Arba Minch University

College of Medicine and

Health Sciences Department
of Midwifery

OB & Gy and Neonatal Nursing

Procedures for Midwifery
Students

Prepared By: Gebremichael Reta Mengistu

(BSc.)

December 21, 2017

Arba Minch University, Arba Minch, Ethiopia
 Lists of Procedures
1. Antenatal assessments and care
2. Post abortion care (MVA)
3. Post abortion family planning counseling
4. IUCD insertion and removal
5. Management of severe pre-eclampsia/eclampsia
6. Assessment of the woman in labor
7. Partographic follow up of labor
8. Medical induction of labor
rd
9. Assisting normal birth ( Including immediate post-partum and newborn care and 3 stage
management)
10. Newborn resuscitation (HBB)
11. Bimanual compression of the uterus
12. Compression of abdominal aorta
13. Manual removal of retained placenta
14. Episitomy and repair
15. Repair of cervical tears
16. Repair of 1st & 2nd degree vaginal & perineal tears
17. Management of breech delivery
18. Management of shoulder dystocia
19. Vacuum assisted vaginal delivery
20. Postpartum assessment and care
21. Newborn assessment

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 1. Antenatal Assessment and Care
This is the procedures you follow when pregnant mothers came to health care center for ANC.
1. Getting Ready

Before going in to any step you must prepare the necessary equipment for the procedure.

Greet the woman respectfully & with kindness, introduce yourself and offer her a seat.

Then do rapid assessment for danger signs, conditions needing emergency treatment.

Tell the woman (and her support person) what is going to be done, listen to her
attentively and respond to her questions and concerns. In addition, you must provide
continual emotional support and reassurance, as possible.
2. History
Identification

Asks her name, age, marital status, address and phone number.
Present Pregnancy (First Visit)

Asks about her menstrual history including last normal menstrual period (LNMP),
calculate the EDD and gestational age correctly.

Asks how many previous pregnancies (gravida), child births (para) including abortions
she has had.

Asks the woman about social support (financial, moral, and physical), also other
problems or concerns related to her pregnancy.

Asks if the woman has felt the fetus move. If yes, asks the woman when the fetus first
moved and whether she has felt it move in the last day.

Asks if the current pregnancy was planned? Wanted? Supported?
Contraceptive History (Fist Visit)
 Inquires about Hx of family planning method use and satisfaction (if used)
 Asks her the number of children she plans to have in the future.
Daily Habits and Lifestyle (First Visit)
Asks the woman:-

For workload and if she get enough sleep/rest?

What she usually eat in a day?

If she sleeps under ITN every day

Do you smoke, drink alcohol or use any other addictive substances?

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 
Who do you live with?

If she has experienced threats, violence or injury.

Past Obstetric History (First Visit)


Asks if the woman had any problem during a previous pregnancy or
during/following childbirth?

Asks if the woman had any problems breastfeeding (if multipara)? And; asks if the
woman is currently breastfeeding.
Medical History (First Visit)

Asks if the woman had any allergies.

Asks if the woman had been tested for HIV and syphilis? If yes, asks if she know the
result. If results were positive for syphilis was treatment provided.

Inquires about history of: - Any chronic illnesses or conditions, hospital admission or any
surgery and whether she takes any drugs/medications.

Asks if the woman had tetanus toxoid (TT) immunizations? If yes, finds out how
many doses and when the last dose was.

Discusses with the woman and her companion about birth preparedness and emergency
readiness plan.
Interim History (Return Visits)

Revises the chart.

Asks if the woman:

o Had any problems since her last visit or at present?

o Had changed her address or lifestyle since last visit and reviews the birth
preparedness and emergency readiness plan, if needed?
o Is she taking drugs/medications (if prescribed) properly?
o Any reactions to or side effects from immunizations or drugs/medications?

Record all the information in the woman’s card/chart. See below.

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 Antenatal Care Checklist

Date: __________ ANC Reg.No: _________ Medical Record Number (MRN):_________

Name of Client: _____________________ Name of Facility __________________________

Woreda: ___________________ Kebele: __________________House No: _____________

Age (Years) _________ LMP____/____/____ EDD ____/____/____

Gravida____ Para _____ Number of children alive_______ Marital Status_____________

INSTRUCTIONS to Fill Classifying form: Answer all of the following questions by placing a cross mark
in the corresponding box.
OBSTETRIC HISTORY No Yes

1. Previous stillbirth or neonatal loss?

2. History of 3 or more consecutive spontaneous abortions?
3. Birth weight of last baby < 2500g
4. Birth weight of last baby > 4000g
5. Last pregnancy: hospital admission for hypertension or pre- eclampsia/eclampsia?
6. Previous surgery on reproductive tract?(Myomectomy, removal of septum, fistula
repair, cone biopsy, CS, repaired rapture, cervical circlage)

CURRENT PREGNANCY No Yes

7. Diagnosed or suspected multiple pregnancy?

8. Age less than 16 years?
9. Age more than 40 years?
10. Isoimmunization Rh (-) in current or in previous pregnancy
11. Vaginal bleeding
12. Pelvic mass 13. Diastolic blood pressure 90mm Hg or more at booking?
GENERAL MEDICAL No Yes

14. Diabetes mellitus

15. Renal disease

16. Cardiac disease

17. Chronic Hypertension
18. Known 'substance' abuse (including heavy alcohol drinking, Smoking)

19. Any other severe medical disease or condition TB, HIV, Ca, DVT..
A "Yes" to any ONE of the above questions (i.e. ONE shaded box marked with a cross) means that the woman is not
eligible for the basic component of the new antenatal care mode and require more close
follow up or referral to specialty care. If she needs more frequent ANC visits use and attach additional
recording sheets

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Danger signs identified ________________ ______________________ ___________________ ____________________
and Investigation: ________________ ______________________ ___________________ ____________________
________________ _______ ___________________ ____________________
________________ _________________ ___________________ ____________________
Action, Advice, ________________ ______________________ ___________________ ____________________
counseling ________________ ______________________ ___________________ ____________________
________________ _______ ___________________ ____________________
________________ _________________ ___________________ ____________________
Appointment for next
_______________ _______________ _______________ _______________
follow-up
Name and Sign of ________________ ______________________ ___________________ ____________________
Health care Provider ________________ ____________ ___________________ ____________________

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Physical Examination
Assessment of General Well-Being (Every Visit)

Observes gait and movements, facial expression, general cleanliness and skin for lesions
& bruises.

Explains to the woman before conducting the examination what is going to done and each
step of the examination responding to her concerns.

Measures body weight (height taken once on the first visit) and vital signs.

If diastolic BP is >90 mmHg. asks her if she has severe headache, blurred vision or
epigastric pain, and check urine for protein.

Ensures that the bladder is empty her before physical examination begins.

Ensures her privacy and confidentiality throughout the examination.

Asks the woman to lie on the examination bed, while helping her on the bed and place a
pillow under her head and neck.

Washes hands thoroughly with soap and water and dry them.

Conducts head to toe assessment, checks the woman’s conjunctiva and palms for pallor
for anemia, face and hands for edema

Inspects the breasts (i.e. contours, skin, nipples, abnormalities) and responds accordingly
in the event of any breast problem
Abdominal Examination (Every Visit)

Asks the woman to uncover her abdomen and lie on her back with her knees slightly
bent.

Inspects abdomen for surgical scars and for size & shape of the abdomen at the same time
asking for fetal movement if more than 20 weeks of gestation
Fetal Lie and Presentation (After 36 weeks)
Fundal Palpation

Measures fundal height gently palpating the abdomen and using the finger method or
measuring tape.

Carries out lateral palpation to determine the side of the fetal back.

Turning and facing the woman’s feet carries out pelvic palpation determine the
presentation observing the woman’s face for signs of pain.
Fetal Heart Beat

6
 
Listens to the fetal heart rate with fetal stethoscope and counts beats for a full
minute, while feeling the woman’s pulse at wrist simultaneously.
Vaginal Examination (First Visit/As Needed)

Asks the woman to uncover her genital area and covers or drapes her to preserve
privacy and prepares her for examination.

Washes hands thoroughly with soap and water and dry them.

Puts new examination gloves on both hands.

Touches the inside of the woman’s thigh before touching genital area.

Looks at perineum, noting scars, lesions, inflammation, or cracks in skin.

