POSTNATAL ASSESSMENT

DEFINITION: Assessing the state of uterus in the post-delivery period as it returns to the pregravid state PURPOSE: 1. To rule out infection 2. To estimate the rate at which involution takes place 3. To assess the puerperal condition of women who had complicated labour ARTICLES: Screen Sanitary pad Clean gloves Pericare set Machintosh Measuring tape A sheet of paper Pens PROCEDURE: NURSING ACTION 1. Explain the women what will be done and how she may co-operate. 2. Arrange the unit and assemble necessary articles at bedside. 3. Ensure that the bladder is empty RATIONALE Enhance co-operation Save time and energy Full bladder may cause upward displaced of uterus

4. Put curtains/screen the bed 5. Position the patient in supine and drape the patient exposing only the lower abdomen 6. Don gloves 7. Locate fundus with the palm of one hand 8. Place lateral side of hands slightly above fundus 9. Place your other hand above the symphysis pubis 10. Gently but firmly press into abdomen towards the spine and then slightly downwards towards the perineum until a mass is felt in the palm of the hand.

Provide privacy Enhances easy assessment

Supports and stabilizes uterus during palpation

11. Measure the number of finger breath at which the fundus is felt below the umbilicus. With the help of an inch tape measure from the level of fundus to the upper border of symphysis pubis

Finger breath measurement should correspond to yhe number of days after delivery OR st on 1 postpartum day the fundus is felt about 10-12cm above the symphysis pubis and from 2nd 11th day fundus descends article of inch/one finger breath per 24 hours. By 11th day uterus sinks below the level of symphysis pubis and becomes a pelvic organ Allows for assessment of rate of involution

12.with gloved hand check perineal pad lochia

for colour of Maintains hygiene and prevents infection Prevents spread of microorganisms Documentation helps in obtaining a clear picture about involution of uterus.

13.offer perineal care if needed and provide a clean pad 14.replace the articles and wash hands . 15.make the fundal height in nurses record BIBLIOGRAPHY:

Annamma Jacob. Clinical nursing procedure. The art of nursing practice. 2nd edition. Jaypee brother medical publisher (p)ltd. Pp-600-601

PERINEAL CARE DEFINITION: Cleansing the patients external geitalia and surrounding skin using antiseptic solution PURPOSE: 1. 2. 3. 4. 5. To cleanse the perineal skin To reduce chances of infection of episiotomy wound To stimulate circulation To reduce body odour and improve self-image To promote the feeling of well-being

ARTICLES: A clean tray containing: Sterile antiseptic lotion-dettol or savlon Sterile normal saline in a bottle Cheatle forceps Antiseptic or antibiotic medication if recorded Sterile sanitary pad Kidney tray Sterile gloves Machintosh

Sterile pack or tray containing Artery forceps-1 Dissecting forceps Cotton balls gauze pieces Sterile towel to wipe hands after surgical scrub

Additional items Infra-red light Bedpan(if procedure is done at bedside)

PROCEDURE: NURSING ACTION 1. Explain the women what will be done and how she may co-operate. RATIONALE Enhance co-operation and gain confidence of the patient

2. Arrange the unit and assemble necessary articles at bedside.

Save time and energy

3. Ask the patient to empty her bladder and bowel and wash the perineal area before coming for perineal care 4. Screen the bed or close the doors as appropriate

Ensure cleanliness and reduces number of organisms in the perineal area Provides privacy reduces embarrassment Dorsal position facilitates better viewing of the perineum

5. Assist the patient to ensure dorsal recumbent position with knees bend and drape the area using diamond draping method 6. Open sterile tray, arrange articles with the cheatle forceps and pour antiseptic solution in the sterile gallipot in tray 7. Adjust the position of the infra-red light so that it shines on the perineum at a distance of 45-50cm 8. Scrub hands and dry with the sterile towel 9. Put on sterile gloves 10. Take the cotton swabs with artery forceps, dip in savlon and squeeze excess lotion with dissecting forceps into the kidney tray 11. With the swabs clean from urethra towards anus. Clean the area from midline outward in the following order until clean and discard the swab after each stroke. Strokes are to be in the following order Separate the vestibule with non-dominant hand and clean vestibule starting from clitoris to fourchette Inside of labia minora downward, farther inside first then nearer side Take off the nom-dominant hand Labia majora downward farthest side and then nearer side Discard the used forceps (if a second one is available) Using the second forceps clean the episiotomy wound from center outwards and outside of episiotomy both sides

