Obg Lab Module

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FEMALE PELVIS
DEFINITION:
Bony pelvis forms the bony part of birth canal through which the fetus pass during the
process of labour.
FUNCTIONS OF PELVIS:
 The primary function of the pelvic girdle is to allow movement of the body, especially
walking and running.
 The pelvis bears the weight of the sitting body on to the ischial spines.
 It permits the person to sit and kneel. The women’s pelvis is adapted for
childbearing and because of its increased width and rounded brim women’s are less
speedy than men.
 Provide attachments for and withstand the forces of the powerful muscles of
locomotion and posture
 The pelvis affords protection to the pelvic organs and to lesser extent, to the
abdominal organs.
 The sacrum transmits the cauda equina and distributes the nerves to the various
parts of the pelvis.
TYPES OF PELVIS:
On the basis of shape of inlet, the female pelvis is divided into 4 parent types:
• Gynaecoid (50%)
• Anthropoid (25%)
• Android (20%)
• Platypelloid (5%)
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FEATURES OF THE FOUR TYPES OF PELVIS:
FEATURE GYNAECOID ANDROID ANTHROPOID PLATYPOID
Brim (Shape) Rounded Heart Shaped Long Oval Kidney Shaped
Forepelvis Generous Narrow Narrowed Wide
Side Walls Straight Convergent Divergent Divergent
Ischial Spines Blunt Prominent Blunt Blunt
Sciatic Notch Rounded Narrow Wide Wide
Sub Pubic 90 <90 >90 >90

Angle
Incidence 50% 20% 25% 5%
PELVIC BONES:
1. Two Innominate bones (ilium, Ischium, Pubis)
2. One Sacrum
3. One Coccyx
A). INNOMINATE BONES (Ilium, Ischium, and Pubis):
ILIUM:
• The Ilium is the large flared outer part.
• Main features are:

o Iliac crest (upper border of ilium; when hands are placed on the hip, it rest on the
iliac crest)
o 2/5 of acetabulum (deep cup to receive the head of the femur)
o Anterior superior iliac spine (bony prominence at the front of iliac crest)
o Anterior inferior iliac spine (short distance below from anterior superior iliac
spine)
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o Posterior inferior iliac spine (bony prominence at the behind of iliac crest)
o Posterior superior iliac spine (short distance below from posterior inferior iliac
spine)
o Iliopectineal eminence
o Sacroiliac joint (articulation between sacrum and ilium)

o Iliac fossa (concave anterior surface of the ilium)
o Iliopectineal line
ISCHIUM:
• It’s the thick lower part.

o 2/5 of acetabulum
o Ischial tuberosities (large prominence on which the body rests when sitting)
o Ischial spines (inwards projection above the tuberosity )
o Lower border of obturator foramen
THE PUBIC BONE:

• This bone forms the anterior part.

 1/5 of acetabulum
 Superior ramus and inferior ramus (two oar like projections)

 Symphysis pubis
 Pubic arch (two inferior rammi forms the pubic arch).
 The space enclosed by the body of the pubic bone, the rami and the Ischium is called
the obturator foramen.
The innominate bone contains a deep cup to receive the head of the femur. This is
termed the acetabulum. On the lower border of the innominate bone are two curves. One
extends from the posterior inferior iliac spine up to the ischial spine and is called greater
sciatic notch. It is wide and rounded. The outer lies between the ischial spine and the ischial
tuberosity and is the lesser sciatic notch.
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Figure 1: Innominate bone
THE SACRUM:
• Sacrum is wedge shape bone consisting of five fused vertebrae.
• The upper border of the first sacral vertebrae just forward and is known as the sacral
promontory.
• The anterior surface of sacrum is concave and is referring to as the hollow of the sacrum.
• Laterally the sacrum extends into a wing or ala.
• Four pairs of holes or foramina pierce the sacrum and, though these, nerves from the cauda
equina emerge to supply pelvic organs.
• The posterior is roughened to receive attachment of muscle.
Figure 2: Sacrum and Coccyx
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THE COCCYX:
• The coccyx is vestigial tail.
• It consists of 4 fused vertebras, forming small triangular bone.
• It is referred to as rudimentary tail.
JOINTS OF PELVIS:
There are 4 pelvic joint:
• Symphysis pubis-1
• Sacroiliac joint-2
• Sacro-coccygeal joint-1
Symphysis pubis
• It is form at the junction of 2 pubic bones, which are united by a pad of cartilage.
• Fibro-cartilaginous joint
• Articular surfaces are covered with hyaline cartilage
• Has no capsule & no synovial cavity
Sacroiliac joint
• It is Synovial joint.
• This is the strongest joint in the body.

• They join the sacrum to the ilium and thus connect the spine to the pelvis.
• Has got a capsule & a synovial cavity
Sacrococcygeal joint
• This joint is formed where the base of coccyx articulates with the tip of sacrum.
• The sacro-coccygeal joint permit the coccyx to be deflected backward during the
birth of foetal head.
PELVIC LIGAMENTS:
Each pelvic joint is held together by ligaments.
o Interpubic ligaments at the symphysis pubis..
o Sacroiliac ligament
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o Sacrococcygeal ligament
o Sacrotuberous ligament
o Sacro spinous ligament
• Sacrotuberous ligaments run from sacrum to ischial tuberosity.
• Sacrospinal ligaments run from the sacrum to the ischial spine.
• These two ligaments cross the sciatic notch and form the posterior wall of pelvic
outlet.
Figure 3: Pelvic Ligaments
PELVIC MUSCLES:
There are two layers of muscles of pelvic floor:
A).SUPERFICIAL LAYER: this layer is composed of five muscles.
 External anal sphincter muscles: it encircles the anus and is attached behind by few
fibres to the coccyx.
 Transverse perineal muscles: pass from the ischial tuberosities to the centre of
perineum.
 Bulbocavernous muscles: pass from the perineum forwards around the vagina to
the corpora cavernosa of the clitoris.
 Ischiocavernous muscles: pass from the ischial tuberosities to the corpora

cavernosa.
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 Membranous sphincter of urethra: composed of muscle fibres passing above and

below the urethra and attached to the pubic bones.
B).DEEP LAYER OF MUSCLES: this layer is composed of three pairs of muscles, which
together are known as levator ani muscles. They are so called because they lift the anus.
Each levator ani muscle (right and left) consists of the following:
 Pubo-coccygeus muscle: pass from the pubis to coccyx
 Ilio-coccygeus muscle: pass from fascia covering obturator internus muscle to the
coccyx.
 Ischio-coccygeus muscle: pass from ischial spine to the coccyx.
Figure 4: Muscles of Pelvic Floor
FALSE AND TRUE PELVIS:

Pelvis is divided into two parts, the false and the true pelvis.
A).The false pelvis:

• It is the part above the brim and consists mainly of the flared out iliac bones and is
bound by the iliac crest.
• It supports the enlarged uterus during pregnancy
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• It has very little obstetrics importance.
Figure-5: True and False Pelvis
B).The true pelvis:

• Chief concern to the obstetricians
• True pelvis is the bony canal through which the fetus passes during birth. It has brim,
cavity and outlet
• Shallow in front, formed by symphysis pubis & measures 4cm.
• Deep posteriorly formed by sacrum, coccyx and measures 11.5cm.

• It is divided into: inlet (brim), cavity and outlet.
4. INLET OF PELVIS (PELVIC BRIM):

• The brim is round except where the sacral promontory projects into it.
• The promontory and wings of the sacrum form its posterior border, iliac bones its
lateral borders and pubic bone its anterior border.
• The midwife needs to be familiar with the fixed points on the pelvic brim which are
known as its landmarks.
Landmarks of pelvis
1. Symphysis pubis
2. Pubic crest
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3. Pubic tubercle
4. Pectineal line
5. Ilio-pubic eminence
6. Iliopectineal line
7. Sacro-iliac articulation
8. Anterior border of ala of sacrum
9. Sacral promontory
Figure 6: Landmarks of Pelvis
Diameter of inlet:
 ANTERO-POSTERIOR: It is the distance between the midpoint of the sacral
promontory to the inner margin of the upper border of symphysis pubis (11cm)
 OBSTETRIC CONJUGATE: It is the distance between the midpoint of the sacral

promontory to prominent bony projection in the midline on the inner surface of pubic
symphysis (10cm)
 DIAGONAL CONJUGATE: It is the distance between the lower border of symphysis

pubis to the midpoint on the sacral promontory (12cm)
 TRANSVERSE DIAMETER: It is the distance between the two farthest points on the
pelvic brim over the Iliopectineal lines (13cm)
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 OBLIQUE DIAMETER: there are two oblique diameters-right and left. Each one
extends from one sacro-iliac joint to the opposite ilio-pubic eminence (12cm)
 SACRO-COTYLOID: It is the distance between the midpoint of the sacral
promontory to ilio-pubic eminence (9.5cm)
Figure-7: Diameters of Inlet
2. CAVITY OF PELVIS:
 Cavity is the segment of the pelvis bounded above by the inlet and outlet below.
 The anterior wall is formed by the pubic bone and symphysis pubis and its depth
is 4cm. The posterior wall is formed by the curve of sacrum which is 12 cm in
depth.
 Shape: It is almost round.
 Diameters
 ANTERO-POSTERIOR DIAMETER: It measures from the midpoint on the posterior
surface of the symphysis pubis to the junction of 2nd and 3rd sacral vertebrae (12cm)
 TRANSVERSE DIAMETER: It cannot be precisely measured as the points lie over
the soft tissues covering the sacrosciatic notches and obturator foramina
5. OUTLET OF PELVIS:
Obstetrical outlet:
• It is the segment of the pelvis bounded above by the plane of least pelvic dimensions
and below by the anatomical outlet
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• Its anterior wall is deficient at the pubic arch, lateral walls are formed by ischial bones
and the posterior wall includes whole of coccyx
• Shape-it is antero-posteriorly oval.
• Diameters:
 TRANSVERSE:BISPINOUS- It is the distance between the tip of two ischial spines

(10.5cm)
 ANTERO-POSTERIOR :It extends from the inferior border of symphysis pubis to the
tip of the sacrum (11cm)
 POSTERIOR SAGITTAL: It is the distance between the tip of sacrum and the
midpoint of bispinous diameter
Anatomical outlet:
• It is bounded in front by the lower border of the symphysis pubis; laterally by the
ischio-pubic rami, ischial tuberosity & Sacrotuberous ligament and posteriorly by the
tip of coccyx.
• Shape: It is diamond shaped
• Diameters:
 ANTERO-POSTERIOR: It extends from the lower border of the symphysis pubis to
the tip of the coccyx. (13cm)
 TRANSVERSE DIAMETER: It measures between inner borders of ischial
tuberosities. (11cm)
 POSTERIOR SAGITTAL DIAMETER: It is the antero-posterior distance between

the Sacrococcygeal joint and the midpoint of transverse diameter of outlet (8.5cm)
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REVIEW OF DIAMETERS:
Anteroposterior Oblique Transverse
Brim 11 12 13
Cavity 12 12 12
Outlet 13 11 11
REFERENCES:
1) Manocha.Snehlata. Procedures and Practice in Midwifery.2nd edition. New Delhi:

Kumar Publishing House; 2013.p 44-49.
2) Dutta. DC. Textbook of Obstetrics.6th edition. Calcutta: New central book agency (P)
ltd; 2004. p 87-94.
3) Myles. Textbook for Midwifes.14th edition. China: Elsevier Pub. Co; 2005.p 939-49.
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FETAL SKULL
Fetal skull is to some extent compressible, and made mainly of thin pliable tabular (flat)
bones forming the vault. This is anchored to the rigid and incompressible bones at the base of
the skull.
SIGNIFICANCE OF THE FETAL SKULL:
1. It protects the brain.
2. Ability to mould during the birth process – fetal skull in relation to the maternal bony
pelvis
3. Land marks of the fetal skull used to determine fetal position and attitude
REGIONS OF FETAL SKULL:
The skull is divided into vault, face and base.
VAULT- it is largest dome shaped compressible part made up of two parietal bones, upper
part of the frontal bone, occipital, temporal bones and is the region above as imaginary line
drawn from the orbital region to the nape of neck.
BASE- it is comprised of bones firmly united to afford protection to the vital centers in
medulla.
FACE- is composed of 14 small bones which are also firmly united and non compressible.
The regions of the skull are divided as follows:
VERTEX-It is quadrangular area bounded anteriorly by the bregma and coronal sutures
behind by the lambda and Lambdoidal sutures and laterally by lines passing through the
parietal eminences.
BROW or sinciput-It an area bounded on one side by the anterior fontanelle and coronal
sutures and on the other side by the root of the nose and supra-orbital ridges of either side.
FACE-It is an area bounded on one side by root of the nose and other by the junction of the
floor of the mouth with neck.
OCCIPUT- occiput lies between the foramen magnum and the posterior fontanelle. The part
below the occipital protuberance is known as the sub-occipital region. The protuberance itself
can be seen and felt as prominent point on the posterior aspect of skull.
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BONES OF THE VAULT:
1. Two frontal bones.
2. Two parietal bones.
3. One occipital bone.
4. Two temporal bones.
1. The frontal bone, which forms the forehead. In the fetus, the frontal bone is in two
halves, which fuse (join) into a single bone after the age of eight years. These two
bones form the baby’s forehead or sinciput; at the centre of each one is a slightly
raised area known as a frontal eminence (frontal boss).
2. The two parietal bones, which lie on either side of the skull and occupy most of the
area. At the centre of each parietal bones are the parietal eminences (ossification
centre)
3. The occipital bone, which forms the back of the skull and part of its base. It joins
with the cervical vertebrae (neck bones in the spinal column, or backbone). This is a
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single bone that is located at the back of the fetal skull. The occipital bone forms part
of the base of the skull, which contains the foramen magnum that protects the spinal
cord. At the centre, there is occipital protuberance
4. The two temporal bones, one on each side of the head, closest to the ear. These
bones are flat and their upper aspects form a small part of the vault of the skull;
however, they do not have a significant role in child birth, bone formation and
development.
SUTURES:
Membranous space between skull bones of fetus is known as sutures. In other words, sutures
are cranial joints and are formed where two bones adjoins.
1. Frontal suture-Between two frontal bones.
2. Sagittal suture-Between two parietal bones.
3. Coronal suture-Between two parietal and two frontal bones.
4. Lambdoid suture-Between two parietal and one occipital bone. Its shaped like Greek letter
lambda.
FONTANELLES:
Wide gap in the suture line, where two or more than two sutures meet. These are:
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1. Anterior fontanelle (BREGMA):
– It is diamond or kite in shape. About 2.5 cm long and 1.25 cm wide.
– It is membranous space at junction of sagittal, coronal and frontal suture.
IMPORTANCE:
1. Its palpation through internal examination denotes the degree of flexion of the
head.
2. It facilitates moulding of the head.
3. Palpation of the floor reflects intracranial status-depressed in dehydration,
elevated in raised intracranial tension.
4. Collection of blood and exchange transfusion, on rare occasion, can be
through it via the superior longitudinal sinus.
5. Cerebrospinal fluid can be drawn, although rarely, through the lateral angle of
the anterior fontanelle the lateral ventricle.
2. Posterior fontanelle (LAMBDA):
1. It is situated at the junction of sagittal and Lambdoidal suture.

2. It is smaller than anterior fontanelle.
3. It is triangular in shape.
4. It should close after 6 weeks of birth.
DIAMETERS OF FETAL SKULL:
ANTERIOR-POSTERIOR DIAMETER:
1) Sub occipito bregmatic

2) Sub-occipito frontal
3) Occipito frontal
4) Mento vertical
5) Sub-mento vertical = 11.5cm(extends from the junction of the floor of the mouth and
neck to the highest point on the sagittal suture)
6) Sub-mento bregmatic
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TRANSVERSE DIAMETER:
1) Biparietal = 9.5cm (It extends between two parietal eminences.)

2) Super- sub parietal =8.5cm(It extends) from a point placed below one parietal
eminence to a point placed above the other parietal eminence of the opposite side)
3) Bitemporal = 8cm (It is the distance between the antero-inferior ends of the coronal
suture.)
4) Bimastoid = 7.5cm.( It is the distance between the tips of the mastoid processes)
Figure: Transverse diameters of fetal skull
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MOULDING:
 It is the alteration in the shape of the fore coming head while passing through the
resistance of birth passage during labour.
 Alteration in the shape is possible because the bones of the vault allow a slight degree
of bending and the skull bones are able to override at the sutures.
 This overriding allows the considerable reduction in the size of presenting diameter
while the diameter at the right angles to them is able to lengthen.
 Shape changed but not the volume.
IMPORTANCE OF MOULDING:
1) It enables the head to pass more easily through the birth canal.
2) Moulding is a protective mechanism and prevents the fetal brain from being
compressed as long as it is not excessive, too rapid or in an unfavourable direction.
MECHANISM OF MOULDING:
 In normal vertex presentation with the fetal head in a fully flexed attitude, the sub-
occipito bregmatic and the biparietal diameters will be reduced and the mento-vertical
will be lengthened. The shortening may be as much as 1.25cm
 The skull of the preterm infant, being soften and having wider suture, may mould
excessively.
 The skull of post mature fetus doesn’t mould well and its hardness tends to make
labour more difficult.
 Moulding disappears within few hours after birth.
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 Degree of moulding assessed vaginally:
 Bones are separated & the sutures can be felt easily (0)
 Bones are just touching each other (+)
 Bones are overlapping but can be separated easily with pressure of finger (++)
 Bones are overlapping severely& cannot be easily separated with pressure of finger
(+++)
 Absence of moulding (-)
REFERENCES:
1. Manocha.Snehlata. Procedures and Practice in Midwifery.2nd edition. New Delhi:

2. Dutta. DC. Textbook of Obstetrics.6th edition. Calcutta: New central book agency (P)
ltd; 2004. p 83-86.
3. Myles. Textbook for Midwifes.14th edition. China: Elsevier Pub. Co; 2005.p 987-92.
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MECHANISM OF NORMAL LABOUR
LABOUR:
 Series of events that take place in the genital organs in an effort to expel the viable
products of conception out of the womb through the vagina into the outer world is
called labour.
 It is a process by which the fetus, placenta and membranes are expelled through the
birth canal.
DELIVERY:
 Delivery is the expulsion or extraction of fetus out of the womb.

 It is not synonymous with labour; delivery can take place without labour as in elective
Caesarean section.
 Delivery may be vaginal, either spontaneous or aided or it may be abdominal.
PARTURITION:
 Parturition: it is the process of giving birth

 Parturient: a parturient is a patient in labour.
o Term: 37 completed weeks to 42 weeks gestation
o Preterm: 28-37 completed weeks
o Post-dates: after 42 weeks
MECHANISM OF NORMAL LABOUR:
Definition:
As the fetus descends, soft tissue and bony structures exert pressures which force him to
negotiate the birth canal by a series of passive movements. Collectively, these movements are
called the mechanism of labour.
Principles of Mechanism of Labour:
Principles common to all mechanisms are:
 Descent takes place throughout.
 Whichever part leads and first meets the resistance of the pelvic floor will rotate
forwards until it comes under the symphysis pubis.
 Whatever emerges from the pelvis will pivot around the pubic bone.
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The fetus is normally situated can be described as follows:
 The lie is longitudinal.
 The presentation is Cephalic.
 The position is right or left occipitoanterior.
 The attitude is one of good flexion.
 The denominator is the occiput.
 The presenting part is the posterior part of the anterior parietal bone.
CARDINAL MOVEMENTS OF LABOUR:
1) Engagement
2) Descent
3) Flexion
4) Internal rotation of head
5) Crowning
6) Extension
7) Restitution
8) Internal rotation of shoulders and external rotation of head.
9) Delivery of shoulder and trunk by lateral flexion.
1).Engagement:
 The greatest transverse diameter, BPD passes through the pelvic inlet.
 In primigravidae, engagement occurs in few weeks before onset of labour, while in

multiparae, it may occur in late first stage with rupture of membrane.
 Engaging antero-posterior diameter of head is sub-occipito frontal 10cm.
 Engaging transverse diameter of head is bi-parietal 9.5cm.(Figure-1)
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Figure-1: Engagement of Fetal Head
2).Descent:
 In nulliparous engagement takes place before the onset of labour & further descent
may not occur till the 2nd stage.
 In multiparae descent begins with engagement.
 It is slow or insignificant in first stage and but pronounced in second stage till the
fetus is delivered.
 It is affected by the uterine contractions, bearing down efforts of mother & thinning of
the lower segment. (factors responsible??/)
3).Flexion of Head:
 The descending head meets resistance of pelvic floor, Cervix & walls of the pelvis
which leads to flexion of head.
 With flexion of head sub-occipito frontal diameter 10cm will convert to sub-occipito
bregmatic 9.5 cm. (Figure-2) (factors responsible??/)
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Figure-2: Flexion of Head
4).Internal Rotation of Head:
 This is forward turning of the part of fetus that reaches the anterior, lateral half of the
gutter-shaped pelvic floor.
 In a well flexed vertex presentation the occiput leads and meets the pelvic floor first
and rotates anteriorly through one-eighth of circle.
 In LOA, the occiput rotates forward, one-eighth of circle. From the left Iliopectineal
eminence to the symphysis pubis, where it can escape under the pubic arch and allow
the sub-occipital region to pivot on the lower border of the symphysis pubis. (Fig-3)
 This causes a slight twist in the neck of the fetus as the head is no longer in direct
alignment with the shoulder.
Figure-3: Internal Rotation of Head
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5).Crowning:
 After internal rotation of the head, further decent occurs until the sub-occiput lies
underneath the pubic arch.
 At this stage, the maximum diameter of the head (biparietal diameter) stretches the
vulval outlet without any recession of the head after the contraction is over.
 Now head will be visible at the outlet. (Figure-4)
Figure-4: visible head in crowning
6).Extension of the Head: (couple of force theory????)
 Once crowning has occurred the fetal head can extend, pivoting on the sub-occipital
region around the pubic bone.
 This releases the sinciput, face and chin, which sweeps the perineum and are born by
a movement of extension (Figure-5).
 The sub-occipitofrontal diameter 10cm distends the vaginal outlet.
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Figure-5: Extension of Head
7). Restitution:
 It is visible passive movement of the head due to untwisting of the neck sustained
during internal rotation.
 The twist in the neck of the fetus which resulted from internal rotation is now
corrected by a slight untwisting movement.
 The occiput moves one-eighth of a circle towards the side from which it started.
(opposite to the internal rotation)
 The occiput thus pints to the maternal thigh of the corresponding side to which it
originally lay (Figure-6).
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Figure-6: Restitution
8). Internal Rotation of Shoulder:
 The shoulder undergoes a similar rotation to that of head to lie in the widest diameter
of the pelvic outlet, namely anteroposterior.
 The anterior shoulder is the first to reach the levator ani muscle and therefore rotates
anteriorly to lie under the symphysis pubis.
 As the shoulder rotates towards the symphysis pubis from the oblique diameter, it
carries the head in the movement of external rotation through 1/8th of a circle in the
same direction as restitution.
 The shoulders now lie in the anterior posterior diameter.
 The occiput points directly towards the maternal thigh corresponding to the side to
which it originally directed at the time of engagement.(Figure-7)
Figure-7: External Rotation of Head
9). Delivery of Shoulders and Trunk:
 The shoulders are born sequentially, usually the anterior shoulder first.
 After the shoulders are positioned in anterior-posterior diameter of outlet, further

descent takes place until the anterior shoulder escapes below the symphysis pubis.
 The anterior shoulder slips beneath the sub-pubic arch and the posterior shoulder
passes over the perineum.
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 This enables a smaller diameter to distend the vaginal orifice than if both shoulders
were born simultaneously.
 The remainder of the body is born by lateral flexion as the spine bends sideways
through the curved birth canal. (Figure-8)
Figure-8: Delivery of shoulders and trunk by lateral flexion
REFERENCES:
ltd; 2004. p 125-28.
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ANTENATAL EXAMINATION
DEFINITION:
Collecting data of an antenatal mother by history taking, systemic examination and relevant
lab investigations & advices given to the pregnant women at regular & periodic intervals
based on the individual needs. Antenatal examination is carried out whenever a woman visits
the clinic for antenatal check-up.
PURPOSE:
1. To asses general physical status of mother.

2. To monitor foetal growth and health conditions.
3. To evaluate progress of pregnancy.
4. To identify and prevent complications.
5. To prepare mother for labour and lactations& subsequent care of the child.
6. To detect early & treat promptly, high risk conditions (medical, surgical or
obstetrical) that may endanger life of baby or mother or both.
7. To prevent, detect & to teat at the earliest any untoward complications that may arise.
8. To give required health education to the mother.
ANTENATAL EXAMINATION:
A. Setup of an antenatal examination???

B. Assess antenatal mother:
i. Registration & history taking

ii. Head to toe examination
iii. Obstetric examination/ abdominal examination
C. Detect mother with high risk pregnancy

D. Antenatal education including education on diet, breast care & antenatal exercises.
A. SET-UP OF ANTENATAL CLINIC:

Facilities required to conduct examination are:
 A room with proper lighting. There should be window for ventilation. Temperature of
the room should be according to season.
 Examination table with bed length mattress, mackintosh & bed sheet spread on it & a
pillow for comfort of the woman.
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 Facility for the woman to pass urine.

 Hand washing facility for care provides.
Articles required:
1. Screen or curtain to maintain privacy.

2. Drape sheet to cover the client.
3. Tray with stethoscope to check FHS & B.P.
4. Inch tape (measuring tape) to measure fundal height.
5. Fetoscope to check FHS.
6. Weighing machine to measure weight.
7. B.P Apparatus to check B.P.
8. Temperature tray to check temperature.
9. Urine testing articles and specimen bottles to check urine for albumin & sugar.
10. Kidney tray & paper bag to discard waste.
11. Torch to check pupil.
Prerequisites:
 Explain procedure to the client & provide essential information.

 Have gentle approach.
 Have all the equipment’s necessary for the procedure in proper place to avoid
interrupting the examination.
 Ensure privacy for examination with the help of screen or curtains.
 Environment should be comfortably warm & pleasant (examiner must warm hands).
 Ask patient to empty bladder & obtain urine specimen.
B. ASSESSMENT OF ANTENATAL MOTHER:
I) Registration & History Taking:
The woman should be registered after confirming that she is pregnant, as soon as she
misses her normal period. Afterwards the midwife will carry out the antenatal
examination.
HISTORY TAKING:
1. Identification Data:
Name: ……………
Date of first examination: …………….
Address: …………………..
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Age: Age of woman is extremely important as teenage pregnancy and pregnancy over 35
years of age are of greater risk for pregnancy complications. A woman having her first
pregnancy at the age of 30 or above is called elderly primigravida.
Duration of marriage: This is relevant when dealing with pregnancy in comparatively

advanced age to note the fertility or fecundity. A pregnancy long after marriage without
taking recourse to any method of contraception is called low fecundity and soon after
marriage is called high fecundity. A woman with low fecundity is unlikely to conceive
frequently.
Religion: ………….
Occupation: This may be helpful in interpreting symptoms due to fatigue or occupational

hazards.
Occupation of the husband: A fair idea of the economic state of the client can be assessed.
The data includes complete socio-cultural and economic background of the client and her
family.
Educational Status: Client
Husband
2).Menstrual History: During the first antenatal visit, obtaining a menstrual history is
essential to determine gestational age & EDD.
- Age of menarche
- Last menstrual period date
- Duration of each period
- Any complaints like dysmenorrhoea
- Amount of blood flow
3).Past Medical history:
- History of heart disease
- Any diseases since childhood like Rheumatic fever
- Asthma
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- Convulsions
- Allergies
- Renal diseases
- Diabetes
- History of blood transfusion.
4).Surgical history:
- History of any operation
- Injury or accident
5). Family History:
- Both maternal and paternal history of breech delivery, twin delivery etc.
- Hypertension
- Heart diseases
- Diabetes mellitus or gestational diabetes to any woman in family.
- Congenital malformations
6).Personal History:
- Any personal habits like pica, alcoholism, smoking etc.
7).Obstetrical History: Obstetrical history refers to a record of previous pregnancy, labour

and puerperium.
The history of pregnancy may be recorded by using mnemonics G, P-T, P, A, L.
G – Gravida, it denotes pregnant state both present & past irrespective of the period if
gestation.
P – Parity, it denotes a state of previous pregnancy beyond the period of viability.
T- Term pregnancy
P- Pre term Pregnancy
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A - Denotes abortions.
L - No. of living children
Table 1: Obstetric History
S. Date of Place Duration Course of Method Course Puerperium Baby

delivery of of pregnancy of of
Sex Wt.
No birth pregnancy delivery Labour
8).Present pregnancy history:
Any specific health problems & complications during present pregnancy.
INVESTIGATIONS:
 Urine – albumin and sugar at every visit.

