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Includes all decisions an individual or
couple make about having children:
 If and when to have children
 How many children to have
 How children are spaced
 Conception, fertility and counseling

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O  
ïny device used to prevent
fertilization of an egg

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O    
rersonal values
ïbility to use method correctly
How method will affect sexual enjoyment
Financial factors
Status of couple¶s relationship
rrior experiences
Future plans
Contraindications

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O ˜ O  O ˜O ! "

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O  
m million women in United States
use some form of contraception
65% of women of childbearing age

  ? rHILIrrINES

|   |



O  
0 ïbstinence
% failure rate
Most effective method to prevent
STDs
Difficult to comply with

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O  
u Natural Family rlanning
No chemical or foreign material into
the body
Failure rate of approximately u5%

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O  
Fertility ïwareness Methods
Calendar (rhythm) method
Basal body temperature
Cervical mucus (Billings) method
Symptothermal method
Ovulation awareness
Lactation amenorrhea method
Coitus interruptus

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O  #˜$%
& 
  % $   '
ïction ± periodic abstinence from
intercourse during fertile period;
based on the regularity of ovulation;
variable effectiveness

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O  #˜$%
& 
  % $   '
Teaching ± fertile period may be
determined by a drop in the basal
body temperature before and a slight
rise aftre ovulation and/ or by a
change in cervical mucus from thick,
cloudy and sticky during nonfertile
period to more abundant, clear, thin,
stretchy and slippery as ovulation
occurs
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0  

 

Entails keeping a day-
day-by-
by-day record of
your cycle for 6 consecutive months
noting the onset of bleeding as day 0 and
the last day before your next menstrual
bleeding as the final day of your cycle
This 6 month record will show you your
longest and shortest cycles-
cycles- from which
you can calculate your FERTILE days

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0  

 


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0 O  &$%'%
The first day of menstrual bleeding
(day 0 of your period) counts as the
first day of the cycle
ïpproximately 0m days (or 0u to 06
days) before the start of the next
period, an egg will be released by
one of the ovaries

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0 O  &$%'%
hile the egg from the woman lives
for only around um hours, sperm from
the man can survive for up to 3 days,
possibly longer

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0  

 

First unsafe day: subtract 0 from the
number of days in your shortest cycle
Last unsafe day: subtract 00 from the
number of days in your longest cycle
Ex: shortest: u6 ± 0 = day 
longest: 30 ± 00 = day u
UNSïFE rERIOD!! Days  -u
-avoid coitus or use a contraceptive

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O O

u         u        u u uu u u u u



LONGEST CYCLE
0 u         u        u u uu u u u u u u u  



O


 u         u        u u uu u u u u u u u  

  

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u  $% 

Involves taking the temperature every
morning BEFORE the woman gets out of
bed and recording it
The temperature drops slightly um hours
before ovulation, then rises to about half a
degree higher than normal and remains
thus for up to three days: UNSïFE period!
Not a very efficient method unless
combines with calendar and mucus
methods |   |

ΠO  |


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

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ΠO  |


&   '|
ï few days after menstrual bleeding: little
secretion, vagina is dry
Gradually, secretion increases and
becomes thicker, cloudy white and sticky
ïs ovulation approaches, this secretion or
mucus becomes copious, clear, thin, less
viscous, more liquid, slippery or stringy;
as soon as this change begins and for
3 full days later: UNSïFE rERIOD!!
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ΠO  O  
Spinnbarkeit test
Cervical mucus is
thin, watery and
can be stretched
into long strands
high level of
estrogen:
ovulation is about
to occur
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ΠO  O  
Ferning or
arborization of
cervical mucus
ït the height of
estrogen
stimulation just
before ovulation
Ferning-- due to
Ferning
crystallization of
sodium chloride on
mucus fibers
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$%% %
Combines BBT and cervical mucus
methods

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   ( 
Use of over-
over-the
the--counter OTC
ovulation test kit which detects the
midcycle LH (luteinizing hormone)
surge in the urine 0u to um hours
before ovulation
9 to 0 % accurate

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    % %
ïs long as a woman is breastfeeding
an infant, there is some natural
suppression of ovulation
Not dependable-
dependable- woman may be
fertile even if she has not had a
period since childbirth
ïfter 6 months, she should another
method of contraception

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O 
 


Oldest method
Couple proceeds with coitus until the
moment of ejaculation, then the man
withdraws and spermatozoa are emitted
outside the vagina
Offers little protection because
ejaculation may occur before withdrawal
is co mplete and despite the care used,
spermatozoa may be deposited
in the vagina
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O  
3 Oral Contraceptives
Composed of varying amounts of
estrogen combined with small
amount of progesterone
99 5% effective

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Π O  
Estrogen
suppresses FSH
and LH, thereby
suppressing
ovulation
rrogesterone
decreases the
permeability of
cervical mucus
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Π O   
Monophasic - Fixed doses of
estrogen and progesterone ; u0-
u0-u
day cycle
Biphasic - Constant amount of
estrogen with increased
progesterone
Triphasic - Varying levels of estrogen
and progesterone
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Π O  
Benefits of OC¶s:
DECREïSED incidences of:
Dysmenorrhea
rremenstrual dysphoric syndrome
Iron deficiency anemia
ïcute rID with tubal scarring
Endometrial and ovarian cancer and
ovarian cysts
Fibrocystic breast disease

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Π O  
Side Effects
Nausea
eight gain
Headache
Breast tenderness
Breakthrough bleeding
Monilial vaginal infections
Mild hypertension
Depression
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Π 
 

ïbsolute Contraindications to OC¶s


Breastfeeding
Family history of CVï or CïD
History of thromboembolic disease
History of liver disease
Undiagnosed vaginal bleeding

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Π 
 
rossible Contraindications to OC¶s
ïge m 
Breast or reproductive tract malignancy
Diabetes Mellitus
Elevated cholesterol or triglycerides
High blood pressure
Mental depression

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Migraine or other vascular type headaches
Obesity
rregnancy
Seizure disorders
Sickle cell or other hemoglobinopathies
Smoking
Use of drug with interaction effect

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O  
Continuous or extended regimen
pills
Mini--pills
Mini
Estrogen--progesterone patch
Estrogen
Vaginal rings

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 ))   
 

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Highly effective, weekly hormonal birth
control patch that¶s worn on the skin
Combination of estrogen and progestin
ïbsorbed on the skin and then transferred
into the bloodstream
Can be worn on the upper outer arm,
buttocks, upper torso or abdomen
orn for 0 week, replaced on the same
day of the week for 3 consecutive weeks
patch-mth week
No patch-

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% $   
O  
Morning-after pills´
Morning-
High level of estrogen
Must be initiated within 7u hours of
unprotected intercourse

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m O  

Subcutaneous implants (eg, Norplant)


6 nonbiodegradable Silastic implants with
synthetic progesterone embedded under the skin
on the inside of the upper arm
Slowly release the hormone over the next 5 years
Suppress ovulation, stimulating thick cervical
mucus and changing the endometrium so
implantation is difficult

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m O  

Intramuscular injections
-administered every 0u weeks
Medroxyprogesterone (depo-
(depo-provera)
-0 % effective

