birth event take place in a prepared and safe environment.
 To conduct delivery with least trauma to mothervand baby.
 To assist mother go through the process without undue stress, injury or
complications.
 To promote smooth and safe transition of newborn to the extranterine life.
 To avoid complications.
Article preparation:
Article Purpose
Sponge holding forceps 1 To clean the perineum
With gauze poieces
Cotton pads To mop the areas
Draping sheets and leggings To drape the mother and provude privacy
Sanitary pads 2 One to provude perineal support and the
other to apply over the perineum after the
delivery to soak the lochia.
Small bowel containing betadine To apply over the wound after delivery
Sterile gloves For aseptic techniques
Apron, gloves and mask Personal protection
Mucus sucker To extract the secretions from mouth and
nose
Artery forceps 2 To clamp the umbilical cord
Scissors 1 To cut the cord

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Cord clamp To clamp the cord
Inj. Oxytocine To improve uterine contractions
Tab.Misoprostol 400mg to 800mg To control the bleeding after delivery
Note : In case of episuotomy, refer the procedure of episiotomy giving and repairing.
For newborn:
1. Baby blanket or flannel cloth-2, one to rceive and dry the baby, anoter one to
wrap the baby.
2. Neonatl resuccitation equipment checked and ready for use.
3. Oxygen source withtucking.
4. Suction apparatus.
Points to be remember:
- Follow strict aseptic techniques.
- Never ask the mother to beardown before full dilataion.
- If episiotomy needed, give at the peak of a uterine contraction.
- Check that the resuscitation set, suction apparatus and other equipment are in
good working in condition.
- Record any alteration in uterine contraction or fetal heart rate. Record the time
of rupture of membrane and coulor of amniotic fluid.
- Note the the fetal heart rate when the uterine contractions are absent.
Procedure:
Steps Rationale
As soon as the sign and symptoms of the To observe the progress of labour.
approaching second stage of labour are
observed, put the mother on the delivery
table
Provide dorsal position with legs flexed To enhance the naturl process of
and abducted. delivery.
Give perineal care with 2% antiseptic To clean the perineal area.
solution as available in the hospital.
Scrub hands and arms thoroughly with soap To prevent the cross infection.
and running water; put on sterile gloves.
Arrange the required articles. For conducting delivery inorder of use
on the trolly.
When the mother gets contraction, To maintaine the continue pressure on
encourage her to hold the thighs, take deep the presenting part.
breath, close the mouth, hold the breath and
beardown or push; when the uterine
contraction passes off, advice the motherto
open the mouth and take sveral deep
breath.
Provide sips of cold / warm water to drink; To maintaine the hydration status.
wipe off the sweat from the face with a wet
sponge.
When presenting part is visible during To prevent the cross infection.
contractio, put leggings anddrape with

23
sterile towel over the abdomen and perineal
area.
Support the perineum with the out stretched
right palm with a perineal pad in it; push
occipital region of the head down ward and
backward by the thumb and index finger of
the left hand.
Perform episiotomy if needed under 1%
Xylocaine infiltration just prior to
crowning.
Because if the head progresses slowly, it
is allowed to distend the perineum tilt it
is crowned, i.e. the parietal eminence
discends the vaginal outlet without
retarcting in between contractions.
To prevent threatened injury to the
perineum.

The sinciput is allowed to glide slowly over To maintain the certain amount of
the perineum at the end of a contarction. restaint, i.e. manual pressure, any have
to be applied to the baby‘s head during
the hight of this contraction; this
pressure should be gentle and evenly
districted to avoid intracranial injury.
In between contractions, extend it by the For delivery of the head by extension.
left palm, while the perineum is pressed
back on the face of the baby by the right
palm.
Allow the head to be born with pains till To prevent sudden extension of the head
the occiput comes free under the at the vaginal orifice during strong pains
symphysis pubis. by maintenance of flexion of the head.
Once the head is delivered: For maintaining patent airway of the
 Wash hands by dipping in the bowl baby
with boiled and cooled water.
 Clean the eyes using sterile swabs
seperaly for each eye.
 Suck the throat, mouth and nostrils
with sterile mucus sucker or
extractor.
 Check for cord around the neck; if
present, see whether loose or tight;
the loose loop of the cord can be
slipped over the head, if it is tight,
apply two clamps and cut it
between.

24
By the time eyes, mouth and cord are taken For delivery of shoulders.
are of the next pains bring the anterior
shoulder under the pubic arch.
- To deliver the posterior shoulder,
hold the head of the fetusbetween
two hands an dlift the haed towards
towards mothers abdomen; usually,
delivery of posterior shoulder
occures first.
- Incase of undue delay in the birth of
anterior shoulder under the
symphysis pubis, the anterior
shoulder is brought down under the
pubic arch by depressing the head
towards the perineum.
The rest of the trunk is delivered by lateral To fecilitate the delivery of the trunk.
flexion; when the body is being delivered,
advice the mother to resist pushing and to
take deliberate breaths receive the baby in a
tray covered with prewamed sterile towel.

After the baby is comletely born and is To prevent cardiac overload in newborn.
pink and crying, wait for the pulsations of
the cord to stop as baby obtains about 40-
60 mL of blood from placenta during this
time.
If the baby seemes to be asphyxiated or in
case of Rh-negative mother, the baby
should be seperated as early as possible to
separate the baby, clamp the cord at two
places.
- Apply first clamp near the vaginal
introits.
- Second clamp can be applied
anywhere between the first clamp
and the baby; before applying
thesecond clamp, milking of the
cord should be done towards the

25
 fetus.
Wrap the baby in the sterile towel let the For warmth.
assistant write the identification cards for
the mother and the baby; if the baby
seemes to be normal, do not remove the
baby from the delivery table till the baby
shown to the mother after the expulsion of
the placenta
Check the signs of seperation of placenta; For the delivery of the placenta.
deliver the placenta by controlled cord
traction and counter-traction which is also
called Brandt-Andrews method. In this
method, controlled cord traction is applied
as follows: place the palm of the left hand
over suprapubic region and gently push the
uterus upwards; twist the cord around the
index finger of the right hand and pull
gently
When placenta becomes visible at the This way placenta and mwmbranes will
vaginal introits let the fetal surface the be expelled completely.
outer most; support the placenta with left
hand and gently rotate the placenta with
right hand.
Administer injection Oxytcin 10 IU, IV To controle the bleeding.
bolus after the delivery of placenta as per
the hospital policy.
Show the sex of the baby to the mother The As psychological reaction may lead
mother is not shown the sex of the baby tillcomplication of third stage like retained
expulsion of placenta. placenta and PPH, if sex of the baby is
according to her expectation.
Exmin placenta and membranes for To preventPPH
completeness and abnormalities; measure
cord length, blood loss and wegh placenta.
Inspect thoroughly the vagina and For any tares and lacerations.
perineum
Clean the perineum with anti septic To provide comfort to the mother.
solution; poor betadine into the vagina and
episiotomy wound; apply sterile perineal
pads; dry the mother thoroughly and
provide lateral position.

26
G. Delivery of the posterior shoulder and trunk

27
After care of the mother and newborn:
Care of mother
Recording and charting of the following:
 Blood pressure, pulse rate and respiration to check the hemodynamic
status.
 Consistency of the uterus (should be hard like cricket ball) to check
the tonicity.
 Vaginal bleeding should be checked immediately after delivery and
again after one hour before shifting the mother from labour room to
the ward.
Care of the baby:
 Check baby‘s condition, i.e. APGAR score and any congenital abnormal
defects.
 Check baby‘s weight, length, circumference of the head, chest and
abdomen.
 Carryout newborn assessment and record the findings.
 Leave the baby with the mother and initiate breastfeeding within half an
hour.

28
 7.MAINTAINING PARTOGRAPH
Definition:
Partograph is a composite graphical record of key data (maternal and
fetal) during, labour, entered against time on a single sheet of paper.
WHO Representing graphically the important observations in labour. The
cervical dilatation and descent of head are shown in relation to alert and action
lines intensity and duration contraction are shown with shade.
Objectives:
- To provide necessary information at a glance.
- To predict deviation from normal duration of labour so appropriate steps
could be taken in time.
- To facilitate handover procedure.
- Early identification and management of prolonged labour; thus
improvement in maternal mortality and morbidity, fetal morbidity and
mortality.
Principles of partograph:
- The active phase of labour commences at 4cm cervical dilatation, the
latent phase of labour should last no longer than 8hrs.
- A lag time of 4hrs between a slowing of labour and the lead for
intervention is likely to compromise the fetus or the mother and avoids
unnecessary intervention.
- Vaginal examinations should be performed as is compatible with safe
practice (ones every 4hrs is recommended).
- It is better to use a partograph with preset lines all though too many lines
may add further confusion.
The components of partograph (figure-1):
 The progress of labour.
 Fetal condition.
 Maternal condition.
1. The progress of labour (figure-2):
This part of the partograph has its central feature of a graph of cervical
dilatation against time
The active phase: ones 4cm dilatation is reached, labour enters the active
phase. In about 90% of the primigravida, the cervix dilates at a rate of 1cm/hour
or faster in active phase.
- Alert line: The alert line drawn from 4-10cm represents the rate of
dilation moves to the right of the alert line, it is slow and an indication of
delayed labour. If the woman is in a health center, she should be
transferred to the hospital and should be observed more frequently.
- Action line: the action line is drawn 4 hours to the right of the alert line.
It is suggested that if cervical dilatation reaches this line, there should be
a critical assessment of delay and a decision about the appropriate
management to overcome this delay.

29
Cervical dilatation: the latent phase (slow period of cervical dilatation) is
from0-2cm with a gradual shortening of the cervix. Active phase (faster period
of cervical dilatation) is from 4-10cm (full cervical dilatation).
Uncertain contractions:
Frequency- how often they are felt
Duration- how long do they last
Check number contraction in 10 minutes and record.
Three ways of shading duration of contractions:
Duration Grade Shading Pattern
Less than 20 seconds Mild
Between 21 and 40seconds Moderate
More than 40 seconds Severe

2. The fetal condition:

- The lines for 110 and 160 are darker
- Check fetal heart rate every 30 minutes and mark with a dart
- If an abnormal heart rate is heard, every 15 minutes for at least one
minute immediately after contractions.
- If the heart rate remains abnormal over three observations, action should
be taken unless delivery is very close.
- A heartbeat of 100 or lower indicates very sever distress and actions
should be taken at ones.

30
The Simplified Partograph
Name: W/o: Age: Parity: Reg. No:
Date & Time of Admission: Date & Time of ROM:

Figure 1
Partograph

31
Figure 2: The progress of labour

Figure 3: cervical dilatation

32
Membranes and liquor:
- I-Intact membfane
- C-Clear liquor
- M-Meconeum stained liquor
- B-Blood stained Liquor
- A-Absent membrane
- Thick meconeum at any time or absent liquor at any time of membrane rupture,
listen to the frtal heart morefrquently, as these may be signs of ―fetal distress‖.
- If membranes have been ruptured for 12hours are more, antibiotics shpuld be
admministered prophylactically.
Moulding of the fetal skull bone:
Moulding ia an impportant indication of how adequatly the pelvice can
accomdate the fetal head. Increasing moulding with the head high in the pelvis is an
omnious sign of CPD.
Different ways to recording moulding:
- If the bones are seperated and the sutures can be felt easily: record as letter ‗O‘.
- If the bones are just touching each other : record as + .
- If the bones are over lapping : record as + +.
- If the bnes are over lapping severly: record as + + +.

3. Maternal condition:

-
-
Pulse: record every 30 minutes and mark with dot ( )..
Blood pressure: record every 4 hours and mark with arrows ( ).
- Temperature: record every 2 hours.
- Check for presence of protein, acetone and measure volume – record every
time urine is passed.
The couor code to be used to fillup the partograph.
- The fetal heart rate- red.
- Mild uterine contractions- yellow.
- Moderate uterine contractions- green.
- Everything else should be marked shlash written with blue pen.

33
 8.EPISIOTOMY GIVING AND REPAIRING
Definition
A surgically planned incision on the perineum and the posterior vaginal wall
during the second stage of labour is called episiotomy.
Objectives
 To enlarge the vaginal introits so as facilitate easy and safe delivery of
the fetus-spontaneous or manipulation
 To minimize overstretching and rupture of the perineal muscles and
fascia to reduce the stress and strain on the fetal head.
 To reduce the duration of the second stage, which may be important for
maternal reasons or fetal
 To prevent tearing of the perineum. The clean and properly placed
incision heal more properly than those of ragged ones.
Indications
1. Anticipatory perineal tear
 Widely indicated in primigravida
 Other indications are face to pubis or face delivery, big baby, and
narrow pubic arch.
2. Inelastic perineum
 Failure of advancement of the presenting part because of perineum
rigidity as in elderly primi gravida, old perineum scar of
episiotomy perineorrhaphy
3. Manipulative deliveries
 To get more space for manipulative delivery such a forceps, breech
or internal version, especially in primigravida
4. To cut short the second stage
 Indicated in cases where bearing down efforts even to overcome
the soft tissue resistance entail risks to the mother/or to the baby.
These are heart disease, severe pre-eclampsia, Eclampsia, post-
cesarean cases, post maturity etc.
5. Fetal interest
 Fetal distress
 Premature baby: to minimize compression of the soft pliable skull
bones there by preventing intracranial hemorrhage.
 Breech delivery: to minimize compression of the after coming head
and to facilitate manipulation if req.
Types
1. Mediolateral: incision is made diagonally in a straight line from the
midpoint of the fourchette, either to the right or left, about 2.5 cm away
from the anus
2. Median: incision made from the centre of the fourchette and extends
posteriorly along the midline for about 2.5 cm

34
3. Lateral: incision starts 1cm away from the centre of the fourchette and
extends laterally.
4. J shaped: incision in the centre of the fourchette and is directed
posteriorly along the midline for about 1cm. and then directed downward
and outwards along 5-7 clock position to avoid the anus sphincter

Figure-1: Types of episiotomy

Steps of procedure
Before procedure
Preparation of the mother:
Physical preparation
1. Shave the perineum/trim the hair as per the policy of the hospital
during the 1st stage of labour
2. Keep the mother in lithotomy or dorsal position with thigh flexed and
separated.
3. Drape the mother to maintain the privacy
Psychological preparation
1. Explain the procedure and its uses to the mother to win the confidence.
2. Encourage and reassure during the procedure