Separates labia majora with two fingers, check labia minora, clitoris, urethral opening
and vaginal opening, noting signs of female genital cutting, sores, ulcers, warts, nits,
lice, blood or foul-smelling discharge, urine, or stool coming from vaginal opening.
Palpates the labia minora:
o Looks for swelling, discharge, tenderness, ulcers and fistulas; Feels for irregularities and
nodules.
o Checks Skene’s gland for discharge and tenderness:
o Checks Bartholin’s glands for discharge and tenderness:
o Holding the labia open and asking the woman to bear down checks for abnormal
discharge and bulging of anterior or posterior vaginal walls.
o Immerses both gloved hands in 0.5% chlorine solution and removes gloves by turning
them inside out.
o Washes hands thoroughly with soap and water and drirs them.
o Helps the woman off the examination table.
o Records all relevant findings on the woman’s record/antenatal card
Laboratory Testing
 st
Determines the hemoglobin (1 visit, at about 28 weeks, and as needed): If hemoglobin
is less than 7 g/dL, refers woman to hospital. If hemoglobin is 7-11 g/dL, gives
iron/folate 1 tablet twice daily.

Determines BG & Rh, VDRL, and urinalysis (glucose, protein, infection).

Provides HIV testing and counseling using the national guideline, or refers woman to
VCT services for HIV test, if she volunteers:

7
Care Provision
Note: Individualize care considering all information gathered during assessment.
1. Explains and discusses with the woman about danger signs during pregnancy and that she
should report to a health facility in the event of any of the signs.
2. Provides advice and counseling about diet and nutrition.
3. Develops a birth preparedness and emergency readiness plan with the woman and her
companion if present.
4. Provides advice and counseling about: Use of potentially harmful substances, prevention
of infection/hygiene, rest and activity, sexual relations and safer sex, sleeping under ITN
and early and exclusive breast feeding.
5. Offers HIV testing & counseling service. If her test result turned out positive: starts her
on HAART, discuss on infant feeding options, discuss on test result disclosure to her
partner and partners testing.
Immunizations and other prophylaxis

Gives tetanus toxoid (TT) based on woman’s need.

Dispenses sufficient supply of 1 iron/folate tablet daily until next visit and counsel the
woman about precautions, possible side effects and management.

Dispenses preventive medications based on region/population-specific need.
Return Visits
o Schedules the next antenatal visit making sure the woman knows when and where to
come.
o Completes all information in the woman’s record/antenatal card
o Thank the woman and her family member for coming.
2. Post Abortion Care (Manual Vacuum Aspiration [MVA])
Initial Assessment
 Greets woman respectfully and with kindness.
 Assesses patient for shock or complications.
Medical Evaluation

Takes a reproductive history and perform physical examination and laboratory tests.

Gives her information about her condition and discusses her reproductive goals.

Getting Ready

8
 
Tells the woman (and her support person) what is going to be done, listen to her and
respond attentively to her questions and concerns. Provides continual emotional support
and reassurance, as feasible.

Asks about allergies to antiseptics and anesthetics. Gives pethedine 100mg and Diazepam
10mg or Diclophenac 50 mg as appropriate to the woman before the procedure.

Determines that required sterile or high-level disinfected instruments and cannula are
present.

Checks that patient has recently emptied her bladder and washed her perineal area.

Puts on personal protective barriers and washes hands thoroughly and puts on high-level
disinfected or sterile surgical gloves.

Arranges sterile or high-level disinfected instruments on sterile tray or in high-level
disinfected container.

Checks MVA syringe and charges it (establish vacuum). Ensure that appropriate size
cannula and adapters are available.
Pre procedure Tasks

Give Oxytoxin and antibiotics IV if there is an indication

Cleans the genitalia and drapes the woman

Performs bimanual and speculum examination.

Applies antiseptic to cervix and vagina two times.

Removes any products of conception (POC) and checks for any cervical tears.

MVA Procedure
1. Explains each step of the procedure prior to performing it.
2. Puts single-toothed tenaculum or vulsellum forceps on anterior lip of cervix.
3. Administers paracervical block (if necessary).
4. Applies traction on cervix.
5. Dilates the cervix (if needed).
6. Inserts the cannula gently through the cervix into the uterine cavity.
7. Attaches the prepared syringe to the cannula.
8. Evacuates contents of the uterus.
9. When signs of completion are present, withdraw cannula and MVA syringe then empties
contents of MVA syringe into a strainer.

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 10. Removes forceps or tenaculum and speculum.
11. Performs bimanual examination.
12. If uterus is still soft or bleeding persists, repeats steps 5–10.
13. Inspects tissue removed from uterus to ensure complete evacuation
Post-Procedure Tasks
o Before removing gloves, disposes of waste materials in a leakproof container or plastic
bag.
o Flushes MVA syringe & cannula with 0.5% chlorine solution and disposes needle &
syringe in a puncture proof container or safety box.
o Decontaminates gloves in 0.5% chlorine solution and disposes in leakproof container.
o Washes hands thoroughly.
o Checks for bleeding and ensure cramping has decreased before discharge.
o Instructs patient regarding post abortion care.
o Discusses reproductive goals and, as appropriate, provides family planning
3. Post Abortion Family Planning Counseling
Initial Interview
1. Treats woman respectfully and with kindness.
2. Assesses whether counseling is appropriate at this time (if not, arrange for counseling
at another time) and assures necessary privacy.
3. Obtains biographic information (name, address, etc.).
4. Asks about her previous experience with contraception. Provides general
information about family planning.
5. Gives the woman information about the contraceptive choices available and the
benefits and limitations of each.
6. Discusses woman’s needs, concerns and fears. Helps her begin to choose an appropriate
method.
Screening

Screens woman carefully to make sure there is no medical condition that would be a
problem (complete Screening Checklist).

Performs physical examination, if indicated. (Nonmedical counselors must refer woman
for further evaluation.)

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 
Discusses what to do if the woman experiences any side effect/problems.

Provides followup visit instructions and ensures woman that she can return to the same
clinic at any time.

Asks the woman to repeat instructions and answers any questions.
4. IUCD Insertion and Removal
Pre-Insertion Medical Assessment
1. Greet client politely, introduce one self, offer a seat and ensure privacy for IUCD
insertion.
2. Ask client if she still wants the IUCD (CU-T 380A) inserted.
3. Review with client information in her record and ensure that she has been appropriately
counseled for IUCD (CU-T 380A) insertion; ask client what questions she has about the
IUCD (CU-T 380A) or the insertion.
4. Review reproductive goal and pertinent general medical history with client. To confirm
that the IUCD (CU-T 380A) is an appropriate choice for the client:-

Review Client Screening Checklist to ensure that the client is not pregnant.

Check for conditions requiring special precautions:

Ensure that the client is not at high individual risk for sexually transmitted
infections (STIs).

Date of last menstrual period, number of days between periods, bleeding pattern.

Any current unusual or purulent vaginal discharge, pain with sex, or lower
abdominal pain.

HIV status, if known, to provide appropriate counseling/referral if indicated. If
diagnosed with AIDS, ensure that she is doing well on ARV therapy before
proceeding with insertion.

Known or suspected cancer of genital tract or pelvic tuberculosis.

If delivered recently, ensure that she is not between 48 hours and 4 weeks after
childbirth.
5. If the client is an appropriate user based on the assessment above:-

Explain to client that you will do a pelvic exam and insert the IUCD if all is normal
during the pelvic exam, and also that you will explain each step throughout in order to
avoid surprising her.

11
 
Provide more detailed information about IUCD (Cu-T 380A):

Show the client the package of IUCD (Cu-T 380A)

How it works,

Its effectiveness,

Its characteristics,

How it is inserted and what to expect,

Common side effects,

When to return.

Inform the client that it will need to be removed at the end of 12 years
or anytime she decides to stop using the IUCD.
6. Ask the client to repeat information to ensure that she understands.
7. If client is nervous and tense, explain that analgesics are available, provide if requested,
and wait 20 minutes to insert the IUCD
Pre-Insertion Tasks
o Ensure that needed supplies and equipment are available in the procedure room.
o Confirm the client has recently emptied her bladder.
o Help the client onto the examination table.
o Explaining to client what you are doing at each step; ask her to tell you if she experiences
discomfort; remind her to take deep breaths and relax.
o Palpate abdomen and check for lower abdominal, especially suprapubic, tenderness and
masses or other abnormalities.
o Drape the client appropriately for pelvic exam.
o Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry.
o Open high-level disinfected instrument pan or sterile pack/container without touching
instruments, pour iodine solution in a cup, open gauze package.
o Put new examination gloves on both hands.
o Arrange instruments and supplies on a high-level disinfected or sterile tray or draped area
without touching the parts of the instruments that will go into the uterus or pierce the
mucosa.
Pelvic Examination
 Inspect external genitalia and urethral opening.
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 
Perform bimanual exam:

Palpate Skene’s and Bartholin’s glands for tenderness or discharge.