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O  
 )*ï+ )* , )- 
T-shaped plastic device with copper
ith progesterone
Mechanism of action not fully understood
Must be fitted by physician, nurse practitioner
or midwife
Insertion performed in ambulatory setting after
pelvic examination and pap smear
Device is contained within uterus ± string
protrudes into vagina
Effective for 5-
5-7 years (mirena type) or  years
(Copper T3 )
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 ˜" ˜  !O

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  ˜" ˜  !O
 
Spotting or uterine cramping
Increased risk for rID
Heavier menstrual flow
Dysmenorrhea
Ectopic pregnancy

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6   |
Vaginally inserted spermicidal
products
Diaphragms
Cervical caps
Condoms

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6 ˜˜ ˜| 
SrERMICIDïL ïGENT
goal: to kill the
sperm before the
sperm enters the
cervix
-Nonoxynol
Nonoxynol--9
-gel, creams,
films,foams,
suppositories
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6 ˜˜ ˜| 
DIïrHRïGM
-mechanically blocks sperm
from entering the cervix
-soft latex dome supported
by a metal rim
-can be inserted u hours
before intercourse;
removed at least 6 hours
after coitus or within um
hours
-size must fit the individual
-washable, may be used
for u-
u-3 years

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6 ˜˜ ˜| 
CERVICïL Cïr
-similar to
diaphragm but
smaller
-thimble
thimble--shaped
rubber cap held
onto the cervix by
suction

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6 ˜˜ ˜| 
MïLE CONDOM FEMïLE CONDOM

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MïLE CONDOM
ïction ± prevents the ejaculate and sperm from
entering the vagina; help prevent venereal
disease; effective if properly used; OTC

Teaching ± apply to erect penis with room at the


tip every time before vaginal penetration; use
water--based lubricant, e g , K
water K--Y jelly, never
petroleum--based lubricant; hold rim when
petroleum
withdrawing the penis from the vagina; if condom
breaks, partner should use contraceptive foam or
cream immediately

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½ 
  |
Tubal Ligation
-u% of all women in
US
-fallopian tubes are
cut,tied/ cauterized to
block passage of ova
and sperm
ïBDOMINïL INCISION
MINILïrïROTOMY
LïrïROSCOrY
FOR TUBïL
STERILIZïTION
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½ 
  |
Vasectomy
- 00% of all men in US
-incisions are made in
the sides of scrotum;
vas deferens is cut
and tied, then plugged
or cauterized
-blocks passage of
sperm
-viable sperm for 6
months post op
-reversible 95%

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   %     $
rrocedure to deliberately end a
pregnancy before fetal viability
Induced
(mifepristone--progesterone
(mifepristone
antagonist; misoprostol-
misoprostol-
prostaglandin analog
Medically induced
D&C, D&E, saline induction,
hysterotomy
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$    %
   *% 
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  +   %   
the most intimate examination that a woman may
be ever subjected to
must never be performed without:
0 a careful explanation to the patient about the
examination
u asking permission from the patient to perform the
examination
3 valid reason for performing the examination

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ïT THE FIRST VISIT:
0 The diagnosis of pregnancy during the first trimester
u ïssessment of the gestational age
3 Detection of abnormalities in the genital tract
m Investigation of a vaginal discharge
5 Examination of the cervix
6 Taking a cervical (rapanicolaou) smear

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ïT SUBSEQUENT ïNTENïTïL VISITS:
0 Investigation of a threatened abortion
u Confirmation of rROM with a sterile speculum
3 To confirm the diagnosis of preterm labor
m Detection of cervical effacement and/ or dilatation in a patient
with a risk for preterm labor
5 ïssessment of the ripeness of the cervix prior to induction of
labor
6 Identification of the presenting part in the pelvis
7 rerformance of a pelvic assessment

IMMEDIïTELY BEFORE LïBOR


0 rerformance of artificial rupture of the membranes to induce
labor |   |

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

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  | O 

You will be asked to place your feet in the footrests at the


end of the table

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

If your buttocks and abdominal and vaginal muscles are


relaxed, you will be more comfortable, and the exam will be
more complete

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

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  | O 

You'll feel less tense if you


Breathe slowly and deeply with your mouth open
Let your stomach muscles go soft
Relax your shoulders
Relax the muscles between your legs
ïsk the clinician to describe what is being done as it
is happening

|   |



  | O 
Remember that the exam is not emotional or sexual
for your clinician Talk with your clinician about
your fears
any pelvic pain you may have
your experience of abuse

Talking with your clinician about your experience will


help your clinician
tailor the exam to your special needs
help you feel as comfortable as possible
understand how your physical and emotional health
may be affected
|   |



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

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

It is also okay to have a trusted friend or relative


with the client during the exam

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Usually, the exam lasts just a few
minutes There are four steps:
The External Genital Exam
The Speculum Exam
The Bimanual Exam
The Rectovaginal Exam

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0   
    %

The clinician visually examines the soft folds of


the vulva and the opening of the vagina to check
for signs of irritation, discoloration, discharge,
swelling and other abnormalities She will gently
feel for glands, cysts, genital warts, or other
conditions

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u 

%  %

The clinician inserts a metal or plastic speculum into the


vagina hen opened, it separates the walls of the vagina,
which normally are closed and touch each other, so that the
cervix can be seen

The client may feel some degree of pressure or mild


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

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u 

%  %

Once the speculum is in place, the clinician


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

These tests may not be done unless the client


has concerns about infections and/or asks for
testing The client should talk with her clinician if
she has symptoms or concerns about her
partner(s)

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%  %

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%

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 % 
Usually a small spatula or tiny brush is used to
gently collect cells from the cervix for a rap test
The cells are tested for abnormalities ² 
         
You may have some staining or bleeding after the
sample is taken

ïs the clinician removes the speculum, the


vaginal walls that were covered by it are also
checked for irritation, injury, and any other
problems

|   |



 % 
rap tests can detect
the presence of abnormal cells in the cervix
infections and inflammations of the cervix
symptoms of sexually transmitted infections
(ith the exception of trichomoniasis, rap tests cannot
identify specific sexually transmitted infections, but they
may detect symptoms )
thinning of the vaginal lining from lack of estrogen
commonly related to menopause
The cell sample will be sent to a laboratory The results will
be sent back to the clinician within a few days/ weeks rap
tests need to be repeated if there is too much blood present
for an accurate reading or if there are not enough cells to
be examined

|   |



 % 
If the results are abnormal, the clinician will advise the client on
follow--up care:
follow
If noncancerous abnormalities and infections are found, the client
needs to complete the prescribed treatment and repeat the tests
as advised
If early precancerous or suspicious growths are found, she will
need careful follow-
follow-up and may also be advised to
  Repeat the rap test in a few weeks or have them at more
frequent intervals
  Have other tests
  Have a colposcopy and biopsy
Have growths removed with cryotherapy, laser surgery, or
electrocautery
If cancerous growths are found
  Discuss options with clinician
  See another provider| or specialist
  |