Maintains asepsis

Cleaning from more cleaner area to least clean area prevents contamination

12. Wipe all traces of antiseptic away with sterile normal saline swabs in the same manner as

Cotton fibers are likely to get

described above using thumb forceps 13. Dry the episiotomy with gauze pieces. Do not use cotton balls for this purpose 14. Provide perineal light/infra-red light for 10 minutes if indicated 15. Put prescribed medication on a gauze piece and apply to the episiotomy. 16. Place sanitary pad from front to back. Do not shift position of the pad once it is applied 17. Discard gloves and used items in the kidney tray, wash forceps and tray and keep ready for sterilization 18. Replace other articles in designated places 19. Make the patient comfortable and leave the unit clean 20. Record procedure in the patients chart including details regarding status of lochia and condition

caught while drying if cotton balls are used Provide soothing effect from heat Prevents entry of pathogenic organisms Avoids chances of contamination Reduces chances of contamination

Documentation helps for communication between staff members and provides evidence of care given and observation made

SPECIAL CONSIDERATION: If a sitz bath is prescribed, give it before perineal care If patient has urinary catheter, provides catheter care along with perineal care. BIBLIOGRAPHY: Annamma Jacob. Clinical nursing procedure. The art of nursing practice. 2nd edition. Jaypee brother medical publisher (p)ltd. Pp-600-601

INVITRO-FERTILIZATION AND INVITRO-EBRYO TRANSFER Introduction: The past decade has witnessed at least two dramatic changes in the technique protocol of IVET. One such was the change of natural cycle to super ovulation protocol and the other one was replacement of laparoscopy by vaginal sonography for ovum retrival. Definition: It is a technique used to treat infertility for women who have blocked uterine tubes. Indication: Tubal disease Endometriosis Cervital hostility Unexplained infertility Male factor infertility Failed ovulation induction Patient selection: Age less than 35 years Presence of at least one functional ovary Husband hormonal seminogram Couple must be screen negative for HIV and hepatitis Principal steps: Down regulation using GnRH agonist Controlled ovarian hyperstimulation Monitoring of follicular growth Oocyte retrival Fertilization in-vitro Transfer of gamates or embryo Luteal support with progesterone 1. GnRH analogue for down regulation: GnRH agonist therapy used for down regulation of pituitary, given higher pregnancy rates. GnRH agonist therapy is continued either subcutaneously or intra-nasally during the gonadotropin treatment phase GnRH agonists are currently tried along with gonadotropin stimulation to prevent premature LH surge or premature ovulation 2. Controlled ovarian hyperstimulation: Through COH method, more embryos can be transferred from ovary. Other advantages are; - Improved quality of the oozyte - Timing of the ovulation can be controlled - Suited to the person involved - Extended to the all cases of ovulatory dysfunction 3. Monitoring of follicular growth; It is monitored by cervical mucous study, sonographic measurement of the follicular and serum estrodiol estimation, commensing on 8th day of treatment cycle 4. Oocyte retrival:

