Professional Documents
Culture Documents
Prepared by
Mohamed M. F. Fathalla
PAGE
INTRODUCTION
OBSTETRICS
1- History taking in obstetrics
2- Pregnancy monitoring skills
Measuring blood pressure in pregnant women
Measuring proteinuria using urine strips
Antenatal abdominal examination
3- Labor management skills
- Abdominal and vaginal examination during labor
- management of the first stage of labor
- Management of the second stage of labor
- Active management of the third stage of labor
- Perform and repair episiotomy
- Repair 1st and 2nd degree perineal tears
- Repair of 3rd degree perineal tears
- Repair cervical laceration
-Perform bimanual compression of the uterus
4- Postpartum Assessment and Care
GYNECOLOGY
1- History taking in gynecology
2- Breast Examination
3- Abdominal examination
4- Genital examination
5- Taking a vaginal swab
6- Cervical inspection with Acetic acid staining
7- Contraception
a) Counseling in family planning
b) Fundamental concepts in contraception
b) Insert and remove Cu-T 380-A intrauterine contraceptive device
c) Prescribe oral contraceptive pills
d) Prescribing Depot Medroxy progesterone Acetate Injection
e) Inserting and removing subdermal contraceptive implants
Annexes
1- The WHO medical eligibility criteria for contraceptive use
2- The WHO partograph
References
Guides
3. The Perinatal Care Manual: Geneva Foundation for Medical Education and
Research
Introduction
This manual is intended to help the students/house officers perform the basic clinical
skills required for their practice in the department of Obstetrics and Gynecology. The
skills are outlined as sequential steps (called the Clinical learning guide or CLG).
Each CLG contains a description of the exact steps or tasks and their proper
steps and tasks correlate to the consensus of international best practices, are
Egyptian context.
Clinical Learning Guides are designed to be used primarily in a skill lab or other
simulation environment during the early phases of learning (i.e., skill acquisition)
when learners are practicing with the appropriate models or in the proper simulation
guide for the learner as s/he performs the skill. It is important to recognize that the
learner is not expected to perform all the steps or tasks correctly the first time s/he
practices them.
If used consistently, the learning guides enable each learner to chart her/his
progress and to identify areas for improvement. From these learning guides,
checklists are developed that will form the basis for student/house officer evaluation.
First, some modules needed more elaborate explanation, so, these were provided
before the learning guide. Second, for other topics no learning guide was provided
because they contain no "manual" skills but they were included as they are being
taught in the skill lab. Examples include prescribing oral contraceptive pills. Third,
the history taking part is provided here as a model sheet for use by students. It can
be copied each time they present a case and just fill it. This saves a lot of their time
and effort trying to memorize history items. It also helps them structure their ideas
This manual intentionally draws heavily on the Supreme Counsel of University Clinical
learning guides for Obstetrics and Gynecology. The part on abdominal examination is
adapted from the learning guides of "Foundation skills". Logistic difficulties stood in
the face of using these guides. However, all is not lost. This manual, as it is hoped,
will help the students achieve a better and more enjoyable clinical experience.
Obstetrics
Pregnancy management skills
History Taking in Obstetrics
Introduction
to the usual historical points, specific questions about pregnancy. These peculiarities
Not all women who present to the obstetrician are “ill”. This makes the use of terms
for antenatal care” is perfectly acceptable. However, the presence of pregnancy and
Some women have medical conditions that antedate pregnancy. The mere presence
women, it is important to word the complaint as follows: diabetes since 8 years and
pregnant for 5 months, for example. This will allow the student to analyze the
The obstetric history should include a thorough analysis of previous pregnancies. Any
regarding where it happened, outcome and possible complications. If the woman has
The menstrual history is also of particular importance. The date of the first day of the
last menstrual period is one way of determining the expected date of delivery. The
first day of the last menstrual period is considered unreliable for estimating the
2- The pregnancy took place less than 3 months after lactational amenorrhea
3- The pregnancy took place while on combined oral contraceptive pills or within
History
PERSONAL HISTORY
Name:
Age:
Residence
Occupation:
Marital status:
Special habits:
Husband's name:
Age:
Occupation:
MENSTRUAL HISTORY
Age of menarche:
Regularity:
P/C:
Inter-menstrual bleeding/discharge:
PMS
Gravid , Para +
Abortions
LD LA
PRESENT HISTORY
Onset
Course
Characters
Therapeutic history
PAST HISTORY
Past surgeries
FAMILY HISTORY
Diabetes
Hypertension
Breast/ovarian cancer
Twinning Pre-eclampsia
Examination
General Examination:
Weight:___ Kg height cm
- Head & Neck:
- Breasts:
- Lower Limbs:
Abdominal Examination:
- Inspection:
Pelvic Examination:
- V & V:
- Membranes:
- P.P.: - Position:
Diagnosis:
First visit
GETTING READY
1. Make sure that the clinic is ready: clean, tidy, sphygnomanometre, sonicaid
her carefully.
HISTORY
Personal History
Obtaining the following information from the client:
antenatal visits.
Menstrual and Contraceptive History
Date of the first day of the last menstrual period-------expected date of
delivery
Reliability of the cycle (irregularities before, lactational amenorrhea before or
Asking about any investigations done during (recently before or related to) her
current pregnancy.
GETTING READY
1. Make sure that the clinic is ready: clean, tidy, sphygmomanometer, sonicaid
her carefully.
HISTORY
Note: Flexibility may be used with respect to the order in which the questions
are asked.
History of the present pregnancy
A- Analysis of complaints if any.
B-Warning symptoms of pregnancy
C- Ask about fetal movements/rate of fetal growth
D- Investigations and treatment:
Asking about any investigations done during (recently before or related to) her
current pregnancy.
The following are important if you want to measure the blood pressure accurately:
5. The cuff must be applied correctly. If the patient is sitting in a chair, the blood
pressure apparatus must be at the same level as her upper arm and the right side of
the heart.
The examination couches in most clinics stand with their left side against a wall as it
is most convenient for a right handed person to examine the right side of the patient.
The lower arm (i.e. the right arm if she is lying on her right side) should be used, as
the upper arm will give false low readings as it is above the level of the heart. The
arm must be fully undressed so that the cuff can be correctly applied.
The patient should lie down on her side or sit. Lying on her back may cause
hypotension, giving a falsely low reading. She should also lie slightly turned onto her
side. Lying on her back may cause the uterus to press on the inferior vena cava
resulting in a decreased return of blood to the heart and a drop in blood pressure. A
BLOOD PRESSURE.
Anxiety and the effort of climbing onto the couch often increase the blood pressure.
This will usually return to a resting value if the patient can lie down and relax for 5
minutes.
A standard size cuff (width of 14.5 cm) is usually used. If the arm is very fat, then
use a wide cuff (17.5 cm) to get a correct reading. The cuff must be applied firmly
around the arm, not allowing more than 1 finger between the cuff and the patient's
arm.
The cuff should be pumped up with a finger feeling the brachial or radial pulse. Only
when the pulse can no longer be felt, should the stethoscope be put over the brachial
The Kortokoff phases are times when the sound of the pulse changes during the
PHASE 1 is the first sound which you hear after the cuff pressure is released. This
PHASE 5 is the time when the sound of the pulse disappears. Usually the sound gets
softer before it disappears but sometimes it disappears without first becoming softer.
However, in all cases the diastolic blood pressure must be read when the sound of
The amount of protein in a sample of urine is simply and easily measured with a
1+ = 0,3 g/l
2+ = 1,0 g/l
3+ = 3,0 g/l
4+ = 10 g/l
2. Remove a reagent strip from the bottle and replace the cap.
3. Dip the strip into the urine so that all the test areas are completely covered, then
4. Wait 60 seconds.
5. Hold the strip horizontally and compare with the color blocks on the side of the
bottle. Hold the strip close to the bottle to match the colors but do not rest it on the
bottle as the urine will damage the color chart. The darker the color of the reagent
STEP/TASK
Preparing the patient
1. Ask the patient to relax in a supine position (before 12 weeks). After 12 weeks
measure the blood pressure in the sitting position. Instruct the patient to support the
back; uncross the legs and rest the feet flat on the floor.
2. Wait for 5 minutes.
3. Prepare equipment (stethoscope and mercury or aneroid sphygmomanometer)
4. Measure the radial pulse on both sides, if pulses are equal, use the right arm for
blood pressure measurement; if pulses are unequal, use the arm with the stronger
pulse.
5. Uncover the identified arm. The arm should be abducted and supinated.
6. Choose the correct cuff size :
The cuff-bladder should cover at least 40% of the circumference and 80% of the
connections, placed about one inch above the antecubital space across the inner
(The pulse obliteration pressure). This is the approximate systolic blood pressure.
5. Deflate the cuff
6. Add 20-30 mm Hg to that number to know the maximum inflation level (MIL).
7. Place the earpieces of the stethoscope into ears, with the earpiece angles turned
artery, just below the cuff. (Avoid touching the cuff or tubing)
10. Close the valve.
11. Inflate the cuff rapidly to the MIL while focusing eyes to the level of the midrange
The systolic reading (Korotkov I) will be the first loud sound to be heard.
OBJECTIVES
2. She should lie comfortably on her back with a pillow under her head. She should
not lie slightly turned to the side, as is needed when the blood pressure is being
taken.
2. The presence or absence of scars. When a scar is seen the reason for it should be
specifically asked for (e.g. what operation did you have?), if this has not already
1. The liver, spleen and kidneys must be specifically palpated (felt) for.
1. Check whether the uterus is lying in the midline of the abdomen. Sometimes it is
2. Feel the wall of the uterus for irregularities. An irregular uterine wall suggests
either:
(i) The presence of myomas (fibroids) which usually enlarge during pregnancy and
1. Anatomical landmarks are used, i.e. the symphysis pubis and the umbilicus.
2. Gently palpate the abdomen with the left hand to determine the height of the
(i) If the fundus is palpable just above the symphysis pubis, the gestational age is
probably 12 weeks.