 % 
Remember ²
Most abnormalities that are detected are not
cancer
Early treatment of precancerous growths can
prevent cancer from developing
Follow--up examinations are necessary if an
Follow
abnormal condition is found

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 % 

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 % 

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 % 

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 % 

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 % 

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 % 
Findings of rap¶s Smear
Class I ± Normal findings
Class II ± Normal with atypical cells present
(inflammatory reaction)
Class III ± Suggestive of malignancy, with benign and
malignant cells
Class IV ± rrobably malignant, with signs of malignancy
present
Class V ± Definitely malignant cells

|   |



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

The clinician can then feel the internal organs of


the pelvis between the two fingers in the vagina
and the fingers on the abdomen

|   |



Π % 
  %
The clinician examines the internal organs with both
hands to check for
size, shape, and position of the uterus
an enlarged uterus, which could indicate a pregnancy
or fibroids
tenderness or pain, which might indicate infection
swelling of the fallopian tubes
enlarged ovaries, cysts, or tumors

|   |



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

|   |



 % 
  %

|   |



 % 
  %

|   |



m ˜    %

Many clinicians complete the bimanual exam by


inserting a gloved finger into the rectum to check
the condition of muscles that separate the vagina
and rectum They also check for possible tumors
located behind the uterus, on the lower wall of the
vagina, and in the rectum Some clinicians insert
one finger in the anus and another in the vagina
for a more thorough examination of the tissue in
between
During this procedure, the client may feel as
though she needs to have a bowel movement
This is normal and lasts only a few seconds
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|  
    
|
     
rurposes:
Help prevent the need for cesarean section
Help strengthen pelvic and abdominal muscles
Help reduce discomfort
Help hasten recovery

Ex   ± should be done in moderation and


must be individualized

|   |



˜ )  ˜O   ˜
0 ï
  
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6 ï !   #     
 
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( 4 $
  
  
   
  
  
 
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   ) 
    
    
  

|   |



    
0 It strengthens the thigh and
stretches the perineal
muscles
u Done at least 05 min/day
Sit on floor with thighs
apart, knees bent, legs
parallel to each other, one
ankle should NOT be on
top of the other, push
knees gently towards the
floor until you feel the
perineum stretch Use this
when watching TV, reading
or entertaining friends Do
this for 05 minutes daily

|   |



 ,
  

0 Helps to stretch muscle of


the pelvic floor
u Done at least 05min/day
hen lifting something
from the floor, bend knees
rather than the back; do
not squat on tiptoes but
keep feet flat on the floor;
incorporate this into daily
activities; practice for 05
minutes daily

|   |



O   O   
&- .   '
It is designed to strengthen pubococcygeus
muscle
It may lead to increased sexual enjoyment
Each is a separate exercise and should be done 3x
a day
0 Squeeze the muscle surrounding the vagina as if
stopping the flow of urine, hold for 3 seconds then
relax (0 x)
u Contract and relax the muscles surrounding the
vagina as rapidly as possible 0 ± u5x
3 Imagine that you are sitting in the bath tub of water
and squeeze muscles as if sucking water into the
vagina Hold for 3 seconds then relax 0 x
|   |

 %  |
O  

0 strengthen the abdominal muscles


u help prevent constipation
3 may be done as often as she wishes

Tighten abdominal muscles, then relax and repeat


as often as you can; can be done on lying or
standing position along with pelvic floor
contractions

|   |



 ˜ 

0 Helps to relieve backache during


pregnancy and early labor
u Makes the lumbar spine more flexible
3 Can be done on a variety of positions

The woman arches her back, trying to


lengthen or stretch her spine She holds
the position for 0 minute, and then
hollows her back
- do this at the end of the day (5x)
|   |

  
0 rELVIC TILT ± SUrINE
Do daily and after delivery
rosition: Backlying, knees bent
Exercise: rress small of back against floor by tightening
abdominal muscles and buttocks muscles

|   |



  
u rELVIC TILT ± STïNDING

rosition: Stand with back to wall,


feet about three inches from
base of wall

Exercise: Tighten stomach and


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

|   |



  
3 rELVIC TILT - ïLL FOURS

rosition: On hands and knees

Exercise:Tighten stomach
muscles and arch back
toward the ceiling Hold
Tighten buttocks, pelvic floor
and back muscles and arch
back to produce hollow Hold

|   |




 
 
0 SIT-
SIT-UrS - Modified
rurpose: Strengthen abdominal
muscles Good muscle tone is
important for maintaining good
posture, for effective pushing, and
for early return of figure
postpartum

rosition: Backlying, knees bent, low


back
flat (pelvic tilt)

Exercise: Lift head and shoulders off


floor, reaching hands toward knees
(lift trunk to about m5
m5°° angle)
Slowly return to starting position;
do not drop back
|   |


 
 
u OBLIQUE (DIïGONïL)
SIT--UrS - Modified
SIT
rurpose: Strengthen oblique
abdominal muscles

rosition: Backlying, knees bent,


low back flat

Exercise: ïs above, but reach up


and across to the outside of
the  

|   |



 
" # !O ˜ 

rosition: Backlying, legs straight, ankles crossed, arms at sides

Exercise: rinch buttocks, squeeze pelvic floor muscles, squeeze


thighs together, raise head off floor

|   |



 "O˜
 

rosition: Sit on floor with legs straight and slightly apart


Roll knees outward

Exercise: Slowly lean body forward towards the floor with


arms stretched out in front of you Your knees may bend
slightly Do not jerk or bounce Hold forward for 3 to 5
seconds

|   |



 O OO! 
0 Jogging:
ear good shoes; supportive bra Keep pelvic floor muscles strong with
Kegel exercises Jog at a slower pace, shorter distances, less frequently

Remember: increased weight and laxity of ligaments means more strain


on lower body (lower spine, hip joints, knees, ankles and feet) Do not
overexert yourself

u Bicycling and Swimming:


Excellent activities with reasonable limitations Don¶t push yourself!

3 Tennis, Basketball, other sudden stop and start´ ïctivities


More awkward as bulk increases; listen to your body and slow down when
necessary

|   |



m Skating, Horseback Riding:
Danger of falling! ïdvise against Consult your obstetrician or nurse
practitioner as needed

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

ratient Teaching: Consult your obstetrician or nurse practitioner early in your


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

. | 

|  
    
|
 .| "! ˜
systematic method of observation
and palpation to determine fetal
position
woman empties her bladder; lies
supine with her knees flexed slightly
examiner warms hands to avoid
contraction of abdominal muscles
gentle but firm touch
|   |

á á|  
 6
 ralpation of the Uterine Fundus
ill usually indicate the fetal part situated in the fundus;
usually a fetal head; infrequently a fetal breech
rlace hands on either side of the fundal area so that the
fingers of both hands almost touch each other (face the
woman's head)
ï somewhat hard and roundish shape, which when moved
back and forth between the finger pads, also moves the
entire fetus usually indicates a fetal breech
rress gently and firmly with finger pads
ï very hard round well-
well-defined shape that can be moved
back and forth (balloted) usually indicates a fetal head

|   |



 | 

   " 



|   |



| 

%   %     

   %   %

Lateral ralpation of the Uterus


Examiner faces woman's head
ralpate with one hand on each side of abdomen
ralpate fetus between two hands
ïssess on which side is the fetal back or spine
and which side has small parts or extremities

|   |



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

|   |



| 

%   %     

   %   %

|   |



 | 

&(
   %
 '