Gently introduce the index and middle fingers into the vagina.

Follow the anterior vagina wall until you feel the cervix, and identify position,
consistency, and shape.

Carefully determine size, shape, consistency, position and mobility of uterus.

Determine if there is cervical motion tenderness to rule out PID.

Rule out pregnancy or any uterine abnormality.

Check for enlargement or tenderness of adnexa

(Only perform rectovaginal examination if the position or size of the uterus is questionable,
or there is a possible mass behind the uterus.)

Perform speculum exam by gently spreading the labia with two fingers and then inserting
a bivalve speculum, starting obliquely and then rotating it clockwise to the horizontal
position:
o Gently open and maneuver the speculum to be able to inspect the cervix and
check for vaginal lesions or discharge.
o If purulent cervical or abnormal discharge is present, the IUCD insertion should
be delayed until treatment is provided, according to the STI syndromic
management protocol.
o Place, screw and lock the speculum.
Insertion Tasks
1. If both bimanual and speculum exams are normal, tell the client that she is ready for the
IUCD insertion; ask her if she has any questions.
2. Clean the cervix and the vagina with antiseptic solution 2 times using 2 gauzes, and wait
2 minutes for the solution to act.
3. While holding the speculum with one hand, the tenaculum with the other hand, and palms
turned upwards, gently grasp the cervix with the tenaculum horizontally at the 2 and 10
o’clock positions. (Note: Do not lock the tenaculum beyond the first notch).
4. While gently pulling on the tenaculum, pass the sound through the cervix to the top of the
uterus without touching the side walls of the vagina or the speculum blades.

13
 o To easily identify the mark for the uterine depth on the uterine sound, grasp the
sound with a sponge forceps close to the cervix.
5. Remove the sound along with the sponge forceps and determine the depth of the uterine
cavity by reading from the sound.
6. Place the sound in 0.5% chlorine decontamination solution.
7. Load the Copper T 380A while it remains inside the sterile package:

Partially open package (up to one third) and bend back the package flaps

Put the white rod inside the inserter tube

Place the package on a flat surface

Slide the white measurement card (that is in the package) underneath the arms
of the IUCD (CU-T 380A)

Hold the tips of the IUCD (CU-T 380A) arms and push on the inserter tube to
assist in bending the arms

When the arms touch the sides of the inserter tube, pull the inserter tube away
from the folded arms of the IUCD (CU-T 380A)

Elevate the inserter tube and push and rotate it to catch the tips of the arms in
the tube

Push the folded arms into the inserter tube to keep them fixed in the tube
8. With the loaded IUCD (CU-T 380A) still in the partially opened sterile package, move
the flange (blue depth gauge) to the corresponding measurement obtained from sounding
the uterus. Press down on the flange with one finger to keep it stable, and with the other
hand slide the loaded inserter so that the tip of the IUCD (CU-T 380A) aligns with the tip
in the diagram on the white measurement card. Make sure the white rod is against the tip
of the vertical arm of the IUCD (CU-T 380A). The movable blue flange and the folded
wings of the IUCD (CU-T 380A) should be aligned in a horizontal position. Do not bend
the arms of the T into the inserter tube more than 5 minutes before it is introduced into
the uterus.
9. Complete opening the plastic cover of the package in one continuous movement with one
hand, while holding the tube and rod down against the table (at the open end of the
package) with the other hand.
10. Remove the loaded inserter tube without touching anything that is not sterile.

14
 11. Hold the inserter tube with your palms turned upwards and the flange in the horizontal
position. While gently pulling on the tenaculum, pass the loaded inserter tube through the
cervix until the flange touches the cervix or slight resistance is felt (without touching the
vagina and blades of the speculum).
12. Hold the tenaculum and the white rod stationary in one hand (Suggestion: Hold one loop
of the tenaculum with your index and thumb while holding the loop of the white rod at
the top with the index and the middle fingers.
13. Release the arms of the IUCD (CU-T 380A) using withdrawal technique: Pull the inserter
tube toward you while holding the white rod stable. This will release the IUCD (CU-T
380A) arms.
14. Remove the white rod.
15. Carefully move the inserter tube upward toward the top of the uterus until slight
resistance is felt. (This helps ensure that the IUCD (CU-T 380A) is inserted high in the
fundus).
16. Partially remove the inserter tube from the cervical canal until IUCD strings can be seen
protruding from cervical os.
17. With the strings stabilized inside by the partially removed inserter tube cut the IUCD
(CU-T 380A) strings to 3 cm length and remove the inserter.
18. Gently remove the tenaculum and place it in 0.5% chlorine decontamination solution
19. Examine the cervix. If there is bleeding at the tenaculum puncture site(s), place a cotton
swab or gauze over the bleeding site and apply gentle pressure for 30–60 seconds.
20. Gently remove the speculum, pull it out while gently closing the blades and rotating it
counterclockwise to the vertical position and place it in 0.5% chlorine decontamination
solution.
21. Allow the client to rest until she feels ready to get dressed; help her off the table when
she feels ready (HINT: The post insertion tasks can be performed while she is resting)
Post-insertion Tasks

Dispose of waste materials such as cotton balls or gauze by placing them in a leak proof
container or plastic bag.

Immerse both gloved hands in 0.5% chlorine decontamination solution. Remove gloves
by turning them inside out.

15

Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry.

Provide post insertion instructions:

o Inform the client how many years the IUCD (CU-T 380A) is effective (give in
writing), and that the IUCD (CU-T 380A) is effective immediately with no need
for backup contraception.
o Explain that some women like to check the IUCD (CU-T 380A) strings after their
period to assure themselves that the IUCD (CU-T 380A) is in place and to see
what it feels like, but that this is not required; briefly explain how to check the
strings.
o Explain when to return, have client repeat instructions and correct/clarify as
needed:
o Follow-up visit (after her first period or within 3 to 6 week whichever comes
first); give appointment if possible.
o Any time she has any concerns or problems, including side-effects (Emphasize
that many women do not experience side effects and, when they occur, they tend
to decrease after the first 3 months).
o If she experiences warning signs such as late or unusually heavy period,
abdominal pain, signs of infection such as fever, tenderness and abnormal
discharge (emphasize that complications are rare).
o Remind client of condom use for STI protection.
o Explain that the IUCD (CU-T 380A) can be removed whenever client wants, but
that it needs to be done by a provider; the client must not attempt to remove the

o Ask client what questions she has; praise her for choosing an effective
contraceptive method.

Complete the IUCD card, client record and IUCD register/log (as applicable).

After the client has left, wear utility gloves and clean the examination table with the 0.5%
chlorine decontamination solution

16
Removal
Client Assessment

Greet client politely and introduce oneself; offer a seat, ensure privacy; assure client of
confidentiality.

Ask the client her reason (s) for removing the IUCD.

Verify that the client has received counseling and has made an informed decision about
removing the IUCD.

Explain to the client what will be done and ask her what questions she has.

Check that the client has emptied her bladder.

Pre-Removal Tasks
 Ensure that needed supplies and equipment are available in the procedure room.
 Help the client onto the examination table and start explaining the procedure as you
perform it in order to avoid surprising her; explain to client importance of being relaxed,
and taking deep breaths.
 Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry.
 Put new examination gloves on both hands.
 Arrange the instruments and supplies on high-level disinfected or sterile tray or drape
Removal of the Copper T 380A IUCD
1. Insert the bivalve speculum to:
o Check for vaginal lesions or discharge
o See the cervix and the IUCD strings
o Clean the cervix and vagina with the antiseptic solution 2 times with 2 gauzes
o Wait for 2 minutes for the antiseptic solution to act.
o Grasp the strings close to the cervix with hemostat or other narrow forceps.
o Pull on the strings slowly but firmly to remove the IUCD.
o Show the IUCD to the client.
o Immerse the IUCD in 0.5% chlorine solution and dispose it in a leak proof
container or plastic bag. If the woman wants a new IUCD inserted follow the
steps in the insertion guide from this point.
o Gently remove the speculum and place in 0.5% chlorine decontamination solution
Post removal Tasks

17
o Before removing gloves, place all instruments in 0.5% chlorine solution for 10 minutes
for decontamination.
o Dispose of waste materials by placing in a leak proof container or plastic bag.
o Immerse both gloved hands in 0.5% chlorine solution.
o Remove gloves by turning inside out, place them in a leak proof container or plastic bag.
o Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry.
o Encourage client to rest as needed, help her from the examination table, ensure she has
received needed services and referral; encourage questions.
o Record the IUCD removal in the client record and register (if and when applicable).
o After the client has left, wearing utility gloves clean the examination table with the 0.5%
chlorine solution.
5. Management of Severe Preeclampsia/Eclampsia
Getting Ready

Greets the woman respectfully and with kindness.