(ii) If the fundus reaches half way between the symphysis and the umbilicus, the
(iii) If the fundus is at the same height as the umbilicus, the gestational age is
probably 22 weeks (one finger under the umbilicus = 20 weeks and one finger above
1. FEEL FOR THE FUNDUS OF THE UTERUS. This is done by starting to gently palpate
from the lower end of the sternum. Continue to palpate down the abdomen until the
fundus is reached. When the highest part of the fundus has been identified, mark the
skin at this point with a pen. If the uterus is rotated away from the midline, the
highest point of the uterus will not be in the midline but will be to the left or right of
the midline. Therefore, also palpate away from the midline to make sure that you
mark the highest point at which the fundus can be palpated. Do not move the fundus
height, hold the end of the tape measure at the top of the symphysis pubis. Lay the
tape measure over the curve of the uterus to the point marking the top of the
uterus. The tape measure must not be stretched while doing the measurement.
Measure this distance in centimetres from the symphysis pubis to the top of the
3. If the uterus does not lie in the midline but, for example, lies to the right, then the
distance to the highest point of the uterus must still be measured WITHOUT moving
Having determined the height of the fundus, you need to assess whether the height
of the fundus corresponds to the patient's dates, and to the size of the fetus. From
18 weeks, the S-F height must be plotted on the SF growth curve to determine the
gestational age. This method is, therefore, only used once the fundal height has
reached 18 weeks. In other words when the S-F height has reached two fingers
The lie and presenting part of the fetus only becomes important when the gestational
3. THE POSITION OF THE BACK OF THE FETUS. This refers to whether the back of
the fetus is on the left or right side of the uterus, and will assist in determining the
H) METHODS OF PALPATION.
There are 4 specific steps for palpating the fetus. These are performed
systematically. With the mother lying comfortably on her back, the examiner faces
the patient for the first 3 steps, and faces towards her feet for the fourth.
1. FIRST STEP: Having established the height of the fundus, the fundus itself is
gently palpated with the fingers of both hands, in order to discover which pole of the
fetus (breech or head) is present. The head feels hard and round, and is easily
movable and ballotable. The breech feels soft, triangular and continuous with the
body.
2. SECOND STEP. The hands are now placed on the sides of the abdomen. On one
side there is the smooth, firm curve of the back of the fetus, and on the other side
the rather knobby feel of the fetal limbs. It is often difficult to feel the fetus well
when the patient is obese, when there is a lot of liquor or when the uterus is tight, as
in some primigravidas.
3. THIRD STEP. The examiner grasps the lower portion of the abdomen, just above
the symphysis pubis, between the thumb and fingers of one hand. The objective is to
feel for the presenting part of the fetus and to decide whether the presenting part is
loose above the pelvis or fixed in the pelvis. If the head is loose above the pelvis, it
can be easily moved and balloted. The head and breech are differentiated in the
4. FOURTH STEP. The objective of the step is to determine the amount of head
palpable above the pelvic brim, if there is a cephalic presentation. The examiner
faces the patient's feet, and with the tips of the middle 3 fingers palpates deeply in
the pelvic inlet. In this way the head can usually be readily palpated, unless it is
already deeply in the pelvis. The amount of the head palpable above the pelvic brim
1. When you are palpating the fetus, always try to assess the size of the fetus
itself. Does the fetus fill the whole uterus, or does it seem to be smaller than you
would expect for the size of the uterus, and the duration of pregnancy? A fetus
which feels smaller than you would expect for the duration of pregnancy,
suggests intra-uterine growth restriction, while a fetus which feels smaller than
expected for the size of the uterus, suggests the presence of a multiple
pregnancy.
2. If you find an abnormal lie when you palpate the fetus, you should always
consider the possibility of a multiple pregnancy. When you suspect that a patient
1. DOES THE HEAD FEEL TOO SMALL FOR THE SIZE OF THE UTERUS? You should
always try to relate the size of the head to the size of the uterus and the duration
of pregnancy. If it feels smaller than you would have expected, consider the
2. DOES THE HEAD FEEL TOO HARD FOR THE SIZE OF THE FETUS? The fetal
head feels harder as the pregnancy gets closer to term. A relatively small fetus
This is not always easy to feel. The amount of liquor decreases as the pregnancy
nears term. The amount of liquor is assessed clinically by feeling the way that the
32
(ii) There may be a urinary tract obstruction or some other urinary tract
can be serious problems, and the patient should be referred to a hospital where
the fetus can be carefully assessed. The patient needs an ultrasound examination
the fetus.
This means that the uterus feels tight, or has a contraction, while being palpated.
Uterine irritability normally only occurs after 36 weeks of pregnancy, i.e. near
term. If there is an irritable uterus before this time, it suggests either that there
1. WHERE SHOULD YOU LISTEN? The fetal heart is most easily heard, by listening
over the back of the fetus. This means that the lie and position of the fetus must
2. WHEN SHOULD YOU LISTEN TO THE FETAL HEART? You need only listen to the
fetal heart if a patient has not felt any fetal movements during the day. Listening
to the fetal heart is, therefore, done to rule out an intra-uterine death.
3. HOW LONG SHOULD YOU LISTEN FOR? You should listen long enough to be
sure that what you are hearing is the fetal heart and not the mother's heart.
33
When you are listening to the fetal heart, you should, at the same time, also feel
1. KICKING movements, which are caused by movement of the limbs. These are
When you ask a patient to count her fetal movements, she must count both types
of movement.
If there is a reason for the patient to count fetal movements and to record them
1. TIME OF DAY: Most patients find that the late morning is a convenient time to
record fetal movements. However, she should be encouraged to choose the time
which suits her best. She will need to rest for an hour. It is best that she use the
2. LENGTH OF TIME: This should be for 1 hour per day, and the patient should be
able to rest and not be disturbed for this period of time. Sometimes the patient
may be asked to rest and count fetal movements for 2 or more half hour periods
a day. The patient must have access to a watch or clock, and know how to
3. POSITION OF THE PATIENT: She may either sit or lie down. If she lies down,
she should lie on her side. In either position she should be relaxed and
comfortable.
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Clinical learning guide
STEP / TASK
Getting Ready
1. Ask the patient to empty her bladder.
2. Ask the woman to lie on her back on the examination table with her knees
slightly flexed to relax her abdominal muscles and uncover her abdomen.
3. Stand on the right side of the patient.
4. Warm your hands if cold by rubbing them together.
The Procedure
1. Inspect the abdomen (visually) for size, contour, scars of previous
the abdomen. Sometimes it is rotated to either the right or the left. Feel the
wall of the uterus for irregularities. An irregular uterine wall suggests either;
uterus.
2. Fundal Height Determination
ulnar border of the left hand to determine the height of the fundus of the
uterus. Anatomical landmarks are used, i.e. the symphysis pubis and the
umbilicus.
the abdomen with the left hand to determine the height of the fundus of the
uterus starting from the xiphisternum and determine how many fingerbreadth
35
STEP / TASK
the ulnar side of left hand starting from the lower end of the sternum and
moving down the abdomen until the highest part of the fundus is reached and
mark this point. If the uterus is dextro-posed, centralize the uterus before
estimating the S_P height. Hold the end of the tape measure at the top of the
symphysis pubis and lay it over the curve of the uterus to the point marking
becomes important when the gestational age reaches 32-34 weeks. There are
comfortably on her back, the examiner faces the patient for the first three
pole which occupies the fundus. Having established the height of the fundus,
place both hands on the sides of the fundus and palpate its content. The head
feels hard and round and is easily movable and ballotable. The breech feels
identify the position of the fetal back. The hands are now placed on the sides
of the abdomen (uterus) at about the level of the umbilicus. Keep one hand
steady against one side of the uterus while using palm of the other hand to
hands. On one side there is the smooth firm curve of the back of the fetus,
and on the other side the rather knobby feel of the fetal limbs.
• Third step (maneuver) “First Pelvic Grip or Pawlick Grip”: The objective is
to feel the presenting part of the fetus and to decide whether the presenting
part is loose above the pelvis or fixed in the pelvis. Grasp the lower portion of
the abdomen, just above the symphysis pubis, between the thumb and fingers
of the right hand. The head and breech are differentiated in the same way as
36
STEP / TASK
• Fourth step (maneuver) “Second Pelvic Grip”: The objective is to determine
the amount of head palpable above the pelvic brim if there is a cephalic
presentation and to detect any deflexion of the head. Face the woman’s feet,
and with the tips of the middle three fingers of both hands palpate deeply in
the pelvic inlet (try to insert your fingers between the presenting part and the
symphysis pubis).
4. Auscultation of Fetal Heart Sounds
• Place the transducer of the doppler vertically on the abdomen below the
umbilicus in cephalic presentation on the side you palpated the fetal back.
Listen at or above the level of the umbilicus on the side of the fetal back in
motion, while widening the circle until you hear the fetal heart tone.
• If you are using a fetal stethoscope “Pinard Stethoscope”, place the opening of
the cone vertically on the abdomen as in the previous step and place your
good ear on the other end of the stethoscope. Take your hand off the
stethoscope so that it is only held in place by your head. Move your head
slowly in a circular manner until you can hear the fetal heart. Listen to fetal
heart for a full minute, counting beats against the seconds’ hand of your
watch to determine the heart rate. Feel the woman's pulse simultaneously to
ensure that what you are hearing is the fetal and not the maternal heart.
Post-procedure
• Wash your hand
• Explain the findings to the woman and record them in her antenatal card or
your records
37
Labor management skills
38
Abdominal and vaginal examination
during labor
39
Introduction
This does not enable the application of a single learning guide. The
of the mother and fetus and take decision as to when, where (by
place. Covering all skills is beyond the scope of this book but some
40
I) EXAMINATION OF THE ABDOMEN IN LABOUR
OBJECTIVES
LABOUR?
1. On admission.
9. The contractions.
41
C SHAPE OF THE ABDOMEN.
1. The shape of the uterus will be oval with a singleton pregnancy and a
longitudinal lie.
polyhydramnios.
Check if the height of the fundus is in keeping with the patient's dates and the
This is best done by feeling the size of the fetal head. Is the size of the fetus in
keeping with the patient's dates and the size of the uterus? A fetus whose head
1. Incorrect dates.
3. Multiple gestation.
risk of umbilical cord prolapse. An abnormal lie may suggest that there is a
42
G PRESENTATION OF THE FETUS.
abdomen to determine the presenting part of the fetal head (vertex, face or
brow). The following figure indicates some features that can assist you in
The descent and engagement of the head is an important part of assessing the
The amount of descent and engagement of the head is assessed by feeling how
many fifths of the head are palpable ABOVE the brim of the pelvis:
1. 5/5 of the head palpable mean that the whole head is above the brim of the
pelvis.