35
Preparation of the article
Articles Purposes
 Sterile gloves  To prevent infections
 Antiseptic solution  For toileting of vagina, betadine
to pour over the wound
 Cotton swabs  To clean the wound
 Gauze pieces  to apply betadine on the
episiotomy wound
 Draping sheets  to minimize exposure and
prevent infection
 Xylocaine 1%  for local infiltration
 100ml disposable syringe with  for local infiltration
21gauge needle
 Episiotomy scissors  for giving episiotomy
 Toothed thumb forceps  for holding of the edges
episiotomy while suturing
 Round body needle  for suturing mucosal and
muscle layers
 Cutting body needle  for suturing skin
 Suturing material  for suturing episiotomy
 Tampon/sponge  to soak the bleeding
 Needle holder  to hold the needle while
suturing.
Preparation of the environment
 use good source of light
 maintain privacy
 maintain sterile field
During procedure/steps of the procedure
Step-1 Preliminaries
 The perineum is thoroughly swabbed with antiseptic solution and draped
properly.
 Local anaesthesia; the perineum in the line of the proposed incision
infiltrated with 10 ml of 1% solution of lignocaine.
Step-2- incision:
Structures cut during the process of episiotomy
 Posterior vaginal wall
 Superficial and deep transfer‘s perianal muscles, bulbospngiosus and part
of levator ani.
 Fascia covering those muscles
 Transfer perineal branches of pudendal vessels and nerves.
 Subcutaneous tissue and skin

36
Process of giving episiotomy
 Two fingers are placed in the vagina between the presenting parts and the
posterior vaginal wall
 The incision is made by episiotomy scissors, sharped blade of which is
placed inside, in between the fingers and posterior vaginal wall and other
on the skin.
 Incision should the made of the height of the uterine contraction
 Deliberate cut should be made starting from centre of fourchttee
extending diagonally either to the right or the left.
 It is directed diagonally in a straight line which runs about 2.5cm away
from the anus.
Step 3- Repair
 Timing of repair : the repair is done soon after expulsion of the placenta
 Preliminaries: the mother is placed in lithotomy position. The perineum is
cleaned with antiseptic solution draping is done properly and repair is
done under strict aseptic precaution. If oozing is present, vaginal packed
tampon may be inserted placed high up. Remove the packed after repair
is completed.
 Repair is done in three layers
Principles to be followed are
 Perfect haemostasis
 To obliterate the deep space
 Suture without tension
Repair done in the following manner
 Apex is identified and the first bite is taken 0.5-1cm above apex .
 Apex, vaginal mucosa and submucosal tissues or sutured in the continues
and interlocking manner.
 Perianal muscles or sutured in the interlocking manner
 Skin and subcutaneous tissues are sutured in mattress manner.

37
 Figure-2: repairing the episiotomy wound

After Care of the Mother and the Articles

1. Make the mother comfortable
2. Clean the perineum with antiseptic solution
3. Pour betadine over the wound and applied sterile vulval pad
4. Collect equipment. Wash in basin in cold water and send for autoclaving
and disinfectant
5. Clean other equipment and return to the usual places
6. Wash hands
Recording and Reporting
1. Record the mother chart and nurses book with date and time
 Indication of episiotomy
 Type of episiotomy given
 Suture type
2. Report any complication sister and doctor.

38
 9.MANAGEMENT OF THIRD STAGE LABOUR
Definition:
It is the process of expulsion of the placenta along with its membranes.
Objectives:
- To achieve the hemostasis.
- To achieve the involution of the uterus.
Required articles:
Articles Purpose
A clean tray containing
1. Kochers forceps (2) To clamp the cord
2. Umbilical cord cutting seizures To cut the umbilical cord
(1)
3. kidney tray To keep the placenta
4. gloves To protect hands from infection
5. .sponge holding forceps To remove membranes
6. Sterile bowl with cotton swabs To explore the uterus
7. Mackintosh To protect bed from soiling
8. Antiseptic solution To clean the area
9. Sterile pad To cover the perineum
10.Screen For privacy

Procedure
Preparation of the mother:
1. Explain the procedure to the mother.
2. Give lithotomy position to the mother.
3. Tell mother to bear down when contractions occur.

Preparation of the articles:

Articles required procedure should be kept arranged near the bed side of
the mother.
Preparation of the unit:
1. Unit should be well ventilated and lighted.

39
 2. The area where the examination done should be kept clean and neat.
Preparation of the self:
1. The midwife should wash hands before doing procedure.
2. She should be confident.
3. Wear gloves before doing procedure.
Steps of procedure:
Steps Rationale
Normal delivery:
- Put screen - To maintain privacy
- Wash hands - To prevent cross
infections.
- Wear gloves - To prevent cross
infections.
- Give lithotomy position - Facilitates steps of the
procedure
- Tell the mother to bear down - For the easy expulsion of
placenta
- Check the mother characteristics of - To find out the uterus is
the uterus contracted or not
Notify the signs and symptoms of placental - To find out the whether
separation. placenta separation is
 Sudden gush of fresh blood. started or not
 Apparent lengthening of the cord.
 Cricket ball like uterus per abdomen.
 Supra pubic bulge.
 Feeling placenta per vagina.
- Wait for 10 minutes till it descends.
- When the placenta reaches the introits - For the complete expulsion
grasp with hands, twist and round in of placenta.
clock wise direction with gentile
traction.
- If membranes threaten to tear, these
are caught by sponge holding forceps.
- Continue the twisting movements
until the membranes are delivered
Assisted expulsion: - To avoid cord cutting.
a) Controlled cord traction with counter
traction
- Ones the uterus is found contracted,
one hand is placed above the level of
symphysis pubis with palm facing
towards the umbilicus exerting

40
 pressure in an upward direction.
- With the one hand firmly grasping
the cord, apply traction in downward
and backward direction following the
line of birth canal.
- Keep steady tension by pulling firmly
and maintain the pressure.
- Jerky movements and force should be
avoided.
- Keep the steady pressure till the
placenta reaches the introits.
- Follow the steps as spontaneous
expulsion.
b) Fundal pressure:
- Fundus is push downward and
backwards after placing four fingers
behind the fundus and thumb in front
using the uterus as sort of piston.
- Give pressure only when uterus
becomes hard.
- If the uterus is not hard, make it hard
by gentle rubbing.
- The pressure should be with draw as
soon as the placenta passes through
the introits.
- Follow the steps of as those of
spontaneous expulsion of the
placenta.

After care of the mother and articles:

1. After delivery of the placenta keep placenta in kidney tray for
examination.
2. Give comfortable position to the mother.
3. Clean the perineum with antiseptic solution, look for presence of any tear,
laceration and apply sterile pad.
4. Wash the articles with soap and water.
5. After drying, arrange the articles for next use.
6. Discard all the waste.
Recording and reporting:
- The observation made during the procedure should be recorded in the
nurse‘s note and mothers file and any abnormal findings should be
informed to the higher authority.

41
 10.PLACENTAL EXAMINATION
Definition:
Inspection of the placenta for the size, shape, consistency and
completeness of the placenta should be determined, and the presence of
accessory lobes, placental infarcts, haemorrhage, tumours and nodules.
Objectives:
- To observed the placenta for the normal characteristics.
- To visualize the placenta for the abnormal characteristics.
- To observe the umbilical cord any kind of abnormalities.
Required articles
Articles Purpose
A clean tray containing
- Mackintosh To protect the table from the soiling.
- Measuring tape To measure the cord length.
- Pin To measure the thickness of the
placenta
- Cotton thread To measure the diameter of the
placenta and length of the cord
- Weighing machine To measure the weight of the placenta.
- Gloves To protect the hands
- Kidney tray paper bag To discord waste
- Cotton swab To spread membrane
- Yellow plastic cover To discord the placenta
Procedure:
Preparation of the articles:
Articles required procedure should be kept arranged near the bed side of
the mother.
Preparation of the unit:
3. Unit should be well ventilated and lighted.
4. The area where the examination done should be kept clean and neat.
Preparation of the self:
4. The midwife should wash hands before doing procedure.
5. She should be confident.
6. Wear gloves before doing procedure.
Steps of procedure:
Steps Rationale
1. Wash hands To prevent cross infection
2. Wear gloves To prevent cross infection
3. Wash the placenta under To remove blood clots and for easy
running water visualization
Examination of the membrane For easy visualization
- Hold placenta by cord, allow the

42
 membrane to hang.
- Put your right hand through the
hole in the membrane through
which the baby was delivered,
and expand the membrane to
check for the intact ness of the
membrane.
- Keep the placenta on a flat
surface and examine both
placental surfaces under
membrane.
- With the cotton swab try to
separate amnion and chorion.
- The amnion should be pealed
from the chorion right up to the
insertion of the umbilical cord in
the fetal surface, and chorion is
up to the margin of the placenta.
Check for presence of any extra hole To check abnormalities.
in the membrane.
Examination of the placenta Easy visualization
- Spread the placenta palmer
aspect of the both hands. Put the
placenta on a flat surface. Check
the diameter of the placenta with
thread and measuring tape.
- Put pin in the margin and in the To measure the thickness of placenta
center. Check both surfaces i.e
maternal and fetal
- Check fetal surface for colour, To check for any abnormality.
appearance, insertion of cord
and distribution of the blood
vessels
- Check the maternal surface for To find out missing of lobes and
number of lobe, colour, any ageing of placenta
calcium deposition or infracted
area
- Weighing the placenta. To know the weight.
Examination of cord
- Check for presence of true not To check any abnormality
or false not.
- Check the length of the
umbilical cord.
43
 - Cut the umbilical cord, check To find out any congenital deformity.
for number of arteries and veins

After care of articles and mother:

1. After the examination of the placenta, it should be kept in a yellow cover
send for incineration.
2. Wash the articles with soap and water.
3. After drying, arrange the articles for next use.
4. Discard all waste.
Recording and reporting
The observations made during the procedure should be recorded in the
nurses notes and mothers file and any abnormal findings should be inform to
higher authority

44
ABNORMALITIES OF PLACENTA AND CORD

45
 11.ASSISTED BREECH DELIVERY
Breech delivery should be conducted a skilled obstetrician. The following
are to be kept ready before hand, in addition to those required for conduction of
normal labour.
1. Anesthetist- to administer anesthesia as and when required.
2. An assistant- to push down the fundus during contraction.
3. Instruments and suture materials for episiotomy.
4. A pair of obstetric forceps for the after coming head, if required.
5. Appliances for revival of the baby, if asphyxiated.

46
Principles in conduction:
1. Never to rush.
2. Never pull from below push from above.
3. Always keep the fetus with back anteriorly.
Never to pull aggressive and hasty pull affects breech delivery adversely by:
(a) Entrapment of the after coming fetal head through the incompletely
dilated cervix.
(b) Traction from below results in deflexion of the head posing longer
occipito frontal diameter (11.5cm) at the pelvic inlet.
Procedure
 The mother is brought to the table when the anterior buttocks and fetal
anus are visible she is placed in the lithotomy position destends the
perineum.
 To avoid aorto-caval compression, the woman is tilted laterally using a
wedge under the back.
47
  Antiseptic cleaning is done; bladder is emptied with rubber catheter.
 Pudendal block is done liberally in all cases of primigravida and slected
multi para.
Advantages as follows
a) To strengthen the birth canal which specially facilitates the delivery of
breech with extended legs where lateral flexion is inadequate.
b) To facilitate intra vaginal manipulation and for forceps delivery.
c) To minimize compression of the after coming head. The best time for
episiotomy is when the perineum is distended and thinned by the breech
as it is ‗climbing‘ the perineum.
 The mother is encouraged to bear down as the expulsive forces from above
ensure flexion of the fetal head and safe descent. The ‗no touch of fetus‘
policy is adopted until the buttocks are delivered along with the legs in
flexed breech and the trunk slips up to the umbilicus.
a) The extended legs (in frank breech) are to be decomposed by pressure on
the knees (popliteal fossa) in a manner of abduction and flexion of the
thighs.
b) The umbilical cord is to be pulled down and to be mobilized to one side
of the sacral bay to minimize compression. There may be transient
abnormality in cord pulsation at this stage which has got no prognostic
significance. An attempt of hasty delivery of this reason alone should be
avoided.
c) If the back remains posteriorly, rotate the trunk to bridge the back
anteriorly (sacro-anterior).
d) The baby is wrapped with a sterile towel to prevent slipping when held by
the hands and to facilitate manipulation, if required.
Delivery of the arms:
 The assistant is to place a hand over the fundus and keep a steady pressure
during uterine contractions to prevent extension of the arms. Soon, the
anterior scapula is visible.
 The position of the arm should be noted. When the arms are flexed, the
vertebral border of the scapula remains parallel to the vertebral column and
when extended, there is winging of the scapula (parallelism is lost).
 The arms are delivered one after the other only when one axilla is visible, by
simply hooking down each elbow with a finger.
 It is immaterial as to which arm is to be delivered first.
 The baby should be held by the feet over the sterile towel while the arms are
delivered.

48
Delivery of the after-coming head:
 This is the most crucial stage of the delivery.
 The time between the deliveries of umbilicus to delivery of mouth should
preferably be 5-10 minutes.
 There are various methods of delivery for the after coming head. Each
method is quite safe and effective in the hands of an expert who is
conversant with that particular technique.
 The following are the common method employed.
Burns-Maeshall method:
 The baby is allowed to hang by its own weight.
 The assistant is asked to give supra pubic pressure with the flat surface of
hand in a downward and backward direction; the pressure is to be exerted
more towards the sinciput.
 The aim is to promote flexion of the head so that favorable diameter is
presented to the pelvic cavity.
 Not more than 1-2 minutes are required to achieve the objective. When
the nape of the neck is visible under the pubic arch, the baby is grasped
by the ankles with a finger in between the two. Maintaining a steady
traction and forming a wide are of a circle, the trunk is swung in upward
and forward direction.
 Guard the perineum with left hand and help the face and brow to slip off
the perineum successively. When the mouth is cleared off the vulva, there
should be no hurry. Mucus of the mouth and pharynx is cleared by mucus
sucker. The trunk is depressed to deliver rest of the head.
Forceps delivery:
 Forceps can be used as a routine. The head must be in the cavity. The
advantages are (a) delivery can be controlled by giving pull directly on
the head and the forceps not transmitted through the neck; (b) flexion is
better maintained; and (c) mucus can be sucked out from the mouth more
effectively.
 The head should be brought as low down as possible by allowing the
baby to hang by its own weight aided by supra pubic pressure.
 When the occiput lies against the back of the symphysis pubis, an
assistant raises the legs of the child as much to facilitate introduction of
the blades from below.
 Too much elevation of the trunk may cause extension of the head. The
forceps pull maintains an arch which follows the exit of the birth canal
ordinary forceps with usual length of shank, as in Das‘s method, in quite
effective.
 Piper forceps is specially designed (absent pelvic curve) for use in this
condition.