Tells the woman (and her support person) what is going to be done and encourage her
to ask.

Listens to her and respond attentively and provide continual emotional support and
reassurance
Immediate Management
Note: different steps could be carried out simultaneously.

SHOUTS FOR HELP

Turn the woman onto her left side

Ensures airway is open: Begins resuscitation measures if necessary.

Gives oxygen at 4–6 L per minute by mask or cannulae.

Establishes an IV line and give normal saline or Ringer’s lactate.

Checks vital signs

Initiate Anticonvulsive Therapy (Magnesium Sulphate)

NOTE: Give only the loading doses as below and refer urgently to a higher facility. Provide
supportive care until referral is arranged.
Administering Loading Dose of Magnesium Sulphate
1. Wash hands thoroughly with soap and water and dry.

18
 2. Tells the woman that she may experience a feeling of warmth when magnesium
sulphate is given.
3. Draws up 4 grams of magnesium sulphate (20 ml of 20% solution).
4. Gives by IV injection SLOWLY over 5 minutes.
5. Draw up 10 grams of magnesium sulphate (20ml of 50% solution) with 1 ml of 2%
lignocaine in the same syringe.
6. Give 5 grams (10 ml) by DEEP IM injection in upper outer quadrant of one buttock,
replace the needle and inject the remaining 5 grams by DEEP IM injection into the
other buttock.
7. If disposing of needle and syringe, place in puncture proof container.
8. Wash hands thoroughly with soap and water and dry.
9. If convulsions recur AFTER 15 minutes give 2 grams of magnesium sulphate (10 ml
of 20% solution or 4ml of 50% solution) IV injection SLOWLY over 5 minutes.
10. Record drug administration and findings on the woman’s record
Administering Maintenance Dose of Magnesium Sulphate
1. Give 5 grams of magnesium sulphate (10 mL of 50% solution), together with 1 mL
of 2% lignocaine in the same syringe, by DEEP IM injection into alternate buttocks.
2. Before repeat administration check respiratory rate, patellar reflexes and urinary
output. WITHHOLD or DELAY drug if necessary.
3. If respiratory arrest occurs assist ventilation and gives calcium gluconate 1 g (10 ml
of 10% solution) by IV injection SLOWLY until respiration begins.
Anticonvulsive Therapy (Diazepam)
Note: Diazepam should be used ONLY if magnesium sulphate is not available.
Administering Loading Dose of Diazepam
1. Wash hands thoroughly with soap and water and dry.
2. Draw up 10 mg of diazepam and give by IV injection SLOWLY over 2 minutes.
3. Dispose of needle and syringe in puncture-proof container.
4. Wash hands thoroughly with soap and water and dry.
5. If convulsions recur, repeat loading dose.
Administering Maintenance Dose of Diazepam

19
 1. Give 40 mg of diazepam in 500 mL of IV fluid at a rate that keeps the woman
sedated but rousable.
2. If respiratory depression occurs assist ventilation, if necessary
Administering Diazepam Rectally (when IV access is not possible)

Wash hands thoroughly with soap and water and dry.

Draw up 20 mg of diazepam in a 10 mL syringe and remove the needle from the
syringe.

Lubricate the barrel of the syringe and insert the syringe into the rectum to half its
length.

Discharge the contents of the syringe into the rectum and leave the syringe in place
and hold the buttocks together for 10 minutes.

If convulsions are not controlled within 10 minutes, administers an additional 10 mg
of diazepam per hour.

Record drug administration and findings on the woman’s records.
Control Blood Pressure (Anti-Hypertensive Therapy)
Note: The goal is to keep the diastolic pressure between 90 and 100 mm Hg

If the diastolic pressure is 110 mm Hg or more:

Give hydralazine 5 mg IV slowly (3-4 minutes).

If hydralazine is not available, give labetolol 10 mg IV OR Nifedipine
5mg under the tongue

If diastolic blood pressure remains > 90 mmHg, repeat the dose at 30 minute intervals
until diastolic BP is around 90mmHg.

Record drug administration and findings on the woman’s records.
6. Assessment of the Woman in Labor
Getting Ready

Prepares the necessary equipment.

Greets the woman respectfully and with kindness.

Tells the woman (and her support person) what is going to be done, listens to her
attentively, and responds to her questions and concerns.

Provides continual emotional support and reassurance, as possible.
History

20
(Asks the following questions if the information is not available on the woman’s ANC record)
Personal Identification

What is your name, age, address, and phone number?

Present Pregnancy

How many previous pregnancies and births have you had?

Do you have a complication readiness plan if there are any problems during labor or
childbirth?

Are you having a particular problem at present?

Have you received care from another caregiver?

When is your baby due?

Did you receive antenatal care during this pregnancy?

Have you had any (other) problems during this pregnancy?

Present Labor/Childbirth
o Have your membranes ruptured/waters broken?
o Have regular contractions started?
o How often are you having contractions and how long does each one last?
o Have you felt the baby move in the past 24 hours?
o Have you taken any alcohol, drugs, herbs, or other preparations in the last 24 hours?
o When did you last eat or drink?
Obstetric History

Have you had a cesarean section, ruptured uterus, or any surgery to the uterus during
a previous childbirth?

Have you had any other complications during a previous pregnancy, childbirth, or
postpartum/newborn period?

Have you had any previous problems breastfeeding?
Medical History

Do you have any allergies?

Have you been tested for HIV?

Have you had anemia recently?

Have you been tested for syphilis?

21
 
Have you had any chronic illness/condition, such as tuberculosis, hepatitis, heart
disease, diabetes, or other serious chronic disease?

Have you ever been in hospital or had surgery/an operation?

Are you taking any drugs/medications?

Have you had a complete series of five tetanus toxoid (TT) immunizations?

Physical Examination
Assessment of General Well-Being

Observes gait and movements, and behavior and vocalizations.

Checks skin, noting lesions or bruises.

Checks conjunctiva for pallor.

Vital Signs Measurements


Have the woman remain seated or lying down, ensuring that she is comfortable and
relaxed, and observe breathing and measure blood pressure, temperature, and pulse.
Visual Inspection of Breasts (This part of the examination should only be performed if the
woman is in the latent [or early active] phase of the first stage of labor and is not in acute
distress.)

Explains to the woman the next steps in the physical examination and obtains her consent
to proceed.

Asks the woman to empty her bladder.

Asks the woman to uncover her body from the waist up, have her remain seated with her
arms at her sides, and checks her breasts, noting any abnormalities.
Abdominal Examination
1. Asks the woman to uncover her stomach and lie on her back with her knees slightly bent.
2. Checks the surface of the abdomen and the shape of the uterus, and measure fundal
height.
3. Makes sure hands are clean and warm.
4. Stands at the woman’s side, facing her head, make sure she is not having a contraction,
and determines fetal lie and presentation.
5. Determines descent through abdominal palpation.
6. Between contractions, listens to fetal heart for a full minute.

22
 7. Palpates contractions from beginning of a contraction to end of contraction and on to
beginning of next contraction.
Genital and Vaginal Examination

Asks the woman to uncover her genital area, covers or drapes her to preserve privacy and
respect modesty, and asks her to separate her legs while keeping her knees slightly bent.

Turns on light and directs it toward genital area.

Washes hands thoroughly and puts new examination or high level disinfected gloves on
both hands.

Inspects the labia, clitoris, and perineum and palpates the labia minora, noting any
abnormalities.

Assesses dilatation of cervix, membranes, and presenting part.

Immerses both gloved hands briefly in a container filled with 0.5% chlorine solution;
then removes gloves by turning them inside out and places in a plastic bag or leakproof,
covered waste container.

Washes hands thoroughly.
7. Partographic Follow Up of Labour
Patient information: Fill out name, gravida, para, hospital number, date and time of admission
and time of ruptured membranes.

Fetal heart rate: Record every half hour.