 Blood – Hb testing on every visit, once a month to exclude
anaemia. (Normal Hb 10-12 gm %)
 Blood group & Rh factor.
 VDRL for syphilis done on the first visit
 HIV test for high risk groups
 Ultra sound to be done if indicated (If sending for an ultrasound
make sure bladder is full).
 TORCH test- to rule out the following infections:
T – Toxoplasmosis
O – Other viral infections
R – Rubella
C – Cytomegalo virus
H – Herpes simplex virus
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II. HEAD TO TOE EXAMINATION
A. Physical Examination:
This includes complete systematic examination of each system and assessing its function.
Physical measurements include:
 Vitals & B.P: These must be recorded at each visit. At 1st visit in 1st trimester a
baseline data regarding vitals should be obtained & compared with subsequent
reading to detect any changes at the earliest that might occurs during pregnancy.
 Height: Make the woman stand against the wall and measure the height. Average
height of an Indian woman is 140-150 cms. Height indicates the pelvic size.
 Weight: Weight checking should be done at each visit. Average weight of an
Indian woman in the age group of 25-30 yrs. is 60 kg. In pregnancy there is an
increase of approximately 11 kg. 1st trimester: 1 kg, 2nd trimester: 5 kg, 3rd
trimester:5kg
 Pallor: The sites to be noted are lower palpebral conjunctiva, dorsum of the tongue
and nail beds.
 Jaundice: The sites to be noted are bulbar conjunctiva, under surface of the tongue,
sclera, hard palate and skin.
B. General Physical Examination:
1. Built – May be obese, average & thin.
2. Gait – Normal or any abnormality. Some changes in gait is a normal feature in late
pregnancy.
3. Appearance – May be depressed, tired & lethargic.
4. Head – Examination of scalp for cleanliness, infection & infestations & hair for their
lustre & texture.
5. Face – Chloasma & any scar.
6.Eyes – Observe the colour of conjunctiva is yellow/pink/normal, sclera is normal/yellow

tinge suggest jaundice, or any infection or discharge in the eye.
7. Nose – Deviated nasal septum, infection & blockage.
8. Mouth – Observe tongue for pallor/ glossitis /coated, teeth & gums for dental
carries/stomatitis, tonsillitis.
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9. Ear – Infection, blockage, wax.
10. Neck – Thyroid glands, lymph glands for any abnormalities.
11. Upper extremities – For any bony abnormalities, colour of nails pink/pale, shape of
nails, areas of inflammation, presence of scars.
12. Examination of Breast – Breast should be examined for size, symmetry, dimpling,
lesions, masses, areas of thickening, tenderness.
 Nipples should be examined for their development, whether

flat/inverted/underdeveloped/cracked, discharge, crusting.
 Lymph nodes are assessed for size, tenderness.
 Breast changes – normal changes during pregnancy are:
- 3-4 weeks : Pricking and tingling sensation
- 6 weeks : Enlarged, tense, painful
- 8 weeks : Bluish surface, veins visible
- 12 weeks: Montgomery’s tubercles appear, darkening of primary areola
- 16 weeks: Colostrum can be expressed& secondary areola appears
13).Lower extremities:
 Legs should be looked for edema & varicosities.

 Homan’s sign (calf pain on dorsiflexion of the foot) may be elicitated to diagnose
deep vein thrombosis (Elicitation & demonstration of Homan’s sign is avoided
nowadays because of the possibility of dislodging a thrombus from legs & causing
pulmonary embolism. Moreover it is not reliable because it may be negative in
nearly 50% of cases of DVT).
 Edema may be physiological or may be associated with pre-eclampsia, anaemia,
hypoproteinemia, cardiac failure & nephrotic syndrome.
14. Back or Spine: Observe the back and spine for any deformity.
Observe the symmetry of the Rhomboids of Mechales (Figure-1.1) which is a diamond

shaped area formed anteriorly by the fifth lumbar vertebra laterally by the dimples, of the
superior iliac spine and posteriorly by the gluteal cleft.
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(Figure-1.1) Rhomboid of Mechales
III). OBSTETRICAL EXAMINATION/ ABDOMINAL EXAMINATION:
Preliminaries:
1.Client must evacuate the bladder a full bladder places upward pressure on the uterus
causing it to rise higher in to the abdomen.
2.Provide dorsal position to the client with thighs and knees slightly flexed.
3.Maintain privacy and expose only abdomen.
4.Stand on the right side of the client.
5.Warm hands before touching the abdomen. Cold hands will irritate abdominal and
uterine muscles which may go into contractions.
6.Examiner’s arms and hand should be relaxed, nails should be trimmed. Use pads and
not the tip of the fingers.
7.Move hands in stroking position in order to avoid contractions.
8.Palpation should be continuosi.edo not lift hand till the whole palpation is done.
9.Do not press hard with the fingers as it is painful.
10. Steps of abdominal examination:
1) Inspection
2) Palpation
3) Auscultation
1).Inspection:
1.Lie of the fetus, ovoid uterus may be longitudinal or transverse or oblique.
2.Contour of the uterus- fundal notching, convex or flattened anterior abdominal wall,
cylindrical or spherical shape.
3.Undue enlargement of the uterus. It may be due to polyhydraminos or twin pregnancy.
4. Skin condition of the abdomen for evidence of ringworm or scabies etc.
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5. Scar mark on the abdomen which may be indication of previous LSCS or abdominal
surgery like laprotomy
6. Cutaneous changes – Linea nigra (vertical line of pigmentation seen running
longitudinally in the centre of the abdomen below umbilicus, Striae gravidarum (silvery
streaks suggests previous pregnancy; pink streaks occur in present pregnancy). (Fig-1.2)
Fig: 1.2 Cutaneous Changes: a. Linea Nigra Fig b.: Striae Gravidarum
Measurement of Fundal Height:

Fundal height & abdominal girth are measured in centimetres & inches respectively. It
provides information about the progressive growth of pregnancy & fetus & is an important
part of the antenatal assessment. The zero line of a centimetre measuring tape is placed on the
upper edge of the symphysis pubis & the tape is brought over the abdominal curve to the top
of the fundus. (Figure-1.3)
(Fig: 1.3 Measurement of Fundal Height)
Estimation of fundal height:
McDonald’s rule may be used to estimate the height of fundus during late 2nd & 3rd trimester.
It is calculated as follows;
 Height of fundus in cm x 2/7(or 3.5) = Duration of pregnancy in lunar months.
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 Height of fundus in cm x 8/7= Duration of pregnancy in weeks.

After 20 weeks of gestation, the fundal height (measured in centimetres) approximates the
weeks of pregnancy up to 36 weeks. Before 20 weeks of gestation the uterus is measured in
fingers breadths above the symphysis pubis or below the umbilicus.
An alternative popular method is to measure the symphysis pubis fundal height in
weeks. Following steps may be followed:
 Centralized uterus if deviated.
 Place the ulnar border of the left hand on the upper most level of fundus.
 Ascertain approximate duration of pregnancy in terms of week’s gestation.
 Note the number of fingers breadth, which can be easily accommodated from
the level of umbilicus to the upper most level of fundus. Height of the fundus is
midway between the symphysis pubis & umbilicus at 16 weeks & at the level of
umbilicus at 24 weeks. One finger’s breadth corresponds to one week. (Fig-1.4)
 Compare the fundal height obtained through this method with the period of
amenorrhoea. (SFH in cm also, ± 2cm in lag??????)
(Figure-1.4) Indicates Fundal Height at Various Stages of Pregnancy
Fundal height may be more than calculated in cases of:

1. Mistaken dates of LMP.
2. Twins.
3. Polyhydraminos.
4. Big baby.
5. Pelvic tumours-ovarian & fibroid.
6. Hydatidiform mole.
7. Concealed accidental haemorrhage.
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Fundal height may be less than calculated in cases of:

1. Mistaken dates of LMP.
2. Scanty liquor amnii.
3. IUGR.
4. IUD.
Assess abdominal girth: Abdominal circumference is measured with help of tape measure.
Normal increase of 1 inch or 2.5 cms per week after 30 weeks. Measurement in inches is
same as the weeks of gestation after 32 weeks in an average built woman. For example, the
abdominal girth in a 32 weeks pregnant mother may be 32 or 31 inches
2).Palpation:
Palpation should be conducted gently taking care of woman’s comfort; palpating woman’s
abdomen without any purpose is not futile but also can cause undue uterine irritability.
Palpation should never be conducted during contractions.
Obstetric Grips:
i. Fundal Grip
ii. Lateral Grip
iii.Pelvic Grip I
iv.Pelvic Grip II or Pawlik’s Grip
i). Fundal grip: The palpation is done facing the patient’s face. The whole of the fundal
area is palpated using both the hands laid flat on it to find out which pole of the foetus is
lying in the fundus: (a) broad, soft and irregular mass suggestive of breech, or (b) smooth,
hard, globular mass suggestive of head. In transverse lie, neither of the foetal poles is
palpated in the fundal area. (Figure: 1.5)
Figure: 1.5 Fundal Grip
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ii).Lateral or umbilical grip:
The hands are to be placed flat on either side of the umbilicus to palpate one after the other,
the sides and front of the uterus to find out the position of the back, limbs and the anterior
shoulder. The back is suggested by smooth curved and resistant feel. The limb side is
comparatively empty and there are small knobs like irregular parts. After the identification of
the back, it is essential to note its position whether placed anteriorly or towards the flank or
placed transversely. (Figure: 1.6)
Figure: 1.6 Lateral Grip
iii).First pelvic grip:
The examination is done facing the patient’s feet. Four fingers of both the hands are placed
on either side of the midline in the lower pole of the uterus and parallel to the inguinal
ligament. The fingers are pressed downwards and backwards in a manner of approximation
of finger tips to palpate the part occupying the lower pole of the uterus (presentation). If it is
head, the characteristics to note are: (a) precise presenting area, (b) attitude, and (c)
engagement. This grip is also known as Leopold fourth manoeuvre. (Figure: 1.7)
 If the prominence is on the opposite side of the back, it is the baby’s brow and the head is
flexed
 If the head is extended then the cephalic prominence and the foetal head is felt over the
brim of the pelvis, it is Flexed attitude
 In this when there is cephalic prominence and the foetal head is felt over the brim of the
pelvis, it is Flexed attitude.
 When the forehead forms the cephalic prominence and the head is extended it is called
Extension Attitude
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Figure: 1.7 First Pelvic Grip
iv). Pawlik’s grip (Second pelvic grip): The examination is done facing the patient’s
face. The over stretched thumb and four fingers of the right hand are placed over the lower
pole of the uterus keeping the ulnar border of the palm on the upper border of the
symphysis pubis. When the fingers and the thumb are approximated, the presenting part is
grasped distinctly, if not engaged, and also the mobility from side to side is tested. In
transverse lie, Pawlik’s grip is empty. This grip is also known as third manoeuvre of
Leopold. (Figure: 1.8)
Figure: 1.8 Pawlik’s grip (Second pelvic grip)
3). Auscultation:
Auscultation of distinct foetal heart sounds (F.H.S.) not only helps in the diagnosis of a live
baby but its location of maximum intensity can resolve doubt about the presentation of the
foetus. As a rule, the maximum intensity of the F.H.S. is below the umbilicus in cephalic
presentation and around the umbilicus in breech presentation.
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Failure to hear foetal heart rates may be because of:
 Defector Fetoscope or noising environment, anxiety of the examiner

 Foetal death
 Obesity, polyhydraminos, placental soufflé, posterior position of the
foetus.
After palpation and auscultation, findings if the examination is recorded which includes:
1) LIE- Longitudinal/ Oblique/ Transverse

2) Period of gestation in weeks
3) Presentation
4) Attitude: Flexed/ extended
5) Position: Anterior/ Posterior
6) Foetal Heart Rate: 120-140/ above or below
C. DETECTION OF HIGH RISK PREGNANCY:
Pregnancy complicated by one or more factor which adversely affects the outcome of
pregnancy maternal, perinatal or both. It is important to identify these high risk cases & give
them special care to reduce maternal mortality & morbidity.
Screening of high risk cases begins from the 1st antenatal visit in the 1st trimester of
pregnancy. High risk screening may be carried out by trained midwives & the cases may be
referred to higher centre for management by specialists.
Methods of screening:
1. History taking
2. Examination.
i.General physical examination.
ii.Obstetrical examination.
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HIGH RISK SCORING FOR PREGNANCY MOTHER
S. No Risk Factors Score
1. Age less than 18 years or more than 35 years. 1

2. Maternal height less than 145 cm. 1
3. Primi or multi more than 5. 1
4. Bad obstetrical history. 2
5. History of neonatal Jaundice or Rh ABO incompatibility. 2
6. Weight less than 45kg or more than 90 kg. 3
7. History of low birth weight. 1
8. Previous uterine surgery. 2
9. History of APH or PPH. 2
10. History of manual removal of placenta. 2
11. Anemia (less than 6gm %). 3
12. Febrile ailment in pregnancy. 1

13. Pregnancy associated with hypertension. 2
14. Medical condition with pregnancy. 2
15. Bleeding P/V (APH, Abortion). 2
16. Abnormal presentation. 2
17. Maturity less than 37 weeks or more than 45 weeks. 2
18. PROM (Premature rupture of membranes). 2
19. Fetal distress. 2
20. Prolonged labour more than 20 hours. 2
21. Uterine size less than period of gestation. 2
22. Dai handling/Outside interference. 2 or 3
 Normal/Low risk score is less than 3

 High risk score is 3 or more than 3
 Scoring system is not mandatory but identification of risk factors is more important
for screening of high risk mothers.
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D.ANTENATAL EDUCATION:
After the completion of all necessary antenatal examination, a relevant antenatal advice has to
be given to the mother. These advices include information regarding diet, rest and sleep,
travel, personal hygiene and immunization.
Aims:
1. To advise the mother about the need for regular antenatal checkups.
2. To provide the antenatal mother, opportunities for maintaining the optimum health
status throughout maternity cycle.
3. To immunize woman against tetanus.
4. To prepare the women for labour, lactation, and child rearing.
1. Diet:
a. The pregnancy diet ideally should be light, nutritious, easily digestible and rich in
protein, minerals, vitamins, and green leafy vegetables, plenty of fluids, seasonal
fruits, high iron, and high protein.
b. The increased calorie requirement is to the extent of 300 kilocalories over the non-
pregnancy state. (Total-2500kcal.)
c. Supplementary iron therapy is needed to all pregnant mothers from 16weeks
onwards.
d. Natural sources of iron are- meat, egg, grains, jaggery, rice flakes, green leafy
vegetables etc should be included.
e. Eat food that contains roughage, bulk and natural fibres to prevent constipation.
f. Avoid fatty or spicy foods and food that increase heart burns.
2. Antenatal Hygiene:
a. Daily bath; skin is an excretory organ & is to be kept active during pregnancy,
maintain environmental & food hygiene.
b. Any sign of infection should be reported & treated at the earliest.
3. Rest & Sleep:
a. Advise the client to avoid hard and strenuous activities.

b. Woman should be in bed for about 10 hours (8 hours at night and 2 hours in the
afternoon).
c. Avoid lying down immediately after a meal.
d. She should be advised to have short periods of rest in between work with her feet up
through the day.
e. The woman should be taught relaxation exercises so that she can relax, as this will be
of invaluable advantage during labour.
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f. She may continue usual day-to-day activity.
5. Bowel:
a. To avoid constipation and to enhance regular bowel movements, advice the client to
include more fluids, fruits and vegetables in the diet.
b. Regular bowel habit may help in preventing constipation.
c. Strong tea is better avoided because of the constipating effect of tannin.
d. If constipated, milk of magnesia may be ordered by doctor.
6. Clothing & Shoes:
a. The pregnant woman should wear loose but comfortable garments.

b. She should wear clothes in which she feels inconspicuous & happy.
c. The tight brassier may depress the nipples & ought not to be worn.
d. Poor support of the breast during & after pregnancy is the greater cause of future
breast laxity than the act of breast feeding.
e. Sensible shoes should be worn.
f. High heel shoes should be avoided as it cause fatigue in maintaining good posture &
increase the likelihood of stumbling or overbalancing, which is common in
pregnancy.
7. Dental Care:
a. Any tooth extraction or filling of carries should be done at the earliest, preferably in
the second trimester.
b. While brushing of teeth – avoid use of hard bristled toothbrush as gums are congested
& bleed easily due to presence of hormone progesterone, maintain environmental &
food hygiene.
c. Any sign of infection should be reported & treated at the earliest.
8. Care Of Breasts:
a. During pregnancy the expectant mother should be told about the advantages of breast
feeding & encouraged to breast feed.
b. If the nipples are anatomically normal, nothing is to be done beyond the general
cleanliness.
c. If the nipples are retracted, correction is to be done in the later months by
manipulation.
d. Teach to express the fluid coming out during bath massage the nipples by rolling
them between the finger & the thumb during the last months.
e. Avoid the use of soap on the nipples.
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9. Marital Relations:
a. Avoid coitus during the first trimester and last 6 weeks of pregnancy.
b. There is possibility of direct trauma & prostaglandins in seminal plasma may
stimulate the uterus to contract, especially in later pregnancy.
c. There may be an increase in placental abruption, premature rupture of membranes &
amniotic & fetal infection when intercourse has occurred in 4 weeks before delivery.
d. During 1st trimester it may lead to threatened abortion, antepartum cramping &
antepartum bleeding.
10. Travel:
a. Travels by vehicles having jerks are better to be avoided.

b. The long journey is avoided in 1st & last trimesters.
11. Smoking & Alcohol:
a. These should be avoided during pregnancy as they can affect the foetal well being.
b. Smoking can lead to miscarriage, abruption placenta, and placenta previa.
c. In infancy it results in learning difficulty, retarded physical growth & substance
addiction.
d. Excessive alcohol intake is related to congenital anomalies, pregnancy complications
include ketoacidosis, miscarriage, premature labour & pre-eclampsia.
e. In baby it leads to fetal alcohol syndrome, growth retardation, craniofacial &
neurological abnormalities.
12. Warning Signs In Pregnancy:
Teach woman to watch for warning signs and report to hospital in case of:
 Bleeding per vagina

 Leaking per vagina
 Convulsions or coma
 Epigastric pain
 Blurring of vision
 Severe headache
 Edema etc.
13. Immunisation:
a. Immunization in pregnancy is a routine for tetanus.

b.Injection T.T 0.5 ml I/M at 5th & 6th month of pregnancy is advised.
c. If a woman gets pregnant within two years, only one booster dose is given at ninth
month.
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d.Live virus vaccines like rubella, mumps, measles etc. are contraindicated during
pregnancy.
14. Drugs:
a. No drugs should be given as far as possible.

b.Drugs may only be taken with great caution & only on prescription of physician if
necessary. Avoid over the counter drugs.
15. Antenatal Visits:
a. 1st trimester –once.

b. 3 to7 months once a month.
c. 7 to 9 months every fortnightly.
d. After 9 months weekly.
e. More visits in case of complications may be paid.
CONCLUSION:
Antenatal examination of a pregnant woman should be done at regular and periodic

intervals to assess the wellbeing of the mother and the growing fetus. Being a midwife it is
necessary to have knowledge regarding antenatal assessment according to gestational age of
the pregnant woman so that she can find out any deviations from normal at the initial stage
and advice & refer the mother for necessary interventions.
REFERENCES:

ltd; 2004. p 77-82.
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ANTENATAL EXERCISES
INTRODUCTION
Exercise during pregnancy is something many women think about but hardly do. But the fact
remains that exercising during pregnancy has a positive impact on both the baby and the
mother. Exercises can help the pregnant women to adapt to the physical changes in her body
during pregnancy. These will help to ease the minor aches and pains during pregnancy and
may also help to prevent long term postpartum problems.
DEFINITION:
Antenatal exercises are those exercises performed by women during pregnancy, which
stimulate circulation and gives a feeling of well being to the clients.
ADVANTAGES:
1) Improves the circulation for mother and baby.

2) Reduction in aches and pains of pregnancy e.g. backache, cramps etc.
3) Improves the stamina, gives the mother more energy to cope with growing demands
of pregnancy.
4) Improves the posture and body awareness.
5) More controlled weight gain.
6) Improves the sleeping patterns.
7) Reduction in minor ailments of pregnancy such as: stiffness, tension, constipation,
sleeplessness.
8) Minimizes varicose veins and swelling due to improved circulation.
9) Enhance the psychological wellbeing.
10) Ensure an effective bearing down in labour and speedy return to normal postnatal
ADVICES:
Women should be advised to:
1) Consult doctor/midwife before beginning the exercise.
2) Perform exercises regularly, plan a regular schedule that is at least thrice a week.
3) Dress comfortably; wear lose fitting clothes.
4) Void before exercising
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5) Use movements that are slow and deliberate; avoid jerking and bouncing movements;
jogging and running.
6) Exercise on a firm surface.
7) Drink fluid whenever feel the need during the exercise and after the exercise. This
prevents dehydration.
8) Wear supportive shoes when needed.
9) Limit activities to shorter intervals. Exercise for 10-15 min, rest for 2-3 min, then
exercise for another 10-15 min.
10) Decrease exercise level as pregnancy progresses.
11) Take your pulse every 10-15 min. If it is more than 140 beats per min. slow down
until it reaches to the maximum of 90.
12) Rest in left-lateral position for 10 minutes after the exercise.
13) Take an increase in calories to replace those burned during exercises.
14) Always rise slowly from lying to sitting position to prevent orthostatic hypotension.
15) Don’t risk activities such as surfing, mountain climbing and sky diving.
16) Don’t do activities that require holding breath and bearing down.
17) Do not continue the exercise if you experience shortness of breath, pain, numbness,
undue cramping, vaginal bleeding or nausea. Report to the doctor/midwife if it
happens.
18) Don’t become over heated for extended periods.
19) Avoid exercise by lying flat in the later 2nd and 3rd trimester because of the danger of
supine hypotension and decreased placental/fetal circulation. Instead, a half lying
position with the back raised to an angle of approximately 350 can be used
20) Never exercise to a point of fatigue.
PREPARATION OF THE ENVIRONMENT:
I. Arrange the area i.e., a hard, firm bed or a mat spread on the floor.
 Ensure privacy.
 Ensure that there is adequate light and ventilation.
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TYPES OF EXERCISES:
1) Breathing exercises
2) Circulatory exercises:
a. Leg
b. Shoulders
3) Stretching exercises:
a. Leg
b. Arm
c. Neck
4) Abdominal exercise
5) Pelvic tilting & back stretching exercise.
6) Pelvic floor exercises (Kegel’s exercise)
7) Trasversus exercise
8) Tailor sitting exercise
9) Knee rolling exercise
10) Hip hitching exercise
1. BREATHING EXERCISE:
PURPOSES:
 To strengthen muscles of respiration.
 To increase maternal and feto-placental oxygenation.
TECHNIQUE:
 Sit/ lie comfortably with eyes closed and concentrate on breathing.
 Breathe in through the nose and out through the mouth, repeat it 5 times.
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2. CIRCULATORY EXERCISES:
PURPOSES:
 To improve circulation and venous return.
 To stretch and strengthen calf muscles.
 To decrease calf muscles cramps.
TECHNIQUE:
A. Leg Exercise:
I. Sit on a chair with back straight, move feet up and down. Repeat it 10 times. (Figure-
1a &b)
Figure -1a Figure -1b
II. Sitting on a chair, move feet inwards and outwards. Repeat it 10 times.(Figure-1c&d )
Figure -1c Figure -1d
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III. Sitting on a chair, make a circle with both feet at anti-clockwise direction and vice
versa. Repeat it 10 times.( Figure – 1e)
a. Figure -1e
B. Shoulder Circling Exercise:
I. Shoulder Rolls: The fingers tips are placed on shoulder, then brought forward and up
during inhalation, back and down during exhalation or rolling each shoulder forward five
times, then back five time. Repeat it 10 times. (Figure-1f)
Figre-1f: Shoulder Rolls
II. Stand straight with legs apart and stretch arms out to the sides and rotate arms (make a
large circle) clockwise and anticlockwise. Repeat it 10 times. (Figure-1g)
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Figure-1g
3. STRETCHING EXERCISES:
PURPOSES:
 Improve circulation of legs
 Decreases swelling.
 Decreases calf muscles cramps.
TECHNIQUE:
A. Leg Exercises:
I. Stand with feet apart, squat down hold for as long as you are comfortable and back to
standing position. Repeat it 5 times. (Figure: 2a&b)
Figure – 2a Figure -2b
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II. Stand with facing a wall with feet apart, far enough to keep arm straight, move body
towards the wall and holds it for 2 seconds. Repeat it 5 times. (Figure-2c)
Figure: 2c
III. Stand with facing a wall with feet apart, far enough to keep arm straight, bend one leg
forward, move body towards the wall as you lean forward, and keep spine straight and
the other foot on the floor throughout. Repeat it 5 times. (Figure -2d)
Figure -2d
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IV. Lie in supine position and bend one knee alternatively, hold for 5-6 seconds and then
release it (Do not arch your back while lying). Repeat it10 times. (Figure -2d)
Figure: 2d
B. Arm Exercise:
 Sit up straight with head slightly raised, shoulder back, stretch arms out to the sides, keep
the palms facing up make small circles at anti clockwise and vise versa. Repeat it 10
times. (Figure – 2e)
Figure- 2e
C. Neck Exercises:
I. Sit on a chair with straight back, look upward, and bring back head to neutral position.
Repeat it 5 times. (Figure- 2d)
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Figure-2d
II. Sitting; head to left and then to right. Repeat it 5 times. (Figure- 2e & 2f)
Figure -2e Figure- 2f
III. Sitting; bring ear towards left shoulder and then right ear towards right shoulder.
Repeat it 5 times. (Figure- 2g & h)
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Figure: 2g Figure: 2h
4. ABDOMINAL EXERCISE:
 Lie on back with knees bend and arms by the side (use 1 pillow to support head).
 Lift head and shoulders off floor; bring arms to touch knees. Repeat it 5 times.
(Figure-3)
 Lift head and shoulders off floor, bring hand to touch opposite knee .repeat it 5 times
Figure-3
5. PELVIC TILTING & BACK STRETCHING:
PURPOSES:
 Helps to stretch muscles and ligaments in the back preventing or alleviating backache
or strain.
 Improves posture.
 Makes abdominal muscles firm
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TECHNIQUE:
A. Pelvic Tilting or Rocking:
 Lie well supported with pillows, knee bend and feet flats.
 Place one hand under the small of back and the other on top of the abdomen.
 Tighten the abdomen and buttocks, and press the small of the back down onto the
underneath hand. Repeat 5 times. (Figure-4a)
 This exercise can be done in standing, supine and on all four positions. (Figure-4b)
Figure-4a
Fugure-4b: a-hand and knee position (on all four), b- standing position, c- Supine Position
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B. Back Stretching:
 Lie on your back with knees bent and feet on the floor, tighten your abdomen and
press down until your low back flattens against the floor.
 Hold each position for 5 seconds. Repeat 5 times. (Figure-4c)
Figure-4c
6. KEGEL’S EXERCISE:
PURPOSE:
 To strengthen pelvic floor muscles and provide support to the uterus and pelvic
organs.
 Strengthening of the pelvic floor helps to relax the perineal area for speed delivery of
the baby and also prevent perineal tear.
TECHNIQUE:
1. Empty the bladder.
2. Adopt any comfortable position with legs slightly apart (Lying, sitting or standing).
3. Squeeze pelvic floor muscle as though you are preventing the flow of urine and bowel
action, then feel it being lift up.
4. Try to hold for 4 seconds and rest in between 10 sec.
5. After a women has located the correct muscle, kegel exercise can be done in the
following ways:
a. Slow: Tighten the muscle, hold it for the count of three, and relax it.
b. Quick: Tighten the muscle, and relax it as rapidly as possible.
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c. Push out-pulls in: Pull up the entire pelvic floor as though trying to suck up
water into the vagina. Then bear down as if trying to push the imaginary water
out. This uses abdominal muscle also.
6. Take a deep breath in through nose and out through the mouth while doing this.
7. Repeat the above exercise slowly as many times as possible, up to a maximum of 10

seconds hold.
8. Remember: Do breathing exercise in between. Repeat 3 times.
7. TRASVERSUS EXERCISE:
PURPOSE:
 This is simple exercises to relieve backache during pregnancy:
TECHNIQUE:
 Kneel down on feet and arm with back straight.
 Imagine that you are balancing a tray on your back.
 Then tip the tray off by contracting abdominal muscles, tucking in your bottom, and
pushing the small of back again upward.
 Flatten your back again and repeat six to eight times. (Figure-5)
Figure -5
8. TAILOR SIT EXERCISE:
PURPOSE:
 To prepare for labour and delivery.
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TECHNIQUE:
 The pregnant mother should assume a cross legged sitting position whenever
possible. The tailor sit stretches the muscles of inner thigh.(Figure-6)
Figure-6
9. KNEE ROLLING EXERCISE:
PURPOSES:
 To stretch and strengthen the muscles of back and thighs.

 To relieve back pain.
TECHNIQUE:
 Lie flat on supine position, knees bend and feet flat.

