Maternal Health Nursing Skills

Maternal Health
Nursing Skills
Mary Lourdes Nacel G. Celeste, RN, MD
RESPONSIBLE
PARENTHOOD
Reproductive
Life Planning
FAMILY PLANNING
Reproductive Life Planning
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
MLNG CELESTE, RN, MD 4

Responsible Parenthood
A responsible person is a man or woman who is
able and willing to give the proper response to the
demands of a given situation.
With specific reference to marriage and family life,

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

Although some people object to the idea, we

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

The concept of family planning includes these
elements:
Responsibility of parents to themselves and to each

other
Responsibility to their present and future children
Responsibility to their community and country

Purposes of Family Planning
improvement of health
promotion of human right to determine
reproductive performance
relation of demographic change to
economic development

The ultimate goal of family planning is directed
towards:
Birth spacing, to allow the mothers time to rest and

regain their health before the next pregnancy
Birth limitation, when the desired number of children

is reached
Helping those who do not have children to have

children

Advantages of family planning
To the mother:
enables the mother to regain her health after the delivery
gives mother enough time and opportunity to love and
provide attention to her husband and children
provides mother who has chronic illness enough time for
treatment and recovery without further exposure to the
physiologic burden of pregnancy
prevents high risk pregnancy
gives mother more time to herself, family and community

To the children,the practice of family
planning will make them
healthier
happier
feel wanted and satisfied
secure

To the fathers
lightens his burden and responsibility in supporting
his family
enables him to give his children a good home, good
education and better future
enables him to give his family a happy and contented
life
gives him time for his personal advancement
provides a father who has chronic illness enough
time for treatment and recovery from his illness

To the family
gives the family members more opportunity to
enjoy each other’s company with love and
affection
enables the family to save some amount for
improvement of standard of living, and for
emergencies

To the community
improves the economic and social status of the
community
better job opportunities
health status will improve
extra resources in the community (less congestion,
less pollution, potable water supply, etc)
members will have more time to socialize with each
other; to participate in socio-civic activities

Contraceptive
Any device used to prevent
fertilization of an egg

Considerations:
Personal values
Ability to use method correctly
How method will affect sexual enjoyment
Financial factors
Status of couple’s relationship
Prior experiences
Future plans
Contraindications
CONTRAINDICATIONS OF CONTRACEPTIVE USE

Contraceptives
40 million women in United States
use some form of contraception
65% of women of childbearing age
 ? PHILIPPINES

Contraceptives
1. Abstinence
0% failure rate
Most effective method to prevent
STDs
Difficult to comply with

Contraceptives
2. Natural Family Planning
No chemical or foreign material into
the body
Failure rate of approximately 25%

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

Calendar/ Rhythm
(Natural Family Planning)
Action – periodic abstinence from
intercourse during fertile period;
based on the regularity of ovulation;
variable effectiveness

Calendar/ Rhythm
(Natural Family Planning)
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

1. Calendar (rhythm) method
Entails keeping a day-by-day record of
your cycle for 6 consecutive months
noting the onset of bleeding as day 1 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- from which
you can calculate your FERTILE days


The first day of menstrual bleeding
(day 1 of your period) counts as the
first day of the cycle.
Approximately 14 days (or 12 to 16
days) before the start of the next
period, an egg will be released by
one of the ovaries.

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

First unsafe day: subtract 18 from the
number of days in your shortest cycle
Last unsafe day: subtract 11 from the
number of days in your longest cycle
Ex: shortest: 26 – 18 = day 8
longest: 31 – 11 = day 20
UNSAFE PERIOD!! Days 8 -20
-avoid coitus or use a contraceptive

SHORTEST CYCLE
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

1
18 DAYS
LONGEST CYCLE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
11 DAYS
UNSAFE TIME
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
UNSAFE TIME

2. Basal Body Temperature
Involves taking the temperature every
morning BEFORE the woman gets out of
bed and recording it
The temperature drops slightly 24 hours
before ovulation, then rises to about half a
degree higher than normal and remains thus
for up to three days: UNSAFE period!
Not a very efficient method unless combines
with calendar and mucus methods
3. Cervical Mucus
(Billings) Method
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

3. Cervical Mucus
(Billings) Method
A few days after menstrual bleeding: little
secretion, vagina is dry
Gradually, secretion increases and
becomes thicker, cloudy white and sticky
As 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: UNSAFE PERIOD!!
3. Cervical Changes
Spinnbarkeit test
Cervical mucus is
thin, watery and
can be stretched
into long strands
high level of
estrogen:
ovulation is about
to occur
3. Cervical Changes
Ferning or
arborization of
cervical mucus
At the height of
estrogen stimulation
just before ovulation
Ferning- due to
crystallization of
sodium chloride on
mucus fibers

Symptothermal method
Combines BBT and cervical mucus
methods

Ovulation awareness
Use of over-the-counter OTC
ovulation test kit which detects the
midcycle LH (luteinizing hormone)
surge in the urine 12 to 24 hours
before ovulation
98 to 100% accurate

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

Coitus interruptus
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
Contraceptives
3. Oral Contraceptives
Composed of varying amounts of
estrogen combined with small
amount of progesterone
99.5% effective

Estrogen
suppresses FSH and
LH, thereby
suppressing
ovulation
Progesterone
decreases the
permeability of
cervical mucus

Monophasic - Fixed doses of estrogen
and progesterone ; 21-28 day cycle
Biphasic - Constant amount of
estrogen with increased progesterone
Triphasic - Varying levels of estrogen
and progesterone