It is done through vaginal route under ultrasound guidance, with the development of vaginal transfer and vaginal needle aspiration is done about 36hrs after HCG administration but before ovulation occurs. The oozyte is readily regognizable as a single cell surrounded by a mass of cumulus cells. After recovery, the oozytes are maintained in culture in-vitro for 4-6 hrs. 5. Fertilization (in-vitro): The sperm used for insemination in vitro is prepared by the wash and swim-up technique. The eggs may demonstrate signs of fertilization when examined 12-24 hrs after insemination Sperm density and motility are the most important criteria to ovum retrival 6. Embryo transfer: The fertilized ova at the 4-8 cell stage are placed into the uterine cavity close to the fundus about 48-72hrs later through a fine flexible tube transcervically Not more than three embryos are transferred 7. Luteal phase support: It is mainted with progesterone. Oral micronized progesterone 200mg twice a day or progesterone in oil injection 50mg IM daily is continued for about 14 days. By this time, diagnosis of pregnancy by estimation of B-HCG is possible Result: The overall delivered pregnancy rate various from 25-35% per oozyte retrival There is risk of abortion(18%), multiple pregnancy(30%), ectopic(0.9%), low birth weight and prematurity. The risk of congenital malformation of the baby remains inconclusive. ZYGOTE INTRA-FALLOPIAN TRANSFER It was first described by devroey at al(1986) Placement of the zygote(following one day of the in-vitro fertilization) into the fallopian tube can be done either through the abdominal oestium by laparoscope or through the uterine oesteum under ultrasonic guidance. This technique is suitable alternative of GIFT when defects lies in the male factor or in the case of failed GIFT GIFT or ZIFT is avoided when tubal factors for infertility are present.

INTRA-CYTOPLASMIC SPERM INJECTION It was first described by Van Steirteghem and Collageus in Belgium(1992) Indication: Azoospermia Sperm antibodies Obstruction of efferent duct system Congenital absence of vas Failure of fertilization Technique: One single spermatozoan or even a spermatid is injected directly into the cytoplasm of the oozyte by micro-puncture of the zona pellucid. Result: Fertilization rate is about 60-70%. Pregnancy rate is 20-40% embryo transfer. EMBRYO OR OOCYTE DONATION

Indication: Woman with premature ovarian failure Woman with removed ovaries Older woman(poor oocyte quality) Genetic disease Failure to respond with super ovulation regimen The oocyte is collect e from: Sister or friend Oocyte donor one undergoing laparoscopic sterilization Technique: The reciepient must have oestrogen and progesterone therapies to prime the endometrium prior to embyo replacement. Embryos of 4-8 cell stage are transferred on 17th to 19th day of the recipients menstrual cycle. BIBLIOGRAPHY Dutta.D.C, Text book of gynaecology, fourth edition, Calcutta, New central book agency,2004,page no.284-292. Salhan sudha, Textbook of obstetrics and gynaecology,First edition, New Delhi,JP brothers medical publishers,P.Ltd,2006,Page no.402-405. F.Weller Barabara,Balliers nurses dictionary,24th edition, China, Elsvier science limited,2006,Page no.132. Wani reenaj, Essential gynaecology, 1st edition,Mumbai,Bhaluni book limited,1997, Page no.261-262. Marie Elizabeth, Gynaecology for nurses, 1st edition, New Delhi, CBS publishers, Page no.225-229.

CORDOCENTESIS DEFINITION :It is a technique of sampling fetal blood by percutaneous puncturing an umbilical vessels, usually the vein. INDICATION :1.Diagnosis and management of Rh isoimmunisation . 2.Diagnosis of fetalinfecton Toxoplsmosis. Viral infection .

3.Diagnosis of fetal hypoxia. IUGR.

4.Diagnosis of fetal genetic disease Beta thalasemmia. Sickle cell disease. Duchenne muscular dystrophy.

5.Diagnosis and treatment of fetal blood factor abnormality Thrombocytopenia. Haemophilia A ,B.

TECHNIQUE :a) b) c) d) 20 G Spinal needle 10-13 cm long. Syringe (2cc) with 3.8 5 sodium citrate solution as anticoagulant. Anterior abdominal wall prepared. Local anaesthesia infiltrated real time USG control to monitorthe procedure is essential. e) Needle introduced through the abdominal and uterine wall into umbilical cord usually near its junction with the placenta. f) Umbilical vein being larger and thin walled is easier to puncture and less likely to undergo spasm than the arteries. g) Previously the procedure was done under fetoscopic visualization not done now due to high fetal loss rate (5%). COMPLICATION : Maternal infection . Fetal death (1.1%),Abortionupto (1%)

 Cord hematoma ,vessel thrombosis . Fetal trauma.