 Roll both knees alternatively in opposite direction and try to touch the bed while
keeping back straight.
 Hold for 5 seconds and repeat 5 times. (Figure-7)
Figure-7
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10. HIP HITCHING EXERCISE:
TECHNIQUE:
 It is also called leg shortening exercise.

 It is performed with one knee bend and other knee straight.
 Slide the heel of straight leg downwards thus lengthening of leg.
 Shorten the same leg by drawing the hip up towards the rib on same side.
 Keep the abdomen pulled in while doing this.
 Repeat it 6-10 times (Figure-8)
Figure-8
EXERCISES TO AVOID:
Not everything is ideal for pregnancy and woman is advised to avoid several forms of
exercises, including the following:
 Diving
 Water skiing
 Gymnastics
 Netball
 Hockey
 Horse riding
 Cycling
 Rock climbing
 Scuba diving etc
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GUIDELINES FOR GOOD POSTURE:
1. Standing:
 Relax with upright posture.
 Straightening your spine by tucking in your abdomen and buttocks; relax your
shoulders.
2. Sitting:
 Upright with spine well supported.
 Use a small pillow to tuck into small of your back.
 Sit in a high-backed chair that well supports your back.
 Thighs should be supported by the chair, and the feet resting flat on the floor.
 If you are in sitting position for longer time, roll your shoulder in one-way and then
the opposite to release tension.(Figure-9)
Figure-9
3. Side lying:
 Side lying with a pillow under the head and one under the knee and thigh prevent
strain on the sacroiliac joint. This is a good position for women in late pregnancy.
(Figure-10)
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Figure-10
Conclusion:
In pregnancy, exercises help strengthen muscle tone in preparation for delivery and promote
rapid restoration of muscle tone after delivery. The goal of any exercise programme should
be safety and improved well-being of the mother and fetus. Promoting adequate oxygenation,
placental perfusion, venous return and a positive emotional state are important elements of a
well-rounded exercise programme. To gain all the advantages of exercise, mother should
perform these exercises daily.
REFERENCES:

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PER VAGINAL EXAMINATION
DEFINITION:
Vaginal examination is the thorough examination of vagina. It includes inspection of vagina

and internal examination of vagina using speculum and bimanual examination.
INDICATIONS-
A. During Pregnancy:
1. P/V examination is performed as a routine during normal pregnancy at the first visit to
confirm the diagnosis of pregnancy, cervical incompetence, and to detect any
abnormality in the pelvis e.g., fibroid uterus, ovarian cysts etc.
2. It is advisable for diagnosis of any abnormal presentation during last 2 months of
pregnancy.
B. During Labour:
1. To make a diagnosis of labour.

2. To confirm the presentation and position of fetus.
3. To determine whether the head is engaged or not.
4. To ascertain whether the forewaters have ruptured or to rupture them artificially.
5. To assess the station of fetal head.
6. To assess the progress or delay in labour.
7. To determine dilatation and effacement of cervix.
8. To exclude cord prolapse after rupture of the forewaters, especially if there is ill
fitting presenting part.
9. To apply a fetal scalp electrode.
10. To ascertain the lie of second baby in twin pregnancy.
11. As a routine before any obstetrical operation for delivery.
CONTRAINDICATIONS:
1. Bleeding per vagina.

2. Placenta previa
3. Cord prolapse.
PRELIMINARIES:
1. Explain the client and obtain her verbal consent.

2. Bladder must be emptied before the procedure.
3. Maintain privacy and drape the client.
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4. Place the client in the dorsal position with the thighs flexed along with the buttocks
placed on the foot end of the table. Help the client to place the arms alongside her
body or in a comfortable relaxed position away from the examiner.
5. Help the client with relaxation and breathing throughout the examination using very
gentle verbal and physical approach.
6. Clean the perineum using antiseptic solution.
7. Communicate the results of examination and their meaning in terms of labour
progress and management.
8. Abdominal examination should be preceded by vaginal examination.
ARTICLES:
 A vaginal examination pack that contains:

 Sterile swabs to clean the perineum
 Sterile bowl to contain antiseptic solution
 Sponge holding forceps to clean the perineum
 Kocher’s forceps for ARM.
 A clean tray containing:
 Antiseptic solution for perineal cleaning
 Kidney tray and paper bag to discard waste
 Drape sheet to drape the client
 Sterile disposable gloves to maintain asepsis.
STEPS OF PROCEDURE:
1. Bring the articles to the bedside or the client is shifted to examination table.
2. Explain and reassure the client.
3. Client must empty the bladder as full bladder can alter the position of uterus and
clouds the interpretation of the findings and ads to the discomfort.
4. Maintain privacy and after providing position, drape the woman.
5. Wash hands thoroughly and put on sterile gloves.
6. Vulval toileting is to be done using non dominating hand.
7. During Labour, observe external genitalia for signs of:
 Varicosities, edema, vulval sores, warts, rashes.
 Any previous scar from a tear or episiotomy.
 Any discharge or bleeding from the vagina.
 Color and odour of amniotic fluid are to be noted if membranes are ruptured.
(Offensive liquor suggests infection and green fluid indicates meconium,
which is a sign of fetal distress).
 Signs of second stage of labour (passing of stools, bulging of perineum, caput,
puffy or open anus or rectal mucosa)
8. Separate the labia with thumb and index finger of the other hand.
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9. Lubricate the index and middle finger of the dominant hand and slip the index finger
downwards and backwards into the vagina gently pressing against the posterior
vaginal wall, while placing the other hand on the abdomen.
10. The next step is to determine the status of the vagina and cervix. The following
parameters are to be assessed:
A. Condition of Vagina:
The vagina should feel warm and moist. The vaginal walls are soft and distensible.
 Hot and dry vagina indicates obstructed labour. Vagina may feel hot due to
infection and raised temperature but it should not be dry.
 Firm and rigid walls in primiparous may lead to longer labour. Presence of scar
tissue may cause delay in 2nd stage of labour.
 Loaded rectum may be felt through the posterior vaginal wall.
B. Condition of Cervix:
The hand is turned after examining the vagina so that the sensitive pads of hand will face
upwards and come into contact with cervix. Assess for:
 Location of the cervix: posterior, mid position, anterior. It is normally situated

centrally but in early labour it will be posterior. Cervix is situated in extreme
anterior position if the uterus is retroverted.
 Consistency of cervix: firm, medium, soft.
 Effacement: thickness or thinness of the endo-cervical canal. Uneffaced= 2.5cm
long and thick, 30 per cent effaced=1.5cm long, 60 per cent effaced= 1cm long,
80 percent effaced=0.5cm long, 100 per cent effaced=no endo-cervix remains,
feels paper-thin.
 Dilatation of cervix (0-10cm): cervical dilatation is expressed either in terms of
fingers-1, 2, 3 or fully dilated; or better in terms of centimeters (10cm when fully
dilated). It is usually measured with fingers but recorded in centimeters. One
finger equates to 1.6 cm on average.
 Sometimes a lip of the cervix may be confused with “no cervix felt” so the
midwife should be careful and should feel for the cervix in all directions.
11. Determine whether the membranes are ruptured or intact. If they are intact:
 Determines if they are tightly applied to the presenting part or bulging into the
vagina.
 When felt between the uterine contractions fore-water are slack but will become
tense when the uterus contracts and the fluid behind them is readily felt.
 Exclude cord prolapsed if the membranes are ruptured.
12. Check the presentation and position of fetus.
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 There are certain features of vertex presentation, which in relation to pelvis will
give information regarding position.
 These features are sagittal sutures and its slope, anterior and posterior fontanelle.
In a well flexed head posterior fontanelle is reached first. It is small and triangular
with three sutures leaving it. Slope of the sagittal sutures is in right or left oblique
diameter of pelvic inlet.
 Assess the position of the fetus in vertex presentation:
Position of Sagittal Position of fontanelle Position of fetus

suture
Right oblique Posterior fontanelle anteriorly to the left LOA
Anterior fontanelle anteriorly to the left ROP

Left oblique Posterior fontanelle anteriorly to the right ROA
Posterior fontanelle anteriorly to the right LOP
Transverse diameter Posterior fontanelle to the left LOL

of the pelvis
Posterior fontanelle to the right ROL
Anteroposterior Posterior fontanelle felt anteriorly OA
diameter of the
pelvis Posterior fontanelle felt anteriorly OP
13. Check the level or station of presenting part in following manner:

 To assess the descent of the fetus in labour, the level of presenting part is
estimated in relation to maternal ischial spines.
 Presenting part felt above the level of ischial spine is expressed, a “- ” station at
the level of ischial spine as “0” station and below the level of ischial spine is
indicative of “+” station.
 The distance of presenting part (above or below) is expressed in centimeters.
 Assess for moulding: Bones of the skull may be palpated for amount of overlapping.
The parietal bones override the occipital bone and the anterior parietal bone overrides
the posterior.
 Degrees of moulding:
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No moulding – parietal bones (sagital suture) are not apposed.
+1 moulding – parietal bones are touching but not overlapping.
+2 moulding – parietal bones are overlapped but easily reduced.
+3 moulding – parietal bones have overlapped and are irreducible. Severe parieto–
parieto moulding is never normal and should be interpreted as a sign of relative or
absolute cephalopelvic disproportion.
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14. Assess the pelvic capacity: Midwife must assure herself of the adequacy of the pelvis
before she completes the examination.
 Sacral promontory is not reached in normal gynecoid pelvis (Figure-1).
(Figure-1)
 Sidewalls are parallel.

 Sub pubic arch admits two fingers.
 Ischial spines are blunt and not prominent.
 Transverse diameter of outlet admits four knuckles.
15. Direct fingers along the anterior vaginal wall withdraw only when the examination is
complete. Compare findings between and during the contractions.
16. Care must be taken while turning the hand to avoid touching the anus (where it may
get contaminated) or clitoris (where it may cause discomfort) with thumb.
17. Dry the client and leave the client comfortable.
18. Wash hands and dismantle the articles.
19. Record the findings.
COMPLETION OF THE EXAMINATION:
As the midwife withdraws her fingers from the vagina, she should note any blood or amniotic
fluid and compares it with findings made earlier. Remove gloves and check FHS before
giving comfortable position to the woman. Wash hands and dismantle the articles. Inform
woman about the progress of the labour and record the findings.
REFERENCES:
1. Dutta D.C. Textbook of Obstetrics.7th edition. Kolkata: New central book agency (P)
Ltd; 2010.p.130-31.
2. Manocha Snehlata. Procedures and Practices in Midwifery. 2nd edition. New Delhi:
Kumar Publishing House; 2013.p.80-87.
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PARTOGRAPH
DEFINITION
A Partograph is a graphical record of the observations made of a woman in labour for

progress of labour& salient conditions of the mother & fetus.
MODIFIED WHO PARTOGRAPH: - The WHO Partograph has been modified to make it
simpler & easier to use. In modified WHO partograph the latent phase has been removed &
plotting begins in the active phase when the cervix is 4cm dilated.
USES:
1. To monitor the progress of labour and recognize any deviations from normal & early
identification.
2. Increase the quality & regularity of all observations of mother & fetus.
3. Early recognition of maternal & fetal problems.
4. It is used as a tool for prevention & early identification of prolonged and obstructed
labour.
PRINCIPLES OF PARTOGRAPH:
 The active phase of labour commences at 4cm cervical dilatation.

 The latent phase of labour should not last longer than 8hours.
 During active labour the rate of cervical dilatation should not be lower than 1cm/hour
 Lag time of 4hrs between a slowing of labour and need for intervention is unlikely to
Compromise the fetus or the mother and avoid unnecessary intervention.
 Vaginal examination 4 hourly is recommended.
COMPONENTS OF PARTOGRAPH:
A. Foetal condition
B. Progress of labour
C. Maternal condition
The partograph is used in the following manner:
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PATIENT INFORMATION:
Name _____________ Gravida ____________ Para _________ Hospital No.___________
Date of admission _______________ Time of admission _______
Time of rupture of membranes________ Hours
(A).FOETAL CONDITION
1. Foetal heart rate (FHR):
FHR is recorded one hourly during first stage and every 30 minutes in second stage of labour
with the range of 120-160beats/minute.
If >160bt/min - Tachycardia ; if >180bt/min – Severe tachycardia
If <120bt/min –Bradycardia ; if <100bt/min – Severe bradycardia
2. Liquor Amnii:
Amniotic fluid is observed and recorded as:
“I” -If membranes are intact
“C” - Ruptured membrane & liquor is clear
“M” - Ruptured membrane & liquor is meconium stained
“B” - Ruptured membrane & blood stained liquor
“A” - Ruptured membrane & absent liquor.
3. Moulding:
This is recorded as follows:
 Bones are separated & the sutures can be felt easily (0)
 Bones are just touching each other (+)
 Bones are overlapping but can be separated easily with pressure of finger (++)
 Bones are overlapping severely& cannot be easily separated with pressure of finger
(+++)
 Absence of moulding (-)
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(B).PROGRESS OF LABOUR
1. Cervical dilatation:
This is the most important observation to monitor progress of labour. The dilatation is
plotted on the alert line on the graph on admission in active phase and further
examinations are made at least every 4 hours. The points of each dilatation are joined by a
line. The cervical dilatation is divided into two phases;
 Latent phase (not included in the modified WHO partograph): It starts from the
onset of labour until dilatation less than 4cms and last for 8 to 10hours or earlier.
 Active phase (from 4cm to 10cm dilatation): Dilatation of cervix at the rate of 1cm
per hour in primigravida and 1.5cms per hour in multiparae.
 Alert lines: The alert line drawn from 4cm to 10cm represents the rate of
cervical dilatation. Cervical dilatation plotted on the alert line. Therefore if the
cervical dilatation moves on or to the left of alert line, it is well progressed
labour& if it moves, to the right side of alert line, indicates delay in labour.
 Action line: Action line is drawn 4 hours to the right of the alert line. It is
suggested that if cervical dilatation reaches this line, there should be a critical
assessment of the cause of delay and a decision about the appropriate
management should be taken immediately.
2. Station of the fetal head:
When finding out the dilatation, look for the station of the fetal head and chart on right end
of the partograph and join the points.
3. Descent assessed by Abdominal Palpation:
Refers to part of the head (divided into five parts) palpable above symphysis pubis recorded
as a circle (O) at every abdominal examination as 5/5 head completely above pelvic brim and
felt with full width of five fingers and then 4/5,3/5,2/5,1/5,where head is completely engaged.
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Figure-1: Descent assessed by Abdominal Palpation
4. Time:
This is recorded using the time of admission as zero time. The actual time of day is recorded
below the hour’s line. For induced labor the time of induction is recorded as zero time. Time
is recorded at hourly intervals.
5. Uterine contractions:
The contractions are recorded per 10 minutes time in the appropriate square boxes.
Contractions per 10 minutes:
< 20 seconds (Mild contraction)

20- 40 seconds (Moderate contraction)
> 40 seconds (Strong contraction)
6. Oxytocin, drugs and I/V fluids: These are recorded in the space provided.
Oxytocin: Record the amount of oxytocin per volume IV fluids in drops per minute every 30
minutes when used.
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Drugs given: Record any additional drugs given.
(C). MATERNAL CONDITION
1 .Blood pressure, pulse and temperature:
These are recorded in the space provided. Blood pressure every 4 hours and pulse every 30
minutes. Mark upper systolic and diastolic and join with line. Mark pulse by placing dot.
Write down temperature in the bottom line two hourly.
2. Urine:
The amount is recorded every time urine is passed; acetone (ketone) & protein are tested, if
the materials for testing are available.
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Figure-2, is a sample partograph for normal labour:
 A primigravida was admitted in the latent phase of labour at 5am:

o Fetal head was 4/5 palpable
o Cervix dilated 2 cm
o Three contractions in 10 minutes, each lasting 20 seconds.
o Normal maternal and fetal condition.
Note: Because the woman was in the latent phase of labour, this information is not
plotted on the partograph.
 At 9 am:
o Fetal head 3/5 palpable.
o Cervix dilated 5cm
o Four contractions in 10 minutes, each lasting 35 seconds.
 At 11 am:
o Fetal head 2/5 palpable.
o Four contractions in 10 minutes, each lasting 45 seconds.
 At 1 pm:
o Fetal head 0/5 palpable
o Cervical dilatation progressed at rate of more than 1 cm per hour and cervix
fully dilated.
o Five contractions in 10 minutes each lasting 45 seconds.
o Spontaneous vaginal delivery at 1:20 pm.
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Figure-2: Sample partograph for normal labour
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Figure-3, is a sample partograph showing arrest of dilatation and descent in the active phase
of labour. Fetal distress and third degree moulding, together with arrest of dilatation and
descent in the active phase of labour in presence of adequate uterine contractions, indicates
obstructed labour.
 The woman was admmitted in active labour at 10 am:

o Fetal haed 3/5 palpable
o Cervix dilated 4 cm.
o Three contractions in 10 minutes, each lasting 20-40 seconds.
o Clear amniotic fluid draining.
o First degree moulding.
 At 2 pm:
o Fetal head still 3/5 palpable.
o Cervix dilated 6 cm and to the right of the alert line.
o Slight improvement in contractions (three in 10 minutes, each lasting 45
seconds);
o Second degree moulding.
 At 5 pm:
o Fetal head still 3/5 palpable.
o Cervix still dilated 6 cm.
o Third degree moulding.
o Fetal heart rate 92 per minute.
o Amniotic fluid stained with meconium.
 Caesarean section performed at 5:30 pm due to fetal distress.
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Figure-3: Partograph showing obstructed labour
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SET UP OF DELIVERY UNIT
INTRODUCTION:
Preparation for birth in any setting may vary from hospital to hospital. To prepare for birth in
any setting, the delivery trolley is set up during transition phase for nulliparous women and
during active phase for multiparous women. Standard procedures are followed for gloving,
opening sterile packages, unwrapping and handling sterile instruments.
OBJECTIVES:
 To assemble the necessary articles and drugs for conducting a normal delivery.
 To appreciate the system of setting up of a delivery trolley for conducting a normal
delivery.
 To differentiate between the articles required for a normal delivery and operative
procedures in a labour room.
 To develop skills in setting up of conducting normal delivery with episiotomy, forceps
delivery and vacuum extraction.
PHYSICAL SET UP:
 The physical set up of delivery room plays an important role in setting up of trolley and
other articles.
 Labour room as any other operation theatre should have easily washable walls, floors and
bathrooms and toilets should be non slippery.
 Resting rooms for doctors, midwife, and other workers within the reach of the labour
room.
 Cupboards sufficiently available for stationary, linen, drugs and equipments.
 Emergency drug cupboards.
 Labour room has a good lighting system and ventilation and space in between tables
should permit free movements and placements of trolleys.
 Slipper in a rack at the entrance to be used by them who enter the delivery room.
 Furniture – sufficiently placed for health care personnel to sit and do their work and to
relax in between.
 Stools – resolving type for adjusting the height to be used by midwife / obstetrician
helping her / him to make comfortable for suturing after episiotomy or for waiting in
between during delivery to watch the progressive sign.
 Telephone for appropriate communication.
 Refrigerators for storing drugs and specimen.
 Portable extra spot light.
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 Hand washing facilities:

o An elbow operating tap.
o Wide wash basin.
o Nail brush.
o Soap / bottle of antiseptic solution.
o Clean towel on a towel stand.
 Adequate water supply for washing.
The labour room also needs the following facilities:
1. Weighing scale (for mothers and newborn)

2. Temperature tray
3. B. P. apparatus.
4. Stethoscope.
5. Fetoscope.
6. Portable Ultrasonography machine.
7. NST (Non Stress Test) machine
8. Cardio tocography machine (CTG) to assess the uterine contractions and fetal well being.
9. Stretcher.
10. Intravenous infusion pump, IV stand, IV set.
11. Sterile specimen bottles for investigations e.g. sending blood and urine specimens of
mother, cord blood for some tests etc.
12. Oxygen source – central supply or through cylinders, tubings, flow meter, oxygen face
mask of different sizes, hood, catheters.
13. Articles for urine testing – for sugar, albumin and ketone bodies.
14. Sterilizer in a separate room to boil the articles if needed (if there is no provision for
adequate supply or in emergencies)
15. Antiseptics and disinfectant – Dettol, savlon, Chlorhexidine etc.
16. Suppositories.
17. Yellow bucket with yellow polythene lining to receive body fluids and liquid waste
during the process of child birth.
18. Plastic gown.
19. Rubber sheet or ideally a double layered ‘trough’ to protect the labour table and to drain
the fluids directly into the bucket.
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ARTICLES REQUIRED FOR CONDUCTING A DELIVERY:
A. Normal Delivery without Episiotomy:
A hospital usually has a central sterile supply department which looks after supplying sterile
packs of instruments, linen, glassware, and rubber goods required for labour room. The
articles required for normal delivery is as follows:
Sterile Articles: (suction machine & Delivery kit for HIV pts. ??????)
 Sterile gown pack and cap & mask.

 Linen pack with:
 Abdominal sheet – 80 to 90 cm × 90 cm.
 Perineal sheet – same as above sheet with a hole sufficient to deliver the baby and
placenta.
 Sheet – for receiving the baby 90 cm × 90 cm.
 Delivery set:
a) Bowls – 2
 One with cotton swabs
 Another for antiseptic solution for cleaning (e.g. Chlorhexidine 1:2000)
b) Sponge holding forceps-2
 For cleaning the birth passage before and after the delivery.
c) Towel clips – 4 -6
 To keep the linen in position after draping.
d) Kidney tray – big size to receive the placenta and membranes.
e) Straight artery forceps– 2
 For clamping the cord.
f) Syringe with needle – 5 ml
 For administration of drugs.
g) Scissors – to cut the umbilical cord.
h) Perineal pad – 2 (Proportionately bigger and thicker in size).
 One is used for protecting the perineum during delivery of head.
 Another one is used to apply on the perineum after delivery (in fourth stage)
i) Dissecting forceps (non toothed)
 To use as a lifting forceps to pick up sterile cotton etc
j) Cord clamp
k) Goves-1 pair
Other Articles:
l) A soft rubber catheter to drain the bladder.

m) An amniotomy forceps to rupture the membranes.
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 Kocher’s forceps – 1
 Goodwin’s amniotomy forceps – 1
n) Drugs like Oxytocin, Ergometrine, Magnesium Sulphate, analgesics, anaesthesia and
all the emergency drugs to have easy delivery and to prevent any complications.
B. Normal Delivery with Episiotomy:
In addition to the delivery trolley for normal delivery, an extra tray or a pack is used for
performing episiotomy and suturing.

 Linen pack.
 Delivery set.
 Episiotomy and suturing tray articles (In a sterile tray):
1. Syringe – 10ml
2. Needle – 2; G:18 and 22 (18 gauze for withdrawing from the vial and 22 gauze for
infiltration).
3. Episiotomy scissors – 1
4. Dissecting forceps – toothed – 1
5. Mayo needle holder – 1
6. Straight Artery forceps– 2
7. Long straight scissors –1 to cut the suture material
8. Suturing material – Chromic catgut no 1-0 with eyeless round bodied cutting needle
9. Kidney tray-1 to receive the waste
10. A pair of sterile gloves
11. Bowls-2; one to keep cotton swabs and one to keep antiseptic solution for cleaning.
12. Linen: Perineal sheet-1 (Sheet which is used for conducting delivery is removed after
the third stage of labour. For suturing the perineal wound another perineal sheet is
used. This sheet is about 80-90 cms 90 cms which covers the lower abdomen and till
the edge of the table. The hole in the sheet exposes the vulva and vaginal outlet).
13. Cotton swabs: 10-20 (Bigger size) – in a bowl to clean and wipe the blood after giving
episiotomy & also during suturing.
14. Perineal pads – 2
 One is used to control the trickling of blood on the suturing site for placing in
the vagina. The tale is left outside.
 Another one is used to apply on perineum after completing the procedure of
suturing.
Note: The midwife should see that the pad is removed from the vagina before cleaning the
perineum or before transferring the mother to recovery room.
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Clean Tray articles:
1. Local Anaesthetic – Xylocaine or Lignocaine 1%.

2. Bottles with antiseptic solution.
Emergency Drugs Tray Includes:
1. Injection Oxytocin 1 ml
2. Injection Pethidine 100mg (2ml)
3. Injection Atropine 0.6mg
4. Injection Voveran 3ml
5. Injection Lasix 2ml
6. Injection Chromostat 1mg
7. Injection Methergin 0.2 mg
8. Injection Diazepam 10mg
9. Injection Promethazine 25mg
10. Injection Ranitidine 2 ml
11. Injection Avil 2 ml
12. Injection Drotin 2ml
13. Injection Epidosin 1mg
14. Injection Buscopan-1ml
15. Injection Lignocaine 2% in 30 gm
16. Injection Hydrocortisone 100mg
17. Injection Perinorm 2 ml.
18. Dextrose 25% or 10%
19. Ringer lactate
20. DNS, KCL, NACL
21. Tablet Misoprost-800 mcg
C). INSTRUMENTAL DELIVERIES:
Articles Required For Forceps Delivery:
 Articles necessary for cleaning and for conducting delivery.

 Episiotomy and perineal suturing tray.
 Obstetric forceps:
- Midcavity forceps.
- Outlet forceps.
Articles Required For Vacuum Extraction:
 Articles necessary for conducting normal delivery.

 Episiotomy and suturing tray.
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 Vacuum extractor with sterile cups of different sizes and tubing to fix / attach with the
apparatus.
 Obstetric forceps should also be kept for emergency.
Articles for Newborn Resuscitation:
The care of newborn in labour room includes:
 Resuscitation at delivery-TABC (Temperature, Airway, Breathing and Circulation)

 Late care- Examination at birth, tying the cord and identification band, taking weight,
skin to skin contact with the mother (temperature maintenance) and initiation of
feeding.
Articles:
1. Infant radiant warmer in working order.

2. 2 Sheets-clean, dry and pre-warmed
3. Shoulder roll to hyperextend the neck
4. Identification tags, stamp pad and ink.
5. Suction catheter size Fr. 8, 10.
6. A tray containing-Sterile guaze pieces in bowl, sterile cord clamp, sterile cotton
swabs, cord cutting scissors in antiseptic lotion.
7. Tray containing I.V. fluids 5% dextrose. 10% dextrose, normal saline, sterile I.V. set,
sterile disposable insulin syringe.
8. Emergency tray containing: Ambu bag (Self Inflating) with capacity 250-270 ml,
Face mask of sizes 0,1,2; infant laryngoscope with straight blade size 0 and 1 and
emergency injections- Sodium bicarbonate (7.5%), Epinephrine, Naloxone, distilled
water ampoules.
9. Watch with seconds.
CONDUCTION OF NORMAL DELIVERY:
Stages of Labour:
1ST STAGE: Starts from true labour pains to full dilatation of cervix.
2nd STAGE: Full dilatation of cervix to delivery of the baby.
3RD STAGE: Delivery of baby to expulsion of placenta.
4TH STAGE: Till 1 hour after the expulsion of placenta.
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I). CARE DURING 1ST STAGE OF LABOUR:
Objectives: - Prepare mother for smooth delivery.
- Monitor progress of labour, maternal and fetal condition.
Care:
1. Preparation of labour room: Preparation starts from the admission room to

examination room, delivery room and baby room with all instruments, linens and
drugs. Follow all universal precautions.
2. Admission: After admission orient woman to the physical set-up of labour room,
establish a trusting relationship, take consent for procedure, provide nursing support
and collect detailed history.
3. Examination of mother: Examination of mother which covers vital signs, general
examination, abdominal examination, vaginal examination, other investigations
(blood, urine).
4. Psychological care: Providing home like atmosphere and privacy, involve family,
provide companionship, caring attitude and emotional supports.
5. Asepsis: Maintain asepsis to prevent infection.
6. Maintain general hygiene: Comb hair, cut nails, mouth wash, and give hospital
dress.
7. Care of bladder and bowel: Encourage the mother to empty bladder every 1-2
hourly. Catheterize if needed. Give enema if there has been no bowel action for 24
hours or the rectum feels loaded on vaginal examination. Modern concept in
midwifery practice is that a full rectum does not cause delay in progress of labour.
8. Position and Mobility: When membranes intact, ask her to move around. Encourage
her to lie in left lateral position and to maintain upright posture like sitting and
standing with support. Recumbent position leads to compression of inferior vena cava
and consequent supine hypotension syndrome thus it is to be avoided. Woman, who
has an APH or ruptured membranes, when the fetal head is still high, must lie in bed.
9. Diet: Advised for low fat and low residue diet according to her appetite to provide her
energy. After establishment of labour give nothing per orally because this may lead to
regurgitation and aspiration of gastric contents. Maintain hydration level with I.V.
fluids.
10. Relief of pain: Relief of pain and promotion of comfort by verbal anesthesia, sacral
massage, acupressure and drugs (Pethidine 100mg i/m, when pain is established and
cervix is 3cm dilated)
11. Assess of progress of labour by partograph
12. Prophylactic antibiotics: After rupture of membrane administer antibiotics for
prevention of infection.
13. Health education: Regarding hygiene, ambulation, relaxation technique and
breathing exercise, bearing down, self care and family planning.
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14. Recording and reporting: Record maternal and fetal wellbeing, progress of labour
and treatment given in partograph, report any untoward condition.
II). CARE DURING 2ND STAGE OF LABOUR:
OBJECTIVES: - To assist in natural process of expulsion.
- To prevent perineal injuries.
CARE:
 Constant supervision by midwife to note FHS and contractions at every 5 minute

interval. Note pulse and BP at 15 minutes interval.
 Vaginal examination to assess progress of labour.
 Nothing is given by mouth except sips of water.
 Provide dorsal recumbent position with knees flexed on the delivery table.
 Midwife prepares herself by wearing gown, gloves, mask, and cap after thorough
hand washing and keep delivery tray ready.
 Give perineal care after draping the mother.
 Empty the bladder.
 Ask her to bear down during contractions.
Assistance required in spontaneous delivery is divided into three phases:
 Delivery of head
 Delivery of shoulder
 Delivery of trunk
I). Delivery of Head:
 The patient is encouraged for bearing down during contractions. This facilitates
descent of head.
 When the scalp is visible for about 5cm in diameter, maintain flexion by pushing the
occiput downwards and backwards by using thumb and index finger of the left hand
while pressing the perineum by the right palm with the sterile vulval pad to prevent
expulsive crowning. (Figure-1)
 Ask her to breathe deeply and steadily with her mouth open and not to push during
delivery of head. Prevent sudden expulsion of head.
 Once crowned, give episiotomy when perineum is fully stretched.
 The head is born by extension
 The baby’s neck is checked for cord around it.
 If it is loose, it is passed through the head, if tight, cut it.
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Figure-1: Delivery of head
II). Delivery of Shoulder:
 Wait for the uterine contractions to come and for the movements of restitution and
external rotation of the head to occur.
 Placing the hand on each side of the baby’s head, over the ears and applying
downwards traction, the anterior shoulder is born.
 The head is then guided in an upward direction towards the mother’s abdomen so that
posterior shoulder can escape over the perineum. (Figure-2)
Figure-2: Delivery of Shoulder
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III). Delivery of Trunk:
After the delivery of shoulders, the fore fingers of each hand are inserted under the axillae
and the trunk is delivered gently by lateral flexion.
 Note the time of delivery.