Benefits of OC’s:
DECREASED incidences of:
Dysmenorrhea
Premenstrual dysphoric syndrome
Iron deficiency anemia
Acute PID with tubal scarring
Endometrial and ovarian cancer and
ovarian cysts
Fibrocystic breast disease

Side Effects
Nausea
Weight gain
Headache
Breast tenderness
Breakthrough bleeding
Monilial vaginal infections
Mild hypertension
Depression

Absolute Contraindications to OC’s

Breastfeeding
Family history of CVA or CAD
History of thromboembolic disease
History of liver disease
Undiagnosed vaginal bleeding

Possible Contraindications to OC’s
Age 40+
Breast or reproductive tract malignancy
Diabetes Mellitus
Elevated cholesterol or triglycerides
High blood pressure
Mental depression

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

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

Estrogen-progesterone patch

Highly effective, weekly hormonal birth
control patch that’s worn on the skin
Combination of estrogen and progestin
Absorbed on the skin and then transferred
into the bloodstream
Can be worn on the upper outer arm,
buttocks, upper torso or abdomen
Worn for 1 week, replaced on the same
day of the week for 3 consecutive weeks.
No patch-4th week

Emergency Postcoital
Contraceptives
“Morning-after pills”
High level of estrogen
Must be initiated within 72 hours of
unprotected intercourse

4. Other Contraceptives
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
4. Other Contraceptives
Intramuscular injections
-administered every 12 weeks
Medroxyprogesterone (depo-provera)
-100% effective

Contraceptives
5. INTRAUTERINE DEVICES
T-shaped plastic device with copper
With 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 5-7 years (mirena type) or 8 years
(Copper T380)
INTRAUTERINE DEVICE

5. INTRAUTERINE DEVICE
Side Effects:
Spotting or uterine cramping
Increased risk for PID
Heavier menstrual flow
Dysmenorrhea
Ectopic pregnancy

6. Barrier Methods
Vaginally inserted spermicidal
products
Diaphragms
Cervical caps
Condoms

6. BARRIER METHODS
SPERMICIDAL AGENT
goal: to kill the
sperm before the
sperm enters the
cervix
-Nonoxynol-9
-gel, creams,
films,foams,
suppositories
6. BARRIER METHODS
DIAPHRAGM
-mechanically blocks sperm
from entering the cervix
-soft latex dome supported
by a metal rim
-can be inserted 2 hours
before intercourse;
removed at least 6 hours
after coitus or within 24
hours
-size must fit the individual
-washable, may be used
for 2-3 years

6. BARRIER METHODS
CERVICAL CAP
-similar to
diaphragm but
smaller
-thimble-shaped
rubber cap held
onto the cervix by
suction

6. BARRIER METHODS
MALE CONDOM FEMALE CONDOM

MALE CONDOM
Action – 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-Y jelly, never
petroleum-based lubricant; hold rim when
withdrawing the penis from the vagina; if condom
breaks, partner should use contraceptive foam or
cream immediately

7. Surgical Methods
Tubal Ligation
-28% of all women in US
-fallopian tubes are
cut,tied/ cauterized to
block passage of ova
and sperm
ABDOMINAL INCISION
MINILAPAROTOMY
LAPAROSCOPY
FOR TUBAL
STERILIZATION

7. Surgical Methods
Vasectomy
- 11% 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%

8. Elective Termination of Pregnancy
Procedure to deliberately end a
pregnancy before fetal viability
Induced
(mifepristone-progesterone antagonist;
misoprostol-prostaglandin analog
Medically induced
D&C, D&E, saline induction,
hysterotomy

Physical Assessment
of a Pregnant Woman
Genital & Pelvic Examination
the most intimate examination that a woman may
be ever subjected to
must never be performed without:
1. a careful explanation to the patient about the
examination
2. asking permission from the patient to perform the
examination
3. valid reason for performing the examination

Indications
AT THE FIRST VISIT:
1. The diagnosis of pregnancy during the first trimester
2. Assessment of the gestational age
3. Detection of abnormalities in the genital tract
4. Investigation of a vaginal discharge
5. Examination of the cervix
6. Taking a cervical (Papanicolaou) smear

Indications
AT SUBSEQUENT ANTENATAL VISITS:
1. Investigation of a threatened abortion
2. Confirmation of PROM with a sterile speculum
3. To confirm the diagnosis of preterm labor
4. Detection of cervical effacement and/ or dilatation in a patient with
a risk for preterm labor
5. Assessment of the ripeness of the cervix prior to induction of labor
6. Identification of the presenting part in the pelvis
7. Performance of a pelvic assessment
IMMEDIATELY BEFORE LABOR

1. Performance of artificial rupture of the membranes to induce labor

Preparation
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.
Provide 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.
After the procedure, provide tissue to wipe perineum of
lubricant.

TO THE FEMALE CLIENT
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.

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

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

Sexual Abuse and Other Concerns
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

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.

Four Steps
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

Step 1. The External Genital Exam
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.

Step 2. The Speculum Exam
The clinician inserts a metal or plastic speculum into the
vagina. When 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.

Step 2. The Speculum Exam
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).

The Speculum Exam

Insertion of a Speculum

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

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

Pap Smear
Pap tests can detect
the presence of abnormal cells in the cervix
infections and inflammations of the cervix
symptoms of sexually transmitted infections
(With the exception of trichomoniasis, Pap 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. Pap
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.

Pap Smear
If the results are abnormal, the clinician will advise the client on follow-up
care:
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-up and may also be advised to
 Repeat the Pap 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.

Pap Smear
Remember —
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
abnormal condition is found.

