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RLE107MCF- Reviewer (maternal and child health nursing)
Theoretical foundation of nursing (TFN1)
Riverside College
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RLE107MCF: WEEK 1
OVERVIEW OF THE TOPICS TO BE DISCUSSED:
Assessing OB history AOG Computation Fundal Height Determination Leopold’s Maneuver FHB (fetal heart beat) Determination/ Fetal Monitoring
TERMINOLOGIES
Gravida –number of times a woman has been pregnant Para/Parity –number the woman has given birth to a fetus with gestational age of more than 24 weeks whether the child was born live or was stillborn Primigravida – has been pregnant for the first time Primipara – has been given birth to one child Multigravida – has pregnancy previously or been pregnant 2 or more times Multipara – has carried 2 or more pregnancies to viability Grand multipara – carried 5 or more pregnancies to viability Nulligravida – has never been and is not currently pregnant Abortion – termination of pregnancy before the fetus attained viability
Abortus – expelled from the uterus during the first half of gestation (20 weeks or less), or weighing less than 500 gms Stillbirth - infant died in the womb after 20 weeks gestation (earlier regarded as abortion). Sometimes called as fetal demise ( IUFD –fetal death) Stillborn – death or loss of the baby before or during delivery Term – pregnancy with AOG of 38-42 weeks Premature – born before 38 weeks Bloody show – vaginal discharge that occurs at the end of pregnancy or during labor TPAL - Term, Premature, Abortion, Live (describes the outcomes of pregnancies)
ASSESSING OB HISTORY
ANTENATAL CARE
Regular and periodic care of a pregnant woman and her unborn baby throughout pregnancy. Regular visits to a skilled health professional.
OBJECTIVES OF ANTENATAL CARE
- To identify danger signs of pregnancy and manage health problems that have an unfavorable outcome on pregnancy.
- To prevent occurrence of serious complications.
- To educate and counsel women for a health pregnancy, childbirth and postnatal recovery
including care of newborn, promotion of early breastfeeding initiation and exclusive breastfeeding and family planning.
FOCUSED ANTENATAL CARE
In normal, uncomplicated pregnancies, at least 4 antenatal visits with a skilled health provider: 1st visit: within 3 months 2nd visit: 6 months 3rd visit: 8 months 4th visit: 9 months – return if undelivered within 2 weeks after the EDC : Pregnant women who do not come for prenatal care should be visited at home
STEPS TO FOLLOW IN
ANTENATAL CARE
- QUICK CHECK for emergency signs Unconscious/convulsing Vaginal bleeding Severe abdominal pain Looks very ill Severe headache with visual disturbance Severe difficulty in breathing Dangerous fever (looks very weak) Severe vomiting : ATTEND TO A SICK WOMAN QUICKLY
2. Make the woman comfortable. Greet her, make sure she is comfortable and ask how she is feeling. At first visit, register the woman and issue a mother and child book (antenatal record form)
- Assess the pregnant woman At FIRST visit : do a complete history Name and Age Past medical history/alcohol/drug/substance abuse? Obstetric history: gravidity? LMP? AOG?
- Ask about or check record for prior pregnancies for general danger signs.
- Do a complete physical examination: Vital signs, height, weight.
DESIRABLE WEIGHT GAIN On a trimester basis in a woman with normal pre- pregnancy weight:
Desirable weight gain : 11.2-15 kg (25-35 lbs)
1st trimester ( 3 lbs) 0 kg or 1 lb/ mo 2nd trimester ( 12 lbs) 0 kg or 1 lb/week 3rd trimester ( 12 lbs) 0 kg or 1 lb/week
If a woman is high risk for nutritional deficit, more precise estimation of weight gain can be calculated. This is done by computing the body mass index:
AND PROMOTION
Give nutrition education and counseling Counsel on self-care during pregnancy Advise adherence to prophylactic treatments Counsel against unhealthy lifestyle Advise the pregnant woman not to smoke, avoid others who smoke and not allow smoking inside the house and work areas Caution the woman against taking alcoholic drinks Advise on danger signs of pregnancy and where to go during emergency Severe headache Blurring of vision Fever Fast or difficult breathing Severe abdominal pain Vaginal bleeding Convulsions
KEY MESSAGES:
Mother and her family should prepare a birth plan for
birth preparedness and complication readiness together with the health care attendant.
Counsel the woman to deliver in a health facility with a skilled health worker as the birth attendant.