49
  The head should be delivered slowly (over one minute) to reduse
compression decompression forces, as that may cause intra cranial
bleeding.
Malar flexion and shoulder traction (modified mauriceau-Smellie-veit
technique):
 The technique is named after the three grate obstetricians who described
the use of the grip independently.
 The baby is placed on the supinated left forearm (preferred) with the
limbs hanging on either side. The index and middle finger of the same
hand are placed over the malar bones on the either side (original method,
where the index finger was introduced inside the mouth).
 This maintains flexion of the head.
 The ring and little fingers of the pronated right hand are placed on the
child‘s right shoulder and the index finger is placed on the left shoulder
and the middle finger is placed on the sub occipital region.
 Traction is now given in downward and back ward direction till the nape
of the neck is visible under the pubic arch.
 The assistant gives supra pubic pressure during the period to maintain
flexion.
 Thereafter, fetus is carried in upward and forward direction towards the
mothers abdomen release the face, brow and lastly the trunk is depressed
to release occiput and vertex.
Resuscitation of the baby: the baby may be asphyxiated and to be resuscitated
immediately.
Third stage:
The third stage is usually uneventful. The placenta is usually expelled out
soon after delivery of the head. If prophylactic Ergometrine is to be given, it
should be administer intravenously with the crowning of the head.

After care of the mother:

 Make the mother and baby comfortable.
 Record the labour process in labour register.
 Provide postnatal care.

50
12.ASSISTING FOR LOWER SEGMENT CESAREAN SECTION (LSCS)
Definition:
Cesarean section is the operative procedure where by the fetuses after the
end of 28 week are delivered through an incision on the abdominal and uterine
walls.
Indications:
Absolute indications Relative indications
Dead fetus Cephalo pelvic disproportion
Central placenta previea Previous cesarean delivery
Contracted pelvice / CPD Non reassuring fetal FHR
Advanced cervical carcinoma Dystocia (3Ps)
Vaginal obstruction (atresia, stenosis) Antepartum haemorrhage (placenta
previea, placental abruption)
Common indications Mal presentation (breech, shoulder and
Primi gravida transvers lie)
 CPD Bad obstetric history
 Feta distress Hypertensive disorder
 Dystocia Eclampsia
Multi gravida Medical gynecological disorders
 Previous cesarean delivery Un controlled diabetes
 Antepartum haemorrhage Heart diseases
 Mal-presentation Carcinoma of the cervix
Repair of vasico vaginal fistula

Preparation of the LSCS trolley:

Drape the trolley with plastic drape then linen drape after cleaning the
trolley with aseptic solution
Articles in the trolley
Articles Number required Purposes
 Sponge holder 3 Cleaning and painting
 BP handles (no. 3& 1 each For incision
51
 4)
 Blade no.10, 20 2 For incision
 Toothed forceps (bid 1 each To hold the skin and
& small) tissue while suturing
 Plan forceps (big & 1 each To hold the tissue and
small) muscles during incision
and to hold the muscles
while suturing
 Tissue cutting 2 To cut the tissues
scissors
 Mosquito curved 6 To catch the bleeders
artery
 Curved artery 6 For hemostasis
forceps
 Allis forceps (big & 2+4 To catch the tissues
small)
 Babcock‘s forceps 2 To hold the soft organs
 Strait artery forceps 2 To clamp the cord
(big)
 Needle holder (big & 1 each To stich
small)
 Suture cutting 1 To cut the sutures
scissors
 Drapes 6 For draping
 Towel clips 6 To fix the drape
 Suction tube 1 To suck out the blood
and mucus
 Big bowel 2 For normal saline and for
receiving the placenta
 Sponges 5 To mop the wet area
 Gallipot small 2 For betadine, spirit or
savalon
 Kidney tray 2(cautery tip, round During catheterization
body needle-2, cutting
needle-2)
 Langenbeck retractor 2 To retract the muscle in
right angle big area
 Small retractor 2 To retract the muscle in
small area
 Doyens retractor 1 To retract the abdominal
wall
 Green Armytage 2-4 For hemostasis
forceps

52
  Gauze piece bundle 5 To mop the wet area
(5 in each bundle)
 Cautery hand piece 1 For catheterization
 Suture material Catgut 1-0 To stich the incision
Vicryl 1,0
Ethilon 1,1.0

Position:
Dorsal position: in susceptible cases to minimize any adverse effects vasovagal
compression. A 15-degree tilt to her left using sandbags until delivery of the
baby is beneficial.
Incision on the abdomen:
A low transvers incision is made about to fingers above the symphysis
pubis. Some obstetrician makes a vertical infraumbilical or paramidian incision,
which extends from about 2.5cm below the umbilicus to the upper border of the
symphysis pubis.
The anatomical layers incised are
 Skin
 Fat
 Rectus sheath
 Muscle (rectus abdominis)
 Abdominal / pelvic peritoneum
 Uterine muscle
Special instruments:
Instruments Purposes
Green Armytage forceps To hold the cut edges of the lower
uterine segments
Murless head retractor Extraction of fetal head during CS

Procedure:
 The surgeon usually incises the rectus sheath, but divides the rectus
muscle digitally. Care is taken to the bladder and the uterus.
 The scrub nurse must avoid contamination of the sterile field and keep
close account of all swabs, instruments and needles.
 When the uterine cavity is open the amniotic fluid escapes and aspirated.
The baby is delivered in much the same way as in vaginal delivery but
through the uterine incision; obstetric forceps are often used to extract the
head from pelvis.
 When the baby is born, an oxytocic drug is administered before the
placenta and membranes are delivered.
 If she is having general anesthesia the mother may now we given a
slightly deeper anesthetic and the operation proceeds at more leisurely

53
 place. The uterus bleeds freely at this stage and the surgeon will quickly
apply the special hemostatic Green Armytage forceps.
 The uterine muscle is sutured in two layers, the second of which tends to
align or include the cut edges of the pelvic peritoneum. Some
obstetricians preferred to suture the pelvic peritoneum as a distinct layer,
followed by the abdominal peritoneum.
 Repair of the rectus sheath also brings the rectus abdominis into
alignment. Sometimes, the subcutaneous fat is sutured and skin is closed
with sutures or clips.
 A vacuum drain, such as they ‗Readivac‘ drain, may be inserted beneath
the rectus sheath to prevent the formation of a hematoma, wound.
 The uterine muscle is sutured in two layers using continues running
sutures, the second of which tends to be aligning the cut edges of the
pelvic peritoneum. Repair of the rectus sheath brings the rectus
abdominis into alignment.
 The subcutaneous fat is sometimes suture and finally the skin is closed
with sutures or clips.
After care of the mother and the articles:
 Make the mother comfortable
 Observe for any complications like perforation of uterus, acidosis, and
cardiac arrhythmias due high CO2, fluid over load due to fluid distending
media.
 Collect equipment. Wash in basin in cold water and send for autoclaving
and disinfection
 Clean other equipments and return to their usual places.
 Wash hands.
Recording and reporting
 Record the mother chart and nurses notebook with date and time and
results.
 Report any complication to the ward sister and doctor

13.FORCEPS DELIVERY
Definition:
Means extracting the fetus with the aid of obstetric forceps when it is
inadvisable or impossible for the mother to complete the delivery by her own efforts.
Forceps are also used to assist the delivery after coming head in breech presentation
and on occasion to withdraw the head up and out of the pelvis at cesarean section.

54
Purpose
 To assist in delivery after coming head of breech.
 To take out head up and out of pelvis at caesarean section.
 To rotate and take out of head in an unfavourable position of baby in vertex
presentation.
 To delivery baby in case of fetal distress after fulfilling the condition for use of
forceps.
Indication of forceps delivery:
 Delay in the second stage.
 Maternal indications
 Maternal distress
 Pre-eclampsia, eclampsia
 Heart disease
 Failure to bear down.
 Fetal indications (fetal distress).
 Cord prolapsed
 After coming head of breech.
 Post maturity.
Preparation of equipment:
Equipment Purpose
Normal delivery kit with following
articles.
 Long-curved forceps with or  To extract the baby head
without axis traction device
 Short-curved forceps  It has a marked cephalic curve
with a slight pelvic curve.
 Kielland‘s forceps  It has got a sliding lock which is
facilitates correction of the head.
 Drape  To drape the part
 Catheter  To empty the bladder

Pre- requisites of forceps delivery:

 There are certain conditions which must exist before delivery can be
performed.
 The cervix must be fully dilated and effaced.
 Membranes must be ruptured.
 The head must be engaged with no parts of head palpable abdominally.
 No appreciable Cephalopelvic disproportion.
 The bladder must be emptied
 Presence of good uterine contractions as a safeguard to postpartum
hemorrhage.

55
Procedure of Low Forceps Operation:
 The women‘s vulval area is thoroughly cleaned and draped with sterile towels
using aseptic technique. The bladder is emptied using a straight catheter.
 A vaginal examination is performed by the obstetrician to confirm the station
and exact position of the fetal head.
 A pudental block, supplemented by perineal and labial infiltration with 1 %
lignocaine hydrochloride, is given to produce effective local anesthesia
 An episiotomy may be done prior to introduction of the blades or during
traction when the perineum becomes bulged and thinned out by the advanced
head.
 The forceps are identified as left or right by assembling them briefly before
proceeding.
 The women should be prepared in advances for the possibility of a forceps
delivery.
 Full explanation of the procedure and the need for it must be given to the
woman.
 Once the decision has been made, adequate and appropriate analgesia must be
offered.
 The women should be placed in lithotomy position.
 Both legs must be placed simultaneously to avoid strain on the woman‘s back
and hips.
 During the application of the forceps, the woman should be given full support
and attention.
 The fetal heart rate is to be monitored throughout.
 Preparations must also be done for the baby including equipment for
resuscitation. In some hospitals a pediatrician will also be present.
After Care of Articles
 After using the equipment and clean and dry and replace the equipment

14.ASSISTED VACCUM DELIVERY

Definition:
Ventouse is an instrumental device designed to assist delivery by creating
a vacuum between it and the fetal scalp.
Objective: To cut short the second stage of labour
Indications
1. Deep transverse arrest with adequate pelvis.
2. Delay in descent of the high head in case of the second baby of twins.
3. As an alternative to forceps operation, except
 Face presentation and after coming head of breech
 Fetal distress or prematurity.
4. Delay in late first Stage due to uterine inertia or primary cervical dystocia.
5. As an adjunct to symphysiotomy.
56
Conditions to be fulfilled
 There should not be slightest bony resistance below the head.
 The head of a singleton baby should be engaged.
 Cervix should be at least 6 cm dilated.
 Membranes should be ruptured.
 Urinary bladder must be empty.
Principles: Acceleration of the delivery by affecting traction on fetal head with
the help of vacuum.

Steps of Procedure
Before Procedure
Preparation of the mother:
1. Explain the procedure and its uses to the mother to win the confidence
and cooperation during the procedure.
2. Encourage and reassure during the procedure.
Preparation of articles
Article Rationale
 Suction a vacuum pump, For giving vacuum pressure
traction rod device.
 Gloves mask and gown. To prevent infection
 Cotton swabs with antiseptic To clean the perineum and prevent
solution. infection
 Draping and leggings. To minimize unnecessary exposure
and prevent infection
 1% Lignocaine with 10 mL For infiltration
syringe and 21 –gauge needle.

Preparation of the environment:

 Use good source of light.
 Maintain privacy.
 Maintain sterile field.
Preliminaries:
1. Anesthesia: Pudendal block or perineal infiltration with 1% lignocaine is
sufficient. It may be applied even without anesthesia, especially in parous
women.
2. The mother should be placed in the lithotomy position.
3. Full surgical asepsis should be maintained.
- Surgeon and assistant should wear sterile mask, gown and gloves.
57
 - Vulva, vagina should be swabbed with antiseptic solution.
- The perineum should be draped with sterile towel and the legs with
leggings.
4. The instrument should be assembled and the vacuum is tested for proper
functioning prior to its application.
Step I:
Application of the cup
- The largest possible cup according to the dilatation of the cervix should be
selected.
- The cup is introduced after retraction of the perineum with two fingers of the
other hand.
- The cup is placed against the fetal head nearer to the occiput with the 'knob'
of the cup pointing towards the occiput.
- This will facilitate flexion of the head and the knob indicates degree of
rotation.
- A vacuum of 0.2 kg/cm2 is induced by the hand pumps slowly, taking at
least 2 minutes.
- A check is made using the fingers round the cup to ensure that no cervical or
vaginal tissue is trapped inside the cup.
- The pressure is gradually raised at the rate of 0.1 kg/cm2 per minute until the
effective vacuum of 0.8 kg/cm2 is achieved in about 10 minutes time.
- The scalp is sucked into the cup and an artificial caput succedaneum
(chignon) is produced.
Step II:
 Traction must be at right angle to the cup.
 Traction should be synchronous with the uterine contractions.
 Traction should be made using one hand along the axis of the birth canal.
The fingers of the other hand are to be placed against the cup. Note the
correct angle of traction, rotation and advancement of the head.
 If there is no advancement during four successive uterine contractions, it is
to be abandoned. On no account, traction should exceed 30 minutes.
 As soon as head is delivered. The vacuum is reduced by opening the screw-
release valve and the cup is then detached. The delivery is then completed in
the normal way.
Note: Silicon rubber cups are also used; it is soft and can be smoothly applied
over the contour of the fetal head.
Aftercare of the Mother and the Articles
1. Make the mother comfortable.
2. Collect equipment. Wash in basin in cold water and send for
autoclaving or disinfection.
3. Clean other equipment and return to their usual places.
4. Wash hands.
Recording and Reporting

58
- Record on mother's chart and nurse's notebook with date and time.
 Indication of vacuum delivery.
- Report any complication to the ward sister and doctor.
 Mother
 Baby

15.POSTNATAL ASSESSMENT
Definition:
The postnatal period is a post delivery period when the maternal system
returns to a pre-pregnant state. This is a 6 weeks period, which is divided into
three phases:
Immediate: 24 hours after delivery
Early: up to 7days
Late: up to 6 weeks.
Assessment and Examination during Postnatal Period
Before the procedure
 History /preparation of the mother
Collect the history in the following manner.
Steps Rationale
Great the mother It opens the channel for
communication.
Collect information related to family With this information, the activity
profile, for example: level required from mother will be
 Support person known and accordingly instructions
 Other children can be given.
 Type of housing
 Education
 Occupation
 Socioeconomic status
Pregnancy history A quick review of pregnancy history
 Para is useful for further planning
 Gravida
 EDD
 Any problems
 Hypertension or spotting
Delivery history This information will help to plan
 Duration of labour postnatal procedures such as
 Position of fetus episiotomy care
 Type of delivery
 Date and time of delivery
 Problems during labour
Neonatal data This information helps to plan care
59
  Sex for the newborn
 Birth weight
 Any difficulty at birth
 Breastfeeding
 Any congenital anomalies
Postpartum This information is helpful in
 General health assessment of the mother‘s present
 Activity level since delivery condition and planning of her care
 Description of lochia and health education imparted to her
 Any complain of pain in and the family.
abdomen/breast/perineum.

