ANTENATAL ASSESSMENT

INTRODUCTION

A through and systemic abdominal examination beyond 28 weeks of pregnancy can reasonably
diagnose the lie, presentation, position and the attitude of the fetus. It is not unlikely that the lie and
presentation of the fetus might change, especially in association with excess liquor amnii and hence
periodic check up is essential.

DEFINITION

Examination of a pregnant woman to determine the normalcy of fetal growth in relation to the
gestational age, position of the fetus in uterus & its relationship to the maternal pelvis.

PURPOSES
 To measure the abdominal girth & fundal height.
 To determine the abdominal muscle tone.
 To determine the fetal lie, presentation, position, variety (anterior or posterior) &
engagement.
 To determine the possible location of the fetal tones.
 To observe the signs of pregnancy.
 To detect any deviation from normal.

ARTICLES

1) Fetoscope/Stethoscope/Doppler machine.

2) Measuring tape/Pelvimeter.

PROCEDURE

Nursing Action Rational

1. Explain to the women what will be done & Reduces anxiety & promotes relaxation
how she may cooperate. during the procedure.
2. Instruct the woman to empty the bladder.
 3. Draw curtain around the bed.
Avoids discomfort during palpation.
Inspection
Provides privacy.
4. Position the woman for examination.
Promotes relaxation of abdominal
-Place a pillow under her head & upper shoulder. muscles.

-Have her arms by her sides.

- Expose her abdomen from below the breast to the Enables visualization of the whole
symphysis pubis. abdomen.

5. Inspect abdomen for the following:- Provides an estimate whether fetal

growth corresponds to gestational
Scars, diastasis recti, hernia, linea nigra, straie
period.
gravidarum, contour of the abdomen, state of
umbilicus, skin condition.

6. Determine the fundal height using the ulnar

side of the palm.

-12 wks- level of symphysis pubis

-16 wks- midway between symphysis pubis and

umbilicus.

-20 wks- 1-2 finger breadths below umbilicus.

-24 wks- level of umbilicus

-28 wks- 1-2 finger breadths above umbilicus

This method is more accurate.

-32 wks- at the level of xiphoid process.

-40 wks- 2-3 finger breadths below the process.

7. Measure fundal height using only one of the

following methods:-
a)Using measuring tape- The no. of cms measured should be
approximately equal to the weeks of
-Place zero line of the tape measure on the superior
gestation after about 22 to 24 weeks.
border of the symphysis pubis.

-Stretch the tape across the contour of the abdomen

to the top of the fundus along the midline.

b)Caliper method (pelvimeter) Normally, the measurement is 2 inches

(5 cm) less than the weeks of gestation.
-Place 1 tip of the caliper on the superior border of
Measurement >100 cm (39 ½ inches) is
the symphysis pubis & the other tip at the top of the
abnormal at any week of gestation.
fundas. Both placements are in the midline.
These steps reduce the stretching &
-Read the measure on the centimeter scale located
tension of abdominal muscles.
on the arc, close to the joint.
Cold hands may cause muscle
8. Measure abdominal-girth by encircling
contraction & discomfort. Resting hand
women body with a tape, at level of umbilicus.
on the mother’s abdomen would help
her to become accustomed to your
Abdominal Palpation or Leopold’s Maneuvers
touch & dissipate muscle tightening.
9. Instruct the women to relax her abdominal
These measures would aid in gathering
muscles by bending her knees slightly & doing
greatest amount of information with
relaxation breathing.
least discomfort to the woman.
10. Be sure your hands are warm before
Round, hard readily, movable part,
beginning to palpate reset your hand on the
ballotable between the fingers of both
mother’s abdomen lightly while giving explanation
hands is indicative of head. Irregular,
about the procedure.
bulkier, less firm & not well defined or
11. For the technique of palpation, movable part is indicative of breech.
Neither of the above is indicative of
-Use the flat palm or surface of fingers & not
transverse lie.
fingertips. Keep fingers of hands together & apply
smooth deep pressure as firm as is necessary to A firm convex, continuously smooth &
obtain accurate findings. resistant mass extending from breech to
neck is indicative of fetal back. Small
12. Perform the first maneuver (fundal
knobby, irregular mass which move
palpation)
when pressed or may kick or hit your
examining hand is indicative of the
-Face the woman’s head.
fetal small parts all over the abdomen
-Place your hands on the sides of the top of the are indicative of a posterior position.
fundus & curve the fingers around the top of the
uterus.

-Palpate for size, shape, consistency & mobility of

the fetal part in the fundus.

13. Do the second maneuver (lateral

palpation)

-Continue to face the woman’s head.

Avoids discomfort.
-Place your hands on both sides of the uterus about
midway between the symphysis pubis & the fundus. If the fatal head is above the brim, it
will be readily movable & ballotable. If
-Apply pressure with 1 hand against side of uterus
not readily movable, it is indicative of
pushing fetus to other side & stabilizing it there.
an engaged head.

-Palpate the other side of the abdomen with the

examining finger from the midline to the lateral
side & from the fundus using smooth pressure & Avoids pain with the maneuver.
rotator movements.

-Repeat the procedure for examination of opposite

side of the abdomen.

14. Third maneuver (Pawlik’s grip)

-Continue to face the woman’s head make sure the

woman has her knees bent.
-Grasp the portion of the lower abdomen This maneuver determines level of
immediately above the symphysis pubis between engagement.
the thumb & middle finger of one of your hands.

15. Fourth maneuver (pelvic palpation)

-Turn & face the woman’s feet (make sure the

woman’s knees are bent.)

-Place hands on the sides of the uterus, with the

palm of hands just below the level of umbilicus &
your fingers directed towards the symphysis pubis.

-Press deeply with your fingertips into the lower

abdomen & move them toward the pelvic inlet.

-The hands converge around the presenting part

when head is not engaged.
Fetal heart sounds are heard over fetal
-The hands will diverge away from the PP & there back (scapula region) in vertex and
will be no mobility if PP is engaged or dipping. breech presentation over chest in face
presentation.
Auscultation

16. Place fetoscope/ stethoscope over convex

portion of fetus closed to anterior uterine wall.

AFTER CARE
1) Inform the mother of findings. Make her comfortable.
2) Replace articles and wash hands.
3) Record in the patients chart, the time, findings and remarks if any.

POSTNATAL ASSESSMENT
 INTRODUCTION
Puerperium is the period following childbirth during which the body tissues, specially the pelvic
organs revert back approximately to the pre-pregnant state both anatomically and physiologically.
Involution the process whereby the genital organs revert back approximately to the state as they were
before pregnancy. The woman is termed as a puerperal.
Puerperium begins as soon as the placenta is expelled and lasts for approximately 6 weeks when the
uterus becomes regressed almost to the non-pregnant size. In postpartum is normally a well patient.
Complications are possible, but for the most part of the patient is a healthy individual under
temporary confinement expecting to take home a healthy infant. The following are some guidelines
to promote physiological psychological safety of the postpartum patient.

DEFINITION
According to D. C. Dutta
Postnatal care includes systematic examination of the mother and baby and appropriate advice given
to mother during post-partum period.

According to Nadine M. Jacobson

Postpartum care encompasses management of the mother, newborn, and infant during the postpartal
period. The period usually is considered to be the first few days after delivery, but technically it
includes the six week period after childbirth upto the mother’s postpartum checkup with her health
care provider.

HISTORY
1. Identification Data:
1. Name
2. Age
3. Ward No.
4. IP No.
5. Marital Status
6. Address
7. Father’s /Husband’s Name
8. Educational Status
9. Husband’s Educational Status
10. Occupation
11. Family Income
12. Date and Time of Admission
13. Date and Time of Delivery

2. Present Obstetric History:

1. Parity
2. Mode of Delivery:
a) Normal Vaginal
 With episiotomy
 Without episiotomy
 With tear- First Degree/ Second Degree/ Third Degree
b) Spontaneous/ Medical/ Caesarean any other
3. Full Term/ Premature
4. Presentation : Vertex/ Breech/ Shoulder/ Face
3. Past Obstetric History :

S.N Yea Term/ Pre- Sex Weight Remarks/

o r term/ Still Complications
Birth/ live to Mother and
abortion Baby

4. Family History
Illness- TB / Hypertension / Diabetes / Asthma / Jaundice

5. Medical / Surgical History

Any hospitalization
 Surgeries
 Medical Condition
. Personal History
 Dietary
 Habits
 Use of contraceptives

7. Menstrual History
8. Contraception
9. Psychological

PHYSICAL EXAMINATION

General Examination
 Nourishment : Well-nourished /Undernourished
 Body Built : Thin / Obese
 Activity : Active / Dull
 Weight : …Kgs.
 Vital Signs :
 Temperature: ……◦c
 Pulse : ……. /mt
 Respiration : ……….. / mt
 Blood Pressure : ………….. mmHg

Mental Status
 Consciousness : Conscious / unconsciousness / delirious
 Mood : Anxious / worried / depress.
Skin Conditions
 Colour : Pallor / Jaundice / Cyanosis / Flushing
 Texture : Smooth / Rough
 Moisture : Moist /Dry
 Skin Turgor : Hydrated / Dehydrated
 Temperature : Warmth / cold / clammy
 Lesions : Macules / Papules / Vesicles / Wounds
 Presence of Spider nevi, Palmer erythema, superficial varicosities.
  Hyperpigmentation of :
 Areola nevi
 Linea Nigra
 Chloasma
Head
 Scalp :
 Cleanliness
 Condition of the hair
 Dandruff
 Pediculi
 Face : Pale / Flushed / Puffiness / Fatigue

Eyes
 Eyebrows : Normal or absent
 Eyelashes : Infection, Sty
 Eyelids : Oedema, Lesions
 Eyeballs : Sunken / Protruded
 Conjunctiva : Pale/Red/Purulent Discharge
 Sclera : Jaundiced
 Vision : Normal/Shortsighted/ Longsighted

Ear
 Hearing : Hearing Acuity
Any discharges/ cerumen obstructing the ear passage.

