PROCEDURES IN OBSTRETICS AND GYNECOLOGY

BREAST CARE

INTRODUCTION

Breasts are very vulnerable and fragile part of women’s body. During pregnancy because of various hormonal changes in the body, breasts too undergo a number of changes. Therefore, it’s important to take special care of them during this period. The breasts also show prominent signs of pregnancy. They evolve and prepare themselves for the arrival of the newcomer.

DEFINITION

Breast care means care given to the breast by the mother during her prenatal period, intranatal period and postnatal period.

WHY IS BREAST CARE IMPORTANT?

It is important to take care of your breasts if you plan to breastfeed or are breastfeeding. With good breast care, the mother can improve her breastfeeding experience for herself and for her baby. Taking care of breasts will also help to prevent problems that can happen while breastfeeding.

CARE OF THE BREAST DURING PREGNANCY PERIOD

During pregnancy due to increased blood flow, the breasts become tender and swollen. So, special care and attention should be given to the breasts so that after childbirth, the mother is fully prepared to breastfeed her baby without any problem.

 It is important to begin preparing the breast for breastfeeding during the prenatal period.

(1)  A well-fitting support bra should be worn at all times. This will provide good support for the enlarging breasts. As the breasts enlarge, an increase in bra and cup size should be worn. Avoid underwear bras, as under wires can put pressure on milk glands and interfere with milk production.

(2)  Wear a maternity sleep bra that ensures adequate breast support at night.

(3)  During the last weeks of pregnancy, the breasts start preparing themselves for lactation Pads may be worn inside the bra cups to absorb possible colostrum leakage from the nipples. The pads should be changed if they become wet from leakage. Prolonged moisture against the nipples may lead to tenderness and cracking once the newborn infant begins nursing. Select from reusable and disposable varieties available at stores. Change them several times a day and allow the nipples to air dry each change.

(4)  The breasts should be washed daily (without soap) to remove dried colostrum and to prevent irritation to the nipples. Lanolin may be applied to the nipples to prevent evaporation of perspiration, thereby softening the skin. Wet tea bags may be placed on the nipples, as the tea will release tannic acid, which will toughen the skin. The nipples should be air dried or blow dried after washing to help toughen them, especially if the patient plans to breastfeed.

(5)  The major change during this period is the change in the breast size due to increase in fat and milk glands. This means, breast grows in size and weight. Wear a comfortable and correct size of bra. They must wear a good brand bra which provides support and holds the breast in place without squeezing them.

(6)  The bra size should be changed according to the change in breast size during this phase. Choosing the right bra, prevents the breasts from sagging.

(7)  Under wire bras should be avoided as they put pressure on the milk glands and thus interferes with lactation.

(8)  As the size of the breast increases there are chances that this may lead to stretch marks. So expecting mothers should apply and massage stretch mark creams on their breast gently.

The nipples change in color and size as well. They sore, enlarge and stick out more. Too much dryness, too much friction and too much wetness, makes the nipples sore. So, inorder to avoid the dryness, expecting mother should avoid:

* Using soaps on their breasts and instead should apply good moisturising creams on them.
* Rubbing the breast and nipples with towel
* Wearing tight and incorrect size bras
Breasts need regular and special attention during pregnancy. One should not overlook any tumours and must visit breast physician for their advice and treatment. Because even the smallest tumour can start growing during this period and interfere with the ducts and prove to be a hindrance during lactation.

WHY CARE OF THE BREAST SHOULD BE TAKEN DURING PREGNANCY?

Proper education of mother and relatives is possible and mandatory during pregnancy. Flat or inverted nipple can lead to difficulties in breastfeeding for the child. Hence, during pregnancy women can become aware of it & take necessary steps.

CARE OF FLAT AND INVERTED NIPPLES: 

Nipples can be flat, normal, long or inverted. Flat nipples cannot be gripped easily. Inverted nipples cannot be held by fingers. Both can cause feeding difficulties and get injured while giving breastfeeding.

Steps of care:

Once breastfeeding is begun usually nipple starts protracting out.

Following tips can also help:

1. Try gentle pulling of nipples for flat nipples by fingers.

2. As shown in diagram cut a 10 ml syringe at the front end, remove the plunger from hind end and insert it from the cut front end. Then press open hind end of the syringe lightly over the areola covering the nipple and withdraw the plunger (which is now at the front cut end) so that the nipple is pulled into the syringe. Maintain pull for 20 to 30 seconds and then release. Gently remove the syringe. Nipple will remain protruded. Then put the child for breastfeeding.

3. Use “Nipple Shell” (hard plastic shell with holes worn over nipples) for flat and inverted nipples. If not available in the market, make it at home from wood, plastic or cap of feeding bottle. Remember, to make it with smooth margins So file all sharp margins, as there can be injurious.

BREAST DISCHARGE DURING PREGNANCY:

From fourth to sixth month of pregnancy, thick, yellow fluid begins to form inside the breast. This may or may not be, expressed out. There is no definite advantage or disadvantage of expressing this milk. Take care, while expressing this milk, to avoid injury to the nipples.

CARE OF THE BREAST DURING BREASTFEEDING

Need of breast care for all lactating mothers is most necessary as this directly links health of mother and her baby. So it becomes important to take care of your breasts if you are breastfeeding. Good breast care improves health of your breast and in turn breast feeding for you and your baby.

v Avoid pressure on the breasts: 

 Do not wear underwear bras, and avoid wearing bras that are too tight and clothes that are tight over the breasts. Avoid wearing or carrying items that can squeeze or press on the breasts. These include big purses, baby carriers and slings, and diaper bags. After rinsing the breasts, you might want to apply a few drops of breast milk or colostrum to the areolas. These substances will soothe and protect your nipple. In addition, some women find it beneficial to rub a few drops of corn oil or olive oil on their nipples.

v Sleeping Position:

Sleeping in a face down position may squeeze your breasts and block milk ducts.

v Breast support:

Wear a supportive bra. This can be a regular bra that the mother takes off when she breastfeed or a nursing bra with breast flaps. Cotton bras are best as they will not trap moisture that can irritate the nipples. Make sure the bra fits correctly and does not squeeze the breasts.

v Do not use underwire Bra:

Avoid wearing underwire bras. The milk ducts extend up towards the armpits. Underwire bras can squeeze the breasts and pinch on milk ducts, and cause plugged ducts or mastitis (breast infection).

v Cleaning the breasts: 

Always keep the breasts clean. Wash breasts with warm water once or twice every day. Strictly do not use soap or other cleansing agents. These can wash up the natural lubrication and may cause cracking of nipples and may irritate nipples. Always keep the hands clean while touching your breasts to prevent infections. Always wash the hands thoroughly for 15 seconds before breastfeeding, expressing, or pumping. Then dry them completely and always use a clean paper towel after every washing.

v Keep the 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 nipple. Placing cotton fabric breast pads inside your 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.

v Nipple conditioning:

Let the nipples air dry after breastfeeding. Use breast milk or pure lanolin ointment or some pure milk fat on the nipples if needed to keep them from getting chapped and dried out. Avoid creams and lotions that can cause an allergic reaction with irritation of the skin.

v Breast Creams for Dry or Cracked Nipples:

Often, women who are breastfeeding will develop dry and/or cracked nipples. This can make breastfeeding quite painful. In order to soothe and heal nipples, some mothers use a breast cream, such as Pure Lan^® or Lansinoh^®, after they nurse. If the mother chose to use one of these creams, she shouldn't wash it off after application.

When buying a breast cream, look out for products that do not contain alcohol, perfume and other substances that could contribute to drying and irritation.

v Using Nursing Pads to Prevent Leaks:

At some point or another, many breastfeeding moms will experience leakage. In fact, many pregnant women will leak milk or colostrum during their second or third trimesters. Leaking milk can not only stain your clothes but can also lead to embarrassing situations. In order to keep your clothes dry, you might consider wearing nursing pads.

Many breastfeeding moms opt to use washable or disposable nursing pads. If selecting this type of nursing pad, you should look for one that is made of 100 percent cotton. This will allow air to circulate around the breasts and the nipples. Avoid pads with plastic linings, which may not allow sufficient airflow and may contribute to nipple infections.

If the mother does not want to buy nursing pads, she can create one by cutting a disposable diaper into the desired shape and removing the plastic lining. Also, some women use cloth diapers or handkerchiefs as nursing pads. She should not use a sanitary pad as a nursing pad, as it will prevent air from circulating.

If the mother uses a nursing pad, she should change it or dispose of it as soon as it becomes damp. Wearing a moist pad can lead to irritation and infection.

WHAT PROBLEMS MAY OCCUR WHEN BREASTFEEDING?

·        Decreased nipple blood supply: This can cause the mother to have pain and blanching (becoming pale) of her nipples while breastfeeding. Decrease the amount of caffeine the mother drink, such as in coffee, tea, and soda, to help prevent nipple blanching. Do not smoke and avoid being in cold areas. Certain medicines may make the blood vessels get narrow and decrease blood flow to the nipples. Always ask the caregiver before using any medicine. Let him know when the mother has nipple blanching.

·        Engorgement: Although it is normal for the breasts to fill with milk, they can become too full. Breast engorgement is a condition where the breasts are painful and very swollen from too much milk inside. Breastfeeding the baby often will help empty the milk and prevent engorgement. If the baby cannot empty the breast milk, the mother can express milk from her breasts by hand or with a breast pump. Ask the caregiver for more information about breast fullness verses breast engorgement. Tell the caregiver if the mother want more information on expressing breast milk.

·        Leaking breasts: The breasts may leak when they are full of milk and not emptied often. The mother may see milk dripping from her nipples. This is normal. To stop this, cross the arms over the chest and press them lightly over the nipples. The mother can also wear nursing pads inside her bra to soak up the milk. Wear several layers of clothing, and avoid wearing solid colored shirts. Doing these things may make the leaking milk harder to see on her clothes.

·        Nipple pain: The mother can get sore nipples when she first start breastfeeding. This should get better as her body gets used to breastfeeding. She can get sore, cracked, or bleeding nipples if her baby is not latched-on in a good position. To prevent this, she needs to be careful when positioning your baby to feed. Make sure her baby has a mouthful of her breast when he feeds. To latch-on well, his lips and gums should be on her areola and not just on her nipple. Help the baby to latch-on and come off the breast without sucking to prevent injuring the nipple. Ask the caregiver for more information about nipple soreness.