2. 4/5 of the head palpable means that a small part of the head is below the brim
of the pelvis and can be lifted out of the pelvis with the deep pelvic grip.
3. 3/5 of the head palpable means that the head cannot be lifted out of the
pelvis. On doing the deep pelvic grip, your fingers will move outwards from the
neck of the fetus, then inwards before reaching the pelvic brim.
43
4. 2/5 of the head palpable means that most of the head is below the pelvic brim,
and on doing the deep pelvic grip, your fingers only splay outwards from the fetal
5. 1/5 of the head palpable means that only the tip of the fetal head can be felt
It is very important to be able to distinguish between 3/5 and 2/5 head palpable
above the pelvic brim. If only 2/5 of the head is palpable, then engagement has
taken place and the possibility of disproportion at the pelvic inlet can be ruled
out.
1. In some primigravidas.
2. During a contraction.
44
4. When the uterus has ruptured.
When there is both hardness and tenderness of the uterus, without period of
relaxation during which the uterus is not tender, the commonest causes are:
1. An abruptio placentae.
2. A ruptured uterus.
K CONTRACTIONS.
Contractions can be felt by placing a hand on the abdomen and feeling when the
uterus becomes hard, and when it relaxes. It is, therefore, possible to assess the
length of the contractions by taking the time at the beginning and end of the
and also the frequency with which they occur in a period of 10 minutes.
45
II) VAGINAL EXAMINATION IN LABOUR
OBJECTIVES
1. Swabs.
3. Sterile gloves.
An ordinary surgical glove can be used and the patient does not need to be
swabbed, if the membranes have not ruptured yet and are not going to be
done.
3. The patient should lie on her back, with her legs flexed and knees apart. Do
not expose the patient until you are ready to examine her. It is sometimes
46
4. The patient's vulva and perineum are swabbed with tap water. This is done by
first swabbing the labia majora and groin on both sides and then swabbing the
introitus while keeping the labia majora apart with your thumb and forefinger.
3. The examiner must THINK about the findings and their significance for the
PROCEDURE OF EXAMINATION
should be assessed:
2. Cervix.
3. Membranes.
4. Liquor.
5. Presenting part.
6. Pelvis.
VAGINA.
1. When you examine the vulva you should look for ulceration, varices and any
2. When you examine the vagina, the presence or absence of the following
47
(i) A vaginal discharge.
membranes.
THE CERVIX
1. Length.
2. Dilatation.
The cervix becomes progressively shorter in early labor. The length of the cervix
distance between the internal os and the external os on digital examination. The
the cervix is fully effaced there will be no endocervical canal, only a ring of thin
cervix. The length of the cervix is measured in centimeters. In the past the term
F- DILATATION.
the degree of separation of the fingers on vaginal examination, with the set of
circles in the labor ward. In assessing the dilatation of the cervix, it is easy to
make 2 mistakes:
1. If the cervix is very thin, it may be difficult to feel, and the patient may be said
48
2. When feeling the rim of the cervix, it is easy to stretch it, or pass the fingers
through the cervix and feel the rim with the side of the fingers. Both of these
methods cause the recording of dilatation to be more than it really is. The correct
method is to place the tips of the fingers on the edges of the cervix.
one should always feel for the presence of membranes overlying the presenting
part. If the presenting part is high, it is usually quite easy to feel intact
membranes. It may be difficult to feel them if the presenting part is well applied
to the cervix. In this case, one should wait for a contraction, when some liquor
often comes in front of the presenting part, allowing the membranes to be felt.
Sometimes the umbilical cord can be felt in front of the presenting part (a cord
presentation).
An abdominal examination must have been done before the vaginal examination
to determine the lie of the fetus and the presenting part. If the presenting part is
49
the fetal head, the number of fifths palpable above the pelvic brim must first be
determined.
When palpating the presenting part on vaginal examination, there are 4 important
2. If the head is presenting, what is the PRESENTATION, e.g. vertex, brow or face
presentation?
3. What is the POSITION of the presenting part in relation to the mother's pelvis?
The presenting part is usually the head but may be the breech, the arm, or the
shoulder.
shaped. If the head is well flexed, the anterior fontanel will not be felt. If the
50
(ii) The gum margins distinguish the mouth from the anus.
anterior fontanels felt is on one side of the pelvis, the root of the nose on the
If the presenting part is not the head, it could be either a breech or a shoulder.
51
NOTE THAT IN A FACE OR BROW PRESENTATION, THE PRESENTING PART
LOOKS MUCH LOWER THAN ITS ACTUAL STATION. ALWAYS PALPATE THE
(iii) The anus and the ischial tuberosities form a straight line.
examination will be quite easy if the arm has prolapsed. The shoulder is not
always that easy to identify, unless the arm can be felt. The presenting part is
usually high.
Position means the relationship of a fixed point on the presenting part (i.e. the
the occiput).
2. In a face presentation the point of reference is the chin (i.e. the mentum).
52
Figure 9. Examples of the position of the presenting part with the patient
the lowermost part to the ischial spines. When the lowermost part is at the ischial
spine, it is said that the head is station zero, 1 cm above minus one, 2 cm above
minus two and so on. If the lowermost part is 1 cm below the presenting part,
the head is said to be at station plus one, 2 cm plus two and so on. The head is
MOLDING
53
Molding is the overlapping of the fetal skull bones at a suture which may occur
during labor due to head compression as it passes through the pelvis of the
mother.
the sutures of the skull on vaginal examination, and assessing whether or not the
overlap can be reduced (corrected) by pressing gently with the examining finger.
The presence of caput succedaneum can also be felt as a soft, boggy swelling,
which may make it difficult to identify the presenting part of the fetal head
The occipito-parietal and the sagittal sutures are palpated and the relationship or
closeness of the two adjacent bones assessed. The amount of molding recorded
on the partogram should be the most severe degree found in any of the sutures
palpated.
not be allowed to continue beyond this point and the baby should be immediately
delivered.
When assessing the pelvis, the size and shape of the pelvic inlet, the mid-pelvis
1. To assess the size of the PELVIC INLET, the sacral promontory and the
54
2. To assess the size of the MID-PELVIS, the curve of the sacrum, the
3. To assess the size of the PELVIC OUTLET, the subpubic angle, intertuberous
Start with the sacral promontory and follow the curve of the sacrum down the
midline:
2. A small pelvis: The promontory is easily palpated and prominent, the sacrum is
Figure (10) Lateral view of the pelvis, showing the examining fingers just
55
1. An adequate pelvis: Two fingers can be placed on the sacrospinous ligaments
(i.e. they are 3 cm or longer) and the spines are small and round.
2. A small pelvis: The ligaments allow less than 2 fingers and the spines are
Put 2 examining fingers, with the palm of the hand facing upwards, behind the
56
STEP 4. THE SUBPUBIC ANGLE AND INTERTUBEROUS DIAMETER.
To measure the subpubic angle, the examining fingers are turned so that the
palm of the hand faces upward, a third finger is held at the entrance of the vagina
(introitus) and the angle under the pubis felt. The intertuberous diameter is
measured with the knuckles of a closed fist placed between the ischial
tuberosities.
1. An adequate pelvis: The subpubic angle allows 3 fingers (i.e. an angle of about
2. A small pelvis: The subpubic angle allows only 2 fingers (i.e. an angle of about
57
LEARNING GUIDE
Getting ready
1. Prepare the necessary equipment (Pre-packed vaginal examination set –
apart outwards. Put a pillow under her head and ask that she can rest her
• Meconium.
gently into the vagina. The hand should be turned sideways in this initial
step. Keep downward pressure as you insert the fingers to avoid pressing on
the anterior vaginal wall or urethera. The thumb and fore finger on one hand
separate the labia widely to expose the vaginal opening and prevent the
7. Move your fingers the full length of the vagina (usually 7.5-10 cm.).
During the examination, the fourth and fifth fingers should not touch the rectal
area.
58
8. Note the following:
Membranes.
Presenting part.
Position.
Degree of molding.
inch thick and would be described as uneffaced or 0%. A cervix that ½ inch thick
The hard skull with the sagittal suture and follow it to the anterior or
Station: Locate the portion of the presenting part, and then sweep the fingers
deeply to one side of the pelvis to feel for ischial spines. To determine station,
estimate how far (in centimeters) the tip of the presenting part is above or below
ischial spine
Postprocedural tasks
1. Record your findings on the partogram.
2. Clear away the equipments and clean it.
3. Wash hands.
59
LEARNING GUIDE:
STEP/TASK
Getting ready
1. Prepare the necessary equipment.
2. Tell the woman (and her support person) what is going to be
concerns.
3. Provide continual emotional support and reassurance, as feasible.
4. Review the partograph to ensure that there is a need to correct
hands.
4. Clean the vulva with antiseptic solution.
5. Use one hand to examine the cervix and note consistency,
60
proof container or plastic bag.
2. Place all instruments in 0.5% chlorine solution for 10 minutes for
decontamination.
3. Immerse both gloved hands in 0.5% chlorine solution. Remove
at 15 drops/ minute:
over 5 minutes, OR
61
6. Consider induction to have failed if labor is still not well
62
Management of the second stage of
labor
63
Clinical Learning Guide
STEP / TASK
Getting Ready
1. Prepare the necessary equipments.
2. Check beginning of second stage.
3. Encourage woman to adopt dorsal position or the position of choice &start
vaginal opening.
3. The palm of one hand is used to support the perineum and the second hand
& gradually release the pressure on the occiput to allow gradual extension on
the head.
6. Wipe the mucous from the baby’s mouth and nose with a clean cloth or soft
• If the coils around the neck are loose it is slipped around the head.
• If it is coiled tightly, two clamps are applied and the cord is cut between
them.
8. Allow the baby’s head to turn spontaneously.
64
STEP / TASK
9. Place a hand on each side of the baby’s head and apply gentle pressure
downward (toward the mother’s spine) until the anterior shoulder slips under
as it slides out using the other hand on the upper side of the baby.