AOG COMPUTATION &
FUNDAL HEIGHT DETERMINATION
AOG ( Age Of Gestation ) or Gestational Age - Refers to the length of pregnancy measured from the 1st day of the last menstrual period. - Sometimes measured in lunar months (10 months, 40 weeks or 280 days) or in : TRIMESTER (3 months period) 1ST TRIMESTER - 1 TO 12 WEEKS (1-3 MOS.) 2ND TRIMESTER - 13 TO 24 WEEKS (4-6 MOS.) 3RD TRIMESTER - 25 TO 38 WEEKS (7-10 MOS.)
COMPUTATION FOR
AOG DETERMINATION
Data Given : LMP (Last Menstrual Period) 1st Day Of The LMP Date Of Check Up/ Prenatal Visit EXAMPLE : LMP : January 6, 2014 Date Of Check Up: June 7, 2014
JANUARY 31 – 6 = 25 DAYS ( 31 days of january minus 6 which is the date of lmp) JANUARY 25 FEBRUARY 28 MARCH 31 APRIL 30 MAY 31 JUNE 7 (date of check up)
TOTAL: 152 DAYS
152 DAYS = 21 WEEKS
7 DAYS
AOG : 21 Weeks & 5 Days or 21 Weeks 5/7 Days
To get the 5/7 days: 21 weeks x 7 days = 147 days 152 days ( total days) – 147 days = 5 days
Determination of EDC
( Expected Date Of Confinement, Estimated Date Of Birth Or Expected Date Of Delivery )
NAEGELE’S RULE Ask the woman to state the 1st day of the LMP (Last Menstrual Period)
LMP Falls From January – March: + 9 + 7 LMP Falls From April – December: - 3 + 7 + 1
COMPUTATIONS :
LMP: JANUARY 1, 2014 1 – 1- 2014
LMP Falls From January – March: + 9 + 7
1 – 1 – 2014 (LMP)
- 9 +
EDC: 10 – 8 – 2014 ( OCTOBER 8, 2014)
LMP: JUNE 25, 2014 6 – 25 – 2014
LMP Falls From April – December: - 3 + 7 + 1
6 – 25 – 14 (LMP)
- 3 + 7 + 1 3 – 32 – 15 -31 ( days in march) EDC: 4 - 1 – 15 April 01, 2015
NOTE: Only 31 days in march, 1 day is forwarded to April
SOLVING FOR THE AOG BASED
ON THE ULTRASOUND
- counting the days after the date of the previous ultrasound then divided by 7, and add to the AOG as revealed by the ultrasound. Example : Date of ultrasound: June 25, 2020 with AOG of 13 weeks Solution: June 30 – no. of days (subtract) June 25 – date of ultrasound June 05
(add) July 31 (add) Aug. 23 (date today)
20 WEEKS 17 – 20cm Below umbilicus
24 WEEKS 21 – 24cm Level of umbilicus
28 WEEKS 25 – 28cm Above umbilicus
32 WEEKS 29 – 32cm Between Umbilicus & Xiphoid Process
MC DONALD’S RULE
Uses fundal height to determine the duration of a pregnancy. Using a tape measure and recording the distance from the superior aspect of the symphysis pubis to the uterine fundus in cm. as the woman lies supine.
As a rule of thumb your fundal height (in cm) is equal to the weeks of gestation (valid between 20th and 32nd weeks of pregnancy).
McDonald’s Rule: Computing in Weeks
FH [in cm] x 8/7 = GA in weeks
Problem : What is the estimated gestational age in weeks if the fundic height is 21 cm?
Solution: 21 x 8 = 24 weeks 7
FH LARGER THAN
EXPECTED
FH SMALLER THAN
EXPECTED
Thicker uterus Baby prematurely descending into the pelvis Full Bladder Taller or slim stature baby Short stature baby Twins Well conditioned abdominal muscles
Loose abdominal muscles
Miscalculated due date
LEOPOLD’S MANUEVER
Four maneuvers for assessing fetal position, presentation, degree of descent and fetal attitude by external palpation of the mother's abdomen.
OBJECTIVES
To identify number of fetuses To determine fetal presentation, lie, presenting part, degree of descent, and fetal attitude To identify point of maximum intensity (PMI) of fetal heart rate (FHR) in relation to the woman’s abdomen To monitor the descent and internal rotation of the fetus
FACTORS AFFECTING THE PERFORMANCE OF
MANEUVER
Difficult to perform in obese women Women with hydramios Women with full bladder
EQUIPMENTS
Fetal monitoring device – such as
Doppler
Stethoscope
PROCEDURE
- Wash hands.