·        Plugged milk ducts: Milk ducts are pathways where milk flows from milk producing areas in the breast down to the nipple. Things that can block the milk ducts include milk that gets thicker, scar tissue, or something pressing on them. The blockage can decrease or stop the flow of the breast milk in one part of the breast. It can make the milk build up inside and cause the breast to swell. Plugged ducts can lead to getting a breast abscess (area of infection in the breast) or mastitis. Always empty the breasts completely and do not let long periods of time pass between breast feedings. Breastfeeding often will help to prevent from getting plugged ducts again or getting a breast infection. Ask the caregiver for more information about breastfeeding and plugged ducts.

HOW CAN THE MOTHER PREVENT PROBLEMS WITH HER BREASTS BEFORE HER BABY IS BORN?

·        Prenatal nipple conditioning: This uses exercises to help decrease nipple discomfort when the mother starts to breastfeed her baby. These exercises may also cause her uterus to have contractions. This can cause her baby to be born too early. Ask the caregiver first before trying any nipple conditioning exercise. The mother can also dress so that her nipples rub against the clothes she wears. Do these exercises two times each day starting six weeks before the baby is due to be born:

o   Massage the breasts gently.

o   Roll the nipples between the fingers for 1 to 2 minutes. The mother can also use a special cream while rolling her nipples.

o   Rub the nipples gently with a soft towel for 15 seconds.

HOW CAN THE MOTHER PREVENT PROBLEMS WITH HER BREASTS WHILE BREASTFEEDING?

·        Break the suction from the baby's suckling before taking him off the breast. Make sure the baby is not suckling anymore before taking him off the breast. To stop the baby from suckling, gently insert the finger into his mouth. This will loosen his attachment to the breast and the mother can lift him off easily without pulling on her nipple.

·        Breastfeed or pump at least eight times a day, and breastfeed as often as the baby wants. The baby can feed 8 to 12 times a day, or even more. Make sure the baby has a mouthful of the mother’s breast so he could suckle easily. The baby will get the right milk flow when he has a mouthful of her breast. Offer both breasts when breastfeeding. Be sure the first breast is completely emptied before offering the second breast. Use a breast pump to remove and store leftover milk after the baby has finished feeding. The mother may also use it to remove excess milk if she misses a breastfeeding session, or any time her breasts feel very full. Ask the caregiver for more information on how to use a breast pump.

·        Find a comfortable position during breastfeeding. Hold the baby in a position where he can suckle at your breasts easily and comfortably. Learn the feeding positions that are comfortable and line the breast up well with the baby's mouth. Use one of these positions every time you breastfeed your baby. If the baby is not in the right position he may have trouble latching-on and suckling easily. He may not get enough milk and may suck harder. This can cause pain or change the shape of the nipple for a few minutes. Make sure the baby is well latched-on so he can suckle easily. Ask the caregiver for more information about how to hold and breastfeed the baby.

·        Learn how to get the baby to latch-on well. To latch-on means that the baby has taken all of the nipple and part of the areola (dark circle around your nipple) far into his mouth. Latch-on is important for the baby to get enough breast milk. The mother will know the baby is latched-on well if:

o   The breast or nipple does not hurt while feeding.

o   The baby is able to suckle milk right away after he latches-on. Suckling should change from quick short sucks to slow deep sucks. The mother should be able to hear him swallowing and see his jaw move downward with each suck.

o   The nipple is the same shape as it was before the feed started when the baby comes off her breast.

·        Make sure you are relaxed during breastfeeding. The mother should be relaxed and calm during breastfeeding. This helps increase the flow of her breast milk. Put a warm wet cloth on her breast or take a warm shower to increase her milk flow.

·        Make sure the baby is relaxed during breastfeeding. Making sure the baby is relaxed during breastfeeding will help him to completely empty the breasts. Massage the breasts so he does not have to work at getting your milk to start flowing. If the baby is suckling too hard and breastfeeding becomes painful, the mother needs to relax his mouth. To do this she needs to massage his jaw below his ears. Stroke in a circular motion to relax and widen his mouth. She can gently pull her baby's chin down using a finger. This lets his tongue stick out and rest between his gums and her nipple. Hold the baby's head so that his jaw is behind the nipple. In this way, milk can be squeezed out and there will be enough milk flowing out.

·        Use devices for breastfeeding correctly. Read the instructions that come with the breast pump. Use the device as instructed and always keep it clean. If it causes any injury to the breast, stop using it. The mother may need help to learn how to use it. She can get this from a caregiver or other professional, such as a lactation consultant. Do not use breast pads that irritate the breasts or trap too much moisture. These breast pads increase the risk for nipple damage and infection. Use nipple shields or shells only as directed by the caregiver or lactation consultant.

CONCLUSION

Breastfeeding moms know that breast care changes after giving birth. The breasts undergo a number of changes during pregnancy and continue to change as a woman's milk supply comes in and her baby begins feeding. Knowing how to care for the breasts during this time will benefit both the mother and her new baby.

BIBLIOGRAPHY

Books

·       Adele Pillitteri , “TEXTBOOK OF MATERNAL AND CHILD HEALTH NURSING”, 5^th edition, published by Lippincott Williams and Wilkins, Page no: 229-236

·       Annamma Jacob, “A COMPREHENSIVE TEXTBOOK OF MIDWIFERY”,

               2^nd edition,  Jaypee Brothers Medical Publishers, 2008, Page No. 151-153.

·       Diane M. Fraser, “MYLES TEXTBOOK FOR MIDWIVES”, 14^th edition, Library of Congress Cataloging in Publication,2003,Page No. 762.

·       Novak, Broom, “TEXTBOOK OF MATERNAL AND CHILD HEALTH NURSING”, 9^th edition Mosby Publication, Page no: 337-341.

Website

·       http://www.healthtree.com/articles/newborns/breastfeeding/breast-care

·       http://tropicalherbal.com/blog/2010/04/breast-care-during-lactation/

·       http://www.drugs.com/cg/breast-care-for-the-breast-feeding-mother.html

·       http://www.themedguru.com/articles/breast-care-during-and-after-pregnancy-86122143.html

·       http://www.pregnancyihub.com/breast-care-during-pregnancy/

http://www.drketan.com/breastfeed/chapter_2.pdf

BREAST SELF EXAMINATION

INTRODUCTION

Women may perform breast self exams to help detect changes in their breasts to call to their physicians' attention. Performing regular breast self exams can help women become familiar with the individual characteristics of their breasts and notice any changes.

DEFINITION

Breast self – examination (BSE) is a screening method used in an attempt to detect early breast cancer. The method involves the woman herself looking at and feeling each breast for possible lumps, distortions or swelling. Women older than 20 years should perform monthly breast examinations (BSE).

TECHNIQUES TO PERFORM BREAST EXAMINATION

                                 

An pictorial example of breast self-examination in six steps. Steps 1-3 involve inspection of the breast with the arms hanging next to the body, behind the head and in the side. Step 4 is palpation of the breast. Step 5 is palpation of the nipple. Step 6 is palpation of the breast while lying down.

A variety of methods and patterns are used in breast self-exams. Most methods suggest that the woman stand in front of a mirror with the torso exposed to view. She looks in the mirror for visual signs of dimpling, swelling, or redness on or near the breasts. This is usually repeated in several positions, such as while having hands on the hips, and then again with arms held overhead.

The woman then palpates her breasts with the pads of her fingers to feel for lumps (either superficial or deeper in tissue) or soreness. There are several common patterns, which are designed to ensure complete coverage. The vertical strip pattern involves moving the fingers up and down over the breast. The pie-wedge pattern starts at the nipple and moves outward. The circular pattern involves moving the fingers in concentric circles from the nipple outward. Some guidelines suggest mentally dividing the breast into four quadrants and checking each quadrant separately. The palpation process covers the entire breast, including the "axillary tail" of each breast that extends toward the axilla (armpit). This is usually done once while standing in front of the mirror and again while lying down.

In the shower 

A BSE can easily be performed while you're in the bath or shower. Some women discover breast masses when their skin is moist. 

o   Raise your right arm. 

o   With soapy hands and fingers flat, check your right breast. 

o   Use the same small circles and up-and-down pattern described earlier. 

o   Repeat on the left breast.

Finally, women that are not breastfeeding gently squeeze each nipple to check for any discharge.

Various mnemonic devices are used as teaching devices. One is called the seven P's of BSE, after seven steps that are named to have the same first initial: Positions, Perimeter, Palpation, Pressure, Pattern, Practice, and Planning what to do if a change is found in the breast tissue.

For pre-menopausal women, most methods suggest that the self-exam be performed at the same stage of the woman's menstrual cycle, because the normal hormone fluctuations can cause changes in the breasts. The most commonly recommended time is just after the end of the period, because the breasts are least likely to be swollen and tender at this time. Women who are postmenopausal or have irregular cycles might do a self-exam once a month regardless of their menstrual cycle.

DESCRIPTION

To complete a monthly BSE:

• When lying down, place a pillow under the right shoulder and position the right arm behind the head. Using the finger pads of the three middle fingers on the left hand, check the entire breast area. Use small circles and follow an up-and-down pattern while pressing firmly enough to know how the breast feels from month to month. This exam should then be repeated on the left breast using the finger pads of the right hand with the pillow under the left shoulder.

• When standing before a mirror, any changes in the shape or look of the breasts should be checked. In order to look for any skin or nipple changes such as dimpling or nipple discharge, the arms should first be placed at the sides and then overhead. Hands are then placed firmly on hips to flex chest muscles, and then the body should be bent forward.
• When taking a shower, the right arm should be raised. By using soapy hands and fingers flat the right breast and outer part of the breast can be examined. The same small circles and up-and-down pattern used when lying down should be used in an upright position. Repeat on the left breast.

 

PREPARATION

Before beginning a monthly BSE, a woman's breasts should be completely exposed.

THE FIVE STEPS OF BREAST EAXMINATION

Step 1: Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips.

Here's what you should look for:

·        Breasts that are their usual size, shape, and color

·        Breasts that are evenly shaped without visible distortion or swelling

If you see any of the following changes, bring them to your doctor's attention:

·        Dimpling, puckering, or bulging of the skin

·        A nipple that has changed position or an inverted nipple (pushed inward instead of sticking out)

·        Redness, soreness, rash, or swelling

Breast Self-Exam - Step 1

Step 2: Now, raise your arms and look for the same changes.

Breast Self-Exam - Steps 2 and 3

Step 3: While you're at the mirror, look for any signs of fluid coming out of one or both nipples (this could be a watery, milky, or yellow fluid or blood).

Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few finger pads of your hand, keeping the fingers flat and together. Use a circular motion, about the size of a quarter.

Cover the entire breast from top to bottom, side to side — from your collarbone to the top of your abdomen, and from your armpit to your cleavage.

Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were mowing a lawn. This up-and-down approach seems to work best for most women. Be sure to feel all the tissue from the front to the back of your breasts: for the skin and tissue just beneath, use light pressure; use medium pressure for tissue in the middle of your breasts; use firm pressure for the deep tissue in the back. When you've reached the deep tissue, you should be able to feel down to your ribcage.

Breast Self-Exam - Step 4

Step 5: Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4.

Breast Self-Exam - Step 5

NORMAL RESULTS

Each woman's breasts has their own normal look and feel. By completing a BSE each month, a woman can determine what is normal for her and check for changes that may arise. A regular pattern of lumpiness in the breasts is normal.

ABNORMAL RESULTS

If any changes are noticed during a monthly BSE, such as a new, hard lump in the breast or underarms, a doctor should examine the area immediately. Other trouble signs that should not be ignored include:

• change in breast size or shape
• dimpling or puckering of the skin
• redness, swelling, or warmth that does not go away
• pain in one area that does not vary with a woman's monthly cycle
• a nipple that pulls in
• discharge from the nipple that begins suddenly and appears only in one breast
• one nipple that has an itchy, sore, or scaling area

LIMITATIONS

According to a meta-analysis in the Cochrane Collaboration, two large trials in Russia and Shanghai found no beneficial effects of screening by breast self-examination "but do suggest increased harm in terms of increased numbers of benign lesions identified and an increased number of biopsies performed." They concluded, "At present, screening by breast self-examination or physical examination cannot be recommended."

Although breast self-examination increases the number of biopsies performed on women, it does not reduce mortality from breast cancer. In a large clinical trial involving more than 260,000 female Chinese factory workers, half were carefully taught by nurses at their factories to perform monthly breast self-exam, and the other half were not. The women taught self-exam detected more benign (normal or harmless lumps) or early-stage breast disease, but equal numbers of women died from breast cancer in each group.

Because breast self-exam is not proven to save lives, it is no longer routinely recommended by health authorities for general use. It may be appropriate in women who have a particularly high risk of developing breast cancer. Some charitable organizations, whose donations depend on promoting fear of breast cancer, still promote this technique as a one-size-fits-all, universal screening approach, even in the low-risk women who are most likely to be harmed by unnecessary invasive follow-up procedures. Among groups promoting evidence-based medicine, awareness of breast health and familiarity with one's own body is typically promoted instead of self-exams.

CONCLUSION

Breast self examination has been universally accepted by the experts as a very simple, significant and effective method of early detection of Breast cancer. As with all other types of cancer early detection and a high index of suspicion are the keys to combating the menace of cancer.

BIBLIOGRAPHY

Books

1.     Altman, Roberta and Michael J. Sarg, "BREAST SELF-EXAMINATION", The Cancer Dictionary, Checkmark Books, 2000, Page No: 547- 556.

2.     Bruce. R, Richard E. Blackwell, “ESSENTIAL REPRODUCTIVE MEDICINE”, 3^rd edition, Library Of Congress Cataloging-In-Publication, 2005, Page No: 351 - 356.

3.     Pillitiri A, “MATERNAL AND CHILD HEALTH”,5^th edition, Mosby, St.Louis, Philadelphia, 2007, Page No:         245-253.

4.     Norman F. Gant, “WILLIAMS OBSTETRICS”, 21st edition, Library of Congress Cataloging in Publication, 2001, Page No. 400-405.

Website

5.     http://en.wikipedia.org/wiki/Breast_self-examination

6.     http://www.breastcancer.org/symptoms/testing/types/self_exam/bse_steps.

7.     http://health.stateuniversity.com/pages/264/Breast-Self-Examination.html

8.     http://medical-dictionary.thefreedictionary.com/breast+self-examination

9.     http://www.emedicinehealth.com/breast_self-exam/page2_em.html

                            CLINICAL BREAST EXAMINATION

     INTRODUCTION:

The premise underlying CBE is that visually inspecting and palpating of the breast and surrounding tissue can detect breast abnormalities. CBE was considered by the committee to include a continuum of integrally related components, from the examination itself, to interpretation and reporting of findings, to patient follow up. The recommendations for performance in this report represent general standards that can be immediately disseminated and adopted based on current evidence.

     Neither CBE nor mammography is a substitute for the other as an independent examination for detecting breast abnormalities. When a suspicious mass is found on CBE, it must be evaluated and explained even if mammography examination does not show an abnormality.

However, the practitioner needs to be alert to the possibility of carcinoma at all times. Early detection of potential malignancies has been and continuous to be the single most important factor in the successful treatment of this disease. Since professional assessment is done only periodically , each woman is advised to do a breast self-examination on a monthly basis at the time when the breast is least affected by menstrual changes, 4 to 10 days after the last menstrual period.

      As the examiner proceeds through the examination , the woman is taught about BSE or if she already follows a routine for BSE , her knowledge and technique are refreshed.At the start of the examination, the breasts are abserved for symmetry , contour , color, size, and surface characterstics such as vascularity , moles, and nevi. The nipples are checked for areolar pigmentation and discharge and for response to stimulation (i.e., erection, flattening or inversion)

  

1. The Examination:

   a. Adopt standards for CBE that include a stepwise progression of elements consisting of clinical history, visual inspection, and palpation.
      .

View larger version (27K): FIGURE 1  Position of Patient and Direction of Palpation for the CBE. The top figure shows the lateral portion of the breast, and the bottom picture shows the medial portion of the breast. Arrows indicate the vertical strip pattern of examination.

View larger version (24K):   FIGURE 2  Palpation Technique. Pads of the index, third, and fourth fingers (inset) make small circular motions, as if tracking the outer edge of a dime.

View larger version  FIGURE 3 Levels of Pressure for Palpation of Breast Tissue Shown in a Cross-sectional View of the Right Breast. The examiner should make three circles with the finger pads, increasing the level of pressure (subcutaneous, mid-level, and down to the chest wall) with each circle)

Clinicians are encouraged to adopt and implement the following standards for performance of the CBE examination. Efforts to encourage widespread dissemination of these standards must be implemented as a partnership between clinicians and health care organizations.

Clinical History :
A clinical history that identifies the patient’s personal and family health history is useful in assessing risk of breast cancer. Some women will not report symptoms until asked, and a clinical history provides an important opportunity to seek out this information. This health history can direct attention to potentially relevant symptoms and provides important context for interpreting findings. The clinical guidelines and policy statements of many organizations concerning the performance of screening CBE emphasize the importance of a woman’s individual risk for breast cancer.¹⁵ Furthermore, information on clinical history can help guide follow up. The clinical history also provides an opportunity for the provider to explain the benefits and limitations of the examination, its elements, the time involved, and the related events that occur after the examination (interpretation, reporting, and follow up).

The clinical history should:

• Identify screening practices for breast health,when they were performed, and results. These practices include breast self-examination (BSE), prior CBE, and prior screening and diagnostic mammograms.
• Ask about any breast changesand how they were identified. This includes changes in appearance of skin or nipples, presence of lumps, pain (focal versus general and constant versus cyclic), itching, or staining of garments or bed sheets that would indicate spontaneous nipple discharge.
• Assess riskby asking about age and personal history, including benign breast disease, biopsy, cancer, cosmetic or other breast surgery, history of hormonal therapy, and/or oral contraceptive use, obstetric history, family history, and health promotion habits (eg, exercise, nutrition).

    Visual Inspection:
Once the clinical history has been completed, the patient’s breasts should be visually inspected. To minimize awkwardness and potential misunderstandings, providers should inform women in advance that a visual inspection will be performed and describe what is being assessed during this part of the examination. The patient should sit with her hands pushing tightly on her hips. This position contracts the pectoralis major muscles and enhances identification of asymmetries. Although adding multiple positions (eg, hands over head and hands at sides) may further assist identification of asymmetries, it does not add substantively to the single position recommended and may reduce time devoted to palpation. When conducting the visual inspection, the provider must view the breasts from all sides and should:

• Assess symmetry in breast shape or contour (subtle changes or differences) and
• Assess skin changes, particularly any skin erythema, retraction or dimpling, and nipple changes.  Physical signs associated with advanced breast cancer have been summarized using the acronym BREAST, signifying Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, and Tender breast.

If the clinician is seeing the patient on a regular basis, visual inspection allows the monitoring of changes in appearance over time when observations are compared with previously documented examination. Visual inspection takes only a short amount of time, with the remainder of the examination spent predominately on palpation.

Palpation:
Following the visual inspection, the examiner palpates each breast and nearby lymph nodes. To minimize awkwardness and the potential for misunderstanding, providers should inform women in advance that palpation will be performed and describe what is being assessed during this part of the examination. Palpation provides an opportunity for discussion of the normal variability of breast characteristics and the importance of women becoming familiar with the characteristics of their own breasts. Thoroughness is essential; palpation must examine all breast tissue as well as nearby lymph nodes. Appropriate palpation includes five key characteristics:

• Position: Patients should be sitting for palpation of the axillary, supraclavicular, and infraclavicular lymph nodes. Patients should be lying down for breast palpation, with their ipsilateral hand overhead to flatten the breast tissue on the chest wall, thereby reducing the thickness of the breast tissue being palpated (Figure 1). If this maneuver does not result in a relatively even distribution of breast tissue, the breast should be further centralized by placing a small pillow under the shoulder/lower back on the side of the breast being examined. The tissue being examined needs to be as thin as possible over the chest wall. The examiner must be able to see the full palpation area.
• Perimeter: All breast tissue falls within a pentagon shape (as opposed to the traditional perception of the breast as a conical structure). The examiner should use the following landmarks to cover all of this area: down the midaxillary line, across the inframammary ridge at the fifth/sixth rib, up the lateral edge of the sternum, across the clavicle, and back to the midaxilla.
• Pattern of search: The full extent of breast tissue should be searched using a "vertical strip" pattern (Figure 1). (A systematic analysis demonstrated the superiority of the vertical strip search pattern over concentric circle and radial spoke patterns in thoroughness of coverage, as performed by women trained in BSE to examine themselves.) The search should be initiated at the axilla. If a mastectomy has been performed, the chest wall, skin, and incision should be included.
• Palpation: The examiner should use the finger pads of the middle three fingers to palpate one breast at a time (Figure 2). Palpate with overlapping dime-sized circular motions. Tissue at and beneath the nipple should be palpated, not squeezed. Squeezing often results in discharge as well as discomfort. Only spontaneous discharge warrants further evaluation.Breast tissue in the upper outer quadrant and under the areola and nipple should be thoroughly searched, as these are the two most common sites for cancer to arise.
• Pressure: As each area of tissue is examined, three levels of pressure should be applied in sequence: light, medium, and deep, corresponding to subcutaneous, mid-level, and down to the chest wall (Figure 3). Adapt the palpation to the size, shape, and consistency of tissue, and accommodate pressure to other factors such as breast size and the presence of breast implants. Providers sometimes lack confidence performing CBE in women with breast implants; implants correctly placed are located behind the tissue of the breast. Therefore, the steps for CBE are exactly the same as in women without implants.