12. Clamp the cord (if immediate cord clamping is indicated).
13. Place the baby on the mother’s abdomen (if the mother is unable to hold the
measures.
Cord clamping
16. Clamp and cut the umbilical cord (clamp at 3 cm & 5 cm from the umbilicus
65
Third stage of labor
66
1 WHAT IS THE THIRD STAGE OF LABOUR?
The third stage of labor starts immediately after the delivery of the infant and
The normal duration of the third stage of labor depends on the method used to
deliver the placenta. It usually lasts less than 30 minutes, and mostly only 2-5
minutes.
stage.
2. The uterus contracts and becomes smaller and, as a result, the placenta
separates.
3. The placenta is squeezed out of the upper uterine segment into the lower
4. The contraction of the uterine muscle compresses the uterine blood vessels
and this prevents bleeding. Thereafter, clotting (coagulation) takes place in the
dangerous time for the patient. Postpartum hemorrhage is the commonest cause
67
Whenever possible, the active method should be used. However, a midwife
(i) Keep steady tension on the umbilical cord with one hand.
(ii) Place the other hand just above the symphysis pubis and push the uterus
upwards.
4. Placental separation will take place when the uterus contracts. When controlled
cord traction is applied the placenta will be delivered from the upper segment of
the uterus.
5. Once this occurs, continuous light traction on the umbilical cord will now
6. If placental separation does not take place during the first uterine contraction
after giving the oxytocic drug, wait until the next contraction occurs and then
OF LABOUR?
units oxytocin and 0,5 mg ergometrine maleate. The drug must be protected
from direct light at all times and must be kept in a refrigerator. At all times the
68
2. Oxytocin (Syntocinon) 5 units. This is given intramuscularly. It is not necessary
to protect this drug against direct light. Although the drug must also be kept in a
SYNTOMETRINE?
2. The patient has heart valve disease. Tonic contraction of the uterus pushes a
large volume of blood into the patient's circulation, which may cause heart failure
LABOUR?
1. After delivery of the infant the signs of placental separation are waited for.
2. When the signs of placental separation appear, the patient is asked to bear
69
3. Only after the placenta has been delivered is an oxytocic drug given.
1. Uterine contraction.
2. The fundus of the uterus rises in the abdomen, when the placenta moves from
the upper segment of the uterus to the lower segment and vagina.
3. Lengthening of the umbilical cord. This sign is most easily seen if the cord is
clamped with forceps at the vulva. Any lengthening of the umbilical cord above
5. The placenta has definitely separated if the umbilical cord does not shorten
ADVANTAGES:
2. Everyone who conducts deliveries must be trained in the active method, as the
latter must be used if there is excessive bleeding before delivery of the placenta
or if the placenta does not spontaneously separate when the passive method is
used.
3. There is less possibility that oxytocin will be needed to contract the uterus
DISADVANTAGES:
1. The person actively managing the third stage of labor must not leave the
patient. Therefore, an assistant is needed to give the oxytocic drug and examine
the newborn infant, while the person conducting the delivery continues with the
70
2. The risk of a retained placenta is increased if the active method is not carried
out correctly, especially if the first 2 contractions after the delivery of the infant
3. Excessive traction on the umbilical cord can result in inversion of the uterus,
especially if the fundus of the uterus is not supported by placing a hand above the
ADVANTAGES:
1. No assistant is needed.
DISADVANTAGES:
IS USED?
If the signs of placental separation have still not appeared 30 minutes after the
start of the third stage of labor, then an oxytocic drug must be given and the
1. The umbilical cord must NOT be allowed to bleed after the delivery of the first
71
(monochorionic placenta), the undelivered second twin may bleed to death if the
2. The umbilical cord should be allowed to bleed if the patient's blood group is
Rhesus negative (Rh-negative) with a single fetus. This will reduce the risk of
fetal blood crossing the placenta to the mother's circulation and, thereby,
3. Allowing the umbilical cord to bleed during the third stage of labor, reduces the
general rule, the umbilical cord should be allowed to bleed once a multiple
1. COMPLETENESS:
Make sure that both the placenta and the membranes are complete after the
(i) The membranes are examined for completeness by holding the placenta up by
the umbilical cord so that the membranes hang down. You will see the round hole
through which the infant was delivered. Examine the membranes carefully to
(ii) The placenta is now held in both hands and the maternal surface is inspected
after the membranes are folded away. A missing part of the placenta, or
2. ABNORMALITIES:
(i) Cloudy membranes, or membranes that smell offensive, suggest the presence
of chorioamnionitis.
(ii) Clots of blood which adhere to the maternal surface suggest that abruptio
72
3. SIZE:
The weight of the placenta increases with gestational age and is usually 1/6 the
(iii) A placenta which is heavier than would be expected for the weight of the
A placenta which is lighter than would be expected for the weight of the infant, is
4. UMBILICAL CORD:
Two arteries and a 1 vein should be seen on the cut end of the umbilical cord. If
only 1 umbilical artery is present, the infant must be carefully examined for other
congenital abnormalities.
*** Infarcts can be recognized as firm, pale areas on the maternal surface of the
(iv) The condition of the perineum and the presence of any tears.
73
(v) The completeness of the placenta and membranes, and any placental
abnormality.
3. Recordings made during the first hour after the delivery of the placenta:
(i) During this time (sometimes called the fourth stage of labor) it is important to
record whether the uterus is well contracted and whether there is any
excessive bleeding. During the first hour after the completion of the third stage
(iii) If the third stage of labor was not normal, the observations must be repeated
74
Clinical Learning Guide
STEP / TASK
GETTING READY
1. Palpate the fundus of the uterus to exclude presence of
uterus.
2. Put a suitable receptacle under the buttocks to receive all
hand.
4. Place the other hand just above the pubic bone and gently
next contraction.
4. As the placenta delivers, hold it with both hands and twist
75
STEP / TASK
5. If the membranes don’t slip out spontaneously, gently
upwards.
upwards.
completeness.
4. Inspect cut end of cord for presence of two arteries and
one vein.
1. Immediately massage the uterus through the abdomen
until it is contracted.
contraction.
2. Repeat uterine massage every 10-15 minutes for the 1st
two hours.
stop.
1. Inspect the perineum for lacerations / tears.
2. Gently separate the labia and inspect lower vagina for
lacerations / tears.
3. Gently explore the cervix and upper vagina for lacerations
/ tears.
4. Gently clean the perineum with warm water and antiseptic
76
STEP / TASK
solution.
5. Apply a clean pad to the vulva.
1. Place any contaminated items in plastic bags or leak-
inside out.
5. Dispose in plastic bag or leak-proof covered waste
container.
6. Wash hands thoroughly with soap and water and dry with
77
Vaginal and cervical inspection after
birth
78
Introduction
79
Clinical Learning Guide
STEP / TASK
Getting Ready
Have your assistant ready to help you and prepare the necessary
Wash hands thoroughly with soap and water and dry with a clean dry
Move fingers up the side of the wall of the vagina to the cervix, looking
“firmly” on her uterus to move the cervix lower into the vagina.
Insert two high-level disinfected Sim’s specula into the vagina:
If no specula are available, use one hand to press firmly on the back
80
STEP / TASK
Insert a ring forceps and catch the anterior lip of the cervix at the 12
o’clock position.
Insert a second ring or sponge forceps and catch the cervix at the 3
o’clock position.
Inspect the cervix between the two forceps for bleeding points, using a
position).
Catch the cervix at the 6 o’clock position.
Inspect the cervix between the forceps at the 3 o’clock and the 6
o’clock positions for bleeding points, using a gauze swab to wipe blood
o’clock positions for bleeding points, using a gauze swab to wipe blood
o’clock positions for bleeding points, using a gauze swab to wipe blood
blood remnants and that she is decently covered before transfer to the
ward.
Take and record patient’s vital signs, amount of blood lost and
immediately.
Post Procedural tasks
Before removing gloves, dispose of waste materials in a leak-proof
decontamination.
81
STEP / TASK
Immerse both gloved hands in 0.5% chlorine solution. Remove gloves
plastic bag.
Wash hands thoroughly with soap and water and dry with a clean, dry
82
Performing and repairing episiotomy
83
PERFORMING AN EPISIOTOMY
Introduction
84
.E PROBLEMS WITH EPISIOTOMIES-9
The episiotomy is done TOO SOON: This can result in excessive bleeding as the .1
presenting part is not pressing on the perineum. An episiotomy will not help the
.descent of a high head
Extension of the episiotomy by TEARING: This is not only a problem in a .2
midline episiotomy. Both mediolateral and J-shaped episiotomies may also tear
through the anal sphincter into the rectum. However, extension of mediolateral
.and J-shaped episiotomies are less likely to occur than a midline episiotomy
:Excessive BLEEDING may occur .3
.i) When the episiotomy is done too early(
.ii) From a mediolateral episiotomy(
.iii) After the delivery(
Arterial bleeders may have to be temporarily clamped, while venous bleeding is
easily stopped by packing a swab into the wound. Suturing the episiotomy usually
.stops the venous bleeding but arterial bleeders need to be tired off
REPAIRING AN EPISIOTOMY
.F PREPARATIONS FOR REPAIRING AN EPISIOTOMY-9
This is an uncomfortable procedure for the patient. Therefore, it is essential to .1
.explain to her what is going to be done
.The patient should be put into the lithotomy position if possible .2
It is essential to have a good light that must be able to shine into the vagina. A .3
.normal ceiling light usually is not adequate
Good analgesia is essential and is usually provided by local anaesthesia which .4
is given before the episiotomy is performed. As 20 ml of 1% lignocaine may be
safely infiltrated, 5-10 ml usually remains to be given in sensitive areas. An
.episiotomy should not be sutured until there is good analgesia of the site
In order to prevent blood which drains out of the uterus from obscuring the .5
episiotomy site, a rolled pad or tampon should be carefully inserted into the
vagina above the episiotomy wound. As this is uncomfortable for the patient, she
.should be reassured while this is being done
85
Absorbable suture material should be used for the repair. Two packets of .6
chromic 0 are required. One on a round (taper) needle for the vaginal epithelium
and muscles, and 1 on a cutting needle for the skin. With larger episiotomies 2
packets on a round needle may be needed. Non-absorbable suture material such
as nylon and dermalon are very uncomfortable and should not be used.