Amniotic fluid: Record the colour of amniotic fluid at every vaginal examination:

• I: membranes intact;
• C: membranes ruptured, clear fluid;
• M: meconium-stained fluid;
• B: blood-stained fluid.
Moulding:

• 1: sutures apposed;
• 2: sutures overlapped but reducible;
• 3: sutures overlapped and not reducible.

Cervical dilatation: Assessed at every vaginal examination and marked with a cross (X). Begin
plotting on the partograph at 4 cm.

23
Alert line: A line starts at 4 cm of cervical dilatation to the point of expected full dilatation at the
rate of 1 cm per hour.

Action line: Parallel and 4 hours to the right of the alert line.
Descent assessed by abdominal palpation: Refers to the part of the head (divided into 5
parts) palpable above the symphysis pubis; recorded as a circle (O) at every vaginal
examination. At 0/5, the sinciput (S) is at the level of the symphysis pubis.

Hours: Refers to the time elapsed since onset of active phase of labour (observed or
extrapolated).
Time: Record actual time.
Contractions: Chart every half hour; palpate the number of contractions in 10 minutes and
their duration in seconds.

• Less than 20 seconds:

• Between 20 and 40 seconds:
• More than 40 seconds:
Oxytocin: Record the amount of oxytocin per volume IV fluids in drops per minute every 30
minutes when used in hospitals.
Drugs given: Record any additional drugs given.

Pulse: Record every 30 minutes and mark with a dot (●).

Blood pressure: Record every 4 hours and mark with arrows.
Temperature: Record every 2 hours.
Protein, acetone and volume: Record every time urine is passed.

Samples of partographic filling

24
25
26
 Exercise
At admission

Saba was admitted at 05.00 PM on 19.3.2008

Membranes ruptured

Gravida 3, Para 2+0

Hospital number 7886

Fetal heart rate (FHR) 130

Blood pressure 110/70 mmHg

Temperature 36.8°C

Pulse 74/minute

On admission the fetal head was 4/5 palpable above the syphilis pubis and the cervix was 5 cm

dilated
2 contractions in 10 minutes, each lasting < 20 seconds

Bones are separated & sutures felt
At 09.00

PM local time
The fetal head is 3/5 palpable above the symphysis pubis

The cervix is 7 cm dilated

2 contractions in 10 minutes, each lasting 20-40 seconds

Fetal heart rate (FHR) 150

Blood pressure 110/70 mmHg

Temperature 36.9°C

Pulse 78/minute

Bones are overlapping
At 3:00 AM local time
 3 contractions in 10 minutes, each lasting >40 seconds
 The cervix is 7 cm dilated
 Fetal heart rate (FHR) 160
 Membranes ruptured, amniotic fluid clear
 Sutures of the skull bones are apposed
 Blood pressure 120/70 mmHg
 Temperature 36.8°C
 Pulse 80/minute
 Urine output 200 mL; negative protein and acetone
 Bones are overlapping severely

27
28
 8. Medical Induction of Labor

Assemble the necessary materials.

Obtain informed consent after discussing about the indication, the methods, and risks
including the possibility of caesarian section.

Keep the mother in supine position

Checks the bishop score.

Checks the pre-requisites (indication and contra indications).

Dilute oxytocin in normal saline/ringer lactate.

Adjust drop rate. Starts from the minimum dose capable of causing contractions as
continuous intravenous infusion. Increases every 20 minutes until adequate contraction
are achieved.

Assess maternal vital signs every 1 hour, uterine contractions every 30 minutes,
examination for cervical dilatation and station every 4 hours and fetal heart beat every
20- 30 minutes.

If hyper stimulation or fetal distress occurs discontinue the infusion.

Record/document data.

9. Assisting Normal Birth (Including Immediate Post-partum and

Newborn Care and Active Management of the Third Stage of
Labor)
Getting Ready

Washes hands and prepares the necessary equipment.

Encourages the woman to adopt the position of choice and continue spontaneous bearing
down efforts.

Tells the woman what is going to be done, listens to her, and responds

Provides continual emotional support and reassurance

Puts on personal protective barriers.

Assisting the Birth

1. Washes hands thoroughly, and puts on 2 pairs of sterile surgical gloves.
2. Cleans the woman’s perineum and places one drape under the woman’s buttocks and one
over her abdomen - ask woman to pant or give only small pushes with contractions.

29
 3. Controls the birth of the head with the fingers of one hand to maintain flexion, allow
natural stretching of the perineal tissue, and prevents tears, and use the other hand to
support the perineum.
4. Wipes mucous or membranes with gauze if needed from baby’s eyes and mouth.
5. Feels around the baby’s neck for the cord and respond appropriately if the cord is present.
6. Allows the baby’s head to turn spontaneously and, with the hands on either side of the
baby’s head, delivers the anterior shoulder.
7. When the arm fold is seen, guides the head upward as the posterior shoulder is born over
the perineum and lifts the baby’s head anteriorly to deliver the posterior shoulder.
8. Supports the rest of the baby’s body with both hands as it slides out and places the baby
on the mother’s abdomen.
9. Clamps the cord at about 3 cm from the umbilicus and applies second clamp 2cm apart,
ties securely between clamps and cuts with sterile scissors or blade.
10. Notes the time and sex of the baby and tells the mother.
11. Thoroughly dries the baby and assess breathing. If baby does not breathe immediately,
begins resuscitative measures (see Checklist Newborn Resuscitation).
12. Removes wet towel and ensures that the baby is kept warm, using skin-to-skin contact on
the mother’s chest. Covers the baby with a cloth or blanket, including the head (with hat
if possible).
13. Palpates the mother’s abdomen to rule out the presence of additional baby (ies) and
proceeds with active management of the third stage.
Active Management of Third Stage of Labor

If no additional baby, gives oxytocin 10 units IM within one minute of birth.

Changes gloves or removes top pair. Clamps the cord close to the perineum using sponge
forceps and waits for a uterine contraction.

Applies counter traction in an upward direction to stabilize the uterus.

At the same time with the other hand, pulls with a firm, steady tension on the cord in
a downward direction.

Delivers placenta with both hands, gently turning the entire placenta and lifting it up and
down.

Immediately after placenta delivers, massages uterus until firm.

30
 
Examines the placenta, membranes, and cord and disposes into bucket lined with
plastic bag or as culturally appropriate.

Examines the vulva, perineum and vagina for lacerations/tears and carries out appropriate
repair as needed.

Cleanses perineum and area beneath the woman and applies a pad or cloth to vulva.

Assists the mother to a comfortable position for continued breastfeeding and bonding
with her newborn
Post-Procedure Tasks

Disposes of contaminated items in a plastic bag or leakproof, covered waste container.

Decontaminates instruments by placing in a container filled with 0.5% chlorine solution
for 10 minutes.

Decontaminates needle and syringe, hold the needle under the surface of a 0.5% chlorine
solution, fills the syringe, and pushes out (flush) three times; and then places in a
puncture-resistant sharps container.

Immerses both gloves in 0.5% chlorine solution and removes gloves by turning them
inside out.

Washes hands

Records all information on record including estimated blood loss.

Immediate Post-Partum and Newborn Care

Immediate care of newborn:

After the baby has breastfed:

Checks baby’s temperature every 15 minutes for 1 hour by touching his/her chest.

Identifies the baby

Weighs the baby and record

Performs eye care

Gives Vit. K IM

Checks the cord

Ensures the baby is dressed warmly and with the mother

Explains to mother importance of delayed bathing and not to apply anything to
the skin or cord
Care of the mother:

31
 
Monitors the woman every 15 minutes in the first hour after complete delivery of the
placenta checking:

Uterine tone

Vaginal bleeding

Blood pressure

Pulse

Hydration

Encourages the woman to pass urine, to eat and drink.

Encourages the woman to stay in the facility for at least 6 hours.

Records the information on the woman’s clinical record.

10. Helping A Baby Breathe/ Newborn Resuscitation

Getting Ready

Dries the baby, remove the wet cloth, and wraps the baby in a dry, warm cloth.

Places the baby on his/her back on a clean, warms surface and keeps covered except
for the face and chest.
Resuscitation Using Bag and Mask
1. Positions the head in a slightly extended position to open the airway.
2. Clears the airway by suctioning the mouth first and then the nose:

Introduces catheter into the baby’s mouth for approximately 3cm and suctions while
withdrawing catheter;

Introduces catheter into each nostril and suctions while withdrawing catheter
3. Places the mask on the baby’s face so that it covers the chin, mouth and nose.
4. Squeezes the bag with two fingers only or with the whole hand, depending on the size of
the bag.
5. Checks the seal by ventilating two or three times and observing the rise of the chest.
6. If the baby’s chest is rising, ventilates at a rate of 40 breaths per minute, and observes the
chest for an easy rise and fall.
7. If the baby’s chest is not rising, determines why, rectify problem and continue to ventilate.
8. Ventilates for 1 minute and then stops and quickly assesses the baby for spontaneous
breathing and color; if breathing is normal, stop ventilating, and provide routine newborn
care.