Nose
 External Hares : Crust ear discharge
 Nostrils : Inflammation of the mucus membrane/septal deviations

Mouth & Pharynx

 Lips : Redness/Swelling/Crusts/Cyanosis/Stomatitis
 Odor : Foul smelling
 Teeth : Discoloration/Dental Care
 Mucus Membrane : Ulceration/Bleeding/Swelling/Pus Formation & gums.
Throat & Pharynx : Enlarged tonsils/redness/pus
Neck
 Lymph Nodes : Enlarged/Palpable
 Thyroid Gland : Enlarged

Chest

 Thorax : Shape
Symmetry of Expansion
Posture
 Breath Sounds : Vesicular Sounds
Wheezing/Rhonchi
Crepitations
Pleural Rub
 Heart : Heart Rate
Location of Apex Beat
 Cardiac Murmurs
 Axilla : Any lymph Node Enlargement
 Breast : Secretion of colostrum/Milk
 Engorgement : Any Tenderness/Painful/Tense/Dilated Veins/
Warmth/Presence of crust
 Nipples : Retracted/Inverted/Cracked

Abdomen
 Inspection : Presence of Scar/Wound
If caesarean : Discharge/Tenderness
Presence of Striae

 Palpation : Height of the Uterus - ……………..cms

Consistency – Hard / Firm / Boggy
 Auscultation : Bowel sounds – Present / Absent
Perineum
 Clean
 Intact / Tear / Wound
 Episiotomy – Medio-lateral / lateral / medial
(REEDA- REDNESS/ EDEMATOUS/ECCHYMOSIS/ DISCHARGE/
APPROXIMATION)
Lochia
 Amount of bleeding : Scanty / moderate / heavy
No. of pads changed
 Colour : Red / Yellow / White
Rubra / Serosa / Alba
Cervix
 Oedematous / Thin / Fragile

 Clots : Present / absent

 OS : Open / Closed
 Any Tear
 Vaginal Mucosa : Smooth / distended / thin / atrophic
 Vaginal Introitus : Erythematous / Oedematous
 Bladder Function :
1. Amount of Urine Output - …….ml
2. Bladder Distention
3. Discontinuation of catheter
 Bowel Function :
1. Haemarroids/anal varicosities : present/absent
2. Ankeloedema / varicose veins

 Extremities : Generalized muscular fatigue

 Nails :
1. Colour
2. Capillary Refill
3. Shape
 NEWBORN ASSESSMENT

INTRODUCTION
A newborn should have a thorough evaluation performed within 24 hours of birth to identify any
abnormality that would alter the normal newborn course or identify a medical condition that should
be addressed (eg, anomalies, birth injuries, jaundice, or cardiopulmonary disorders) . This
assessment includes review of the maternal, family, and prenatal history and a complete examination.
Depending upon the length of stay, another examination should be performed within 24 hours before
discharge from the hospital.

DEFINITION

A detailed and systematic whole body examination of a stabilized newborn during

the early hours of life.

PURPOSES
1) To determine the normally of different body systems for healthy adaptation to extra uterine
life.
2) To detect significant medical problems for immediate management.
3) To detect any congenital problems present for early management and parent education.

ARTICLES
1) Measuring tape
2) Soft rubber catheter/rectal thermometer
3) Stethoscope
4) Flash light
5) Clean gloves

INDICATION
1) Heat loss and cold stress
2) Decreased infection
3) Regulating/ maintaining temperature.
4) Improve visual inspection.

CONTRAINDICATION
1) Apnea,
2) Tachycardia
3) Bradycardia
 4) Increased crying

GENERAL INSTRUCTIONS
1) The newborn must be stabilized before starting the assessment procedure, i.e. normal body
temperature and color.
2) The examination can be conducted without awakening the baby, although he will need to be
exposed at intervals for a complete and accurate examination.
3) Nurse’s hands must be washed thoroughly before touching the baby.
4) The new born should be protected from harmful processes such as chilling or nosocominal
infection.
5) Examination should be done systematically.
6) A head to toe and systems approach to be followed for complete examination.
7) The examination may be carried out with the baby in a warmed crib or on an examination
table.
PROCEDURE

S.No. Nursing Action Rationale

1. Wash hands thoroughly and dry them and Avoid any chance of introducing infection to the
don gloves. baby.
2. General appearance : For a normal baby the finding include :
 Uncover the baby and note general  Body symmetrical and cylindrical in contour.
appearance.  Head large in proportion to the body.
 Narrow chest.
 Protruding abdomen
 Small hips

3. Take the head and body measurement Normal measurement are :

 Head circumference 33-35 cm.
 Chest rump length 34-35 cm
 Crown rump length 34-35 cm
 Crown heel length 48-52 cm.

4. Assess skin : Normal skin is smooth, soft, elastic, warm and

 moist, the skin is pink, nail beds are blue. Color of
Note the color of skin especially around palms and soles will improve with activity.
mouth and finger nailbuds.
5. Note any vascular nevi, milia, Mongolian Trauma marks may be present on babies born by
spots, or trauma marks on the head, neck instrument delivery or those who had tight nuchal
or body. cord.
6. Assess head : Asymmetry indicates moulding.
Examine the head for symmetry, caput,  Swelling on the scalp from pressure of the
cephalhenatoma and the status of cervix indicates caput succedaneum.
fontanelle.  Subperiosteal bleeding, which does not cross
suture line indicates cephalhematoma.
 Depressed fontanelle indicates dehydration.
 Bulging fontanelle indicates increased
intracranial pressure.

7. Assess face : Asymmetry is usually related to damage to the

Observe symmetry of infant’s face note facial nerve and becomes obvious when the infant
any characteristic feature like flattened cries. These are seen in babies with fetal alcohol
nose, folds below eyes, upturned nose, syndrome, chromosomal abnormality or due to
etc. oligohydramnios.
8. Assess eyes : Normally the eyes are gray, blue or brown in color.
Examine the baby’s eyes for response to  Infants will close their eyes in response to light.
light, puffiness, discharge, opacity or  Puffiness is common after forceps delivery
conjunctival hemorrhage.  Subconjunctival hemorrhage occurs due to
pressure on the fetal head during delivery.
 Opacity suggests cataract formation.
 Ptosis of the eyelids suggests nerve damage.
 Minor drainage may occur after prophylactic
eye medication.

9. Assess nose : Newborns breath through the nose flaring of

Observe the nose for appearance, nostrils indicates respiratory distress.
breathing and any flaring of nostrils.
10. Assess ears : Newborns breath through the nose flaring of
 nostrils indicates respiratory distress.
Examine the ears for the following :  Ear lobes are firm and cartilaginous in mature
 Firm and cartilaginous or term babies.
 Presence of ear canal  Startle reflex to sudden noise indicates that the
 Location on the head newborn can hear.
 Hearing  Deformed ear lobes with upper margin of the
pinna rolled down and thickened are seen in
Down’s syndrome.
 Low set ears are seen Trisomy of 15 and 18.

11. Assess mouth :  Asymmetry of the mouth when open indicates

 Examine the mouth & note the facial nerve paralysis
presence of any of the following :  Pooling of saliva is a sign of trachea-
 Cleft lip or palate oesophageal fistula/Atresia.
 Epstein pearls  Macroglossia is seen in Down’s syndrome.
 Asymmetry when crying
 Natal teeth
 Macroglossia
 Pooling of saliva.

12. Assess neck  Short neck with flexible movement of head to

Examine the neck for the following each side is normal.
 Head freely movable  Neck webbed on shoulder is seen in Down’s
 Neck webbed on shoulders syndrome & Turner’s syndrome.
 Extended arms on one side ( shoulder  Extension of one arm indicates clavicle fracture
Dystocia) or damage to brachial nerve.
 Tightness of muscles on one side  Tightness of neck muscle is a sign of torticollis

13. Assess chest : Diaphragmatic breathing with symmetric

Examine the chest for the following movement of chest and abdomen is normal.
 Shape & movement with breathing  Quiet & free respiration at the rate of 40-60/
 Respiration pattern min is normal after initial activity.
 Grunting sound on expiration  Grunting indicates respiratory distress.
 Retractions on inspiration  Clavicles clearly palpate if fracture is present.
  Hearts rate  Milk secretion is present in response to
 Clavicles palpable on both sides maternal hormones.
 Presence of breast engorgement &
secretion of milk

14. Assess abdomen :  Normal abdomen should be round & protruding

Observe the abdomen and note :  Small scaphoid abdomen may indicate
 Shape diaphragmatic hernia.
 Umbilical cord stump for presence of  If three vessels are not found congenital
three vessels malformations should be invested.
 Any mass  Mass may indicate umbilical or inguinal hernia
 Bowel sounds or abdominal mass.
 Passage of meconium  Bowel sound are normally active
 Passage of meconium indicates a patient anus.

15. Assess genitalia :

Male
Examine if :
 Foreskin covers the glans penis.  Normally foreskin covers glans penis
 Urethral meatus opens at the tip of the  Deviations indicate hypospadiasis or
penis epispadiasis.
 Testicles are palpable in the scrotum  If not palpable, undescended testicles should be
bilaterally. investigated.
Female
 Labia minora is prominent & is not
covered by labia majora.
 Edematous genitalia
 Vaginal discharge &  Edema is normal in breech born babies.
pseudomenstruation.  Vaginal discharge is a normal response to
maternal hormones.

16. Assess back :

Hold the newborns prone & examine the
 back to evaluate the spine
Note the presence of any
 Dimple in the coccygeal or  Normally no abnormal curvatures & lesions are
sacrococcygeal region. seen
 Sinus opening or spina bifida  May denote pilonidol cyst
 Tufts of hair  May indicate fistula.

17. Assess anus Presence of meconium on the catheter on

Verify the presence of a perforate anus by withdrawal indicates patency of anus.
inserting a soft rubber catheter gently into
the rectum
(if the newborn passes meconium earlier,
patency need not be checked)
18. Assess upper extremities : Arms should be of equal length when extended
Note the proportions to the rest of the Infants should normally resist having arm exended.
body, symmetry & spontaneous Long nail are present in post-term babies.
movement of arms & hands.
 Check if the baby holds hands in fists.
 It fingers show webbing,
polydactylism or syndactylism
 If fingers are developed & extend
beyond fingertips.
 If any skin tags are present.

19. Assess lower extremities Should be of equal length when extended.

Check the legs for the following
 Symmetry & length
 Range of motion
 Proportion to the rest of the body If abduction is asymmetrical or hip click is present,
 Symmetry of creases of legs & dislocated hip to be suspected.
buttocks. With knees flexed, abduct
legs to the frog like position.
 Assess if the legs are persistently Persistent limpness, indicates spinal cord lesion
 limp.