BIBLIOGRAPHY Dutta.D.C, Text book of obstetrics, fourth edition, Calcutta, New central book agency,2004,page no.331-335. Salhan sudha, Textbook of obstetrics and gynaecology,First edition, New Delhi,JP brothers medical publishers,P.Ltd,2006,Page no.261-263. F.Weller Barabara,Balliers nurses dictionary,24th edition, China, Elsvier science limited,2006,Page no.132. Wani reenaj, Essential obstetrics, 1st edition,Mumbai,Bhaluni book limited,1997, Page no.261-262. Marie Elizabeth, obstetrics for nurses, 1st edition, New Delhi, CBS publishers, Page no.225-228.

CHRONIC VILLI SAMPLING DEFINITION :Chronic villi sampling is a procedure done to obtain chronic tissue for genetic studies. TIMING:First trimester (9-11 weeks usually). Placental biopsy may be done in later gestation . INDICATION Advanced maternal age (>35 yrs) Previous child with chromosomal anormalities. Abnormal parental karyotype. Fetal karyotyping for x-linked disorder. Maternal anxiety.

CONTRAINDICATION Cervicovaginal infection trans cervical sampling is contraindicated . Patient not willing for medical termination of pregnancy if the fetus is abnormal.

TECHNIQUE:-. Trans cervical The site is more appropriate for determining by USG scanning. With the patient in lithotomy position under aseptic and antiseptic precaution ,the cervix is exposed with a speculum held with the vulsellum and the chorion villus sampling cannula is passed into the chorionfrondosum under ultrasonic control. Chronic villi are aspirate with 5 or 10 ml syringe. The specimen is kept in a petri dish containing cullin medium .Any blod cloths and decidua are removed about 10-20ml of villi are adequate .the procedure ia repeated if the sample is inadequate.

Transabdominal: Aseptic and antiseptic precautions are followed. Sampling is done under local anaesthesia using coaxial needle combination and syringe suction ,single needle and syringe sunction or coaxial combination with biopsy forceps .Alternatively free hand transabdominal sampling s also possible under ultrasonic control. ADVANTAGES :-

Villi contain sufficient mitosis to allow direct preparation for karyotyping without culture hence rapid resulavailable . large quantity of growing tissue for analysis. If pregnancy termination required can be done easier.

DISADVANTAGES: Abortion rate is about 2 % (higher) mosaicism in placental tissue may confuse the genetic picture and give inaccurate results. Misuse of preocedure reported for female feticide.

POST OPERATIVE MANAGEMENT : Rh immune globin to a non sensitized Rh negative gravida with an Rh positive husband. Rest for vaginal spotting which is seen in 35-60% cases. Abstinence for one week . Follow up scan to rule out fetal injury or death . COMPLICATION :Spontaneous abortion. Rh isoimmunization . Fetomaternal harmorrahge.

BIBLIOGRAPHY Dutta.D.C, Text book of obstetrics, fourth edition, Calcutta, New central book agency,2004,page no.331-335. Salhan sudha, Textbook of obstetrics and gynaecology,First edition, New Delhi,JP brothers medical publishers,P.Ltd,2006,Page no.261-263. F.Weller Barabara,Balliers nurses dictionary,24th edition, China, Elsvier science limited,2006,Page no.132. Wani reenaj, Essential obstetrics, 1st edition,Mumbai,Bhaluni book limited,1997, Page no.261-262. Marie Elizabeth, obstetrics for nurses, 1st edition, New Delhi, CBS publishers, Page no.225-228.

ARTIFICIAL INSEMINATION INTRODUCTION-:

Artificial insemination (AI) is the deliberate introduction of semen into a female animal for the purpose of fertilisation, by some means other than ejaculation directly into the vagina or oviduct.

DEFINITION-:
Artificial insemination is a common practice in the breeding of dairy cattle and pigs. Some animal husbandry techniques have been adapted for humans.