Pap Smear

Pap Smear

Pap Smear

Pap Smear

Pap Smear

Pap Smear
Findings of Pap’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 – Probably malignant, with signs of malignancy
present
Class V – Definitely malignant cells

Step 3. The Bimanual Exam
Wearing 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.

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

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.

The Bimanual Exam

The Bimanual Exam

Step 4. Rectovaginal Exam
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.
Perinatal Exercises
Perinatal Exercises
Purposes:
Help prevent the need for cesarean section
Help strengthen pelvic and abdominal muscles
Help reduce discomfort
Help hasten recovery
Exercises – should be done in moderation and

must be individualized

PRE-EXERCISE POINTERS
1. Always let breath flow freely. Let abdomen and ribcage
expand and compress naturally as you inhale and exhale.
2. Warm up with gentle stretching before exercise program -
increase blood flow to muscles and loosen them up.
3. When you finish, take time to relax fully; lie in comfortable
position on floor for 10 minutes with eyes closed; let
breathing slow down.
4. As strength improves, add one repetition of each exercise
until you’re up to 10; also, try holding positions from 3 to 5
counts.
5. Do each exercise slowly and thoroughly. Allow rest
between each exercise.

PRE-EXERCISE POINTERS
6. Avoid extreme motions like deep lunges or twisting
movements.
7. Avoid lying flat on your back for prolonged periods; it may
become uncomfortable and the position allows less blood
flow to the uterus. Lying on your side increases blood flow.
8. Think of opportunities for exercises during day; Kegel’s
while standing in line at grocery store, squatting while
peeling potatoes, talking on the phone, watching television,
etc.
9. If there is a prenatal exercise class in your area, join it. It is
fun to get into shape with other pregnant women.

A. Tailor Sitting
1. It strengthens the thigh
and stretches the perineal
muscles
2. Done at least 15 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 15 minutes daily.

B. Squatting
1. Helps to stretch muscle of

the pelvic floor.
2. Done at least 15min/day
When 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 15
minutes daily

C. Pelvic Floor Contractions
(Kegel’s Exercise)
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.
1. Squeeze the muscle surrounding the vagina as if
stopping the flow of urine, hold for 3 seconds then
relax. (10x)
2. Contract and relax the muscles surrounding the vagina
as rapidly as possible 10 – 25x
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. 10x
D. Abdominal Muscle Contractions
1. strengthen the abdominal muscles
2. 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.

E. Pelvic Rocking
1. Helps to relieve backache during

pregnancy and early labor
2. 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 1 minute, and then hollows
her back.
- do this at the end of the day (5x)
F. Pelvic Tilt
1. PELVIC TILT – SUPINE
Do daily and after delivery.
Position: Backlying, knees bent.
Exercise: Press small of back against floor by tightening
abdominal muscles and buttocks muscles.

F. Pelvic Tilt
2. PELVIC TILT – STANDING
Position: 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.

F. Pelvic Tilt
3. PELVIC TILT - ALL FOURS
Position: 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.

G. Sit ups
1. SIT-UPS - Modified
Purpose: Strengthen abdominal
muscles. Good muscle tone is
important for maintaining good
posture, for effective pushing, and
for early return of figure
postpartum.
Position: Backlying, knees bent, low

back
flat (pelvic tilt).
Exercise: Lift head and shoulders off

floor, reaching hands toward knees
(lift trunk to about 45° angle). Slowly
return to starting position; do not
drop back.

G. Sit ups
2. OBLIQUE (DIAGONAL)
SIT-UPS - Modified
Purpose: Strengthen oblique
abdominal muscles.
Position: Backlying, knees bent,

low back flat.
Exercise: As above, but reach up

and across to the outside of
the opposite knee.

H. GLUTEAL / PELVIC FLOOR SETTING
Position: Backlying, legs straight, ankles crossed, arms at sides.
Exercise: Pinch buttocks, squeeze pelvic floor muscles, squeeze

thighs together, raise head off floor.

I. ADDUCTOR LENGTHENING
Position: 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.

SPECIFIC ACTIVITIES
1. Jogging:
Wear 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.
2. Bicycling and Swimming:

Excellent activities with reasonable limitations. Don’t push yourself!
3. Tennis, Basketball, other “sudden stop and start” Activities.

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

4. Skating, Horseback Riding:
Danger of falling! Advise against. Consult your obstetrician or nurse
practitioner as needed.
5. Walking:
Most highly recommended for the pregnant woman; ideal alternative to more
strenuous exercise. Walk uphill, downhill, and at different speeds.
Patient Teaching: Consult your obstetrician or nurse practitioner early in your

pregnancy. In general, you can continue your 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. Avoid exercising in very hot or humid
weather, or at high altitudes if you’re not used to it.

Leopold’s Maneuvers
LEOPOLD’S MANEUVERs
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

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

First Maneuver
Palpation of the Uterine Fundus

Second Maneuver
Determines small parts and back of fetus
along the sides of maternal abdomen
Lateral Palpation of the Uterus

Examiner faces woman's head
Palpate with one hand on each side of abdomen
Palpate fetus between two hands
Assess 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.
Alternating 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.

Second Maneuver
Determines small parts and back of fetus
along the sides of maternal abdomen

Third Maneuver
(Lower uterine segment or uterine pole)
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.
Assess for cephalic versus Breech Presentation
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
(Pawlick's grip) will provide either
initial information or confirm prior
data gained from the previous steps
of Leopold's maneuvers.
Anchoring the uterine fundus with
the non-dominant hand assist
in identifying the location of the fetal
back and small parts.

Third Maneuver
(Lower uterine segment or uterine pole)

Fourth Maneuver
(pelvic palpation of the uterus
- assess the presenting part)
Provides 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 .
Place 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. Assess 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.