20. Assess feet : Wrinkles are normally present in full term babies
Examine the soles for presence of wrinkles are absent in pre-term babies. The first &
wrinkles, acrocyanosis & conditions such second toes are widely separated in Down’s
as Talipes equinovarus, Talipes syndrome.
calcaneovalgus, bow leg, webbing, Acrocyanosis is common immediately after birth.
polydactylism or syndactylism.
21. Assess CVS : The normal heart rate is 120-160 bpm.
After making the baby quiet, auscultate If cardiac murmurs are heard these should be
the heart sounds & feel for pulses in the documented & informed to the pediatrician.
upper & lower extremities. --Murmurs are common in newborns during the
transition from intrauterine to extra-uterine life.
Congenital heart defects must be excluded.
22. Perform neurologic examination:

Elicit the following reflexes to assess the Lack of a blink in response to a loud noise may indicate
nervous system: deafness

Failure to blink may indicate blindness.

a. Blinking reflex due to loud noise.
Clap your hands or produce a loud
Palate moves.
clicking noise. Be careful not to clap near
the infant to prevent a wave of air from Both hands will flex and can be compared for strength.
causing a blinking of the eyes. Weakness on one side may be indicated by a failure to
b. Blinking reflex due to bright light grasp when the palm is stimulated.
Shine a bright light into the infant's eyes
to elicit the blinking reflex
c. Cranial nerve X can be checked by using
The infant's mouth will open, and the head will turn
a tongue blade to gag the infant.
toward the side stimulated. This reflex is marked during
d. Palmar grasp reflex Place your fingers
the early weeks of life.
across the infant's palm from the ulnar
side. The infant needs to be in a relaxed
position with head in a central position.
Reinforcement may be offered by having The legs flex at the hips and knees (persists for about 4
the infant suck on a bottle at the same months).
time
e. Rooting reflex
Touch the edge of the infant's mouth.
f. Incurving of the trunk Hold the infant
Normally, the infant responds by lifting one knee
horizontally and prone in one arm while
and hip into a flexed position and moving the
using the other hand to stimulate one side
opposite leg forward making a series of stepping
of the infant's back from the shoulders to
movements). Difficulty with the stepping reflex
the buttocks. The trunk curves toward the
stimulated side as the shoulders and and stiffness or spasticity connected with crossing
pelvis move toward the stroking hand of the feet and scissoring is indicative of spastic
(persists until the infant is about age 2 paraplegia or diplegia. it should be noted that the
months). stepping response may be affected by breech
g. Vertical suspension position delivery. (It may also be affected by weakness.)
Place your hands under the infant's axillae The stepping response is evident toward the end of
with thumbs supporting the back of the the first week after birth and persists for a variable
head and hold the infant upright.
time.
h. Stepping response
Hold the infant under its axillae with  The arm and leg on the side to which the head
thumbs supporting the back of the head. is turned will extend, whereas those on the
Allow the infant's foot to touch a firm
other side will flex (the so-called bow and
surface.
arrow
i. Tonic neck reflex
Hold the infant in a supine position with position).
the head turned to one side and the jaw
held in place over the shoulder.  This reflex persists for about 6 month it may be
j. Mass reflexes (Moro or startle reflex) present at birth or delayed until the infant is age
Hold the infant along your arm with the 6 or 8 weeks.
other hand below the lower legs. Lower  Persistence beyond 6 months suggests major
the feet and body in a sudden motion.
cerebral damage.
k. Perez reflex
 The Moro reflex is present at birth and
Hold the infant in a prone position along
disappears at approximately the end of the third
your arm; place the thumb of the other
month. Persistence beyond 6 months is
hand on the sacrum and move it firmly
significant.
toward the head, along the entire
length of the spine.  Asymmetrical response may be caused by

l. Corneal reflex:when the eyes are open, paralysis of the arm after difficult delivery,
touch the cornea lightly with the piece of tension and injury to the brachial plexus, or a
 cotton.Normally the eyes close. fracture of the clavicle or humerus. A
m. Doll’s eye reflex:move the head dislocated hip would produce an asymmetrical
slowly to right or left. Eyes lag behind response in the lower extremities.
and do not immediately adjust to new
The head and spine will extend and the knees will flex
position of head.
upward.
n. Gallant reflex: stoke the back of the
infant lightly lateral to the vertebral Absence of this response denotes lesion of the 5th cranial
column. The baby respond by flexing nerve.
the entire trunk to the side stimulated.
Lack of response indicates This disappears as fixation develops
neurological deficit.
The reflex lasts for about one month.

23. Inform the mother about baby’s condition.

24. Record the finding in the newborn
assessment record.

COMPLICATION
1) Increased crying
2) Tachycardia
3) Irritability of new born
4) Injury

AFTER CARE
 Assist child redress and place child back in comfortable position.
 When the physical examination has been completed, the examiner should ask questions to parents
and child, if age appropriate, whether they have any questions concerning the examination.
 Findings are documented in a complete and concise manner. Deviation from normal and risk
factor should be identified and documented.

ROLE OF NURSE
 Always begin examination in a nonthreatening manner for young children & examine painful
areas last.
 Provide privacy, especially for school-age children and adolescents
 Examine child in a comfortable and secure position
 Reassure child throughout examination, especially for adolescents.
 Praise the child for cooperation during examination.

SPECIAL CONSIDERATION
1) All the preparation should be stabilized before starting the assessment procedure,
2) Nurse’s hands must be washed thoroughly before touching the baby.
3) The nurses should be maintained from harmful processes such as chilling or nosocominal
infection.
4) Examination should be done systematically.

BREAST CARE

INTRODUCTION
Breast changes during pregnancy to prepare for making milk. Breast contains milk glands and milk
ducts that increase in number, causing breast to get larger. It is important to take care of the breasts if
mother plans to breast feed or is breast feeding. With good breast care one can improve breast
feeding experience for self and for the baby. Taking care of the breast will also prevent problems that
can happen while breast feeding.

Avoid pressure on breast:

sleeping in a face down position may squeeze breast and block milk ducts. 1 should not wear
underwire bras, and avoid wearing bras that are too tight and clothes that are tight over the breasts.

Breast support:

wear a supportive bra. Avoid wearing underwire bras. Milk ducts extends up to the armpits.
Underwire bras can squeeze the breast and pinch on milk ducts and cause plugged ducts or mastitis.
Make sure that the bra fits correctly and does not squeeze the breasts.

Cleaning the breast:

wash breast with warm water once every day. Do not use soap or other cleansing agents. These can
irritate the nipples. One should have clean hands when touching the breasts to help prevent getting
infection.

Keep nipples dry:

do not wear plastic nipple shells or plastic lined nursing pads. These can trap moisture and do not
allow air flow to the nipples. Placing fabric breast pads inside the bra will let air inside. Change
breast pads often to prevent irritation. If nipples are damaged, nursing pads may stick to the nipple.
Soak the pads in warm water to help remove them.

Nipple conditioning:
let the nipples air dry after breast feeding. Use breast milk or pure lanolin ointment on the nipples if
needed to keep them from getting chapped and dried out. Some creams and lotions can cause an
allergic reaction with irritation of the skin.

BREAST SELF EXAMINATION

 DEFINITION

Breast examination is the examination of the breasts to determine if the breast are normal or
abnormal.

TECHNIQUE
 Basic requirement for a proper breast examination include the following:
 Patient undressed down to the waist.
 Examining table with access from both sides.
 A mobile bright light with an assistant to focus the light from 1 area to another as the
examination is being conducted.

Adequate breast examination is performed by careful inspection and palpation. This requires a
routine planned procedure with several changes in the patient’s position and meticulous palpation of
the entire extent of the breasts, which commonly cover most of the anterior chest wall.

BREAST SELF EXAMINATION

Part 1

Inspection

 Visual examination
 Performed standing in front of a mirror.
 Arm by side arms-overhead and palms pressed together.
 Arms on hips press firmly.

What to observe?

 Change in size, shape or colour (redness) of the breast.

 Change in position and shape of the nipple e.g. retraction, crackling etc.
 Scaling or sores around the nipples.
 Swelling, dimples or enlargement of the pores of the skin.

Part 2

Palpation
  Performed standing or lying down with pillow under the shoulder of the side (i.e right or left)
where the breast is to examined, using the opposite hand. Then follow the pattern as
described below.
 Starting from the outer part of the breast, palpate by making small circular movements.
Examine the entire surface including the nipples.
 Continue this way up to the nipples, palpate with straightened fingers.
 Squeeze each nipple between the thumb and the index finger to eventually observe any nipple
discharge.
 Hooked fingers will allow to examine the underarm with the wrist bend.

What to observe?

 Any change in the texture of breast e.g. thickening or hardening.

 Appearance of a new lump, if it occurs so contacts the health care provider.
 Abnormal nipple discharge.

STEPS OF BREAST SELF EXAMINATION

STEP 1

1. Stand before a mirror.

2. Inspect both breasts for anything unusual such as any discharge from the nipples or
puckering, dimpling, or scaling of the skin.

STEP 2

1. Watching closely in the mirror, clasp your hands behind your head and press your hands
forward.
2. Note any change in the contour of breast.

STEP 3

1. Next, press your hands firmly on your hips and bow slightly toward your mirror as you pull
your shoulders and elbows forward.

STEP 4
 1. Raise your left arm. Use three or four fingers of your right hand to explore your left breast
firmly, carefully, and thoroughly.
2. Beginning at the outer edge,
3. Press the flat part of your fingers in small circles, moving the circles slowly around the
breast.
4. Gradually work toward the nipple. Be sure to cover the entire breast.
5. Pay special attention to the area between the breast and the underarm, including the underarm
itself.
6. Feel for any unusual lump or mass under the skin.
7. Gently squeeze the nipple and look for a discharge.
8. Repeat the examination on your right breast.

Step 5

1. Steps 4 and 5 should be repeated lying down.

2. Lie flat on your back with your left arm over your head and a pillow or folded towel under
your left shoulder.
3. This position flattens the breast and makes it easier to examine. Use the same circular motion
described earlier.
4. Repeat the exam on your right breast.

PER VAGINAL EXAMINATION AND INTERPRETATION

DEFINITION
It is examination done per vagina to detect the status of the vagina and cervix and to assess the
progress of labor as the fetal presenting part descends through the birth canal.

PURPOSES
 To make a positive diagnosis of labor.
 To monitor cervical dilatation and effacement.
 To make a positive identification of the fetal presentation.
 To ascertain whether fore water have ruptured.
 To determine whether cord prolapsed is likely to occur.
 To assess the progress or delay in labor.
 To detect whether 2nd stage has begun.
 To assess of head and degree of moulding.
 To apply fetal scalp electrode.

ARTICLES
A sterile tray containing:
1. Sterile cotton balls to give perineal care.
2. Art6ery forceps.
3. Bowl with antiseptic solution.
4. Sim’s vaginal speculum.
5. Sterile cream in a bowl with lubrication.
6. Sterile gloves (outside the tray).