Face the woman's head and spread your hands


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

|   |



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

|   |



 | 

&(
   %
 '

|   |




| 

&    


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

|   |



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


| 

&    


)      '

|   |



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     ! "! # ! $! !
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|  
    
|
   
FHR should be 0u -06
beats per minute

Can be heard with a


Doppler : 0 ± 00th week of
pregnancy

Fetoscope: 0-
0-u weeks

|   |



   
ïssist the patient to a supine position
Drape her with a blanket to minimize exposure
ïpply water soluble lubricant to her abdomen or the monitoring
device
To assess FHR in a fetus u weeks or younger, position
Doppler/Stethoscope/ fetoscope on the abdominal midline above the
symphysis pubis ïfter u weeks ïOG, when you can palpate fetal
position, use Leopold¶s maneuvers and position the listening
instrument over the fetal back
rlace the earpieces in your ears and press gently on the patient¶s
abdomen If there are no earpieces, turn the device on and adjust the
volume ïs needed Start listening at the midline, midway between
the umbilicus and the symphysis pubis
Move the instrument from side to side to locate the loudest heart
tones then palpate the maternal pulse

|   |



   
If the maternal radial pulse and FHR are the same, try to locate the
fetal thorax/ back by Leopold¶s maneuver, then reassess FHR for
6 seconds Record FHR
During labor, monitor FHR during the relaxation period between
the contractions to determine baseline
In a low-
low-risk labor, assess FHR every 6 minutes during the latent
phase, every 3 minutes during the active phase and then every 05
minutes during the und stage of labor In high risk labor, assess
FHR every 3 minutes during the latent phase, every 05 minutes
during the active phase, and every 5 minutes during the und stage
of labor
ïuscultate FHR during a contraction and for 3 seconds afterward
to identify the response to the contraction
ïuscultate FHR before administration of medications, ambulation,
and artificial rupture of membranes, changes in the
characteristics of contractions, vaginal examinations and
medications |   |

O
  ˜" / 
0
0     O-

|   |




"
 
 r
 )
 7 )
Tachycardia (>06 bpm) Maternal or fetal infection Depends on the cause
Fetal hypoxia (ominous sign)
Bradycardia (<0u bpm) Fetal hypoxia or stress rlace client on her left side
Maternal hypotension after Increase fluids to counteract
epidural initiation hypotension
Stop oxytocin (ritocin) if in
use
Early deceleration "
   :not None required
(deceleration begins and ends ominous
with uterine contraction) Vagal stimulation
Late deceleration Fetal stress and hypoxia Change maternal position
(HR decreases after peak of , 

 Correct hypotension
contraction and recovers after Supine position Increase IV fluid rate as
contraction ends) Maternal hypotension ordered
Uterine hyperstimulation Discontinue oxytocin
ïdminister oxygen as
ordered
Variable deceleration -   Change maternal position
(transient decrease in HR Hypoxia or hypercarbia ïdminister Oxygen
anytime during contraction
Decreased variability Fetal sleep cycle Depends on the cause
Depressant drugs
Hypoxia
CNS anomalies
|   |

|
  
  
|  
    
|

  
McDonald¶s Rule ± determines during
midpregnancy, that the fetus is growing in
utero by measuring the fundal (uterine)
height

Typically, the distance from the fundus to


the symphysis in centimeters is equal to
the week of gestation between the u th and
30st weeks of pregnancy
|   |


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

Typical measurements
 Over the symphysis pubis: 0u wks
 ït the umbilicus: u wks
 ït the xiphoid process: 36 wks
Rises about 0cm per week; after which it
varies
|   |
 

  

|   |


 
  


0u weeks š at the level of the symphysis pubis
06 weeks š halfway between symphysis pubis and umbilicus
u weeks š at the level of the umbilicus
um weeks š two fingers above umbilicus
3 weeks š midway between umbilicus and xiphoid process
36 weeks š at the level of xiphoid process
m weeks š two fingers below umbilicus,
drops at 3m weeks level because of lightening

|   |


 
O%
  
O+
 |
   
%
|  
    
|
O
LïST MENSTRUïL rERIOD ± first day of the last menses

|   |





COMrUTïTION OF ïGE OF GESTïTION


Example: LMr: January 0, u 9
Date of consult: ïugust 30, u 9

ïOG: Total # of days from LMr up to date of consult


7

January 3 days
February u Total = umu days
March 30 ïOG = umu
ïpril 3 7
May 30 3m to 35 weeks
June 3
July 30
ïugust 30
|   |

    $#
%
G__ r__ (T, r, ï, L)
Gravida ± the total number of pregnancies regardless of duration
(includes present pregnancy)
rara ± number of past pregnancies that have gone beyond the
period of viability (capability of the fetus to survive the outside of
the uterus; currently considered any time after u -wk gestation),
regardless of the number of fetuses or whether the infant was
born alive or dead
Term infant ± an infant born between 3 and mu weeks of gestation
rreterm ± an infant born before 3 weeks
rost term ± an infant born after mu weeks
ïbortion ± pregnancy that terminates before the period of viability
(u wks)
Live birth ± a live birth is recorded when an infant born shows
sign of life

|   |



    1
 
1 +  
  
|  
    
|
    
part of fetus that presents to
(enters) maternal pelvic inlet
  Cephalic/vertex ± head presentation
(>95% of labors)
  Breech

|   |


 
|   |
 
Breech presentation
Complete ± flexion of hips and knees
Frank (most common) ± flexion of
hips and extension of knees
Footling/incomplete ± extension of
hips and knees

|   |


 
|   |
 
ï  #   
relationship of fetal parts to each other;
usually flexion of head and extremities
on chest and abdomen to accommodate
to shape of uterine cavity
-x ± head is maximally flexed
|   ± head is partially flexed
 ± head is maximally extended
  ± head is partially extended

|   |


 
|   |
 
 

‰ relationship of spine of fetus to


spine of mother;
longitudinal (parallel)
transverse (right angles)
oblique (slight angle off a true
transverse lie)

|   |



|   |

  
relationship of fetal reference point to mother¶s
pelvis

Fetal reference point


! 
 ± dependent upon degree of
flexion of fetal head on chest; full flexion±
flexion±occiput
(O); full extension±
extension±chin (M); moderate extension±
extension±
brow (B)
 
 ± sacrum (S) / Sa
   
 ± scapula (SC) / ï (acromion)

|   |



  

ÈRelation of the presenting part to a specific


quadrant of a woman¶s pelvis
ÈRight anterior
ÈLeft anterior
ÈRight posterior
ÈLeft posterior

|   |


 
Maternal pelvis is designated per her
right/left and anterior/posterior
  Expressed as standard three letter
abbreviation; e g , LOï = left occiput anterior,
indicating vertex presentation with fetal
occiput on mother¶s left side toward the front
of her pelvis

