Maternal Health Nursing Skills

Maternal Health Nursing Skills
Mary Lourdes Nacel G. Celeste, RN, MD
RESPONSIBLE PARENTHOOD
Reproductiv e Life FAMILY PLANNING 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
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.
MLNG CELESTE, RN, MD 5
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
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To the family gives the family members more opportunity to enjoy each others company with love and affection enables the family to save some amount for improvement of standard of living, and for emergencies
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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
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Contraceptive
Any device used to prevent fertilization of an egg
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Considerations:
Personal values Ability to use method correctly How method will affect sexual enjoyment Financial factors Status of couples relationship Prior experiences Future plans Contraindications
CONTRAINDICATIONS OF CONTRACEPTIVE USE
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Contraceptives
40 million women in United States use some form of contraception 65% of women of childbearing age
? PHILIPPINES
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Contraceptives
1. Abstinence
0% failure rate Most effective method to prevent STDs Difficult to comply with
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Contraceptives
2. Natural Family Planning No chemical or foreign material into the body Failure rate of approximately 25%
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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
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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
Calendar/ Rhythm (Natural Family Planning)
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
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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.
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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 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
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
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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 MLNG CELESTE, RN, MD 30
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
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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 MLNG CELESTE, RN, MD 34
Symptothermal method
Combines BBT and cervical mucus methods
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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
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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
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3. Oral Contraceptives
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 OCs: 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 OCs Breastfeeding Family history of CVA or CAD History of thromboembolic disease History of liver disease Undiagnosed vaginal bleeding
Possible Contraindications to OCs Age 40+ 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 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
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Estrogen-progesterone patch
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Highly effective, weekly hormonal birth control patch thats 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
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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
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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
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5. INTRAUTERINE DEVICE
Side Effects: Spotting or uterine cramping Increased risk for PID Heavier menstrual flow Dysmenorrhea Ectopic pregnancy
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6. Barrier Methods
Vaginally inserted spermicidal products Diaphragms Cervical caps Condoms
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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
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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
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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; misoprostolprostaglandin 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
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Indications
1. 2. 3. 4. 5. 6. AT THE FIRST VISIT: The diagnosis of pregnancy during the first trimester Assessment of the gestational age Detection of abnormalities in the genital tract Investigation of a vaginal discharge Examination of the cervix Taking a cervical (Papanicolaou) smear
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Indications
1. 2. 3. 4. 5. 6. 7. AT SUBSEQUENT ANTENATAL VISITS: Investigation of a threatened abortion Confirmation of PROM with a sterile speculum To confirm the diagnosis of preterm labor Detection of cervical effacement and/ or dilatation in a patient with a risk for preterm labor Assessment of the ripeness of the cervix prior to induction of labor Identification of the presenting part in the pelvis Performance of a pelvic assessment
IMMEDIATELY BEFORE LABOR 1. Performance of artificial rupture of the membranes to induce labor MLNG CELESTE, RN, MD
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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.
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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.
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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 clients 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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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.
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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.
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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
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Insertion of a Speculum
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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. MLNG CELESTE, RN, MD 84
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.
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Pap Smear
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Pap Smear
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Pap Smear
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Pap Smear
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Pap Smear
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Pap Smear
Findings of Paps 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
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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.
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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
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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.
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The Bimanual Exam
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The Bimanual Exam
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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
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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 youre 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; Kegels 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.
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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
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C. Pelvic Floor Contractions (Kegels 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.
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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.
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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.
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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.
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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.
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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.
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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.
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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. Dont 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 youre not used to it.
Leopolds Maneuvers
LEOPOLDS 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.
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Palpation of the Uterine Fundus
First Maneuver
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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
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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
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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.
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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)
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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)
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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 examiners 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 infants anteroposterior position. If brow is very easily palpated, fetus is at posterior position (occiput pointing towards womans 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
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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 Leopolds maneuvers and position the listening instrument over the fetal back. Place the earpieces in your ears and press gently on the patients 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 Leopolds 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
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Fetal Heart Rate Patterns Tachycardia (>160 bpm) Bradycardia (<120 bpm)
Indicative of Maternal or fetal infection Fetal hypoxia (ominous sign) Fetal hypoxia or stress Maternal hypotension after epidural initiation
Intervention Depends on the cause Place client on her left side Increase fluids to counteract hypotension Stop oxytocin (Pitocin) if in use None required
Early deceleration (deceleration begins and ends with uterine contraction) Late deceleration (HR decreases after peak of contraction and recovers after contraction ends)
Head compression :not ominous Vagal stimulation Fetal stress and hypoxia Deficient placental perfusion Supine position Maternal hypotension Uterine hyperstimulation
Change maternal position Correct hypotension Increase IV fluid rate as ordered Discontinue oxytocin Administer oxygen as ordered Change maternal position Administer Oxygen Depends on the cause
Variable deceleration (transient decrease in HR anytime during contraction Decreased variability
Cord compression Hypoxia or hypercarbia Fetal sleep cycle Depressant drugs Hypoxia CNS anomalies
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Measuring Fundic Height