Preparation of the articles:

Articles required are as follows:
Articles Purposes
 Measuring tape to measure the height of the mother
and fundal height
 Weighing machine to check the weight of the mother
 Vital signs articles to assess the vital signs and note any
deviation from normal
 Cotton swab to clean the breast if any secretion is
present
 Sterile perineal pad to apply in the perineum
 Newspaper to collect the soiled perineal pad

Actual steps of the procedure

Wash hands and do a full examination of the mother systematically as described
in the following text;
a. General appearance
 Gestures of pain and her facial expression
 Face: Oedema
 Whether she has combed her hair; neatly dressed?(to know about her
feeling of well-being )
b. Vital signs
 Pulse: Check the pulse, which varies from70 -80 per min. Pulse rate> 100
per min should be investigated for fever and shock
 Respiration: Observe the respiration whether it is normal or abnormal (i.e.
labored, shallow or fast breathing)
 Temperature: It should not be more than 99oF within the first 24 hrs. on
the third day, there may be slight rise in the temperature due to breast
engorgement

60
  Blood pressure: Blood pressure remains unchanged. If there has been any
history of hypertension in pregnancy. Blood pressure should be checked
at every visit
c. Head –to-toe examination
Eyes
- Examine eye for detecting anemia (conjunctiva)
Breast
- Expose the breast to observe for any engorgement, hardness or redness
- Observe for any abnormality of the nipple(i.e. cracked, retracted, or
depressed nipple )
- First and second day: breast tissue feels soft and palpation
- Third day: engorgement occurs, breast feel firm and warm to the touch.
Uterus
- Ensure that the mother has emptied the bladder before examination
- Ask the women to lie on flat surface
- Give a gentle fundal massage to stimulate uterine contraction and expel
out the clots
- Note the height of the fundal by placing the ulnar border of the left hand
over the fundus and other on the symphysis pubis with a measuring tape.
Note the findings in cm.
- Note the consistency of the uterus.
Findings
- Immediately after the delivery , the height of the fundus will be 13.5cm
above the fundus
- For first 24hrs, it will remain constant
- Thereafter, uterus involutes 1-2 cm in 24hrs.
Perineum
- Ask the women to turn on her side, inspect the perineum, as it is more
visible in lateral position. Look for
- Hematoma
- Intact episiotomy stitches
- Any discharged /bleeding from the wound
- Swelling
- Pain

Check lochia for

- Amount
- Consistency
- Pattern (rubra to serosa to alba )
- Odour
Assessment for weight loss
- Record weight of the mother. There is weight loss of at least 2kg apart
from the loss after delivery.

61
Observation for sings of thrombophlebitis
- Check for Homan‘s signs
- In supine position, ask the women to dorsiflex the legs; noted pain in the
calf muscle.
Assessment for bowel and bladder activities
- Ask the women
- Whether she has passed urine
- About the amount and frequency of micturition
- About pain and burning sensation during micturition
- About incontinence
- Ask when she passed her first motion
Assessing psychological changes
 Her facial expression
 Involvement with her baby like breastfeeding, cuddling, talking to the
baby and taking care of the baby.
 Her appearance (Grooming)
Acronym for postnatal assessment: BUBBLEHE
B: Breast
U: Uterus
B: Bladder
B: Bowel
L: Lochia
E: Episiotomy
H: Homan‘s signs
E: Emotional response
After care of the Mother and the Articles
1. Make the mother comfortable
2. Collect the soiled perineal pad and dispose it in the dustbin covering with
newspaper.
3. Give perineal care if necessary
4. Put new sterile vulva pad
5. Inform her about the findings for the examination
6. Clean equipment return to their usual places
7. Wash hands
Recoding and reporting
1. Record on mother‘s chart and nurse‘s notebook with date and time
2. Report any complication or abnormal findings to the ward sister and
doctor.

62
 16.PERINEAL CARE
Definition:
It is an aseptic irrigation or sponging of the perineum during a specific
period following delivery or operation on the reproductive system, urinary
meatus or anus.
It is defined as the care provided to clean the external genitalia and the
surrounding area in-order to maintain the perineum hygiene.
Purposes:
1. To clean the perineum.
2. To relieve inflammation.
3. To relieve pain.
4. To stimulate circulation.
5. To prevent the spread of infection and bacterial growth.
6. To promote healing.
7. To apply medication over episiotomy wound and any other perineal
wound.
8. To promote a sense of well-being and comfort.
Indications
 Mothers who are unable to do self-care.
 Mothers with genitourinary tract infection.
 Postnatal mothers.
 Mothers with excessive vaginal discharge.
 Before procedure like per vaginal examination and catheterization.
 Mothers after surgery on the genitourinary system.
 Gynaecological conditions like vaginitis, prolapse of uterus, etc.
Steps of the Procedure
Before Procedure
Preparation of the mother
 Explain the procedure to the mother and make her comfortable on the
bed/examination table.
 Provide privacy by screen.
 Drape the mother as per for vaginal examination — fanfold the top linen.

63
  Spread out the mackintosh.
 Offer the bed pan to the mother — place the bed pan in position and
adjust it comfortable for the mother.
 Ensure that there is adequate light and put off the fan.
Preparation of the article
Articles required
Articles Rationale
A Sterile Tray Containing
 A bowl with sterile 9—11 To clean the perineum
cotton swabs soaked in Savlon
solution of 1:20 ratio.
 A bowl with sterile 9—11 To clean the perineum
cotton swabs soaked normal
saline or boiled and cool cotton
swabs.
 Artery forceps, sponge holding To hold the swabs for cleaning
forceps – 1.
 Dissecting forceps — 1. To pick the cotton swab from the bowl
 Bowl with sterile gauze pieces To dry tie perineum
(9-11).
 1 pair of gloves. To maintain sterility and self-
protection
 1-2 sanitary pads. For perineal discharge soakage.
 Betadine ointment To apply over the episiotomy wound.
A Clean Tray Containing
 A bow with warm water or To flush the perineum
normal saline.
 Mackintosh (medium) — 1. To prevent the soiling of the bed
 Bed sheet — 1. To drape the mother
 BP apparatus with stethoscope To check the blood pressure
 Measuring tape. To check the fundal height
 3 or 4 cotton pads For examination of the breast and to
clean the buttocks
 Kidney tray medium – 1 To squeeze the cotton swabs
 Paper bag (big)- 1 To receive the waste
 Piece of paper To remove the soiled pad
 T binder To tie the pad
 Scissors To cut the extra binder
 Screen To provide privacy
 Bed pan To collect the flushed water

Actual Steps of the Procedure:

64
  Collect all the articles.
 Wash hands.
 Be on the right side of the mother.
 Perform complete postnatal examination.
Head-to-foot examination
Breast examination
Abdominal examination: Locate the fundus, give gentle fundal
massage and check fundal height
 Loosen the soiled pad: Take it out holding it with the paper and then
observe the type. colour, amount and odour of lochia.
 Wrap the soiled pad with the paper and discard it in the dustbin.
 Spread the mackintosh to protect the soiling of bed.
 Put the bed pan and make the mother comfortable on it.
 Pour lukewarm water over the perineum.
 Wash hands.
 Wear gloves.
 Clean the perineum using wet Savlon swabs with forceps from above
downwards in the following order in a single stroke manner.
The vulva
Labia minora — farthest side
Labia minora — nearest side
Inner side of the labia majora — farthest side
Inner side of the labia majora — nearest side
Outer side of the labia majora — farthest side
Outer side of the labia majora — nearest side
 Clean the episiotomy wound in one stroke.
 Clean the anus thoroughly in a circular motion.
 Clean the perineum with normal saline swab in the same order.
 Dry the perineum in the same order.
 Apply the Soframycin ointment or Betadine ointment/solution over the
wound.
 Apply the pad over the perineum.
 Remove the bed pan.
 Secure the pad with 'T' binder.
 Turn the mother to her left side and clean the buttocks in upward
direction.
Aftercare of the Mother and Articles
 Make the mother comfortable
 Remove the bed pan and mackintosh and replace all the articles after
washing for sterilizing.
 Inform the mother about the nature of lochia and condition of the perineal
wound.
 Tidy the unit.

65
Recording and Reporting
Record and report the observation made in the nurse's notes and mother's
clinical Chan.

17.IMMEDIATE / ESSENTIAL NEW BORN CARE

Definition:
 Care provided to baby soon after birth
Purposes:
1. To clear air passage and facilitate breathing
2. To observe for any external anomalies
3. To provide adequate warmth
4. To help the new born to adapt to the extra uterine environment
5. To prevent injury and infections
6. To keep the baby clean
Equipments:
1. Suction machine
2. Mucous sucker
3. Radiant warmer
4. Cord clamp
5. Sterile cotton balls
6. Sterile cord cutting scissors

66
 7. Measuring tape
8. Rectal thermometer
9. Baby cloth (frock)
10. Baby sheet
11. Identification tag
12. Acriflavin solution/ chlor hexidine powder
General instructions:
1. The emergency equipment for neonatal resuscitation is to be always kept ready
in neonatal area
2. Inj.naloxane to be kept ready in case mother was sedated prior to delivery
3. Do not stimulate baby (rubbing the back or suctioning nose and avoid bagging)
is amniotic fluid is meconium stained
4. If there is any deviation from the normal, a neonatologist is to be informed. If
mother has diabetes mellitus and is no insulin , and if the baby‘s weight is less
than 2kg or more than 3.8 kg , transfer to nursery
Procedure:
STEPS RATIONALE
Immediate care:-
1. Plan the baby soon after delivery in - Facilitates drainage of the mucous
a tray covered with sterile linen accumulated in the trachea-
with the head slightly downward bronchial tree by gravity
(15º)
2. Place the tray between the legs of - Facilitates gravitational flow of
the mother at a lower level than the blood from the placenta to the
uterus fetus
3. Clear the air passage of mucosa - Maintains patent airway
using a mucus extractor or bulb
syringe
4. Check apgar rating at I minute and - Assess the health status of new-
5 minute record born
5. Clamp ant cut the cord. Cord is to - Identifies abnormality , separates
be clamped and divided as soon as the baby from mother for extra
convenient following birth of the uterine life
baby
6. Dry the baby thoroughly, remove - Prevents loss of heat by
the linen and wrap the baby in dry, evaporation and chilling
warm blanket sheet
7. Tie identification tags which has - Avoids confusion between staff
mother‘s name and hospital and chances of wrong
number on wrists of both mother identification
and baby an don legs of baby
8. Apply cord clamp or ligature and - To separate the baby from mother
cut the cord shorter to desirable
length
9. Place the baby under a radiant - Maintains body temperature of the
warmer ( if one is available) until baby

67
 temperature is stable
10. Clean the eyes with sterile cotton
balls soaked in normal saline
11. Instill soframycin eye drops
erythromycin eye ointment to each
eye. Acts as a prophylaxis against
opthalmia neonatrum and
chlaymidia trachomatis
12. Cloth the baby using a dress that is - Moisture increases chances of
appropriate for the climate, microorganisms colonizing in the
extremities should be free for skin
movement. Apply a napkin which
should be changed periodically
13. Check patency of rectum by
introducing lubricated rubber
catheter. Identifies imperforated
anus
14. Check the weight and length of the
baby, the baby should be weighed
naked. - To compare with normal
Weight- Indian baby – 2.3-3.0 kg measurements
Length- 50cm
15. Check vital signs - Identifies any deviation from
normal
16. Administer vitamin-K, 1 mg - Minimizes the risk of haemorrhage
intramuscularly
17. Administer prophylactic antibiotic - Prevents secondary infection
therapy if ordered in conditions
like:
- Delivery following premature
rupture of membranes
- Instrumental delivery

18. Observe the baby frequently at - Identifies any abnormal signs

least 4-5 hours developing in new-born

19. Fill baby cord and ante natal folder - Acts as a communication between
and document any abnormality staff members

After care of newborn and articles:

- Do not separate the mother and the newborn
- Leave the newborn skin to skin with the mother
- Encourage breast feeding within one hour of birth.
Recording and reporting:
- Document the procedure in the baby file.

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 18.NEW BORN ASSESSMENT TOOL
Definition: A detailed and systematic whole body examination of stabilized
newborn baby during the early hours of life.
Purpose:
- To determine the normality of different body system for healthy
adaptation to extra uterine life.
- To detect significant medical problem for immediate assessment.
- To detect any congenital problem.
- To assess the need for resuscitation.
- Any disorder which may affect the wellbeing of the baby.
Biographic data:
Baby of:
Sex of the baby:
Date and time of birth:
Father‘s name:
IP no. Name of the Hospital…………………
Address:…………………………………………………………..
…………………………………………………………..
Birth History-
a) Antenatal history
 Age of the mother…………………………
 Consanguineous marriage: yes/no, relationship:………………
 Regular antenatal checkup: yes/no
 Tenanus toxoid: yes/no
 Exposure to drug/radiation: yes/no; if yes, specify………………
 Illness during pregnancy: yes/no; if yes, specify………………...
b). Intranatal history
 Place of delivery: Home/Hospital/Health center; ……………….
 Delivery conducted by: Skilled/unskilled personnel; specify……
 Mode of Delivery: Normal/operative……………………………
 Gestational age of infant (weeks): ………………………………
 Birth weight:
 Birth injury: yes/no, specify…………………….