PREPARATION-: 1) A sperm sample will be provided by the male partner of the woman undergoing
artificial insemination, but sperm provided through sperm donation by a sperm donor may be used if, for example, the woman's partner produces too few motile sperm, or if he carries a genetic disorder, or if the woman has no male partner. Sperm is usually obtained through masturbation or the use of an electrical stimulator, although a special condom, known as a collection condom, may be used to collect the semen during intercourse. The man providing the sperm is usually advised not to ejaculate for two to three days before providing the sample in order to increase the sperm count. A woman's menstrual cycle is closely observed, by tracking basal body temperature and changes in vaginal mucus, or using ovulation kits, ultrasounds or blood tests. When using intrauterine insemination (IUI), the sperm must have been washed in a laboratory and concentrated in Hams F10 media without L-glutamine, warmed to 37C.[1] The process of washing the sperm increases the chances of fertilization and removes any mucus and non-motile sperm in the semen. Pre and post concentration of motile sperm is counted. If sperm is provided by a sperm donor through a sperm bank, it will be frozen and quarantined for a particular period and the donor will be tested before and after production of the sample to ensure that he does not carry a transmissible disease. Sperm samples donated in this way are produced through masturbation by the sperm donor at the sperm bank. A chemical known as a cryoprotectant is added to the sperm to aid the freezing and thawing process. Further chemicals may be added which separate the most active sperm in the sample as well as extending or diluting the sample so that vials for a number of inseminations are produced. For fresh shipping, a semen extender is used. If sperm is provided by a private donor, either directly or through a sperm agency, it is usually supplied fresh, not frozen, and it will not be quarantined. Donor sperm provided in this way may be given directly to the recipient woman or her partner, or it may be transported in specially insulated containers. Some donors have their own freezing apparatus to freeze and store their sperm. Private donor sperm is usually produced through masturbation, but some donors use a collection condom to obtain the sperm when having sexual intercourse with their own partners.

2) 3) 4)

5)

6)

PROCEDURE-:
1) When an ovum is released, semen provided by the woman's male partner, or by a sperm donor, is inserted into the woman's vagina or uterus. The semen may be fresh or it may be frozen semen which has been thawed. Where donor sperm is supplied by a sperm bank, it will always be quarantined and frozen and will need to be thawed before use. Specially designed equipment is available for carrying out artificial inseminations. 2) In the case of vaginal artificial insemination, semen is usually placed in the vagina by way of a needleless syringe. A longer tube, called a tom cat, may be attached to the end of the syringe to facilitate deposit of the semen deeper into the vagina. The woman is generally advised to lie still for a half hour or so after the insemination to prevent seepage and to allow fertilization to take place. 3) A more efficient method of artificial insemination is to insert semen directly into the woman's uterus. Where this method is employed it is important that only 'washed' semen be used and this is inserted into the uterus by means of a catheter. Sperm banks and fertility clinics usually offer 'washed' semen for this purpose, but if partner sperm is used it must also be 'washed' by a medical practitioner to eliminate the risk of cramping. 4) Semen is occasionally inserted twice within a 'treatment cycle'. A double intrauterine insemination has been theorized to increase pregnancy rates by decreasing the risk of missing the fertile window during ovulation. However, a randomized trial of insemination after ovarian hyperstimulation found no difference in live birth rate between single and double intrauterine insemination.[2] 5) An alternative method to the use of a needleless syringe or a catheter involves the placing of partner or donor sperm in the woman's vagina by means of a specially designed cervical cap, a conception device or conception cap. This holds the semen in place near to the entrance to the cervix for a period of time, usually for several hours, to allow fertilization to take place. Using this method, a woman may go about her usual activities while the cervical cap holds the semen in the vagina. One advantage with the conception device is that fresh, non-liquified semen may be used. 6) If the procedure is successful, the woman will conceive and carry to term a baby. The baby will be the woman's biological child, and the biological child of the man whose sperm was used to inseminate her, whether he is the woman's partner or a donor. A pregnancy resulting from artificial insemination will be no different from a pregnancy achieved by sexual intercourse. However, there may be a slight increased likelihood of multiple births if drugs are used by the woman for a 'stimulated' cycle.

DONOR VARIATIONS-:

Either sperm provided by the woman's husband or partner (artificial insemination by husband, AIH) or sperm provided by a known or anonymous sperm donor (artificial insemination by donor, AID or DI) can be used.