Fourth Maneuver
(pelvic palpation of the uterus
- assess the presenting part)

1st What is at the uterine fundus?
MANEUVER Head is more firm, hard and round that moves independently of
the body.
Breech is less well defined that moves only in conjunction with
the body.
nd
2 Where is the fetal back?
MANEUVER Fetal back is smooth, hard, resistant surface.
Knees and elbows of fetus feel with a number of angular
nodulation.
rd
3 What is at the inlet of the pelvis?
MANEVER By grasping the lower portion of the abdomen (just above the
symphisis pubis.
Not engaged (not firmly settled in the pelvis) if the presenting
part moves upward so an examiner’s hands can be pressed
together.
th
4 What is the fetal attitude? (degree of flexion)
MANEUVER Fingers on both sides of the uterus (2 inches above inguinal
ligaments) pressing down and inwards. The fingers of the hand
that do not meet obstruction above the ligament palpates the
fetal brow.
Good attitude if brow corresponds to the side (2nd maneuver)
that contained the elbows and knees.
Poor attitude if examining fingers will meet an obstruction on
the same side as fetal back (hyperextended head).
Also palpates infant’s anteroposterior position. If brow is very
easily palpated, fetus is at posterior position (occiput pointing
towards woman’s back).
Taking FHT
Fetal heart rate
FHR should be 120-160
beats per minute
Can be heard with a

Doppler : 10 – 11th week of
pregnancy
Fetoscope: 18-20 weeks

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

Fetal heart rate
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
60 seconds. Record FHR.
During labor, monitor FHR during the relaxation period between
the contractions to determine baseline.
In a low-risk labor, assess FHR every 60 minutes during the latent
phase, every 30 minutes during the active phase and then every 15
minutes during the 2nd stage of labor. In high risk labor, assess
FHR every 30 minutes during the latent phase, every 15 minutes
during the active phase, and every 5 minutes during the 2nd stage
of labor.
Auscultate FHR during a contraction and for 30 seconds afterward
to identify the response to the contraction.
Auscultate FHR before administration of medications, ambulation,
and artificial rupture of membranes, changes in the
characteristics of contractions, vaginal examinations and
medications. MLNG CELESTE, RN, MD 133
LOCATING FETAL HEART SOUNDS BY FETAL POSITION
FHT – heard best at the FETAL BACK

Fetal Heart Rate Patterns Indicative of… Intervention
Tachycardia (>160 bpm) Maternal or fetal infection Depends on the cause
Fetal hypoxia (ominous sign)
Bradycardia (<120 bpm) Fetal hypoxia or stress Place client on her left side
Maternal hypotension after Increase fluids to counteract
epidural initiation hypotension
Stop oxytocin (Pitocin) if in
use
Early deceleration Head compression :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 Deficient placental perfusion Correct hypotension
contraction and recovers after Supine position Increase IV fluid rate as
contraction ends) Maternal hypotension ordered
Uterine hyperstimulation Discontinue oxytocin
Administer oxygen as
ordered
Variable deceleration Cord compression Change maternal position
(transient decrease in HR Hypoxia or hypercarbia Administer Oxygen
anytime during contraction
Decreased variability Fetal sleep cycle Depends on the cause
Depressant drugs
Hypoxia
CNS anomalies
Measuring Fundic Height
Fundic Height
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 20th and
31st weeks of pregnancy.
Fundic Height
Measure from the notch of the symphysis
pubis to over the top of the uterine fundus as
the woman lies supine.
Place 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
2. (inaccurate in the 3rd trimester esp after 32
wks)
Typical measurements
- Over the symphysis pubis: 12 wks
- At the umbilicus: 20 wks
- At the xiphoid process: 36 wks
Rises about 1cm per week; after which it
varies
Fundic Height

Location of the fundus:
12 weeks  at the level of the symphysis pubis
16 weeks  halfway between symphysis pubis and umbilicus
20weeks  at the level of the umbilicus
24 weeks  two fingers above umbilicus
30 weeks  midway between umbilicus and xiphoid process
36 weeks  at the level of xiphoid process
40 weeks  two fingers below umbilicus,
drops at 34 weeks level because of lightening

Computation of
EDC & AOG based on LMP
Obstetrical Number
EDC
LAST MENSTRUAL PERIOD – first day of the last menses

AOG
COMPUTATION OF AGE OF GESTATION
Example: LMP: January 1, 2009
Date of consult: August 31, 2009
AOG: Total # of days from LMP up to date of consult

7
January 30 days
February 28 Total = 242 days
March 31 AOG = 242
April 30 7
May 31 34 to 35 weeks
June 30
July 31
August 31
Obstetrical History/ Number
G__ P__ (T, P, A, L)
Gravida – the total number of pregnancies regardless of duration
(includes present pregnancy)
Para – 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 20-wk gestation),
regardless of the number of fetuses or whether the infant was
born alive or dead
Term infant – an infant born between 38 and 42 weeks of gestation
Preterm – an infant born before 38 weeks
Post term – an infant born after 42 weeks
Abortion – pregnancy that terminates before the period of viability
(20 wks)
Live birth – a live birth is recorded when an infant born shows
sign of life

Fetal Presentation,
Attitude, Lie & Position
Station
Presentation
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

Attitude/ habitus
relationship of fetal parts to each other;
usually flexion of head and extremities
on chest and abdomen to accommodate
to shape of uterine cavity
Vertex – head is maximally flexed
Military – head is partially flexed
Brow – head is maximally extended
Face – head is partially extended

Lie
Lie – relationship of spine of fetus to
spine of mother;
longitudinal (parallel)
transverse (right angles)
oblique (slight angle off a true
transverse lie)

Position
relationship of fetal reference point to mother’s
pelvis
Fetal reference point

Vertex presentation – dependent upon degree of
flexion of fetal head on chest; full flexion–occiput
(O); full extension–chin (M); moderate extension–
brow (B)
Breech presentation – sacrum (S) / Sa
Shoulder presentation – scapula (SC) / A (acromion)

Position
Relation of the presenting part to a specific
quadrant of a woman’s pelvis
Right anterior
Left anterior
Right posterior
Left posterior

Maternal pelvis is designated per her
right/left and anterior/posterior
 Expressed as standard three letter
abbreviation; e.g., LOA = 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.