Fundic Height
McDonalds 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 MLNG CELESTE, RN, MD 140
Fundic Height
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Location of the fundus:

12 weeks 16 weeks 20weeks 24 weeks 30 weeks 36 weeks 40 weeks at the level of the symphysis pubis halfway between symphysis pubis and umbilicus at the level of the umbilicus two fingers above umbilicus midway between umbilicus and xiphoid process at the level of xiphoid process two fingers below umbilicus, drops at 34 weeks level because of lightening
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Computation of EDC & AOG based on LMP Obstetrical Number

EDC
LAST MENSTRUAL PERIOD first day of the last menses
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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 February March April May June July August 30 days 28 31 30 31 30 31 31 Total = 242 days AOG = 242 7 34 to 35 weeks
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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
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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
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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
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Lie
Lie relationship of spine of fetus to spine of mother; longitudinal (parallel) transverse (right angles) oblique (slight angle off a true transverse lie)
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Position
relationship of fetal reference point to mothers pelvis Fetal reference point Vertex presentation dependent upon degree of flexion of fetal head on chest; full flexionocciput (O); full extensionchin (M); moderate extension brow (B) Breech presentation sacrum (S) / Sa Shoulder presentation scapula (SC) / A (acromion)
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Position
Relation of the presenting part to a specific quadrant of a womans pelvis Right anterior Left anterior Right posterior Left posterior
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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 mothers left side toward the front of her pelvis Fetal position reflects the orientation of the fetal head or butt within the birth canal.
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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.
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Left occiput anterior (LOA)
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Right occiput anterior (ROA)
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Left occiput transverse (LOT)
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Right occiput transverse (ROT)
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Occiput posterior (OP)
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Occiput Anterior (OA)
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Left occiput posterior (LOP)
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Right occiput posterior (ROP)
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FETAL POSITION
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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
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STATION or DEGREE OF ENGAGEMENT
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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
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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 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). MLNG CELESTE, RN, MD 179
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.
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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.
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Insertion of Catheter
Catheterization
INSERTION OF CATHETER / Catheterization involves the introduction of a catheter through the urethra into the urinary bladder
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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 MLNG CELESTE, RN, MD 185
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
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Catheterization
Types of catheter: 1. Straight or Robinson catheter a single lumen tube with a small eye or opening about 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 MLNG CELESTE, RN, MD 190 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. MLNG CELESTE, RN, MD 191 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 females thigh. 20. Secure drainage bag to the bedframe using its hook. Suspend it off the floor but keep it below the level of the patients bladder. Make sure the emptying base of the drainage bag is closed. 21. Document catheterization.
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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). 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.
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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).
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Perineal Preparation
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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 MLNG CELESTE, RN, MD 209 lacerations caused by pressure of the fetal head)
Types of Episiotomy
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10. Control the delivery by Ritgens 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)
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Ritgens maneuver
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12. Remove mucus and fluid from the neonates 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.)
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Normal Spontaneous Delivery
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Umbilical cord
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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.
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Placenta
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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 patients 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 motherinfant bonding process. One of the mothers first needs is to be reassured that her infant is normal)
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Cesarean Childbirth
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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
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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.
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Cleaning the perineum