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Physical measurements:
Birth weight: Length:
Head circumference:
Chest circumference:
Mid arm circumference:
Physical Examination:
General appearance:
Vital signs: Temperature:
Pulse: Respiration:
Skin:
Colour: Pink: Pallor: Cynosis:
Petechial: Vernix caseaosa:
Lanugo: Ecchymosis:
Acrocyanosis: Mangolian spots:
Birth trauma:
Loose wrinkled skin:
Others:
Head:
Hair distribution: Scanty: Thick:
Color of Hair: Black………….. Gray……….. Brown…………..
Any other specifies:
Shape: Round…………. Irregular…………… Molding…………..
Head circumference: Fontanelle………………………...
Anterior fontanels: Width: Length:…………………….
Posterior fontanelle: Width:…………... Length:…………………….
Sutures: closed………… Widened…………. Stenosed………………
Birth trauma:………… Forceps mark: Present…….. Absent…………
Hydrocephalus: Present………………. … Absent…………………..
Macrocephalus: Present…………………. Absent…………………...
Microcephalus: Present………………….. Absent……………………
Anancephalus: Present………………….. Absent…………………...
Caput succedenum: Present……………... Absent……………………
Cephalohaematom:……………………...
Piagiocephaly:…………………………..
Eyes:
Symmetrical:…………….. Asymmetrical:……………….
Position: Normal………… Slant……………
Conjuntiva: Pale…………. Yellow………...
Tearing / Watering……………………………
Pus formation: Present………….. Absent…………
Nystagmus: Present…………………. Absent………………
Strabismus: Present………………….. Absent………………
Eyelids: Normal……………………… Drooping……………

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Closed……………… Open ………………
Sunset eyes: ………... Epicanthal folds:……………..
Ulcerations:…………. Anisocoria:…………………..
Eyelashes: Present…………. Absent………………..
Ears:
Symmetrical:……………… Asymmetrical………………
Position: Normal…………... Abnormal…………………..
Lowset ears: ……………….
Cartilage formation:…………………..
Adherent ear lobes:……………………
Periauricular skin tags:………………..
Discharge:………… Any other specify:………………….
Nose:
Symmetrical:…………………... Asymmetrical:…………………..
Nostril:………… Flaring:…………….. Narrow:………………….
Obstructed……….. Deviated Nasal Septum: Present…….. Absent………..
Discharge:………... Nasolabial Bridge:………. Low bridge:………………
Any other:……………………………………...
Mouth and Throat:
Mouth Shape:……………………………
Lip couor: Pink…………….. Dark red……………….
Pale……………... Cyanosis:……………...
Cleft lip: Present……………. Absent………………... Degree:……………
Grimaces:…………………....
Symmetric facial grimaces:…………………………….
Gums: Bleeding…………. Tongue:………….. Palate: hard……………
Soft………………… normal……………
Cleft Palate: Present……………….. Absent………………..
Tongue: tie……….. Oral thrush: Present…………… Absent……………..
Precocious teeth:………………………..
Cheeks: Chubby:……………………….. Hallow……………………
Chest:
Shape: Normal……………. Barrel shaped………… Pigeon………..
Chest:………………………
Circumference:………………… Respiratory rate:…………………..
Rhythm:…………. Expansion and retraction:……………………..
Breath sounds: Normal:……………. Adventitious:………………..
Grunting…………….. Distress…………………….
Thorax:
Symmetric: ……………….. Asymmetric:…………….
Anteroposterior diameter: ………………………………
Bulging:………………… Rib flaring:………………….
Breast:

71
Nipple point: Symmetric:……………. Asymmetric:……………
Areola:…………………
Breast: Swollen………………….. Flat………………
Secretion of witch milk:…………..
Abdomen:
Shape: Round…………… Distended…………….. Hallow……………..
Shiny abdomen with prominent vessels:……………
Liver: Palpable…………….. Not Palpable…………………….
Spleen: Palpable…………… Not Palpable……………………
Peristalsis: Present………… Absent…………………………..
Cord: Moist……. Dry……… Fallen off…………. Discharge…………..
Any signs of infection: Redness……………… Swollen……………….
Pus discharge………………….
Omphalocele:………………….
Back: Spine: Normal……….. Spina bifida………. ……..
Meningomyelocele………….. Meningocele……………………

Extremities:
Upper extremities: Symmetrical …………….. Asymmetrical…………….
Movement………… Position: Flexed………..Extended…………………
Tone……… Digits………. Polydactyly…………. Syndactyly…………..
Simian crease on palm: Present……………… Absent……………………
Clubbing of fingers: Present………………… Absent…………………….
Phantom limb: Present………………………. Absent……………………
Short limbs: Present………………………… Absent……………………
Lower extremities:
Symmetrical…………………. Asymmetrical……………………………
Movement………. Position: Flexed………… Extended………………..
Tone………… Digalits…………. Polydactyly……….. Syndactyly………
Talipes equinovarus:…………………………
Dislocaton of lips:………………… Short limbs:………………………..
Genetalia:
Femele: Labia majora ……………… Labia minora………………………
Clitoris:……………. Vagina: Present………… Absent…………………..
Edematous………….. Ambiguous Genertalia……………………………...
Ambiguous genetalia:……………….
Male: Penis: Normal…………………Micropenis………………………….
Hypospadias: Present:………………. Absent……………………………..
Epispadias: Present………………….. Absent……………………………..
Scrotum: Present………………………..Absent……………………
Testis: Descended……………………… Underscended……………
Rectum & Anus:
Anal opening: Present………………….. Absent……………………

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Imperforated anus: Rectal atresia………………………..
Pilonidal dimple……………… Fissures ……………….
Stools:
Meconium: Passed …………….. Not passed………………
Frequentcy of stools: …………… Amount…………………
Transitional stools:……………… Color ……………………
Urination:
Passed……………… Not passed…………… Frequency………….
Amout………………
Neonatal reflexes:
1. Rooting reflex: Present…………….. Absent………………………
2. Suncking reflex: Present…………….. Absent………………………
3. Gagging reflex: Present…………….. Absent………………………
4. Blink reflex: Present…………….. ….Absent………………………
5. Starle reflex: Present………………… Absent………………………
6. Sneezing and Coughing reflex Present………..Absent…………
7. Moto reflex: Present……………….... Absent………………………
8. Dolls eye reflex: Present…………….. Absent………………………
9. Extrusing reflex: Present…………….. Absent………………………
10. Palmar and plantar grasp reflex: Present………Absent……………
11. Babinski reflex: Present…………….. Absent………………………
12. Dancing reflex: Present…………….. Absent………………………
13.Tonic neck reflex: Present…………….. Absent………………………
After care of Baby and Articles
 Dress the baby as early as possible.
 Wrap in the blanket to prevent chills.
 Comb the Hair.
 Hand over the baby to its mother to give the feed.
 Take the articles to the utility room, to clean, dry them and replace in their
proper places.
 Discard the Waste.
 Wash hands.
Recording and reporting:
 Record the procedure in the Nurses record with date and time.
 Inform the ward sister and doctor if any abnormality found.

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 19.BABY BATH
Definition:
Baby bath is the cleansing bath given to the newborn baby in order to
develop good sense of humour for both baby and the mother.
Types of bath
Preliminary Assessment
 Check the physician‘s orders to see the specific precautions to be taken
any.
 Assess the infants need for bathing.
 Check the temperature, respiration and colour of the skin.
 Check whether the child has taken the feed in the previous 1 hour
 Check the articles available in the unit.
General instructions for giving bath
 Use worm room and worm water
 Bath quickly and gently
 Dry quickly and gently
 Never leave the baby unattended in a bath tub or table.
 The infant is given bath after the cord falls and umbilicus is well healed
(within 7th 10th day )
 The nurse should use right judgment in selecting the soap, and clothes.
 The ideal time of bath should be one hour after feeding the baby.
 While giving baby bath, give opportunity to the mother to participate
 The clothing for baby should be selected according to the environmental
temperature.
 There should be a fixed time for bath, which will help the baby to form a
habit of orderly schedules.
Preparation of the environment
 Close windows to keep off draught and to provide privacy.

74
  Collect all the articles in readiness before beginning the procedure.
 Keep the table against the wall, place the tub or basin on one end of the
table and the tray with articles on the other end conveniently so that the
baby will be protected on 3 sides and there is chance of the baby‘s rolling
of the table.
 Place mackintosh and towel over the table, wash hands and wear apron.
 See whether the baby is passed motion or urine. If so clean the part
Bring the baby wrapped in a towel to the bath table.
Purposes:
- To promote sense of humour.
- To maintain intact skin of baby.
- To stimulate circulation and growth.
- To maintain body temperature.
Preparation of articles:
Equipment Rationale
1. Two jugs of Water (hot and -To take water
cold)
2. Basin -To collect water and dip the sponge
cloth
3. A towel and sponge cloth. -To place under the baby during bath
4. Baby‘s Dress and blanket -To cover the baby
5. Mild non- perfumed soap in a -To apply the baby
container
6. Oil, comb -To groom the baby
7. Weighing scale -To measure the baby
8. Bucket if necessary -For discard the waste water
9. Sterile swabs in Bowl -To plug the ears and clean the eyes.
10.Vaseline -To prevent eyes wet
11.Diaper if necessary -To prevent soiling.
12.Kidney basin and paper bag -To collect the waste.

Steps of procedure
Steps Rationale

1.Explain the procedure to the mother -Helps in obtaining co-operation and

reduce anxiety
2.Ensure that the room is warm and free - Temperature regulating mechanism
from draughts this is particularly is not completely developed in new
important when caring for new born born.

3. Pour water into the basin and adjust -To prevent chances of Hypothermia
temperature by checking with the elbow

75
or dorsal side of the palm

4.Reassure the infant before and during -To safe guard the baby from slipping
the bath by holding the infant firmly but
gently

5.Undress the baby and place in a -To made ready for bath
supine position on a bath towel

6. Place the head of the baby on your -Safeguards the baby from slipping
non dominant palm and support the
baby body with the forearm.

7.Clean the baby eyes with sterile
Cotton only using clean cotton swabs,
use separate cotton swabs for each eye
and wipe from inner canthus to outer
canthus
8. Close the baby ears with the cotton
bolls
-Using separate cotton swabs prevent
the transmission of micro-organisms
from one eye to another avoid entry of
debris into the nasolacrimal duct.
-To prevent entry of water

9.Wet hair and scalp, with sponge cloth -Drying immediately prevents
and dry hair with towel hypothermia

10.Dip sponge cloth in water and wipe -Follows the principle less
face using only plain water contaminated to most contaminated
area
11.Apply soap clean with sponge cloth. - Rubbing can cause irritation
and dry each arm hand avoid using soap Avoid soap on palms prevents baby
to the palmed surface & avoid excessive putting soapy fingers in mouth.
rubbing dry immediately

12.Apply soap clean with the Sponge -covering the baby prevents chilling
cloth and dry chest and abdomen, keep
the baby covered with the bath blanket.

13.Apply the soap & with the use of Keeping exposure to minimum
sponge cloth the legs and feet dry it maintains the baby‘s warmth
expose only one leg and foot at a time of
give special attention to the area
between toes

14.Turn the baby on her stomach and

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clean with the sponge cloth.

15.Remove the infant diaper and away -The rectal area is cleaned last since it
any feces on the baby‘s perineum with is most contaminated
the tissue

16.Place the baby on her back clear and - The smegma that collects between
dry the genitalia & anterior perineal area the folds of the labia and under the
from front to back foreskin in males, it facilitates
- Clean the folds of groin bacterial growth and must be removed
- For females separate the labia & clean
the front to back using moisture cotton
balls use clean swab for each stroke.

17.Clean the base of the umbilicus cord - Exposing the site to air will produce
with a cotton ball healing or promote healing.

18.Cloth the baby with a clean dress -This position allows more air to
and diaper below the cord site. circulate around the cord site.

19.Return the baby mothers and provide -Gives the baby a sense of security as
needed instructions well as keep him warm

20.Clean and replace discard used -mothers continues care and

articles as appropriate observation of baby

21.Record any significant observation -Helps in planning treatment.

such as reddened area or skin rashes the
colour and state of the cord.

After care of Baby and Articles

 Dress the cord stump, if any, with spirit and cord powder.
 Dress the baby as early as possible.
 Wrap in the blanket to prevent chills.
 Comb the Hair.
 Hand over the baby to its mother to give the feed.
 Take the articles to the utility room.
Disinfect the towels and basin.
Clean, dry them and replace in their proper places.
 Discard the Waste.
 Wash hands.
Recording and reporting:
 Record the procedure in the Nurses record with date and time.
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 Inform the ward sister and doctor if any abnormality found.

20.BREAST FEEDING
Definition:
It is a nurturing procedure of the post-partum mother for her new born
baby in which the proper position and technique, is utilized while feeding the
baby.
Purposes:
1. Enhance the condos t bolls baby and mother while feeding.
2. Meet nutritional needs of the baby adequately
3. Minimise the breast problem'.
4. Promote the maternal new born bonding
5. Promote pre pregnant body physique

78
Preparation of articles:
Article Purpose
1. Big bowl with lukewarm water To clean the breast
2. A small bath towel To wash the breast
3. A small sponge bowel To dry the breast
4. Pillow2-3 To support the baby according to the
desired comfort
Contraindications for both mother and neonate:
Mother Neonate
 Tuberculosis  Very low birth weight baby
 Contagious diseases  Asphyxia
 Puerperal sepsis  Acute illness
 Puerperal psychosis  Severe degree of cleft lip and
cleft palate
 Acute mastitis  Galactosaemia
 Abscess of breast
 Fissure / crack of nipple
 Mother on chemotherapeutic
drug / antiseptic drugs /
antithyroid drugs

Procedure:
Steps Rationale
1. Arrange, all the articles bed side Economies time
2. Explain the procedure to the mother Gain co-operation
3. Instruct the mother to expose her
breast
4. Inspect and palpate the both breast Assess condition
5. Clean the breast Facilities feeding hygienically and
• Dip the bath towel in the lukewarm water maintain the intact skin the breast
• Clean the breast. Firstly, nipple and
areola and then the rest of it
• Dry n with sponge towel
6.Give position to the mother Facilities easy feeding
• Postoperative mother side lying position
• Post vaginal delivery mother
79
(a) Cradle hold
(b) Football hold
(c) Cross-cradle or modified cradle hold
a) Cradle hold: Position head at or near Adjust height and mother don‘t need to
the antecubital space and level with her bend forward
nipple with her hand supporting infant
body.

Cradle hold method

b) Football hold: Instruct the mother to

support the infants head in her hand with
the infant‘s body resting on pillow
alongside her hip.

Football method

c) Cross-cradle: Place pillow on her lap

and assist the mother to sit with her back

80
upright and at right angles to her lap.
Mother holds the baby with her extended
arms.