 Hold the baby with head slightly downwards (15 degree).
 Check Apgar score at 1 minute and 5 minutes
 Clamp cord 2-5 cm away from the umbilicus and cut the cord.
 Hand over baby to the assistant and show the sex to the mother and give newborn
care.
NEW BORN CARE:
 Maintain Temperature (Dry & cover).

 Maintain airway (Suction).
 Breast feed.
 Care of eyes.
III).CARE DURING 3RD STAGE OF LABOUR:
Objectives:
 Ensure strict vigilance
 Follow the management guidelines strictly so as to prevent complications.
CARE:
 Constant watch is mandatory, never leave the mother unattended.

 Wait for separation of placenta (maximum 30 minutes).
 Keep left hand to stabilize the fundus and with right hand apply traction to deliver
placenta. Hold it with hands and rotate it and ask mother to cough to take it out
completely.
 Give uterotonic agents like injection. Methargin 0.2mg, /Inj. Oxytocin 10units i/m
prophylactically to prevent PPH.
 Examine placenta and membranes.
 Inspect vulva, vagina, and perineum for injuries and to be repaired, if any.
 Clean and dry the perineum and give sterile pad and ask her to lie with closed and
crossed legs.
 Watch pulse, BP and behaviour of the uterus and any abnormal bleeding.
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IV). CARE DURING 4TH STAGE OF LABOUR:
Objectives: - To monitor maternal and fetal wellbeing.
- To prevent complications.
CARE:
 Observe uterine behaviour - it should be well contracted, hard, round and no heavy
bleeding. Repeat checking every 5 minutes.
 If uterus is not well contracted, massage the uterus.
 Observe the vital signs of the mother and newborn (every 10 minutes for first 30
minutes and then every 15 minutes for next 30 minutes).
 Change her clothes.
 Encourage her to have hot drinks and pass urine.
 Check the episiotomy for any hematoma.
 Advice her for hygiene, nutrition, contraception, care of newborn, breast feeding,
danger signs and post natal visit.
Conclusion:
Normal child birth process requires minimum articles and minimum drugs. But every
delivery room in a hospital should be well equipped with all the necessary equipments and
supplies at each stage of labour till it is completed safely.
References:

ltd; 2004. p 135-140.
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EPISIOTOMY AND SUTURING
INTRODUCTION:
Instrumental deliveries become essential during the process of childbirth and these
procedures are accompanied by episiotomy which is followed by its suturing.
DEFINITION:
Episiotomy is a planned surgical incision made on the perineum & posterior vaginal wall
during late second stage of labor in order to widen the introits and straighten the lower end of
the birth canal. This is an attempt to prevent tearing of the underlying muscle and fascia as
the head is born.
PURPOSES:
 To enlarge the vaginal introitus so as to facilitate easy and safe delivery of the fetus.
 To avoid intra cranial hemorrhage to fetal head as prolonged pressure on the fetal
head which can cause brain injury and intra cranial haemorrhage leading to hypoxia
especially premature baby.
 To avoid an irregular perineal tear which can be partial or complete, clean cut incision
can be easily repaired and heals better than a ragged laceration.
 To prevent the third degree tears, in case of presence of scar tissue, which does not
stretch well.
 To cut short the 2nd stage of labour in case of maternal & fetal distress thus to reduce
the bearing down effort of the mother and hasten the birth of the baby.
 To facilitate vaginal or intra uterine manipulations.
 To avoid prolonged stretching of the perineal floor thus prevent the permanent
weakening of the muscles which supports the vagina and bladder which may result in
cystocele.
INDICATIONS:
A). Maternal:
1. Rigid perineum e.g. primi routinely and rarely multi.

2. Previous history of gynecological operations:
 Colpoperineorraphy
 Repair of third degree perineal tear
3. Disproportion between fetus and vaginal orifice. e.g.
 Large fetus
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 Face presentation
4. To cut short the second stage of labour in cases where bearing down effort
entails risk to mother or the fetus e.g., maternal cardiac disease.
5. Prolonged second stage of labor
6. Presence of previous L.S.C.S scar.
B).Fetus:
1. Pre-term babies to reduce trauma to fetal head

2. Cord prolapse in second stage of labor
C). Others:
1. Breech extractions
2. Instrumental vaginal delivery like the use of obstetric forceps, vacuum extraction.
TYPES OF EPISIOTOMY:
1. Median
2. Mediolateral
3. J- shaped
4. Lateral
1. MEDIAN:
Characteristics:
 From the centre of the fourchette directed posteriorly 2.5cm in the mid line of
perineum (Figure-1a).
 Successful only by experienced person who have absolute control of the advancing
fetal head.
Advantages:
 Less bleeding
 More easily and successfully repaired
 Greater subsequent comfort of the mother.
Disadvantages:
 More risk of third degree tear

 Do not provide adequate space especially in cases of vaginal manipulations and large
fetus.
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 Delayed healing as the stitches get moistened soon.
2. MEDIOLATERAL:
 RML (Right Medio Lateral) – more common (Because most of the

obstetricians are right handed and it’s easier to give than left one).
 LML (Left Medio lateral) – less common
Characteristics:
 The incision begins in the centre of the fourchette and is directed posteriorly. i.e.,
made diagonally in a straight line, 2.5cm away from the anus, i.e., 7 o’ clock position.
(Figure-1b)
Advantages:
 Does not lead to complete perineal tear.

 Adequate room is provided for the fetus.
Disadvantages:
 More difficult to repair

 Painful in 1/3rd of the cases due to tension of skin and underlying tissues.
 Greater blood loss
Figure-1a: Median Episiotomy Figure-1b: Mediolateral Episiotomy
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3. J- SHAPED:
Characteristics: The incision is made in the centre of the fourchette and directed posteriorly
in the midline for about 2cm and then directed towards 7 o’clock position (Figure-3).
Advantages:
 Less bleeding
 3rd degree tear can be avoided
Disadvantages:
 Suturing is difficult
 Shearing of tissues occur.
 Repaired wound tends to be puckered.
4. LATERAL
Characteristics:
 One or more cms distant from the fourchette (Figure-3)

 This is not at all in practice as more disadvantages.
Advantages:
 Quickens healing
Disadvantages:
 More profuse bleeding.

 Suturing is more difficult
 More discomfort to the mother.
 Bartholin’s gland may be severed.
 The levator ani muscle is weakened.

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Figure-3: J-Shaped and lateral Episiotomy
COMPONENTS OF EPISIOTOMY:
1. Infiltration with local anaesthetic

2. Making an episiotomy incision
3. Suturing of episiotomy incision.
ARTICLES FOR EPISOTOMY:
Episiotomy and suturing tray articles (In a sterile tray):
15. Syringe – 10ml

16. Needle – 2; G:18 and 22 (18 gauze for withdrawing from the vial and 22 gauze for
infiltration).
17. Episiotomy scissors – 1
18. Dissecting forceps – toothed – 1
19. Mayo needle holder – 1
20. Straight Artery forceps– 2
21. Long straight scissors –1 to cut the suture material
22. Suturing material – Chromic catgut no 1-0 with eyeless round bodied cutting needle
23. Kidney tray-1 to receive the waste
24. A pair of sterile gloves
25. Bowls-2; one to keep cotton swabs and one to keep antiseptic solution for cleaning.
26. Linen: Perineal sheet-1 (Sheet which is used for conducting delivery is removed after
the third stage of labour. For suturing the perineal wound another perineal sheet is
used. This sheet is about 80-90 cms 90 cms which covers the lower abdomen and till
the edge of the table. The hole in the sheet exposes the vulva and vaginal outlet).
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27. Cotton swabs: 10-20 (Bigger size) – in a bowl to clean and wipe the blood after giving
episiotomy & also during suturing.
28. Perineal pads – 2
 One is used to control the trickling of blood on the suturing site for placing in
the vagina. The tale is left outside.
 Another one is used to apply on perineum after completing the procedure of
suturing.
 Note: The midwife should see that the pad is removed from the vagina before
cleaning the perineum or before transferring the mother to recovery room.
Clean Tray articles:
1. Local Anaesthetic – Xylocaine or Lignocaine 1%.

2. Bottles with antiseptic solution
PROCEDURE OF GIVING & SUTURING EPISIOTOMY:
Prerequisites:
 Place the patient in lithotomy/ dorsal with flexed knee position.

 Perineal area is thoroughly swabbed with antiseptic lotion
 Drape the area
 Load the Lignocaine 1% in 10 ml syringe.
1. THE INFILTRATION:
 Insert the first two fingers of the gloved left hand into the vagina during the
interval between two contractions between the perineum and fetal scalp to ensure
that the drug is not injected into the fetus.
 Introduce the needle in the midline of the inner edge of the fourchette and directed
subcutaneously for a distance of 2.5cms away from the anal sphincter.
 Withdraw the piston of the syringe if no blood appears, inject 3ml without
removing the needle, redirect it 1cm to either side and inject 3-5ml,
simultaneously after withdrawing. The three injections will infiltrate over a fan
shaped area and the incision is made down to the centre (Figure-4).
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Figure-4: Proper technique for infiltration of perineal tissue prior to episiotomy incision
2. MAKING THE INCISION:
Points to be kept in mind:
 Length of the incision should not be more than 3cms on a stretched perineum.
 Positions: Lithotomy/ dorsal with flexed knee.
 Protect the fetal scalp from injury by scissors by inserting two fingers between the
perineum and head.
 The episiotomy is given with crowning, so that the blood loss is less. If
episiotomy is given before crowning, the forward bulging rectum may be injured
by the tip of episiotomy scissors.
 One step cut should be given because a series of small snips will result in a ragged
incision which is difficult to suture and delay healing.
 The scissors should be sharp because blunt scissors bruise the perineum.
Timing the incision:
 The ideal time of the episiotomy is bulging thin perineum during contractions just
prior to crowning.
 If done early, blood loss will be more.
 If done late, it fails to prevent the invisible lacerations of the perineal body and
thereby fails to protect the pelvic floor.
Vertex: Head should be well down in the perineum about 4-5 cms seen outside, low enough
to keep it stretched.
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Breech: The posterior buttock would be distending the perineum. Perineum should be well
stretched, bulging and thinned.
Method of making the incision:
 Two fingers are placed in the vagina between the presenting part and the posterior
vaginal wall
 The incision is made by the episiotomy scissors, one blade of which is placed inside
in between the fingers and the posterior vaginal wall and other on the skin. (Figure-5)
 The incision should be made at the height of uterine contractions
 Deliberate cut is made starting from the centre of the fourchette (0.5 cm) extending
laterally (2.5 cms more) either to the right or to the left (medio lateral). The incision
should be 2.5 cms away from the anus.
Figure-5: Technique of giving episiotomy incision
3. PROCEDURE OF SUTURING EPISIOTOMY:
An episiotomy is comparable with the wound of a second degree perineal tear and must be
repaired in three layers.
1. Vaginal mucosa and sub-mucosal tissues– by plain continuous suture
2. Perineal muscle – by plain interrupted suture
3. Perineal skin and subcutaneous tissues – by interrupted plain or mattress suture
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Timing of repair:
The repair of the perineum should be done as soon as after expulsion of placenta. Early repair
prevents sepsis and excessive bleeding per vagina.
Preparation:
 The patient is placed in lithotomy position.

 A good light source from behind is needed for adequate inspection of the wound.
 The area is cleaned with antiseptic solution and blood clots are removed from the
vagina.
 Perineal pad or gauze pieces should be inserted into the vagina to stop the oozing
from the uterus and make the field clear for suturing. The pack must be removed
after the repair is completed.
 Repair should be done under strict aseptic precautions.
Method of Repair:
 Find the apex of the vaginal incision and repair posterior wall of vagina downwards
with continuous 1-0 chromic catgut suture. The other vaginal lacerations should be
repaired. (Figure-6)
 Repair perineal muscles with deeper plain interrupted suture with 1-0 catgut.
 Repair fourchette and skin layer with interrupted plain or mattress suture.
 At the end of the procedure insert the gloved finger into the rectum in case a suture
has been extended beyond the intended limit and to check the patency of rectum.
 Clean the perineum with antiseptic solutions, remove the vaginal pack and make the
woman comfortable.
 Apply pad and make her lie crossed or closed legs.
Figure-6: Repair of Episiotomy
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COMPLICATIONS:
1. Profuse bleeding:
2. Extensions of episiotomy
3. Haematoma, edema and pain
4. Retention of urine
5. Infection and gapping
6. Dyspareunia due to painful perineum and narrow introitus.
7. Injury to bowel-fistula formation.
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PLACENTAL EXAMINATION
INTRODUCTION:
The placenta is an organ that connects developing fetus to the uterine wall through umbilical
cord to allow nutrient uptake, waste elimination and gas exchange via mother’s blood supply.
DEFINITION:
It is the thorough inspection of placenta after delivery to check for its completeness and
abnormalities.
PURPOSES:
1. To make sure that no part of placenta or membrane has been retained.

2. To check for any variations in placenta or cord, which may indicate either congenital
anomalies in baby or may complicate labour/postpartum period.
ARTICLES:
S. NO ARTICLE RATIONALE
1. Placenta with cord For examination
2. Sink with tap water For washing the placenta of fresh blood and
blood clots
3. Gloves – 1 pair To protect the hands of the examiner.
4. Mask To protect face of the examiner from spilled
blood.
5. Plastic apron -1 To protect clothing of examiner
6. Basin with clean water -1 To keep placenta with cord for examination.
7. Table -1 To keep basin with placenta and cord.
8. Gauze pieces in a bowl To remove clots from maternal surface
9 Mackintosh with paper lining -1 To spread on the table so as to prevent soiling of
the table.
10. Kidney tray and paper bag To discard waste.
11. Weighing scale To measure the weight of placenta.
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STEPS OF PROCEDURE: (add how to weight the placenta and check thickness or cord
length??????)
1. Wear apron and gloves.

2. Weight the placenta.
3. Keep placenta with cord in the basin and wash under running water to remove clots..
4. Now fill the basin with clear water and keep washed placenta with cord in it so as it
dips in water.
5. Spread mackintosh and paper lining on the table and place the basin with placenta on
it.
6. Lay placenta on flat surface to examine.
7. Examine membranes, umbilical cord and both surfaces-maternal and fetal surface, one
after the other in good light.
PLACENTA AT TERM:
1. Placenta at term is a round flat discoid structure of 15 – 20 cms in diameter and 2 -

2.5cms in thickness. It thins off towards the edge.
2. It feels spongy and weighs about 500 gm, the proportion to the weight of the baby
being roughly 1:6 at term and occupies about 30% of the uterine wall. Weight of the
placenta may be affected by the time of clamping the cord. Early clamping of the cord
results in more placental weight while late clamping leads to less placental weight,
owing to amount of blood retained in placenta.
3. It presents two surfaces, fetal and maternal surface.
4. At term, about four-fifths of the placenta is of fetal origin and maternal portion of
placenta amounts to less than one-fifth of the total placenta.
1. Examination of Membranes:
1. Hold placenta by the cord thus allowing the membranes to hang. (Figure-1a)
2. Spread out the hand inside the membranes through the hole from which the baby was
delivered. This aids in the inspection of membranes.
3. Check for the hole in the membranes. There should be only one hole in the membrane
through which the fetus has escaped. More than one hole indicate that some part of
membrane is retained in the uterus.
4. If the membranes are complete, strip the amnion from the chorion and see if both
membranes are present.(Figure-1b)
5. The amnion can be peeled off from fetal surface except its insertion from the cord.
6. Observe amnion. It is smooth, glistening and transparent membrane and is in contact
with amniotic fluid in the uterus.
7. Chorion is the membrane below the amnion which is thin, grayish and translucent in
nature.
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Figure-1a: Examination of membrane Figure-1b: Stripping of amnion from chorion
2. Examination of Fetal Surface of Placenta:
1. Fetal surface is white and shiny surface which is covered by smooth and glistening
amnion with the umbilical cord attached at or near its centre (Figure-2).
2. Branches of umbilical veins and arteries are visible spreading out from the insertion
of the umbilical cord.
3. Separate amnion and chorion and peel off amnion from the fetal surface till the
insertion of the cord to see the chorionic plate from which the placenta develops.
Figure-2: Fetal Surface
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3 .Examination of Maternal Surface of Placenta:
1. Hold the placenta in hand so as to expose maternal surface, which is rough, spongy
and dull red in colour due to maternal blood. It is attached to the endometrium of the
uterus.
2. Remove blood clots on the maternal surface using gauze pieces and discard gauze
pieces in paper bag.
3. Observe for the arrangement of cotyledons (quadrilateral areas convex in shape)
which are 15 -20 in numbers and are divided by sulci (fissures). (Figure-3)
4. Any breakage in the arrangement of cotyledons may indicate missing cotyledons
which may be left in the uterus.
5. Observe for whitish – yellow spots which indicate calcification of placenta.
6. Check for placental infarct (old clots usually in depressed area), these are due to
blockage maternal and fetal circulation.
7. The edges of maternal surface form a uniform circle.
Figure-3: Maternal Surface
4. Examination of Cord:
1. Cord extends fetal umbilicus to the fetal surface of placenta. It is a connecting link
between fetus and placenta and is inserted in the fetal surface of placenta.
2. Cord does not contain any pain receptors.
3. The total cord length should be estimated in the delivery room, since the delivering
physician has access to both the placental and fetal ends.
4. During the placental examination, the delivering physician should count the vessels in
either the middle third of the cord or the fetal third of the cord, because the arteries are
sometimes fused near the placenta and are therefore difficult to differentiate.
5. Observe for the following characteristics of placenta.
 Diameter of the cord: 1 – 2.5cms
 Average length: 55cms and ranges from 33 -100cms.
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 Normally cord is little longer than the fetal length.

 From outside to inside cord is covered by amnion, mucoid embryonic connective
tissue and Wharton’s jelly.
 Cord contains 2 arteries and 1 vein which are supported by Wharton’s jelly.
Observe for these blood vessels on the cut end of cord after cleaning of the cord
stump.
 Observe for true and false knots. False knots formed due to accumulation of
Wharton’s jelly. (Figure-4)
 The membranes and the placenta have a distinctive metallic odor that is difficult
to describe but is easily recognized with experience. Normally, the placenta and
the fetal membranes are not malodorous.
 Normally cord is attached to the centre of placenta.
o In 73% cases – lateral insertion
o In 7% cases – marginal insertion (battledore insertion)
o In 1 -2% cases – Velamentous insertion (inserted into the membranes)
8. After the complete examination of placenta, discard it in the yellow bag. Discarded
placenta is sent for incineration.
9. Dismantle the articles, remove gloves, aprons and mask and dispose it off.
10. Wash hands thoroughly with antiseptic lotion.
Figure-4a: True umbilical knot
Figure-4b: False umbilical knot
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ABNORMALITIES OF THE PLACENTA AND CORD:
A. Abnormalities of Cord and its Attachments:
1. Short cord: Length less than 40 cms may lead to premature separation of placenta
and fetal distress.
2. Long cord: Excessive long cord may lead to cord prolapse, cord loops around the
neck, looped or knotted cord.
3. Single umbilical artery: It may indicate a baby born of a diabetic mother may
associate with congenital malformations of the fetus (10-20%). Renal and genital,
Trisomy 18 are common.
4. Battledore insertion of cord: The cord is attached at the very edge of the placenta in
the manner of a table tennis bat. It is unimportant unless the attachment is
fragile.(Figure-5)
5. Velamentous insertion of the cord: The cord is inserted into the membranes some
distance from the edge of the placenta. The umbilical vessels run through the
membranes from the cord to the placenta.(Figure-6)
Figure-5: Battledore insertion of the cord Figure-6: Velamentous insertion of the cord
B. Anatomical Variations of Placenta:
1. Placenta Succenturiata: A small extra lobe is present, separate from main placenta
and joined to it by blood vessels, which run through the membrane to reach it.(Figure-
7)
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Figure-7: Placenta Succenturiata
2. Circumvallate placenta: An opaque ring is seen on fetal surface. The ring is formed
by a doubling back of the chorion and amnion and may result in the membranes
leaving the placenta nearer the centre instead of at the edge as usual. (Figure-8)
Figure-8: Circumvallate Placenta
3. Bipartate placenta: Two complete and separate lobes are present, each with a cord
leaving it. The bipartite cord joins a short distance from the two parts of the
placenta.(Figure-9)
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Figure-9: Bipartite Placenta
4. Tripartate placenta: Similar as bipartite placenta but with three distinct lobes.
REFERENCES:

ltd; 2004. p 218-20.
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NEW BORN EXAMINATION
DEFINITION:
A complete head- to- toe examination of the newborn is usually conducted within 24 hours of
birth to identify the needs and provide nursing care accordingly.
PURPOSES OF EXAMINATION:
1- To identify the physical and neurological characteristics of newborn and any deviation
from normal.
2- To identify congenital malformations and birth injuries
3- To classify the neonate according to the birth weight and gestational age.
4- To provide basis for identification of needs and plan nursing care
FREQUENCY OF EXAMINATION:
 First examination : a detailed one in labour room within 2 hours of birth.

 Second examination: before discharge.
 Third examination : after 6-8 weeks of neonatal life.
SPECIFIC INSTRUCTIONS:
To perform through skilled examination of newborn, the following specific instructions
should be kept in mind:
1) Observation should be made when the newborn is quiet and awake
2) Ensure adequate light in examination room as well as room should be warm (28
degree centigrade) and draft free.
3) Prior to examining the baby, the examiner wash her hands to prevent spread of
infection, her hands should be warm to prevent chilling of the baby.
4) Expose only required body parts as the newborn is at risk for developing hypothermia
because of immature thermoregulation mechanisms.
5) Examination of the baby should, whenever possible, be performed beside the parents
so that nurse can inform the parents about normal growth and development and
appearance, and also answer any questions.
6) Examination should be performed in an orderly manner from the crown to heel.
ARTICLES:
1. Hand washing articles to prevent cross infection

2. Clean sheet to wrap the baby.
3. Weighing machine to measure weight
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4. Measuring tape to measure head circumference, Chest circumference and abdominal

circumference
5. Infantometer to measure the crown to heel length
6. Temperature tray to check temperature
7. Stethoscope to auscultate heart rate.
8. Spirit swabs to clean the thermometer, measuring tape and stethoscope.
9. Torch to check pupillary reflex and to observe oral cavity.
10. Bowl containing cotton wisp to check nasal patency.
11. Kidney tray& paper bag to discard waste
12. Record Sheet to record the finding
PREPARATION FOR EXAMINATION:
1) Before actual examination, the important maternal and perinatal history should be
reviewed. Maternal history (age, parity, medical disorders etc), pregnancy problem
present and past (drugs, IUFD, preeclampsia, IUGR, prematurity) Labour and
Delivery history (duration, anaesthesia, Apgar score) should be obtained.
2) Inform to the parents regarding the physical examination of the newborn and invite
the parents to observe and participate in examination.
3) Collect required articles and ensure their proper functioning.
4) Ensure warm environment by closing the door and windows as well as switching off
the fan. Room heater can be utilized in winter season
5) Wash hands thoroughly and make them warm by drying and rubbing.
6) Place the newborn on a flat surface at a comfortable height to yourself.
7) Handle the newborn gently.
8) Undress the baby and cover up in a clean sheet as well as avoid unnecessary exposure.
9) Precede the examination of newborn systematically.
INITIAL ASSESSMENT OF NEWBORN:
1. Identification:
Check and identify the sex of the infant, and verify the records with the correct name, sex and
registration number.
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II. Gestational Age:
 Full term: 37 to 42 weeks or 259 to 294 days.

 Pre term: after 28 weeks & before 37 weeks.
 Post term: after 42 weeks.
A.PHYSICAL ASSESSMENT:
1. Recording of Vital Signs:
a) Respiration:
Observe by watching abdominal movements and count for one minute. The normal
respiration rate is 40-60 breath per minute.
b) Heart rate:
Check by placing the stethoscope apically i.e. fourth inters-costal space in the mid clavicular
line for one minute (Figure-1).The normal heart rate is 120-160 beats/minute.
Figure-1: Method of checking apical Pulse
c) Temperature:
The temperature is taken by axillae. The thermometer should be placed for at least 3 minutes.
Normal axillary temperature is 95.5-99.3degree.
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2. Measurements:
The baby’s head circumference, length and weight are measured to provide parameters
against which future growth can be monitored
a) Baby’s weight:
 Place a paper lining on the scale.