Anterior Fontanel
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 1st 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. After
the patient is nearly completely dilated, it
becomes easier to feel the fontanel.
When attaching a fetal scalp electrode, it is
better to not attach it to the area of the fontanel.
Posterior Fontanel
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.

Left occiput anterior (LOA)

Right occiput anterior
(ROA)

Left occiput transverse
(LOT)

Right occiput transverse
(ROT)

Occiput posterior
(OP)

Occiput Anterior
(OA)

Left occiput posterior (LOP)

Right occiput posterior (ROP)

FETAL POSITION

Station
level of presenting part of fetus in
relation to imaginary line between
ischial spines (zero station) in
midpelvis of mother
 –5 to –1 indicates a presenting part
above zero station (floating); +1 to +5,
a presenting part below zero station
 Engagement – when the presenting
part is at station zero
STATION or DEGREE OF ENGAGEMENT

Perinatal Care
Monitor vital signs and FHR
Provide comfort measures (ambulate if tolerated
and if BOW is not ruptured yet; side lying is
usually most comfortable, sacral pressures, back
rubs)
Breathing techniques

Slow-Paced Breathing
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:
Assume a comfortable position.
Try to maintain a relaxed state throughout the contraction.
Close her eyes or
Concentrate on a focal point while doing the breathing (e.g., a pretty
picture, a button on someone'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-Paced Breathing
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.
1. Take a cleansing breath as soon the contraction begins.
2. 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
60-second contraction (the cleansing breaths do not count).

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

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

Insertion of Catheter
Catheterization
INSERTION OF CATHETER / Catheterization

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

Catheterization
Purposes:
1. To relieve discomfort due to a bladder distention and to provide
gradual decompression of a distended bladder.
2. 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
4. 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
8. To facilitate accurate measurement of urinary output for critically ill
client whose output needs to be monitored hourly

Catheterization
Points to consider:
1. There are 2 hazards in the process, namely,
sepsis and trauma, hence asepsis technique
should be maintained and the catheter should be
inserted gently.
2. When 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

Catheterization
Types of catheter:
1. Straight or Robinson catheter – a single lumen tube with a
small eye or opening about ½ inch from the insertion tip
2. Retention or Foley catheter- contains a second smaller tube
throughout its length on the inside. This tube is connected
to a balloon near the insertion tip. After 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 8 – 10
are used in children. French 14, 16 and 18 are for adults.

Straight Catheter
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

Straight Catheter
Procedure:
1. Explain the procedure to the client.
2. Put on a mask, gown or cap if required by agency.
3. (Percuss and) Palpate the bladder to assess urinary retention.
4. Assist client to a supine position, with knees flexed and thighs externally
rotated.
5. Drape the client. Prevent unnecessary exposure.
6. Don disposable gloves.
7. Adjust the light to view the urinary meatus.
8. Drape the client with sterile drapes (expose the perineum).
9. Pour antiseptic solution over the cotton balls if they are not already prepared.
10. Lubricate insertion tip of the catheter and place it in a sterile container/ area
ready for use.
11. Clean the meatus. With the nondominant hand, separate the labia majora
with the thumb and finger and clean the labia minora on each side using
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)
Straight Catheter
12. Expose the urinary meatus by retracting the tissue of the labia minora in an
upward direction. Clean from the meatus downward on either side, then work
outward. Once the meatus is cleaned, do not allow the labia to close over it.
13. Inspect the meatus for any swelling, excoriation, discharge.
14. Insert the catheter gently with the uncontaminated gloved hand into the urinary
meatus until urine flows. Keep the drainage end in the urine receptacle. When 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.
15. Collect specimen if required (usually 30 ml) by transferring the drainage end into
a sterile bottle.
16. Empty or partially drain the bladder and then remove the catheter. Limit amount
of urine drained to 700-1000 ml. rapid removal of large amounts of urine is
thought to induce engorgement of the pelvic blood vessels and hypovolemic
shock.
17. Pinch the catheter. Remove the catheter slowly.
18. Dry the perineum with a towel or drape.
19. Assess the urine.
20. Document the catheterization.

FOLEY/ INDWELLING/
Retention Catheter
Additional Equipment: syringe prefilled with fluid (usually 15 ml)
Follow steps as for straight catheterization up to #15.
16. Insert the catheter an additional 2.5 – 5 cm (1-2 in) beyond the point at
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.
17. Inflate the balloon by injecting the contents of the prefilled syringe into
the valve of the catheter.
18. Ensure effective balloon inflation applying slight tension on the catheter
until you feel resistance (well anchored in the bladder).
19. Tape the catheter to the inside of the female’s thigh.
20. Secure drainage bag to the bedframe using its hook. Suspend it off the
floor but keep it below the level of the patient’s bladder. Make sure the
emptying base of the drainage bag is closed.
21. Document catheterization.