Cross-cradle

7.Hold the baby according to the desired Assist baby to search out the nipple
position and move the baby‘s mouth
against her nipple
8. As the baby opens his mouth. Insert the Helps the baby to latch on the nipple for
nipple so that the baby latches on to the feed
nipple
9. Keep the baby on each breast for at least Facilities proper feed
5 minutes and then change the breast side
by inserting the fingertip inside the baby
mouth and continue to another breast for
next 5 minutes
10. While feeding take care for the nose of Avoids suffocation for baby
baby not to be pressed.
11. Burp the baby immediate after the feed. Reduces risk of vomiting and aspiration
12. Lay the baby on her side Prevents aspiration if the baby vomits

Recording and reporting:

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 - Replace all articles and document the procedure.
General instructions:
- Maternal hygiene such as daily bath and changing dress is important.
- The last feed breast should be starting breast for the next feed.
- Breastfeeding mothers need to wear proper fitting brassieres to provide
comfort to the breast.
- During the feeding if the baby is sleeping stroke the sole of feet or the
earlobe.
- Initially, try to feed baby 1-2 hourly and on demand.

21.KANGAROO MOTHER CARE

Definition of Kangaroo mother care: Kangaroo Mother Care (KMC) is a
special way of caring low birth weight (LBW) infants by skin-to-skin contact. It
promotes their health and wellbeing by effective thermal control, breastfeeding
and bonding. KMC is initiated in hospital and continued at home.
Purpose:
 For premature or low birth weight babies in neonatal care
 For low birth weight and full-term babies
 For full-term babies or infants who are separated from their mothers due
to some medical reasons
 To establish breastfeeding and a good milk supply.
Pre-requisites:
- Wash hands before and after the procedure to prevent cross infection.
- Explain the procedure to the mother to gain willingness of the mother.
- Place the mother in a comfortable position.
- Provide screen to maintain privacy.
- Collect required articles at bed side.
- Stand at the right side of the mother.
- Record and reporting to be done
The Ten Steps to Successful Breastfeeding
1. Have a written breastfeeding policy that is routinely communicated to all
health care staff.
2. Train all health care staff in the skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of
breastfeeding.
4. Help mothers initiate breastfeeding within one hour of birth.

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5. Show mothers how to breastfeed and how to maintain lactation, even if they
are separated from their infants.
6. Give infants no food or drink other than breast-milk, unless medically
indicated.
7. Practice rooming in – allow mothers and infants to remain together 24 hours
a day.
8. Encourage breastfeeding on demand.
9. Give no pacifiers or artificial nipples to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers
to them on discharge from the hospital or birth centre.
Essential Components of KMC
Kangaroo mother care has three essential components:
1. Skin-To-Skin Contact or Kangaroo Position: Kangaroo position involves
the infant coming in skin-to-skin contact with the mother. The infant is placed
on the mother‘s chest, between her breasts. The primary feature of KMC is
early, prolonged, and continuous contact between the mother and her baby.
2. Exclusive Breastfeeding or Kangaroo Nutrition: Kangaroo nutrition
involves exclusive breastfeeding for the baby. The direct skin-to-skin contact
helps in the production of breast milk, and it also helps the baby to suckle
better, because of easy accessibility to the mother‘s breasts. However, in some
cases, the baby may be fed expressed breast milk. The direct skin contact also
helps strengthen the bond between the mother and her baby.
3. Support to the Mother and the Baby or Kangaroo Support: Kangaroo
support involves providing medical, physical, or emotional support to the
mother and the baby without separating them.
Preparation of the baby and mother
For baby:
 All stable LBW babies are eligible for KMC.it is particularly used for
caring LBW infants weighing below 2000gm.
 In a stable baby, KMC can be initiated soon after birth.
 KMC should be started after the baby is haemodynamically stable.
 Sick LWB infants may take a few days to initiate KMC. So, the sick baby
needs transfer to proper facility immediately.
 Infants of birth weight less than 1200gms with serious prematurity related
morbidity may take days to weeks to allow initiation of KMC.
 KMC can be initiated who is otherwise stable but may still be on IV fluid
therapy, tube feeding and /or O2 therapy.
For mother:
 All mothers can provide KMC irrespective of age, parity, education,
culture and religion.
 Mother should be free of serious illness and able to take adequate diet and
supplements recommended by her doctor.
 She must be willing to provide KMC to her baby.

83
  She should maintain good hygiene, daily bath/sponge, change clothes,
Hand hygiene, short and clean finger nails etc.
 She should have supportive family and community to be encouraged to
continue KMC to her baby
Preparation for KMC:
Preparation of mother and baby. Rational
Mother’s clothing:
 Mother should ware front It will promote the easy to provide
open, light dress, as per local skin to skin contact to the bay to the
culture mother can wear sari mother
blouse, gown, shawl etc…
Baby’s clothing:
 Baby should be dressed with Easy to provide skin to skin contact
front open sleeveless shirt, and prevent hypothermia.
cap, socks, and nappy and
hand gloves.
KMC procedure:
Steps of procedure Rationale
Kangaroo positioning
 The baby should be placed
between the mother‘s breasts in
an upright position.  This helps to keep the air
way open and allows eye –
 Baby‘s head should be turned to -eye contact between
to one side and in a slightly mother and baby.
extended position.
 To promotes skin to skin
 Baby‘s hip should be flexed contact to the mother and the
and abducted in a froglike baby.
position. the arms should also
be flexed and placed on
mother‘s chest
Monitoring during KMC:  By providing froglike
 During initial stage of KMC, position may close the nose
the baby should be monitored of the baby and by providing
for airway, breathing, colour skin to skin contact we
and temperature. Hands and monitor the baby for
feet should be examined to maintain normal vitals.

84
 assess the warmth. The airway
must be kept clear with regular
breathing normal skin colour
and temperature.
Feeding:
 Mothers needs help to  Stimulates milk production
breastfeed her baby during and the kangaroo position
KMC, holding the baby near makes the breast feeding
the breast. easier
 Baby could be fed with paladai,
spoon and tube depending upon
the baby‘s condition.
Psychological support to mother:
 Mother needs motivation to
continue KMC and she should
be encouraged to ask questions.
 To remove anxiety.
Privacy:
Privacy should be maintained to
avoid unnecessary exposure on the  To gain confidentiality.
part of the mother.
Time of initiation of KMC:
 KMC should be initiated
gradually with a smooth
transition from conventional
care to continuous KMC.
 KMC can be started as soon as
the baby is stable in the
neonatal care unit.
 Short KMC sessions can be
initiated during recovery with
ongoing medical treatment, i.e.
IV fluid, O2 therapy, etc..
 KMC can provided with the
baby is with gavage feeding.

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 Duration of KMC:
 Duration of KMC should not
be less than one hour.
Gradually the length of KMC
sessions should be increased up
to 24 hours a day. Interruption
only can be done for changing  Frequent handling which
of diapers. may be stressful to the baby.

 KMC should be continued in

postnatal ward and home. when
mother is not available then
other family members such as
father, grandmother, aunty can
provide KMC
Dis continuation of KMC:
KMC can be continued until the baby
gains weight around 2500gm or  To prevent hypothermia.
reaches 40 weeks of post conception
age.
KMC can be discontinued if the baby
starts wriggling to show discomfort or
pulls limbs out cries and fusses every
time, mother tries to put the baby
back into skin contact.
Advantages of Kangaroo Mother Care:
1. Better Adaptation to the Environment: Premature babies face the
challenge of thermal regulation. KMC helps the baby to come in skin-to-skin
contact with the mother that helps in regulating the body temperature. Being in
close contact with the mother makes it easier for the child to adapt to the new
surroundings.
2. Helps Baby to Sleep Better: Babies, who are in close contact with their
mothers, tend to sleep better than babies who are in neonatal care units. This
happens because the baby is less stressed and feels relaxed in the mother‘s
warmth.
3. Aids Better Mental Development: KMC promotes better sleeping patterns,
stabilised heart rate, and oxygenation, which results in better brain development
until adolescence. There is better brain development in babies who received
KMC in comparison to babies who were kept in incubators.

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4. Makes Breastfeeding Convenient: Kangaroo Mother Care helps the baby to
breastfeed exclusively, as the baby is placed close to the mother‘s breast. Babies
have a heightened sense of smell, and they tend to suckle instantaneously.
5. Promotes Healthy Weight Gain: KMC helps the baby in gaining weight.
When the baby feels warm, the baby does not use its energy to stay warm. The
mother‘s warmth and protection help the baby to suckle better and thus, aids in
gaining weight.
6. Reduces Baby’s Stress Levels: Close skin contact with the mother for a few
minutes a day brings down the cortisol levels (the hormone responsible for
stress) in the baby. KMC also increases oxytocin the cuddle hormone, which
helps the baby feel relaxed.
7. Helps the Mother to Produce Milk: Close contact with the baby helps to
regulate the hormone that helps in lactation. This promotes milk production in
the mother‘s body and makes breastfeeding easier.
8. Helps the Mother to Fight Postpartum Depression: KMC is beneficial for
mothers as well, as skin-to-skin contact with the baby helps the mother‘s
anxiety levels to go down. It also promotes attachment with her baby and
reduces the chances of postpartum depression.
9. Helps in Bonding with the Father: KMC is very useful in building a bond
between the father and the baby. Skin contact with the father has a calming
effect on the baby and helps in better bonding.
Care of the mother and baby: Make the mother and baby comfortable.
Recording and reporting: Record the duration the KMC.

22.PHOTOTHERAPY
Definition
It is specially designed, electronically based instrument which has an
effective light source for the therapeutic purposes.
Purposes
 It is used to treat the neonatal jaundice by decreasing the serum bilirubin
level.
 It is also to prevent the acute bilirubin encephalopathy, hearing loss and
kernicterus.
Preparation of articles:
Articles Rationale
1. Phototherapy machine with To provide fluorescent light therapy
white and blue lights.
2. Radiant warmer/phototherapy To provide warmth
isolette.
3. Diaper To close the genitalia of the baby.
4. Eye bandage or pads To cover the eyes
5. Cotton swabs with sterile water To clean the phototherapy unit.
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 or antiseptic solution
6. Kidney tray or waste bin To discard the waste products.
7. Baby sheets. To provide comfort

Indications
 When there is an abnormal rise in the bilirubin level which may be due to
physiological or pathological jaundice or any other problem.
 In severely bruised premature infants and who are likely to develop
dangerous level of bilirubin.
 In hemolytic disease of the newborn, phototherapy is used while the rise
in the serum bilirubin level is plotted and while waiting for exchange
transfusion. In such cases, phototherapy is started immediately at birth.
Contraindications:
Do not give phototherapy for conjugated jaundice.

Set up Phototherapy unit

 Phototherapy generally consists of four to eight cool white, day bright, or
special blue fluorescent tube light covered by a plastic shield and placed
about 18 inches or 45 cm away from the baby.
 The spectrum of the light at 420-460 nm is the most effective. The energy
output in this spectrum should be checked periodically to ensure
efficiency.
 The efficiency of phototherapy depends on energy output of the spectrum
and on the surface area of the infant exposed to those lights.
 Though, blue lights are the most effective, they are not widely used
because they mask the clinical signs of cyanosis and color change in the
infant.
 White light permits better visual monitoring. The plastic shield absorb
ultraviolet irradiation.
 A photo reaction occurs in the very outer layer (to 2 mm) of the skin.
 Once phototherapy has been initiated serum levels of the bilirubin must
be monitored frequently (every 4-12 hours).
Keep the child in Phototherapy unit
Place the infant naked under the lights with shielding over the eyes. A
small cloth may be placed for scrotum protection in male babies. The infant‘s
position should be changed frequently. This permits maximal skin exposure to
the lights. Make sure that baby is 18 inches or 45 cm away from the light.
Procedure/ Nursing care of the newborn receiving phototherapy
Phototherapy is not without side effects so a comprehensive plan of
nursing care should be implemented to avoid any complications.
Explanation and reassurance to parents
 Encourage parents to continue feeding, caring for and visiting their infant.
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  The lights should be turned off and eye patches removed during visits, so
that normal parent infant interaction can occur.
 Explain to the parents what newborn jaundice is, why the infant is being
treated, what precautions will be taken and that the lights being used do
not contain ultraviolet light.

Steps Rationale
Skin care
 Infants in isolates who are <  For complete exposure of the
1200gm are generally nursed skin
without a nappy on an absorbent
sheet protector.
 Infants in isolates who are >
1200gm may be nursed with a
nappy on if the bilirubin is not
rising rapidly.
 If intensive phototherapy is
required then the nappy should
be removed.
 Keep the infant clean and dry.
 Clean only with water. Do not  To the exposed skin.
apply oils or creams
 Eucerin has been proven to be  For use when the infant is
safe receiving phototherapy.
 Infants nursed in nappies where  To areas of skin excoriation.
the buttocks are not exposed
may have zinc and castor oil
applied

Eye care
 The eyes should be covered
 To ensure safety.
while phototherapy is in use.
 Cover the eyes with pads
 To protect the eyes from radiant
without placing excessive light.
pressure on the eyes and be
carefully positioned
 Eye patches should be removed
every 4 hours and should be
cleansed with normal saline and
changed every 8 hours.
 The patches should be removed  To permit evaluation of the
during feedings and parental infant‘s eyes
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 visits.

