MATERNAL

ASSESSMENT
 The Mortality and Morbidity

Three Delays Model

•Delay in deciding to seek medical care.
•Delay in Identifying and reachin the appropriate health facility.
•Delay in receiving appropriate care at the heath facility.
A Skilled Attendant is an accredited health professional
(a midwife, Doctor and nurse) who has been educated
and trained to proficiency in the skills needed to manage
normal pregnancies, childbirth and the immediate
postnatal period and in the identification, management
and referral of complications in women and newborn.
 Prenatal care
• Is the health care you get while you are pregnant.
• It can help keep mother and the baby healthy.
• Early treatment can cure many problem and prevent others.
Steps to follow in prenatal care
Steps to follow in prenatal care
• Always records findings
• All pregnancies are at risk.
• Encourage all pregnant women to deliver in the health facility.

*REFER patients with abnormal findings to higher facility.

 AOG Computation
• Naegele’s Rule: derived from a German obstetrician, subtract 3
months and add 7 days to calculate the estimated due date
(EDD).
Formula:
(-3 months +7 days +1 year)
from LMP ( last menstrual period)
Example:
• Suppose a woman’s LMP was October 10, 2022. Calculate her estimated
date of delivery (EDD) using Naegele’s rule.

10 10 22
-3 +7 +1
7 17 23 – EDD
 Fundic Height Measurement

Why measure the fundic Height?

•To determine if the uterine size is compatible with the age
of gestation
- Coincides with the age of gestation from 18-30 weeks
•To aid in the estimation of fetal weight.
 How to measure Fundic Heaight?

• Bladder must be empty

• Upper edge of symphysis pubis
• Apply the tape with calibration hidden to avoid bias
• Top of fundus
 Leopold's Maneuver

• used to palpate the gravid uterus systematically.

This method of abdominal palpation is of low
cost, easy to perform, and non-invasive. It is used
to determine the position, presentation, and
engagement of the fetus in utero.
 Leopold Maneuver 1( fundal grip)

• Empty the bladder

• To determine fetal part lying in the fundus and
determine presentation.
• Face the woman’s head with both hands, feel the height
of the fundus.
 Leopold Maneuver 2 (Umbilical grip)
• To identify location of fetal back and to determine
position.
• Feel the sides of the uterus to find the position of the
baby’s back and extremities.
• Back feels smooth
• Extremeties feel irregular
 Leopold Maneuver 3 (Pawlik’s grip)

• To determine engagement of presenting part.

• Grasp area immediately above the symphysis between
thumb and fingers
- Head: hard and round movable if not engaged
- Breech: feels softer and irregular.
 Leopold Maneuver 4 (pelvic grip)
• To identify of the fetal part in the pelvic cavity.
• Face the womanb’s feet. Place fingers on both sides of the
lower abdomen and press downwards and inwards
• Determine fetal occipital prominence
• Helps to identify the presenting part and whether it is
engaged.
MONITORING PROGRESS OF LABOR

* INTERVAL
- the length of time between the first contraction and the another contraction.* *
*DURATION
- time from when you first feel a contraction until it is over.
* FREQUENCY
- From the beginning of one contraction to the beginning of the next contraction.
 Fetal Heart Tone
• Easiest to hear over the baby’s back
• FHT can be heard
- Using hand-held doppler starting 10-12 weeks gestation
- Using standard stethoscope
-Starting 18-20 weeks gestation for Primis.
- Starting 16-18 weeks gestation for Multis.
• Normal FHT 120 bpm to 160 bpm
• If FHT cannot be heard after 6th month and no fetal movement- REFER.
 Use of Electronic Fetal Monitor
• Electronic fetal monitoring is a procedure in which instruments are
used to continuously record the heartbeat of the fetus and the contractions
of the woman's uterus during labor.
Slight Decelaration of FHR
Normal Pattern
 Internal Vaginal Examination
-a surest way to know if a labor is progressing normally.
-do one initially, do more every 4 hours unless necessary.
-never do vaginal exam if there is bleeding from the vagina.
This could be a sign of placenta previa.
 Step by step Procedure
- Explain how it will be done and why.
- Ask for women’s consent.
- Ask her to urinate first before the exam.
- To begin with, do your hand hygiene.
- Use gloves as your PPE.
- Have the women bend her knees and open her legs. (don’t force her to open her legs, be patient and talk to her if she is
afraid or reluctant).
- Wash the perineal area with clean water.
- Notice if there is any condition such as infections or scars from genital cutting that could affect the delivery.
- Wait until she has finished her contraction, suggest to take deep slow breath to relax.
- Separate the labia and gently insert your 2 fingers.
- First, check the position of the cervix.
 What to note during Internal
Examination.
• Cervix
- Dilatation
- Thickness or effacement
• Bag of water
• Presenting part/ station
• Pelvimetry (architecture, adequacy of diameters)
 When to do an I.E
• Only during labor
• When the BOW ruptures
• If malpresentation is suspected
• Before transferring a woman to ward
• In the 3rd stage, if there is postpartum hemorrhage
 Do not proceed!