 Balance weighing scale, beam balance.
 Place nude newborn on weighing scale.
 While weighing, nurse should place a hand an inch above the newborn’s body to
quickly grasp the newborn if necessary
 The mean birth weight in India is 2.9 kg (2.8 to 3.2 kg).
b) Length:
Crown heel length is measured accurately through the calibrated equipment. But when using
this equipment it is essential that the baby’s legs are fully extended and that the head and feet
are in full contact with the measuring device. Crown heel height is 47-53 cm.
c) Head circumference:
Place the tape measure firmly over the supra orbital ridges anteriorly and posteriorly over the
occipital protuberance that gives maximum circumference (Normal head circumference is 33-
35.5cm).
d) Chest circumference:
The tape measure should be placed across the lower border of scapula and cover the nipples
i.e. it is measured at nipple line. It is 2 cm less than head circumference. Chest circumference
less than 30 cm indicates pre maturity.
e) Abdominal circumference:
The circumference should measure at umbilicus. It is not usually measured unless indicated.
Abdominal circumference is less than 2 cm from chest circumference.
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Figure-2: Measurements of newborn.
3. General Appearance:
A) Posture:
Observe the posture while newborn is quite and in supine position. Flexed posture, as a result
of in-utero position. Legs flexed and abducted and arms completely flexed & symmetrical
unrestricted movements of the limbs are observe in normal newborn.
B) Behaviour:
Observe the behaviour of newborn, whether the baby is active, alert or dull.
4) SKIN:
Inspect the skin with general survey and as each body part is examined, during the
examination of specific body parts, all creases and skin folds should be carefully examined.
A. Skin colour:
The skin colour may change rapidly in response to activity and temperature changes. Normal
variations in skin colour and pigmentation include following.
 Pallor: May be due to anemia, birth asphyxia, or shock

 Cyanosis/Acrocyanosis (cyanosis of hands and feet) may appear, especially if the
baby is chilled. Persistent cyanosis may represent a congenital heart problem.
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 Harlequin sign (one side of baby is pink and other side is pale) may be present
because of vasomotor instability.
 Plethora (deep red coloration of skin with crying) caused by polycythemia.
B. Skin Turgor:
The skin of the newborn appears soft and smooth. Dry, flaky, peeling skin may indicate
prolonged gestation
 Vernix caseosa: is a white cheese like substances that cover the skin of the fetus and
is almost always seen in skin folds and creases.
 Lanugo: is a fine silky covering of hair present over body. It is absent in post
maturity baby and extensive in pre maturity.
 Extensive bruising: may be due to difficult or traumatic delivery
Normal variations:
 Milia: appear as small white papules on the face, especially on the nose, cheeks and
chin & usually disappear within 2months. They are formed from the plugged
sebaceous glands. (Figure-3)
Figure-3: Milia
 Mongolian Spots: are the areas of dark blue or black pigmentation that are seen on
the back, buttocks or thighs & usually disappear by four years of age. (Figure-4)
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Figure-4: Mongolian Blue Spots
 Erythema Toxicum: are small red papules of 2-4mm in size with white pinpoint
centers appearing within 24 hours after birth on trunk.
5. HEAD:
Observe hair distribution, shape, size and symmetry of face and skull.
a) Fontanelles: Palpate anterior and posterior fontanel. Bulging fontanelles may be due to
increased intracranial pressure or hydrocephalus. Depressed fontanelles are seen with
dehydration
b) Hair: observe the texture of hair usually silky separate strands
c) Caput succedaneum or swelling of scalp tissues is noted. (Figure-5)
Figure-5: Caput succedaneum
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F) Cephalohematoma:-This is the collection of blood between the bone and the periosteum.
(Figure-6)
Figure-6: Cephalohematoma
Difference Between Cephalhematoma and Caput Succedaneum
G) Craniosyntosis: Premature closure of one of sutures of the skull.
6). FACE:
Face: Face is looked for facial nerve injury (Facial Palsy). (Figure-7)
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Figure-7: Facial Palsy
Eyes:
 Examine the symmetry in size and shape. Check for hypertelorism (distance between
eyes more than 3 cm).
 Lens opacity for congenital cataract.
 Conjunctiva: for sub-conjunctival hemorrhage (traumatic delivery).
 Sclera: Jaundiced (Yellow) sclera is due to hyper-bilirubinemia.
 Eyelids may be edematous for 2 days, it is normal.
 Discharge is not present in normal eyes, purulent discharge is indicative of infection.
Nose:
 Observe for shape, placement, patency and configuration of bridge of nose. The nose
may be flattened.
 Check the nares for patency (wisp of cotton is placed at the nares to check the
movement of air).
 Note any flaring of nares and evaluate immediately; it may represent respiratory
distress.
Oral cavity:
 Usually moist, but generarally no salivation is present.

 Inspect the tongue, gums and cleft palate, cleft lips and deciduous teeth, epithelial or
Epstein’s pearl (small white or yellow vesicles seen in median palatal raphe of
mouth), Ankyloglossia or tongue tie, deciduous teeth (baby teeth), oral thrush,
pooling of saliva (abnormal).
Ears:
 Assess the ear for position, size, shape and firmness of cartilage by palpation.
 Check ear recoil by folding pinna forward band release it.
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 Tympanic membrane visualization is not performed on newborns; because the canal

usually filled with Vernix caseosa.
 Low set ears are indicative of chromosomal disorders (Down syndrome), mental
retardation. (Figure-8)
Figure-8: Method to check low set ears
7) Neck and Clavicle:
 Neck is short, thick and has several thick folds of skin.

 The short thick neck of the baby must be examined to exclude the presence of
swellings and to ensure that rotation and flexion of the head are possible.
 The clavicle areas should be carefully palpated and inspected. A broken clavicle in a
common complication of birth and may be indicated by swelling, visible dislocation
and tenderness.
 Moro’s reflex is absent in a baby who has fracture of clavicle.
 Check for webbing of neck (torticolis) is associated with Turner’s syndrome
8) Chest:
 Observe size, shape of chest as well as retraction.

 Breast nodules are approx. 6mm in term infant. Lack of breast tissue shows
prematurity.
 New born breast may be enlarged (1 cm in diameter) due to maternal estrogen.
 Check Supernumerary Nipples (more than 2 nipples).
 Breast engorgement may be evident 2-3 days after birth due to effect of withdrawal of
maternal estrogen and the secretion of cloudy fluid may be observed and is called
witch’s milk.
 Observe respiratory movements.

 Occasional retraction (chest in withdrawing) may be seen during crying. Retraction if
present all the times is indicative of respiratory distress or prematurity.
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9) Abdomen:
 The contour of the abdomen is rounded and dome shaped. Note any variation,
including a scaphoid abdomen (boat shaped) which may indicate malnourished fetus
or diaphragmatic hernia or any protrusion above the chest may be result of feces or
organ enlargement.
 Observe the umbilical cord. Initially umbilical cord is white and gelatinous later it
dries and shrivels. Two arteries and one vein
 Normal umbilicus is clean, and no discharge or bleeding is present. Bleeding or
purulent discharge from the cord may indicate loose cord ties, hemorrhagic lesions or
omphalitis.
 Kidneys are normally palpable, liver 2-3 cm, Spleen palpable.
10) Genitalia and Anus:
 The genitalia should be examined carefully. The passage of meconium stool is

associated with patency of gastrointestinal tract. Perianal tags(excess growth of skin
near anus) may be present.
 Check the anus for perforation.
a). Female:
 Observe development of labia majora, urethral meatus, and vaginal. The labia majora
completely cover the labia minora. The clitoris appears large. The infant may have a
mucoid, occasionally blood-tinged discharge as a result of maternal hormonal
influence (pseudo menstruation). The urethra is located anterior to vaginal orifice.
 A female genitalia is examined for vaginal discharge (smegma), and edematous
genitalia.
b). Male:
 Male genitalia is examined for penis (>2 cm), descent of testes within the scrotum,
any hydrocele (accumulation of clear fluid in tunica vaginalis), Hypospadiasis
(urethra opens at ventral aspect of the shaft) or Epispadiasis (opening of urethra on the
upper aspect of the penis).
 Observe the scrotal rugae.
 Testes descended in the scrotum. Scrotum pendulous and deeply pigmented.
11) Back:
Observe the spinal curve while newborn is in supine position. Any swelling, dimples or hairy
patches may signify an occult spinal defect and also observe for spina bifida, meningocele,
myelomeningocele. (Figure-9)
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Figure-9: Spinal Defects
12) Limbs:
 Count the fingers of hands and toes. Observe for sole creases after stretching the skin.
 Observe for Syndactyly (fused fingers of finger and toes), Polydactyly (more than 5
fingers), simian crease (single line that runs across palm of hand), talipes equinovarus
(club foot). (Figure-10)
Figure-10: Club Foot
 Check for hip dislocation:

 Observe for asymmetrical thighs and gluteal folds. (Figure-11a)
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Figure-11a: Asymmetrical thighs and gluteal folds
 Limited abduction of affected thigh (less than 400). (Figure-11b)
Figure-11b: Limited abduction of affected limb
 A positive Galeazzi Sign: finding of one knee lower than the other knee when the new
born is in supine position with hips and knee flexed. (Figure-11c)
 This sign suggest the shortening of involved limb and possibly developmental
dysplasia.
Figure-11c: Positive Galeazzi Sign
 Inspect the hip area carefully for signs of either hip instability or dislocation by
performing the Ortolani and Barlow test. (Figure-11d)
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Procedure:
1. Lay the infant in a supine position and flex the knee to 90 degrees at the hips. Proper
position of the infant ensures accurate results.
2. Hold the infant’s pelvis with one hand to stabilize it during manipulation.
3. Using the other hand, the place the middle fingers over the great trochanter of the
femur and the thumb on the internal side of the thigh over the lesser trochanter.
Placing the fingers in this manner allows easy abduction of the hips.
4. Slowly and gently abduct the hips while applying pressure over the greater trochanter.
The femur is pulled forward while the greater trochanter is used as a fulcrum.
5. Listen for a clicking or clunking sound while performing step number four. Normally,
no sound is heard. A clicking or clunking sound is a positive Ortolani sign and it
happens when the femoral head is re-entering the acetabulum.
6. With the fingers in the same position, assess the infant for Barlow’s sign. Hold the
hips and knees at 90 degree flexion while exerting a backward pressure (down and
laterally).
7. Slowly and gently adduct (bringing the thigh towards the midline) the hip. Note any
feeling of the femoral head slipping. Normally, the hip joint is stable. The feeling of
the femoral head slipping out of the socket post laterally is a positive Barlow’s sign.
Figure-11d
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ASSESSMENT OF GESTATIONAL AGE AT BIRTH:
Character ≤36 weeks 37-38 weeks ≥39 weeks

Sole creases 1-2 transverse Multiple creases, Entire sole with
creases , 3/4th smooth 2/3rd of heal smooth creases
sole
Breast nodule 2mm 4mm 7mm
Scalp hair Fine, wooly, fuzzy Fine, wooly, fuzzy Coarse , silky
Ear lobe No cartilage Moderate amount of Stiff ear lobe ,thick
cartilage cartilage
Testes and scrotum Testis partially Testes fully Testes fully
descended, scrotum descended, scrotum descended, scrotum
small normal size normal size
B.NUROLOGICAL EXAMINATION:
The baby’s reflex responses are elicited in order to establish normality of the neurological
system. These are tested while the baby is in quite alert state. Absent or weak responses may
indicate immaturity, cerebral damage or abnormality.
I. PROTECTIVE REFLEX:
1) Blinking reflex:
 When the eyes are open touch the cornea lightly with the piece of cotton.
 Absence of this response denotes lesions of the 5th cranial nerve.
2) Coughing:
3) Sneezing:
4) Gag reflex: Stimulation of posterior pharynx by food, suction or while passing tube
causes newborn to gag.
II. PRIMITIVE REFLEX
 Most primitive reflexes begin to occur in utero through the early months of the baby’s
postnatal life.
 These reflexes are then replaced by voluntary motor skills.
1) Head lag (Traction response): When pulled upright by the wrists to a sitting position the
head will lag initially; the neonate then responds by lifting the head and holding it upright.
Neonate will be able to maintain head in line with the body. The amount of head lag noted
depends on the maturity and muscle tone of the neonate. (Figure-12)
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Figure-12: Head lag
2) Glabellar reflex:
 The examiner taps lightly over the forehead

 The neonate responds by blinking the eyes for the first 5 taps.
 Continued blinking may indicated extra pyramidal disorder
3) Corneal reflex:
 When the eyes are open touch the cornea lightly with the piece of cotton.
 Absence of this response denotes lesions of the 5th cranial nerve.
4) Doll’s eye reflex:
 Move the head slowly to left or right

 Eyes lag behind and do not adjust immediately to new position of head.
 This disappears when fixation develops.
5) Rooting reflex:
 In response to stroking of the cheeks or side of the mouth the baby will turn
towards the source of stimulus and open the mouth ready to suckle. (Figure-13)
 This reflex is inhibited anywhere between 6 and 12 months of age.
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Figure-13: Rooting Reflex
6) Sucking reflex:
 This should be checked while feeding the baby.

 Or by placing finger in baby’s’ mouth.
 Rhythmical sucking movements will be felt.
 Disappears: around 12 months.
7). Extrusion reflex:
 Touch or depress the tongue with the finger. Baby will respond by forcing it outward.
 This reflex last for about 4 months
8.) Tonic neck reflex:
 Place the newborn in supine position turn the head to one side. The arm and leg on
the side to which head is turned extend while the opposite arm and leg are getting
flexed. (Figure-14)
 This reflex is present at 18 wks in utero.
 Disappears by 6 months after birth.
Figure-14: Tonic neck reflex

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9).Grasp reflexes.
 A palmer grasp is elicited by placing a pencil or finger in the palm of the baby’s hand.
The finger or pencil is grasped firmly. (Figure-15)
 Planter grasp is also checked in same manner.
 This reflex emerges 11 weeks in utero, and is inhibited 2-3 months after birth
Figure-15: Palmer Grasp Reflex
10). Startle reflex:
 When newborn is exposed to loud noise, there will be sudden change in the position.
 It results in abduction or arms with flexion clenched.
 It disappears in 4 months.
 Failure to elicit this reflex may be abnormal try again to elicit the reflex before
deciding it is absent.
11) Moro reflex:
 This response occurs in response to a sudden stimulus. The baby is held supine, with the
trunk and head supported below. When the head and shoulder are suddenly allowed to fall
back, the baby responds by abduction and extension of arm with fingers fanned. (Figure-
16)
 Emerges 8-9 weeks in utero, and is inhibited by 16 weeks.
 The reflex is symmetrical. The most common cause for asymmetric response is a fracture
of humerus or clavicle, or brachial plexus palsy.
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Figure-16: Moro’s Reflex
12). Magnet reflex:
 The neonate is placed on the back, partially flexes both legs and applies slight
pressure on the soles of the feet.
 The neonate responds by extending both legs against the source of pressure. (Figure-
17)
Figure-17: Magnet Reflex.
13). Step or Dance reflex:
 Hold the newborn in upright position so that sole of the foot touches examination
table. Newborn makes stepping movements. (Figure-18)
 This reflex appears at birth, lasts for 3-4 months, and then reappears at 12-24 months.
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Figure-18: Stepping or Dancing Reflex
14). Babinski reflex (Planter reflex):
 Stroke lateral aspect of foot from heel toward little toe with tongue blade or other
edged object. The toes flare open. (Figure-19)
 Emerges at 18 weeks in utero and disappears by 6 months after birth.
Figure-19: Babinski reflex
15) Galant Reflex:
 It is elicited by placing the neonate in prone position.

 The neonate back is stimulated by stroking the back about 5 cm from supine in a
downward motion.
 Their trunk and hips should moves toward the side of stimulus.(Figure-20)
 This reflex emerges 20 wks in utero and is diminished by 3 months.
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Figure-20: Galant Reflex
16). Ventral suspension reflex:
 Hold the baby prone and suspended over examiner’s arm, the baby temporarily holds
the head level with the body and flexes the limbs. (Figure-21)
Figure-21: Ventral Suspension.
POST PROCEDURE CARE:
 Redress the baby after the completion of the examination.
 Give the baby to the mother for feeding
 Record the finding in case notes and any abnormalities are brought to the attention of
the pediatrician.
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REFERENCES:

ltd; 2004. p 445-47.
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POSTNATAL ASSESSMENT
Definition:
Systematic examination and advices given to a mother after delivery is called postnatal
assessment.
AIMS AND OBJECTIVES:
 To identify any deviation from normal physical and physiological progress following
delivery and to treat them at the earliest.
 To detect high risk condition of the mother after delivery.
 To prepare the woman for lactation and baby care.
 To detect and to treat at the earliest any gynecological condition arising during this
period
 To impart family planning guidance.
Frequency of Examination:-
 1ST EXAM is done within 24 hrs of delivery.

 2ND EXAM is done before discharge.
 3RD EXAM is done after the puerperium
PUERPERIUM AND ITS DURATION:
Puerperium: Puerperium is the period following childbirth, during which the body tissues,
especially the pelvic organs revert back approximately to the pre-pregnant state both
anatomically and physiologically. Involution is the process whereby the genital organs revert
back approximately to the state as they were before pregnancy.
Duration:
Puerperium begins as soon as the placenta is expelled and lasts for approximately 6 weeks.
1. Immediate- within 24hours
2. Early- up to 7 days
3. Remote- up to 6 weeks
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POSTNATAL EXAMINATION:
E. Setup for postnatal examination

F. Assess postnatal mother:
iv. History taking

v. Head to toe examination
vi. Obstetric examination
G. Postnatal advices and health education
A. SET-UP FOR POSTNATAL EXAMINATION:

Facilities required to conduct examination are:
 A room with proper lighting. There should be window for ventilation. Temperature of
the room should be according to season.
 Examination table with bed length mattress, mackintosh & bed sheet spread on it & a
pillow for comfort of the woman.
 Facility for the woman to pass urine.
 Hand washing facility for care provides.
Articles required:
12. Screen or curtain to maintain privacy.

13. Drape sheet to cover the client.
14. Inch tape (measuring tape) to measure fundal height.
15. Weighing machine to measure weight.
16. Vitals tray to check the vitals of the mother.
17. Kidney tray & paper bag to discard waste.
18. Torch to check pupil.
Prerequisites:
 Approach the women pleasantly to establish rapport.

 Maintain privacy while doing assessment.
 Make her comfortable while taking history to gain her confidence.
 Have all the equipment’s necessary for the procedure in proper place to avoid
interrupting the examination.
 Environment should be comfortably warm & pleasant (examiner must warm hands).
 Ask her to empty her bladder before conducting fundal palpation.
 Avoid too much palpation as it may cause discomfort and pain.
 Check the fundal height daily at the same time for accurate measurement.
 Record and report if there is any deviation from normal.
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B. ASSESSMENT OF POSTNATAL MOTHER:
I. History
1. Identification Data:
Name
Age
IP No
Address
Marital Status
Duration of marriage
Father’s / Husband’s Name
Religion
Educational Status: Client
Husband
Occupation: Client
Husband
Family Income
Date and time of Admission
Date and Time of Delivery
2).Past Medical history:
 History of heart disease

 Any diseases since childhood like Rheumatic fever
 Asthma
 Convulsions
 Allergies
 Renal disease
 Diabetes
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 History of blood transfusion.
4).Surgical history:
- History of any operation
- Injury or accident
5). Family History:
- Hypertension
- Heart diseases
- Diabetes mellitus or any other disease
6).Personal History:
- Any personal habits like alcoholism, smoking etc.
7).Past Obstetrics History: Record of previous pregnancy, labour and puerperium.
The history of pregnancy may be recorded by using mnemonics G, P-T, P, A, L.
G – Gravida, it denotes pregnant state both present & past irrespective of the period if
gestation.
P – Parity, it denotes a state of previous pregnancy beyond the period of viability.
T-Term pregnancy
P- Pre-term pregnancy
A - Denotes abortions.
L - No. of living children
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Table 1: Obstetric History
S. Date of Place Duration Course of Method Course Puerperium Baby

delivery of of pregnancy of of
Sex Wt.
No birth pregnancy delivery Labour
8). Present Obstetric History:
i). Parity
ii). Mode of labour:
 Spontaneous
 Induced
iii). Mode of Delivery:
 Normal Vaginal delivery

o With episiotomy
o Without episiotomy
o With tear – First Degree/Second Degree/Third Degree
 Caesarean
iii) Full term / Premature
iv) Presentation- Vertex / Breech / Shoulder / Face
v) Duration of labour-1st, 2nd and 3rd stage of labour
vi) Problem during labour
vii) Date and time of delivery
viii) Blood loss: WNL/ Excessive
ix) Method of placental separation
x) Method of placental expulsion
xi) Weight of the placenta
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xii).Length of the cord
Baby Details:
i. Weight of the baby

ii. Sex of the baby
iii. Presence of any congenital anomalies
II. HEAD TO TOE EXAMINATION:
A. Physical Examination
B. General Physical Examination
III). OBSTETRICAL EXAMINATION:
Assess the patient for BUBBLER:
1. B : Breast
2. U : Uterus
3. B: Bowel
4. B:Bladder
5. L:Lochia
6. E:Episiotomy (REEDA Scale)
7. R: Emotional Response
II. HEAD TO TOE EXAMINATION:
A. Physical Examination:
This includes complete systematic examination of each system and assessing its function.
Physical measurements include:
i).Vitals & B.P:
 Temperature:
On the 3rdday, there may be slight rise in temperature due to breast engorgement
which should not last for more than 24 hours. Genito-urinary tract infection should be
excluded if there is rise of temperature.
 Pulse:
The raised pulse settles down to normal during the 2nd day. Increase pulse rate with
increase temperature indicate presence of puerperal infection.
 Respiration:
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Respiratory rate returns normal with the release of the upward pressure on the
diaphragm following delivery of the baby.
 Blood Pressure:
Low B.P. indicates presence of haemorrhage and hypovolemic shock. If there is any
history of hypertension, then check the B.P. frequently.
ii). Weight: In addition to the loss of about 5 to 6 kg due to uterine evacuation and normal
blood loss, there is usually a further decrease of 2 to 3 kg through diuresis. Record the weight
of the mother. Apart from weight loss from uterine evacuation, blood loss and diuresis, there
is additional 2kg weight loss during puerperium.
iii). Pallor: The sites to be noted are lower palpebral conjunctiva, dorsum of the tongue
and nail beds.
iv). Jaundice: The sites to be noted are bulbar conjunctiva, under surface of the tongue,
sclera, hard palate and skin.
v). Observation of Signs of hypovolemic shock:
Hypovolemic shock may occur after delivery due to dehydration and excessive bleeding.
The signs of hypovolemic shock are:
 Persistent and significant bleeding- perineal pad soaked within 15 minutes.

 Changes in vital signs like pulse is fast and feeble, low B.P.
 Skin feels cold and clammy.
 Atonic uterus.
 Mother becomes anxious.
B. General Physical Examination:
1. Built – May be obese, average & thin.
2. Gait – Normal or any abnormality
3. Appearance – May be depressed, tired & lethargic.
4. Head – Examination of scalp for cleanliness, infection & infestations & hair for their
luster & texture.
5. Face – Chloasma & any scar.
6.Eyes – Observe the colour of conjunctiva is yellow/pink/normal, sclera is normal/yellow

tinge suggest jaundice, or any infection or discharge in the eye.
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7. Nose – Deviated nasal septum, infection & blockage.
8. Mouth – Observe tongue for pallor/ glossitis /coated, teeth & gums for dental
carries/stomatitis, tonsillitis.
9. Ear – Infection, blockage, wax.
10. Neck – Thyroid glands, lymph glands for any abnormalities.
11. Upper extremities – For any bony abnormalities, colour of nails pink/pale, shape of
nails, areas of inflammation, presence of scars.
12. Examination of Breast –For assessment of the breast of postnatal mother:
 Ask the mother- How do your breast feel?

 Inspection:
 Look at the nipple for fissure, flat and inverted nipple
 Look at the breast for-
 Swelling
 Shininess
 Redness
 Observe a breastfeed if not yet given.
 Palpation: Feel gently for tender, painful part of the breast.
SIGNS CLASSIFY
 No swelling, redness or tenderness. Breast healthy

 Normal body temperature.
 Nipple not sore and no fissure visible.
 Baby well attached.
 Nipple sore or fissured. Nipple soreness or fissure
 Baby not well attached.
 Both breasts are swollen, shiny and Breast Engorgement
patchy red.
 Temperature < 380C.
 Baby not well attached.
 Not yet breastfeeding.
 Part of breast is painful. Mastitis
 Temperature > 380C.
 Feels ill.
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13). ABDOMEN (UTERUS):
Uterine tone:
Immediately after the delivery, the uterus becomes firm and retracted with alternate
hardening and softening. Palpate the uterus. Normally the fundus is firm and may be returned
to a state of firmness with intermittent gentle massage. Atonic or relaxed uterus suggests
bleeding.
Fundal height:
 Immediately postpartum, the uterine fundus is palpable at or near the level of the
maternal umbilicus.
 1st 24 hours after delivery, the height of the fundus is 5cms below the umbilicus or
13.5cms above the symphysis pubis.
 After 1 week 7.5 cm above the symphysis.
 12 days after labour the fundus is usually not palpable.
 Note the height of the fundus by placing the ulnar border of the palm.
 In first 24 hours fundal height should be assessed for future reference (comparison) to
know the involution of the uterus. (per day decrease hw mch cm in primi & multi??)
Signs of satisfactory involution:
 The uterus is firm.

 Fundal height decrease about 1 cm each day in the initial 7-10 days.
Signs of sub-involution:
 Bulky uterus.
 No decrease or less decrease in fundal height than normal.
14). Bladder and bowel function:
 Diuresis in the 1st few days following delivery is normal as the body excrete extra
fluid.
 She may have constipation for initial one to two days following delivery.
To assess the bladder and bowel function, ask the mother about:
 Whether she has passed urine or not.

 Void within 4 hours, then 4-6 hours.
 About the amount and frequency of urination.
 About pain and burning during urination.
 About incontinence of urine.
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 About the constipation.

 Constipation causes pressure on sutures, increases discomfort (I/O cart??)
15). LOCHIA:
 Early in the puerperium, sloughing of decidual tissue results in a vaginal discharge of

variable quantity; this is termed lochia.
 It consists of erythrocytes, shredded decidua, epithelial cells, and bacteria. It is the
discharge for the first fortnight during the puerperium.
 It originates from the uterine body, cervix and vagina.
 The amount of flow and color of the lochia can vary considerably.
 Maternal age, parity, infant weight do not influence the duration of lochia.
It occurs in the following manner:
 Lochia Rubra: this discharge is red and bloody and may contain few small blood
clots. Lasts for 1-4 days in profuse amount.
 Lochia Serosa: occurs in next 5-9 days, colour is yellowish pink or pale brownish and
in diminished quantity.
 Lochia Alba: Pale white because of the presence of leucocytes, lasts for 10-14 days
and scanty in amount.
Assessment:
In the first 24 hours, the amount of lochia is normally same as normal menstrual flow of
woman. The average amount of discharge for 5-6 days is estimated to be 250 ml (Partially
saturate 4-8 pads, average 6 pads /day). While observing lochia, turn the mother on her side
to inspect her perineum and check under the buttocks. In this way, the blood pool beneath her
will not be missed. To observe the lochia in first 24 hours:
 Check the perineal pad frequently, to ensure that blood loss is not excessive.
 Check under the mother’s buttocks and as well as the perineal pad because bleeding
may flow between the buttocks on the linen under the mother while perineal pad is
slightly soaked.
 A perineal pad that is soaked through from tail to tail contains approximately 60-80
ml of blood.
 More than one pad soaked in 5 minutes suggests heavy vaginal bleeding.
 If patient reports heavy bleeding, change pad, reassess in 1 hr.
 For accurate assessment, can weigh pad; 1g = 1cc.
 Inspect the vulval hematoma and swelling because the blood loss with vulval
hematoma is excessive.
 If constant vaginal flow and soaking of pad every 60 minutes is observed, check for
cervical and vaginal tear.
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Basic features of lochia:
TYPE CHARACTERISTICS DURATION QUANTITY
Lochia Rubra Blood tinged red 3-4 days Profuse

discharge
Lochia Serosa Brown to yellow 5-14 days Diminished

discharge
Lochia Alba Turbid whitish 15days to 6 weeks Scanty
discharge
i. Amount: Types according to size of pad area soiled:
 Scanty: Less than 1 inch stain on perineal pad

 Small: < 4 inch stain
 Moderate: 6 inch stain
 Heavy: 6 inch stain
 Excessive: Pad saturation within 15 min
ii. Consistency:
Lochia should not have big clots. Clots may indicate retained pieces of placenta. Clots are not
a good sign and indicate poor uterine contractions which need to be corrected.
iii. Pattern:
The pattern of the lochia should not reverse (normally lochia Rubra to Serosa to Alba). If
there is a red flow after lochia Serosa or Alba, it usually indicates that placental pieces have
been retained or uterine contraction is slow leading to fresh bleeding.
iv. Odour:
Lochia should not have an offensive odour. It has the same odour as menstrual blood. An
offensive odour usually indicates infection.
v. Absence:
Lochia should never be absent. The absence of lochia indicates postpartum infection.
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16). Episiotomy:
To inspect the episiotomy, remove the undergarments of the mother and ask the mother to
turn on her side and lift buttock to expose perineum. It is more visible in the lateral position.
Assess episiotomy for REEDA:
 Redness
 Edema
 Ecchymosis
 Discharge
 Approximation
REEDA for assessment of Episiotomy wound healing:
CHARACTE- 0 1 2 3
RISTICS
Redness None 0-2.5 mm B/L 2.5 mm B/L >5 mm Bilateral
Edema None <10 mm B/L 10-20 mm B/L >20 mm Bilateral

Ecchymosis None <2.5 mm B/L 2.5-10 mm B/L >10 mm Bilateral
Discharge None Serous Sero-sangious Bloody, purulent

Approximation Closed < 5 mm B/L Separated >20 mm, fascia
separated.
Total Score: 15
0 = No infection
1-5 = Mild infection
6-10 = Moderate infection
11-15 = Severe infection.
17).Lower extremities:
 Legs should be looked for edema & varicosities. Look for any inflamed area over a
vein of the calf muscles.
 Palpate gently and note if the inflamed area is warm, red, feels hard and is tender to
touch.
 Homan’s sign (calf pain on dorsiflexion of the foot) may be elicitated to diagnose
deep vein thrombosis (Elicitation & demonstration of Homan’s sign is avoided
nowadays because of the possibility of dislodging a thrombus from legs & causing
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pulmonary embolism. Moreover it is not reliable because it may be negative in nearly

50% of cases of DVT).
18.) Back or Spine: Observe the back and spine for any deformity.
19). EMOTIONAL RESPONSE:
To check the emotional response of the mother, assess her grooming, facial expressions, way
of talking, attitude towards her baby and her activities. Normal response of the mother after
delivery is:
A.-TAKING - IN PHASE: First 2-3 Days-Mothers primary needs her own sleep and food.
B- TAKING HOLDS PHASE: 3rd Postpartum Day to 2 Weeks- Begins to take hold task of
mothering.
C-LETTING GO PHASE- Mother may feel a deep loss over separation of baby from her
body, may have difficulty in mothering role.
Three types of psychological changes are seen after delivery:
1) Postnatal or’ 3rd day’ Blues (Postpartum Blues).