Fluid Requirement
All Infants
 Accurately document fluid intake (oral or intravenous) and output.
 Urinalysis and specific gravity should be checked 8 hourly.
 Assess and record stools.
Term Infants
 Breast fed infants should continue on demand breast feeds.
 Sucking, attachment and mother's supply should be observed and
documented.
 Bottle fed infants should be fed on demand 4-6th hourly.
 Complementary feeds in the form of intra gastric or bottle feeds with
EBM/formula may be required if oral intake is insufficient and there are
concerns that the infant is dehydrated.
 Breastfed infants > 32 weeks gestation should be complemented with a
hydrolyzed formula (eg: Nan Ha) if there is insufficient breast milk and
the parents consent to formula feeding.
 Assessment of dehydration should take into account the baby‘s fluid input
and output, weight and urine specific gravity.
Preterm Infants
 Preterm infants have about a 20% increase in trans epidermal water loss
when they receive phototherapy despite being nursed in humidity and a
double walled crib.
 The daily fluid rate may need to be increased by 10ml-15ml/kg/day to
prevent dehydration.
 Baby birth weight < 1000 g requires 100 ml/kg on the 1 st day and daily
increases 10-15 ml/kg till 7th day onwards.
 Baby birth weight 1000-1500 g requires 80 ml/kg on the 1st day and daily
increases 15 ml/kg till 7th day onwards.
 Baby birth weight >1500 g requires 60 ml/kg on the 1 st day and daily
increases 15 ml/kg till 7th day onwards.
 When increasing the daily fluid rate the gestational and postnatal age,
fluid input and output, serum sodium levels and urine specific gravity
need to be reviewed and the fluid rate must be individualized for each
infant.
Observation of the child
 Infants must be weighed on admission to the nursery and 2nd daily as per
the protocol.
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  All infants in Newborn Care receiving phototherapy should have a
temperature, pulse and respiration rate documented 4 hourly.
 If an infant requires continuous cardio-respiratory monitoring for other
reasons, then, this should continue whilst under phototherapy.
 Infants under the Blue fluorescent lights need at least saturation
monitoring as it is difficult to assess the infant‘s color under these lights.
 If the infant receiving phototherapy by the Micro-Lite system is
tachycardic, plethoric or restless, then the temperature should be
rechecked as the infant may be overheating.
 Well babies > 35 weeks gestation who are receiving white light
phototherapy do not require any monitoring unless they are nursed prone
and then they will require cardiorespiratory monitoring.
Complications of phototherapy
 Insensible water loss
 Temperature instability
 Retinal damage in animals, but there is no evidence in humans.
 Gastrointestinal effects such as watery diarrhea and increased fecal water
loss.
 Erythema, skin rashes and increased blood flow.
 Bronze baby syndrome.
 Cell damage
Aftercare of the Baby and the Articles
1. Make the baby comfortable.
2. Collect and clean all equipment and arrange for next baby.
3. Clean other equipment and return to their usual places.
4. Wash hands.
Recording and Reporting
- Record on Baby case file and nurse's notebook with date and time.
 Indication of phototherapy.
- Report any complication to the ward sister and doctor.
 Baby condition.

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 23.NEW BORN RESUSCITATION
Definition:
Series of actions, used to assist new born babies who have difficulty with
making the physiological transition from the intra uterine to extra uterine life.
It is an intervention after a baby is born to help it breath and to help its
heartbeat.
Purpose:
 The purpose of Newborn resuscitation is to help the newborn to establish
spontaneous breathing.
 Facilitate oxygen delivery to its organs and tissues- particularly the brain,
which is very quickly damaged by oxygen shortage
Indications:
 Preterm delivery
 Delivery other than normal
 Mal presentation
 Multiple Pregnancy
 Fetal Distress
 Meconium staining
 Severe IUGR
 Antenatal diagnosis of fetal abnormalities.
Contra indication:
 Diaphragmatic hernia
 Non- Vigorous baby born through meconium-stained liquor.
Preparation of environment:
 Flat surface
 Warm and clean
 Room temperature 26 degree Celsius
 Radiant warmer/ heater/ a 200-watt bulb
 Keep heat source on before delivery
 2 pre warmed towels to receive the baby.
 Medications
Preparation of articles:
Articles Purpose
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  A self – inflating ambu bag  To provide positive pressure
(new born size) Two infant ventilation
masks (for normal and small
newborn)
 A suction device(Mucus  To remove the oral secretions
extractor)
 A radiant heater (if available)  To maintain the body
or Warm towels or blankets. temperature of new born

 A clock is needed.  To record the time

 Stethoscope
 To check the baby heart sounds

ABC’s of Resuscitation:
A- Establish open airway position, suction.
B- Initiate breathing by tactile stimulation, oxygen.
C- Maintain circulation chest compression.
D- Medications.
Initial steps:
 Thermal management
 Positioning
 Suctioning
 Tactile stimulation
Anticipation of resuscitation;
 Resuscitation must be anticipated at every birth.
 Every birth attendant should be prepared and able to resuscitation.

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Initial stabilization and evaluation:
- This consist of drying (thermal management) the neonate under radiant
warmer to minimize heat loss.

94
- Positioning of the newborn baby Suctioning of mouth and nose (tracheal
suctioning if meconium present) and provide tactile stimulation.
This should only take approximately 30 seconds.
(1) Open the airway put the baby on its back. Position the head so that it is
slightly extended. The upper airway (the mouth than nose) should be sanctioned
to remove fluid if stained with blood or meconium.
(2) If there is no cry, assess breathing; if the chest is rising symmetrically
with frequency >30/minute, no immediate action is needed if the new born is
not breathing or gasping.
(3) Immediately start resuscitation. There are two techniques to provide
breathing:
- Technique for artificial respiration.
- Positive pressure ventilation.
1. Technique for artificial respiration:
 Clear the mouth of mucous
 Hyper extended the neck with one hand, clamp the nostrils with
fingers or
 Seal nose and mouth
 Take deep breath and force air into lungs.
When no equipment is available:
Mouth to mouth and nose breathing should be done.
2. Positive pressure ventilation:
The most important aspect of newborn resuscitation for ensuring
adequate ventilation of the lungs, oxygenation of vital organs and initiation of
spontaneous of breathing. Ventilation can almost always be initiated using a bag
and mask.
Two basic kinds of resuscitation bags are available.
Self-inflating bag
Flow inflating bag
( it is rarely necessary to intubate)
Procedure:
Sno Procedure Rationale
1 Place back with head slightly Helps in opening airway.
extended. The newborn on his Hyperextension may cause
airway obstruction.
2 A tight seal is to be formed over Prevents leakage of air from the
the infant‟s mouth and nose with sides of the mask.
the face mask.
3 Ventilate at a rate of 40-50 per
minute.
4 Ventilate for 15-30 seconds and Spontaneous respiration may be
evaluate initiated with initial attempts to
ventilate.
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5 Have an assistant to evaluate,
listen to the heart rate for 6
seconds and multiply by 10.

Evaluate the Heart Rate: After 30 sec. count the heart for 6 sec and multiply it
by 10 to obtain heart rate per minute.
- If the heart rate >100 bpm and baby have spontaneous respiration and
discontinue ventilation, provide tactile stimulation and free flow oxygen.
- If HR is <100 bpm ensure ventilation with 100% oxygen initiate chest
compression.
Chest compression: Whenever the HR remains <60 bpm in spite of positive
pressure ventilation.
2 types:
1. Thumb Technique
2. Two Finger Technique
 Pressure to be applied vertically, cannot use effectively if the baby is
large or if our hands are small.
 Position of the baby on firm surface with neck slightly extended.
Location: Lower third of sternum which lies between the xyphoid and the line
drawn between nipples.
Depth of Compression:
Infant - 1/2 -3/4, Child – 1- 1 1/2
Compression and ventilation rates and ratios:
 for adults – 30 compression and 2 breath
 for infant and child – 15:2
Chest Compressions:
S.no Procedure Rationale
1 Compress the chest by placing the Correct hand position compresses the
hands around the newborns chest heart and avoids injury to the liver,
with the fingers under the back to spleen, fracture of the ribs and
provide support and the thumbs pneumothorax.
over the lower third of the
sternum (just above the xiphoid
process) 0r Use two fingers of one
hand to compress the chest and
place the other hand under the
back to provide support.
2 Compress the sternum to a depth The size of the newborn determines
of approximately one third of the the depth of compressions to avoid
anteroposterior diameter of the injury.
chest and with sufficient force to
cause a palpable pulse. The
fingers should remain in contact
96
 with the chest between
compressions.
3 Use three compressions followed Simultaneous compression and
by one ventilation for a combined ventilation may interfere with
rate of compressions and adequate ventilation. The short pause
ventilation for a combined rate of allows air to enter the lungs
compressions and ventilations of
120 each minute. Pause for ½
second after every third
compression for ventilation.
4 Check the heart rate after 30 Periodic evaluation is necessary to
seconds. If it is 60 bpm or more, ensure that treatment is appropriate to
discontinue compressions but the infant status.
continue ventilation until the heart
rate is more than 100bpm and
spontaneous breathing begins.

- If there is no gasping or breathing at all after 20 minutes of ventilation

stop ventilation.
- There may be required in newborn who do not respond to adequate
ventilation with 100% oxygen and chest compressions.
- Sodium bicarbonate: sodium bicarbonate is not recommended in the
immediate post-natal period.
- If there is no documented metabolic acidosis. If it is given administered 2
meq /kg (umbilical vein) slowly not faster than a rate of 1 meq/kg/mt.
Epinephrine:
Epinephrine in a dose of 0.01 – 0.03 mg/kg should be administered if the
heart rate remains <60 bpm after a minimum of 30 seconds of adequate
ventilation and chest compression
Routes: Umbilical veins, Endotracheal, intravenous.
Volume expanders: NS & RL10 ml/kg umbilical veins to be infused over 5-10
minutes.
Naloxone hydrochloride: 10 mg/ml solution, intravenous.
Care after successful resuscitation:
 Do not separate the mother and the newborn
 Leave the newborn skin to skin with the mother
 Encourage breast feeding within one hour of birth.
 The newborn that needs resuscitation is at higher risk of developing
 Hyperglycemia
 Observe suckling
Good suckling is a sign of good recovery.
Recording and reporting: Document the procedure in the baby file.
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 24.FORMULAS FOR DRUG CALCULATION
Equivalents:
1mcg = 0.000001g
1mg = 1000mcg or 0.001g
1g = 1000mg
1oz = 30mL
1tbps = 15mL (tbps-tablespoon)
1 tsp = 5mL (tps-teaspoon)
1kg = 2.2lb
1lb = 0.45kg
1 pint = 500mL
Basic dose calculation:
Desire x Quantity / Available Dose (D X Q / AD)
Drops per minute:
Total infusion X Drop factor / Time in minutes
Macro set = 15 drops / minute (adults)
Micro set = 60 drops / minute (children)
(Note: GTT =drops / minute)
Infusion time: Volume in mL / Drop rate
Young’s formula:
Pediatric dose = Age x adult dose / Age + 12
Fried’s rule:
Infant dose = Age x adult dose / 150
Clerck’s rule:
Pediatric dose = Age x adult dose / 150

Temperature conversion formula:

C = (F-32) X 5/9
F = C+32 X 9/5
IQ calculation formula:
Mental Age X 100 / Chronological age
EDD calculation:
Naegle‘s formula = LMP + 9Months+ / - 7 days
Mean Arterial Pressure:
Systolic BP + (2 x Diastolic BP) / 3
Body Mass Index:
BMI = Weight in kg / Height in (m)2

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 25.MTP SETUP
DEFINITION:
Medical termination pregnancy is a method of terminating pregnancy
using medicines. It is feasible only up to 9 weeks of pregnancy after that
surgical termination takes over. It is one of the safest modes of terminating an
unwanted pregnancy.
[OR]
Deliberate termination of pregnancy either by the medical & surgical
method before the viability of the fetus is called induction of abortion.
Provisions of MTP ACT:
(a) When pregnancy involves serous of life or risk injury to the physical or
mental health of the pregnant woman.
(b) Eugenic consideration; serious confidential disorders are being born with
serious or mental physical handicaps.
(c) Social indication: pregnancy is caused by rape both in case of major or
minor girls and mentally imbalanced woman.
(d) Pregnancy caused as a result of failure of contraception.
Indications for Medical Termination of Pregnancy:
 To save the life of mother(therapeutic or medical termination)

99
  Sever cardiac decompression which response poorly treatment.

 Chronic uncontrolled hypertension.

 Diabetes with complications of retinopathy, neuropathy and nephropathy.

 Certain psychiatric disorders.

 Rubella infection in the first trimester.

 Women facing the birth of potentially handicapped or malformed child

 Pregnancies in unmarried girls under the age of 18 years with the consent
of guardian

 Pregnancies that are results of failure in sterilization.

Preparation of equipments:
Facilities for safe and hygienic place for performing MTP in centre
approved up to 12 weeks of pregnancy:
1. Gynaecology examination/labour table should be available.
2. Resuscitation equipments should be available (Ambu bag, Oral airway,
Oxygen cylinder with oxygen).
3. Equipments required for MVA/EVA available.
4. Sterilization equipments should be available (Autoclave, Boiler, Cidex
tray)
5. Essential drugs available.
6. Drugs required for treatment of emergencies should be available.
7. Intra Venous fluids.
8. Essential supplies should be available.
9. Drugs required for medical method of abortion if available (Mifepristone,
Misoprostol, Analgesics, Anti emetics)
10.Facility for transportation available if needed to transfer the patient to
higher centre.

100
Facilities for safe and hygienic place for performing MTP in centre
approved up to 20 weeks of pregnancy:
- Gynaecology operation table.
- Essential equipment/instruments for performing abdominal /
gynaecological surgery should be available (Ovum forceps, Foley‘s
catheter No.12, 14, 16, instruments for laparotomy, gynaecological and
abdominal surgery).
- Anesthetic equipments should be available (Boyle‘s Apparatus,
endotracheal tubes etc.)
- Resuscitation equipments.
- Sterilization equipments.
- Drugs required for MTP.
- Intra Venous fluids.
- Back up facilities for treatment of shock should be available if needed.
- Facility for transportation available if needed to transfer the patient to
higher centre.
Equipments Purpose
1. Sim‘s and/ or Cusco‘s speculum To Examine the vagina and cervix
2. Anterior vaginal wall retractor To retract the vaginal wall
3. Allis forceps or vulsellum Used to grasp the cervix. And also
(small toothed) used for grasp for fibroid polyp
4. Sponge holding forceps To hold the sponges
5. Blunt and sharp curette To remove the conception products
from the uterine cavity
6. Cheatles forceps To remove the sterilised instruments
7. Bowel For antiseptic solution
8. Proper light source/Torch For proper examine and comfortable
9. MVA aspirator and /or Electric To aspirate the remaining tissue with

101
 Suction machine in the womb
10.Cannula of required sizes For cannulisation
11.Kidney tray To collect the waste
12.Strainer For tissues
13.Plastic bucket For chlorine solution and keeping
soiled instruments.

Essential Drugs:
1. Antibiotics: Ampicilline, Amoxicilline, Cephalexin or a suitable
alternative
2. Analgesic: Paracetamol, Pentazocin, Dicyclomine or a suitable
alternative
3. Injection Atropine sulphate
4. Local Anaesthetic: Inj. Lignocaine 1-2%
5. Injection Diazepam
6. Uterotenics: Inj. Oxytocin, Methylergometrine, Inj. Prostaglandins and/or
tablet Mesoprostol.
7. Dextrose 5% and Ringer lactate, IV set, Cannula or scalp vein sets
Drugs for Treatment of Emergencies:
 Injection Adrenaline
 Injection Aminophyline
 Injection Sodiumbicarbonate 7.5%
 Injection Calcium Gluconate 10%
 Inj. Metchlopramide (suitable antiemetic).
 Inj. Promethasine (suitable antihistamine)
 Hydrocartisone [steroid]
 Sterile saline or water for washing before instruments that are chemically
sterilized or high level disinfected before use.