Duration for CBE:

·        The duration of the examination is intentionally not specified, for several reasons. First, while thoroughness is related to time spent performing CBE, performance time can decrease with increased proficiency. Additionally, a variety of patient factors, such as breast size, tenderness, lumpiness, body weight, and risk factors, can influence the time required to perform a proficient CBE.

2. Interpretation and Reporting:

   a. Reporting should consist of a summary of the relevant portions of a patient’s history and a description of whether the CBE is interpreted as normal/negative or abnormal. If abnormal, include a description of the visual and palpable findings, including changes in the appearance of skin or nipples, the presence of nipple discharge, the presence of breast masses or palpable asymmetries, and the presence of palpable lymph nodes.

The primary function of CBE is to identify abnormalities that warrant further evaluation; CBE alone is not capable of accurately distinguishing benign from malignant status. Interpreting the visual and tactile observations of CBE is complex. A variety of patient characteristics can influence interpretation, including age, parity, tissue density and nodularity, menopausal status, phase of the ovarian cycle, and health history.²

Ø  For example: bloody nipple discharge during the last trimester of pregnancy or the first 3 months of lactation may be considered a normal physiologic change, but it would be interpreted quite differently in a woman who was not pregnant or lactating.

Ø   Similarly, skin erythema or lymphedema would not necessarily be cause for further evaluation in a woman having recently undergone radiation therapy of the breast but would certainly require follow up in a woman without such a history.

Ø   A more common and difficult challenge involves breast lumpiness or nodularity, which varies considerably among women and over time for the same woman. For example, increased nodularity might be normal during the luteal phase of the menstrual cycle, but at other times it might be cause for further examination.

In the most general form, the results of CBE can be interpreted in two ways:

• Normal/Negative: No abnormalities on visual inspection or palpation.
• Abnormal: Asymmetrical finding on either visual inspection or palpation that warrants further evaluation and possible referral. Findings will reflect a continuum of possible outcomes, from probably benign to highly suspicious of cancer. Determination of benign or malignant status, however, can be established only through further evaluation.

    Reporting
Reporting should include a description of all findings in specific and precise language, regardless of interpretation. In the case of a negative interpretation, description of findings provides a baseline for interpreting future results from visual inspection and palpation. In the case of an abnormal interpretation, a description provides an important guide for follow-up examination.

Reporting should follow the same sequence as the examination itself. The following outline directs providers’ attention to those aspects of the exam that represent unique patient characteristics or abnormalities. To the extent possible, electronic reporting should be encouraged to provide compatibility with existing medical records systems and more efficient analysis of reporting trends.

    CHARACTERSTICS OF NORMAL & ABNORMAL BREAST:

 Normal Breast Characteristics:

• Clinical history – describe:
•    Breast screening practices.
•    Breast changes.
•    Risk factors for breast cancer.
•    Hormonal factors at time of examination (eg, time in menstrual cycle, pregnancy, breast feeding, hormonal contraceptives, hormone therapy).
• Visual inspection – describe:
•    Scarring.
•    Symmetry of breast shape and appearance of skin and nipple-areolar complex.
• Palpation of lymph node – describe results with respect to:
•    Infra- and supraclavicular nodes.
•    Axillary nodes.
• Breast palpation – describe results with respect to:
•    Nodularity.
•       Normal nodularity should not be described as a fibrocystic condition.
•       Normal cyclic breast tenderness should not be described as a pathologic condition.
•    Symmetry.
•    Tenderness (focal versus generalized and constant versus intermittent).
• Recommended follow up.

    Abnormal CBE: Abnormal Breast Characteristics:

• Clinical history – describe:
•    Breast screening practices.
•    Breast changes.
•    Risk factors for breast cancer.
•    Hormonal factors at time of examination (eg, time in menstrual cycle, pregnancy, breast feeding, hormonal contraceptives, hormone therapy).
• Visual inspection – describe:
•    Contour (skin retraction, dimpling).
•    Color (erythema).
•    Texture (skin thickening or lymphedema).
•    Skin retraction or dimpling.
•    Nipple scaling or retraction.
•    Nipple inversion (age of onset during adulthood).
•    Location of abnormal findings or mass according to a clock face as the examiner faces the patient, clearly indicating whether the abnormality is in the right or left breast.
•    Size/extent of abnormal finding or mass.
• Palpation – for each palpable abnormality (including breast tissue and infraclavicular,supraclavicular, and axillary lymph nodes), describe:
• Three-dimensional dominant mass or two-dimensional thickening.
•    Location in three dimensions (subcutaneous, midlevel, next to chest wall, and according to a clock face as the examiner faces the patient).
•    Size.
•    Shape (round, oblong, irregular, lobular [having one to four rounded or curved extensions from a central mass]).
•    Mobility (mobile, fixed to skin or chest wall).
•    Consistency (soft, similar to surrounding breast tissue, hard).
•    External texture (smooth, irregular [having bumps distributed over the external surface of the mass]).
• Nipple discharge.
•    Spontaneous.
•    Color.
•    Number of involved ducts.
•    Right or left breast, or both.

FOLLOW-UP:

The final but equally important component of the CBE is follow up; different types of findings will require different follow-up actions, but appropriate follow up is essential.

    Follow Up for Normal/Negative CBE
In the case of a normal/negative CBE, a repeat CBE at the next screening interval or preventive health examination is the appropriate follow up. Descriptive findings from the normal/negative CBE should serve as the baseline for the next interval CBE.

    Follow Up for Abnormal CBE
In the case of an abnormal CBE:

• The provider should not discount an abnormal CBE because of a negative mammogram or other imaging examination.
• Providers must follow up all conflicting or abnormal findings to satisfactory resolution using the actions outlined below.
• All referrals must ensure that a copy of the CBE report is provided to specialists performing follow-up imaging to assist in examination and interpretation.

One or more of the following follow-up options are available:

• Repeat CBE.
• Medical management of probably benign condition.
• Referral to a breast specialist.
• Imaging (ultrasound, mammography, magnetic resonance imaging).
• Aspiration.
• Biopsy (percutaneous or excisional).

    Timing
The timing of follow-up actions must be appropriate to the findings and should be designed to minimize patient burden and psychological stress. For women aged 40 and older, a repeat CBE in the case of negative findings will likely occur as part of the woman’s regular preventive health care. Among women aged 40 and younger with a negative CBE, this interval may be longer. In the case of abnormal findings, follow up should take place at a shorter interval, at least within 6 months and usually within a shorter time frame.

^CONCLUSION:

           CBE can contribute to the ability of health care professionals and women to detect some breast cancers and should lead to appropriate follow-up care.

BIBLIOGRAPHY

Books

1.     Laura R, Kathway A Mary, “TEXTBOOK OF COMPREHENSIVE MATERNITY NURSING”, 2^nd edition, published by Mahlmeister, Page no: 868-872.

2.     Norman F. Gant, “WILLIAMS OBSTETRICS”, 21st edition, Library of Congress Cataloging in Publication, 2001, Page No. 423-428.

Website

1.     http://www.medscape.com › ... › MedGenMed Ob/Gyn & Women's Health

2. http://www.healthline.com/galecontent/clinical-breast-examination 
3. http://www.fpnotebook.com/gyn/Exam/ClnclBrstExm.html

4.     http://www.medicalhealthtests.com/breast...examination/clinical-breast-examination.html 

CHEST PHYSIOTHERAPY

INTRODUCTION

Chest physiotherapy (CPT) is a broad, non-specific term used to describe treatments generally performed by physiotherapists & respiratory therapists whereby breathing is improved by the indirect removal of mucus from the breathing passages of a patient.

Chest physiotherapy is the term for a group of treatments designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system.

DEFINITION

-Chest physiotherapy is removal of excess sputum secretions from the respiratory system.

-A treatment used with neonates who have heart surgery and who may have partial collapse of their lung tissue or lung secretions which they are unable to clear by themselves.

PURPOSES

The purpose of chest physiotherapy

Ø  To clear the secretions of the neonate.

Ø  To facilitate easy breathing.

Ø  To provide comfort for the neonate.

Ø  To get more oxygen into the body.

Ø  To provide the caregiver with instruction to follow for home care.

ARTICLES O F CHEST PHYSIOTHERAPY

Sl.	ARTICLES	RATIONALES
1 2 3 4	Stethescope Suction catheter Pillow Cup of ambu bag mask	To assess the air entry and the secretions. To remove the secretions. To provide slight elevation to the head. To provide physiotherapy to the children in different lobes of lungs.

INDICATIONS

Child with

Ø  In conditions with copious retention of airway secretions  like bronchiectasis,

cystic fibrosis (CF).

Ø  Neuromuscular diseases like Guillain-Barré syndrome, progressive muscle weakness (myasthenia gravis), or tetanus.

Ø  Lung diseases such as bronchitis, pneumonia, or chronic obstructive pulmonary disease (COPD)

Ø  Child with weak respiratory mechanics like cerebral palsy or muscular dystrophy

Ø  Bedridden, immobilization or who cannot breathe deeply because of postoperative pain.

Ø  Kyphoscoliosis

PRECAUTIONS/ CONTRA-INDICATIONS

Chest physiotherapy should not be performed on child with

·                  Bleeding from the lungs

·                  Neck or head injuries

·                  Fractured ribs

·                  Collapsed lungs

·                  Damaged chest walls

·                  Tuberculosis

·                  Acute asthma

·                  Pulmonary embolism

·                  Lung abscess

·                  Active hemorrhage

·                  Some spine injuries

·                  Recent surgery, open wounds, or burns

 PREPARATION OF THE NEONATE

The only preparation needed for chest physiotherapy is an evaluation of the patient's condition and determination of which chest physiotherapy techniques would be most beneficial.