32
 9. If the baby’s heart rate is normal but breathing is less than 30 breaths per minute or
irregular, continues to ventilate for 3-5 minutes until the baby is breathing well; stops
ventilating and monitors baby with mother.
10. If breathing is not normal, and the heart rate is normal or slow manages accordingly (calls
for help and improves ventilation; continues ventilation with oxygen if available).
11. If the baby is not breathing regularly after 20 minutes of ventilation, continues ventilation
with oxygen organizes transfer and refers baby to a tertiary care centre, if possible.
12. If there is no gasping or breathing at all after 20 minutes of ventilation, stops ventilating,
provides emotional support to mother and family.
Care after Successful Resuscitation

Keeps the baby skin-to-skin with the mother until the baby’s condition is stable.

Monitors the baby’s respiratory rate and observes for other signs of illness.

Provides reassurance to the mother.

Post-Resuscitation Tasks

Soaks suction catheters and mask in 0.5% chlorine solution for 10 minutes for
decontamination.

Wipes exposed surfaces of the bag with a gauze pad soaked in 0.5% chlorine solution or
60-90% alcohol and rinses immediately.

Washes hands thoroughly with soap and water and dries with a clean, dry cloth (or air
dry).

Completes records with details of resuscitation and condition of newborn.
11. Bimanual Compression Of The Uterus
Getting Ready

Tells the woman what is going to be done, listens to her, and responds attentively to her
questions and concerns.

Provides continual emotional support and reassurance, as feasible.

Puts on personal protective barriers.

Bimanual Compression
1. Washes hands and puts on high-level disinfected or sterile gloves.
2. Cleans the vulva and perineum with antiseptic solution.

33
 3. Inserts fist into anterior vaginal fornix and applies pressure against anterior wall
of uterus.
4. Places the other hand on the abdomen behind the uterus, presses the hand deeply into the
abdomen, and applies pressure against the posterior wall of the uterus.
5. Maintains compression until bleeding is controlled and the uterus contracts.
Post-Procedure Tasks

Immerses both gloved hands briefly in a container filled with 0.5% chlorine solution;
then removes gloves by turning them inside out and places in a plastic bag or leak proof,
covered waste container.

Washes hands thoroughly.

Monitors vaginal bleeding, takes the woman’s vital signs and makes sure that the uterus
is firmly contracted.

Completes documentation.
12. Compression of the Abdominal Aorta
Getting Ready

Tells the woman what is going to be done, listen to her, and respond attentively to her
questions and concerns.

Provides continual emotional support and reassurance, as feasible.
Compression of the Abdominal Aorta
1. Places a closed fist just above the umbilicus and slightly to the left.
2. Applies downward pressure over the abdominal aorta directly through the abdominal
wall.
3. With the other hand, palpates the femoral pulse to check the adequacy of compression.
4. Maintains compression until bleeding is controlled.
Post-Procedure Tasks

Monitors vaginal bleeding, take the woman’s vital signs, and ensures the uterus is firmly
contracted.

Complete documentation.

34
 13. Manual Removal of Placenta
Getting Ready

Prepares the necessary equipment.

Tells the woman what is going to be done, listen to her, and respond attentively to her
questions and concerns.

Provides continual emotional support and reassurance, as feasible.

Asks the woman to empty her bladder or inserts a catheter.

Gives anesthesia or analgesia such as pethedine and diazepam IV slowly or ketamine

Gives prophylactic antibiotics.

Puts on personal protective barriers.

Manual Removal of Placenta

1. Washes hands and forearms thoroughly and puts on high-level disinfected or sterile
surgical gloves (use elbow-length gloves, if available).
2. Cleans the vulvas and perineum and drapes the woman.
3. Holds the umbilical cord with a clamp and pulls the cord gently.
4. Inserts the other hand into the uterine cavity and locates the placenta.
5. Provides counter-traction abdominally.
6. Detaches the placenta by slowly working around the placental bed until the
whole placenta is separated from the uterine wall.
7. Withdraws the hand from the uterus, bringing the placenta with it while continuing to
provide counter-traction abdominally.
8. Ensures that all placental tissue has been removed.
9. Gives oxytocin in IV fluid.
10. Have an assistant massage the fundus to encourage a tonic uterine contraction.
11. If there is continued heavy bleeding, gives ergometrine by IM injection, or
give prostaglandins.
12. Examines the uterine surface of the placenta to ensure that it is complete.
13. Examines the woman carefully and repairs any tears to the cervix or vagina, or
repairs episiotomy.
Post-Procedure Tasks

35
 
Immerses both gloved hands briefly in a container filled with 0.5% chlorine solution;
then remove gloves by turning them inside out and places in a plastic bag or
leakproof, covered waste container.

Washes hands thoroughly.

Monitors vaginal bleeding, take the woman’s vital signs, and ensure that the uterus is
firmly contracted.

Completes documentation
14. Episiotomy and Repair
Getting Ready

Prepares the necessary equipment.

Tells the woman what is going to be done and encourages her to ask questions.

Listens to what the woman has to say.

Makes sure that the woman has no allergies to lignocaine or related drugs.

Provide emotional support and reassurance, as feasible.

Administering Local Anesthetic


Washes hands and puts on sterile gloves

Cleanses perineum with antiseptic solution and places drape under the woman’s buttocks
and over her abdomen.

Draws 10 ml of 0.5% or 1% lignocaine into a syringe.

Places two fingers into vagina along proposed incision line.

Inserts needle beneath skin for 4–5 cm following same line.

Draws back the plunger of syringe to make sure that needle is not in a blood vessel:

If blood is returned in syringe, remove needle, rechecks position carefully,
and try again;

If no blood is withdrawn, continues as follows.

Injects lignocaine into vaginal mucosa, beneath skin of perineum and deeply into perineal
muscle.

Waits two minutes and then pinches incision site with forceps.

If the woman feels the pinch, waits two more minutes and then retests.

Making the Episiotomy

1. Waits to perform episiotomy until:

36
 
Perineum is thinned out

3–4 cm of the baby's head is visible during a contraction

2. Places two fingers between the baby's head and the perineum.
3. Inserts open blade of scissors between perineum and two fingers:

Cuts the perineum about 3 cm in a mediolateral direction (45º angle to the midline
toward a point midway between ischial tuberosity and anus).
4. If birth of head does not follow immediately, applies pressure to episiotomy site between
contractions, using a piece of gauze, to minimize bleeding.
5. Controls birth of head and shoulders to avoid extension of the episiotomy.
Repairing the Episiotomy
1. Asks the woman to position her buttocks toward lower end of bed or table (use stirrups if
available).
2. Asks an assistant to direct a strong light onto the woman’s perineum.
3. Gently cleans area around episiotomy with antiseptic solution.
4. Using 2/0 suture, inserts suture needle just above (1 cm) the apex of the vaginal cut.
5. Uses a continuous suture from apex downward to level of vaginal opening.
6. At opening of vagina, brings together cut edges.
7. Brings needle under vaginal opening and out through incision and tie.
8. Uses interrupted or continuous sutures to repair perineal muscle, working from top
of perineal incision downward.
9. Uses interrupted or continuous subcuticular sutures to bring skin edges together.
10. Washes perineal area with antiseptic, pat dry, and places a sterile sanitary pad over the
vulva and perineum.
11. Explains to the woman how to keep the area clean and dries and to return for postpartum
care.
12. Gives analgesic where necessary
Post-Procedure Tasks

Disposes of waste materials (e.g., blood-contaminated swabs) in a leakproof container or
plastic bag.

Decontaminates instruments by placing in a plastic container filled with 0.5%
chlorine solution for 10 minutes.

37
 
Disposes of needle and syringe in a puncture proof container.

Immerses both gloved hands in 0.5% chlorine solution and remove gloves by
turning them inside out, dispose in leak proof container.

Washes hands thoroughly with soap and water and dries with clean, dry cloth or air dry.

Records procedure on woman’s record.

15. Repair of Cervical Tears

Getting Ready

Prepares the necessary equipment.

Tells the woman what is going to be done, listens to her, and responds attentively to her
questions and concerns.