Typically, youll 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 youre 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 youre 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 Simss position. When inspecting the wound area, be alert for such signs of infection as unusual swelling, redness and foul-smelling discharge.
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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
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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.
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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
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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.
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Sitz Bath
SITZ BATH (Kozier)

A sitz bath, or a hip bath, is used to soak a clients 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 MLNG CELESTE, RN, MD 238 minutes, depending on the clients 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 clients feet; a footstool can prevent pressure on the backs of the thighs. Provide a bath blanket for the clients 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. RN, MD MLNG CELESTE, 239
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 clients 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 clients 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 clients 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 tubing. MLNG 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 patients reactions. A bulb over 60 watts must be used. Wash the perineal light in a utility room with a germicide.
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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 infants mouth covers a large portion of the areola and release infants mouth from nipple by inserting finger to break suction Rotate breastfeeding positions
Engorgement nurse frequently (every -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
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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 infants mouth to ensure proper sucking
BREASTFEEDING Non-allergenic Meet infant s specific nutritional needs Immunologic properties help prevent infection Easily digested Constipation unlikely Overfeeding less likely No formula or bottles to buy No formula and bottle to prepare Oxytocin release help involution Mother more likely to eat well balance diet May help with mothers weight loss Enhances mother/infant attachment through skin to skin contact Frozen -20c (6 mos) Refrigerated 4c ( 24 H)
BOTTLEFEEDING Father or others may feed infant day or night Feed less frequently (34H) Amount of milk taken at each feeding known
A D V A N T A G E S
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BREASTFEEDING Feed more frequently (2-3 H) More frequent diaper changes Amount of milk taken at each feeding unknown Medications taken by mother present in milk Discomfort of som mothers to nurse in public Expense of pumping and storing milk for periods when mother is unavailable ( such as work)
BOTTLEFEEDING Expense of formula, bottles Washing bottles Fixing and refrigerating formula Carrying bottles on outings May cause constipation
D I S A D V A N T A G E S
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Breastfeeding
Cradling
Position for feeding The infant should be held with head slightly higher than the rest of the body Cradle hold with infants head in the bend of the mothers elbow and arm supporting the infants body OTHERS: Football hold Side lying position Across lap
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Breastfeeding
Cradling
Latching on The mother should use the infant's rooting reflex to allow positioning of the nipple in the infants mouth Brushing the nipple against the infants 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
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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 breastfeeding. However, their effectiveness is questionable. Inverted nipples may naturally become more erect after the birth of your baby.
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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.
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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. Breastfeeding on demand promotes more frequent feeding, which prevents sore nipples, breast engorgement and early weaning.
The benefits of breast milk: A mothers 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.
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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 womans enlarged abdomen. Late in pregnancy, therefore, therefore a rescuer might use successive chest thrusts instead.
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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 breastbonenot the ribsand 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 youre 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.
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Maternal Health Nursing Skills

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Maternal Health Nursing Skills

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Maternal Health Nursing Skills

Mary Lourdes Nacel G. Celeste, RN, MD

Reproductiv e Life FAMILY PLANNING Planning

Reproductive Life Planning

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CONTRAINDICATIONS OF CONTRACEPTIVE USE

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Calendar/ Rhythm (Natural Family Planning)

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Calendar/ Rhythm (Natural Family Planning)

1. Calendar (rhythm) method

1. Calendar (rhythm) method

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1. Calendar (rhythm) method

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1. Calendar (rhythm) method

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2. Basal Body Temperature

3. Cervical Mucus (Billings) Method

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3. Cervical Mucus (Billings) Method

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Lactation amenorrhea method

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Emergency Postcoital Contraceptives

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8. Elective Termination of Pregnancy

Physical Assessment of a Pregnant Woman

Genital & Pelvic Examination

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TO THE FEMALE CLIENT

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TO THE FEMALE CLIENT

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TO THE FEMALE CLIENT

Sexual Abuse and Other Concerns

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Step 1. The External Genital Exam