2) Psychosis or ‘Puerperal’ psychosis.
3) Postpartum depression
i) Postnatal Blues:
This is transient period of depression in first few days after delivery which is normal. Mother
may experience this in the 1st postnatal week. Usually resolve naturally in 10-14 days.
Symptoms include:
 Rapid mood changes with crying and or laughing for no apparent reason.
 Anorexia, difficulty sleeping, feelings of letdown.
 Assure the women that this is normal and she should not worry about these
symptoms.
ii) Psychosis or Puerperal psychosis:
This occurs in the 1st few days of delivery and beyond the 2-3 weeks. If following symptoms
occur, then she should be referred to the psychiatrist.
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Symptoms related to her:
 Extreme mood swings, during which feeling of anxiety or guilt may be expressed.
 Bizarre behaviour
 Delusions or hallucinations.
 At times she may appear depressed
 May appear confused or hyperactive.
Symptoms related to her child:
 If mother state that her baby is abnormal and may believe it to be possessed, but
not express this vocally.
 She will avoid the baby.
 She will not feed the baby.
 She will not give attention to the hygienic and elimination needs of baby.
 She will not be able to recognize psychological and physiological needs of the
child even if the child is crying.
 Mother- Child bonding will not be maintained.
iii). Postpartum Depression:
This usually develops after the 2nd postnatal week and may lasts for 3-6 months. To observe
the signs and symptoms of depression:
Ask the mother:
 How have you been feeling recently?

 Have you been in low spirits?
 Have you been able to enjoy the things you usually enjoy?
 Have you had your usual level of energy or have you been feeling tired?
 How has your sleep been?
 Have you been able to concentrate?
If two or more of the following symptoms present, will indicate presence of postpartum
depression:
 Inappropriate guilt or negative feeling towards self.

 Cries easily.
 Decreased interest or pleasure.
 Feels tired, agitated all the time.
 Disturbed sleep (Sleeping too much or too little, waking early).
 Diminished ability to think or concentrate.
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 Marked loss of appetite.
20). Others: Apart from BUBBLER following assessment should be done:
1) After pains
2) Observation of signs of infection
3) Return of menstruation
i). After pains:
After pains is intermittent contractions of uterus which usually gone in 5 minutes. These may
be very uncomfortable for 2-3 days. Usually, they decrease in intensity and become mild by
the third day. More common in multiparous, retained placenta or with overdistention of
uterus. In primiparous, the puerperal uterus tends to remain tonically contracted, whereas in
multiparae, the uterus often contracts vigorously at intervals, giving rise to after-pains. They
are more pronounced as parity increases. They worsen when the infant suckles, likely
I1). Observation of signs of infection:
To observe the signs of infection:
 Feel lower abdomen and flanks for tenderness.

 Look for abnormal lochia.
 Measure temperature.
 Look or feel for stiff neck.
 Look for lethargy.
SIGNS CLASSIFY
 Temperature > 380C and any of: UTERINE INFECTION
 Very week
 Abdominal tenderness.
 Profuse lochia.
 Uterus not well contracted.
 Lower abdominal pain.
 History of heavy vaginal
bleeding.
 Fever > 380C and any of: UPPER URINARY TRACT INFECTION
 Burning on urination
 Flank pain.
 Burning on urination LOWER URINARY TRACT
INFECTION
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 Temperature > 380C and any of: VERY SEVERE FEBRILE DISEASE
 Stiff neck.
 lethargy
iii). Return of Menstruation:
Return of menstruation varies from 2 to 18 months. In non- lactating mothers, menstruation

may occur as early as 4 weeks. Lactating mothers may experience lactational amenorrhea
until the baby is breastfed.
C). ADVICES AND HEALTH EDUCATION:
After the completion of all necessary postnatal examination, a relevant postnatal advice has to
be given to the mother. These advices include information regarding diet, breast feeding, care
of baby, personal hygiene, postnatal exercises and immunization of baby..
Aims:
5. To advise the mother about need for regular follow ups.

6. To provide the mother, opportunities for maintaining the optimum health status
throughout puerperium.
7. To immunize baby timely.
8. To motivate the mother for contraception.
1. Postnatal Check-ups:
Regular check-ups after childbirth is also very important and mother should not miss even
one of them. These check-ups usually include checking blood pressure, temperature,
involution of uterus, stitches and episiotomy wound. Advise the mother to report any kind of
pain or discomfort immediately to the doctor.
2. Breastfeeding:
Mother should be advised for exclusive breast feeding to her baby up to six months. It has
manifold benefits and in addition to giving all the nutrients and vital elements to the child, it
helps strengthen the bonding between the mother and the child. Feed the baby 2 hourly or on
demand.
3. Diet: Special care should be taken to have a good and nutritious diet. Lactating mother diet
should include high calories, adequate protein, fat, plenty of fluids, minerals and vitamins
 Bread, other cereals and potatoes (including breakfast cereals, pasta and rice).
These foods should make up the main part of diet.
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 Fruit and vegetables including fresh, frozen and tinned varieties, salad vegetables,
beans and lentils, dried fruit and fruit juice.
 Milk and dairy foods. Eat or drink moderate amounts and choose lower fat versions
whenever possible.
 Meat, fish and alternatives. Alternatives include eggs, beans and lentils, nuts. Eat
moderate amounts and choose lower fat versions whenever possible.
 Foods containing fat and sugar. Eat sparingly, i.e. infrequently and/or in small
amounts.
4. Rest: Looking after a new born baby is demanding. Mother gets less time due to baby care.
Mother should be advised to avoid one night feed and take rest for 2 hours in day time
5. Exercise: Mothers should not keep themselves confined to bed. Postnatal exercises should
be started immediately after delivery if possible in order to improve circulation, strengthen
pelvic floor and abdominal muscles, and to prevent transient & long term problems.
6. Perineal Care: Mother should be advised to keep episiotomy area clean and dry after
urination and defecation from upward to downwards. After 12 hours of episiotomy, to relieve
pain and to promote healing, mother should be advised for Sitz bath.
7. Care of stitches in Caesarean: Take care of stitches any time when move or hold the
baby. Whenever hold the baby or feed him, see that there is no kind of pressure on the
sutures. If there is problem with the stitches, ask for someone’s help in moving around and
holding baby while feeding him.
8. Avoid intercourse up to six weeks after delivery.
9. Advise the mother for methods of contraception to maintain space between the children
and if her family is complete advise her for permanent methods of contraception.
10. Advise her for timely immunization of her baby.
CONCLUSION:
Postnatal examination of mother should be done at regular and periodic intervals to assess the
wellbeing of the mother and her baby. Being a midwife it is necessary to have knowledge
regarding postnatal assessment so that she can find out any deviations from normal at the
initial stage and advice & refer the mother for necessary interventions.
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REFERENCES:
 Dutta. DC. Textbook of Obstetrics.6th edition. Calcutta: New central book agency (P)
ltd; 2004. p 145-47.
 Cunningham. FG. Williams Obstetric. 22nd edition. China: McGraw Hill; 2007.p876-
898.
 Training Module on Skills in Midwifery Practices, UNICEF.
 Integrated management of Pregnancy and Child birth. WHO, Geneva.2003.
 Maternal Health and Nursing Interventions. IGNOU. p113-24.
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BREAST CARE
Breast care is the activity to prepare & clean the breast during pregnancy & lactation for
breast feeding.
Purposes:
 To prepare the women for breastfeeding.

 To correct the minor defects of the breasts.
General instructions:
1. Pay special attention to nipples.

2. Use circular movements while applying soap.
3. Never use strong soap/antiseptic.
4. Inspect breast for any breast problems like engorgement, retracted, depressed, cracked
nipples, mastitis & other complications.
5. Break suction before taking out nipple from baby’s mouth.
6. Teach mother to cut her fingernails short.
7. Wash hands before feeding.
Articles required:
A tray containing
 Bowl with cotton swabs.
 Sponge clothes-2
 Soap in a soap dish.
 Kidney tray.
 Mackintosh lined with treatment towel.
 One basin.
 Jug of hot water.
 Screen.
Procedure:
1. Wash hands to prevent cross infection.

2. Explain the procedure to the client to gain her confidence & co-operation.
3. Provide privacy with screen or curtain.
4. Arrange the articles to the bedside.
5. Provide comfortable sitting position to the client. If the general condition of the client
is week, place her in side lying position.
6. Fold the upper garments above the breast. Expose only required area.
7. Place the mackintosh & towel under the breast to protect bed & garments.
8. Allow the client to adjust the kidney tray under her breast according to her
convenience.
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9. Pour hot water in the basin.

10. Apply soap with the sponge cloth in a circular movement starting below areola and
working outward. Do not apply soap on nipples and areola. (Use soap only for first
time washing to remove dirt and grease collected due to sweating in labour).
11. Remove the soap and clean the breasts with sponge cloth.
12. Clean the nipples and remove all the clogs & crusts with cotton swab to prevent the
blockage of the duct.
13. Express little milk to ensure the patency of the nipple.
14. Check for cracks & inversion of nipples or engorgement of the breasts.
15. Dry the breast with towel.
16. Remove the mackintosh & towel.
17. Put the baby on the breasts. Before putting the baby to breast, any discharge from the
baby’s eyes or nose is to be cleaned and the napkin must be changed.
18. Advise her to wear supporting bra to prevent over stretching of tissues.
19. Make the mother and child comfortable.
20. Remove all articles and screen from the bedside and replace them after cleaning.
21. Wash hands and record the procedure and abnormal findings.
Early problems with breast feeding:
Mothers like to stop breastfeeding if they have feeding problems.it is very important to know
how to prevent & solve these situations to make breastfeeding successful.
These problems are as follows:
1. Flat or inverted nipples.

2. Sore nipple.
3. Engorged breast, mastitis & breast abscess.
4. Cracked nipple.
5. Not enough milk.
6. Refusal to the breastfeed.
I. Flat or inverted nipple:
Sometimes a nipple will not protract well if one tries to pull it out rather it goes deeper into
the breast.
Management:
 Build the mother’s confidence. Explain that it may be difficult at the beginning, but
with patience & persistence she can succeed. Explain that her breast will improve &
suckling will help to pull her nipples out.
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 Explain that a baby suckles from the breast not from nipple. Explain also that as the
baby breastfeeds, he will pull the breast & nipple out.
 Encourage her to give plenty of skin-to-skin contact, & to let her baby explore her
breasts.
 Ensure good suckling position.
 Help her to try different positions to hold her baby. Sometimes putting a baby to the
breast in a different position makes it easier for him to attach.
 Detect the problem early & mange it preferably soon after birth so that intervention
can be done before the breast become heavy, at that time suckling will be very
painful.
 Effective method is to use 10ml plastic syringe.(Figure-1)
Figure-1
Exercises for inverted nipple:
1. Nipple Rolling:-
 Gently pull the nipple between thumb & index finger.
 Hold them in this position for 1 minute.
 Tell the client to repeat this for 5-6 times.
2. Nipple Stretching:-
 Place thumb/index finger opposite each other near the edge of the areola of the
breast.
 Press the breast & stretch outwards.
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 Hold them in this position for 1 minute.

 Tell the client to repeat this 5-6 times.
II. Sore nipple/crack nipple:
If a baby does not have enough of the breast in his mouth he sucks only the nipples & so
enough milk is not removed from the breast & breastfeeding becomes a painful experience
for the mother.
Causes:
It occurs due to poor attachment. It may be due to candida infection.
Management
 Develop mother’s confidence. Explain that the soreness is temporary & that soon
breastfeeding will be completely comfortable.
 Ointments are not recommended & are harmful.
 Help her to improve her baby’s attachment.
 Help the mother to reduce engorgement if necessary. She should breastfeed
frequently, or expresses her breast milk.
 Consider treatment of candida if the skin of the nipple areola is red, shiny, or flaky; or
if there is itching, or deep pain, or if the soreness persists.
Advices given to the mother
 Advice her not to wash her breasts more than once a day, & not to use soap on
areola & nipple, or rub hard with a towel. Breasts do not need to be washed before
or after feeds-normal washing as for the rest of the body is all that is necessary.
Washing removes the natural oils from the skin, & makes soreness more likely.
 Advise her not to use medication lotions & ointments, because these can irritate
the skin, & can block the ducts.
 Suggest that after breastfeeding she rubs a little expressed hind milk over the
nipple & areola with her finger. This promotes healing.
III. Care of Engorged Breast
Engorgement is a condition in which the breasts become enlarged, heavy, hard, & tender. It is
seen in varying degrees commonly between 3rd& 5th day of the pueperium.
Purposes
 To reduce discomfort of the mother by relieving pain & tenderness.
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 To maintain lactation.
 To prevent further complications of the breasts.
Articles required:
A tray containing:
 A medium sized basin with hot water.

 Four sponge clothes.
 Kidney tray with paper bag.
 Mackintosh lined with towel.
 A few pads of cotton wool in a bowl.
 A small towel to dry the breast after the procedure.
 Screen for privacy.
General Instructions:
 Breasts must be completely emptied after expression.

 An effort should be made to maintain lactation.
 Water should not be very hot.
 Inspect for any breast complications.
 Sucking by the baby & manual expression are avoided in severe engorgement.
Procedure:
1. Bring the tray to the bedside.

2. Explain the procedure to the mother.
3. Screen the mother.
4. Put the mother in a sitting or side lying position according to her comfort.
5. Expose the mother’s breasts.
6. Place the mackintosh lined with towel under the breasts.
7. Soak 2 sponge clothes in hot water, wring the sponge clothes well, test their
temperature & apply on breasts.
8. Soak the other 2 sponge clothes in hot water.
9. Change the sponge clothes when cold.
10. Continue fomentation of the breasts for 10-15 minutes.
11. Put baby to the breasts, after drying using towel.
12. Express the rest of the milk from the breast manually in to the kidney tray.
13. Clean the breast & wipe it to dry.
14. Ask the mother to wear well-fitting bra. She can use cotton pads in the bra for
absorbing the milk secretion from breast.
15. Wash & replace all articles.
16. Record condition of breasts & nipples.
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Treatment of breast engorgement:
To treat engorgement it is essential to remove milk. If milk is not removed, mastitis may
develop, an abscess may form & breast milk production ceases.
 If the baby is able to suckle, he should feed frequently.

 If the baby is not able to suckle, help the mother to express her milk.
 Before feeding or expressing, stimulate the mother’s oxytocin reflex by:
 Putting a warm compress on her breasts or takes a warm shower.
 Massage her neck & back.
 Massage her breast lightly.
 Stimulate her breast & nipple skin.
 Help her to relax.
 After a feed, put a cold compress on breast. This may help to reduce oedema.
 Use of chilled cabbage leaves can relieve breast engorgement. This is a remedy that
goes back to ancient times.
Instructions: How to use of cabbage leaf compresses
1. Take a common green cabbage.

2. Remove the core and gently peel individual leaves away from the centre of the head
pulling outward. Try to avoid tearing the leaves.
3. Thoroughly wash the leaves.
4. Leaves can be chilled in the refrigerator for extra benefits. Cool compresses tend to
relieve swelling more effectively than warm compresses.
5. Just before use, crush the veins in the leaf with a rolling pin (or similar object), or
slice off the tops of the "veins" with a sharp knife.
6. Drape several leaves over each breast. Use enough to cover ALL the engorged tissue,
including any swollen tissue under arms.
7. Leave the compress on until the leaves become wilted, about 20 to 30 minutes.
8. Repeat application of cabbage leaves three or four times (about every 4 to 6 hours)
per 24 hours, until engorgement subsides (usually in 1 or 2 days). If the engorgement
is severe, compresses can be used as often as needed.
9. For the mother who is not breastfeeding, continuous cabbage compresses can also be
used to help reduce the swelling in her breasts.
10. Discontinue direct use immediately if skin breaks out, blisters, or becomes irritated.
EXPRESSING BREAST MILK:
Introduction
There are many situations in which expressing breast milk is useful & important to enable a
mother to initiate or continue breastfeeding.
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Expressing milk is useful to:
1. Relieve engorgement.
2. Relieve blocked duct or milk stasis.
3. Feed a baby while he learns to suckle from an inverted nipple.
4. Feed a baby who has difficulty in coordinating suckling.
5. Feed a low birth weight baby who cannot breastfeed.
6. Feed a sick baby, who cannot suckle enough.
7. Keep up the supply of breast milk when a baby or mother is ill.
8. Leave breast milk for a baby when his mother goes out to work.
9. Prevent leaking when a mother is away from her baby.
10. Prevent the nipple & areola from becoming dry & sore.
Stimulating an oxytocin reflex:
The oxytocin reflex may not work well when a mother expresses as it does when a baby
suckles. A mother needs to know how to help her oxytocin reflex or she may find it difficult
to express her milk.
How to stimulate the oxytocin reflex
Help the mother psychologically:
 Build her confidence.

 Try to reduce any sources of pain or anxiety.
 Help her to have good thoughts & feelings about the baby.
Help the mother practically or by giving advices:
 Sit quietly & privately.

 Hold her baby with skin-to-skin contact if possible. She can hold her baby on her lap
while she expresses.
 Take warm soothing drink. The drink should not be a coffee.
 Warm her breasts. For example: she can apply a warm compress or warm water or
have a warm shower.
 Stimulate her nipples. She can gently pull or roll her nipples with her fingers.
 Massage or stroke her breasts lightly or gently roll closed fist over the breast towards
the nipple.
 Ask a helper to rub her back. The mother sits down, lean forward, folds her arms. Her
breasts hang loose, unclothed. The helper rubs down both sides of the mother’s spine.
She uses her closed fist with her thumbs pointing forwards. She presses firmly making
small making small circular movements with her thumbs. She works down both sides
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of the spine at the same time, from the neck to the shoulder blades, for two or three
minutes (Figure-2).
Figure-2: Stimulation of Oxytocin reflex by rubbing the mother' back
How to prepare a container for expressed breast milk
 Choose a cup, glass, jug or jar with a wide mouth.

 Wash the cup with soap & water.
 Pour boiling water into the cup, & leave it for few minutes. Boiling water will kill
most of the germs.
 When ready to express milk, pour the water out of the cup.
How to express breast milk by hand:
 Wash hands thoroughly.

 Sit comfortably, & hold the container near the breast.
 Massage the breast gently towards the nipple. (Figure-3.1)
 Put thumb on breast above the nipple & areola, & first finger on the breast below the
nipple & areola, opposite the thumb. She supports her breast with her other fingers.
(Figure-3.2)
 Press thumb & first finger slightly inwards towards the chest wall. She should avoid
pressing too far, because that can block the milk ducts. (Figure-3.3)
 Press breast behind the nipple & areola between her finger & thumb. She must press
on the lactiferous sinuses beneath the areola. Sometimes in a lactating breast it is
possible to feel sinuses. (Figure-3.4)
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 Press & release, press & release. This should not hurt. If it hurts, the technique is
wrong. At first no milk may come, but after pressing a few times, milk starts to drip
out. It may flow in stream if the oxytocin reflex is active.
 Press the areola in the same way from sides, to make sure that milk is expressed from
all segments of the breast. (Figure-3.5)
 Avoid rubbing or sliding her fingers along the skin. The movement of the fingers
should be more like rolling.
 Avoid squeezing the nipple itself. Pressing or pulling the nipple cannot express the
milk. It is the same as baby sucking only the nipple.
 Express one breast for at least 3-5 minutes until the flow slows; then express the other
side; & then repeat both sides. She can use either hand for either breast, & change
when they tire.
Figure-3.1(Step-1) Figure-3.2 (Step-2)
Figure-3.3 (Step-3) Figure-3.4 (Step-4)
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Figure-3.5 (Repeat step 4 at different positions around the areola)
 Explain that to express milk adequately it takes 20-30 minutes, especially in the first
few days when only a little milk is produced. It is important not to try to express in a
shorter time.
How often a mother should express milk:
1. To establish lactation, to feed a low birth weight or sick newborn: she should start to
express milk on the first day, within 6 hours of delivery if possible.
a) She may only express a few drops of colostrum at first, but it helps breast milk
production to begin, in the same way that a baby suckling soon after delivery
helps breast milk production to begin.
b) She should express as much as she can, as often as her baby will breastfeed.
This should atleast every 3 hours, including during the night.
c) If she expresses only a few times, or if there are long intervals between
expressions she may not be able to produce enough milk.
2. To keep up her milk supply to feed a sick baby; she should express as much as she
can, as often as her baby would feed, at least every 3 hours.
3. To build up her milk supply, if it seems to be decreasing after a few weeks; express
very often for a few days, & at least every 3 hours during the night.
4. To leave milk for a baby while she is out at work; express as much as possible before
she goes to work, to leave for the baby. It is also very important to express while at
work to help keep up the supply.
5. To relieve symptoms such as engorgement or leaking at work; express only as much
as necessary.
6. To keep nipple skin healthy; express a small drop to rub on her nipple after a bath or
shower.
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REFERENCES:

2. Ayers, J. F. (2000). The Use of Alternative Therapies in the Support of
Breastfeeding. Journal of Human Lactation , 16, 52-56.
3. Caplan, L. M. (1999). Drawing Action of Cabbage Leaves (A letter to the
editor). Journal of Human Lactation , 15, 4.
4. Smith, M. K. (2000, Jan). New Perspectives on Engorgement . LEAVEN , Vol. 35 No.
6, December 1999-January 2000, pp. 134-36
BREAST FEEDING TECHNIQUES
INTRODUCTION:
The two vital considerations for the infant’s in tropical countries are breast feeding and
avoidance of infection. All the babies regardless of the type of the delivery should be given
early and exclusive breast feeding up to 6 months of age. Exclusive breast feeding means
giving nothing orally other than colostrum and breast milk.
Preparation for Breast Feeding:
Ideally, breast feeding should begin soon after the delivery of the baby, preferably within one
hour of birth. During the period of reactivity (i.e., the first hours after birth), the infant is
awake and alert and responsive to breast feeding. Preparations for the mother include voiding,
washing her hands, and assuming a comfortable position.
BREAST FEEDING TECHNIQUES:
Positioning: Both the mother and the infant must be positioned to be comfortable during
breast feeding. Using different positions is important because this varies the pressure points
on the nipple and areola which helps to avoid nipple soreness. The mother may prefer the
cradle hold, lying position, cross-cradle-hold, or the football hold.
 Cradle hold: The most common position is the cradle hold. This is when mother is
sitting with baby in her lap and the baby's head is resting on the mother’s bend elbow
on the same side where she will breast-feed. The baby's chest should be against
mother’s chest so that he doesn't have to turn his head to reach nipple. Be sure the arm
of the chair is at the right height to support arm. Use pillows to support mother’s back,
arm, and the baby's head. A footstool is also very helpful to raise mother’s feet.
 A cross-cradle hold: The cross-cradle hold is similar to the cradle hold except baby is
supported on the arm and hand opposite the breast mother is using. The baby's head
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rests between mother’s thumb and fingers and his upper back is in the palm of
mother’s hand. This is a good position when first learning to breast-feed because it
gives mother more control of the baby's head while helping baby take the breast in his
mouth. It also is a good position for small babies and babies having trouble learning to
latch correctly.
 Clutch hold (Football hold): In this mother hold her baby like a football along her
forearm, with the baby's body on her arm, his feet pointing toward mother’s back and
his face toward breast. Mother uses other hand to support her breast. The football hold
helps if mother have large and engorged breasts or sore nipples. It is also a good
position if mother have had a cesarean section and cannot lay the baby on her
stomach. If mother often have plugged milk ducts, the football hold can help her baby
to drain the ducts at the bottom of the breast. It is also a good position for nursing
twins.
 The side lying position: This position is good for night feeding. This position also
avoids pressure on the episiotomy or on the abdominal incision. Pillows are placed
behind the mother’s back to protect an abdominal incision and to increase her comfort.
Folded blankets or pillows can be used to elevate the infant to breast level so there is
no tension on the nipple. Pulling on the nipple can make it tender and sore. The
infant’s head and body should directly face the breast.
 Laid-back nursing: In this position, mother lies at her back and place baby’s tummy
on her tummy. Gravity keeps baby’s body securely against mother’s body. This
position may also help baby to latch on properly and suck deeply with less effort.
Hand position: Once the infant is properly positioned, the mother should hold her hand in a
C position supporting the breast from below and placing her thumb above (on top) and her
fingers below the areola.
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Figure-1: Breast Feeding Positions
Signs of Good Attachment:
For the infant to receive milk from the breast, the jaws must compress the milk sinuses
beneath the areola. The tongue should visible between the lower gum and the breast. The lips
are widely flanged and sealed around the breast with an absence of clicking sounds as the
infant sucks. Because the infant is a nose breather, make sure the infant’s nose is not blocked
by breast tissues. The mother can elevate the infant’s hips, which will provide more breathing
space for him/her.
It is important that the baby learns to suckle in a good position. For proper
positioning of the baby for breast feeding:
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 Let the mother sit on a comfortable position

 Hold the baby in arms so that he faces the breast & his stomach is against the
mother’s. The baby’s entire body should face the breast.
 Offer the whole breast, not just the nipple, to the baby
 The mother should touch the baby’s cheek or the side of his mouth with the nipple to
stimulate the rooting reflex
 Wait until the baby’s mouth is wide open & move him quickly onto the breast so that
he takes a mouthful. He should come on to the nipple from below it, not from the top.
A baby is in good position:
 Is close to the mother, and the chin touches the breast.

 Mouth widely open
 The whole of the areola in baby’s mouth.
 Lower lip turned out (may be able to see the tongue).
 Takes slow, deep sucks with audible sucking sounds
 Baby’s ear, shoulder, and the hips coming in a straight line.
 Causes no pain to the mother
LATCH-ON:
L – lower lip attached
A – audible swallowing
T – tumble moves
C – comfort of the mother
H ON – hold on for 10-15 minutes
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Figure-2: Proper breast feeding technique and LATCH-ON
Removal from the breast: To avoid trauma to the breast, the infant should be removed
properly. The mother should insert her finger into the corner of the baby’s mouth to break the
suction, and then remove the breast quickly before the infant begins to suck again. Downward
pressure on the infant’s chin is another way to break the suction.
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Figure-3: Removing the baby from the breast
BURPING: (BREAKING UP WIND)
At the end of feeding each breast, baby is held in upright position either on lap or shoulder
and to gently pat the baby at the back thus helping him to bring out swallowed air from
stomach. Time for burping is 5 minutes.
Figure-4: Technique of burping
SUMMARY & CONCLUSION:
Breast feed is considered to be the optimal food for the baby for the first few months of his
life. It has got many nutritive & therapeutic values. To ensure the maximum availability of
these nutrients to the baby, it is indeed essential to follow the proper feeding habits.
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REFERENCES:
1. Students Handbook of Infant & Young Child Feeding. WHO.19-25.

ltd; 2004. p 77-82.
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EPISIOTOMY CARE
INTRODUCTION:
Episiotomy during childbirth is associated with significant pain in the postpartum period.
Pain from episiotomy if poorly treated can result in significant discomfort and interference
with basic daily activities and adversely impact motherhood experiences.
DEFINITION:
Episiotomy care includes all those interventions which are helpful in healing of episiotomy
wound. It includes cleanliness, applying ice pack, and topical application by dry heat
(infrared therapy and dry heat with hair dryer), Sitz bath, and perineal care.
 Mother should be advised to keep episiotomy area clean and dry after urination and
defecation.
 Perineal care should be given to clean the episiotomy & to prevent infection.
 To relieve pain in the first 12 hours after episiotomy ice pack may be applied locally.
 After 12 hours of episiotomy, to relieve pain and to promote healing, Sitz bath and
local application of dry heat by infra red lamp or hair dryer may be given.
 Analgesics drugs may be given as and when required.
1). PERINEAL CARE:
DEFINITION:
Perineal care is the cleaning and washing down of external genitalia and perineum including
episiotomy wound under aseptic precautions.
PURPOSES:
1. To clean the perineum.

2. To assess the condition of the episiotomy sutures.
3. To relieve inflammation and congestion.
4. To relieve pain.
5. To stimulate circulation.
6. To prevent infection.
7. To promote healing.
8. To prevent the spread of infection.
9. To enhance comfort.
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INDICATIONS:
1. Before doing any procedures like p/v examination or catheterization.

2. Before and after delivery.
3. Postnatal mothers after delivery with episiotomy.
4. After abortion.
5. Pre and post operatively (In case of vaginal surgery).
6. Gynecological conditions like vaginitis, prolapse of uterus.
PRE- LIMINARY ASSESSMENT:
1. Assess the condition of the perineal skin for any itching, ulcers, edema, drainage etc.
2. Assess the need and frequency of perineal care.
3. Check the physician’s order for any specific instructions.
4. Assess the patient’s ability for self care.
5. Check the articles available in the patient’s unit.
6. Observe signs of normal involution of uterus and type & amount of lochia in postnatal
mother.
PRECAUTIONS:
 Maintain privacy and expose only required area.