PROCEDURE OR TECHNIQUES FOR NEONATE CHEST PHYSIOTHERAPY

1.     Check chart for orders.

2.     Wash hands.

3.     Ascultate lungs before and after procedure.

4.     Perform procedure prior to feeding and oral medication.

5.     Perform percussion and vibration in position best for particular premature infants, depending on which part of lung affected.

6.     Monitor oxygen saturation throughout procedure not to exceed 10 mints.

7.     Suction gently.

8.     Place in position of comfort.

9.     Return articles.

10.  Wash hands.

It is essential part of management of chronic suppurative lung disease. This may be used with advantage in some acute conditions also when drainage of a segment or lobe is desirable.

The segment affected should be determined by X ray of the chest PA and lateral views. The appropriate position for drainage is discussed here. Percussion should be done with cupped hand (not the flat of hand) at appropriate locations. Air pocket in the cupped hand creates enough air vibrations but still cushions the blow and hence discomfort is minimum.

Upper lobe – apical segment: Let the infant rest comfortably over the shoulder of mother and percuss the area above the scapula to drain the posterior sub-segment. (1) Bigger child can bend to about 30⁰ forward angle (eg. bend over a pillow placed in his lap). With the child sitting and leaning back 30⁰, percuss over the top of the shoulder and clavicle. (2) to drain the anterior sub-segment.

Upper lobe anterior segment: Let the infant lie flat on its back. Percuss the anterior chest below the clavicles.

Upper lobe posterior segment: The child is sitting, leaning forward and rotated to the right (generally holding on to a pillow). Percuss over the left scapula to drain the left upper lobe posterior segment. (4) The right side drains better with the child lying flat, rotated into the left side and percussion over the right scapula.

Right middle lobe: Foot end of the bed is elevated to 30⁰ (slightly less angle for infants). Patient rotates from supine to left side by about ¼ turn (now child’s position is midway between supine and lying on the left side). Percuss over the nipple area (5).

Reverse this position to the other side to drain the lingular segment of the left upper lobe.

Lower lobes: For drainage of any segment of lower lobes foot end of the bed must be elevated to 45⁰ angle (slightly less angle for infants).

Anterior basal: Child lies supine; percuss above the lower ribs anteriorly and antero laterally (right or left) (6).

Lateral basal (right side): Child lies on his left side and percuss over right lateral thorax (approximately at the level of 8^th rib). Reverse the position for left side (7).

Posterior basal: Patient lies prone; percuss over the lower most ribs lateral to the vertebral column (but not over the vertebral column) (8).

For drainage of all the above segments of the lower lobe foot end of the bed must be elevated. However for the superior segment of lower lobe foot end need not be raised. Instead with the patient prone, just place a folded pillow under the hips and percuss below the inferior angle of the scapula (9).

Lying in the above positions for some time each day will enhance postural drainage of the affected segment. Chest physiotherapy may be more rewarding when done after a steam inhalation or when necessary, after nebulised salbutamol.

         AFTERCARE OF THE NEONATE

a)     Completion of therapy and neonate’s response to the therapy.

b)     Adjunctive treatments given concurrently (nebulizer or inhaled medication) and the neonate’s response to these treatment.

c)     Education provided to the care giver

RISKS/ COMPLICATIONS

Risks and complications associated with chest physiotherapy depend on the health of the patient. Although chest physiotherapy usually poses few problems, in some patients it may cause

·                  Oxygen deficiency if the head is kept lowered for drainage

·                  Increased intracranial pressure

·                  Temporary low blood pressure

·                  Bleeding in the lungs

·                  Pain or injury to the ribs, muscles, or spine

·                  Vomiting

·                  Inhaling secretions into the lungs

·                  Heart irregularities

·                  Normal results

The patient is considered to be responding positively to chest physiotherapy if some, but not necessarily all, of these changes occur:

·                  Increased volume of sputum secretions

·                  Changes in breath sounds

·                  Improved vital signs

·                  Improved chest x ray

·                  Increased oxygen in the blood as measured by arterial blood gas values

·                  Patient reports of eased breathing

CONCLUSION

Lung is an unique organ in the body in many ways. Inspite of constant exposure to microorganisms, pollutants and allergens, it remains sterile beyond the first order bronchi. Several defense mechanisms play role for it, including microciliary mechanism. Chest physiotherapy helps by promoting drainage of lung secretions and ensuring expansion of lung parenchymal tissues.

 BIBLIOGRAPHY

Books

1.     Bobak, Jenson, “MATERNAL NURSING”. 3^rd edition, Mosby Year Book St. Louis, 1991, Page No: 628-630.

2.     Wilson D & Hockenberry MJ, “NURSING CARE OF INFANTS AND CHILDREN”, 8^th ed, New Delhi, Elsevier Private Ltd; 2007, Page No: 532- 538.

3.     Nicholas, Zwelling, “MATERNAL NEWBORN NURSING”. 1^st edition, WB Saunders Company Publications, 1997, Philadelphia, Page No: 389-390.

4.     Marlow DR, Redding BA, “TEXT BOOK OF PEDIATRIC NURSING”, 6^th ed, New Delhi, Elsevier India Private Limited; 2006, Page No: 210- 215.

5.     Gupte S. “THE SHORT TEXTBOOK OF PEDIATRICS”, 10^th edition, New Delhi, Jaypee Brothers Medical Publishers (P) Ltd; 2004, Page No: 422- 427.

Website

6.     http://www.buzzle.com/articles/chest-physiotherapy.html

7.     http://medind.nic.in/ibv/t05/i6/ibvt05i6p559.pdf 

8.     http://en.wikipedia.org/wiki/Chest_physiotherapy

9.     http://www.jtsma.org.uk/in013.html

10.  http://docs.google.com/viewer?pid=bl&srcid=ADGEESifS

CONTROLLED CORD TRACTION (CCT)

INTRODUCTION

At the beginning of the third stage of labour, a strong contraction results in the fundus being palpable below the umbilicus. It feels broad as the placenta is still in the upper segment. As the placenta separates and falls into the lower uterine segment there is a small fresh blood loss, the cord lengthens and the fundus becomes rounder, smaller and more mobile as it rises in the abdomen above the level of the placenta.

But sometimes the placenta remains in the uterus, but has separated, exposing the bleeding blood vessels, but inhibiting the uterus from contracting down completely to control the bleeding. If the placenta remains in the cervix, the uterus can continue to bleed, filling with blood, even though not that much blood will be seen coming away from the woman's vagina because the cervix has been sealed off by the placenta. Occasionally after the placenta separates and is being expelled from the uterus into the vagina, it will become 'held up' in the opening of the soft cervix. The placenta may need some gentle assistance to be completely expelled from the uterus. 

  

DEFINITION

Controlled cord traction involves traction on the umbilical cord during a contraction combined with counterpressure upwards on the uterine body by a hand placed immediately above the symphysis pubis. Controlled cord traction facilitates expulsion of the placenta once it has separated from the uterine wall.

USES

This manoeuvre is done

v to reduce blood loss

v shorten the third stage of labour

v minimise the time during which the mother is at risk from haemorrhage.

BEFORE DURING CONTROLLED CORD TRACTION

If CCT is to be used, there are several checks to be made before proceeding:

·       that an oxytocin  drug has been administered.

·       that it has been given time to act

·       that the uterus is well contracted

·       that countertraction is applied

·       that signs of placental separation and descent are present

PROCEDURE

After the syntometrine is given (with consent) - intramuscularly in the upper outer quadrant of the buttock - you must wait for signs of separation, this will be blood loss and lengthening of the umbilical cord, use the clamps as a guide to cord lengthening.




Maintain your abdominal hand over the uterus, using your flattened fingers just above the pubic bone to aid the placenta as it exits the cervical os into the vagina. Instead of pressure with flattened fingers, the Brandt Andrews manuver may also be used, but this is more uncomfortable for the mother.

Place your fingers in the clamp at the point where the cord is attached, and apply steady cord traction with a downward motion, stop if you feel resistance. Wait a minute or two and then try again, gently, if you do not feel resistance then continue traction but upward along the curve of Carus as the placenta becomes visible at the the introitus.

When the placenta is visable at the introitus, lift it partially through with the hand holding the clamp.

Remove your other hand from the abdomen and let the placenta fall into your hands. At this point drop the cord and the clamp.

Move the placenta up and down and rotate it gently to bring it through the os. This has been called 'feathering'.

Continue to rotate the placenta to make a thick cord of the trailing membranes, if necessary.

 

If this is not sufficient, grasp the membranes with the clamp to encompass them laterally.

Rotate the ring forceps to make a thicker cord of membranes and then gently tease the membranes through the introitus by a slight up and down movement.


Important Note: Remember: slow controlled delivery to avoid tearing the cord or membranes.
It is important to apply steady traction by pulling the cord firmly and maintaining the pressure. Force and jerky movements must be avoided.

CONCLUSION

The uterus continues to contract and relax during the three stage of labour and as a result the separated placenta descends from the upper segment of the uterus to the lower segment of the uterus to the lower segment of the vagina. It is at this point that the classical signs of separation are elicited. In many instances when C.C.T, is used the placenta is delivered when it lies free in the upper segment and before it has descended into the lower segment and vagina. If the placenta is still attached to the uterine wall C.C.T will be unsuccessful.

BIBLIOGRAPHY

Books

1.     Bobak. Lowdermilk. Jenson, “MATERNITY NURSING”, 4^th edition, Mosby Publication, St. Louis; 1997, Page No: 445 – 448.

2.     Bennet Ruth. V, Brown Linda. K, “MYLES TEXT BOOK FOR MIDWIVES”; 13^th edition, Churchill Livingstone, Edinburg,1999, Page No: 515 - 517.

3.     Annamma Jacob, “A COMPREHENSIVE TEXT BOOK OF MIDWIFERY”, 1^st edition, Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, 2005, Page No: 121 – 122.

4.     Dutta D.C., “TEXT BOOK OF OBSTETRICS”, 4^th edition, New central book agency, Calcutta, 1998, Page No: 141.

5.      Basavanthappa B.T, “TEXT BOOK OF MIDWIFERY & REPRODUCTIVE HEALTH NURSING”, 1^st edition, Jaypee Brothers (P) Ltd, New Delhi, 2006, Page No: 605.

