1. Midwifery Skills RA 7392

2. Independent Functions of Midwives RA 7392 Insertion of IV fluids during obstetric emergencies Internal examination during labor Suturing of perineal lacerations Injection of oxytocin after delivery of the placenta

3. INTRAVENOUS FLUID INSERTION

4. Objectives Indications of IV placement Methods for proper IV placement complications of IV therapy

5. Indications of IVF Placement Fluid resuscitation Administration of medications Blood product transfusion Short term parenteral nutrition

6. METHODS OF PROPER IV PLACEMENT

7. GATHER ALL THE EQUIPMENT

8. IV FLUIDS Normal saline and LSS are ideal for patients who need fluid replacement

9. IV TUBING

10. IV CATHETERS Basic components  The metal needle has a beveled tip and is used to the enter the vein.  The catheter, made of Teflon or other synthetic material, slides over and off the needle.  The flash chamber is located behind the needle, and will fill with blood upon entry into the vein to confirm proper placement.  Finger grips on the sides of the flash chamber allow the device to be held securely in the hand.

11. IV CATHETERS The larger the gauge, the smaller the diameter

12. PREPARE FOR IVF INSERTION Check the patient identification Explain the procedure in simple terms to the patient and make her comfortable Organize correct and adequate lighting Wash hands to prevent infection or cross- contamination Wear protective gloves Place yourself in a comfortable position; sitting, if possible

13. Prepare the IV administration set Check the type, clarity and expiration of fluid “Spike “ the IV bag  Remove plug from the bottom of the bag.  Close the flow regulator, remove the protective covering from the spike of IV tube  Insert the spike into the port of IVF bag or bottle.

14. Prepare the IV administration set 2  Place the fluid bag or bottle higher, squeeze the drip chamber to fill 1/3 of it  Open the flow regulator to flush the air and bubbles from the tubing and close the flow regulator Hang the bag on an IV pole. Care should be taken not to contaminate the end of the tubing

15. CHOOSE THE SITE OF INSERTION Target a good sized vein with a straight segment at least the length of the catheter. Use of the non-dominant extremity Avoiding joint areas Avoiding use of the lower extremities Avoid veins irritated by previous use Hand or forearm veins preferred

16. Inserting the IV catheter/cannula Apply a tourniquet above the chosen site to create an adequate venous filling. Ask patient to make a fist to maximize vein engorgement. Palpate the vein or tap it to help it dilate.

17. Clean the entry site with alcohol for 60 seconds using a circular motion, working your way outwards from the site. Allow it to dry. Do not repalpate.

18. Apply distal traction to the vein by using your non- dominant thumb. Traction stabilizes the vein and prevents it from "rolling" during the insertion sequence. Grip the IV catheter between the thumb and middle finger of the dominant hand.

19. Insert the IV catheter into the skin at 15-30º angle with the bevel up and in the direction of the vein. Advance the catheter to enter the vein until blood is seen in the “flash chamber” of the catheter

20. Holding the hub of the plastic catheter with your index finger, withdraw the needle a few millimeters. Advance the plastic catheter on into the vein while leaving the needle stationary, until the hub of the catheter abuts the skin.

21. Once the catheter is fully advanced, release the traction then use the thumb and index finger of your non-dominant hand to hold the hub of the catheter. The other fingers are used to tamponade the vein, just beyond the tip of the catheter, to prevent blood from leaking out. Remove the needle

22. Connect the plastic catheter to the previously- prepared IV tubing set and open the flow regulator.

23. Tape the catheter in place - a loop ("U" shape) should be incorporated to prevent any tension placed on the line from pulling out the catheter. Adjust the flow rate.

24. Adjusting the flow rate (Amount to be infused ml) X (drops/ml) = drops (time for infusion in minutes) minute Example: 1000 ml X 20 drops/ml = drops 240 minutes 1 minute 20000 drops = 83 drops/minute 240 min

25. Complications of IVT Infiltration or Swelling at the injection area Thrombophlebitis Septicemia Air embolism Fluid overload

26. What have we learned?

27. INTERNAL EXAMINATION DURING LABOR

28. > 8 cm WHEN to do an I.E WHEN to do an I.E. ONLY DURING LABOR When the BOW ruptures (to rule out cord prolapse) If malpresentation is suspected on abdominal examination Before transferring a woman to another facility to ensure she is not likely to deliver on the journey. In the 3 rd stage, if there is postpartum hemorrhage, caused by retained placenta or suspected laceration.