 Explain the procedure to the client to gain her confidence and co-operation.
 Empty the bladder before procedure.
 Complete aseptic precautions should be maintained.
 Temperature of solution should not be more than 105 degree F
 Strength of solution :
o Dettol 1:60
o Savlon 1:100-120
ARTICLES REQUIRED:
A.GENERAL ARTICLES:
1. Hand washing articles (soap in a soap dish and running water)

2. Screen to maintain privacy.
3. Draping sheet/bath blanket to drape the patient
4. Jug with warm water to pour on the perineum.
5. Bed pan with cover to prevent the soiling of the bed.
6. Newspaper to keep the bedpan.
7. Bucket or dustbin with yellow colour polythene lining to dispose of cotton balls and
pads soaked in blood.
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8. Lotion thermometer to check the temperature of water.
B.LOWER SHELF ARTICLES (CLEAN TRAY ARTICLES):
1. Measuring tape to measure the fundal height.

2. A clean thumb forceps in the bottle with lotion to take out the soiled pad
3. Kidney tray and paper bag to dispose of the waste.
4. Mackintosh with towel to prevent soiling of the bed.
5. Bandages to make a T-binder as and when required.
6. Ounce glass to measure the required quantity of antiseptic lotion.
7. Disposable gloves to maintain asepsis.
8. Bottle with antiseptics dettol, betadine, savlon etc
C.UPPER SHELF ARTICLES (STERILE TRAY ARTICLES):
1. Sterile drum with pad, cotton swabs, gauze pieces and swab sticks.
2. Thumb forceps (for picking up the sterile swabs) and artery forceps (for giving
perineal care).
3. 3 Bowls: one to keep sterile swabs in antiseptic lotion, one to keep saline swabs and
one to keep dry sterile swabs.
4. Cheatals forceps to shift sterile supply.
5. Warm normal saline to clean the perineum after cleaning with antiseptic solution to
prevent irritation.
PROCEDURE:
1. Explain the procedure and its purposes to the client.

2. Collect and prepare the articles at the bedside (if the care is to be given in the treatment
room, then prepare the perineal care trolley and shift the patient to the treatment room).
3. Do medical hands washing.
4. Pull curtain around client’s bed or screen the client to provide privacy.
5. Fold the bed linen to the foot of the bed and raise client’s gown above genital area.
6. Place the client in dorsal recumbent position. Help the client to flex knees and spread
legs.
7. Spread the mackintosh and towel under the buttocks of the client.
8. “Diamond” drape client by placing bath blanket with one corner between client’s legs,
one corner pointing toward each side of bed and one corner over client’s chest. Tuck side
corners around client’s legs and under hips.
9. Ask the client or assist to raise back up and place bed pan under the buttocks.
10. Wear gloves.
11. Fold lower corner of bath blanket up between client’s legs onto abdomen.
12. Remove the pad with clean forceps, assess for colour, smell and amount of Lochia and
discard it into dustbin lined with yellow bag and put the forceps in kidney tray.
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13. Let the client pass the urine, massage the uterus and expel out the clots.
14. Pour the Luke warm water (temperature not exceeding more than 1050 F) over vulva to
soften the blood and mucous.
15. Wash hands thoroughly again.
16. Put on sterile gloves.
17. Clean the mons pubis with swab dipped in antiseptic solution in 7o’clock manner.
18. Clean the labia majora from front to back (from perineum to rectum).
19. Separate labia with non dominant hand to expose labia minora. Clean it from front to
back using one swab for one stroke.
20. Then thoroughly clean clitoris and vaginal orifice.
21. Give episiotomy stitch care with antiseptic lotion like diluted savlon dipped gauze pieces
by rolling over the suture line. Observe episiotomy for REEDA.
22. Clean the client’s thighs from inner to outside if soiled.
23. Clean the perineum with warm normal saline swabs to prevent irritation from antiseptic
solution.
24. Dry perineal area thoroughly using sterile gauze pieces or cotton balls.
25. Put sterile pad.
26. Remove the bed pan by supporting hips and mackintosh.
27. Turn the client on one side and clean & dry the buttocks after removing the bed pan.
28. Fold the lower corner of bath blanket back between client’s legs and over perineum.
29. Remove drape sheet and ask client to lower legs and provide comfortable position.
30. Help the client to put on clothes.
31. Remove disposable gloves and dispose in proper receptacle.
32. Wash hands using medical hand washing.
33. Measure fundal height and involution of uterus.
34. Record procedure and findings like type of Lochia, condition of stitches and fundal height
and any other abnormal findings.
35. Dismantle all the articles.
36. Give health education to the client regarding following:-
 Advice the woman to keep the perineal area clean and dry.
 Wash hands before and after touching perineal area.
 Educate to wash the perineal area with water and antiseptic solution every time after
defecation and apply antiseptic cream if prescribed.
 Advise her to avoid sitting in crossed legs position.
 Instruct the woman to wear pad loosely.
 Advice not to strain while defecating.
 Educate to eat diet rich in vitamin C for early healing and prevention of infection.
 Educate to eat high fiber diet to prevent constipation.
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AFTER CARE OF THE PATIENT AND ARTICLES:
1. Change the linen if necessary. Straighten the bed cloths and arrange the bed linen.
2. Make the patient comfortable.
3. Take the bed pan to the sanitary annex and empty the contents into the toilet. Rinse the
bed pan with cold water using brush. Immerse it in the bleaching solution (1:49) to
disinfect it. Wash and dry well and keep it on the bedpan rack.
4. Clean all the articles and replace them.
5. Remove the screen and tidy up the unit.
6. Wash hands.
7. Record the procedure with date and time.
CONCLUSION:
Perineum is the part of body which is more favorable to the growth of micro organism
especially in case of woman, because of its close proximity to the anus and vaginal discharge
during puerperium. So maintenance of hygiene is necessary during postnatal period to
prevent further complications.
2). Moist Heat (Sitz Bath):
It is the local application of moist heat to the pelvic organs. The patient is usually immersed
in warm water from the mid thigh to the iliac crests. The temperature of the water should be
105 degree F to 110 degree F. Duration of the bath is 15 to 30 minutes.
 It is used often to reduce the swelling at the site of the episiotomy. .
 Fill the Sitz bath with warm water to increase blood flow to the vaginal area which
promotes healing.
 Ask to sit every day for the first 7 days after 12 hours of delivery.
Articles:
• A bed screen if treatment is to be done at bedside.
• A suitable size bath tub in which mother can sit comfortably.
• A lotion thermometer to check the temperature of water.
• A jug with warm water.
• One sheet to cover the legs during Sitz bath.
• A bath blanket to wrap the patient’s shoulders to protect her from chill.
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• A clean cloth to dry the perineal area after Sitz bath.
• Perineal pad to apply on the perineum after Sitz bath.
• One stool to help the mother to sit after Sitz bath.
Procedure:
 Explain the purpose of the procedure to the patient.
• Fill the tub with water about half full (3-4 inches) at a temperature of 105 degree F to
110 degree F.
• Screen the patient at bedside or ask the patient to go to bathroom if her condition
permits.
• Assist the patient to remove lower garments, avoid unnecessary exposure.
• Stand directly at the patient’s back. Help the patient to sit down in the tub with
keeping legs towards outer side and feet flat on the floor. There should be no pressure
on the sacrum or thighs. (Figure-1)
• Ask the patient to test the water temperature with inner aspect of wrist before sitting
in it. The perineum may not be sensitive to heat or cold while it is healing or if patient
is using a spray or ointment to relieve discomfort
• Be sure that the thighs, buttocks and lower abdomen are immersed in the water.
• Drape the patient’s legs and thighs. Wrap a bath blanket around the patient’s
shoulders to protect her from chill.
• Observe the patient’s closely for any sign of weakness and fatigue. Discontinue the
bath if the patient has sign of faintness, pallor, rapid pulse and nausea.
• Allow the patient to remain in the basin for 15 to 20 minutes.
• Do not leave the patient alone unless it is absolutely certain that it is safe to do so.
• Help the patient to come out of the basin when the bath is completed. Stand in front of
her. Place hands under the axillae and partially lift her from the tub to the stool.
• Dry the perineal area with cloth and help the mother to wear lower garments & to
apply perineal pad. Assist her into the bed.
• Rinse the basin, scrub well with soap, rinse, dry, sterilize and replace.
• Leave the patient comfortable and leave the bathroom in order. Remove the bedside
stool.
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• Record time, duration & reaction of the patient.
Figure-1: Sitz Bath
2) Dry Heat
Infrared lamp:
Infra red lamp is used to provide dry heat to the episiotomy wound to reduce pain and
swelling.
Instruction to use Infrared treatment:
 Provide heat by infrared lamp 2 times per day.
 The duration of treatment is 15 minutes in each session.
 The distance between the infrared lamp and episiotomy wound is about 45 cm.
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Figure-2: Infrared Lamp
CONCLUSION:
Perineal pain is most commonly associated with child birth by vaginal delivery. Pain
following episiotomy appears to be universal. The mother undergoing episiotomy is
characterized by greater blood loss in conjunction with delivery, and there is a risk of
improper wound healing and increased pain during early puerperium. Various interventions
are found to aid the healing process, which include cleanliness, applying ice pack, topical
application by dry heat (infrared therapy and dry heat with hair dryer), Sitz bath, and perineal
care.
REFERENCES:
1. Karen Boyden; Donna Olendorf; Christine Jeryan (2008), "sitz bath", The Gale
Encyclopedia of Medicine (reproduced on TheFreeDictionary.com), Detroit, Mich.:
Gale Research Co., retrieved 17 February 2011.
2. David C. Dugdale (23 February 2009), Sitz bath, MedlinePlus, retrieved 17 February
2011.
3. Parswa Ansari; Norman Sohn (October 2007), Hemorrhoids (Piles), The Merck
Manuals Online Medical Library, Merck & Co., retrieved 17 February 2011.
4. Venkadalakshmi V. Effect of Infrared Therapy on Episiotomy Pain and Wound
Healing in Postnatal Mothers. TNAI. 2010; 10(9).
ltd; 2004. p 134-35.
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POSTNATAL EXERCISES
INTRODUCTION:
Childbirth and care of the newborn are both physically exhausting tasks. After childbirth, the
new mother hardly finds time for herself as the care required for the baby doesn't give the
time to look after her health. Many women post delivery find difficulty in getting back the
abdomen to its original tone. Postnatal exercises are a must to boost up the energy levels and
keep the woman in shape. Postnatal exercises should be started immediately after delivery if
possible in order to improve circulation, strengthen pelvic floor and abdominal muscles, and
to prevent transient & long term problems.
DEFINITION:
A series of physical exercises that are performed by the postnatal mother to bring about
optimal functioning of all the systems and to prevent complications.
ADVANTAGES:
1. Strengthens muscles and firm up the body particularly those stretched during
pregnancy and labour i.e., abdominal and pelvic floor muscles.
2. Promotes circulation and hence minimises the risk of puerperal venous thrombosis.
3. Prevents from aches and pains and gives more energy on being tired.
4. Helps to regain pre pregnant figure and lose weight.
5. Improves mood, relieve stress and helps to prevent postpartum depression.
6. Maintains firm shape of breasts and secure milk supply.
7. Improves physical strength and stamina which will make looking after a newborn
baby easier.
8. Prevents incontinence of urine.
9. Prevents genital prolapse.
10. Aid in the involution of reproductive organs.
ADVICES:
Advise the women to:
1. Consult doctor/midwife before beginning the exercise.
2. Start the exercises slowly and rhythmically after 24 hours of delivery.
3. Before starting and after finishing exercises-must practice deep breathing.
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4. Commence with five minutes of gentle exercise, such as slow walking, gentle arm
circles and knee lifts to warm up the body. This is very important to prepare your
body for exercise and help prevent injuries.
5. Begin exercise with few minutes and then gradually increase the time.
6. Relax all muscles at the finish of each exercise.
7. Perform exercises regularly, plan a regular schedule that is at least thrice a week.
8. Perform only mild to moderate exercise
9. Use movements that are slow and deliberate; avoid jerking and bouncing movements.
10. Dress comfortably; wear lose fitting clothes.
11. Void before exercising
12. Exercise on a firm surface.
13. Drink fluid whenever you feel the need during the exercise and after the exercise.
This prevents dehydration.
14. Wear supportive shoes when needed.
15. Limit activities to shorter intervals. Exercise for 10-15 min, rest for 2-3 min, then
exercise for another 10-15 min.
16. Take your pulse every 10-15 min. If it is more than 140 beats per min. slow down
until it reaches to the maximum of 90.
17. Rest for 10 minutes after the exercise.
18. Take an increase in calories to replace those burned during exercises.
19. Always rise slowly from lying to sitting position to prevent orthostatic hypotension.
20. Avoid swimming until lochia disappear. If mother had stitches or a caesarean section,
wait until six-weeks and ask doctor for advice.
21. Never hold breath whilst performing an exercise.
22. Don't exercise in a hands-and-knees position for the first six weeks as there is a small
risk that a little clot of air can form at the site where your placenta was attached.
23. Do not exercise full stomach.
24. Do not continue the exercise if you experience shortness of breath, pain, numbness,
undue cramping, vaginal bleeding or nausea. Report to the doctor/midwife if it
happens.
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25. Don’t become over heated for extended periods.
26. Never exercise to a point of fatigue.
PREPARATION OF THE ENVIRONMENT:
 Arrange the area i.e., a hard, firm bed or a mat spread on the floor.
 Ensure privacy.
 Ensure that there is adequate light and ventilation.
A). EXERCISES FOLLOWING NORMAL DELIVERY:
1st DAY:
1. Lying on abdomen with pillow under, for 30 minutes on empty stomach.

2. Breathing Exercise:
PURPOSES:
1. To strengthen muscles of respiration.

2. To improve circulation.
I). Simple Deep Breathing (Chest Breathing):
1. Lie on bed with knees bent, with a pillow under the head.
2. Close the eyes and concentrate on breathing.
3. Breathe deeply in through the nose and out through the mouth, repeat it 5 times.
II). Abdominal Breathing:
1. Lie on bed with knees bent, with a pillow under the head.
2. Inhale through the nose, keep the rib cage as stationary as possible and allow the
abdomen to expand and then contract the abdominal muscles as exhales slowly
through the mouth. (Figure-1)
3. Place one hand on the chest and one on the abdomen when inhaling. The hand on
the abdomen should rise and the hand on the chest should remain stationary,
repeat it 5 times.
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Figure-1: Breathing Exercise
3. Circulatory Exercises (Foot and Leg Exercise):
Purposes:
 To improve circulation and venous return.

 To stretch and strengthen calf muscles.
 To decrease calf muscles cramps.
Technique:
V. Lie or sit on a chair with back straight, move feet up and down. Repeat it 10 times.
(Figure-2a &b)
Figure -2a Figure -2b
VI. Lie or sit on a chair, move feet inwards and outwards. Repeat it 10 times.(Figure-
2c&d )
Figure -2c Figure -2d
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VII. Lie or sit on a chair, make a circle with both feet at anti-clockwise direction and vice
versa. Repeat it 10 times.( Figure – 2e)
a. Figure -2e
IV. Lie in supine and brace both knees, hold for a count of four, and then relax. Repeat it 10
times.
2nd DAY:
1. Arm Raising: lying on back with legs slightly parted, place arms at right angles to the
body. Slowly raises arms keeping elbows still do they are perpendicular. Lower the
arms gradually.
2. Shoulder Rolls: The fingers tips are placed on shoulder, then brought forward and up
during inhalation, back and down during exhalation or rolling each shoulder forward
five times, then back five time. This is done to tone up the breast. Repeat it 10 times.
(Fig-3)
Figre-3: Shoulder Rolls

3. Kegel’s Exercise:
Purpose:
 To strengthen pelvic floor muscles.
 Prevents incontinence of urine.
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 Prevents genital prolapse.
Technique:
9. Empty the bladder.
10. Adopt any comfortable position with legs slightly apart (Lying, sitting or standing).
11. Squeeze pelvic floor muscle as though you are preventing the flow of urine and bowel
action, then feel it being lift up.
12. Try to hold for 4 seconds and rest in between 10 sec.
13. After a women has located the correct muscle, kegel exercise can be done in the
following ways:
d. Slow: Tighten the muscle, hold it for the count of three, and relax it.
e. Quick: Tighten the muscle, and relax it as rapidly as possible.
f. Push out-pulls in: Pull up the entire pelvic floor as though trying to suck up
water into the vagina. Then bear down as if trying to push the imaginary water
out. This uses abdominal muscle also.
14. Take a deep breath in through nose and out through the mouth while doing this.
15. Repeat the above exercise slowly as many times as possible, up to a maximum of 10
seconds hold.
16. Remember: Do breathing exercise in between. Repeat 3 times.
4. Lie in supine position and cross the legs at ankles, then:

a. Press the thighs from the back.
b. Press buttocks in and relax.
c. While doing above two steps, pull up the urethra, vagina and anus though to
prevent micturition and defecation.
4. Neck Exercises:
IV. Sit on a chair with straight back, look upward, and bring back head to neutral position.
Repeat it 5 times. (Figure- 4a)
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Figure-4a
V. Sitting; head to left and then to right. Repeat it 5 times. (Figure- 4b & c)
Figure -4b Figure- 4c
VI. Sitting; bring ear towards left shoulder and then right ear towards right shoulder.
Repeat it 5 times. (Figure- 4d & e)
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Figure: 4d Figure: 4e
3rd DAY:
1. Pelvic Tilting:
Purpose:
 To tone up the straight abdominal muscles (rectus abdominis).

 To ease up any postural back ache that may occur in the first few days of the
puerperium.
Technique:
1. Lie on back with knees bent and feet on the floor.
2. Place one hand under the small of back and the other on top of the abdomen.
Tighten the abdomen and buttocks, and press the small of the back down onto
the underneath hand. Repeat 5 times. (Figure-5)
Figure-5: Pelvic Tilting
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2. Abdominal tightening:
1. Lie on your back with knees bent and feet on the floor, tighten abdomen and
press down until low back flattens against the floor.
2. Hold each position for 5 seconds. Repeat 5 times. (Figure-6)
Figure-6: Abdominal Tightening
3. Breast Exercise:
 Raise the arms to the shoulder level and cross them in front so that right hand
collapsed under left elbow and left hand under right elbow. Breathe in and
with a succession of quick jerks.
 Grip the forearm and try to push the skin towards elbows. Jerking movements
tighten the breast muscles.
4th DAY:
1. Pelvic Tilting (Buttocks Lift):
 Lie on back with knees bent and feet on the floor, tighten abdomen and press
down until low back flattens against the floor.
 Then buttocks off the bed (lifting the pelvis) by putting weight on heels. (Fig-
7)
Figure-7: Pelvic Tilting (Buttocks Lifting)
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2. Head Raising: On the 2nd postpartum day instruct woman to lie flat without pillow and
raise head until the chin touches the chest.
5th DAY:
1. Head and Shoulder Raising: Instruct woman to lie flat without pillow and raise both head
and shoulder off the bed and lower them slowly. Gradually increase the number of repetitions
until able to do this for 10 times.
6th DAY:
1. Curl Up (Abdominal Tighteners):
I).Partial Curl-up:
 Lie flat on supine position, knees bend and keep feet flat & together
 Tighten abdomen, press pelvis downwards to flatten the back against the bed.
 Lift head and shoulder just off the bed with both hands touching the knees i.e., trying
to sit up. Hold for a while and lie down slowly. (Figure-8a)
Figure-8a
 II). Diagonal Curl Up: Lift head and shoulders to make the right shoulder points
towards the left knee. Touch left knee with both hands. Hold for a while and return to
starting point slowly. Repeat the same on right side. (Figure-8b)
Figure-8b
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7th DAY:
Oblique Abdominal Tighteners:
1. Knee Rolling Exercise:
Purposes:
 To stretch and strengthen the muscles of back and thighs.

 To relieve back pain.
Technique:
 Lie flat on supine position, knees bend and feet flat.

 Roll both knees alternatively in opposite direction and try to touch the bed while
keeping back straight. Hold for 5 seconds and repeat 5 times. (Figure-9)
Figure-9: Knee Rolling
2. Hip Hitching Exercise:
Technique:
 It is also called leg shortening exercise.

 It is performed with one knee bend and other knee straight.
 Slide the heel of straight leg downwards thus lengthening of leg.
 Shorten the same leg by drawing the hip up towards the rib on same side.
 Keep the abdomen pulled in while doing this.
 Repeat it 6-10 times (Figure-10)
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Figure-10: Hip Hitching
3. Straight leg Raise:
a. Instruct woman to lie on the floor with no pillows under the head, point toe
and slowly raise one leg keeping the knees straight then other. (Figure-11a)
b. Lower the leg slowly.
c. Never attempt double leg lifts (Figure-11b)
Figure-11a: Raising one leg
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NEVER
Figure-11b: Never Attempt Double leg Lifts
8th DAY:
1. Knee Bending:
 Lie in supine and bend hips & knees, then:

 Press in both knees towards the chest and relax. (Figure-12a)
 Bend alternate knees towards chest. With stomach pulled in and the back pressed
firmly to the floor/bed. Hold for 5-6 seconds and then release it (Do not arch back
while lying). (Figure-12b)
Figure-12a Figure-12b
2. Abdominal Crunch:
 Lie flat on supine position, knees bend and keep feet flat & together
 Tighten abdomen, press pelvis downwards to flatten the back against the bed.
 Keep hands under the head and lift the head and shoulder just off the bed and try to sit
up.
 Return to the starting point slowly and repeat it 10-15 times and increase the number
gradually.
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Figure-13: Abdominal Crunch
3. Shoulder and Back Lifting:
 Lie on abdomen and lift the shoulder and back while inhaling. (Figure-14)
 Hold for a while and return to starting point slowly while exhaling.
Figure-14: Shoulder and Back Lifting
B). EXERCISES FOLLOWING CAESAREAN SECTION:
A caesarean is a major operation and the first six weeks after the operation is a time for
healing.
Don't do any strenuous exercise or heavy lifting in the first couple of months. Postnatal
exercises should be started after 6 weeks. However, mother can begin practising pelvic floor
exercises as soon as she feel up to it.
1. Every time while lifting baby, tighten pelvic floor muscles and lower tummy muscles
at the same time. This will help to protect back.
2. Foot and leg exercises as described earlier should be started as soon as possible.
3. These may be followed by not more than four deep breaths to ensure full expansion of
lungs and pumping action on the inferior vena cava.
4. In spite of abdominal breathing, deep diaphragmatic breathing (Huffing) exercise
should be started as early as possible.
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Technique:
 Huffing is a forceful outward breath using the diaphragm rather than abdominal
muscles to push air out of lungs.
 The abdominals are pulled up & in rather then pushed out causing decreased
abdominal pressure & less strain on the incision.
 Support the incision with pillows or hands during cuffing or huffing & say “HA”
forcefully while pulling in abdominal muscle.
5. Mother can start Kegel’s exercise from 2nd postpartum day.
6. To ease backache and to relieve flatulence the pelvic tilting exercise can be practised
gently after 3rd postpartum day.
Conclusion:
After delivery, exercises help strengthen muscle tone and firm up the body particularly those
stretched during pregnancy and labour. The goal of any exercise programme should be safety
and improved well-being of the mother. Promoting adequate oxygenation, venous return and
a positive emotional state are important elements of a well-rounded exercise programme. To
gain all the advantages of exercise, mother should perform these exercises daily.
REFERENCES:

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Tray Setup for Dilatation and Curettage (D&C)

Dilation (or dilatation) and curettage (D&C) refers to the dilation of the cervix and surgical
removal of part of the lining of the uterus and/or contents of the uterus by scraping
(curettage). It is a therapeutic gynaecological procedure as well as a rarely used method of
first trimester abortion.
INDICATIONS:
The indications are grouped into:
A. Diagnostic
B. Therapeutic
C. Combined.
A). Diagnostic:
 Infertility
 DUB (Dysfunctional Uterine Bleeding)
 Pathologic amenorrhea
 Endometrial tuberculosis
 Endometrial carcinoma
 Postmenopausal bleeding
B). Therapeutic:

 Endometrial biopsy
 Incomplete Abortion
C). Combined:

 Endometrial polyp
PHYSICAL SET UP:
 The physical set up of minor OT plays an important role in setting up of trolley and other
articles.
 Minor operation theatre should have easily washable walls, floors and bathrooms and
toilets should be non slippery.
 Cupboards sufficiently available for stationary, linen, drugs and equipments.
 Emergency drug cupboards.
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 Should have a good lighting system and ventilation and space in between tables should
permit free movements and placements of trolleys.
 Slipper in a rack at the entrance to be used by them who enter the delivery room.
 Stools – resolving type for adjusting the height to be used by obstetrician for comfortable
sitting while performing procedure.
 Telephone for appropriate communication.
 Refrigerators for storing drugs and specimen.
 Portable extra spot light.
 Hand washing facilities:
o An elbow operating tap.
o Wide wash basin.
o Nail brush.
o Soap / bottle of antiseptic solution.
o Clean towel on a towel stand.
 Adequate water supply for washing.
ARTICLES REQUIRED:
A). Upper Shelf Articles (Sterile Articles):

 Linen pack with:
 Abdominal sheet – 80 to 90 cm × 90 cm.
 Perineal sheet – same as above sheet with a hole
 Sterile D&C Pack which consists:
i. Bowls – 2
 One with cotton swabs
 Another for antiseptic solution for cleaning (e.g. Betadine)
ii. Towel clips: 4 -6 to keep the linen in position after draping.
iii. Sterile kidney tray-1 for holding tissue
iv. Sponge holding forceps-2 to clean the perineum
v. Sims vaginal speculum-1 to visualize the birth canal.
vi. Vulsellum-1 to hold the anterior lip of cervix
viii. Uterine Sound-1 to confirm the position and length of uterine cavity.
ix. Set of Hager’s dilators to dilate the cervical canal
x. Blunt curettor-2, 1 small and 1 medium size for curettage of gravid postpartum uterus
and in suspected malignancy.
xi. Sharp curettor-2, 1 small and 1 medium size for curettage of benign lesion of uterus.
xii. Ovum forceps-1 to remove scrapped pieces of endometrium.
xiii. Straight Artery forceps-2 for hemostasis.
 Dressing drum with pad, cotton swabs, gauze pieces.
 Cheatals forceps-1 to shift sterile supply.
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 Sterile container with10% formalin-saline solution (Saline for suspected Tubercular

Endometritis) to preserve the curetted material.
B). Lower Shelf Articles (Clean Articles):
i. Disposable gloves to maintain asepsis
ii. Disposable syringes-5ml, 10ml for administration of medication.
iii. IV set, Cannula and infusion solution for infusion.
iv. Adhesive tape to fix the Cannula.
v. Drugs which will be used during and after the procedure.
vi. Bottles with antiseptic solution (e.g. Betadine).
OTHER ARTICLES:
20. Suction apparatus.

21. Temperature tray
22. B. P. apparatus.
23. Stethoscope.
24. Stretcher.
25. Intravenous infusion pump, IV stand, IV set.
26. Oxygen source – central supply or through cylinders, tubing’s, flow meter, oxygen face
mask of different sizes, hood, catheters.
27. Sterilizer in a separate room to boil the articles if needed (if there is no provision for
adequate supply or in emergencies)
28. Antiseptics and disinfectant – Dettol, Savlon, Chlorhexidine etc.
29. Yellow bucket lined with yellow polythene to receive body fluids and liquid waste.
30. Plastic gown.
31. Rubber sheet or ideally a double layered ‘trough’ to protect the table and to drain the
fluids directly into the bucket.
NURSE’S RESPONSIBILITY:
A.Preparation of the Patient:
1. Explain the procedure to the patient to win her confidence and co-operation.
2. Explain the sequence of the procedure and explain how she can co-operate during
procedure.
3. Take informed consent from the patient.
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4. Help her to wear hospital dress.

5. If the patient is ambulant, she is asked to empty the bladder before she is placed on
the table; otherwise catheterization is to be done.
6. Administer pre-medication as ordered by the doctor
7. Help the client to maintain lithotomy position on the table.
B. After care of the patient and articles:
1. Help the client to wear the undergarments and lower clothes.