Website

6.     http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1959032/?page=4

7.     http://www.birth.com.au/An-overview-of-a-natural-3rd-stage-of-labour

8.     http://www.clinicaltrials.gov/ct2/show/NCT00781066

9.     www.pphprevention.org/files/Glossaryofterms_000.doc

10.  http://www.studentmidwife.net/educational-resources-35/midwifery-glossary-and-definition-terms-41/730-controlled-cord-traction-cct.html

GASTRIC LAVAGE

INTRODUCTION

Although the use of “Stomach Pumps” in animals dates to the mid eighteenth century, its first use (in human poisoning) is attributed to Physic of Pennsylvania, who in 1812, lavaged twins poisoned with laudanum, prescribed for whooping cough. The lavage fluid was brandy and water.

DEFINITION

Gastric lavage, also commonly called stomach pumping or Gastric irrigation, Gastric suction or Nasogastric tube suction.

Gastric lavage is a procedure that empties the contents of the stomach. It may be done for tests, or to remove materials such as poisons.

INDICATIONS

v Oral poisons (except hydrocarbons and corrosives) – to remove the poison from the stomach, to prevent its absorption and to neutralize the poison with the use of antidote. It is effective only when performed within two hours of ingestion. Little is gained by gastric lavage after this time unless the patient has been in shock, with resulting delay in gastric emptying and slowing of absorption.

v Gastrointestinal bleeding:

·       To remove the retained blood from the stomach.

·       To quantify the blood loss.

·       To prevent the further bleeding.

·       In newborn, to differentiate between maternal blood and fetal blood by Apt test.

v Meconium aspiration syndrome and meconium induced gastritis to remove the retained meconium from the stomach.

v Suspected congenital tuberculosis – to confirm the diagnosis by identification of acid fast bacilli in gastric fluid.

CONTRAINDICATIONS 

v Ingestion of corrosive poisons: Gastric lavage should not be performed more than 30 minutes after ingestion. By this time, tissue destruction may have progressed to the point where perforation may occur if tube is passed.

v Ingestion of most hydrocarbons: since passing a gastric tube is likely to induce severe retching and vomiting in child, increasing the risk of aspiration of gastric contents into trachea. Kerosene apparently passes readily into trachea because it is oily and does not stimulate the cough reflex. Most hydrocarbons however, need not be removed from the stomach.

v Presence of neurologic symptoms likely to impair normal airway protective mechanisms (i.e. coma, or seizures). However, these patients can be safely lavaged following intubation preferably with a cuffed endotracheal tube.

v Tetanus is a relative contraindication because passage of tube may trigger spasms in these patients but still, tube can be passed after generous sedation.

MATERIALS

Ø  Stomach tube (Ryle’s tube, named after GA Ryle, a British Physician) appropriate size.

Ø  Suction machine, syringe or aspirating bulb.

Ø  Liquid paraffin or Vaseline.

Ø  Mouth gag.

Ø  Normal saline

Ø  Endotracheal tubes with inflatable cuffs, appropriate sizes for children; laryngoscope.

TECHNIQUE

ü  Measure the distance on the tube from the mouth or tip of nose to ear lobule to epigastrium and mark the tube with an indelible marking pencil or with a piece of adhesive tape.

ü  Keep the child, in supine position with head slight hyperextended and supported from beneath with hand.

ü  Smear the tube with liquid paraffin or vaseline as a lubricant. It should not be used in neonates so as to prevent aspiration.

ü  Open the patients mouth, using gag, if necessary.

ü  Pass the tube until the mark on the tube reaches upto lips or anterior nostrils. If the tube meets an obstruction when introduced about half way to the mark, it has probably entered the trachea. Sudden aphonia also indicates tracheal introduction. In such cases, do not use force but simply remove the tube and gently repeat the procedure until the tube passes readily to the mark indicated.

ü  Confirm the presence of tube in stomach by pushing the air through syringe and auscultating over stomach or by placing the other end of tube in a glass of water. Bubbling on expiration indicates placement in trachea.

ü  After confirmation, secure the tube with adhesive tube applied over face or forehead.

ü  Remove the gastric contents by use of gentle suction or syringe or aspirating bulb.

ü  After the stomach contents have been removed, perform gastric lavage by normal saline, because it minimizes the risk of electrolyte imbalance. The use of tap water or hypertonic saline should be avoided.

ü  Repeat the introduction and withdrawal of fluid until the return is clear for several passes.

ü  Recommended volumes of lavage fluid are 5-10 ml/kg/ cycle to the maximum of 100 ml/cycle in children.

ü   Always ensure to close the tube by pinching while withdrawing it from the stomach to prevent the spilling of tube contents into respiratory tract.

COMPLICATIONS

o   Aspiration pneumonia, secondary to vomiting during procedure. It emphasizes the need of prior intubation in children whose neurologic status may compromise airway protection.

o   Laryngospasm with cyanosis which can be prevented by gentle hand, alert mind and precise technique.

o   Esophageal perforation, again, speaks against the use of force.

o   Trauma and false passage formation further strengthen need of gentleness.

CONCLUSION

Gastric lavage using a large-bore lavage tube and sufficient warm fluid is quick and effective method for emptying the stomach. Gastric lavage is used when a child has ingested an antiemetic substance that could prevent the action of an emetic drug, when infant has been poisoned, or when the administration of syrup of ipecac is contraindicated. Although some physicians believe that gastric lavage can be used for selected children who have petroleum distillate poisoning, others do not approve of this practice.

It is useful in poisonings to remove the substance from the stomach. In corrosives and hydrocarbons ingestion, gastric lavage is contraindicated. In corrosives, passing the tube may cause perforation. Since passing the gastric tube is likely to induce vomiting, it increases the risk of aspiration of hydrocarbons into trachea and lungs which causes pneumonia. After passing the tube in the stomach as described in nasogastric tube insertion, lavage of the stomach using aliquots of normal saline is done in cases of poisoning. It is continued till the colour of the lavage is normal.

BIBLIOGRAPHY

Books

1.     Baldev Prajapati, “ESSENTIAL PROCEDURES IN PEDIATRICS”, New Delhi, Jaypee Brothers Medical Publishers, 2003, Page No: 221- 223.

2.     Parulekar S.V, Abraham P, “CLINICAL MANUAL OF MEDICAL PROCEDURES”, Bombay, Bhalani Publishing House, 1996, Page No: 271- 275.

3.     Mc Douggal CB, Mc Lean M.A, “MODIFICATIONS IN THE TECHNIQUE OF GASTRIC LAVAGE”, Ann Emerg Med, 1981, Page No: 514-517.

Website

4.     http://medical-dictionary.thefreedictionary.com/gastric+lavage

5.     http://www.wikigenes.org/e/mesh/e/12032.html

6.     http://www.kosmix.com/topic/gastric_lavage

OXYGEN THERAPY

DEFINITION

Oxygen may be classified as an element, a gas, and a drug. Oxygen therapy is the administration of oxygen at concentrations greater than that in room air to treat or prevent hypoxemia (not enough oxygen in the blood). Oxygen delivery systems are classified as stationary, portable, or ambulatory. Oxygen can be administered by nasal cannula, mask, and tent. Hyperbaric oxygen therapy involves placing the patient in an airtight chamber with oxygen under pressure. Modern oxygen therapy was initiated by J. S. Haldane in 1917.

PURPOSE

The body is constantly taking in oxygen and releasing carbon dioxide. If this process is inadequate, oxygen levels in the blood decrease, and the patient may need supplemental oxygen. Oxygen therapy is a key treatment in respiratory care. The purpose is to increase oxygen saturation in tissues where the saturation levels are too low due to illness or injury. Breathing prescribed oxygen increases the amount of oxygen in the blood, reduces the extra work of the heart, and decreases shortness of breath. Oxygen therapy is frequently ordered in the home care setting, as well as in acute (urgent) care facilities.

Some of the conditions oxygen therapy is used to treat include:

• documented hypoxemia
• severe respiratory distress (e.g., acute asthma or pneumonia)
• severe trauma
• chronic obstructive pulmonary disease (COPD, including chronic bronchitis, emphysema, and chronic asthma)
• pulmonary hypertension
• cor pulmonale
• acute myocardial infarction (heart attack)
• short-term therapy, such as post-anesthesia recovery

INDICATIONS

Oxygen may be administered to any patient, particularly including patients with the following:

       i.          Respiratory problems

     ii.          Altered Mental Status

   iii.          Cardiaovascular problems

   iv.          Indications of shock

     v.          Trauma patients

   vi.          Seizure patients

 vii.          To raise the arterial and alveolar oxygen levels above physiological limits as in carbonmonoxide poisoning, abnormal hemoglobin like methemoglobin or Bart’s hemoglobin.

viii.          Acceleration of reabsorption of nitrogen from the intrapleural space in pneumothorax and in treatment of gas gangrene.

CONTRAINDICATIONS:

·       Oxygen should never be used in explosive environments, and its use is cautioned against when there is a risk of sparks or materials combusting as oxygen accelerates combustion. Smoking during oxygen therapy is a fire hazard and a danger to life and limb, especially with home oxygen if compliance is poor.

·       Exercise caution with oxygen administration in chronic obstructive pulmonary disease (COPD) patients

TYPES OF OXYGEN DELIVERY SYSTEMS:

The types of oxygen delivery systems include:

• Compressed oxygen—oxygen that is stored as a gas in a tank. A flow meter and regulator are attached to the oxygen tank to adjust oxygen flow. Tanks vary in size from very large to smaller, portable tanks. This system is generally prescribed when oxygen is not needed constantly (e.g., when it is only needed when performing physical activity).
• Liquid oxygen—oxygen that is stored in a large stationary tank that stays in the home. A portable tank is available that can be filled from the stationary tank for trips outside the home. Oxygen is liquid at very cold temperatures. When warmed, liquid oxygen changes to a gas for delivery to the patient.
• Oxygen concentrator—electric oxygen delivery system approximately the size of a large suitcase. The concentrator extracts some of the air from the room, separates the oxygen, and delivers it to the patient via a nasal cannula. A cylinder of oxygen is provided as a backup in the event of a power failure, and a portable tank is available for trips outside the home. This system is generally prescribed for patients who require constant supplemental oxygen or who must use it when sleeping.
• Oxygen conserving device, such as a demand inspiratory flow system or pulsed-dose oxygen delivery system—uses a sensor to detect when inspiration (inhalation) begins. Oxygen is delivered only upon inspiration, thereby conserving oxygen during exhalation. These systems can be used with either compressed or liquid oxygen systems, but are not appropriate for all patients.