  Fetal position reflects the orientation of the


fetal head or butt within the birth canal

|   |


 
ï 

The bones of the fetal scalp are soft and meet at
"suture lines " Over the forehead, where the
bones meet, is a gap, called the "anterior
fontanel," or "soft spot " This will close as the
baby grows during the 0st year of life, but at
birth, it is open
The anterior fontanel is an obstetrical landmark
because of its' distinctive diamond shape
Feeling this fontanel on pelvic exam tells you
that the forehead is just beneath your fingers
Early in labor, it is usually difficult (if not
impossible) to feel the anterior fontanel ïfter
the patient is nearly completely dilated, it
becomes easier to feel the fontanel
hen attaching a fetal scalp electrode, it is
better to not attach it to the area of the fontanel
|   |
 
r 

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

|   |



˜  
  
&˜'

|   |



 
   
&'

|   |



˜  
   
&˜'

|   |


 
 
  
&'

|   |


 
 
 
&'

|   |


 
 
  &'

|   |



˜  
  &˜'

|   |



|   |

Ä 

|   |



 
level of presenting part of fetus in
relation to imaginary line between
ischial spines (zero station) in
midpelvis of mother
  ±5 to ±0 indicates a presenting part
above zero station (floating); 0 to 5,
a presenting part below zero station
  Engagement ± when the presenting
part is at station zero
|   |

|   |

  Ä   

|   |



   O 
|  
    
|
Monitor vital signs and FHR
rrovide comfort measures (ambulate if tolerated
and if BO is not ruptured yet; side lying is
usually most comfortable, sacral pressures, back
rubs)
Breathing techniques

|   |



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

Begin the Breathing Technique


This technique is done only during contractions Rest and sleep
between contractions is important Instruct the laboring woman to
do the following:
ïssume a comfortable position
Try to maintain a relaxed state throughout the con-traction
Close her eyes or
Concentrate on a focal point while doing the breathing (e g , a
pretty picture, a button on some-one's shirt)
|   |

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

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

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

|   |



Comfort Measures for the Laboring oman
Do not leave alone in active labor
Change soiled and damp linen promptly
rrovide mouth care
Ice chips, lubricate lips
Keep room cool, uncluttered, quiet and privacy
rromote participation of coach

|   |



  O 
|  
    
|
O  2  

INSERTION OF CïTHETER / Catheterization


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

|   |



O  2  

rurposes:
0 To relieve discomfort due to a bladder distention and to provide
gradual decompression of a distended bladder
u To access the amount of residual urine if the bladder is to be
emptied completely
3 To obtain a urine specimen to assess the presence of abnormal
constituents and the characteristic of the urine
m To empty the bladder completely prior to surgery to prevent
inadvertent injury to adjacent organ such as to the rectum or the
vagina
5 To manage incontinence when all other measures have failed
6 To provide for intermittent or continuous bladder drainage and
irrigation
7 To prevent urine from contacting an incision after perineal surgery
 To facilitate accurate measurement of urinary output for critically
ill client whose output needs to be monitored hourly
|   |

O  2  

roints to consider:
0 There are u hazards in the process, namely,
sepsis and trauma, hence asepsis technique
should be maintained and the catheter should be
inserted gently
u hen catheterization is ordered to relieve bladder
distention, gradual decompression of the bladder
should be done to prevent engorgement of the
vessels as well as improve the muscle tone of the
bladder by adjusting the intravesical pressure

|   |



|   |

O  2  

Types of catheter:
0 Straight or Robinson catheter ± a single lumen tube with
a small eye or opening about ½ inch from the insertion tip
u Retention or Foley catheter-
catheter- contains a second smaller
tube throughout its length on the inside This tube is
connected to a balloon near the insertion tip ïfter
catheter insertion, the balloon is inflated to hold the
catheter in place within the bladder
Catheters are sized by the diameter of the lumen and are
graded on French scale numbers The larger the number,
the larger the lumen size Small sizes such as French  ±
0 are used in children French 0m, 06 and 0 are for
adults
|   |

 O 
Equipment:
lamp or flashlight
mask, if required by hospital
blanket/ drape
soap, basin of warm water, washcloth, towel
disposable gloves
water soluble lubricant
sterile gloves
sterile drapes (optional)
antiseptic solution
cotton balls or gauze squares
forceps
basin for urine
sterile catheter (straight)
specimen container if required
bag or receptacle for disposal of the cotton balls

|   |



 O 
rrocedure:
0 Explain the procedure to the client
u rut on a mask, gown or cap if required by agency
3 (rercuss and) ralpate the bladder to assess urinary retention
m ïssist client to a supine position, with knees flexed and thighs externally
rotated
5 Drape the client rrevent unnecessary exposure
6 Don disposable gloves
7 ïdjust the light to view the urinary meatus
 Drape the client with sterile drapes (expose the perineum)
9 rour antiseptic solution over the cotton balls if they are not already
prepared
0 Lubricate insertion tip of the catheter and place it in a sterile container/
area ready for use
00 Clean the meatus ith the nondominant hand, separate the labia majora
with the thumb and finger and clean the labia minora on each side using
forceps and cotton balls soaked in antiseptic Use a new swab for each
stroke Move downward from the pubic
|  area to the anus (prevents transfer
 |

of microorganisms)
 O 
0u Expose the urinary meatus by retracting the tissue of the labia minora in
an upward direction Clean from the meatus downward on either side,
then work outward Once the meatus is cleaned, do not allow the labia to
close over it
03 Inspect the meatus for any swelling, excoriation, discharge
0m Insert the catheter gently with the uncontaminated gloved hand into the
urinary meatus until urine flows Keep the drainage end in the urine
receptacle hen the urine flows, transfer the hand from the labia to the
catheter to hold it in place and prevent its expulsion by a possible bladder
contraction
05 Collect specimen if required (usually 3 ml) by transferring the drainage
end into a sterile bottle
06 Empty or partially drain the bladder and then remove the catheter Limit
amount of urine drained to 7 -0 ml rapid removal of large amounts of
urine is thought to induce engorgement of the pelvic blood vessels and
hypovolemic shock
07 rinch the catheter Remove the catheter slowly
0 Dry the perineum with a towel or drape
09 ïssess the urine |   |

u Document the catheterization
 /# * 
#
˜ O 
ïdditional Equipment: syringe prefilled with fluid (usually 05 ml)
Follow steps as for straight catheterization up to #05
06 Insert the catheter an additional u 5 ± 5 cm (0
(0--u in) beyond the point at
which the urine began to flow to ensure that the balloon near the insertion
tip will be inflated inside the bladder and not the urethra, where it could
produce trauma
07 Inflate the balloon by injecting the contents of the prefilled syringe into
the valve of the catheter
0 Ensure effective balloon inflation applying slight tension on the catheter
until you feel resistance (well anchored in the bladder)
09 Tape the catheter to the inside of the female¶s thigh
u Secure drainage bag to the bedframe using its hook Suspend it off the
floor but keep it below the level of the patient¶s bladder Make sure the
emptying base of the drainage bag is closed
u0 Document catheterization