Provides continual emotional support and reassurance, as feasible.

Have the woman empty her bladder or insert a catheter.

Gives anesthesia, if necessary.

Puts on personal protective barriers.

Repair of Cervical Tears

1. Washes hands thoroughly and puts on high-level disinfected or sterile surgical gloves.
2. Cleans the vagina and cervix with an antiseptic solution.
3. Grasps both sides of the cervix using ring or sponge forceps (one forceps for each side of
tear).
4. Places the first suture at the top of the tear and closes it with a continuous suture,
including the whole thickness of the cervix each time the suture needle is inserted.
5. If a long section of the rim of the cervix is tattered, under-runs it with a continuous
suture.
6. If the apex is difficult to reach and ligate, grasps it with forceps and leaves them in place
for eight hours.
Post-Procedure Tasks

Before removing gloves, disposes of waste materials in a leakproof container or
plastic bag.

Places all instruments in 0.5% chlorine solution for 10 minutes for decontamination.

Immerses both gloved hands in 0.5% chlorine solution. Removes gloves by turning them
inside out:

38
 
If disposing of gloves, places them in a leakproof container or plastic bag;

If reusing surgical gloves, submerges them in 0.5% chlorine solution for 10
minutes for decontamination.

Washes hands thoroughly.

16. Repair of 1st and 2nd Degree Vaginal and Perineal Tears
Getting Ready

Prepares the necessary equipment.

Tells the woman what is going to be done and encourage her to ask questions.

Listens to what the woman has to say.

Makes sure that the woman has no allergies to lidocaine or related drugs.

Provides emotional support and reassurance, as feasible.

Repairing the Tears

1. Cleanses perineum with antiseptic solution.
2. Administers local anesthetic.
3. Uses a continuous suture from apex of tear downward to repair vaginal tear(s).
4. At opening of vagina, brings together torn edges.
5. Brings needle under vaginal opening and out through the tear and tie.
6. Uses interrupted sutures to repair perineal muscle, working from top of perineal
tear downward.
7. Uses interrupted or subcuticular sutures to bring together skin edges.
8. Washes perineal area and cover with a sterile sanitary pad.
Post-Procedure Tasks

Before removing gloves, disposes of waste materials in a leakproof container or plastic
bag.

Decontaminates instruments by placing in a plastic container filled with 0.5%
chlorine solution for 10 minutes.

Decontaminates or disposes of syringe and needle:

If reusing needle or syringe, fills syringe (with needle attached) with 0.5%
chlorine solution and submerges in solution for 10 minutes for decontamination;

If disposing of needle and syringe, flushes needle and syringe with 0.5%
chlorine solution three times, then places in a puncture proof container.

39
 
Immerses both gloved hands in 0.5% chlorine solution and remove gloves by
turning them inside out:

If disposing of gloves, places in leakproof container or plastic bag;

If reusing surgical gloves, submerges in 0.5% chlorine solution for 10 minutes
to decontaminate.

Washes hands thoroughly.

Records procedure on woman’s record.

17. Breech Delivery

Getting Ready

Prepares the necessary equipment.

Tells the woman (and her support person) what is going to be done, listens to her and
respond attentively to her questions and concerns.

Provides continual emotional support and reassurance, as feasible.

Ensures that the conditions for breech delivery are present.

Puts on personal protective barriers.

Pre-procedure Tasks

Washes hands thoroughly and puts on high-level disinfected or sterile surgical gloves.

Cleans the vulva with antiseptic solution.

Puts sterile drap under the women’s buttock and one on her abdomen

Catheterizes the bladder, if necessary.

Breech Delivery
Delivery of the Buttocks and Legs
1. When the buttocks have entered the vagina and the cervix is fully dilated, tells the woman
she can bear down with contractions.
2. Performs an episiotomy, if necessary.
3. Let’s the buttocks deliver until the lower back and shoulder blades are seen.
4. Gently holds the buttocks in one hand.
5. If the legs do not deliver spontaneously, delivers one leg at a time.
6. Holds the baby by the hips.
Delivery of the Arms
7. If the arms are felt on the chest, allows them to disengage spontaneously.

40
 8. If the arms are stretched above the head or folded around the neck, uses Lovset’s
maneuver.
9. If the baby’s body cannot be turned to deliver the arm that is anterior first, delivers the
arm that is posterior.
Delivery of the Head
10. Delivers the head using the Mauriceau Smellie Veit maneuver.
11. Assesses the baby’s condition for breathing and completes the delivery as in normal birth
12. Following delivery, checks the birth canal for tears and repairs, if necessary. Repairs the
episiotomy, if one was performed
13. Provides immediate postpartum and newborn care, as required.
Post-Procedure Tasks

Before removing gloves, dispose of waste materials in a leakproof container or plastic
bag.

Places all instruments in 0.5% chlorine solution for decontamination.

Removes gloves and discards them in a leakproof container or plastic bag if disposing of
or decontaminate them in 0.5% chlorine solution if reusing.

Washes hands thoroughly.

Documents all relevant information

18. Management of Shoulder Dystocia


Assemble the necessary materials

Obtain informed consent

Keep the mother in supine/lithotomic position.

Make sure bladder is empty.

Evaluate for episiotomy

Mcrobert maneuver

Hyper flex the maternal pelvis onto the maternal abdomen.

Supra pubic pressure is applied while gentle downward pressure on the head is applied.

Rubin / Wood's maneuver


Rotate the fetal shoulders into the oblique position by placing 2 fingers against the
posterior shoulder and pushing it toward the fetal chest
Barnum maneuver

41
 
Insert hand in front of the fetus

Identify the posterior arm and elbow. Ensure the elbow is flexed across body

Grasp and deliver the hand and forearm.

Carry out delivery as usual after the hand released.

Record/document data

19. Vacuum Extraction

Getting Ready

Prepares the necessary equipment.

Tells the woman what is going to be done listens to her and responds attentively to her
questions and concerns.

Provides continual emotional support and reassurance, as feasible.

Ensures that the conditions for vacuum extraction are present.

Makes sure an assistant is available.

Puts on personal protective barriers.

Pre-procedure Tasks

Washes hands thoroughly and puts on high-level disinfected or sterile surgical gloves.

Cleans the vulva with antiseptic solution.

Places one sterile drape under the women’s buttock one over the women abdomen

Catheterizes the bladder, if necessary.

Checks all connections on the vacuum extractor and test the vacuum.

Vacuum Extraction
1. Assesses the position of the fetal head and identifies the posterior fontanels.
2. Applies the largest cup that will fit.
3. Performs episiotomy if necessary for placement of the cup.
4. Checks the application and ensures that there is no maternal soft tissue within the rim of
the cup.
5. Have assistant create a vacuum of negative pressure and checks the application of
the cup.
6. Increases the vacuum to the maximum and then applies traction. Correct the tilt or
deflexion of the head.

42
 7. With each contraction, applies traction in a line perpendicular to the plane of the cup rim
and assesses potential slippage and descent of the vertex.
8. Between each contraction, checks

Fetal heart rate (by assistant)

Application of the cup.

9. Continues the “guiding” pulls for a maximum of 30 minutes. Releases the vacuum
when the head has been delivered.
10. Checks the birth canal for tears following delivery, and repairs if necessary. Repairs the
episiotomy, if one was performed
11. Provides immediate postpartum and newborn care, as required.
Post-Procedure Tasks

Before removing gloves, disposes of waste materials in a leak proof container or
plastic bag.

Places all instruments in 0.5% chlorine solution for decontamination

Removes gloves and discard them in a leak proof container or plastic bag if disposing
of or decontaminate them in 0.5% chlorine solution if reusing.

Washes hands thoroughly.

Completes documentation.

20. Postpartum Assessment (History and Physical Examination) and Care

Getting Ready

Prepares the necessary equipment.

Greets the woman respectfully and with kindness.

Tells the woman (and her support person) what is going to be done, listens to her
attentively, and responds to her questions and concerns.

Provides continual emotional support and reassurance, as possible.
History
(Ask the following questions if the information is not available on the woman’s record.)
Personal Information (Every Visit for items followed with an “*”; First Visit for other
items)
1. What is your name and age, and the name of your baby?
2. What is your address and your phone number?