Prevents nosocomial infection
- Ask woman to empty bladder.
Increases maternal comfort during examination,
facilitates accurate assessment 3. Position woman in supine position with one pillow under her head and with her knees slightly flexed.
Ensures comfort, relieves tension of abdominal
musculature 4. Place small rolled towel under woman’s right hip.
Displaces uterus to left off of major blood vessels.
(Avoids supine hypotensive syndrome) 5. If right-handed, stand on woman’s right facing her.
Facilitates examination by using dominant hand.
- FIRST MANEUVER. Identify fetal part that occupies the fundus. The head feels round, firm, freely movable and palpable by ballottement; the breech feels less regular and softer. ( Fundal Grip) Identifies fetal lie (vertical or horizontal) and presentation (vertex or breech)
- SECOND MANEUVER. Using palmar surface of one hand, locate and palpate the smooth convex contour of the fetal back and the irregularities that identify the small parts (feet, hands, elbows)
( Umbilical Grip )
Assists in identifying fetal presentation
- THIRD MANEUVER. With the right hand, determine which fetal part is presenting over the inlet to the true pelvis. Gently grasp the lower pole of the uterus between the thumb and fingers, pressing in
Describes the location of a fixed reference point on the presenting part in relation to the four quadrants of the maternal pelvis LOA, LOP, ROA, ROP, RSA, LMP
PRESENTATION
BREECH PRESENTATION
ATTITUDE
FLEXED EXTENSION LIE
Flexion is NORMAL
Transverse lie is UNCOMMON
Lie- the relationship of long axis of the fetus to the
long axis of the woman
MONITORING LABOR
Uterine Contraction - tightening and shortening of cervix - Resulting in effecement and dilation of cervix
Phases of Uterine Contraction:
1. Increment- intensity increases 2. Acme- contraction is at peak 3. Decrement- intensity decreases Duration - length of uterine contraction from the beginning of uterine contraction to the end of the same uterine contraction. Frequency – time when contractions begin to the beginning of the next uterine contraction. Interval – time from the end of uterine contraction to the beginning of uterine contraction (resting period of uterine contraction).
Explain the procedure and it’s purpose.
Let the patient assume a Semi-Fowler’s position.
Expose farther breast and place rolled towel around.
Using sterile cotton ball wet with sterile water, clean breast from nipple going outward in rotating motion. Get another cotton ball wet with soapsuds solution, clean breast from areola going outward.
Using sterile cotton balls wet with sterile water, rinse the breast from nipple going outward in rotating motion until soap solution is all washed out.
Observes aseptic technique in handling pick-up and sterile forceps.
Avoid wetting patient’s clothing and bed sheets with cleansing solutions.
Dry area with sterile cotton ball (pat to dry).
Apply sterile OS or Clean diaper over the nipple.
Repeat steps 6-10 to the other breast.
Remove towel and adjust patient’s gown.
Make patient comfortable.
Return equipment to CSR.
Wash hands.
EVALUATION
1 care has been comfortably and effectively provided.
2’s breast appears free of complicating conditions. 3 understands the importance and technique for proper breast care.
Perineal Care - The aseptic cleansing of the vulva and
perineum. ASSESSMENT
1 general assessment data about patient.
2 for signs of perineal itching, burning on urination, or skin irritation. Ask patient if he or she experiences any of these problems. 3 patient's ability to bathe him or herself and to perform perineal care. 4 patient's learning needs related to perineal care. 5 providing privacy, assess the perineal/genital area for abnormalities. OBJECTIVES
1. To keep the vulva and perineum clean.
- To promote healing of perineal wound.
- To prevent infection.
- To prevent disagreeable odor.
- To remove secretions.
- To provide comfort. GENERAL CONSIDERATIONS
1 flushing water should be of the right temperature to
avoid burning the patient. 2 special care when a patient has a perineal wound or stitches to avoid much discomfort.
3 the patient defecated or voided, empty the bedpan first before giving perineal care. 4 used perineal balls into the waste receptacle, not into the bedpan.