OXYGEN ADMINISTRATION

Oxygen kit showing a demand valve and a constant flow mask

METHOD OF ADMINISTRATION

The equipment used to convey oxygen from the cylinder or pipeline to the patient consists of a pressure gauge, regulator (optional), flow meter, tubing, mask or nasal cannulae and humidifier (if required).

1. MASKS

a) Venturimask :- These masks have colour coded adapters which by stating the flow rate to be used enable a given concentration of oxygen (as prescribed) to be administered eg 8L per minute of oxygen delivered via a yellow adapter will enable the patient to breath an atmosphere containing 35% oxygen.

VENTURI MASK IN DIFFERENT COLOURS.

This is because venturi masks are able to provide total inspiratory flow at a specified FIO2 to patients therapy. The kits usually include multiple jets in order to set the desired FIO2 which are usually color coded. The color of the device reflects the delivered oxygen concentration, for example: blue = 24%; yellow = 28%; white = 31%; green = 35%; pink = 40%; orange = 50%. The color however varies with different brands and the user must check the instructions to determine the correct color for the desired FIO2 (In the UK, the colours and respective delivery concentrations are; Blue 24%, White 28%, Yellow 35%, Red 40%, Green 60%).

Oxygen enters the mask through a narrow jet opening, thereby increasing the speed of the flow. Room air is drawn through the ports, mixing with the steam of oxygen giving the desired oxygen concentration.

   .

c) M C Mask:- This is a soft plastic mask with a central bore and is connected via oxygen tubing to the oxygen supply. Vent holes are incorporated into the design to allow the clearance of expired carbon dioxide and to prevent the development of high pressures. This mask MUST NOT be used if accurate percentages are required. This mask delivers an oxygen concentration between 40 and 60%, but concentration is not always accurate.

High Concentration Mask / Non re breathing (trauma mask)

This mask delivers an oxygen concentration of between 60 and 90%

2. NASAL CANNULAE

   These consist of a pair of tubes approximately 2cm long, placed in the patients nostrils and the tubing connected directly to the oxygen flow meter. They may be used as an alternative to masks, especially if used in patients who require a low supplement of oxygen. However, they do not deliver as predictable a percentage of oxygen as the ventimask. They may also be used for patients who cannot tolerate facial masks. Nasal cannulae are the preferred choice for patients receiving long term oxygen therapy.

3. AMBU BAG

A self inflating rubber bag. One end is fitted with a one way air valve and a connection for attaching tubing to the oxygen supply. The other end is connected either via an angle mount to a face mask , or a catheter mount to a tracheal tube. The percentages of oxygen delivered will depend on the flow rate and volume of bag. This method is usually used for resuscitation procedures.

4. WATERS CIRCUIT

Usually consists of a 2 litre rubber bag fitted to an adjustable release valve attached to the oxygen supply and to the patient via a catheter mount and tracheal tube, or angle mount and face mask. This will deliver 100% oxygen and require additional training in it use.

5. MECHANICAL VENTILATION

This is a specialized area, and has therefore not been covered by this procedure.

6.  HUMIDIFICATION

Humidification of oxygen is desirable as the administration of oxygen without humidification can result in the retention of secretions with small areas of the lung collapsing.

Humidification can be achieved using either a hot or cold water system or in some cases a heat and moisture exchanger (HME). Advice should be sought from either the Respiratory Nurse Specialist or Medical staff on which option is the preferred system to be utilised.

Nasal Cannula

The nasal cannula is a thin tube with two small nozzles that protrude into the victim's nostrils. It can only provide oxygen at low flow rates: 2-6 liters per minute, delivering a concentration of 28-44%. Use of the nasal cannula at higher flow rates than 6 liters per minute can cause discomfort by drying the nasal passages and pain from the force of the oxygen.

Bag-Valve-Mask

The task of administrating oxygen with bag-valve-mask (BVM) is not very demanding, and requires only one hand to squeeze the bag and one to maintain a good seal with the mask. Thus, this task can advantageously be achieved by one rescuer, who will then keep their mind free and, being at the head of the victim, have a good view of the overall situation. The head of the victim can be secured between the knees of the BVM operator. The bag-valve-mask (BVM) is used for victims in critical condition who require pure oxygen. A reservoir bag is attached to a central cylindrical bag, attached to a valved mask that administers 100% concentration oxygen at 8-15LPM. The central bag is squeezed manually to ventilate the victim.

Non-rebreathing Mask

The non-rebreathing mask (NRB) is utilized for patients with multiple trauma injuries, chronic airway limitation/chronic obstructive pulmonary diseases, smoke inhalation, and carbon monoxide poisoning, or any other patient that requires high-flow oxygen, but does not require breathing assistance. It has an attached reservoir bag where oxygen fills in between breaths, and a valve that largely prevents the inhalation of room or exhaled air. This allows the administration of high concentrations of oxygen, between 65-85%. This device is set to 10-15 lpm, or at least enough to keep the reservoir inflated between breaths. Due to the poor seal on a patient's face, it is exceedingly difficult to obtain anything approaching 100% oxygen with this device. While some patients with Chronic Obstructive Pulmonary Disease (COPD) rely on what is called hypoxic drive, high flow oxygen should never be withheld from COPD patients who require it.

Pocket Mask

The pocket mask is a small device that can be carried on one's person. It is used for the same victims that the BVM is indicated for, but instead of delivering breaths by squeezing a reservoir, the first aider must actually exhale into the mask. Pocket masks normally have one-way valves built into them to protect against cross-contamination. Many masks also have an oxygen intake built-in, allowing for administration of 50-60% oxygen.

OXYGEN HOOD

An oxygen hood is a plastic dome or box with warmed and humidified oxygen inside. The oxygen hood is used for babies who can breathe on their own but still need extra oxygen.

Dosage

a. Nasal Cannula 2-61pm

b. Non Rebreather Mask 12-15 Ipm

c. Blow By 12-15 Ipm

d. Bag Valve Mask 12-15 Ipm

Administration Procedure

a. Patients should receive oxygen via non-rebreather mask (NRB) at a rate of 12-15 1pm in the following circumstances:

i. Patient has an altered mental status

ii. Patient experiencing shortness of breath or any respiratory problem

iii. Patients with oxygen saturation level below 94% as determined by a pulse oximeter device

IV. Any other circumstances where EMTs feel that a high concentration would benefit the patient

Take the following precautions when using oxygen:

·       Always make sure that oxygen is flowing before placing the delivery device over the victim’s mouth and nose.

·       Do not use oxygen around flames or sparks. Oxygen causes fire to burn more rapidly. Do not smoke or let anyone else smoke around oxygen in transport, in use or on standby.

·       Do not use grease, oil or petroleum products to lubricate or clean the pressure regulator or any fitting hoses, etc. This could cause an explosion.

·       Do not stand oxygen cylinders upright unless they are well secured.

·       If the cylinder falls, the regulator or valve could become damaged or cause injury.

·       Do not drag or roll cylinders.

·       Do not carry a cylinder by the valve or regulator.

·       Do not hold onto protective valve caps or guards when moving or lifting cylinders.

·       Do not deface, alter or remove any labeling or markings on the oxygen cylinder.

·       Do not attempt to mix gases in an oxygen cylinder or transfer oxygen from one cylinder to another.

·       Never use oxygen without a safe regulator that fits properly.

·       When the tank is not in use keep vavlves closed even if thetank is empty. Store oxygen tanks below 125°F.

·       If defibrillating, make sure that no one is touching or is in contact with the victim or the resuscitation equipment.

·       Do not defibrillate someone when around flammable materials, such as gasoline or free-flowing oxygen.

·       Never drag or roll cylinders.

·       Carry a cylinder by both hands and never by the valve or regulator.

·       Do not store oxygen cylinders near flammables or hot water heaters, near electric or phone boxes, where they can have something heaby fall on them, where they could be tipped over or exposed to heat or direct sunlight.

·       When transporting oxygen cylinders: do not store them in the trunk; secure then in case of a sudden stop, acceleration or sharp turn, when they could become a serious projectile hazard; immediately remove them from the vehiole rather than risk heat exposure which could cause a potentially hazardous release of gas.

MONITORING OXGENATION    

Oxygen concentration can be measured by in dwelling arterial catheter, capillary sampling, pulse oximetry, transcutaneous oxygen monitoring etc. Continuous and precise monitoring of aterial oxygenation is important in the management of critically ill neonates to prevent adverse effects of both hypoxia and hyperoxia. The safe limit of arterial oxygen recommended for the newborn is PaO₂ between 60 and 80 mmHg. Periodic measurement of ABG is necessary to ensure that PaO₂ values are in the acceptable range.

STOPPING OXYGEN THERAPY

Before stopping oxygen therapy, the child should have a trial period without oxygen. If the child remains comfortable and does not become cyanosed, oxygen therapy is no longer needed.

COMPLICATIONS

ü  Potential risks of high FiO₂ include absorption atelectasis and oxygen toxicity. Alveoli are normally kept open by nitrogen rich gas. When a high FiO₂ is administered the inhaled oxygen washes out and replaces nitrogen in the alveoli and blood. This oxygen diffuses down the concentration gradient into the blood flowing past it. When oxygen molecule leaves the alveoli, it collapses. This complication can be identified when a falling PaO₂ is documented by ABG analysis associated with increasing FiO₂ requirement.

ü  FiO₂ of more than 50 percent to diseased lungs for atleast 8-12 hours under high pressure can cause situation similar to ARDS.

ü  Retinal damage in preterm babies.

ü  Bronchopulmonary dysplasia in newborns receiving high concentration of oxygen for prolonged periods.

ü  CNS irritability.

CONCLUSION

Oxygen is essential for human survival. It is one of the most common therapeutic substances used in the management of the critically ill child. Its ubiquitous nature tends to foster a casual attitude towards its application. However, it must be realized that oxygen at enriched level is a drug with well characterized toxic effects.

BIBLIOGRAPHY

Books

1.     The Royal Marsden Hospital (2000). Manual of Clinical Policies and Procedures. Blackwell Science.

2.     Baldev Prajapati, “ESSENTIAL PROCEDURES IN PEDIATRICS”, , Jaypee Brothers Medical Publishers, New Delhi, 2003, Page No: 158- 166.