|   |



How to insert a catheter (women)
0 ïssemble all equipment: catheter, lubricant, sterile gloves, cleaning supplies, syringe with water
to inflate the balloon, drainage receptacle
u ash your hands Use betadine or cleansing product to clean the urethral opening In women
clean the labia and urethral meatus using downward strokes ïvoid the anal area
3 ïpply the sterile gloves Make sure you do not touch the outside of the gloves with your hands
m Lubricate the catheter
5 Spread the labia and locate the meatus (opening which is located below the clitoris and above
the vagina
vagina))
6 Slowly insert the catheter into the meatus
7 Begin to gently insert and advance the catheter
 Once the urine flow starts, advance the catheter another u inches Hold the catheter in place
while you inflate the balloon Care must be taken to ensure the catheter is in the bladder If pain is
felt which inflating the balloon, stop; deflate the balloon; advance the catheter another u inches;
and attempt to inflate the balloon again
9 Secure the catheter, and attach the drainage bag

|   |



|   |

|   |

|   |

|   |

|   |

|   |

|   |

|   |

|   |


O  
|  
    
|
!   $
|  
    
|
˜O "˜  O˜
&O
 %  $'
rurpose: To provide safe outcome for the mother and to deliver a
healthy baby

Equipment: Standard delivery room equipment


Delivery table with stirrups
Instrument table
ïnesthesia machine
Resuscitator with heating machine for infant
Sterile pack containing:
Drapes
Leggings
Towels
Gowns
Sponges

|   |



˜O "˜  O˜
&O
 %  $'
Sterile instruments
u scissors ( 0 for episiotomy, 0 for cutting the
umbilical cord)
u cord clamps/ kelly forceps
m allis clamps (for episiotomy repair)
u needle holders
Suture needles
u ring forceps (to aid in the delivery of the
placenta and membranes)
0 vaginal retractor (to aid in inspection of the
birth canal)

|   |



˜O "˜  O˜
&O
 %  $'
rrocedure:
Nursing ïction/ Rationale
0 Observe strict aseptic technique in gowning and gloving
(To prevent introduction of microorganisms into the uterine
cavity)
u Drape and cleanse perineal area (To maintain asepsis)

|   |



     

|   |



˜O "˜  O˜
&O
 %  $'
3 Catheterize patient rRN (To prevent bladder trauma)
m Instruct patient to push (This is a technique of using the
abdominal muscles to assist in uterine expulsive efforts during
contractions)
5 ipe the perineum with sponges and antiseptic solution using a
downward and backward motion (To prevent fecal contamination)
6 ïvoid the use of fundal pressure to hasten delivery (Fundal
pressure may cause uterine damage)
7 ïvoid too rapid delivery (To preserve the flexion of the fetal head)
 ïssess for leg cramps which may occur when the head crowns
These may be relieved by changing the position of the legs
(Caused by the pressure of the fetal head on the pelvic nerves)
9 ïssess the necessity for episiotomy when the head crowns
slightly, if a tear seems inevitable, a midline or right or left
mediolateral episiotomy may be performed (To prevent perineal
lacerations caused by pressure of the fetal head)
|   |

$   %$

|   |



˜O "˜  O˜
&O
 %  $'
0 Control the delivery by Ritgen¶s maneuver This consists of
covering the anus with sterile towel and exerting upward and
downward pressure on the area beneath the fetal chin while
maintaining pressure against the occiput with the other hand to
control the emerging head and to effect delivery between
contractions (To prevent injury to the mother and infant)
00 Feel and look for the cord around the back of the neonate as
soon as the head is delivered Loosen the cord and slip over the
head If unable to loosen coils, occlude the cord with u clamps
and cut between them (To prevent interference with fetal
oxygenation)

|   |



|   |

˜  . % 


|   |



˜O "˜  O˜
&O
 %  $'
0u Remove mucus and fluid from the neonate¶s face and suction
oropharynx (To prevent aspiration of the mucus when the
newborn gasps during initial respiration)
03 Do not hasten completion of the delivery ait until the head
rotates externally (ïs soon as the head is delivered , there is
usually a lull in contractions Rotation of the head is indication
that the shoulders have rotated externally)
0m Observe for continued uterine contractions and for the shoulder
to lie directly anterposteriorly rull the head gently downward
and backward until the anterior shoulder is behind and against
the symphysis pubis Lift the head for delivery of the posterior
shoulder
05 Clamp the cord at about u 5 cm (or depending upon the hospital
policy) from the umbilicus (hether sustained benefit is
obtained by waiting for cessation of pulsation before clamping the
cord has not been established )
|   |

|   |

%  
 $

|   |



"%   

|   |



06 rlace newborn in a heated crib (To prevent heat loss and
hypothermia)
07 Circulating nurse should administer oxytocin IM to the patient
(To administer effective uterine contractions for the purpose of
expelling the placenta and preventing uterine atony)
0 Observe for resumption of contraction and for indications that
the placenta has separated from the uterine wall (There is
sudden gush of blood; the uterus rises upward in the
abdomen, changes from discoid to a globular shape and the
cord lengthens outside the vagina )
09 Express the placenta by pushing downward on the fundus
with moderate pressure and with slight tension on the cord If
membranes begin to tear, grasp with clamp and tease out
slowly (Excessive pressure on the relaxed uterus may cause
inversion)

|   |



u Examine the placenta carefully (a To make certain that
none of the placental membranes have been retained in the
uterus; b To identify the gross changes that may have
pathological significance)
u0 Inspect the vaginal canal and cervix for lacerations or
injury (The examination is carried before the episiotomy
repair, otherwise, if bleeding should occur following repair,
inspection at that time would cause tension on recently
placed sutures and could damage the episiotomy wound)
uu Repair the episiotomy

|   |



 

|   |



u3 Estimate blood loss (Observe the saturation sponges and
towels as well as the amount of bleeding)
um Remove soiled linen, replace end of the delivery table and
lower the patient¶s legs from the stirrups simultaneously
(To prevent injury or muscle spasm)
u5 ïpply a sterile perineal pad, warm gown, and blanket
(Chilling accompanied by shaking often occurs immediately
following delivery )
u6 Help the mother to hold the infant and inspect it if she
wishes (Early contact with the infant assists in the mother
mother--
infant bonding process One of the mother¶s first needs is
to be reassured that her infant is normal)

|   |



O  O  
|  
    
|
|   |

|   |

|   |


" 
O#
Scheduled Cesarean Birth
 If it is to be a repeat cesarean birth
(eg, cephalopelvic disproportion)
 If labor is contraindicated (eg, complete
placenta previa, hydrocephaly)
 If labor cannot be induced and birth is
necessary
Clients have some time to prepare for the
cesarean birth
|   |

Unscheduled/ Emergency Cesarean
Birth
 Usually a result of some difficulty in
the labor process/ failure to progress
in labor
 rlacenta previa
 ïbruptio placenta
 Fetal distress
|   |

Vaginal Birth after Cesarean (VBïC)
 hen the reason for the initial cesarean is
a nonrecurring situation such as placenta
previa, prolapsed cord, or breech
presentation, the client may be able to
have a vaginal birth with the next
pregnancy
 Low transverse uterine incision: trial of
labor is recommended
 Classic uterine incision: trial of labor is CI
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˜"| ˜ O˜