GENERAL INSTRUCTIONS
 The bladder should be empty.
 The fingers should not be withdrawn until the required information has been obtained.
 Perineal care should be given before performing vaginal examination.
 It should be restricted/limited after membranes have ruptured.
 It should be avoided in case of antepartum haemorrhage.
PROCEDURE

Nursing Action Rational

a. Explain procedure to mother. Promotes compliance.
 Avoids discomfort during procedure.
b. Ask mother to void if the bladder is not
empty. For smooth and safe performance of the
c. Explain how she should relax during the procedure.
examination. Serves as a baseline data.
d. Read the chart for previous findings.
e. Position the women in dorsal recumbent For good visualization.
position with knees flexed.
f. Drape the patient. Provides privacy.
g. Do a surgical hand washing.
h. Wear sterile gloves. Prevents spread of infection from hands
to the mother and fetus.
i. Observe the external genitalia for the
following:
 Signs of varicosities, edema, vulval
warts/sores. The external genitalia must be observed
 Scar from previous episiotomy/laceration. before cleansing the vulva.
 Discharge/bleeding from vaginal orifice.
 Color/ odour of amniotic fluid, if membranes
have ruptured.
Lubricates the fingers.
j. Cleanse the vulva and perineal area.
k. Dip the 1st 2 fingers of the right hand into the Touching clitoris cause discomfort.
antiseptic solution.
l. Holding the labia apart from thumb and index Touching anus cause contamination.
finger of left hand, insert the lubricated
fingers into vagina, palm side down, pressing Normally vagina is warm and moist.
Hot, dry vagina is a sign of obstructed
downwards.
labor, seen in maternal fever.
m. With the fingers inside, explore the vagina for
the required information taking care not to Firm and rigid walls suggest long labor.
touch the clitoris/anus. Note the following: Normal findings is soft vaginal walls.
 The feel on touch of vaginal walls.
 Consistency of vaginal walls. Normally cervix is situated centrally. In
 Scar from previous perineal wound, cystocele, early labor, cervix is situated posteriorly.
Thinning of the cervix and shortening of
rectocele.
the canal indicates effacement.
Enlargement of the external os indicates
n. Examine the cervix with the fingers in the dilatation. Normal cervix is soft, elastic
vagina turned upwards. Locate the cervical os and well applied to the presenting part in
by sweeping the fingers from side to side. normal labor. Intact membranes which
Assess the cervix for: becomes tense during contractions with
well fitting presenting part indicates
 Effacement
forewater. Protruding membranes are
 Dilatation seen with ill fitting presenting part.
 Consistency Membranes will not be felt if they
 Forwaters rupture early.
o. Assess the level of presenting part in relation
 to maternal ischial spines. The distance of the presenting part
p. Identify the presentation by feeling the hard above and below the ischial spines is
expressed as – and + station
bones of the vault of the skull, fontanelles and respectively.
sutures.
The saggital suture may be felt in right,
left or transverse diameter of pelvis in
q. Identify the position by feeling the features of early labor.
presenting part.
Posterior fontanelle will be felt in case
of well flexed head. Location of
r. With fingers, follow the saggital sutures to fontanelle in relation to pelvis will give
feel the fontanelle. information about the position.

The parietal bones override the occipital

bone in case of moulding.
s. Assess the moulding by feeling the amount of For comparison with the earlier findings
overlapping of skull bones.
t. At the completion of examination, withdraw Encourages mother to relax and
fingers from vagina. Take care to note the participate in labor.
presence of any blood or amniotic fluid.
u. Remove gloves and wash hands. Act as a communication between the
staff members.
v. Auscultate for fetal heart tones.
w. Assist the woman to a comfortable position
and inform her of the progress of labor.
x. Record the findings and observations in the
patient’s chart and inform the physician of the
observations and progress of labor.

ANTENATAL EXCERCISE

INTRODUCTION:-
 Regular exercise during pregnancy can improve health, reduce the risk of excess weight gain
and back pain, and it may make delivery easier.

DEFINITION:-
According to Wikipedia

“ Antenatal exercise aims at preventing low back pain and enhancing physical and psychological
preparation for delivery by means of joint stretching and muscle strengthening.’’

Or

“”antenatal exercise promote comfort and maintain or increase muscle tone, fracture that
determine the type and amount of exercise recommended depends on the individuals, need the
patients general, physical condition during pregnancy, and the current stage of pregnancy”.

BENEFITS:-
1. Make the patient understand the change in the body. A machine during pregnancy due to the
various physical changes.
2. Promotes awareness of good posture and training for the same.
3. Relaxes the whole body.
4. Builds exercise tolerance and endurance .
5. Prepare the body for easy labour by strengthening and stretching the back, abdominal and
pelvic floor muscles.
PRECAUSTIONS DURING EXERCISE:-
1. Prepares the mother to go through labour and understand the importance of postnatal
excercise Drink fluids before, during and after excercising to prevent dehydration , which can
use serious problems with pregnancy.
2. Start slowly. Begin with as little as 5 min a day and add 5 min a week until the mother can
stay active for 30 minutes a day.
3. Choose low – intensity activities such as gentle stretching or walking .
4. Exercise regular- at least 3 times a week. This will improve the fitness, reduced risk of injury.
5. Warm up and cool down.
 Begin each exercise season with 5-10 min of light activity and stretching.
 And each exercise session with a 5-10 min cool down a period of slow the mother
activity and stretching .
6. Do not exercise to exhaustion.

TYPES OF ANTENATAL EXERCISE:-

1. Circulatory exercise.
2. Stretching exercise.
3. Leg exercise
4. Arm
5. Breathing exercise
6. Back stretch
7. Knee excercise
8. Abdominal exercise
9. Pelvic tilting
10. Pelvic floor exercise.

1. DIAPHRAGMETIC BREATHING:-
Purpose :-
To enhance oxygen exchange and efficient expansionof the lunges. To decrease
breathlessness on minimal exertion. Since the main vein from the legs and pelvis pass
through the diaphragm, its pumping action will improve blood circulation.
Position:-
Preferred position is sitting (but can be done in any position). Place hands on abdomen.
Movement technique: as the breathe in, the abdomen and rids should expand outward
outward, as the content of the abdomen. Exhale through partially lips, pulling in abdominals.

2. KEGEL EXERCISES
Purpose:-
To strengthen the pelvic floor muscles which helps prevent urine leakage during a laugh,
cough, or sneeze.
Position :-
Any position, sitting, standing, or lying down. Movement technique: contract the pelvic floor
muscles as would to stop urine flow for 3 seconds and then relax the muscles for 3 seconds.
This muscles fatigues quickly so only do five to ten repetition at a time. Do not hold breath
normally while doing this exercise. This exercise can be done during a variety of daily
activity, such as sitting in a meeting, while waiting at a traffic light, while talking over the
phone, etc.

3. PELVIC ROCKING EXERCISE

Purpose
To strengthen the muscles of the abdomen and the lover back. it helps to relive back pressure
by moving the baby forward off of the mother back temporarily. It also relives pressure on
the blood vessels in the area around the uterus, and relives pressure on the mother bladder. It
will help the mother relax and will also improve the digestive process.

Position
Lie on the floor on the back with the knees bent and the feet on the ground. Ones done with
this exercise , do not continue to lie on back. Movement technique:
Inhale contract the abdominal muscles and flatten the small off back on the floor. Hold this
for a count of five as exhale. Repeat five times. To make sour doing it right, put the hand
under the small of back as rock the pelvis. Repeat 5 times a day do not exercise if it make feel
light headed

4. BRIDGING
Purpose
 To assist in alleviating discomfort from decreased intestinal mobility, including gas.
position

lying on back knees bent and feet on the floor movement technique: lift hips several inches
off

the floor. Come back to original position.

5. ARM/LEG RAISES:-

Purpose:-

To reduce backaches, swelling and constipation.

Position :-

hands and knees movement technique: tighten the abdominal tight, raise one arm and the
opposite leg away hold this position 4 seconds. Lower the arm and leg slowly and alternate
sides.

6. WALL SLIDES:

Purpose

To reduce backaches, swelling, and constipation.

Position

Stand with the back, shoulder, and hand against a wall and straight ahead. Keep the shoulders
relaxed and feet 1 food away from the wall and a shoulders width apart movement technique.

Keeping the head against the wall, side down the wall, lowering the buttocks toward the floor
until the thighs are almost parallel to the floor. Hold this position for 10 seconds. Make sure
to tighter the thigh muscles as slowly slide back up to the starting position.

7. HEEL RAISES

Purpose :-

To reduce backaches and swelling

Position:-

Balance while standing behind a chair or counter

Movement technique
 Raise the body up onto the toes an hold it for 5 seconds, then slowly lower self down

8. THORACIC EXTENSION

Purpose;-

To strengthen the arms and back

Position:-

While sitting in chair, clasp both arms behind the head.

Movement technique

Gently arch backward the lock up toward the calling, repeat 10 times, do this several times per
day.

9. SQUATTING POSITION:-

Purpose:-

The exercise stretches the perineal muscles.

Position :-

The patient must squat and keep her feet, flat on the floor. Do this 15 min per day.

10. TAILOR SITTING:-

Purpose:-

This exercise stretches the perineal muscle and strengthe the thigh muscle.

Position:-

a. Sit flat on the floor with legs out stretched, knees are gently pushed to the floor until the
perineal muscles begin to stretch.
b. Hold this position for increased amount of each time performed
c.

POSTNATAL EXERCISE

DEFINITION
Postnatal exercise is a series of physical exercises that are performed by the postnatal mother to bring
about optimal functioning of all systems and prevent complications.

PURPOSES
 To improve the tone of muscles which are stretched during pregnancy and labor specially the
abdominal and perineal muscles.
 To lessen the problem of backache.
 To speed up return of muscle strength after delivery.
 To educate about correct posture and body mechanics.
 To minimize the risk of puerperal venous thrombosis by promoting circulation and
preventing venous stasis.
 To prevent genital prolapsed.
 To prevent stress incontinence of urine.
 To improve circulation & reduce problems such as leg cramp, edema & varicose vein.

PROCEDURE

Postnatal exercises help to strengthen the abdominal muscles and firm the waist. The exercise can be
started soon after the childbirth and repeated up to 5 times twice a day at 1st. the number of exercise
is gradually increased as the mother gains strength.

Nursing Action Rational

i. Explain the procedure to the patient. Minimize anxiety and facilitates
ii. Provide privacy. patient cooperatio
A. Abdominal Exercise
Strengthen the diaphragm.
a. Abdominal Breathing
 Instruct the women to assume a supine
position with knees bent.
 Instruct her to inhale through the nose, keep
cage as stationary as possible, and allow the
abdomen to expand and then contract the
abdominal muscles as she exhales slowly
through the mouth.
 Instruct her to place 1 hand on the chest and
 another on the abdomen when inhaling. The
hand on the abdomen should rise and the
hand on the chest should remain stationary.
 Repeat the exercise 5 times..
b. Head Lift
This exercise can be started within a few days after
Ensure that the exercise is being
childbirth.
done correctly and ensures
 Instruct the mother to lie supine with knees
adequate intake of air while
bent and arms out stretched at her side.
inhaling.
 Instruct her to inhale deeply at 1st and then
exhale while lifting head slowly and to hold
the position for a few seconds and relax.
c. Head & Shoulder Raising
On the 2nd postpartum day instruct the client to
 Lie flat without pillow and raise head until Strengthen abdominal muscles.

the chin touches the chest.