EQUIPMENTS :
Flushing Tray Containing the Following: Extra sterile forceps Waste receptacle Ordered medicine Tissue paper Bedpan Perineal pad Bath towel
Gloves
PREPARATION
Flushing tray containing:
a of dry perineal balls b of sterile soap suds solution c pitcher with warm sterile water d-up forceps soaked in cidex solution •Extra sterile forceps •Waste receptacle (preferably emesis basin lined with paper) •Ordered medicine •Tissue paper •Rubber protector (if needed) •Bedpan •Perineal pad, if necessary
•Bath towel •Gloves PROCEDURE
- Prepare and gather equipment.
- Explain the procedure and its purpose.
- Screen the patient.
- Remove perineal pad, if any. Wrap it with paper and discard into waste can.
- Wash hands and wear gloves
- Loosen the foot part of the top sheet and place patient in dorsal recumbent position.
- Place rubber protector under patient's buttocks.
- Place the patient on bedpan. Fan fold the top sheet towards the knees, to expose vulva and perineum. Put a bath towel over the abdomen.
- Place lined kidney basin outside the tray and position it conveniently for use.
- Use perineal balls soaked in soap sud solution for cleaning the vulva.
- Pour sterile/tap water over the vulva.
- Clean the vulva and perineum using perineal balls soaked in soap sud solution. Use a downward stroke in the following sequence: a of vulva b labia minora c labia minora d labia majora e labia majora
2 the 4 core steps of immediate newborn care of the EINC protocol. 3 the evidence-based routine care of a newborn baby at the time of birth. 4 how to manage special situations concerning breast- feeding problems in the first hour of life.
Skills
1 the necessary equipment and arrange them in the proper sequence for a delivery. Perform proper handwashing and put on sterile gloves. i and thorough drying. ii - to - skin contact iii- timed cord clamping iv- separation of mother and newborn for early initiation of breastfeeding. 2 out the four core steps of immediate newborn care in the EINC protocol. 3 breast-feeding problems in the first hour of life. 4 clearly and effectively by written or oral means with the health team members, the client and the family. 5 complete and accurate records.
Attitudes
1 mindful of the standard precautions for infection control.
2 meticulous and thorough in the performance of the four core steps in the EINC protocol. 3 lifelong learning as a goal to be able to deliver the best care to the ones patients. 4 the rights of patients including the right to confidentiality at all times. 5 in empathy with women and their families. 6 own competency level and have self-awareness to call for help from colleagues, clinical and nonclinical, when necessary. 7 the necessity for adhering to appropriate use of protocols and guidelines. 8 the highest standards of professionalism and personal integrity from oneself.
Introduction ➢The essential intrapartum and newborn care protocol tackles the time bound sequence of actions that will ensure the safe care of both the mother and the newborn during birth and beyond. It focuses on the care of the newborn during the period immediately after birth. ➢The detailed procedure as well as the rationale for each of the four core steps step are discussed. ➢In addition, unnecessary and or potentially harmful practices that should be avoided are likewise examined.
Preparations for Delivery
1 in the workplace.
- Make sure all necessary shipment and supplies are available
- Staffing and schedules are in order
- Proper documentation
2. Maintaining the ideal room temperature at 25 to 28°C to prevent cold stressed and hypothermia in the baby. 2. Check room temperature using a room thermometer 2. Close windows draw curtains, turn off electric fans to eliminate air drafts. 2. Turn off the air-conditioning unit at the time of delivery 2. If air-conditioning is centralized, adjust the thermostat setting prior to the delivery
3. Repair necessary equipment 3. Delivery instruments 3.1 Hand washing implements 3.1 Sterile gloves two sets if solitary healthcare worker 3.1 Warm towels or linens 3.1 A bonnet 3.1 Sterile plastic cord clamp or cord tie 3.1 Sterile instrument clamp 3.1 Sterile pair of scissors (separate from that use for episiotomy, if done)
3.1 Oxytocin 10 IU and sterile syringe for IM injection 3.1 Receptacle for placenta container we are 0% chlorine for instruments
3 Newborn Care Interventions/ Supplies after the first breastfeed, approximate 1 to 2 hours after birth 3.2 Eye prophylaxis erythromycin or tetracycline ointment 3.2 Vitamin K ampule, cotton balls, sterile syringe for IM injection. 3.2 Anti- hepatitis B vaccine, cotton balls , sterile syringe for IM injection 3.2 BCG vaccine, cotton balls, sterile syringe for ID injection
4. Perform hand hygiene ➢ Protect health workers and their patients from risk of infection.
5. Wearing of sterile gloves ➢ Sterile gloves are worn routinely for each delivery to protect the mother, her baby and health workers from exposure to diseases spread by blood and other body fluids.