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  Chlorine solution/ bleaching powder Infrastructure required for Second
Trimester Terminations

Pre-Operative Procedure:

The patient undergoes with ultrasound and examination while receiving

oral medication before the procedure. Doctors prescribe the patient with pain
medications and antibiotics and instructions are given to follow before, during,
and after the procedure. Patient will be given with an option to choose for a
birth control method if they want to.

DURING PROCEDURE:

In this method, a set of pills named Mifepristone is given to the

patient which can be taken orally or by injection. After this initial medication,
another set of pills Misoprostol is given to the patient which can be taken
orally or inserted vaginally at home or clinic. Generally, the gap between these
two medicines is 3 to 7 days.
Along with medicines, antibiotics are also given to prevent any kind
of infection. This medication is preceded and followed by a medical
examination to determine positive pregnancy and positive abortion.
AFTER PROCEDURE:

- Medical terminating pregnancy is a painful procedure both physically

and mentally that continues for a couple of weeks. It is always suggested
to take complete rest for complete recovery before getting on with your
daily life. It is preferable to have a support system to cheer up your
emotional mood swings and drastic hormones change that you go
through after abortion.

103
 - In the case of cramps, it is preferred to massage and use heating pads to
relieve cramps. Patient can also use medicine like ibuprofen to reduce
cramps and pain. Staying hydrated if they are feeling vomiting or
diarrhoea. Patient should use a tight-fitting bra to avoid breast
tenderness.

- Clean and replace the articles which are used during medical
termination of pregnancy.
- Remove gloves and wash the hands.
- Record the details of termination of pregnancy and condition of the
mother in the patient chart.

26.INSERTION AND REMOVAL OF IUCD

Definition of IUCD:

104
 A contraceptive device fitted inside the uterus and physically
preventing the implantation of fertilized ova.
An intrauterine device also known as intra uterine contraceptive
device or coil.is a small often T shaped birth control device that is inserted into
a women‘s uterus to prevent pregnancy. IUDS are one form of long acting
reversible birth control.
PURPOSES:
1. To avoid unwanted pregnancy.
2. To space pregnancies.
GENERATIONS OF IUDS:
First generation: plastic device - Lippies loop.
Second generation: copper bearing plastic device-CuT200
Third generation: CuT380A, multi load250, 375, and hormone release IUCD.
CURRENT IUCDs use in India.
• Cu-T 200A,
• Multi load copper devise 250, 375
• Cu-T 380A.

TIME OF INSERTION OF COPPER DEVICES:

1. Post menses week, after 6 weeks of child birth.
2. Concurrent with MTP or evacuation of spontaneous abortion.
3. during menstruation in 4 or 5 day
4. In middle if needed first confirm the pregnancy test along with scanning
if pregnancy is not confirmed than insert the IUCD by trained person

105
INDICATIONS:
• Women after child birth who is lactating or has no menorrhagia and those
who cannot take daily oral contraceptive pills, husband is not serious to
continue condom.
CONTRA INDICATIONS:
Absolute: - Suspected pregnancy.
- Pelvic inflammatory disease.
- Vaginal bleeding of undiagnosed pregnancy.
- Previous ectopic pregnancy.
Relative:
- Anaemia.
- Menorrhagia.
- History of pelvic inflammatory disease.
- Distortion of the uterine cavity due to congenital malformations, fibroids.
Pre-requisites:
 Explain the procedure including advantages and dis advantages,
effectiveness ad side effects of IUCD
 Arrange all articles near the examine table.
 Instruct the women to empty the bladder
Articles Rationale

IUCD sterilized insertion package. To insert the IUCD

Sterile tray containing:

1. Vaginal speculum (cuscus)-1 To visualization.

2. Vulsellum-1 Reduce the risk of uterine perforation.

3. Uterine sound-1 To measure the length of the cervix.

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 4. Sponge holding forceps-2 To hold the cotton for the cleaning.

5. Bowl containing cotton swab. For cleaning.

6. Sterile gloves. To maintain sterile area.

7. Scissors. To cut the excessive thread.

8. Disinfectant solution. To prepare the sterile area.

9. Kidney tray with paper bag. To collect the waste

Procedure (insertion of copper T)

Nursing action Rationale

1. Explain the procedure Helps in obtaining cooperation of

including advantages, dis patient and reduce anxiety.
advantages, effectiveness and
side effects of IUCD

2. Arrange the equipment near

examination table

3. Instruct the women to empty

her bladder

4. Position woman on her back

with knee flexed and buttocks
at the edge of table

5. Provide privacy and drape

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 patient

6. Wash hands and don sterile Prevent embracement

gloves

7. Load the IUCD (Cu-T) inside

the applicator in the following
manner. The threads, the
vertical stem and then the Loading in this manner facilitates
horizontal stem folded on to the release of the device as the inserter is
vertical stem through the distal withdrawn.
end of the inserter.

8. Inspect external genitalia,

urethra and vagina for signs of
infection, lesions or discharge

9. Cleans the perineum

10.Explain to the women that

there will be slight discomfort
during speculum insertion.

11.Insert the speculum gently and

observe the cervix for signs of
infection and erosion.
Helps in obtaining co-operation.
12.Clean the external cervical os
with antiseptic soaked swab by
using sponge holding forceps.

13.Instruct the patient that there

will be discomfort when

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 applying the vulsellum. Apply
vulsellum at the 12o clock
position on the cervix; grasp
the lip of the cervix.

14.Pass the uterine sound into the

cervical canal and insert
carefully into the uterine cavity
Applies traction to the cervix and
while pulling steadily
straightness the cervical canal.
downward and outward on the
vulsellum. (A slight resistance
indicates indicate that the top
of the uterine sound has
reached the fundus), and
remove the uterine sound.

15.Measure the length of the

Determine the length of the uterine
device to be inserted into the
cavity by noting the level of mucus or
uterine cavity the depth of
blood on the uterine sound.
gauge on the inserter tube is
used to mark the depth of the
uterus. Pull the loaded inserter
tube gently until the distance
between the top of the folded T
and edge of the depth gauge
closest to the T is equal to the
depth of the uterus as measured
on uterine sound.

16.Carefully peel the clean plastic

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 cover of the package away
from the white packing. Lift
the loaded inserter keeping it
horizontal so that neither the T
nor the white rod falls out. Be
careful not to push the white
rod towards the T.

17.Grasp the vulsellum and pull

firmly downwards to align the
uterine cavity and cervical
canal with the vaginal canal.

18.Gently introduce the loaded

inserter assembly through the
cervical canal. Keeping the
depth gauge into a horizontal
position.

19.According to the position and

direction of the uterine cavity
gently and carefully advance
the loaded inserter assembly
until the depth gauge comes in
contact with the cervix or
resistance of the uterine fundus
is felt.

20.Hold the vulsellum and the

white rod in one hand

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21.Gently and slowly withdraw
the inserter keeping the plunger
in place.

22.Check for the strings

protruding from the uterus. cut
the strings shorter so that they
protrude only 3cm outside the
cervix (from the external OS)

23.Remove the vulsellum if there

is excessive bleeding from the
vulsellum site, press a sterile
cotton ball to the site using
forceps until the bleeding stops. Place the loaded application in the
uterine cavity.
24. Remove the speculum and
drapes.

25.Instruct patient to stay in bed

for some time.

26.Wash perineum with soap and

water and dry it.

27.Remove gloves and discard.

This action frees IUCD into uterine

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 cavity.

The strings can be seen and felt in the

vagina.

Advantages Disadvantages

1. Simplicity: no complex 1. Pelvic Infection

procedures are involved in insertion.

2. Hospitalization is not required.

2. Bleeding and pain
3. IUCD stays in place as long as
3. Spontaneous expulsion
required.

4. Inexpensive.
4. Ectopic pregnancy
5. Contraceptive effect is
reversible by removal of IUCD. 5. Perforation and dis location

6. Free from systemic metabolic

side effects associated with hormonal 6. Pain during menstruation
pills.

7. There is no need for continual

motivation.

Withdrawal technique: This withdrawal of inserter tube releases the entire

copper T at high fundal position of the uterine cavity. Then plunger rod is
withdrawn. Finally i inserter tube is gently withdrawn over from external os
into vagina. Lower half of nylon tail is removed by scissors. Instrument are
removed the procedure is practically pain less except sharp pain felt when

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cervix is caught by vulsellum. The women rest on table for 15-20 minutes and
there after leaves for home. If she gets uterine cramp Tab. Ultragesic is taken.
She can start sex from the same day.
Follow up: a woman is checked per vagina after 3 months of insertion to see the
hanging nylon thread from external os. Thereafter regular frequent 3-6 monthly
check-ups are not done. She reports for follow up check-ups if any problem.
However annual check-up is done to assure the women.
Instruct the women on follow –up measures:
1. To confirm presence of IUCD periodically by feeling the presence of
threads in vagina.
2. Instruct patient to visit clinic whenever she experiences the warning signs
of problems related to IUCD such as:
• P-delayed period, spotting, bleeding or missing period.
• A-abdominal pain or pain during coitus
• I-infection, any vaginal discharge.
• N-not feeling well, fever or pelvic pain.
• S-strings (Not feeling the strings in vagina).
Lifespan of IUCDs:
Five years for Cu-T 200 and 10 years for Cu-T 380 A in single insertion.
Second insertion can be done at the end of the period other multi load copper
device 250,375 are kept for 5 years. All IUCDs are removed when menopause
ensures.
Indications for removal:
1. Uterine bleeding
2. Post insertion uterine pain
3. Dislocated IUCD.
Procedure of removal: On Cusco‘s speculum the hanging nylon thread is
caught by long clamp and IUCD is pulled out from the uterus women feels little
pain.

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Care of the articles: clean all articles under running water and steel articles
send for the sterilization.
Recording and reporting:
Record the type of the IUCD insertion and its time.
27.TUBECTOMY
Definition:
It is an operative procedure where resection of both segment of fallopian
tube is done to achieve permanent sterilization.
Objectives:
- To avoid un-wanted birth.
- Produce a change in the number of children born.
Preparation of articles:
Articles Purpose
A sterile tray containing
- Surgical gowns To protect us from soiling and
- Drape (hole towel) maintaining a sterile field.
- Towel clip-2 To
- 22 no. blade-1 To incise the skin
- BP handle-1 To hold the blade.
- Toothed forceps-1 To hold the skin while suturing
- Small retractor-1 To retract the rectus and get a good of
the intra peritoneal structures
- Babcock -1 To hold the fallopian tube
- Straight artery -2 To hold the ampulla and isthmus
- Curved scissors-1 To cut the body tissues (Fallopian
tubes, skin if needed)
- Straight scissors-1 To cut the suture material.
- Catgut-1.0 To ligate the Fallopian Tubes
- Vicryl -1.0 To close the rectus and the skin
- Sterile gauze piece -1 For dressing
- Bowel with betadine To clean before the surgery and after
- Bowel with spirit the procedure
Clean tray containing
- Ointment For the incised wound
- Dressing tape To close the wound
- Leggings To cover the legs

Procedure:
Steps Rationale
- Clean the abdomen with Betadine -To maintain sterility
following single strokes
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 - Clean the abdomen again using sprit
using single strokes
- Drape the patient exposing the area To expose the area to be incised
to the incised
- Incise the skin with 22 no. blade To open the abdomen
- Separate the rectus sheath To view the abdominal parts
- Retractor is placed on the lower side To reach the fallopian tubes
of the Incision
- The fallopian tube is located and To get a grip of the tube
hold with Babcock‘s
- Two straight arteries are used to To hold the tubes to ligate
stabilize the tubes
- Using curved scissors the tube is cut To cut the tubes
on both the sides
- The tube is then ligated with Catgut To ligate the tube
on both the sides
- The rectus sheath is then sutured To suture the rectus and skin
with Vicryl following the skin
The incision is Cleaned with To clean the incision with
Betadine antiseptic solution
- Ointment is applied and closed with To close the suture and to maintain
sterile gauze and secured with a the sterility and for wound healing
surgical tape.

After care of the Articles:

- The gauze, instrument, and needle count is noted and informed to the
surgeon, circulating nurse and is recorded in the checklist.
- The instruments are soaked in the solution and are washed dried and
sterilized.
Recording and Reporting:
- The procedure is recorded in the Case sheet and in the Family Planning
register.

28.PAP SMEAR PROCEDURE

Definition: - Papsmear or Pap test is a procedure to test for cervical cancer in
women.
Purpose: -
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 - To detect early cancer of the cervix.
- To determine estrogen activity related to menopause or endocrine
abnormalities.
Indications: -
 Women start within 3 years of sexual activity or by age of 21
 High risk factors for cervical dysplasia
a) Early onset of sexual activity
b) Multiple sexual partners
c) Smoking habits
d) HPV and HIV
Preparation of client: -
 Educate to avoid intercourse, douching, or using vaginal medicines or
spermicidal foams for 2 days before the papsmear test.
 Ask the client to come after menstrual period for papsmear test.
Articles used for papsmear
Name of the Articles Purpose
 Examination table with foot step  To lie down on the table for
procedure
 For good lighting
 Examination on light
 To visualize cervix
 Metal or plastic speculum Cusco‘s
bivalent Self retraing vaginal
speculum
 Examination gloves  To maintain sterility
 Cervical spatula and cyto brush  To collect secretion
 Liquid – based cytology container  To keep the smear on slide
or glass slide and fixative
 Sponge holder  To clean the perineum
Pre procedure
 Inform and explain the procedure to patient
 Provide privacy
 Assist for lithotomy position
 Drape patient permit minimal exposure
During procedure
 Explain the procedure as needed
 Encourage patient to take deep breath

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  Support to patient by midwife
 Assist doctor in doing papsmear
 Help to focus torch light in perineal area of patient
Procedure
 Sterile tray containing, speculum, sponge holder
 Keep patient on lithotomy position
 Undress vulva part
 Insert speculum into vagina, the speculum holds the walls of vagina, the
doctor can easily see cervix.
 Take samples of cervical cells using a soft brush and a flat scraping
device called spatula.
After procedure
 Observe any discharge from vagina
 Perineal care is needed
 Assist patient to change from lithotomy position to supine position
 Documentation, date, time, doctor, staff involved
 send the specimen to laboratory with requisition form
Care of articles
 Gloves should keep in 0.5% chlorine solution along with speculum,
sponge holders for 10 to 20/minutes for disinfection.
 Rinse with detergent, with plain water, dry it and send for sterilization in
a covered tray
 Soiled linen sends to laundry.

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