43
 3. Do you have access to reliable transportation?
4. What sources of income/financial support do you/your families have?
5. How many times have you been pregnant and how many children have you had?
6. How many of your children are still living?
7. Are you having a particular problem at present?*
8. Have you received care from another caregiver?*
(Some of the following steps/tasks should be performed simultaneously.)
Daily Habits and Lifestyle (Every Visit for items followed with an “*”; First Visit for other
items)
1. Do you work outside the home?*
2. Do you walk long distances, carry heavy loads, or do physical labor?*
3. Do you get enough sleep/rest?*
4. What do you normally eat in a day?*
5. Do you eat any substances such as dirt or clay?
6. Do you smoke, drink alcohol, or use any other possibly harmful substances?
7. Who do you live with?
8. Has anyone ever prevented you from seeing family or friends, stopped you from leaving
your home, or threatened your life?
9. Have you ever been injured, hit, or forced to have sex by someone?
10. Are you frightened of anyone?
Present Pregnancy and Childbirth (First Visit)

When did you have your baby?

Where did you have your baby and who attended the birth?

Did you have any vaginal bleeding during this pregnancy?

Did you have any complications during this childbirth?

Were there any complications with the baby?

Present Postpartum Period (Every Visit)

1. Have you had any heavy bleeding since you gave birth?
2. What color is your vaginal discharge and how often do you need to change
your pad/cloth?
3. Have you had any problems with bowel or bladder function?

44
 4. Do you feel good about your baby and your ability to take care of her/him?
5. Is your family adjusting to the baby?
6. Do you feel that breastfeeding is going well?
Previous Postpartum History (First Visit)

Have you breastfed a baby before?

Did you have any complications following previous childbirths?

Contraceptive History (First Visit)


How many more children do you plan to have?

Have you used a family planning method before?

Are you going to use family planning in the future?

Medical History (Every Visit for items followed with an “*”; First Visit for other items)

Do you have any allergies?

Have you been tested for HIV?

Have you had anemia recently?

Have you been tested for syphilis?

Have you had any chronic illness/condition, such as tuberculosis, hepatitis, heart disease,
diabetes, or any other chronic illness?

Have you ever been in hospital or had surgery/an operation?

Are you taking any drugs/medications, including traditional/local preparations, herbal
remedies, over-the-counter drugs, vitamins, and dietary supplements?*

Have you had a complete series of five tetanus toxoid immunizations?

When did you have your last booster of tetanus toxoid?

Interim History (Return Visits)


Do you have a problem at present?

Have you had any problems since your last visit?

Has your address or phone number changed since your last visit?

Have your daily habits or lifestyle (workload, rest, dietary intake) changed since your
last visit?

Have you received care from another caregiver since your last visit?

Have you taken drugs/medications prescribed and followed the advice/recommendations
(plan of care) provided at your last visit?

45
 
Have you had any reactions to or side effects from immunizations or drugs/medications
given at your last visit?
Physical Examination
1. Observe gait and movements, and behavior and facial expressions.
2. Observes general hygiene, noting visible dirt and odor.
3. Checks skin, noting lesions and bruises.
4. Checks conjunctive for pallor.
5. Have the woman remain seated and relaxed, and measure her blood
pressure, temperature, and pulse.
6. Explains the next steps in the physical examination to the woman and obtains her consent
to proceed.
7. Asks the woman to empty her bladder.
8. Washes hands thoroughly.
9. Ask the woman to uncover her body from the waist up, have her lie comfortably on her
back, and examines her breasts, noting any abnormalities.
10. Asks the woman to uncover her stomach and lie on her back with her knees slightly bent.
11. Looks for old or new incisions on the abdomen, and gently palpates abdomen between
umbilicus and symphysis pubis, noting size and firmness of uterus, and checks
whether bladder is palpable above the symphysis pubis.
12. Examines the woman’s legs, noting any calf pain.
13. Asks the woman to uncover her genital area, covers or drapes her to preserve privacy
and modesty, and asks her to separate her legs.
14. Turns on the light and directs it toward genital area.
15. Washes hands thoroughly and puts new examination or high-level disinfected gloves on
both hands.
16. Inspects/examines labia, clitoris, and perineum, noting lochia, scars, bruising, and skin
integrity.
17. Immerses both gloved hands briefly in a container filled with 0.5% chlorine solution;
then remove gloves by turning them inside out:

If disposing of gloves (examination gloves and surgical gloves that will not be
reused), places in a plastic bag or leakproof, covered waste container;

46
 
If reusing surgical gloves, submerge in 0.5% chlorine solution for 20 minutes
for decontamination.
18. Washes hands thoroughly.
Care Provision
Note: Individualize the woman’s care by considering all information gathered during
assessment.

If the woman does not know her HIV status or has not been tested for HIV, provides HIV
counseling.

Based on the woman’s breastfeeding history, provides information about breast feeding
and breast care.

Reviews the woman’s complication readiness plan with her (or develop one if she does
not have one.

Encourages family involvement with the newborn and assists the family to identify
challenges/obstacles and devise strategies for overcoming them.

Introduces the concepts of birthspacing and family planning.

Provides advice and counseling about diet and nutrition.

Provides advice and counseling about self-care.

Gives tetanus toxoid (TT) based on woman’s need.

Dispenses sufficient supply of iron/folate until next visit and counsels the woman about
taking the pills.

Dispenses other medications based on need.

Schedules the next antenatal visit.

21. Assessment of the Newborn

Getting Ready

Prepares the necessary equipment.

Tells the mother what you are going to do, encourage her to ask questions, and listens to
what she has to say.
History (Ask the following questions if the information is not available on the mother’s/baby’s
record.)
Personal Information (First Visit)
1. What is your name, address, and phone number?

47
 2. What is the name and sex of your baby?
3. When was your baby born?
4. Do you have access to reliable transportation?
5. What sources of income/financial support do you/your families have?
6. How many times have you been pregnant and how many children have you had?
7. Is your baby having a particular problem at present?
8. Has your baby received care from another caregiver?
(Some of the following steps/tasks should be performed simultaneously.)
The Birth (First Visit)

Where was your baby born and who attended the birth?

Did you have an infection (in the uterus) or fever during labor or birth?

Did your bag of water break more than 18 hours before the birth?

Were there any complications during the birth that may have caused injury to the baby?

Did the baby need resuscitation (help to breathe) at birth?

How much did the baby weigh at birth?

Medical History (First Visit)


Do you have diabetes?

Have you had any infectious diseases such as hepatitis B, HIV, syphilis, or TB?

Does the baby have a congenital malformation (a deformity at birth)?

Has the baby received newborn immunizations such as for polio, TB, and hepatitis B?

Newborn Period (Every Visit)


Do you feel good about your baby and your ability to take care of her/him?

Is your family adjusting to the baby?

Do you feel that breastfeeding is going well?

How often does the baby feed?

Does the baby seem satisfied after feeding?

How often does the baby urinate?

Has the baby passed the first stool?

When was the last time the baby passed stool? What was the color/consistency?

Interim History (Return Visits)

o Is your baby having a problem at present? Has s/he had any problem since the last

visit? 48
 o Has your baby received care from another caregiver since the last visit?
o Have there been any changes in your address or phone number since the last visit?
o Have there been any changes in the baby’s habits or behaviors since the last visit?
o Have you been able to care for the baby as discussed at the last visit?
o Has the baby had any reactions or side effects from immunizations, drugs/medications, or
any care provided since the last visit?
Examining the Newborn
Assessment of Overall Appearance/Well-Being (Every Visit)
1. Tells the mother what you are going to do, encourage her to ask questions, and listens to
what she has to say.
2. Washes hands thoroughly and puts on clean examination gloves, if necessary.
3. Places the baby on a clean, warm surface or examine her/him in the mother’s arms.
4. Weighs the baby. Measures respiratory rate and temperature.
5. Observes color, movements and posture, level of alertness and muscle tone, and skin,
noting any abnormalities.
6. Examines head, face and mouth, eyes, noting any abnormalities.
7. Examines chest, abdomen and cord, and external genitalia, noting any abnormalities.
8. Examines back and limbs, noting any abnormalities.
9. Immerses both gloved hands in 0.5% chlorine solution:

Removes gloves by turning them inside out;

If disposing of gloves, places in leakproof container or plastic bag;

If reusing gloves, submerges in 0.5% chlorine solution for 10 minutes
to decontaminate.
10. Washes hands thoroughly with soap and water and dries them with a clean, dry cloth or
allow them to air dry.
Breastfeeding (Every Visit)

Helps the woman feel relaxed and confident throughout the observation.

Looks for signs of good positioning and attachment, effective suckling and
finishin breastfeed.
Mother-Baby Bonding (Every Visit)

Looks for signs of bonding.

49