On the 3rd postpartum day instruct the client to
 Raise both head and shoulder off the bed
and lower them slowly.
 Gradually increase the number of repetitions
until she is able to do this for 10 times.
d. Leg Raising
The exercise may begin on the 7th postpartum day.
Instruct woman to:
 Lie down on the floor with no pillows under
the head, point toe and slowly raise 1 legt
keeping the knee straight.
 Gradually increase the number of repetitions
until she is able to do this for 10 times.
e. Pelvic Tilting or Rocking Tightens abdominal muscles and

Instruct woman to: muscles of the buttocks.

 Lie down flat on the floor with knees bent

and feet flat, inhale and while exhaling
flatten the back hard against the floor so that
 there is no space between the back and the
floor.
 Inhale normally, holds breath for up to 10
secs and then relaxes.
 Repeat up to 10 times.
f. Knee & Leg Rolling
Instruct woman to:
 Lie down flat on the floor with knees bent
and feet flat on the floor or bed.
 Keep the shoulders & the feet stationary and
roll the knees to side to touch 1st 1 side of
the bed, then the other. Maintain a smooth
motion as the exercise is repeated 5 times.
 Later, as flexibility increases, the exercise
can be varied by the rolling of the 1 knee
only. (the mother rolls her left knee to touch
the left side of the bed.)
g. Hip Hitching
Instruct woman to:
This exercise will strengthen the
 Lie on her back with 1 knee back and other
oblique abdominal muscles.
straight.
 Slide the heel of the straight leg downwards,
thus lengthening the leg.
 Shorten the same leg by drawing the hip up
towards the ribs on the same side.
 Repeat up to 10 times keeping the abdomen
pulled in.
 Change to the opposite side and repeat.
h. Abdominal Tightening This exercise will strengthen the

Instruct woman to: deep transverse muscles which are

 Sit comfortably or kneel down on floor. the main support for the spine and

 Breathe in and out, and then pull in the play a large part in prevention of

lower part of abdomen below the umbilicus

 while continuing to breathe normally.
long term back problems.
 Hold up to 10 secs.
 Repeat up to 10 times.
B. Circulatory Exercises
a. Foot & Leg Exercise This exercise must be performed
Instruct woman to: very frequently in the immediate
 Sit or half lie with legs supported. postnatal period to improve
 Bend or stretched the ankles at least 12 circulation, to reduce cramping,
times. edema and to prevent deep vein
 Circle both feet at the ankle and at least 20 thrombosis.
times in each direction.
 Brace both knees, hold for a count of 4, and
then relax.
 Repeat 12 times.
C. Pelvic Floor Exercise
Instruct woman to:
 Sit, stand or half lie with legs slightly apart, This exercise helps to regain full

close and draw up around the anal passage bladder control. Prevents uterine

as though preventing a bowel action, then prolapsed and ensures normal

repeat for front passages as if to stop the sexual satisfaction in future.

flow of urine in the midstream.

 Hold the contractions for 10 secs and this is
repeated up to 10 times.
 Continue to do this exercise for 2-3 months.
 After 3 months if the mother is able to
cough deeply with a full bladder without
leaking urine, she may stop the exercise.
 If leaking occurs, she may continue the
exercise for the rest of her life.
D. Chest Exercise
Instruct woman to:
 Lie flat with arms extended straight out to
the side; bring both hands together above This exercise increaser the tone of
the chest, while keeping the arms straight,
 hold for a sec and return to starting position. the chest muscles.
 Repeat the exercise 5 times initially and
follow the advice of the health care provider
for increasing the number of repetitions.
 Instruct the mother to bend her elbows,
clasp her hands together above her chest,
and press her hands together for a few
seconds. Repeat this for at least 5 times.

EXPRESSION OF BREAST MILK TECHNIQUE

INTRODUCTION

If a mother is not in a position to feed her baby (e.g. ill mother, preterm baby, working
mother, etc.) or has engorged breasts, she should express her milk in a clean wide mouthed container
and this milk should be fed to her baby. Expressed breast milk can be stored at room temperature for
6 hours in a refrigerator for 24 hours and a freezer at -20 OC for 3 months.

EQUIPMENT
 Clean wide mouthed container
 Mechanical or electrical operated pumps
FREQUENCY OF EXPRESSION OF MILK

It depends on the reason for expressing the milk, but usually as often as the baby would be breastfeed
(at least 8 to 10 times /day)

 To establish lactation, to feed a low birth weight or sick newborn.

 She should start to express milk on the first day, within six hours of delivery is possible.
She may only express a few drops of colostrums at first, but it helps breast milk production
to begin.
 She should express as often as her baby would breastfeed. Hence, it should be done at least
every 3 hours, including the night hours. If she expresses only a few times or if there are
long intervals between expressions, she may not able to produce enough milk.
 To sustain her milk supply to feed a sick baby: She should express at least every 3 hours.
 To build up her milk supply: Express very often for a few days (every ½- 1 hours) and at
least every 3 hours during the night.
 To leave milk for the baby while she is out at work: Express as much as possible before she
goes to work. It is also important to express while at work to help keep up her supply.
 To relieve symptoms such as engorgement of breast: Express only as much as necessary.

PROCEDURE
1. Preparation of container
 Choose a cup, glass or jar with a wide mouth.
 Wash the cup in soap and water
 Pour boiling water into the cup, and leave it for a
few minutes. Boiling water will kill most of the
germs.
 When ready to express milk, pour the water out
of the cup.
2. Massaging the breast before expression
 Take a wet warm towel and wrap it around the
breast. Let it be there for 5 min.
 With two fingers, massage the breast using
circular motion of finger. Use pulp of fingers
only with modest pressure. Alternately she can
use knuckles of a fist. Massage the breast
towards nipple as if kneading dough. Massage
should not hurt her.
 Provide massage for 5-10 on each breast before
expression of milk.

3. Expression of breast milk.

 The mother should wash her hands thoroughly.
 She shall sit or stand comfortably and hold the
container near her breast.
 She should think lovingly of the baby or look at
a picture of her baby.
 Ask her to put her thumb above the nipple and
areola, and her first finger below the nipple and
areola opposite the thumb. She supports the
breast with her other fingers.
 Ask her to press her thumb and first finger
slightly inward towards the chest wall. She
should avoid pressing too far or she may block
the milk ducts.
 Press her breast behind the nipple and areola
between the fingers and thumb. She must press
on the lactiferous sinuses beneath the areola.
Sometimes in a lactating breast it is possible to
feel the sinuses. They are like pods or peanuts. If
she can feel them, she can press on them.
 Press and release, press and release. This should
not hurt-if it hurts, the technique is wrong.
 At first no milk may come, but after pressing a
few times. Milk starts to drip out. It may flow in
streams if the oxytoxin reflex is active.
 Press the areola in the same way from the sides
to make sure that milk is expressed from all
segments of the breast.
 Avoid rubbing or sliding her fingers along the
skin. The movements of the fingers should be
more like rolling.
 Avoid squeezing the nipple itself .pressing or
pulling the nipple cannot express the milk. It is
the same as the baby sucking only the nipple.
 Express one breast for at least 3-5 minutes until
the flow slows; then expresses the other side; and
then repeats both sides. She can use either hand
for either breast or change when they tire.
 In case of using breast pump, fix the pump cup
on to the nipple.
 Explain that adequate expression of breast milk
takes 20-30 minutes, especially in the first few
days when only a little milk is produced, it is
important not to try to express in a shorter time.
 Expression Of Milk Using Breast Pump
 KATORI-SPOON FEEDING TECHNIQUE

INTRODUCTION
 Feeding with a spoon (or a similar device such as ‘paladai) and katori (or any other container
such as cup) has been found to be safe in LBW babies. This mode of feeding is a bridge
between gavage feeding and direct breast feeding.
 It is based on the premise that neonates with a gestation of 30-32 weeks or more are in a
position to swallow the feeds satisfactorily even though they may not be good at sucking or
coordinated sucking and swallowing. Use a katori and a spoon. Both utensils must be
washed, cleaned and boiled.
 Take the required amount of expressed breast milk in the katori. Place the baby in a semi-
upright posture with a napkin around the neck to mop up the spillage.
 Fill the spoon with milk, a little short of the brim, place it at the lips of the baby in the corner
of mouth and let the milk flow into the baby’s mouth slowly avoiding the spill. The baby will
actively swallow the milk.
 Repeat the process till the required amount has been fed. If the baby does not actively accept
and swallow the feed, try gentle stimulation. If he is still sluggish, do not insist on this
method. It is better to switch back to gavage feeds till the baby is ready.
TIPS FOR INFANT SPOON FEEDING
1. Baby feeding starts out with liquids and baby becomes quite comfortable with digesting
liquids. So when it comes to the big day to add solids to the diet, spoon feeding baby can
become quite the challenge. At some point your baby will need to learn how to handle eating
from a baby spoon, but this is many times easier said than done. Here you will find 5
techniques for infant spoon feeding. It is important to remember that it will take your baby
some time to get used to spoon feeding and it will take a whole lot of patience from you as
the parent.
2. Use a Soft, Rubber Tipped Baby Spoon Your baby's mouth is very sensitive and he or she
has never had anything in their mouth except for a nipple so trying to make the baby spoon as
soft and flexible as nipple may help your baby relate the baby spoon with the positive
thoughts of the nipple.
3. Distract Your Baby It is a little sneaky but if it makes spoon feeding baby a little easier on
everyone, it is well worth the effort. When babies are distracted they tend to open their mouth
and focus on the distraction making it a perfect time to put solid food in the mouth. The old
 standby of: here comes the airplane and allowing the spoon to fly into the mouth still works
wonders or placing a suction cup bowl on the highchair will even distract baby for a few
minutes, allowing enough time to get food in the mouth.
4. Use Finger FoodsSpoon feeding baby is the trick but the ultimate goal is to get the food into
baby's mouth and into the tummy. Take advantage of finger foods such as bananas and allow
your baby to dip the bananas in to apple sauce so that he or she are getting two nutrient foods
in one shot and the best part is that baby thinks he or she is getting to play.
5. Baby TeethingMake sure when trying to spoon feed baby consider what other things could
be going on with your baby such as teething. If your baby is teething, in pain and
uncomfortable you are probably not going to get him or her to spoon feed no matter how hard
you try. You may want to save your baby and yourself frustration and just hold off on spoon
feeding a little longer until your baby is feeling better.
6. Is Your Baby Ready:-Keep in mind that every baby matures at different rates and no one
can manipulate the rate of maturity. If you are really struggling to get your baby to spoon
feed, consider the possibility that your baby may not be developmentally ready. It is not
really a big deal in baby world if your baby needs a little more time feeding on liquids and is
not quite ready for solids. He or she will let you know when they are ready when the struggle
to eat solids is minimal. Spoon feeding a baby is just like everything else having to do with
an infant, it becomes a journey. You may take a few steps forward on your spoon feeding
journey and then out of no where, you may take a few steps back.
7. Infant spoon feeding takes a lot of patience on the parent's part and some creativity too.
Your baby will eventually start spoon feeding without any effort at all, but only when he or
she is ready.
PREVENTING CHOKING

When feeding to babies, keep in mind the following:

Keep feeding times calm by avoiding too much excitement or disruption during eating. Feed
the baby in a quiet area away from noise and distractions such as a TV set.
Have babies in an upright position during feeding
Hold babies while giving them a bottle.