2. Put the patient in the comfortable position.
3. Check her B.P., Pulse, and Respiration.
4. Administer medication as ordered by the doctor.
5. Shift her in the observation room and watch for any complications.
6. Send the sample (Curetted material) if taken to the lab with proper labeling.
7. Keep the dirty linens in the dirty linen bucket.
8. Wash all the instruments and send for autoclaving.
9. Reset the trolley articles for the next patient, if any.
10. Record the procedure in the patient’s file with date and time and record any
complications which arise during and after D&C.
Dangers of the D&C procedure:
1) IMMEDIATE-
 Excessive haemorrhage
 Injury to genital tract
 Uterine perforation
 Shock
 Perforation injury to the blood vessels, bowel and bladder
 Sepsis
 Haematometra
2) LATE:-
 Pelvic Inflammation
 Cervical incompetence
CONCLUSION:
In D&C procedure nurse’s role mainly is in physical set-up and to provide assistance to
doctor during procedure. Physical set-up includes preparation of articles, patient,
environment and after care of patient and articles. So being a midwife it is indeed necessary
to have knowledge about D&C procedure and its set-up.
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REFERENCES:
ltd; 2004. p 561-63.
2. Dutta. DC. Textbook of Gynaecology.5th edition. Calcutta: New central book agency
(P) ltd; 2008. p 557-58.
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INSTRUMENTS IN OBSTETRICS
INTRODUCTION:
There are several instruments used in obstetrics in several procedures.
GENERAL INSTRUMENTS:
1. Allis’ forceps:
The instrument is available in two sizes- 12 & 17 cm in length. Its blades are curved inward
and have 4 in5 or 5in6 fine teeth. A ratchet lock is present on the handles (figure-1).
Figure-1 Allis Forceps
Indications:
 To hold the cut edges of the vagina during abdominal and vaginal
hysterectomy
 To hold the cervix as a vulsellum
 To hold the uterine fundus during abdominal and vaginal hysterectomy.
 To hold the cut edges of the uterus during suturing.
 To hold the leiomyoma being enucleated.
2. Sponge Holding Forceps:

This instrument is 22.5 cm long. It has ring shaped ends which have transverse serrations on
the inner surface for better grip. A ratchet catch on the handles locks the blades on closure
and prevents the sponge from slipping (Figure-2).
Figure-2: Sponge Holding Forceps
Indications:
 Preparation of the vagina, vulva and abdominal wall for operation by application
of detergent and antiseptic solutions.
 To hold a sponge to swab blood from a distance during an operation.
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3. Mayo Needle Holder:
A needle holder, also called needle driver, is a surgical instrument, similar to a hemostat,
used to hold a suturing needle for closing wounds during suturing and surgical procedures.
(Figure-3)
Figure-3: Mayo Needle Holder
FORCEPS:
1. Long straight homeostatic forceps
 It can be used to clamp the pedicle while removing the uterus as in rupture uterus.
 The umbilical cord may be clamped as an alternative to Kocher’s. (Figure-4a).
Figure-4a: Long straight homeostatic forceps
2. Kocher’s Homeostatic Forceps
It has transverse serrations on its blades. The tips of the blades have one in two
teeth. The blades can be tightened by means of a ratchet lock on the handles. (Figure-4b).
Indications:
 To clamp the umbilical cord of newborn.

 Used in low rupture of membrane as surgical Induction of labour or augmentation
of labour.
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 To clamp the ligaments and blood vessels in hysterectomy.
Figure-4b: Kocher’s Homeostatic Forceps
3. Ovum Forceps
It has got no catch and the blades are slightly bent and fenestrated. Absence of catch
minimizes the uterine injury, if accidentally caught. It is used to introduced with the blades
closed, to open up inside the uterine cavity to grasp the products and to take out the
instrument with a slight rotator movements (Figure-5).
Indications:
 To remove the products of conception.

 In dilatation &curettage.
Figure-5: Ovum Forceps
4. Laminaria Tent Introducing Forceps
In this forceps there is a groove on either blade to catch the laminaria tent. It is the stems of
laminaria digitata , a species of seaweed. Laminaria tents are intensely hygroscopic and they
swell in moist environment such as the cervical canal. Thus they achieve slow cervical
dilatation.
Indications:
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 Evacuation of a vesicular mole.

 To achieve slow cervical dilatation.
5. Uterine Dressing Forceps
The instrument is most often confused with laminaria tent introducing forceps. In this the
blades are transversely serrated. (Figure-6)
Indications:
 To swab the uterine cavity following D&E with small gauze pieces.
 To dilate the cervix in lochiometra or pyometra.
Figure-6: Uterine Dressing Forceps
6. Green – Armytage Homeostatic Forceps
This instrument has triangular solid tips with transverse serrations .A ratchet lock makes its
grip secure. Its functions are homeostasis and to catch hold the margins so that they are not
missed during suture. (Figure-7)
Indications:
 To hold the cut edges of the lower segment after delivery of the fetus and after
births during caesarian section.
 It can be used as an alternative to both sponge and allis tissue forceps.
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Figure-7: Green – Armytage Homeostatic Forceps
7. Willets Scalp Traction Forceps:
This instrument is available in two sizes 18.7cm & 30cm in length. The ends of the blades are
T-shaped with oblique serrations. A ratchet lock on the handles ensures a firm grip. (Fig-8)
Indications:
 To control bleeding due to degree I &II placenta previa.

 To give traction on the fetal head after craniotomy.
Figure-8: Willets Scalp Traction Forceps
SPECULUMS:
A vaginal speculum is an instrument which allows inspection of the vagina by retracting the
vaginal walls. Speculums are made of stainless steel and are sterilized by boiling or
autoclaving.
1. Sims’ Speculum
Because of its peculiar shape, it is also called duck-bill speculum. It is either double ended or
single ended. The speculum has a handle in the centre and the blades at right angle to the
handle (Figure-9).
Indications:
 Visual examination of the cervix and vagina as a part of gynecological examination.
 To inspect the cervix and vagina to detect any injury following delivery.
 To clean the vagina following delivery.
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Figure-9: Sims’ Speculum
2. Cusco’s Speculum
It has two blades connected by a hinge so that they open and close around a transverse
axis. The blades are somewhat concave inside and have rounded ends. Both the blades
have handles at right angles and there is a nut and screw arrangement to fix the distance
between the two blades. Thus it can be used in vagina of different sizes. (Figure-10)
Indications:
 Inspection of vagina and cervix as Sims speculum.
 Suitable for short procedures like taking a cytological smear, cervical biopsy
,insertion or removal of an
 IUCD.
Figure-10: Cusco’s Speculum
3. Sims’ Anterior vaginal wall Retractor

This is a long instrument with spoon shaped ends which have transverse serrations on either
surface. The loops make an angle of 15 degree with the shaft and are angled in opposite
directions.
Indications:
 Retraction of the anterior vaginal wall to expose the cervix, in conjunction with sims’
speculum.
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 Blunt curettage: when the cervix is widely open and the uterine cavity is large as after
a second trimester abortion or delivery of a viable fetus.
SCISSSORS:
1. Episiotomy Scissors:
Episiotomy scissors are 16 cm long. The blades are angled on the side. The angle makes the
instrument convenient for use, as the handle of straight scissors would butt against the
patients’ buttocks or upper thigh. The lower finger grip is in the same direction as the upper
finger grip. This makes it more convenient to use. (Figure-11a &b)
Indications
 As name indicates it is used in episiotomy.
Figure-11a: Curved blunt pointed sharp scissors Figure-11b: Straight blunt pointed
sharp scissors
2. Embryotomy Scissors
It is much heavy and is used in destructive operation. (Figure-12)
Indications:
 To cut the thoracic cage or the abdominal wall during evisceration.
 To cut the remnant of the soft tissue of the neck left behind during decapitation.
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Figure-12: Embryotomy Scissors
3. Long Straight Scissors
It is commonly used to cut the umbilical cord, in episiotomy, to cut the suture materials also
in caesarean section. (Figure-13)
Figure-13: Long Straight Scissors
OBSTETRIC FORCEPS:
Obstetric forceps are made of stainless steel and are sterilized by boiling or autoclaving .Each
forceps has two branches .Each branch has a blade, a handle and a shank between the two.
The two branches are connected by a lock .Each blade has a cephalic curve for
accommodation of the fetal head when the branches are locked together. Each branch usually
has a pelvic curve along its length, which lies along the curve of carus on correct pelvic
application. The pelvic curve and cephalic curve maintain a strict 90 degree relationship with
each other.
1. Wrigley’s Forceps
This forceps has a length of 27.5 cm and has English lock. (Figure-14)
Indications:
200
201
It can be used as outlet forceps for extension of the head.
Figure-14: Wrigley’s Forceps
2. Simpson’s Long Forceps

This forceps has a length of 35cm with cephalic and pelvic curve .The distance between
the blades is 8.5 cm. (Figure-15).
Indications:
 It is commonly used in low forceps operation
Figure-15: Simpson’s Long Forceps
3. Kielland’s Forceps
It is 40 cm long and blades 4cm broad, slightly thicker than usual due to beveled edges
which achieve a better grip on the fetal head. (Figure-16)
Indications:
It is usually used as rotation forceps in deep transverse arrest of occipito- posterior position
of the head
201
202
Figure-16: Kielland’s Forceps
OTHER INSTRUMENTS:
1. Giant Vulsellum
This instrument is 28 cm long. Its blades are curved on side in a gentle manner. The tips of
the blades have 2 in 3 teeth. These teeth give a good grip on the structure held. (Figure-17)
Indications:
 To hold and steady the cervix during various surgical procedures.
 To assess the degree of uterine descent.
 To hold a leiomyomatous polyp and twist it during vaginal myomectomy.
 Used in destructive operation especially in evisceration to have a good grip of the
fetal parts for giving traction.
Figure-17: vulsellum
2. Uterine Sound
This instrument is 30 cm long, of which 5 cm length is that of its handle. Rest of the
instrument is graduated in inches or centimeters. The sound is olive tipped. (Figure-18)
Indications:
 To measure the uterocervical length.
 To measure the length of the cervical canal and to diagnose supravaginal elongation
of the cervix.
 To determine the relation of a pelvic mass to the uterus.
 Diagnosis of cervical stenosis and congenital malformation of the uterus.
 To sound the uterine cavity to detect any foreign body.
 It acts as a first dilator of the cervical canal.
Figure-18: Uterine Sound
3. Hegar’s or Das & Hawkin-Ambler Dilators
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203
This instrument may be single ended or double ended. It is a solid rod curved near the top and
somewhat tapering towards the tip. (Figure-19)
Hegar’s or Das: It is a double ended one .The minimum size is ½ and the maximum size is
11/22.The number represents the diameter in mm. Both the sides are used with the lower
number first.
Hawkin- Ambler: It has got 16 sizes, the smallest one being 3/6 and the largest one being
18/21.The number is arbitrary in the scale of Hawkin-Ambler. The smaller one denotes
measurement at the tip and the larger one measures the maximum diameter at the base in mm.
Indications:
 Used in dilatation of the cervical canal prior to evacuation operation.
 To drain the uterine fluid contents.
 Application of intrauterine source of radiation, eg: radium
 As treatment for cervical stenosis.
 In primary dysmenorrhea, when all other forms of therapy have failed.
Figure-19: Hegar’s or Das Dilators
4. Blake’s Uterine Curette

This instrument has a central shaft and one small oval loop at each end. The loops are set an
angle to the shaft so that the tip of the loop is directed away from the direction of the shaft
and can curette the endometrium easily. The loops are angled in opposite directions. The edge
of the loop is either sharp or blunt. (Figure-20)
Indications:
 Used for curetting the endometrium in D&E and D&C
 Used in the diagnosis of endometrial carcinoma and tuberculosis.

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204
Figure-20: Uterine Curette
5. Blunt Flushing Curette

This instrument is 30cm long. It has a narrow handle, a long slender shank and a spoon
shaped fenestrated curetting end. The opening at the end of the handle is connected by means
of a rubber tube to an irrigator at a height of no more than 60 cm above the level of uterus.
Indications:
 Used in the operation of D& E
 Previously it was used to flush the uterine cavity with Luke warm antiseptic
solution.
6. Doyen’s Retractor
This instrument has a curved, sturdy blade and a stout handle. (Figure-21)
Indications:
Used to retract the abdominal wall as well as the bladder for proper exposure of lower uterine
segment during LSCS.
Figure-21: Doyen’s Retractor
7. Axis Traction Devices
It includes axis traction rods (right and left) and handle. The rods are assembled in the blades
of long curved obstetric forceps prior to introduction and lastly the handle is attached to the
rods. (Figure-22)
204
205
Indications:
 The devices are required where much forces are necessary for traction as in mid
forceps operation.
These are less commonly used now.
.
Figure-22: Axis Traction Device
8. Ventouse cup with Traction Device
Silastic vacuum cup is available now. It is flexible so that it can be inserted into the vagina
with ease. However it is rigid enough to maintain its shape on creation of vacuum and during
traction. It is less traumatic to the fetal head than a metal cup. (Figure-23a & 23b)
Indications:
 It is used in the operation of vacuum extraction of the head.
Figure-23a: Silastic Vacuum cup Figure-23b: Metal Vacuum Cup
9. Simpsion’s Perforator
This instrument is made of stainless steel and is sterilized by boiling or autoclaving .It is
28.5cm long. Its blades have triangular tips with outer cutting edges. There are two shoulders
on the blades. There is a locking system between the ends of the handles, which locks the
blades in closed position. To open the blades, the lock has to be opened by inward pressure,
and the handles have to be approximated. (Figure-24)
Indications:
 Craniotomy
 Opening fetal thorax or abdomen for evisceration.
205
206
Figure-24: Simpsion’s Perforator
10. Decapitation hook with Knife

This instrument has a long handle with a narrow hook at its end. The tip of the hook is
bulbous. It has a knife edge fitted in the concavity of the hook. (Figure-25)
Indication:
 It is used in decapitation operation in neglected transverse lie.
Figure-25: Decapitation hook with Knife

11. Hook with Crochet
The hook is used to give groin traction in a dead baby when the breech is impacted at the
outlet and groin traction fails to deliver the baby. The crochet is used to deliver the
decapitated head by hooking the mandible through mouth. (Figure-26)
Indications:
 Craniotomy
Figure-26: Hook with Crochet
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207
12. Braun’s Cranioclast:

This instrument is 42cm long sturdy instrument shaped somewhat like obstetric forceps. Its
blades are small, concavo-convex with coarse serrations on the apposed surfaces. A winged
screw on the ends of the handles allows firm fixation of the blades. The curve of the blades is
in the same direction. One blade is solid and with a blunt pointed tip. The other blade is
fenestrated. (Figure-27)
Indications:
 To crush the vault of the skull after craniotomy.
 To crush the base of skull after craniotomy.
 To break up the vault of skull and remove it piecemeal.
 To extract the fetal head after craniotomy and crushing.
Figure-27: Braun’s Cranioclast
13. Pinard’s Fetal Stethoscope

The instrument is made of either of wood or aluminium. It is funnel shaped and has a broad
flat disc with a central perforation attached at the narrow end of the funnel at right angles to
the long axis of the funnel. The rim of the broad end is rounded to avoid pain to the patient by
the edge cutting into the abdominal wall. (Figure-28)
Indication:
 To hear fetal heart sounds in the antenatal & the intrapartum period.
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208
Figure-28: Pinard’s Fetal Stethoscope
REFERENCES:

ltd; 2004. p 655-66.
OXYTOCICS IN OBSTETRICS
OXYTOCICS:
Oxytocics are the drugs of varying chemical nature that have the power to excite contractions
of the uterine muscles. Commonly used in clinical practice are:
1) Oxytocin
2) Ergot derivatives
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209
3) Prostaglandins
1). OXYTOCIN:
Oxytocin is a nonapeptide. It acts through receptor and voltage mediated calcium channels to
initiate myometrial contractions. It stimulates amniotic and decidual prostaglandin
production. It has a half life of 3-4 minutes and duration of action is approximately 20
minutes.
PREPARATIONS USED:
 Synthetic oxytocin (Syntocinon-Sandoz or Pitocin) is widely used. (Pitocin 5

I.U/ml).
 Syntometrine (Sandoz) — A combination of Syntocinon 5 units and Ergometrine

0.5 mg.
 Desamino oxytocin — It is not inactivated by oxytocinase and is 50 -100% more

effective than oxytocin. It is used as buccal tablets containing 50 I.U.
 Oxytocin nasal solution contains 40 units /ml.
INDICATIONS:
A. Therapeutic:
B. Diagnostic
A. THERAPEUTIC:
 Pregnancy:
Early:
 To accelerate abortion-Inevitable or missed and to expedite expulsion of hydatidiform

mole.
 To stop bleeding following evacuation of the uterus.
 Used as an adjunct to induction of abortion along with other abortifacient agents

(PGE1 or PGE2 )
Late:
 To induce labour
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210
 To facilitate cervical ripening for effective induction
 Labour:
 Augmentation of labour
 Uterine inertia
 In active management of third stage, it is used along with Ergometrine (Syntometrine)
during crowning of the head
 Following expulsion of placenta as an alternative to Ergometrine.
 Puerperium :
 To minimize blood loss and to control postpartum haemorrhage.
B.DIAGNOSTIC:
 CST ( Contraction stress test )
 OST( Oxytocin sensitivity test )
ROUTES OF ADMINISTRATION:
 Controlled intravenous infusion is the widely used method.
 Bolus I.V. or I.M. — 5-10 units after the birth of the baby as an alternative to
ergometrine.
 Intramuscular — the preparation used is Syntometrine.
Buccal tablets or nasal spray — Limited use on trial basis.
METHOD OF ADMINISTRATION:
For Induction of labour (IOL):
 Principles :
1. Start with a low dose.
2. When the optimal response is achieved (uterine contraction sustained for about 45
seconds and 3 contractions in 10 minutes), the administration of the particular
concentration in mU/ per minute is to be continued. This is called oxytocin titration
technique.
 Calculation of the infused dose: Infusion is expressed in terms of milliunits per minute
210
211
 Convenient Regime: Start with a low dose (4 mU /minute) and to escalate at every 20
min. intervals if there is no response. A dose of less than 16 milliunits per minute (2 units
in 500 ml Ringer solution will drop rate of 60/minute) is enough to achieve the objective
Calculation of dose delivered in mU and its correlation with drop rate per minute
Units of Oxytocin mixed in Drops per minute

500ml Ringer Solution
(15 drops= 1ml)
(1 Unit= 1000 mU)
15 30 60
In terms of mU /minute
1 2 4 8
2
8 4 8 16
16 32 64
The Convenient Regime

Dose of oxytocin Solution used Escalating drop rate at
intervals of 20-30 min
 To start with 1 unit 500 ml Ringer solution 15 - 30 – 60
 If no response- 2 units
 If still no response - 8 -do- -do-
units
-do- -do-
Observations during Oxytocin Infusion:
1. Rate of flow of infusion: Observe rate of flow of infusion by counting the drops per
minute or monitoring the infusion pump.
2. Uterine Contractions: Observe number of contractions per 10 minute, duration of
contraction and period of relaxation. “Finger tip” palpation for the tonus in between
contractions may be done where gadgets are not available.
3. Peak intra uterine pressure: When intra uterine pressure monitoring is used
optimum peak intra uterine pressure is 50-60 mm Hg with a resting tone 10-15 mm
Hg.
4. FHR Monitoring: Monitor FHR by auscultation at every 15 minutes interval or by
continuous electronic fetal monitoring (EFM).
211
212
5. Assessment of progress of labour: Monitor descent of fetal head and rate of cervical
dilatation.
Indications of Stopping the Infusion:
 Nature of uterine contractions:

o Abnormal uterine contractions occurring frequently (every 2 minutes or less)
or lasting more than 60 sec (hyper stimulation).
o Increased tonus in between contractions.
 Evidences of fetal distress.
 Appearance of untoward maternal symptoms.
Contraindications of oxytocin:
I. Pregnancy:
 Grand multiparae
 Contracted pelvis
 History of caesarean section or hystrotomy
 Malpresentation
II. Labour:
 All the contraindication in pregnancy

 obstructed labour
 Inco-ordinate uterine contraction
 Fetal distress
III. Others:
 Hypovolemic state
 Cardiac disease
DANGERS OF OXYTOCIN:
I.MATERNAL:
 Uterine hyper-stimulation: There may be excessive duration of uterine contraction

(hypertonia) or increased frequency (> 6 in 10 min. time) contractions (polysystole). It is
often associated with abnormal FHR pattern.
212
213
 Uterine rupture: with violent uterine contractions common. High risk cases are: grand
multiparae, malpresentation, contracted pelvis, prior uterine scar (hysterotomy) and
excessive oxytocin use.
 Water intoxication is due to its antidiuretic function when used in high dose (30-40
mlU/min). Manifested by hyponatremia, confusion, coma, convulsions, congestive
cardiac failure and death
 Hypotension: Bolus IV injections of oxytocin causes hypotension especially when
patient is hypovolemic or with a heart disease.
 Antidiuresis: Antidiuretic effect is observed when oxytocin infusion rate is high (40-50
mlU/min.) and continued for a long time.
II. FETAL:
 Fetal distress, fetal hypoxia or even fetal death may occur due to uterine hyper-
stimulation. Uterine hypertonia or polysystole causes reduced placental blood flow.
2).ERGOT DERIVATIVES:
A. Ergometrine
B. Methergin
Mode of Action:
Ergometrine acts directly on the myometrium. It excites uterine contractions which come so
frequently one after the other with increasing intensity that the uterus passes into a state of
spasm without any relaxation in between.
Dose and Chemical Name:
Preparation Ampoules Tablet

Ergometrine( Ergonovine) 0.25mg or 0.5 mg 0.5- 1mg
Methargin (Methyl-ergonovine) 0.2 mg 0.5 – 1 mg
Syntometrine (Sandoz) 0.5 mg Ergometrine + 5 units
Syntocinon
STORE AND DISPENSE:
TABLET: store below 230 c, in tight light resistant container.

AMPULES: store in refrigerator, 20 c, protect from light, administer only if solution is
clear.
PHARMACOKINETICS:
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 In contrast to the amino acids ergot alkaloids, ergometrine and methyl-ergomterine are
rapidly and nearly completely absorbed from the oral route
 The onset of uterine action is: oral- 15 min; I.M.- 5 minutes; I.V. – almost immediate
 They are partially metabolized in liver and excreted in urine.
 Effect of single dose last for 3-4 hour.
INDICATIONS:
A. Therapeutic: To stop the atonic uterine bleeding following delivery, abortion or

expulsion of hydatidiform mole.
B. Prophylactic: As a prophylaxis against excessive haemorrhage following delivery, it may

be used after the delivery of the anterior shoulder (Active management of 3rd stage of labour)
CONTRAINDICATIONS:
1. Suspected plural pregnancy: If given accidentally with the delivery of the first baby,
the second one is likely to be compromised by the titanic contraction of the uterus.
2. Organic cardiac diseases: It may cause sudden squeezing of blood of the uterine
circulation into the general circulation causing overloading of the right heart and
precipitating failure.
3. Severe pre-eclampsia and eclampsia: There may be sudden rise of blood pressure.
4. Rh-negative mother: There is more chance of feto-maternal micro-transfusion.
HAZARDS:
 Nausea and vomiting.
 Because of its vasoconstrictive action, it may precipitate rise of blood pressure,

myocardial infarction, stroke and bronchospasm.
 Prolonged use - gangrene of the toes due to its vasoconstrictive effect.
 Prolonged use in puerperium may interfere with lactation by decreasing the

concentration of prolactin.
CAUTIONS:
Ergometrine should not be used during pregnancy, first stage of labour, second stage prior
to crowning of the head and in breech delivery prior to crowning.
3.) PROSTAGLANDINS (PGs):
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215
Prostaglandins are the derivatives of prostanoic acid from which they drive their names. They
have the property of acting as “local hormones”.
PREPARATIONS:
PGE1 (MISOPROST):
 100 and 200 µg tablets – orally, sublingual.

 Transvaginal misoprostol: 50µg every 3 hours to maximum of 6 hours. Or 25µg every 3
hours to maximum of every 8 hours
 It is effective as PGE2 for cervical ripening.
 It is cheap, stable at room temperature, easily administered and has fewer side effects.
PGE2 (DINOPROSTONE):
 Gel: 0.5 mg into the cervical canal below the level of internal os in preloaded syringe
with applicator (Cerviprime)
 Vaginal pessary: 3 mg
 Tablet: 0.5 mg
Vaginal suppository: containing 20 mg PGE2
 Parenteral: Prostin E2 containing 1 mg/ml
 PGF2α (Prostin) containing 5mg /ml.
 Methyl analogue of PGF2α (Carboprost -containing 2.5mg /10 ml vial).
MECHANISM OF ACTION:
 The probable mechanism of action is change in myometrial cell membrane permeability

and/or alteration of membrane-bound Ca++.
 PGF2α acts predominantly on the myometrium
 PGE2 acts mainly on the cervix due to its collagenolytic property. They make cervix soft
and shorten and more open by action on the cervical smooth muscle
 PGS also sensitize the myometrium to oxytocin.
 PGE2 is at least 5 times more potent than PGF2α.
INDICATIONS:
 Induction of abortion (MTP and missed abortion )
 Termination of molar pregnancy
 Induction of labour
215
216
 Cervical ripening prior to induction of abortion or labour
 Acceleration of labour
 Management of atonic postpartum haemorrhage
 Medical management of tubal ectopic pregnancy
CONTRAINDICATIONS:
 Hypersensitivity to the compound

 Uterine scarred
ADVANTAGES:
 It has got powerful oxytocic effect, irrespective of period of pregnancy. As such, it

can be used independently specially in induction of abortion (PGE1) with success.
 In later months, where the pre-induction score is low or in intrauterine death, it is

more effective than oxytocin. Thus, it is a useful drug not only for induction but also
for acceleration of labour.
 It has got no antidiuretic effect.
DRAWBACKS:
 It is costly.
 Unpleasant side effects on systemic use are nausea, vomiting, diarrhea, pyrexia or
bronchospasm.
 When used as an abortifacient, extensive cervical lacerations may occur.
 The tachysystole (hyper-stimulation) of the uterus may occur during induction and
may continue for a variable period.
RISKS:
 Incidence of tachysystole (hyper-stimulation)

 Meconium passage are high
 Rupture of uterus through rare, has also been observed
 It should not be used for cases with previous caesarean birth because the risk of rupture is
high.
REFERENCES:
216
217

ltd; 2004. p 498-505.
217

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1

FEATURES OF THE FOUR TYPES OF PELVIS:

FEATURE GYNAECOID ANDROID ANTHROPOID PLATYPOID

Brim (Shape) Rounded Heart Shaped Long Oval Kidney Shaped

Forepelvis Generous Narrow Narrowed Wide

Side Walls Straight Convergent Divergent Divergent

Ischial Spines Blunt Prominent Blunt Blunt

Sciatic Notch Rounded Narrow Wide Wide

Sub Pubic 90 <90 >90 >90

Incidence 50% 20% 25% 5%

A). INNOMINATE BONES (Ilium, Ischium, and Pubis):

• Main features are:

o Sacroiliac joint (articulation between sacrum and ilium)

• Main features are:

THE PUBIC BONE:

• Main features are:

 Superior ramus and inferior ramus (two oar like projections)

Figure 1: Innominate bone

• Laterally the sacrum extends into a wing or ala.

• The posterior is roughened to receive attachment of muscle.

Figure 2: Sacrum and Coccyx

• It is referred to as rudimentary tail.

• Articular surfaces are covered with hyaline cartilage

• Has no capsule & no synovial cavity

• This is the strongest joint in the body.

• Has got a capsule & a synovial cavity

• Sacrospinal ligaments run from the sacrum to the ischial spine.

Figure 3: Pelvic Ligaments

 Ischiocavernous muscles: pass from the ischial tuberosities to the corpora

 Membranous sphincter of urethra: composed of muscle fibres passing above and

 Pubo-coccygeus muscle: pass from the pubis to coccyx

 Ischio-coccygeus muscle: pass from ischial spine to the coccyx.

Figure 4: Muscles of Pelvic Floor

FALSE AND TRUE PELVIS:

A).The false pelvis:

• It has very little obstetrics importance.

Figure-5: True and False Pelvis

B).The true pelvis:

• Deep posteriorly formed by sacrum, coccyx and measures 11.5cm.

4. INLET OF PELVIS (PELVIC BRIM):

Figure 6: Landmarks of Pelvis

 OBSTETRIC CONJUGATE: It is the distance between the midpoint of the sacral

 DIAGONAL CONJUGATE: It is the distance between the lower border of symphysis

Figure-7: Diameters of Inlet

 Shape: It is almost round.

 TRANSVERSE:BISPINOUS- It is the distance between the tip of two ischial spines

 POSTERIOR SAGITTAL DIAMETER: It is the antero-posterior distance between

Anteroposterior Oblique Transverse

1) Manocha.Snehlata. Procedures and Practice in Midwifery.2nd edition. New Delhi:

SIGNIFICANCE OF THE FETAL SKULL:

1. It protects the brain.

REGIONS OF FETAL SKULL:

The skull is divided into vault, face and base.

The regions of the skull are divided as follows:

BONES OF THE VAULT:

1. Two frontal bones.

2. Two parietal bones.

3. One occipital bone.

4. Two temporal bones.