How to insert a catheter (women)
1. Assemble all equipment: catheter, lubricant, sterile gloves, cleaning supplies, syringe with water
to inflate the balloon, drainage receptacle.
2. Wash your hands. Use betadine or cleansing product to clean the urethral opening. In women
clean the labia and urethral meatus using downward strokes. Avoid the anal area.
3. Apply the sterile gloves. Make sure you do not touch the outside of the gloves with your hands.
4. Lubricate the catheter.
5. Spread the labia and locate the meatus (opening which is located below the clitoris and above
the vagina).
6. Slowly insert the catheter into the meatus.
7. Begin to gently insert and advance the catheter.
8. Once the urine flow starts, advance the catheter another 2 inches. Hold the catheter in place
while you inflate the balloon. Care must be taken to ensure the catheter is in the bladder. If pain is
felt which inflating the balloon, stop; deflate the balloon; advance the catheter another 2 inches;
and attempt to inflate the balloon again.
9. Secure the catheter, and attach the drainage bag.

Procedure on Childbirth
Vaginal Delivery
PROCEDURE ON CHILDBIRTH
(Conduct of Normal Delivery)
Purpose: To provide safe outcome for the mother and to deliver a
healthy baby
Equipment: Standard delivery room equipment

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

Sterile instruments
2 scissors ( 1 for episiotomy, 1 for cutting the
umbilical cord)
2 cord clamps/ kelly forceps
4 allis clamps (for episiotomy repair)
2 needle holders
Suture needles
2 ring forceps (to aid in the delivery of the
placenta and membranes)
1 vaginal retractor (to aid in inspection of the
birth canal)

Procedure:
Nursing Action/ Rationale
1. Observe strict aseptic technique in gowning and gloving.
(To prevent introduction of microorganisms into the uterine
cavity)
2. Drape and cleanse perineal area. (To maintain asepsis).

Perineal Preparation

3. Catheterize patient PRN. (To prevent bladder trauma)
4. Instruct patient to push. (This is a technique of using the
abdominal muscles to assist in uterine expulsive efforts during
contractions)
5. Wipe the perineum with sponges and antiseptic solution using a
downward and backward motion. (To prevent fecal
contamination)
6. Avoid the use of fundal pressure to hasten delivery. (Fundal
pressure may cause uterine damage)
7. Avoid too rapid delivery. (To preserve the flexion of the fetal head)
8. Assess for leg cramps which may occur when the head crowns.
These may be relieved by changing the position of the legs.
(Caused by the pressure of the fetal head on the pelvic nerves)
9. Assess 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
MLNG CELESTE, fetal head)
RN, MD 209
Types of Episiotomy

10. 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)
11. Feel and look for the cord around the back of the neonate as
soon as the head is delivered. Loosen the cord and slip over the
head. If unable to loosen coils, occlude the cord with 2 clamps
and cut between them. (To prevent interference with fetal
oxygenation)

Ritgen’s maneuver

12. 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)
13. Do not hasten completion of the delivery. Wait until the head
rotates externally. (As 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)
14. Observe for continued uterine contractions and for the shoulder
to lie directly anterposteriorly . Pull 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.
15. Clamp the cord at about 2.5 cm (or depending upon the hospital
policy) from the umbilicus. (Whether sustained benefit is
obtained by waiting for cessation of pulsation before clamping
the cord has not been established.)
Normal Spontaneous Delivery

Umbilical cord

16. Place newborn in a heated crib . (To prevent heat loss and
hypothermia)
17. 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)
18. 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 )
19. 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)

20. 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)
21. 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)
22. Repair the episiotomy.

Placenta

23. Estimate blood loss. (Observe the saturation sponges and
towels as well as the amount of bleeding)
24. 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)
25. Apply a sterile perineal pad, warm gown, and blanket.
(Chilling accompanied by shaking often occurs
immediately following delivery.)
26. Help the mother to hold the infant and inspect it if she
wishes. (Early contact with the infant assists in the mother-
infant bonding process. One of the mother’s first needs is
to be reassured that her infant is normal)

Cesarean Childbirth
Scheduled or Unscheduled C/S
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
- Placenta previa
- Abruptio placenta
- Fetal distress

Vaginal Birth after Cesarean (VBAC)
- When 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

POSTPARTUM PERINEAL CARE
I. Vaginal birth (which stretches and sometimes tears the perineal

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

Cleaning the perineum
Typically, you’ll use a water-jet irrigation system or a peribottle to

clean the perineum. Assist 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 2 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.

Assessing healing progress
To inspect the perineum, put on gloves, ensue adequate

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

PERINEAL CARE
Perineal Care- cleansing the vulva and perineal area
Purposes:
1. To clean the perineum in the following after a bowel or
bladder elimination prior to any vaginal examination or
treatment
2. To prevent vaginal or perineal wound infection and
unpleasant odor.
3. To provide for personal cleanliness and comfort

PERINEAL CARE
Special considerations:
Avoid 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.
Avoid unnecessary exposure.
If the patient defecated, empty the bedpan first before
giving perineal flushing.

PERINEAL CARE
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

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

PERINEAL CARE
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.
Apply medication as ordered or perineal pad as necessary.

Sitz Bath
SITZ BATH (Kozier)
A sitz bath, or a hip bath, is used to soak a client’s

pelvic area. The client sits in a special tub or chair and
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 40 to 43 C
(105 to 110 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 15-20
minutes, depending on the client’s health.
SITZ BATH
To provide a sitz bath, the nurse carries out the
following steps:
Assist the client into the tub, and provide support for
comfort. Provide support for the client’s feet; a footstool
can prevent pressure on the backs of the thighs.
Provide 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.