Amount of milk (or fluid) needed per day by birth weight and age
Birth Feed DAY-1 DAY-2 DAY-3 DAY-4 DAY-5 DAY- 6- DAY-14
weight every 13
1000-1499g 2hour 60 ml/kg 80 ml/kg 90 ml/kg 100 110 120-180 180-200
ml/kg ml/kg ml/kg ml/kg
≥ 1500g 3hour

Approximate amount of breast milk needed per day by birth weight and age
Birth Number DAY-1 DAY-2 DAY-3 DAY-4 DAY-5 DAY- DAY-14
weight of feeds
6-13
1000g 12 5 ml/kg 7 ml/kg 8 ml/kg 9 ml/kg 10 ml/kg 11-16 17 ml/kg
ml/kg
1250g 12 6 ml/kg 8 ml/kg 9 ml/kg 11 ml/kg 12 ml/kg 14-19 21 ml/kg
ml/kg
1500g 8 12 ml/kg 15 ml/kg 17 ml/kg 19 ml/kg 21 ml/kg 23-33 35 ml/kg
ml/kg
1750g 8 14 ml/kg 18 ml/kg 20 ml/kg 22 ml/kg 24 ml/kg 26-42 45 ml/kg
ml/kg
2000g 8 15 ml/kg 20 ml/kg 23 ml/kg 25 ml/kg 28 ml/kg 30-45 50 ml/kg
ml/kg

ARTIFICIAL FEEDING
 INTRODUCTION

Infants must have adequate intake to maintain weight gain along their own growth curve. Infants are
exclusively breast feed or fed human milk for the first 3 to 6 months of life whenever possible.

Contraindicated to breast feeding include galactosemia, maternal use of illegal drugs, nitrated active
tuberculosis, human immunodeficiency virus infection (HIV) and administration of certain drugs
(radioactive isotopes, antimetabolites, and cancer chemotherapy.

Prepared formula can be kept refrigerated for 24 to 48 hours, although it is safest to consume within
the first 24 hours.

ARTICLES FOR ARTIFICIAL FEEDING

 Measuring cup
 Appropriate formula ,either store breast milk, powdered concentrated liquid, or ready to feed
formula
 Scoop
 Bottled water
 Additives as prescribed.
 Long handled spoon
 Bottles with appropriate nipples and rings or disposable bottle liners with nipple, rings and
support form.
CHILD AND FAMILY ASSESSMENT AND PREPARATION
 Assess the general health status (including weight and length), developmental age,
chronological age and previous feeding experiences.
 Assess the infant’s oral motor development, particularly if the infant has been intubated, was
drug exposed in utero, or has a congenital defect (such as cleft lip or palate).
 Assess the parent preference to breast feed or bottle feed.
 Assess parents level of comfort with feeding, knowledge about positioning infant with head
slightly elevated during feeding and level of knowledge regarding formula preparation and
storage if bottle feeding and maternal nutrition and fluid intake if breast feeding.
 Determine infant state before feeding and assist infant to achieve quiet alert state.
 Assess financial resources of the family to purchase formula and equipment and whether a
social service referral may be needed.
 PROCEDURE

Steps Rationale
1. Gather the necessary supplies Promotes efficient time management and provides
and organized approach to the procedure.
2. Perform hand hygiene. Reduces transmission of microorganisms.

3. Prepare concentrated or powdered Ensures appropriate preparation.

formula exactly as recommended.

4. Ready to feed formulas need only be Ingredients of formula may have settled in the
lightly shaken before use. container, so shaking slightly helps to redistribute
all ingredients equally.
5. Stored breast milk preparation must be Handling and use of stored breast milk requires
bring first at room temperature. that specific guidelines are followed to ensure
safety.
6. Warm the Formula slowly to comfortable Slow heating is recommended to avoid scalding
temperature. contents or exploding bottles. Infant burns from
overheated bottles can be severe enough to require
hospitalization and even amputations have been
reported.
7. Position supplies so that they are readily Provides organized approach to the procedure.
accessible to the faster.

8. Hold infant on the lap with head elevated Reduces chance of aspiration and otitis media.
and close to the parent’s body. Facilities bonding.

9. Using bottle: Tilt bottle to keep the Reduces the amount of air ingested and prevents
nipple full at all times. The nipple should the potential development of otitis media. Slow
have a steady drip, but not a steady flow causes the infant to suck very hard and
stream of flow. potentially tire quickly; too fast a stream increases
10. Using a cup, and spoon or Palade : the risk for aspiration.
 Hold the baby in semi upright
position, rest the cup or Palade or
spoon lightly on the baby’s lower lip
 and touch the outer part of the baby’s
upper lip with the edge of the cup.
 Tip the cup or Palade/spoon, so the
milk just reaches the baby’s lip,
 Allow the baby to take the milk,
 Do not pour the milk into the baby’s
mouth, end the feeding when the
baby closes her/his mouth and is no
longer interested in feeding.

11. Stimulate rooting reflex by ribbing nipple Encourages infant to open mouth. Positions nipple
along lower lip or ticking side of cheek. appropriately.
Place nipple on top of tongue.

12. After 5 minutes or 1-2 oz, stop and burp Expels ingests air, allows infant to take more
infant .Burp again at end of feeding. formulas, and decreases potential for reflux and
colic like symptoms.
13. When feeding is to be discontinued, assist Ensures safety of infant and prevents aspiration.
the mother/parents to place.

14. Discard bottle and formulas remaining in Formula may be contaminated with bacteria
bottle at end of feeding. during feeding.

15. Perform hand hygiene Reduces transmission of microorganisms.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 Evaluate family understanding of nutritional needs of an infant and formula preparation.
 Determine concerns of the parents regarding feeding
 Evaluate infant’s weight gain and document serial measurements on standardized growth
chart.
 Evaluate feeding behaviors and infants –parent interaction and attachment behaviors. Provide
written instructions as needed.
 Document the following
 Time of feed
  Type of feeding (human milk or formula)
 Method of feeding(breast or bottle

KANGAROO MOTHER CARE

INTRODUCTION
Kangaroo mother care (KMC) is care of preterm or low birth weight infants carried skin to-skin with
the mother. KMC was initially conceived as an alternative to the usual minimal in-hospital care for
stable low birth weight infants. KMC was first suggested in 1978 by Dr Edgar Rey in Bogotá,
Colombia .The term kangaroo care is derived from practical similarities to marsupial care-giving, i.e.
the premature infant is kept warm in the maternal pouch and close to the breasts for unlimited
feeding. The mothers are used as "incubators" and as the main source of food and stimulation for
LBW infants while they mature enough to face extra uterine life in similar conditions as those born
at term. The method is applied only after the LBW infant has stabilized Introduction of KMC results
in early hospital discharge of low birth weight infants.

DEFINITION

KMC is a powerful, easy to use method to promote the health and wellbeing of low birth weight
babies. Its key features are

Early, continues and prolonged skin to skin contact between mother and baby

Exclusive breast feeding

Initialed in a facility and continued at home

According to Suraj Gupta

KMC is a very effective method of providing nursing and warmth through skin to skin contact to
preterm/LBW infants in developing countries as a substitute for the expensive incubator.

BENEFITS OF KMC

Physiological Benefits

Heart and respiratory rates, respiration, oxygenation, oxygen consumption, blood glucose, sleep
patterns and behavior observed in preterm/LBW infants held skin to skin tend to better than those
observed in infants separated from their mothers.

Clinical Benefits

1. Breast feeding-KMC result in increased duration of breast feeding rates in infants.

 2. Thermal control-prolonged skin to skin contact between the mother and her preterm
infant/LBW infant provide effective thermal control with a reduced risk of hypothermia. For
stable babies, KMC is at least equivalent to incubator care in terms of safety and thermal
protection.
3. Early discharge-KMC cared LBW infants could be discharged from the hospital earlier than
the conventionally managed babies. The babies gain more weight on KMC than on
conventional care
4. Less morbidity-babies receiving KMC has more regular breathing and less predisposition to
apnea. KMC protects against nosocomial infection. Even after discharge from the hospital,
the morbidity amongst babies managed by KMC is less.
5. Other effects-KMC helps both infant and parents. Mother are less stressed during KMC
compared with baby kept in incubator. They report stronger bonding with baby, increased
confidence and deep satisfaction that they were able to do something special for their babies.
COMPONENTS OF KMC
1. Skin to skin contact – this component involves skin to skin contact of the new born with the
mother who should be early and continued for prolonged periods of time.
2. Exclusive breast feeding - most of the babies below 2000 gm would gain weight adequately
on exclusive breast milk feeding.
3. Physical, emotional and educational support – this should be provided by the nursing and
medical staff to the mother and the family.

Early discharge and follow up - KMC should be initiated in the hospital under supervision. KMC
would facilitate early discharge from the hospital and this practice should be continued at home.
These babies should be followed up regularly to ensure a normal outcome.

CRITERIA FOR ELIGIBILITY OF KMC

Baby

All stable LBW babies are eligible for KMC. However, very sick babies needing special care should
be cared under radiant warmer initially. KMC should be started after the baby is thermodynamically
stable

Birth weight >1800 g: These babies are generally stable at birth. Therefore, in most of the KMC can
be initiated soon after birth.
Birth weight 1200-1799 g: Many babies of this group have significant problems in neonatal period.
It might take a few days before KMC can be initiated.

Birth weight <1200 g: Frequently, these babies develop serious prematurity-related morbidity, often
starting soon after birth. It may take days to weeks before baby's condition allows initiation of KMC.

Mother

All mothers can provide KMC, irrespective of age, parity, education, culture and religion. The
following points must be taken into consideration when counseling on

 Willingness: The mother must be willing to provide KMC. Healthcare providers should counsel
and motivate her. Once the mother realizes the benefits of KMC for her baby, she will learn and
undertake KMC.
 General health and nutrition: The mother should be free from serious illness to be able to provide
KMC. She should receive adequate diet and supplements recommended by her physician.
 Hygiene: The mother should maintain good hygiene: daily bath/sponge, change of clothes, hand
washing, short and clean finger nails.
 Supportive family: Apart from supporting the mother, family members should also be
encouraged to provide KMC when mother wishes to take rest. Mother would need family's
cooperation to deal with her conventional responsibilities of household chores till the baby
requires KMC.
 Supportive community: Community awareness about the benefits should be created. This is
particularly important when there are social, economic or family constraints.
INITIATION OF KMC

When baby is ready for KMC, arrange a time that is convenient to the mother and her baby. The first
few sessions are important and require extended interaction. Demonstrate to her the KMC procedure
in a caring, gentle manner and with patience. Answer her queries and allay her anxieties. Encourage
her to bring her mother/mother in law, husband or any other member of the family. It helps in
building positive attitude of the family and ensuring family support to the mother which is
particularly crucial for post-discharge home-based KMC.25 It is helpful that the mother starting
KMC interacts with someone already practicing KMC for her baby.
Mother’s clothing: KMC can be provided using any front-open, light dress as per the local culture.
KMC works well with blouse and sari, gown or shawl. Suitable apparel that can retain the baby for
extended period of time can be adapted locally.