1.1. If after 30 seconds newborn is breathing or crying normally, do skin to skin contact 1.1. However if after 30 seconds the newborn is not briefing or is gasping, clamp and cut the umbilical cord, call for help and start basic resuscitation.
1. Reminders : 1.2. Do not routinely suction the mouth and nose of the vigorous newborn unless the mouth/ nose is blocked by secretions. Routine suctioning has no proven benefit if amniotic fluid is clear and especially with the newborns her cry and breathe immediately after birth. Unnecessary suctioning in a baby who Is crying and breathing normally Can cause apnea vagal induced bradycardia, slower rise in oxygen saturations and mucosal trauma with possibly an increased risk for infection if in expertly performed. 1.2. Do not ventilated within the first 30 seconds unless the baby is both flappy lips and not breathing. Only a small number of all babies born in facilities need some form of resuscitation. In my depressed newborns drying provide sufficient stimulation. 1.2. Do not slap shake or rub the baby. 1.2. Do not hang the baby upside down 1.2. Do not squeeze the babies chest 1.2. Do not wipe off the white greasy substance covering the newborn’s body (vernix). This helps to
protect the newborn skin and gets re absorbed very quickly.
2. (Second core step) Skin to skin contact 2. Skin to skin contact facilitates bonding between the mother and her newborn. It also provides warmth with prevents hypothermia and it’s complication. It provides protection from infection by exposing the baby to the good bacteria of the mother and it increases the blood sugar of the baby more importantly it aids in the initiation of breast-feeding with colostrum and facilitates successful breast-feeding. 2. Remove the mothers gown then place the newborn prone on the mother’s chest, skin to skin with the head turned to one side to facilitate drainage of any secretions from the mouth and nose. 2. Cover the newborn’s back with a dry blanket and head with a bonnet. 2. Place the identification band on the ankle. 2. Make sure that the room temperature is properly maintained at 25 to 28°C and the babies temperature is between 36 to 37°C.
2. Reminders : 2.6. Do not separate the newborn from the mother if the newborn does not exhibit severe chest in drawing gasping or apnea and the mother does not
need urgent medical or surgical management ( e. emergency hysterectomy) 2.6. Do not put the newborn on a cold or wet surface. 2.6. Do not do foot printing. It is an inadequate technique for newborn identification purposes. DNA genotyping and human leukocyte antigen test are better methods of identification. 2. Check for multiple birth as soon as the newborn is securely position on the mother. Palpate the mothers abdomen to check for a second baby or for multiple births. If there is no second baby give 10 IU of oxytocin intramuscularly to the mother with in one (1) minute of babies birth. If there is another baby ( or more ) call for help deliver the second baby and manage like the first baby. 2. The first skin to skin contact should last uninterrupted for at least one hour after birth or until after the first full breast-feed. 2. Skin to skin contact can restart at anytime if the mother in the newborn have to be parted for a minute treatment or care procedures. If they are separated, Wrap baby and warm covers and place in a cot in a warm room. A radiant warmer maybe use if the room is not warm or if the newborn is small.
3. (Third Core Step) Properly- timed Cord clamping, within 1 to 3 minutes
- The placenta transfuses blood to the newborn after delivery, providing oxygen, nutrients and additional blood volume through the pulsating cord. Once this transfusion is completed cord pulsations will stop and the Cord will flatten. Placental transfusion can provide the infant with more blood volume and additional red blood cells resulting in less anemia in both term and preterm babies. In preterm, it reduces the need for blood transfusion in the first 4 to 6 weeks of life and the occurrence of intraventricular hemorrhage and late onset sepsis.
- Remove the first set of gloves immediately prior to Cord clumping
- Palpate the Umbilical cord in the Wait for the cord pulsation to stop (typically at 1 to3 minutes)
- After cord pulsations have stopped and the cord has flattened, clamp and cut the cord as follows: 3.4. Place the first plastic clamp/tie 2 cm From Umbilical Cord base And the second instrument clamp/tie at 5 cm from the base. 3.4. Cut the cord near the plastic clamp/first tie. 3.4. Observe for oozing of blood. If there is, place a second tie near the plastic clamp.
3. Reminders. 3.5. Do not milk the cord towards the newborn.
RLE107MCF- Reviewer (maternal and child health nursing)
Course: Theoretical foundation of nursing (TFN1)
University: Riverside College
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