.Remember that the patient has to sit on her wound
86
.There are 4 important steps in the repair of an episiotomy wound
:STEP 1
Place a suture (stitch) at the apex (the highest point) of the incision in the vaginal
epithelium. Then insert 1 or 2 more continuous sutures in the vaginal epithelium.
Do not complete suturing the vaginal epithelium when the episiotomy is large or
deeply cut but leave this suture and do not cut it. When placing the suture at the
.apex be very careful not to prick your finger with the needle
.Figure 9-D. Suturing the vaginal epithelium
:STEP 2
Insert interrupted sutures in the muscles. Start at the apex of the wound. The
aim is to bring the muscles together firmly and to eliminate any "dead space", i.e.
87
any spaces between the muscles where blood can collect. Remember that the
.sutures must be inserted at 90 degrees to the line of the wound
point of the needle is seen when crossing from the one side to the other of the
deepest part of the wound, the stitch will not be too deep. “Figure 8” stitches
(double stitches) are used to suture the muscle layer. When the muscles have
been correctly sutured the cut edges of the vaginal epithelium and the skin
:should be lying close together. The markers for correct alignment are
.The remains of the hymen .1
The junction of the skin and the vaginal epithelium. The skin is recognized by .2
.the darker pigmentation
.Figure 9-F. The correct position of the skin and vaginal epithelium
88
:STEP 3
Return to the vaginal epithelium and complete the continuous catgut suture,
ending at the junction with the skin. Do not pull the sutures tight as they only
.need to bring the edges of the vaginal epithelium together
:STEP 4
Use interrupted sutures with an absorbable suture material to repair the perineal
skin. Mattress sutures may be used. Do not pull the sutures tight as they only
need to bring the edges of the skin together. Sutures that are too tight become
.uncomfortable for the patient
89
Get the patient out of the lithotomy position and make sure that she is .4
.comfortable
90
Clinical Learning Guide
STEP / TASK
Getting Ready
1. Prepare the necessary equipment.
2. Tell the woman (and her support person) what is going to be done,
and aspirate by drawing the plunger back slightly to make certain the
anesthetic substance to all layers and over the whole length to the
beneath the skin of the perineum and into the perineal muscle.
8. Wait 2 minutes and then pinch the incision site with forceps. (If the
woman feels the pinch, wait 2 more minutes and then retest).
1. Wait to perform episiotomy until crowning where the head distending
the vulva and does not recede back in contractions and the perineum
91
STEP / TASK
5. If delivery of the head does not follow immediately, apply pressure to
minimize bleeding.
6. Control delivery of the head to avoid extension of the episiotomy.
Repair of episiotomy
1. Ask the woman to position her buttocks toward the lower end of the
vaginal incision.
10. Continue the suture to the level of the vaginal opening.
11. At the opening of the vagina, bring together the cut edges.
12. Bring the needle under the vaginal opening and out through the
working from the top of the perineal incision downward (in 2 layers if
deep incision).
14. Use interrupted or subcuticular sutures to bring the skin edges
together.
15. Clean with a disinfectant then place a clean pad on the woman’s
perineum.
Post Procedure
1. Before removing gloves, dispose waste materials in a leak-proof
decontamination.
3. Decontaminate or dispose of syringe and needle:
92
STEP / TASK
0.5% chlorine solution and submerge in solution for 10 minutes for
decontamination.
container.
4. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves
bag.
5. Wash hands thoroughly with soap and water and dry with a clean dry
93
Repair of lower genital lacerations
Introduction
Anaesthesia is not required for most cervical tears. For tears that are high and
extensive, give pethidine and diazepam IV slowly (do not mix in the same
Gently grasp the cervix with ring or sponge forceps. Apply the forceps on both
sides of the tear and gently pull in various directions to see the entire cervix.
Close the cervical tears with continuous 0 chromic catgut (or polyglycolic) suture
starting at the apex (upper edge of tear), which is often the source of bleeding.
If a long section of the rim of the cervix is tattered, under-run it with continuous
If the apex is difficult to reach and ligate, it may be possible to grasp it with
artery or ring forceps. Leave the forceps in place for 4 hours. Do not persist in
attempts to ligate the bleeding points as such attempts may increase the
bleeding. Then:-
A laparotomy may be required to repair a cervical tear that has extended deep
94
B) Repair of vaginal and perineal tears
There are four degrees of tears that can occur during delivery:
• First degree tears involve the vaginal mucosa and connective tissue.
• Second degree tears involve the vaginal mucosa, connective tissue and
underlying muscles.
95
• Apply antiseptic solution to the area around the tear.
• Infiltrate beneath the vaginal mucosa, beneath the skin of the perineum and
deeply into the perineal muscle using about 10 mL 0.5% lignocaine solution.
o Note: Aspirate (pull back on the plunger) to be sure that no vessel has
the needle. Recheck the position carefully and try again. Never inject if blood
lignocaine occurs.
• At the conclusion of the set of injections, wait 2 minutes and then pinch the
area with forceps. If the woman feels the pinch, wait 2 more minutes and
then retest.
o Start the repair about 1 cm above the apex (top) of the vaginal tear. Continue
o At the opening of the vagina, bring together the cut edges of the vaginal
opening;
o Bring the needle under the vaginal opening and out through the perineal tear
and tie.
96
• Repair the perineal muscles using interrupted 2-0 suture. If the tear is deep,
• Repair the skin using interrupted (or subcuticular) 2-0 sutures starting at the
vaginal opening.
• If the tear was deep, perform a rectal examination. Make sure no stitches are
in the rectum.
97
REPAIR OF THIRD AND FOURTH DEGREE PERINEAL TEARS
Note: The woman may suffer loss of control over bowel movements and gas if a
torn anal sphincter is not repaired correctly. If a tear in the rectum is not
repaired, the woman can suffer from infection and rectovaginal fistula (passage of
- Feel the surface of the rectum and look carefully for a tear.
• Apply antiseptic solution to the tear and remove any faecal material, if
98
present.
• Repair the rectum using interrupted 2-0 or 3-0 sutures 0.5 cm apart to bring
• Remember: Place the suture through the muscularis (not all the way through
the mucosa).
• Cover the muscularis layer by bringing together the fascial layer with
interrupted sutures;
o Grasp each end of the sphincter with an Allis clamp (the sphincter retracts
when torn). The sphincter is strong and will not tear when pulling with the
clamp;
o Repair the sphincter with two or three interrupted stitches of 2-0 suture.
99
• Apply antiseptic solution to the area again.
• Examine the anus with a gloved finger to ensure the correct repair of the
POST-PROCEDURE CARE
100
Clinical Learning Guide
STEP / TASK
Getting Ready
1. Prepare the necessary equipment.
2. Tell the woman (and her companion) what is going to be
if necessary.
6. Put on personal protective barriers.
7. Wash hands thoroughly with soap and water and dry with
hands.
9. Have an assistant massage the uterus.
Assessment of the degree of the tear
1. Examine the tear, if the tear is long and deep through the
degree tear:
sphincter.
Tear.
2. Immerse both gloved hands in 0.5% chlorine solution.
101
STEP / TASK
4. Apply antiseptic solution to the areas around the tear.
Injecting local anesthetics
1. Draw 10 ml of 0.5% Lignocaine (Bupivacaine) solution
perineal muscle.
Repair
1. Place the first suture about 1 cm above the top (the apex)
(an oblique tear will lead to one edge being longer than
102
STEP / TASK
1. Before removing gloves, dispose waste materials in a
103
Repair of a third and fourth degree
perineal tear
104
LEARNING GUIDE
PERINEAL TEARS
STEP/TASK
Getting ready
1. Prepare the necessary equipment.
2. Tell the woman (and support person) what is going to be done,
concerns.
3. Provide continual emotional support and reassurance, as
feasible.
4. Ask about allergies to antiseptics and anesthetics.
necessary.
6. Put on personal protective barriers.
Repair the tear
1. Wash hands thoroughly with soap and water and dry with a
hands.
3. To see if the anal sphincter is torn:
tear.
Immerse both gloved hands in 0.5% chlorine solution.
decontamination.
105
STEP/TASK
4. Wash hands thoroughly with soap and water and dry with a
0.5 cm apart:
working.
9. If the sphincter is torn:
sutures.
14. Apply antiseptic solution to the area again.
15. Examine the anus with a gloved finger to ensure correct
both hands.
106
STEP/TASK
19. Repair the vaginal mucosa, perineal muscles and skin (see
Perineal Tears).
Post-procedural tasks
1. Before removing gloves, dispose of waste materials in a
for decontamination.
107
Repair of a cervical tear
108
LEARNING GUIDE: REPAIR OF CERVICAL TEARS
STEP/TASK
Getting ready
1. Prepare the necessary equipment.
2. Tell the woman (and her support person) what is going to be
and concerns.
3. Provide continual emotional support and reassurance, as
feasible.
4. Have the woman empty her bladder or insert a catheter, if
necessary.
5. Give anesthesia (IV pethidine and diazepam, or ketamine), if
necessary.
6. Put on personal protective barriers.
Repairing cervical laceration
1. Wash hands thoroughly with soap and water and dry with a
hands.
3. Have an assistant shine a light into the vagina.
4. Clean the vagina and cervix with antiseptic solution.
5. Have the assistant massage the uterus and provide fundal
pressure.
6. Insert a ring or sponge forceps into the vagina and grasp the
toward you.
9. Place the first suture at the top (the apex) of the tear.
109
STEP/TASK
10. Close the tear with a continuous suture:
remove.
for decontamination.
110
Bimanual compression of the Uterus
111
Introduction
112
Learning Guide
STEP / TASK
Getting Ready
1. Tell the woman (and her support person) what is going to be done, listen
against the posterior wall of the uterus and compress the uterus between
both hands.
8. Maintain compression until bleeding is controlled and the uterus
contracts.
Post Procedure
1. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by
113
Postpartum assessment and care
114
Clinical Learning Guide
STEP / TASK
Getting Ready
1. Make sure that the clinic is ready: clean, tidy and equipment is
ready.