I Vaginal birth (which stretches and sometimes tears the perineal


tissues) and episiotomy (which may minimize tissue injury)
usually cause perineal edema and tenderness rostpartum
perineal care aims to relieve discomfort, promote healing and
prevent infection

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O    
%

Typically, you¶ll use a water-


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

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To inspect the perineum, put on gloves, ensue adequate


lighting, and place the patient in the lateral Sims¶s position
hen inspecting the wound area, be alert for such signs of
infection as unusual swelling, redness and foul-
foul-smelling
discharge

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 ˜ O˜

rerineal Care-
Care- cleansing the vulva and perineal area

rurposes:
0 To clean the perineum in the following after a bowel or
bladder elimination prior to any vaginal examination or
treatment
u To prevent vaginal or perineal wound infection and
unpleasant odor
3 To provide for personal cleanliness and comfort

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 ˜ O˜

Special considerations:
ïvoid burning the patient by using the right temperature
of the flushing water
Observe special care in order to avoid discomfort when a
patient has a perineal wound or stitches
ïvoid unnecessary exposure
If the patient defecated, empty the bedpan first before
giving perineal flushing

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 ˜ O˜

Equipment:
Bedpan with cover
Screen
Flushing tray with the following:
jar with dry cotton balls
jar with cotton soaked with cleansing solution
flushing pitcher with warm water
pick up forceps in antiseptic solution
emesis basin for soiled cotton balls
bed protector
ordered medicine or perineal pad (if necessary)
drape

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 ˜ O˜
rrocedure:
ïssemble all your equipment
Set up screen to cover the patient Explain
procedure
ash your hands
rosition the patient in a back lying position with the
knees flexed or (dorsal recumbent position)
rlace rubber protector and bedpan
Drape exposing only the part to be cleansed
Flush the perineal area with warm water

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 ˜ O˜

Using pick up forceps, get cotton balls soaked with


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

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 2 
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3&-2 '

ï sitz bath, or a hip bath, is used to soak a client¶s


pelvic area The client sits in a special tub or chair and
is usually immersed from the midthighs to the iliac
crests or umbilicus Special tubs or chairs are
preferred because when the legs are also immersed,
as in a regular bathtub, blood circulation to the
perineum or pelvic area is decreased Disposable sitz
baths are also available
The temperature of the water should be from m to m3 C
(0 5 to 00 F), unless the client is unable to tolerate the
heat Determine hospital protocol Some sitz tubs have
temperature indicators attached to the water taps The
duration of the bath is generally 05- 05-u minutes,
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depending on the client¶s health
3
To provide a sitz bath, the nurse carries out the
following steps:
ïssist the client into the tub, and provide support
for comfort rrovide support for the client¶s feet;
a footstool can prevent pressure on the backs of
the thighs
rrovide a bath blanket for the client¶s shoulders
and eliminate drafts to prevent chilling
Observe the client closely during the bath for
signs of faintness, dizziness, weakness,
accelerated pulse rate and pallor
Maintain the water temperature
Following the sitz bath, assist the client out of the
tub Help the client to dry
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3&   '
rurpose: To aid healing of the perineum through application of moist
heat
rrocedure:
0 ash your hands, identify client and explain procedure
u ïssess client¶s condition; ascertain whether client is able to
ambulate to bathroom; assist and modify as necessary
3 ïssemble equipment, including sitz bath, clean towel, perineal
pad
m rlace sitz bath on toilet seat Fill collecting bag with warm water at
a temperature of 0 F to 0 5 F (3 C to m0 C) Hang the bag
overhead so a steady stream of water will flow from the bag,
through the tubing, and into the basin
rrinciple: using correct temperature of water eliminates risk of
thermal injury ïdequate flow of warm water increases circulation
to the perineum, thereby reducing inflammation and aiding
healing
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3
5 ïssist client while ambulating to bathroom; help with
removal of perineal pad from front to back ïssist client to
seat in basin
6 Instruct client to use clamp on tubing to regulate water flow;
use robe or blankets to prevent chilling and provide for
privacy Have call bell within reach
7 ïfter u minutes, assist client with drying perineum and
applying clean pad (holding pad by the bottom side or
ends) ïfter u minutes, heat is no longer therapeutic
because vasoconstriction occurs
 ïssist client with ambulating back to room
9 Evaluate client¶s tolerance and response to procedure; ask
client to report how she feels Institute health teaching,
such as continuing sitz baths when at home
0 Record completion of procedure, condition of perineum
and client¶s condition and response
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  %    
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 ˜
| ˜
the application of warmth to the perineal area by means of lamp

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

Nursing objectives:
ïvoid burning the patient by prolonged exposure or too-
too-close proximity
to light
rrevent cross contamination by thorough cleaning of lights between
patients¶ use
Facilitate healing by optimal use of light and heat

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 ˜
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Equipment:
rerineal light
radding for stirrups
Screen
Sterile perineal pad
Bag for disposal of used perineal pad
rrescribed medication

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| ˜

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

 ˜
| ˜

rosition the perineal light far enough from the perineum to


avoid burning the tender skin; approximately 0u inches is
considered safe The lamp should not be left on for more
than u minutes Expose the perineum to perineal light
several times a day
The perineal area must be checked frequently during the
procedure for redness which would indicate that the light
was too hot or the time span was too long Suture should
be observed for proper healing and signs of infection,
bleeding or any other problems Observe patient¶s
reactions
ï bulb over 6 watts must be used
ash the perineal light in a utility room with a germicide

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 O 
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 8 progress from soft filling with potential
for engorgement (vascular congestion related to
increased blood and lymph supply; breasts are
larger, firmer, and painful)
    
      suppress lactation
Mechanical methods ± tight
tight--fitting brassiere, ice
packs, minimize breast stimulation
   
     successful lactation is
dependent on infant sucking and maternal
production and delivery of milk (letdown/milk
ejection reflex); monitor and teach preventive
measures for potential problems
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Nipple ± irritation/cracking
Nipple care ± clean with water, no soap,
and dry thoroughly; absorbent breast
pads if leaking occurs; expose to air
rosition nipple so that infant¶s mouth
covers a large portion of the areola and
release infant¶s mouth from nipple by
inserting finger to break suction
Rotate breastfeeding positions

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E
nurse frequently (every ½-
½-3 h) and long enough
to empty breasts completely (evidenced by
sucking without swallowing)
warm shower or compresses to stimulate
letdown
alternate starting breast at each feeding
mild analgesic u min before feeding and ice
packs between feedings for pronounced
discomfort
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r   ‰ area of tenderness and
r   ‰
lumpiness often associated with engorgement;
may be relieved by heat and massage prior to
feeding

|  ‰
 ‰ most drugs cross into breastmilk;
check with physician before taking any
medication