29. > 8 cm If the woman has had vaginal bleeding after 5 th month of pregnancy NEVER do an I.E. unless you have a good indication for doing so. Every I.E. may bring INFECTION to the woman and her baby.

30. > 8 cm Procedure for internal examination Explain to the woman what you are going to do. Take full aseptic precautions INSPECT THE VULVA:  Is there amniotic fluid? Is it clear or meconium stained?  Is there any abnormal discharge, blood or pus? Rinse the vulva with clean water. Wear clean gloves Feel inside the vagina with the middle and index fingers.

31. > 8 cm What to note during internal examination Cervix  Dilatation  Thickness or Effacement Bag of waters Presenting part

32. Cervical dilatation Gradual opening of the cervix Measured in centimeters Feel with your 2 fingers The fully dilated cervix is 10 cm open.

33. Assessing Cervical Dilatation Insert the middle & index fingers into the open cervix and gently open them to the cervical rim. The distance between the outer rim of both fingers is the cervical dilatation 1 finger = 1.25 cm 5 fingers = 7 cm 2 fingers = 3 cm 6 fingers = 8.5 cm 3 fingers = 4.5 cm 7 fingers = 9.5 cm 4 fingers = 5.5 cm

34. Cervical Effacement The gradual thinning, shortening and drawing up of the cervix measured in % from 0-100% Causes expulsion of the mucus plug In normal labor, the cervix starts from a length of 2-3 cm and gradually becomes thinner  50% effaced cervix is about 1 cm long  70% effaced cervix is about 0.5 cm long

35. > 8 cm A thick swollen cervix in a woman who has been in labor for many hours is a sign of obstructed labor

36. Determine status of Bag of Waters (BOW) Is BOW intact or ruptured? Is there amniotic fluid leaking? Clear or meconium stained?

37. > 8 cm BE CAREFUL NOT TO RUPTURE THE BAG OF WATER IF THE PRESENTING PART IS FLOATING OR NOT ACCESSIBLE

38. Determine presenting part What is the presentation? What is the presentation? Is the cord palpable? What is the level of the presenting part?

39. Determine the presenting part Cephalic: Feels hard. Sutures and fontanelles of the baby’s head are felt Malpresentation: Hardness of the baby’s head is not felt but soft buttocks or extremeties (foot or hand).

40. Fetal Head Diameters

44. Fetal Station The level of the presenting part in the birth canal The relationship of the presenting part to the ischial spines (which are halfway between the pelvic inlet and outlet) Station -5: pelvic inlet (floating) Station 0: level of ischial spines Station +5: pelvic outlet (crowning )

45. Descent of the head assessed by abdominal palpation

47. THE PELVIC INLET THE PELVIC OUTLET Pelvic Architecture

48. Assess the following: Promontory of the Sacrum Sacral curvature Sacrosciatic notch Ischial spines Pubic arch

49. ≥ 11.5 – 12 cm The promontory of the sacrum is not accessible

50. The Diagonal Conjugate should be > 11.5-12 cm

51. Prominence of the Ischial Spines

52. Assessing the Pubic Arch

53. > 8 cm

54. A pelvis is adequate if The promontory of the sacrum is not accessible The pelvic sidewalls are parallel The ischial spines are not prominent The sacrum is not flat The pubic arch is wide (>90°) The fetal head is engaged or descends through the pelvic inlet with fundal pressure

55. > 8 cm What to note during internal examination Cervical dilatation Cervical dilatation Status of the Bag of waters Status of the Bag of waters Presenting part Presenting part Adequacy of the Pelvis Adequacy of the Pelvis

57. SUTURING PERINEAL LACERATIONS

58. Outline SUTURING OF PERINEAL LACERATIONS Review of Perineal anatomy General Principles of Perineal Repair Classification of Perineal Lacerations Choice of Suturing Materials Equipment needed Administration of local Anesthesia Technique of Repair After Care

60. What is a perineal laceration? Injury or tear in the vaginal canal and outlet that occurs during delivery of the baby  Anterior – involves the labia, anterior vagina, urethra or clitoris  Posterior – involves the posterior vaginal wall, perineal muscles, or anal sphincter Assessment includes determination of damage.