2. Wash and dry your hands.
3. Greet the lady, introduce yourself and offer her a seat.
4. Explain what you are going to do to your client, obtain consent and
• Neonatal outcome
• Bleeding
• Fever
• Color of discharge
• Abdominal pain
• Breast tenderness
and delivery)
115
STEP / TASK
2. Each pregnancy (if ended in delivery)
abnormal behavior
2. Take pulse, blood pressure and temperature
3. Examine the head and neck for pallor
4. Breast examination for
• Visible lumps.
• Abnormal discharge.
• Palpate for the size of the uterus and tenderness over it.
6. Vaginal examination
and urine or stool leaking from the vagina. Notice the amount, color
116
STEP / TASK
Advise her about general personal hygiene, perineal hygiene and warn
• Exclusive breastfeeding
• Positions
• Bleeding
• Fever
• Color of discharge
• Abdominal pain
• Breast tenderness
card.
117
Gynecology
118
CASE SHEET IN GYNECOLOGY
119
Introduction
Nnnnnnnnnnnnnnnn 8.7.08
120
Case sheet in gynecology
History
PERSONAL HISTORY
Name:
Age:
Residence
Occupation:
Marital status:
Special habits:
Husband's name:
Age:
Occupation:
MENSTRUAL HISTORY
Age of menarche:
Regularity:
P/C:
Inter-menstrual bleeding/discharge:
PMS
121
OBSTETRIC HISTORY
Gravid , Para +
Abortions
LD LA
PRESENT HISTORY
Onset
Course
Characters
Therapeutic history
PAST HISTORY
Past surgeries
FAMILY HISTORY
Diabetes
Hypertension
Breast/ovarian cancer
122
Examination
General Examination:
- Pulse: ____/min.
- Temp. ____ °C
- Weight:___ Kg
- Breasts:
- Lower Limbs:
Abdominal Examination:
Inspection:
Superficial palpation
Deep palpation
Percussion
Auscultation
Pelvic Examination:
1- Inspection
- Vulva:
Labia majora
Labia minora
Clitoris
Urethra
123
Skene glands
Bartholin glands
Special comments
2- Palpation
- Vagina
- Cervix
3- Bimanual Palpation
- Uterus
- Adnexa
4- Speculum examination
Rectal examination
Diagnosis:
G ____, P____,
124
Clinical learning guide
Gynecologic History
STEP / TASK
Getting Ready
1. Prepare the client care area, necessary supplies and equipment.
2. Wash and dry hands.
3. Greet the woman and her companion respectfully and with kindness,
grandmultipara)
2. Special habits: including dietary habits, Exercise, Hygienic, recreational
habits.
3. Husband's name, Age, Occupation and Special habits of medical
importance
Complaint and duration
1. Record in the patient's own words and arrange in a chronological order.
Menstrual history
1. Age of menarche.
2. Rhythm:
• Days/Cycle
• PMS
accurately).
Obstetric history
1. Gravidity and parity.
2. Record each pregnancy separately and analyze it.
3. Record each abnormal delivery separately and analyze it.
4. Record the date of last delivery/last abortion.
5. Record number of living children.
6. Record if there were dead children & cause of death.
Present history
Analysis of the complaint: This is variable according to each case but it
125
STEP / TASK
follows the general rules below…
1. Onset.
2. Course, duration.
3. Characters, severity.
4. Associated symptoms (to detect causes / complications).
5. Effects on the patient (complications and quality of life).
6. Symptoms of other systems related to her condition specially urinary
supplements.
8. Investigations done for the patient and their results and the treatments
endemic diseases.
Contraceptive history
1. Including recent methods.
2. Duration of use.
3. Cause of discontinuation if any.
Family history
1. Record if there is a family history of diabetes mellitus or Hypertension.
2. Record if there is a family history of similar condition.
3. Record if there is a family history of Breast / ovarian cancer.
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127
Breast examination
128
Clinical learning guide
Breast Examination
STEP/TASK
Getting ready
1. Greet the woman respectfully and with kindness
2. Tell the woman you are going to examine her breasts and explain the
procedure to her.
3. Ask the woman to undress from her waist up. Have her sit on the
• Shape
• Size
• Dimpling or bulging
2. Inspect the nipples and note size, shape and direction in which they
presses her hands on her hips or the palms together in front of the
surface of the index, middle and ring fingers using light medium and
the nipple to the outer edge (the spiral technique),. Note any lumps
129
9. Repeat steps 4 to 8 for the right breast. If necessary repeat
procedure with the woman is sitting up or standing and with her arms
at her sides. This may disclose a lesion not palpated in the supine
position.
10.The tail of the breast, the axillary and supraclavicular lymph nodes
Supporting the ipsilateral arm of the side being examined allows full
relaxation so that the nodes deep within the axilla can be palpated.
normal, tell the woman everything is normal and healthy and when
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Abdominal examination in Gynecology
131
Clinical learning guide
Abdominal examination
STEP/TASK
1. Greet the patient respectfully and with kindness.
2. Explain the procedure to the patient.
3. Ask the patient to undress from the nipple line to the mid-thigh.
hands.
5. Exposure: uncover the patient from the nipple line to just below
with the legs extended. You may also ask the patient to flex the
hips to 45° and the knees to 90° in order to relax the abdominal
muscles.
Inspection
1. Look from both ends of the bed
2. Look from both sides
3. Look tangentially (get down to your knees to have the eyes at
Breasts
Palpation
1. Stand by the right side of the patient (unless you are left handed)
132
3. Instruct the patient to:
muscles
Tenderness:
expiration
Swelling:
or extra abdominal)
Try to reach the lower border of the mass , if you can insinuate your fingers
Hernia orifices:
Examine the anatomical sites of hernia for swelling and any expansile
133
Dilated veins:
Determine the direction of the flow by placing two fingers on the vein,
sliding one finger along the vein to empty it and then releasing one finger
Place your right hand on the right iliac fossa in one of the
following positions:
patient
right costal margin till you palpate lower border of the right
Put your hand in the midline and repeat the above steps till
you palpate the lower border of the left lobe of the liver.
and the other hand at the back. Ask the patient to hold her
Start palpation from the right iliac fossa with the tips of the
The left hand is placed over the lateral aspect of the left
134
Follow the rules of palpation moving toward the left
135
Spleen
Ask the patient to place the fist of the left hand under the
Put your left hand behind the patient's right loin (between the
Put the right hand on the right lumbar region just above the
deep breath.
During expiration push your right hand deeply but gently and
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• Parietal swellings:
sternocostal junction
Percuss down along each inter-costal space in the MCL and
when you reach the dullness ask the patient to take a deep
Area defined by the anatomical apex (5th ICS in MCL), left sixth
and eighth ribs superiorly, the left midaxillary line (9th, 10th&11th
137
Percussion for the lateral edge of the fluid
opposite side,
dullness is negative)
Intestinal sounds
Bruits
Venous hum
Rub
Succession splash
Scratch sign
EXAMINATION OF THE BACK
138
Palpate for tenderness over vertebrae
Percuss the upper border of the fluid, placing your hand transversely in
the epigastrium (resonant) and move towards the symphysis pubis till
Percuss the lateral edge of the fluid, placing your fingers parallel to the
Place one hand flat over the lumbar region on one side
Get the patient (or assistant) to put the hand in the midline of the
abdomen
METHOD
Place your hand in the right hypochondrium and push the abdominal wall
139
140
Female Genital Examination
141
Examination of the female genitalia
General
The examination should take place in a well lit environment, a wall or floor
The room should be warm and the couch should have a sheet for lying on
The procedure should be fully explained to the patient, who should be asked to
Only expose as much of the patient as is needed and cover the lower abdomen
The patient should be in a supine position with the hips and knees flexed and
Steps
I) Inspection
Ask the patient to strain down and observe for any bulging or prolapse
Ask the patient to cough and observe for any leakage of urine
II) Palpation
Internal examination
• Insert index finger into the vagina at the lower edge and feel at base of
• Using finger and thumb, palpate each side for swelling or tenderness.
142
Gently introduce the lubricated right index finger, followed by the middle finger
Cervix will be felt as a semi-hard dome with a dimple in the middle (the
external os)
The normal cervix is mobile and movement does not cause pain.
Apply upward pressure on the cervix and uterus by pressing in either the
Fingers of abdominal hand are applied flat to abdominal wall below umbilicus
Use lateral surface of the index finger of the abdominal hand to detect
To palpate this you may have to place your finger tips above the pubis and
The uterus should be assessed for size, shape, mobility and consistency as well
Ovaries are not always palpable in patients unless enlarged or patient is thin
Ovaries are firm, ovoid in shape (like an olive) and approximately 2-3cms in
length.
Place the fingers of your abdominal hand over the iliac fossa whilst readjusting
Gently but firmly appose the fingers of either hand by pressing the abdominal
hand inward and downward, and the vaginal fingers upward and laterally
143
Feel for adnexal structures as the interposed tissues slip between your fingers.
If adnexal structures are felt describe the Size, shape, consistency, mobility and
tenderness
Rotate your examining hand back to the midline before removing your fingers
Offer the patient tissues to wipe any excess lubricant etc. away. (If patient
unable to, ensure you explain what you are doing before you are doing this for
the patient)
Remove gloves from at least one hand before covering the patient up (to avoid
144
Learning guide
Vaginal Examination
Getting ready
1. ask her if the bladder is empty
2. Adjust the position of the patient so that she lies in the full dorsal
area
4. Put on gloves
5. Explain the procedure to the patient
Inspection
Separate the labia majora gently with the index finger and thumb of
and the thumb on the perineum at about 5 and 7 o’clock and gently
introitus
Hold the closed blades of the bivalve speculum between the index and
middle fingers of the right hand and place the thumb on the upper
145
Place the tip of the speculum at the vaginal introitus and gently
advance the blades of the speculum into the vagina bearing in mind its
vagina
Bimanual palpation
Apply a water soluble jelly to the index and middle fingers of the right
gloved hand
Separate the labia majora with the index finger and thumb of the left
only insert the middle finger as the patient relaxes the muscles around
the vagina and when it is clear that a two finger examination is possible
and cervix
look for any unusual growths, the size, position, direction, consistency,
(the position and direction of the cervix indicates whether the uterus is
anteverted or retroverted)
Place the vaginal fingers in front of the cervix in the anterior fornix and
move the cervix as far backwards to rotate the fundus downwards and
forwards
Place the palmer surface of the fingers of the left hand (abdominal
hand) just below the umbilicus and gradually move it lower until the
fundus is caught and pressed against the fingers in the anterior fornix
To palpate the uterus gently move the fingers of the abdominal hand
146
Palpate the right and left adnexa by placing the vaginal fingers in the
respective lateral fornix and gradually lower the abdominal hand toward
pressure or movement
Place the fingers of the vaginal (right) hand in the posterior fornix and
canal and the left hand on the lower abdomen and proceed as in the
finger of the same hand in the rectum and palpate the intervening
tissue.