TECHNIQUES-: 1) INTRACERVICAL INSEMINATION-:

Intracervical insemination, or 'ICI' is the easiest way to inseminate. This involves the deposit of raw fresh or frozen semen (which has been thawed) into the cervix usually by injecting it with a needle-less syringe. This process closely replicates the way in which fresh semen is directly deposited on to the neck of the cervix by the penis during vaginal intercourse. When the male ejaculates, sperm deposited this way will quickly swim into the cervix and toward the fallopian tubes where an ovum recently released by the ovary(s) hopefully awaits fertilization. It is the simplest method of artificial insemination and 'unwashed' or raw semen is normally used. It is probably therefore, the most popular method and is used in most home, self-insemination and practitioner insemination procedures. Alternative methods may be used to deposit the sperm in the vagina, such as by a conception cap. Advanced technical (medical) procedures may be used to increase the chances of conception. When performed at home without the presence of a professional this procedure is sometimes referred to as intravaginal insemination or IVI.[3] 2) INTRA UTERINE INSEMINATION-: 'Washed sperm', that is, spermatozoa which have been removed from most other components of the seminal fluids, can be injected directly into a woman's uterus in a process called intrauterine insemination (IUI). If the semen is not washed it may elicit uterine cramping, expelling the semen and causing pain, due to content of prostaglandins. (Prostaglandins are also the compounds responsible for causing the myometrium to contract and expel the menses from the uterus, during menstruation.) The woman should rest on the table for 15 minutes after an IUI to optimize the pregnancy rate.[4] To have optimal chances with IUI, the female should be under 30 years of age, and the man should have a TMS of more than 5 million per ml.[5] In practice, donor sperm will satisfy these criteria. A promising cycle is one that offers two follicles measuring more than 16 mm, and estrogen of more than 500 pg/mL on the day of hCG administration.[5] A short period of ejaculatory abstinence before intrauterine insemination is associated with higher pregnancy rates.[6] 3) INTRAUTERINE TUBOPERITONEAL INSEMINATION-: Intrauterine tuboperitoneal insemination (IUTPI) is insemination where both the uterus and fallopian tubes are filled with insemination fluid. The cervix is clamped to prevent leakage to the vagina, best achieved with the specially designed Double Nut Bivalve (DNB) speculum. The sperm is mixed to create a volume of 10 ml, sufficient enough to fill the uterine cavity, pass through the interstitial part of the tubes and the ampulla, finally reaching the peritoneal cavity and the Pouch of Douglas where it would be mixed with the peritoneal and follicular fluid. IUTPI can be useful in unexplained infertility, mild or moderate male infertility, and mild or moderate endometriosis.[9]. In non-tubal sub fertility, fallopian tube sperm perfusion may be the preferred technique over intrauterine insemination.[10].

4) INTRATUBAL INSEMINATION-:

IUI can furthermore be combined with intratubal insemination (ITI), into the Fallopian tube although this procedure is no longer generally regarded as having any beneficial effect compared with IUI.[11] ITI however, should not be confused with gamete intrafallopian transfer, where both eggs and sperm are mixed outside the woman's body and then immediately inserted into the Fallopian tube where fertilization takes place.

PREGNANCY RATES-: Success rates, or pregnancy rates for artificial insemination may be very misleading, since many factors including the age and health of the recipient have to be included to give a meaningful answer, e.g. definition of success and calculation of the total population.[12] For couples with unexplained infertility, unstimulated IUI is no more effective than natural means of conception. Generally, it is 10 to 15% per menstrual cycle using ICI, and[15] and 15-20% per cycle for IUI.[15][unreliable source?] In IUI, about 60 to 70% have achieved pregnancy after 6 cycles. BIBLIOGRAPHY-: 1) Adams, robert M.D.In vitro fertilization technique. 1st edition. Published by monterey CA:new delhi:1988:P.NO. 236-238. 2) G.S. shekhawat, M.D. Intrauterine insemination versus fallopian tube sperm perfusion in non tubal infertility. 2nd edition.published by medical journal:calcutta :1996:P.NO. 224-227.