62. A first degree tear is a tear that involves only the skin around the vagina:

63. A 2nd degree tear has damage beyond the fourchette, into the muscle tissue but not involving the rectum or anal sphincter

64. A third degree tear extends into the anal sphincter

65. A fourth degree tear extends into the rectum:

66. Prevention of perineal tears 1. Avoid sudden expulsion of the fetal head during the bearing-down effort 2. Maintain flexion of the fetal head to allow smaller diameter to pass through the perineum 3. Control extension of the fetal head (Ritgen’s Maneuver) 4. Await external rotation of the baby before delivery of the shoulders.

67. Controlled delivery of the head Ritgen’s maneuver

68. Instruments and supplies needed for perineal repair Sterile drapes and gloves Irrigation solution Antiseptic Needle holder Suture scissors Forceps with teeth 10-mL syringe with 22- gauge needle 1% lidocaine (Xylocaine) suture Gauze sponges

69. Choice of Suture Material CHROMIC CATGUT is used for the repair of vaginal tears  Polyglycolic sutures (Vicryl, Dexon) Size of suture: 2/0 or 3/0 Round needle for muscle and mucosa, cutting needle for skin and fascia. An ABSORBABLE SUTURE is required for vaginal repair.

70. General Principles of Perineal Repair 1. Woman in lithotomy position 2. Use of a good light 3. Assess the extent of the laceration 4. Aseptic technique 5. Gentle handling of tissue 6. Careful use of swabs so that none are “lost” in the vagina 7. Use of local anaesthetic injected early enough 8. Explanation and sensitive approach to the woman

71. Steps in Perineal Repair GETTING READY Prepare the necessary equipment Tell the woman what is going to be done Provide emotional support and reassurance Ask about allergies to antiseptics and anesthetics Wear gloves, cap, mask and gloves Use antiseptic handrub or wash hands thoroughly with soap and water and dry with a sterile cloth or air dry. Put on high level disinfected or sterile surgical gloves on both hands.

72. Steps in Perineal Repair 2 Administering the local anesthetic Clean the perineum with antiseptic solution Fill the syringe with 10 ml of lidocaine Insert the whole length of the needle beneath the vaginal mucosa & beneath the skin of the perineum Aspirate by drawing the plunger back slightly to make certain the needle is not penetrating a blood vessel. If lidocaine is injected into a blood vessel, it can cause heart irregularity, seizures and death.

73. Infiltration of Local Anesthetic Inject the lidocaine solution into the vaginal mucosa, beneath the skin of the perineum and into the perineal muscle. Wait 2 minutes then pinch the incision site with forceps. If the woman feels the pinch, wait 2 more minutes then retest.

74. Repair the Perineal Laceration Suture the vagina first, using a continuous suture Start about 1 cm above the apex of the wound. Tie the stitch with 3 alternating knots. Continue the suture, placing each suture about 1 to 1.5 cm from the last. Stitches should include the same amount of tissue from each side.

75. Perineal Repair Repair the perineal muscle layer using interrupted suture or figure of 8 suture. The plane of the needle should be at right angles to the plane of the holder. The needle holder must be held parallel with the wound edges, otherwise a puncture of the rectum may occur.

76. Perineal Repair 2 Suture the perineal skin using interrupted suture starting at the vaginal opening. If tear was deep, perform a rectal exam to make sure no stitches are in the rectum. If so, they must be removed. Removal will help prevent infection as well as a formation of an open sinus tract from perineum to rectum.

77. Suturing Techniques Continuous SutureInterlocking SutureSimple interrupted

78. AFTER CARE Wash perineal area Pat dry the area Clean away all soiled linen Put a sanitary pad Gently lay the woman’s leg down together at the same time. Make the woman comfortable Always maintain privacy and modesty

79. Postpartum care of the wound Advise the woman to clean the genital area including the suture line, with clean water twice daily, and always after defecation. Provide pain relief  Give analgesics  Warm compress to lessen the edema  Hot sitz bath  Medicinal / Herbal wash

80. If a woman has excessive pain in the days after a repair, she should be examined immediately because pain is a frequent sign of infection in the perineal area

81. At the Postpartum Visit …. Examine the sutured perineum for healing and any signs of infection, e.g. marked inflammation, excessive swelling, pus. If the wound becomes infected:  If the infection is mild, antibiotics are not required  If the infection is severe - refer. Refer to clinicians for further evaluation if in doubt.

82. MagandangAraw!

83. Good afternoon!