Inspect glove for blood or abnormal discharge
Take off glove and properly dispose of it
Wash the hands thoroughly with soap and water and dry with clean
towel
Enter the results of the examination into the patient’s record
N.B. Left handed examiners may switch hands
147
VAGINAL EXAMINATION: PICTURES
148
149
Preparing and interpreting a vaginal smear
150
Clinical Learning Guide
STEP / TASK
Client Assessment
1. Greet the woman respectfully and with kindness.
2. Explain why the vaginal smear is recommended and
discharge.
2. Palpate Skene's and Bartholin's glands.
3. Insert dry sterile speculum according to its specific learning
151
STEP / TASK
5. Move the light source so that you can see the cervix and
vagina clearly.
6. Samples of fluid inside the vagina are then collected with
spores.
Vaginal pH.
Put sample of vaginal discharge on a slide.
Test the normal vaginal pH (3.8 to 4.5) by litmus paper.
Bacterial vaginosis , trichomoniasis, and atrophic vaginitis
record.
5. Discuss the results with the woman and answer any
questions.
152
STEP / TASK
6. If the test is negative, tell her when to return for repeat
the testing.
7. After counseling, provide treatment or refer if the test is
153
Visual inspection of the cervix using
Acetic acid
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Clinical Learning Guide
CLIENT ASSESSMENT
1. Greet the woman respectfully and with kindness.
2. Explain why the VIA test is recommended and describe the procedure.
3. Tell her what the findings might be and why follow-up or treatment might be
necessary.
GETTING READY
1. Check that the instruments and supplies are available.
2. Ensure that the light source is available and ready to use.
3. Check that the woman has emptied her bladder and washed and rinsed her
full dorsal position with her buttocks at the edge of examination table and drape
her.
6. Wash hands thoroughly with soap and water and dry with clean, dry cloth or
remain in place with the cervix in view. If using outer glove, immerse this hand
in 0.5% chlorine solution and remove the glove by turning it inside out. Place it
ulcers.
7. Use a clean cotton swab to remove any discharge, blood or mucus from the
zone.
155
9. Soak a clean swab in dilute acetic acid and apply it to the cervix. Dispose of
change to appear.
11. Inspect the SCJ carefully.
• Look for any raised and thickened white plaques or aceto-white epithelium.
12. As needed, reapply acetic acid or swab the cervix with a clean swab to
plastic bag.
13. When visual inspection has been completed, use a fresh swab to remove any
remaining acetic acid from the cervix and vagina. Dispose of swab in a leak-
If the VIA test was positive, place speculum on high-level disinfected tray or
container.
15. Perform the bimanual examination and rectovaginal examination (if
indicated).
POST-VIA TASKS
1. Wipe light source with 0.5% chlorine solution or alcohol.
2. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by
air dry.
4. If VIA test is negative, ask woman to sit up, get down from the examining
156
Contraception
157
Contraceptive counseling
158
The Elements of Counseling
GATHER describes the 6 elements of counseling about family planning and other
G: Greet Patients
• Be polite, friendly, and respectful: greet patients, introduce yourself, and offer
them seats.
• Tell patients that you will not tell others what they say.
• Ask patients about their reasons for coming and how you can help.
• Help patients express their feelings, needs, and wants, as well as any doubts,
concerns, or questions.
• Ask patients about their experience with the reproductive health matter that
concerns them.
• Keep questions open, simple, and brief. Look at your client as you speak.
• Ask patients what they want to do. Listen actively to what the client says.
159
• Help patients to understand their possible choices.
o Ask which methods interest them. If no medical reason prevents it, patients
o Mention other available methods that might interest the client now or later.
• Tell patients that the choice is theirs. Offer advice as a health expert, but avoid
• To help patients choose, ask them to think about their plans, family situations,
o “Do you or your partner have sex with anyone else?” (To gauge STD risk)
• Ask whether the client wants anything made clearer, and reword and repeat
information as needed.
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• Explain that some family planning methods may not be safe for patients with
Once a client states a choice, ask about these conditions. If a method would not
• Check whether the client has made a clear decision. Specifically ask, “What
E: Explain What to Do
• If the method or services cannot be given at once, tell the client how, when,
• For sterilization, the client may have to sign a consent form. Help the client to
• Explain how to use the method or how to follow other instructions. As much as
• Explain when to come back for routine follow-up or more supplies, if needed.
• Tell patients to come back whenever they wish, if side effects bother them, or if
161
• Ask whether the client has any questions or anything to discuss. Treat all
concerns seriously.
• Ask whether any health problems have come up since the last visit. Determine
• Determine whether the client might need STD protection now. If a client is not
satisfied with a temporary family planning method, ask whether she/he wants to
try another method. Help the client choose, and explain how to use, the method.
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Clinical Learning Guide
Contraceptive counseling
Getting Ready
1. Greet the woman respectfully and with kindness.
of each].
concerns.
• Do not decide for her but rather help her to express herself.
4. Explain the procedure / method in full details.
5. Repeat the instructions:
• Discuss the need for return and follow up either routine or if she
163
Medical eligibility checklists for
contraceptive use
164
Checklist of questions asked to women who want to use Combined Oral
Contraceptive Pills
Ask the client the questions below. If she answers NO to ALL of the
instructions.
No Yes _Urge her to stop smoking. If she is 35 or older and will not stop
smoking, do not provide COCs. Help her choose a method without estrogen.
No Yes _If you cannot check blood pressure (BP) and she reports high
BP, do not provide COCs. Refer for BP check if feasible or help her choose a
method without estrogen. If no report of high BP, you can provide COCs.
Check BP:
COCs. Help her choose another method. (One BP reading in the range of 140–
159/90–99 is not enough to diagnose high BP. Offer condoms or spermicide for
use until she can return for another BP check, or help her choose another method
if she prefers. If BP reading at next check is below 140/90, she can use COCs and
100 or higher, she also should not use DMPA or NET EN.
165
No Yes _Can provide COCs now with instruction to start when she stops
If she is not fully or almost fully breastfeeding, also give her condoms or
spermicide to use until her baby is 6 months old. Other effective methods are
better choices than COCs when a woman is breastfeeding, whatever her baby’s
age.
4. Do you have serious problems with your heart or blood vessels? Have
No Yes _Do not provide COCs if she reports heart attack or heart disease due to
blocked arteries, stroke, blood clots (except superficial clots), severe chest pain
with unusual shortness of breath, diabetes for more than 20 years, or damage to
vision, kidneys, or nervous system caused by diabetes. Help her choose another
effective method.
No Yes _ Do not provide COCs. Help her choose a method without hormones.
No Yes _Perform physical exam or refer. If she has serious active liver disease
(jaundice, painful or enlarged liver, active viral hepatitis, liver tumor), do not
that cause nausea and are made worse by light and noise or moving
166
No Yes _If she is 35 or older, do not provide COCs. Help her choose another
method. If she is under age 35, but her vision is distorted or she has trouble
speaking or moving before or during these headaches, do not provide COCs. Help
her choose another method. If she is under age 35 and has migraine headaches
without distortion of vision or trouble speaking or moving, she can use COCs.
8. Are you taking medicine for seizures? Are you taking rifampin
(rifampicin) or griseofulvin?
with COCs or, if she prefers, help her choose another effective method if she is on
long-term treatment.
No Yes _Assess whether pregnant (see page 4–6). If she might be pregnant, also
give her condoms or spermicide to use until reasonably certain that she is not
10. Do you have gallbladder disease? Ever had jaundice while taking
COCs?
Planning surgery that will keep you from walking for a week or more?
No Yes _If she has gallbladder disease now or takes medicine for gallbladder
disease, or if she has had jaundice while using COCs, do not provide COCs. Help
her choose a method without estrogen. If planning surgery or just had a baby,
can provide COCs with instruction on when to start them later. Be sure to explain
the health benefits and risks and the side effects of the method that the client will
167
use. Also, point out any conditions that would make the method inadvisable when
168
Checklist of questions asked to women who want to use Progestin-Only
Oral Contraceptives
Ask the client the questions below. If she answers NO to ALL of the questions,
then she CAN use progestin-only pills (POP) if she wants. If she answers YES to a
No Yes _ Do not provide POCs. Help her choose a method without hormones.
No Yes _ Perform physical exam or refer. If she has serious active liver disease
(jaundice, painful or enlarged liver, viral hepatitis, liver tumor), do not provide
POCs. Refer for care. Help her choose a method without hormones.
No Yes _ Can give her POCs now with instructions on when to start—when the
4. Do you have serious problems with your blood vessels? If so, what
problems?
No Yes _ Do not provide POPs if she reports blood clots (except superficial clots).
griseofulvin?
169
spermicide to use along with POCs. If she prefers, or if she is on long-term
No Yes _ Assess whether pregnant. If she might be pregnant, also give her
condoms or spermicide to use until reasonably sure that she is not pregnant.
Then she can start POCs. Be sure to explain the health benefits and risks and the
side effects of the method that the client will use. Also, point out any conditions
that would make the method inadvisable when relevant to the client.