3.     Jacob A, Rekha R, Tharachand S J. “CLINICAL NURSING PROCEDURES: THE ART OF NURSING PRACTICE”. 2^nd ed. Jaypee publications: Newdelhi; 2007, Page No: 326-332.

4.     Clement I. “BASIC CONCEPTS ON NURSING PROCEDURES”.  Jaypee publications: Newdelhi; 2007, Page No: 124-130.

5.     Wong D L. Wong and Whaley’s: “CLINICAL MANUAL OF PEDIATRIC NURSING”. 4^th ed. Mosby publications: Philadelphia.2000, Page No: 313-318.

Website

6.     www.medind.nic.in/maa/t07/i2/maat07i2p149.pdf

7.     www.ped.si.mahidol.ac.th/e-diary/makehtml/division/.../Oxygen.pdf

8.     www.rcjournal.com/cpgs/ -

9.     www.oxygentherapy.accunews.net/

10.  www.pediatriconcall.com/fordoctor/conference.../oxygen.ppt

                                   UTILIZATON OF PARTOGRAPH 

INTRODUCTION 

Approximately half a million women lose their lives every year because of complications of pregnancy and about 99% of these occur in developing countries. Other risk of women dying as a result of obstructed labour and ruptured uterus contribute up to 70% of maternal mortality. Early detection of abnormal progress & prevention of prolonged labour can significantly reduce maternal mortality. Recognizing the unacceptable high maternal mortality, the preventable nature in the majority and social consequences of mother’s death to the family and children, the Safe Motherhood Conference organized jointly by the WHO in February 1987concluded with a ‘ call to action’. This action is to ensure that all pregnant women are screened by supervised and trained non-physician health workers with relevant technology (including partographs), to identify those at risk and to provide prenatal care and care during labour.

DEFINITION

The partograph is a composite graphical record of cervical dilation and descent of head against duration of labour in hours. It also gives information about fetal and maternal conditions that are all recorded on single sheet of paper.

USES

v To detect labour that is not progressing normally

v To indicate when augmentation of labour is appropriate

v To recognize CPD long before obstruction occurs

v Increases the quality of all observations on the mother and fetus in labour

v Serves as an “Early warning system”

v Assists in early decision on transfer, augmentation, termination of labour

PRINCIPLES

The principles of the WHO partograph are:

Ø  Eight hours are allowed for the latent stage of labour.

Ø  The active stage of labour commences at 3cm cervical dilatation.

Ø  During the active stage of labour, the woman should dilate at least at 1cm per hour.

Ø  The lag time of four hours between slowing of labour and the need for intervention is unlikely to compromise the fetus or the mother and avoids unnecessary intervention.

Ø  Vaginal examinations should be performed as infrequently as is compatible with safe practice ( 4 hourly is recommended).

Ø  Midwives and other personnel managing labour may have difficulty in constructing alert and active lines and it is better to use a partograph with pre-set lines, although too many lines may add further confusion.

The average time in labour after admission to a health institution in the developing world is 5-6 hours. In most cases, therefore, not more than 2 vaginal examinations should be necessary.

COMPONENTS

The components of a partograph are:

a)     Patient identification

b)     Time – recorded at hourly interval. Zero time for spontaneous labour is the time of admission in the labour ward and for induced labour is the time of induction.

c)     Fetal heart rate – recorded hourly.

d)     State of membranes and colour of liquor: to mark ‘I’ for intact membranes, ‘C’ for clear and ‘M’ for meconium stained liquor.

e)     Cervical dilatation and descent of the head.

f)      Uterine contractions – the squares in the vertical columns are shaded according to duration and intensity.

g)     Drugs and fluids.

h)     Blood pressure (recorded in vertical line) at every 2 hours and pulse at every 30 minutes.

i)      Oxytocin – concentration in the upper box and dose (m IU/ min) in lower box.

j)      Urine analysis.

k)     Temperature record.

WHO USES IT?

Nurse midwife, medical doctor, nurse.

WHY TO USE IT?

To assist in making the correct decision about transfer, Caesarean section, or other life-saving interventions.

WHEN TO USE IT?

To monitor all stages of labor of all women arriving at the maternity or health facility

WHO SHOULD NOT HAVE A PARTOGRAPH?

Women with problems which are identified before labour starts or during labour which need special attention.

OBSERVATIONS CHARTED ON THE PARTOGRAPH

THE PROGRESS OF LABOUR

§  Cervical dilatation

§  Descent of fetal head

§  Uterine contractions – duration, frequency

FETAL CONDITION

§  Fetal heart rate

§  Membranes and liquor

§  Moulding of the fetal skull

MATERNAL CONDITION

§  Pulse/ BP / Temp

§  Urine – volume, acetone, protein

§  Drugs & IV Fluids

§  Oxytocin regime

STARTING A PARTOGRAPH

The part of the graph has as its central feature a graph of cervical dilatation against time. It is divided into a latent phase and an active phase.

The Latent Phase

A partograph must be started only when a women is in labor. In the latent phase (cervix dilatation not more than 2 cm), she should have two or more contractions in 10 minutes, each lasting 20 seconds or more. If this phase is delayed for longer than 8 hours in the presence of at least 2 contractions in ten minutes, the labour is more likely to be promblematical and therefore, if the woman is in peripherial unit she should be transferred to hospital. If she is in hospitalshe needs critical assessment and a decision about subsequent management.

The Active Phase

A partograph should be started only when a woman is in active phase of labour

ü  Contractions must be 1 or more in 10mins, each lasting for 20secs or more

ü  Cervical dilatation must be 4cms or more

ü  In the centre of partograph is a graph. Along the left side are numbers 0 -10 against squares. Each square represents 1cm dilatation.

ü   Along the bottom of the graph are numbers 0-24. Each square represents 1hour

ü  The dilatation of cervix is plotted with an ‘X’. Vaginal examinations are done at admission and once in 4 hours

The Alert Line

It is drawn from 3cm to 10cm.

Therefore, if cervical dilatation moves to the right of the alert line it is slow and an indication of delay in labour. If the woman is in peripherial unit she should be transferred to hospital; if in hospital she should be observed more frequently.

The Action Line

It is drawn four hours to the right of the alert line.

It is suggested that if cervical dilatation crosses this line that there should be critical assessment of the cause of delay and a decision about the appropriate management to overcome this delay.

1. Cervical dilatation:

The rate of dilatation of the cervix changes during labor, this is represented by the bold lines in the graph.

Dilatation of the cervix is measured by the diameter in cm. This is recorded with an X in the center of the partograph, at the intersection of vertical and horizontal lines. The vertical scale represents dilatation by 10 squares of 1 cm each. The horizontal scale represents time by 24 squares of one hour each.

When labor goes from latent to active phase, the dilatation must be plotted on the alert line. The latent phase should normally not take longer than 8 hours. When admission takes place in the active phase, the dilatation is immediately plotted on the alert line.

If progress is satisfactory, the plotting of the cervical dilatation will remain on or to the left of the alert line (see graph).

2. Descent of fetal head:

Descent of the fetal head may not take place until the cervix has reached about 7 cm of dilatation. This is measured by abdominal palpation and expressed in number of finger widths (fifths of the head) above the pelvic brim. It is also recorded in the central part of the partograph with an "O".

Example:

• Admission time was 13:00, the dilatation of the cervix was 1 cm and the head was 5/5 above the pelvic brim.
• At 17:00, the dilatation was 5 cm (active phase), and the head was 4/5 above the brim.
• Labor is now in active phase. Cervical dilatation is immediately transferred to the alert line; descent of the head and time are transferred to the vertical line intersecting the 5 cm line on the alert line.
• At 20:00, the cervix was fully dilated (10 cm), and the head was only 1/5 above the pelvic brim.
• The total length of the first stage of labor observed in the unit was 7 hours.

It is generally accepted that the head is engaged when the portion of the head above the brim is represented by 2 fingers are less

UTERINE CONTRACTION

Observations are every half hour in active phase

o   Frequency – Number of contractions in a 10 minutes period.

o   Duration – Measured in seconds from the time the contraction sets into the time the contraction passes off.

  

ADVANTAGES

(i)              A single sheet of paper can provide details of necessary information at a glance.

(ii)            No need to record labour events repeatedly.

(iii)          It can predict deviation from normal duration of labour early. So appropriate steps could be taken in time.

(iv)          It facilitates handover procedure.

(v)            Introduction of partograph in the management of labour (WHO 1994) has reduced the incidence of prolonged labour and caesarean section rate. There is improvement in maternal morbidity, perinatal morbidity and mortality.

CONCLUSION

The partograph is used to assess the progress of labor and to identify when intervention is necessary. Studies have shown that using the partograph can be highly effective in reducing complications from prolonged labor for the mother and for the newborn. Prolonged labour, augmented labor, caesarean sections/ operative interventions, neonatal morbidity and intrapartum fetal deaths were reduced with the use of the partograph. Easy and early recognition of poor progress of labour (with the use of partograph) and the prevention of prolonged labour significantly reduce the risk of postpartum haemorrhage and sepsis, and eliminate obstructed labour, uterine rupture and thereby reduce the maternal mortality

BIBLIOGRAPHY

Books

1.     Annamma Jacob, “A COMPREHENSIVE TEXT BOOK OF MIDWIFERY”, 1^st edition, Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, 2005, Page No: 214 - 216.

2.     Dutta D.C., “TEXT BOOK OF OBSTETRICS”, 4^th edition, New central book agency, Calcutta, 1998, Page No:403– 404, 528 - 529.

3.      Basavanthappa B.T, “TEXT BOOK OF MIDWIFERY & REPRODUCTIVE HEALTH NURSING”, 1^st edition, Jaypee Brothers (P) Ltd, New Delhi, 2006, Page No: 605.

4.     Norman F. Gant, “WILLIAMS OBSTETRICS”, 21st edition, Library of Congress Cataloging in Publication, 2001, Page No. 313-315.

5.     Diane M. Fraser, “MYLES TEXTBOOK FOR MIDWIVES”, 14^th edition, Library of Congress Cataloging in Publication,2003,Page No. 435-467.

Website

6.     http://www.ispub.com/journal/the_internet_journal_of_gynecology_and_obstetrics/volume_7_number_1

7.     http://www.cpc.unc.edu/measure/publications/pdf/ms-02-09-tool30.pdf

8.     http://www.scribd.com/doc/6586685/PARTOGRAPHY

9.     http://www.google.co.in/imgres?imgurl=http://info.k4health.org/inforeports/fistula/partograph.gif&imgrefurl