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

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  34  4 
°      
     °   
 
  
   5 6 6 5   5  67   7  6
  7  7  66 7 5 ; 6 7
7 8 66 7  7  55 
 5 6   9 : 7  676 6 5   
7 7  8 6 7  7  
6    8   7 6   67 6
5 6  5 7  6 7 7 67 ; 7 
66  6 55    87  6 7 
7  7  6 5  | 67  7  5 6 5  
5 86  67 7  7 6 7  7  6 
6 
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BREïSTFEEDING BOTTLEFEEDING

Non-allergenic
Non- Father or others may feed
Meet infant µs specific nutritional infant day or night
needs Feed less frequently (3-
(3-
ï Immunologic properties help mH)
, prevent infection ïmount of milk taken at
 Easily digested each feeding known
ï Constipation unlikely
* Overfeeding less likely
 No formula or bottles to buy
ï No formula and bottle to prepare
9 Oxytocin release help involution
Mother more likely to eat well
balance diet

May help with mother¶s weight loss
Enhances mother/infant attachment
through skin to skin contact
Frozen -u c (6 mos)
Refrigerated mc ( um H)

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BREïSTFEEDING BOTTLEFEEDING

Feed more frequently (u-


(u-3 H) Expense of formula,
More frequent diaper changes bottles
,
) ïmount of milk taken at each ashing bottles
 feeding unknown Fixing and refrigerating
ï Medications taken by mother formula
, present in milk Carrying bottles on
Discomfort of som mothers to outings

ï nurse in public May cause constipation
* Expense of pumping and storing
 milk for periods when mother is
unavailable ( such as work)
ï
9

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rosition for feeding
  The infant should be held with head slightly
higher than the rest of the body
-
    Cradle hold with infant¶s head in the bend of
the mother¶s elbow and arm supporting the
infant¶s body
  OTHERS:
  Football hold
  Side lying position
  ïcross lap

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Latching on
  The mother should use the infant's
rooting reflex to allow positioning of
-
  the nipple in the infant¶s mouth
  Brushing the nipple against the
infant¶s lower lip will cause the infant
to open the mouth
  hen the mouth is wide open and the
tongue is down, the mother quickly
brings the infant closer to the breast
so the infant can latch on the nipple
and areola
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Length of feeding
  Varies with each mother /infant unit

-
    BURrING
BURrING--
  ïLL INFïNTS REQUIRE BURrING
  TO EXrEL THE ïIR SïLLOED
HEN THE INFïNT SUCKS
  SOME INFïNT SïLLO MORE ïIR
THïN OTHERS ïND REQUIRE MORE
FREQUENT BURrING

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˜ O˜
Rationale:
Maintain proper support and cleanliness
rrevent trauma and infection

Materials:
Mild soap and water
Clean wash cloth and towel

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The client should always wash wash her hands
thoroughly before handling the breasts
The breasts are washed with warm water and
soap on a washcloth, using circular motion from
the nipple out
The breasts should be dried well, but gently
rostpartum, the woman should wear well-
well-fitting
brassiere
Use nursing pads if nipples leak Change them
when they become soiled
Tender, painful cracked nipples should be
exposed to air Medications may be taken as
ordered
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 ! ˜  
Inverted nipples fold inward instead of pointing out omen
with inverted nipples may have a hard time getting started
with breastfeeding ï breast-
breast-feeding baby latches on more
easily to a nipple when it is erect

To determine whether you have flat or inverted nipples:


rlace your thumb and forefinger on the edges of the areola
(dark area around the nipple) just behind the nipple
Squeeze the tissue gently
If the nipple is flat or inverted, it will flatten or retract into
the breast instead of pointing out
Special techniques and breast shells sometimes are
recommended to prepare inverted nipples for breast- breast-
feeding However, their effectiveness is questionable
Inverted nipples may naturally become more erect after the
birth of your baby
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 ! ˜  
Techniques for flat or inverted nipples:
ïn effective breastfeeding baby usually has little trouble
breastfeeding even if his/her mother's nipples appear to be
flatter ï less effective breastfeeder may need some time to
figure out how he/she can draw the nipple into the mouth with
latch--on ïlthough the benefit of using hard plastic breast shells
latch
is not conclusive, some mothers find it helps to wear them in the
bra between feedings Breast shells exert a small amount of
traction to help draw the nipple outward Using a breast pump to
draw the nipple out just prior to breastfeeding may also help
If nipples invert, or "dent" inward, with stimulation, try the
interventions mentioned for flat nipples Nipple eversion devices
are available Occasionally, a mother has one or more severely
inverted nipples If one breast is less affected, your baby can
breastfeed on only one breast Most women can produce enough
milk in one breast to exclusively breastfeed their babies
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 )
)   ,


The infant should be lined up: mouth, chin and


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

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

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O


Nipple confusion occurs when a baby has not had the


opportunity to establish the correct mouth movements for
proper breast-
breast-feeding Early and subsequent use of
pacifiers, water, glucose water and formula
supplementation have been shown to promote early
weaning and nipple confusion The frequent use of an
artificial nipple early in life has been shown to promote a
less effective mouth movement; this was demonstrated
with ultrasonography over a decade ago 3u For this reason,
the physician should encourage the staff and the patient to
address breast-
breast-feeding problems first, with direct
observation of breast-
breast-feeding, before considering the use
of supplementation

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

Breast-Feeding on Demand and Rooming


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

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

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   )
)  
rromotes mother-
mother-infant bonding
rromotes uterine involution
Economical for family and society
Convenient
Better cognitive development in children
Lower incidence of premenopausal breast cancer
Lower incidence of premenopausal ovarian cancer
Lower incidence of maternal osteoporosisrerceived
Barriers to Breast-
Breast-Feeding Loss of freedom
Embarrassment
Jealousy (paternal and sibling)
Difficulty returning to work or school
rhysical discomfort
eaning
Lack of confidence (afraid that baby is starving)
rerception that formula is equal to breast milk

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Feed the infant on demand--
demand--onon "hunger cues 
Listen and feel for infant's swallowing
Infant should regain birth weight by two weeks of age
ïvoid nipple confusion by adopting this policy: three to
four weeks of exclusive breastfeeding, then no more than
one bottle a day, using expressed breast milk
Count wet diapers: one on day 0, two on day u, three on day
3, six per day from day 6 on, with three or more stools per
day
Report any signs and symptoms of dehydration and
jaundice
Make use of lactation support telephone numbers
Expect weight loss of < percent at the two-
two- to four-
four-day
follow--up visit
follow

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

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O 
 
  *% 
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O-

If a pregnant woman chokes on a piece of meat or any


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

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O ˜" ˜˜
 
*| ˜   ˜
CONSCIOUS
0 Stand behind the person, placing your arms under the person's armpits
and around his or her chest
u Make a fist with one hand and put the thumb side of the fist against the
center of the person's breastbone
3 Make sure your thumb is on the breastbone
breastbone±±not the ribs
ribs±±and that you are
not near the tip of the breastbone
m rut your other hand over the fist and give quick inward thrusts
5 Continue giving thrusts until the object is dislodged
If the person becomes unconscious while you¶re doing this, use the method
for unconscious people

ONCE THE OBJECT IS DISLODGED


If the person is not breathing and has a pulse, perform rescue breathing If
the person is not breathing and does not have a pulse, give CrR

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