170
Checklist of questions asked to women who want to use DMPA
Injectables
Ask the client the questions below. If she answers NO to ALL of the
questions, then she CAN use DMPA. If she answers YES to a question
No Yes _ She can start using DMPA beginning 6 weeks after childbirth. If she is
fully or almost fully breastfeeding, however, she is protected from pregnancy for 6
first. Then she must begin contraception at once to avoid pregnancy. Encourage
2. Do you have problems with your heart or blood vessels? Have you ever
No Yes _ Do not provide DMPA if she reports heart attack, heart disease due to
stroke, blood clots (except superficial clots), severe chest pain with unusual
shortness of breath, severe high blood pressure, diabetes for more than 20
No Yes _
Check BP
If systolic BP below 160 and diastolic BP below 100, okay to give DMPA. If
systolic
171
BP over 160 or diastolic BP over 100, do not provide DMPA. Help her choose
No Yes _ Do not provide DMPA. Help her choose a method without hormones.
No Yes _ Perform physical exam or refer. If she has serious active liver disease
(jaundice, painful or enlarged liver, viral hepatitis, liver tumor), do not provide
DMPA. Refer for care. Help her choose a method without hormones.
No Yes _ Assess whether pregnant (see page 4–6). Give her condoms or
spermicide to use until reasonably sure that she is not pregnant. Then she can
start DMPA.
No Yes _ If she is not likely to be pregnant but has unexplained vaginal bleeding
that suggests an underlying medical condition, can provide DMPA. Assess and
treat any underlying condition as appropriate, or refer. Reassess DMPA use based
on findings.
Be sure to explain the health benefits and risks and the side effects of the method
that the client will use. Also, point out any conditions that would make the
172
Checklist of questions asked to women who want to use Copper-Bearing
IUCDs
Ask the client the questions below. If she answers NO to ALL of the
questions, then she CAN use an IUD if she wants. If she answers YES to a
No Yes _ Assess whether pregnant (see page 4–6). Do not insert IUD. Give her
condoms or spermicide to use until reasonably sure that she is not pregnant.
2. In the last 3 months have you had vaginal bleeding that is unusual for
medical condition, do not insert IUD until the problem is diagnosed. Evaluate by
history and during pelvic exam. Diagnose and treat as appropriate, or refer.
No Yes _ Delay inserting an IUD until 4 or more weeks after childbirth. If needed,
No Yes _ If she has puerperal sepsis (genital tract infection during the first 42
days after childbirth), do not insert IUD. Refer for care. Help her choose another
effective method.
inflammatory disease (PID) in the last 3 months? (ask about pain in lower
173
abdomen and possibly also abnormal vaginal discharge, fever, or frequent
urination with burning.) If she has no tenderness in the abdomen or when the
cervix is moved, however, she probably does not have pelvic infection.
No Yes _ Do not insert IUD now. Urge her to use condoms for STD protection.
Refer or treat client and partner(s). IUD can be inserted 3 months after cure
No Yes _ Do not insert IUD. Treat or refer for care as appropriate. Help her
Be sure to explain the health benefits and risks and the side effects of the method
that the client will use. Also, point out any conditions that would make the
174
Intrauterine contraceptive Device
175
Clinical Learning Guide
IUCD insertion
STEP / TASK
Pre-Insertion Counseling
1. Greet the woman respectfully and with kindness.
2. Ask woman about her reproductive goals and need for
to performing procedure.
4. Determine that the woman's contraceptive choice is the
IUD.
5. Review the woman Screening Checklist to determine if the
lady?
6. Assess woman's knowledge about the IUD's major side
effects.
IUD.
8. Describe insertion procedure and what to expect.
176
STEP / TASK
Pre-insertion counseling
1. Obtain or reviews brief reproductive health history.
2. Check that the woman has recently emptied her bladder
uterus.
7. Insert the Copper T 380A IUD using the withdrawal
technique.
8. Cut IUD strings to 3-4 cm in length.
9. Gently remove Tenaculum and speculum and places in
decontamination.
Post-procedure tasks
1. Before removing gloves, place all instruments in 0.5%
plastic bag.
177
STEP / TASK
• Immerse both gloved hands in 0.5% chlorine solution and
effects or problems.
3. Provide follow up visit instructions and answer any
questions.
4. Assure the woman that she can have the IUD removed at
any time.
5. Observe the woman for at least 15 to 20 minutes before
178
Clinical Learning Guide
IUCD removal
STEP / TASK
Pre-Removal Counseling
1. Greet the woman respectfully and with kindness.
2. Ask the woman her reason for removal and answers
any questions.
3. Review the woman's reproductive goals and need for
strings.
7. Apply antiseptic solution two times to the cervix,
decontamination.
2. Dispose of waste materials in leak proof container or
plastic bag.
3. Immerse both gloved hands in 0.5% chlorine
179
STEP / TASK
• If disposing of gloves, place in leak-proof container or
plastic bag.
method, if desired.
3. Help the woman obtain new contraceptive method or
180
Implanon insertion and removal
181
Clinical Learning Guide
Implanon Insertion
Getting ready
2. Ask woman about her reproductive goals and need for protection
against STDs.
Insertion
1. Check to be sure that client has thoroughly washed and rinsed her
questions.
solution, and the sterile cloth (Optional) and marker pen (Optional) are
available.
4. Allow the client to lie on her back with the non dominant arm turned
outward and bent at the elbow. Place clean, dry cloth under her arm pen
(Optional).
5. Mark position on arm for insertion of the implant at the inner side of
the upper arm 6-8 cm above the elbow crease. You can use the groove
182
between the biceps and triceps.
skin; by advancing the needle about 4 cm under the skin and injects 1-2
11. Checks for anesthetic effect before introducing the applicator needle.
12. Remove the sterile disposable applicator carrying the Implanon from
its blister
13. Visually Verify the presence of the implant inside the metal part of
the cannula. If the implant protrudes from the needle, return it to its
original position by tapping against the plastic part of the cannula. Make
14. Hold the applicator with the needle pointed upward until insertion, to
15. Stretch the skin around the insertion site with thumb and index.
Introduce the needle in the space between the biceps and triceps
directly under the skin and as superficial as possible, slightly angled and
16. While lifting the skin with the tip of the needle, advance the needle
17. While the cannula is kept parallel to the skin surface, break the seal
of the applicator and turn the obturator 90° with respect to the cannula.
19. With your free hand slowly pull the cannula out of the arm with the
183
injection where the plunger is pushed and the syringe is fixed. And it is
22. Before removing gloves, fill or flush needle and syringe with 0.5%
chlorine solution and places all instruments in 0.5% chlorine solution for
10 minutes.
plastic bag.
turning inside out and place in leak proof container or plastic bag.
26. Complete client record, including the insertion side and any difficulty
Post-insertion care
emphasis the need to keep the removal area dry for 24 hours, and
4. Assure client that she can have Implant removed at any time if she
desires.
184
Clinical Learning Guide
Implanon Removal
PREREMOVAL COUNSELING
2. Ask client her reason for removal and answers any questions.
3. Review client's present reproductive goals and asks if she wants another set of
Norplant implants.
Getting Ready
1. Check to be sure client has thoroughly washed and rinsed her entire arm.
2. Tell client what is going to be done and encourages her to ask questions.
3. Position woman's arm and palpates Implant to determine point for removal
incision. Ask the client to bend her arm to make palpation easier. Do not start the
procedure if the implant has not been located and consult a senior physician.
This should include Scalpel, 2 forceps, sterile gloves, syringes, local anesthetic,
Pre-removal Tasks
6. Put sterile or high-level disinfected gloves on both hands (if gloves are powdered,
9. Inject 0.5 – 1ml of local anesthetic (1% without epinephrine) at the incision site
which is just under the distal end of the Implant. Application above the implant
makes the skin swell, which may cause difficulties in locating the implant.
185
10. Check for anesthetic effect before making skin incision.
REMOVAL:
1. Make a small (2 mm) skin incision in the longitudinal direction of the arm at the
2. Push the implant towards the incision until the tip is visible.
4. Place the removed implant in bowl containing 0.5% chlorine solution for 10 minutes
for decontamination.
A. If the implant is encapsulated, open fibrous sheath over the end with scalpel.
Gently squeezes the end of the implant into the incision, till it "pops out" and remove
it with a forceps.
B. If the tip is not visible, gently insert a forceps into the incision and grasp the
implant and uses a second forceps to dissect tissues around the implant till it pops out
and removed.
Post-removal Tasks
7. Before removing gloves, fill or flush needle and syringe with 0.5% chlorine solution
and place all instruments in 0.5% chlorine solution for 10 minutes for
decontamination.
9. Immerse gloved hands in 0.5% chlorine solution. Remove gloves by turning inside
11. Complete client record. This should include any difficulty in removal and the total
POSTREMOVAL COUNSELING
186
1. Instruct client regarding wound care. The instruction should emphasis the need to
keep the removal area dry for 24 hours, and removal of the covering gauze and
2. Ask the client to makes return visit appointment, if necessary ( as in case of pain or
irritation).
4. Counsel client regarding new contraceptive method, if desired. Emphasis the rapid
method until method of choice can be started. A new implant can be inserted
immediately after removal in the same site using the same removal incision.
187
Annexes
188
The WHO partograph
189
190
WHO Medical eligibility Criteria for starting
contraception
191
Summary table of WHO medical eligibility criteria of FP methods
192
CERVICAL
INTRAEPITHELIAL 2 2 1 2 2
NEOPLASIA (CIN)
CERVICAL CANCER
(awaiting treatment)
2 2 1 2 2
DMPA Subdermal
CONDITION COCs CICs POPs
NET-EN Implants
BREAST DISEASE
a) Undiagnosed mass 2 2 2 2 2
b) Benign breast disease 1 1 1 1 1
c) Family history of cancer 1 1 1 1 1
d) Cancer
(i) current 4 4 4 4 4
(ii) past and no evidence of
3 3 3 3 3
current disease for 5 years
ENDOMETRIAL CANCER
1 1 1 1 1
OVARIAN CANCER
1 1 1 1 1
UTERINE FIBROIDS
a) Without distortion of the
1 1 1 1 1
uterine cavity
b) With distortion of the
1 1 1 1 1
uterine cavity
PELVIC INFLAMMATORY
DISEASE (PID)
a) Past PID (assuming no
current risk factors of
STIs)
(i) with subsequent
1 1 1 1 1
pregnancy
(ii) without subsequent
1 1 1 1 1
pregnancy
b) PID - current or within
1 1 1 1 1
the last 3 months
193
194