SITZ BATH (Pilliteri)
Purpose: To aid healing of the perineum through application of moist
heat
Procedure:
1. Wash your hands, identify client and explain procedure.
2. Assess client’s condition; ascertain whether client is able to
ambulate to bathroom; assist and modify as necessary.
3. Assemble equipment, including sitz bath, clean towel, perineal
pad.
4. Place sitz bath on toilet seat. Fill collecting bag with warm water at
a temperature of 100 F to 105 F (38 C to 41 C). Hang the bag
overhead so a steady stream of water will flow from the bag,
through the tubing, and into the basin.
Principle: using correct temperature of water eliminates risk of
thermal injury. Adequate flow of warm water increases circulation
to the perineum, thereby reducing inflammation and aiding
healing.
SITZ BATH
5. Assist client while ambulating to bathroom; help with removal
of perineal pad from front to back. Assist 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. After 20 minutes, assist client with drying perineum and
applying clean pad (holding pad by the bottom side or ends).
After 20 minutes, heat is no longer therapeutic because
vasoconstriction occurs.
8. Assist 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.
10. Record completion of procedure, condition of perineum and
client’s condition and response.

Perilight Administration
PERILIGHT ADMINISTRATION
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:
Avoid burning the patient by prolonged exposure or too-close proximity
to light.
Prevent cross contamination by thorough cleaning of lights between
patients’ use.
Facilitate healing by optimal use of light and heat.

Equipment:
Perineal light
Padding for stirrups
Screen
Sterile perineal pad
Bag for disposal of used perineal pad
Prescribed medication

Procedure:
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. A distended bladder may cause discomfort
during the procedure.
Screen the patient.
Position the patient flat on her back in bed. If the bed
has stirrups, they should be padded for comfort.
Plastic 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
MLNG tubing.
CELESTE, RN, MD 245
Position the perineal light far enough from the perineum to
avoid burning the tender skin; approximately 12 inches is
considered safe. The lamp should not be left on for more
than 20 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.
A bulb over 60 watts must be used.
Wash the perineal light in a utility room with a germicide.

Breast Care
Breasts – progress from soft filling with potential
for engorgement (vascular congestion related to
increased blood and lymph supply; breasts are
larger, firmer, and painful)
Non-nursing woman – suppress lactation
Mechanical methods – tight-fitting brassiere, ice
packs, minimize breast stimulation
Nursing woman – 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
Nipple – irritation/cracking
Nipple care – clean with water, no soap,
and dry thoroughly; absorbent breast
pads if leaking occurs; expose to air
Position 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

Engorgement
nurse frequently (every 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 20 min before feeding and ice
packs between feedings for pronounced
discomfort
Plugged ducts – area of tenderness and
lumpiness often associated with engorgement;
may be relieved by heat and massage prior to
feeding
Medications – most drugs cross into breastmilk;

check with physician before taking any
medication

Expression of breast milk
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 48 h or
frozen in plastic bottles (to maintain stability of
all elements) in refrigerator freezer for 2 wk and
deep freezer for 2 months (do not thaw in
microwave or on stove)

LACTATION PRINCIPLES
Breast Care – Antepartum Initiating Breast Feeding
and Postpartum
Soap on nipples should be Relaxed position of mother is
avoided during bathing to essential – support
prevent dryness dependent arm with pillow
Nipples can be “prepared” Both breasts should be offered
antepartum by exposure to at each feeding
sun, air, and by wearing Five minutes on each breast is
loose clothing sufficient at first – teach
Redness or swelling can proper way to break suction
indicate infection and should Most of the areola should be
always be investigated infant’s mouth to ensure
proper sucking
BREASTFEEDING BOTTLEFEEDING
Non-allergenic Father or others may feed

Meet infant ‘s specific nutritional infant day or night
needs Feed less frequently (3-
A Immunologic properties help 4H)
D prevent infection Amount of milk taken at
V Easily digested each feeding known
A Constipation unlikely
N Overfeeding less likely
T No formula or bottles to buy
A No formula and bottle to prepare
G Oxytocin release help involution
E Mother more likely to eat well
balance diet
S
May help with mother’s weight loss
Enhances mother/infant attachment
through skin to skin contact
Frozen -20c (6 mos)
Refrigerated 4c ( 24 H)

BREASTFEEDING BOTTLEFEEDING
Feed more frequently (2-3 H) Expense of formula,

More frequent diaper changes bottles
D
I Amount of milk taken at each Washing bottles
S feeding unknown Fixing and refrigerating
A Medications taken by mother formula
D present in milk Carrying bottles on
V Discomfort of som mothers to outings
A nurse in public May cause constipation
N Expense of pumping and storing
T milk for periods when mother is
unavailable ( such as work)
A
G
E
S

Breastfeeding
Position for feeding
 The infant should be held with head slightly
higher than the rest of the body
Cradling  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
 Across lap

Breastfeeding
Latching on
 The mother should use the infant's
rooting reflex to allow positioning of the
Cradling nipple in the infant’s mouth
 Brushing the nipple against the infant’s
lower lip will cause the infant to open the
mouth.
 When 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.
Breastfeeding
Length of feeding
 Varies with each mother /infant unit
Cradling  BURPING-
 ALL INFANTS REQUIRE BURPING
 TO EXPEL THE AIR SWALLOWED
WHEN THE INFANT SUCKS
 SOME INFANT SWALLOW MORE AIR
THAN OTHERS AND REQUIRE MORE
FREQUENT BURPING

BREAST CARE
Rationale:
Maintain proper support and cleanliness
Prevent trauma and infection
Materials:
Mild soap and water
Clean wash cloth and towel

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.
Postpartum, the woman should wear 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.