Baby’s clothing: Baby is dressed with cap, socks, nappy, and front-open sleeveless shirt.

PROCEDURE
 . Time of initiation – KMC can be started as soon as the baby is stable. Babies with severe
illness or requiring special treatment should wait until they are reasonably stable before KMC
can be initiated. Short KMC sessions can be initiated during recovery with on-going medical
treatment (IV fluids, low concentration of oxygen). Once the baby begins to recover, family
members should be motivated to practice KMC
 Kangaroo positioning – the baby should be placed between the mother’s breast; in an upright
position. The head should be turned to one side and in slightly extended position. This
position keeps the airway open and allows eye to eye contact between the mother and her
baby. The hips should be flexed and abducted in a “frog” position; the arms should also be
flexed. Baby’s abdomen should be at the level of the mother’s epigastrium. Mother’s
breathing stimulates the baby, thus reducing the occurrence of apnea. Support the baby’s
bottom with a sling/binder.
 Monitoring – babies receiving KMC should be monitored carefully, especially during the
initial stages. Nursing staff should make sure that baby’s neck position is neither too flexed
nor too extended; airway is clear, breathing is regular, color is pink and baby is maintaining
temperature. Mother should be involved in observing the baby during KMC so that she
herself can continue monitoring at home.
 Feeding - the mother should be explained how to breastfeed when the baby is in KMC.
Holding the baby near the breast stimulates milk production. She may express milk while the
baby is still in KMC position. The baby could be fed with paladai spoon, or tube, depending
on the condition of the baby.
 Privacy – KMC unavoidably requires some exposure on the part of mother. This can make
her nervous and could be de motivating. The staff must respect mother’s sensitivities in this
regard and ensure culturally acceptable privacy standards in the nursery and the wards where
KMC is practiced.
  Duration – skin to skin contact should start gradually in the nursery, with a smooth transition
from conventional care to continuous KMC. The length of skin to skin contact should be
gradually increased up to 24hours a day, interrupted only for changing diapers.

The mother can sleep with baby in kangaroo position in reclined or semi-recumbent
position about 15 degrees from horizontal. This can be done with an adjustable bed or with
pillows on an ordinary bed. A comfortable chair with an adjustable back may be used for resting
during the day.

TIME TO STOP KMC

KMC is continued till the baby finds it comfortable and easy. KMC is unnecessary once the
baby attains a weight of 2500gm and a gestation of 37 wesek. A baby who, upon being put in the
kangaroo position, tends to wriggle out, pulls limbs out, or cries/fusses, is not in need of KMC
anymore.

DISCHARGE CRITERIA

The standard policy of the unit for discharge from the hospital should be followed.

Generally the following criteria are accepted at most centers:

 Baby's general health is good and no evidence of infection

 Feeding well and receiving exclusively or predominantly breast milk.
 Gaining weight (at least 15-20 gm/kg/day for at least three consecutive days)
 Maintaining body temperature satisfactorily for at least three consecutive days in room
temperature.

The mother and family members are confident to take care of the baby in KMC and should be asked
to come for follow-up visits regularly.

POST DISCHARGE FOLLOW UP

 In general a baby is followed up once or twice a week till 37-40 weeks of gestation or the
baby is 2.5-3kg of weight.
 There after a follow up once in 2-4 weeks, may be sufficient till 3 months of post
conceptional age. After that 1-2 months during first year of life. The baby should gain weight
15-20gm/kg/day up to 40weeks of post conceptional age and 10gm/kg/day subsequently.

ASSISITING MOTHER WITH EXCLUSIVE BREAST FEEDING

 INTRODUCTION

Breast feeding is natural & instinctive and most mother are able to breast feed without any
difficulties. There are many ways to breast feed and every mother develops her own style to suit her
baby. There are certain steps that will help the mother to breast feed with ease and comfort. She
should the master the art and breast feeding by practice, perseverance and self confidence.

DEFINITION
 Breast feeding is the sucking of an infant at the mother’s breast to provide nourishment.
 Breastfeeding is the normal way of providing young infants with the nutrients they need for
healthy growth and development.
PURPOSE
 To provide psychological & emotional satisfaction.
 To feed the infant a natural & ideal food that supplies him with adequate nutrition.
 To have milk always available at the right temperature.
 To prevent chances of gastrointestinal disturbances & development of allergies.
 To provide physical closeness of baby to the mother during pregnancy.
 To provide comfort.
 To enable mothers to feed their babies adequately without discomfort.
 To promote mother – baby bonding.
 To minimize chances of developing breast problems due to stasis of milk.
TECHNIQUES AND BASIC PRINCIPLES
 Breast feeding should be done in as clean and safe a manner as possible.
 The mother and the baby should be comfortable and relaxed at the feeding time.
 She should be well conversant with “how to put the baby to breast & how to remove him off
it.
 Correct position consist in supporting whole body of the infant so that it faces the mother and
the head & body are in the same plane , and his abdomen touches mother abdomen.
 Good attachment of infant’s mouth on mother’s areola and nipple is important for good
suckling.

It is indicated by
 Infant’s mouth wide open
 Infant’s lower lip turned outward
 Infant’s chin touches mother’s breast
 Most of the part of lower areola inside infant’s mouth
 At least one breast should be completely emptied at every sitting.
 In case of a working mother, her “expressed” milk can be spoon fed to the baby in her
absence
 Starting from the initial 5min, the nursing time can be gradually increased to 15 to 20 min in
the subsequent days.
 In order to “kick out “the swallowed air the act of nursing should be followed by burping.
 Mother should be give adequate attention to her diet, personal hygiene, health & have
sufficient rest.
EQUIPMENT
1) Bowl with lukewarm water
2) Tray lined with towel
3) Kidney tray
4) Few rag pieces or sponge towel
5) Bath towel
6) Pillows ( 1-2 )
7) Soap (if mother has not taken bath of feeding baby for first time after delivery).
INDICATION
1) Promote health
2) Reduce infection
3) Improve immunity
4) Baby satisfaction
CONTRAINDICATION
1) Maternal disease such as tuberculosis cardiac disease, acute illness or contagious disease,
severe grade of anemia, sever puerperal sepsis, puerperal psychosis.
2) Local conditions preventing breastfeeding.
 Fissures of the nipples
 Acute mastitis
 Abscess of the breast.
 TEMPORARY PERMANENT
Maternal 1. Acute puerperal illness Chronic medical illness such as
2. Acute breast complications such as decompensated organic heart lesion,
cracked nipples, mastitis or breast active pulmonary tuberculosis, puerperal
abscess. psychosis.
3. Following exhaustive and Patients having high doses of
complicated labour and delivery. antiepileptic and anti thyroid drugs.

Neonatal 1. Very low birth weight baby Severe degree of cleft palate
2. Asphyxia and intracranial stress Galactosaemia.
3. Acute illness

PROCEDURE

S.No. Nursing Action Rationale

1. Explain to the mother about breastfeeding and Prepares mother for the act of
how you can assist with the procedure. breastfeeding.
2. Instruct the mother to expose her breasts.
3. Clean the nipples and areolar region with a wet Use of soap on nipples is not
wash cloth and dry them. With a rag piece first recommended as it is a drying agent
clean nipple area then clean breast with soap and can lead to cracking.
and water. Clean one breast at a time.
4. Postoperative mothers Facilitates feeding without strain to the
a) Assist the mother to a sidelying position. incisional area. Placing a pillow under
b) Tuck a pillow under her ribs if feeding the ribs brings baby and breast closer
from the lower breast. and provides a shirls over the incision.

5. Post vaginal delivery mother who wishes to Sitting in a chair with back and feet
feed in sitting position. Instruct the mother to supported in comfortable position for
use one of the following positions : feeding.
 Cradle hold This would adjust the height so that she
 Football hold need not bend forward.
 Cross-cradle or modified cradle hold.
  Side-lying position
 Saddle hold position
I. For cradle hold :
 Position the infants head at or near the
antecubital space and level with her nipple, with
her arm supporting the infant’s body and with
her other hand to hold the breast.
II. For football hold:
 Instruct mother to support the infants head
in her hand with the infant’s body resting on
pillows alongside her hip.
III. For cross-cradle or modified cradle hold:
 Assist the mother to sit with her back
upright and at right angles to her lap.
 Place a pillow on her lap
 Let the mother hold the baby supporting his
head with her extended arms.
IV. For side lying:
 Lie baby next to you so that your tummies
are touching, his mouth in line with your
nipple. Place something behind his back or
your arm under him to prevent him from
rolling backwards.
 Offer breast to the baby by supporting it
with fingers underneath and thumb above,
well behind the areola.
V. For saddle hold position

6. Feeding techniques:--Move the baby near the

breast, turned towards the mother’s body with
neck slightly extended and the mouth near the
nipple..
7. Let the mother move the baby’s mouth against
her nipple.
8. As the baby opens his mouth dropping lower Having the bottom lip about 1.5 cm
jaw and darting his tongue, insert the nipple and away from the base of the nipple allows
breast tissue inside his mouth, so that the baby the baby to latch on the breast.
latches on to the nipple and areola correctly. With this position the lactiferous
sinuses will be inside the baby’s mouth.
9. Provide assistance as needed to help for correct
attachment of the baby to the breast and to start
sucking.
10. When the baby releases to breast, burp him
11. Encourage the mother to feed the baby from the When the baby has had sufficient milk,
second breast in the same manner. he releases the first breast.
12. Burp the baby as he comes off the second Burping the baby reduces risk of
breast. vomiting and aspiration.
13. Wrap the baby and lay him on his side in the Prevents risk of aspiration if the baby
crib vomits.
14. Replace the articles.
15. Record in the chart the time and duration of
feeding and any observation made.