• NEVER do an I.E.
• Unless you have a good indication for doing so. Every I.E.
may bring INFECTION to the woman and her baby.
• If the woman has had vaginal bleeding after 5th month of
pregnancy.
 Effacement and dilatation

• Effacement
- it is the cervix stretches and gets thinner.

• Dilatation
- it is the cervix is open.
 Dilatation of the Cervix
• You will learn with practice how many centimeters the cervix is dilated by how far apart your fingers are
as you gently stretched the cervix open.
• The dilatation is always determined by the inner cervical opening next to the baby’s head.
- 1cm (there is hole but your finger cannot enter)
- 2cm (can enter the 1 finger but not fits for 2 fingers)
- 3cm fits 2 fingers loosely.
- 4cm fits 2 fingers a little more open than 2 loose finger.
- 5cm fits 2 fingers to open further and further at 6,7,8,9 centimeters.
- 10cm the cervix is completely open, fully dilated you will never feel any cervix in front of baby’s head.
You can sweep your fingers around the head to be sure you feel no cervix at all. The women can safely
push the baby out without risking a tear of the cervix.
Fetal Head Station
 Partograph

• A tool to help in the management of labor.

• This will guide the birth attendant to identify women
whose labor is delayed and therefore decide appropriate
action.
 Partograph
• Assessment of progress of labor
- Cervical Dilatation
- Contraction
- Alert and action lines
• Assessment of maternal well being
- Pulse, temperature, blood pressure
- urine voided
 Partograph
• Assessment of fetal well being
- fetal heart rate and pattern
- color of amniotic fluid
Partograph is not recommended and
referral is necessary
 ER ADMISSION
• Upon admission the nurse on duty shall ask the pt/ watcher for her
attending physician OF CHOICE (AP)- ask for admitting orders if any and
carry out orders.
• Inform the AP of her/his patients arrival/ admission
• Obtain history of relevant medical details ( LMP, when does labor starts)
• Do a brief general physical examination. (isolate the patient if a
contagious disease is discovered or suspected)
• Obtain vital signs and record
• Do Leopolds maneuver to determine fetal presentation, position and engagement.
• Check for FHT and fundic height
• Check for vaginal bleeding or leakage of amniotic fluid. )its is important to note the color
of amniotic fluid to determine if is meconium stained
• Perform Internal Examination aseptically
• Note the cervical dilatation, effacement and fetal head station and the presence of show
• Inform attending physician of your assessment, inform OR/ DR staff of the admission
Note: 8cm - fully dilated cervix proceed to OR/DR
For pt. with negative rtpcr result proceed to OR/DR
For patient with pending rtpcr result proceed to Isolation DR(Dirty DR)
Pt. with 7cm and below cervical dilation shall be transferred to
the ward for monitoring
evaluate the pt. pain, effacement and fetal head station
if patient is multigravida (3) pt is monitored @ OR/DR
Preparation of patient in labor at ward
• -NURSE on duty will received the patient from ER with proper
endorsement before proceeding to the assigned room.
• -Advise patient to clean vaginal area ( perineal shaving is not necessary)
take a bath if the patient is still able.
• -monitor and record progress of labor (interval and duration). Observe the
patients reactions and her tolerance of labor pain. Restlessness and
discomfort often develop as labor progresses.
• -MONITOR and FHT q15 minutes during the first stage of labor and also if membranes is
already ruptured. If while on monitoring sudden changes or any unusuality may occur
monitor pt. q5minutes 3 times) then refer immediately to AP
• -encourage pt. to do squatting If unable to do squats advise the patient to lay down at left
lateral position
• -Encourage pt. to void frequently. Palpate abdomen occasionally for signs of bladder fullness.
• -- perform Internal Examination every 4 hours or whenever it is necessary
• If patient is 8cm dilated to fully dilated inform the OR nurse and AP and prepare for transfer
OR/DR.
 AFTER DELIVERY (AT WARD)
FOR NORMAL DELIVERY:
• -Nurse shall received the patient from the OR Nurse with proper
endorsement
• Note any unusualities that occur during the time of her delivery.
• -Monitor Vital signs every 15 minutes for the first two hours then q 30 for
another hour or as per AP order and record.
• Note if patient show signs of eclampsia, tachycardia or any unsuallities
refer immediately.
• -Monitor discharges (mild, moderate or heavy bleeding)
• - Palpate uterus for contraction
• Watch out for uterine atony
“ BEST WAY TO PREVENT UTERINE ATONY IS TO INITITIATE
BREAST FEEDING”
THANK YOU