Inverted Nipples
INVERTED NIPPLEs
Inverted nipples fold inward instead of pointing out. Women
with inverted nipples may have a hard time getting started
with breastfeeding. A breast-feeding baby latches on more
easily to a nipple when it is erect.
To determine whether you have flat or inverted nipples:

Place 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-feeding.
However, their effectiveness is questionable. Inverted nipples
may naturally become more erect after the birth of your baby.

INVERTED NIPPLEs
Techniques for flat or inverted nipples:
An effective breastfeeding baby usually has little trouble
breastfeeding even if his/her mother's nipples appear to be flatter.
A less effective breastfeeder may need some time to figure out
how he/she can draw the nipple into the mouth with latch-on.
Although the benefit of using hard plastic breast shells 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.

Proper breast-feeding technique
The infant should be lined up: mouth, chin and

umbilicus. The head is neutral, the mouth 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.
The infant's lips are flanged, with the tongue
protruding over the lower gum.

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

Nipple Confusion
Nipple confusion occurs when a baby has not had the
opportunity to establish the correct mouth movements for
proper 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.32 For this reason,
the physician should encourage the staff and the patient to
address breast-feeding problems first, with direct
observation of breast-feeding, before considering the use
of supplementation.

A 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-In

Rooming-in and breast-feeding on demand should be an
integral part of routine postpartum care. 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
much more effectively than a busy nurse could. Breast-
feeding on demand promotes more frequent feeding, which
prevents sore nipples, breast engorgement and early
weaning.

The benefits of breast milk:
A 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. Although 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.

Benefits of Breast-Feeding
Promotes mother-infant bonding
Promotes 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 osteoporosisPerceived
Barriers to Breast-Feeding Loss of freedom
Embarrassment
Jealousy (paternal and sibling)
Difficulty returning to work or school
Physical discomfort
Weaning
Lack of confidence (afraid that baby is starving)
Perception that formula is equal to breast milk

Hospital Discharge
Breastfeeding Instructions
Feed the infant on demand--on "hunger cues.“
Listen and feel for infant's swallowing.
Infant should regain birth weight by two weeks of age.
Avoid 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 1, two on day 2, 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 <8 percent at the two- to four-day
follow-up visit.

Breast-Milk Expression
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
prevent nipple confusion and early weaning. After 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.

Chest Thrusts for
A Pregnant Woman
CHOKING
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.

CHEST THRUSTS FOR PREGNANT
WOMAN OR OBESE PERSON
CONSCIOUS
1. Stand behind the person, placing your arms under the person's armpits
and around his or her chest.
2. 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–not the ribs–and that you are
not near the tip of the breastbone.
4. Put 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 CPR.

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


Thank
You.

Maternal Health Nursing Skills

Diunggah oleh

Informasi Dokumen

Deskripsi Asli:

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Maternal Health Nursing Skills

Diunggah oleh

Hak Cipta:

Format Tersedia

Maternal Health

MLNG CELESTE, RN, MD 4

With specific reference to marriage and family life,

MLNG CELESTE, RN, MD 5

Although some people object to the idea, we

MLNG CELESTE, RN, MD 6

Responsibility of parents to themselves and to each

Responsibility to their present and future children

Responsibility to their community and country

MLNG CELESTE, RN, MD 7

MLNG CELESTE, RN, MD 8

Birth spacing, to allow the mothers time to rest and

Birth limitation, when the desired number of children

Helping those who do not have children to have

MLNG CELESTE, RN, MD 9

MLNG CELESTE, RN, MD 10

MLNG CELESTE, RN, MD 11

MLNG CELESTE, RN, MD 12

MLNG CELESTE, RN, MD 13

MLNG CELESTE, RN, MD 14

MLNG CELESTE, RN, MD 15

MLNG CELESTE, RN, MD 17

MLNG CELESTE, RN, MD 18

MLNG CELESTE, RN, MD 19

MLNG CELESTE, RN, MD 20

MLNG CELESTE, RN, MD 21

MLNG CELESTE, RN, MD 22

MLNG CELESTE, RN, MD 23

MLNG CELESTE, RN, MD 24

MLNG CELESTE, RN, MD 25

MLNG CELESTE, RN, MD 26

MLNG CELESTE, RN, MD 27

MLNG CELESTE, RN, MD 28

MLNG CELESTE, RN, MD 29

MLNG CELESTE, RN, MD 31

MLNG CELESTE, RN, MD 34

MLNG CELESTE, RN, MD 35

MLNG CELESTE, RN, MD 36

MLNG CELESTE, RN, MD 37

MLNG CELESTE, RN, MD 39

MLNG CELESTE, RN, MD 40

MLNG CELESTE, RN, MD 41

MLNG CELESTE, RN, MD 42

MLNG CELESTE, RN, MD 43

Absolute Contraindications to OC’s

MLNG CELESTE, RN, MD 44

MLNG CELESTE, RN, MD 45

MLNG CELESTE, RN, MD 46

MLNG CELESTE, RN, MD 47

MLNG CELESTE, RN, MD 48

MLNG CELESTE, RN, MD 49

MLNG CELESTE, RN, MD 50

Subcutaneous implants (eg, Norplant)

MLNG CELESTE, RN, MD 53

MLNG CELESTE, RN, MD 55

MLNG CELESTE, RN, MD 56

MLNG CELESTE, RN, MD 57

MLNG CELESTE, RN, MD 59

MLNG CELESTE, RN, MD 60

MLNG CELESTE, RN, MD 61

Teaching – apply to erect penis with room at the

MLNG CELESTE, RN, MD 62

MLNG CELESTE, RN, MD 63