DELATCHMENT OF THE BABY FROM THE BREAST

 When the baby is satisfied or falls asleep while feeding, he automatically releases the breast.
 But when the baby has stopped sucking but is still maintaining strong suction, do not pull him
off nipple.
 Instead, mother should slide her index finger in to the corner of the baby’s mouth to break the
suction & detach the baby.
DURATION OF EACH BREAST FEED
 It is variable, but most active babies take 10 – 15 min to finish a feed.
 Mother should play and interact with her baby while feeding by touching the ears or stroking
the soles.
 During breast feeding mother provide warmth, skin to skin contact, love, affectionate look &
tender touch & music of her hearts beat to her baby thus stimulating all five special senses of
her baby.
SIGNS INDICATING BABY IS GETTING ENOUGH MILK
 When the baby is adequately fed he is satisfied, happy and playful for 2-3 hrs. After a feed.
 When a baby passes dilute water – like urine at least 6-8 times in a day.
 Satisfactory weight gain.
COMMON BREAST FEEDING PROBLEM
 Inverted or retracted nipple
 Sore nipple
 Breast engorgement
 Breast abscess
 Not enough milk
COMPLICATION
1) Vomiting
2) Irritability
3) Baby crying
4) Diarrhea
5) Fissures of the nipple
6) Acute mastitis
HEALTH TEACHING TO MOTHER
1) Placement of the baby on the breast should enable him to feed from the breast rather than
from the nipple.
2) The finishing breast at one feed should be the starting breast for the next feeding so that both
breasts get emptied.
3) Baby led feeding/demand feeding generally will be long feeding with longer intervals ( 6-8
hrs) in between for the first one or two days and shorter and frequent after two days. (That is
every 3-4 hrs).
4) Daily bathing and change of dress are important for breast hygiene for nursing mothers.
5) Breastfeeding mothers need to wear proper fitting brassieres to provide comfortable support
to breasts.
6) Arouse baby in between feeds by stroking the sole of this feet or earlobe.
 NEONATAL RESUSCITATION

DEFINITION

Measures taken to revive newborn who have difficulty in establishing respiration at birth and
includes suctioning, positive pressure ventilation, external cardiac massage, intubations and
medications as necessitated by neonatal condition at 1 minuter of age.

PURPOSE
 To establish and maintain airway.
 To ensure effective circulation.
 To correct any acidosis present.
 To prevent hypothermia, hypoglycemia and hemorrhage.

ARTICLES
1) Suctioning Articles
 Bulb syringe
 De Lee mucous trap with No. 10 Fr catheter or mechanical suction.
 Suction catheters No. 8 Fr and 20 ml syringe.
2) Bag & Mask Articles
 Infant resuscitation bag with pressure release valve or pressure gauze with reservoir, capable
of delivering 90-100 % oxygen.
 Face masks with cushioned rims (newborn and premature sizes)
 Oral airways (newborn and premature sizes)
 Oxygen with flow meter and tubing.
3) Intubation Articles
 Laryngoscope with straight blades No. 0 for premature and 1 for newborn.
 Extra bulbs and batteries for laryngoscope.
 Endotracheal tubes sizes 2.5, 3.0, 3.5 and 4.0 mm internal diameter.
 Stylet.
 Scissors.
4) Medications
 Epinephrine 1:10,000 ampoules (1 ml ampoule of 1:1,000 available in India).
 Nalaxone HCl (neonatal narcan 0.02 mg/ml)
 Volume expander
- 5% albumin solution
- NS
- RL
 Sodium bicarbonate 4.2 % (1mEq/2 ml)
 Dextrose 10 % concentration 250 ml.
 Sterile water 30 ml.
 NS 30 ml.
5) Miscellaneous
 Radiant warmer.
 Stethoscope
 Adhesive tape and bandage, scissors.
 Syringe 1ml, 2ml, 5ml, 10ml and 20ml sizes.
 Needles No. 21, 22 and 26G.
 Umbilical cord clamp.
 Gloves.
 Warm dry towels.
PROCEDURE

Nursing Action Rational

a) Assess the Apgar score. Help to know if resuscitation if needed or not.
b) Place infant under warmer, quickly dry
Prevents heat loss.
off amniotic fluid, replace wet sheets
with a dry one.
c) Place the baby on his back with slightly
head down 15 degree tilt, neck slightly Straightens the trachea and opens the airway.
extended. Hyperextension may cause airway obstruction.
d) Suction the mouth 1st and then the nose.
Clears the airway passage. Infants open gasp
when the nose is suctioned and may aspirate
secretion from mouth into lungs.
e) Give tactile stimulation if infant does
not breathe (flick or tape the sole of the Tactile stimulation of drying may bring
foot twice or rub the back). Do not slap.
f) Check the vital signs and the color of
spontaneous respiration.
the newborn.

Helps in determining further need for

resuscitation.
 PERINEAL CARE WITH EPISIOTOMY CARE
INTRODUCTION:
The perineal area is conducive to the growth of pathogenic organisms because it is warm, moist
and is not well-ventilated. Since, there are many orifices (urinary meatus, vaginal orifice and anus)
situated in this area, the pathogenic organisms can enter into the body. Perineal care involves
cleaning the external genitalia and surrounding area.

DEFINITION:
“Perineal care is an aseptic irrigation of the vulva and perineum after voiding/ defecation in
specified period following delivery/ an operation of the birth canal, perineum, urinary meatus and
anus.”

OR

“Perineal care is usually called “peri care.” It mean swashing the genitals and anal area. Peri
care can be done during a bath or as a separate procedure. Peri care prevents skin breakdown
of perineal area, itching, burning, odor, and infections.”

PRINCIPLE:
The most pertinent principle for the perineal are is to clean the perineum from the cleanest to the less
clean area. The urethral orifice is considered as the cleanest area and the anal orifice is considered as
the dirtiest area. As the orifices in the perineal area are in proximity, cross contamination is a
potential problem. Entry of organisms from the anal orifice can cause urinary tract infections. During
perineal care, clean the area around the urethral meatus cleaning the area around the anus. The
perineal area also has hair follicles which tend to harbor organisms.

PURPOSES:
i. To clean the skin and mucus membrane of the vulva and perineum.
ii. To discourage the growth of bacteria by application of antiseptics.
iii. To encourage healing with protective substances.
iv. To relieve itching of the area.
v. After each urination and defecation. Everyone should practice to clean the perineum and hand
washing should be emphasized after attending to perineum.

INDICATIONS:
1. Postpartum patients especially with stitches in the perineum.
2. Persons with surgery of the genitourinary tract.
3. Patients with lesions, ulcer/surgery of the perineal area/ rectum.
4. Patients having excessive vaginal discharge.
5. Patients having indwelling catheters.
6. Patients having excessive vaginal discharge.
7. Patients with genitourinary tract infection.

Persons who are unable to do the perineal care by themselves.

PRELIMINARY ASSESSMENT OF PATIENT AND ENVIRONMENT:

 o Check the doctor’s orders for specific instruction about the time of treatment, type of solution to
be used, etc and identify the patient.
o Observe the condition of the perineum and note any discharges, itching, irritation, edema,
drainage tube etc.
o Assess the need and frequency of perineal care and the ability of the patient to follow
instructions and self-care.
o Assess whether the perineal care is to be done under aseptic technique/ clean technique. If there
is any wound in the perineum, it should be done under aseptic technique and if it is only for
cleaning/ for thermal effect, it need to be done under clean technique.
o Get the immediate instructions and help (if needed) from the senior sister.
o Find out and collect the articles available in the unit.

EQUIPMENTS:
A clean tray containing:

o Sterile antiseptic lotion-2%dettol/ savlon.

o Sterile normal saline in a bottle.
o Cheatle forceps.
o Antiseptic/ antibiotic medication if ordered.
o Kidney tray
o Sterile gloves
o Mackintosh

A sterile pack/tray containing:

o Artery forceps-2
o Dissecting forceps-1
o Cotton balls
o Gauze pieces
o Sterile towel to wipe hands after surgical scrub.

Additional items:

o Infrared light
o Bedpan (if procedure is done at the bedside).
o Screen
o T-binder if needed.
o Medicines according to the instruction.

PROCEDURE:
NURSING ACTION RATIONALE
1. Explain the procedure to the patient; the purpose Gains confidence and cooperation of the
and how she has to cooperate. patient.
2. Assemble articles at the bedside/ in the treatment
room. Saves time and effort.
3. Ask the patient to empty her bowel and bladder and
wash the perineal area before coming for perineal Ensures cleanliness and reduces number
care. of organisms in the perineal care.
4. Screen the bed/ close the doors as appropriate.
5. Assist the patient to assume dorsal recumbent Provides privacy and reduces
position with knees bend and drape the area using embarrassment.
diamond draping method. Dorsal position facilitates better viewing
6. Open sterile tray, arrange articles with cheatle of the perineum.
forceps and pour antiseptic solution in the sterile
gallipots in this tray.
7. Adjust the position of the infrared light so that it
shines on the perineum at the distance of 45-50cm.
8. Scrub hands and dry with the sterile towel. Maintains asepsis.
9. Put on sterile gloves.
10. Take the cotton swabs with artery forceps, dip in
savlon and squeeze excess lotion with dissecting Cleaning g from cleaner area to least
forceps into the kidney tray. clean area prevents contamination.
11. With the swab, clean from urethra towards anus.
Clean the area from the midline outward in the
following order until clean and discard the swab after
each stroke. Strokes are to be in the following order:
o Separate the vestibule with the non-dominant
hand and clean vestibule starting from clitoris to
fourchette.
o Inside labia minora downward, farther side first
then nearer side.
o Take off the non-dominant hand.
o Labia majora downward farthest side and then
nearer side.
o Discard the used forceps ( if a 2nd one is Cotton fibers are likely to get caught
available). while drying.
o Using 2nd forceps clean the episiotomy wound
Provides soothing effect from heat.
from centre outwards and outside of episiotomy on
both sides.
12. Wipe all traces of antiseptic away with sterile
Prevents entry of pathogenic organism.
normal saline swabs in the same manner as described
above using thumb forceps.
Avoids chances of contraindication.
13. Dry the episiotomy with gauze pieces. Do not
Reduce chance of contamination
use cotton balls for this purpose.
Keeps article ready for next use
14. Provide perineal light /infrared light for 10
Completes the procedure
minutes if indicated.
Documentation helps for communication
15. Put prescribed medication on a gauze piece and
between staff members and provides
apply to the wound.
evidence of care given and observations
16. Place sanitary pad from front to back.
made.
17. Replace the articles to the wash room and send
to sterilization.
18. Make sure the patient is comfortable and the unit
should be clean.
Record procedure in the patient’s chart including details
regarding status of lochia and condition of episiotomy
wound.

SPECIAL CONSIDERATIONS:
1. If a sitz bath is prescribed, give it before perineal care.
2. 2If patient has urinary catheter, provide catheter care along with perineal care
RECAPITUALIZATION:
Perineal care is the cleansing the patient’s external genitalia and surrounding skin using
antiseptic solution. In this, we dealt regarding definition, purposes, principles, indications,
preliminary assessment, equipments procedure and special considerations of perineal care. It is
effective only when the patient’s practices by themselves