INFANT CARE – Physiological Developments and Role of Nurse in Infant Care (CHILD HEALTH NURSING)

Infant growth and development is rapid and enables maturation to unfold in a relatively short time. Health status is based on the infant’s ability to adapt to these rapid changes. As healthcare providers, the nurse must have an understanding of these changes to ensure the infant and his or her family maintains an optimal health

PHYSIOLOGICAL DEVELOPMENTS

Height and weight: height increases during the first 6 months by approximately one inch per month. The rate of growth in height slows to approximately 0.5 inches per month by 12 months of age. The weight gains 1.5 lb per month or 5-7 oz per week. By 12 months of age, the infant’s birth weight will have tripled

Head growth: the size of the head changes rapidly during infancy, reflecting rapid brain growth. By the age of 12 months the infant’s brain will be two thirds the size of a adult brain. During first 6 months the head circumference will increase by approximately 0.5 inches per month

Motor development: motor development is related to physical, cognitive, and social development, which provides the infant with the means and freedom to explore the environment. Gross motor development is the ability to use large muscle groups to maintain balance and postural control or locomotion. Fine motor development is the ability to coordinate hand-eye movement in an orderly and progressive manner

Health screening: health screening provides the opportunity to assess for detect any problems, the infant may have and includes test to detect phenylketouria (PKU), iron deficiency anemia, lead poisoning and hypothyroidism. The infant’s health screening actually begins immediately after birth with the Apgar scoring and physical examination. The screening visits typically include health assessment, physical examination, growth indicators, anticipatory guidance, parental concerns and administration of scheduled immunizations

A ROLE OF A NURSE IN INFANT CARE

The community health nurse can be instrumental in providing information related to development, nutrition, elimination, hygiene, safety, immunization and play. The nurse should provide information about possible reactions the infant might experience after receiving the immunizations

Feeding of infants: a child who is on breastfed has greater chances of survival than a child artificially fed. Prolonged breastfeeding does protect the infant from early malnutrition and some infections. Artificial feeding given the babies suffer with prolonged illness or death of the mother

Weaning is not sudden withdrawal of child from the breastfed. It is a gradual process starting around the age of 4-5 months because the mother’s milk alone is not sufficient to sustain growth beyond 4-5 months. It should be supplemented by suitable foods rich in protein and other nutrients. The community health nurse should clearly explain to the mother and family

GROWTH CHART – Uses of Growth Chart, Alternative Methods of Growth Monitoring and Child Health Problems (CHILD HEALTH NURSING)

The growth chart or ‘road to health chart first designed by David Morley and later modified by WHO. It is visible display of the child’s physical growth and development. It is designed primarily for the longitudinal follow up of a child

USES OF GROWTH CHART

• Growth monitoring which is of great value in child health care
• It is used as diagnostic tool for identifying “high risk children”
• It helps planning and policy making in relation to child health care at the local and central levels
• Educational tool for the mother to participate more actively in growth monitoring
• It helps the health worker on the type of intervention that is needed. It will help to make referrals easier.
• It provides a good method to evaluate the impact of a program or of special interventions for improving child growth and development
• It is used as tool for teaching, for example, the importance of adequate feeding

ALTERNATIVE METHODS OF GROWTH MONITORING

The growth chart or road to health chart is described as a passport to child healthcare. The road to health chart helps to identify “at a glance”. It also provided on the card to record important events such as immunization, birth history and if any treatment given. Growth charting is only one method of growth monitoring; there are other indications such as height for age, weight for height and arm circumference

CHILD HEALTH PROBLEMS

Low birth weight: International agreement of low birth weight has been defined as birth weight of less than 2.5kg. the measurement being taken preferably within the first hour of life, before significant postnatal weight loss has occurred. There are two main groups of low birth weight babies those born prematurely (short gestation) and those with fetal growth retardation

Malnutrition: malnutrition makes the child more susceptible to infection. Undernourished children do not grow to their full potential of physical and mental abilities. Malnutrition in infancy and childhood leads to stunted growth. Micronutrient malnutrition refers to a group of condition caused by deficiency of essential vitamins and minerals

Infectious and parasitic disease: the leading childhood diseases are diarrhea, respiratory infections, measles, pertussis, polio, neonatal tetanus, tuberculosis, and diphtheria. Parasitic diseases such as eruptive fevers, poliomyelitis, malaria, intestinal parasites such as ascariasis, hook worm giardiasis and amoebiasis, etc. which are common because of poor environmental sanitation and paucity of portable drinking water

Accidents and poisoning: children and young adolescents are particularly vulnerable to domestic accidents including falls, burns, poisoning and drowning. Accidents among children are home accidents and traffic accidents

Other factors affecting child health: child health is affected by various factors – behavioral problems, maternal health, family environment, socioeconomic circumstances, environment and social support and health care

BABY-FRIENDLY HOSPITAL – Introduction, Steps in Global BFHI, Objectives of BFHI, Guidelines for Successful Lactation and International Act (CHILD HEALTH NURSING)

INTRODUCTION

• Baby-friendly hospital is a movement under which breastfeeding is protected and encouraged
• Baby-friendly hospital initiative (BFHI) was launched in 1922 as part of the Innocenti Declaration on promotion, protection and support of breastfeeding by WHO and UNICEF
• BFHI is a global programs organized by UNICEF, after the introduction in 1922, exclusive demand feeding is accepted as the only mode of early infant feeding
• BFHI plus program incorporates other child survival and safe motherhood components like immunizations, antenatal care, oral rehydration therapy, ARI control programs

STEPS IN GLOBAL BFHI

• A written breastfeeding policy that is routinely communicate to all healthcare staff
• Training of all cares staff in skilled necessary to implement this policy
• Informing all pregnant women about the benefits and management of breastfeeding
• Helping mothers initiative breastfeeding within a half hour of birth
• Showing mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants
• Giving newborn infants – no food or drink other than breast milk
• In practicing room, allow mother and infants to remain together for 24 hours a day
• Encouraging breastfeeding on demand
• Giving no artificial teats or pacifiers
• Fostering the establishment of breastfeeding support groups and refer mothers to them on discharge from hospital or clinic

OBJECTIVES OF BFHI

International pediatric association conference objectives:

• To enable mother to make an informed choice about how to feed their babies
• To support early initiation of breast feeding
• To promote exclusive breast feeding for the first 4-6 months
• To discourage commercial infant milk substitutes being supplied free to hospital

GUIDELINES FOR SUCCESSFUL LACTATION

• Before starting breastfeeding mother should sit in a comfortable position
• Rooming in, bedding in allows the mother to identify cues and feed immediately
• Start feeding the baby before gets angry or hungry
• Wait until mouth is wide open and move him quickly from below the nipple
• Offer the breast in such a way that the areola is almost inside the baby’s mouth
• Hold infant close-facing the breast’s with chest-to-chest, abdomen-to-abdomen, head and body of infant aligned
• Allow him to suckle at one breast for 10-15 min or more. If the infant is still hungry switch on the other breast. For the next feed start from breast which was fed last
• Encourage demand feeding that to every 2-3 hours, even more frequently if infant desires
• End the feed by introducing a finger in between corner of mouth of the infant and breast tissue to break the suction to avoid injuring the nipples
• Place the baby in right lateral position
• Educate mother that they are feed their babies when they and their babies have the following illnesses like vomiting, cough, fever, diarrhea and cold, etc
• The importance of support from family members plays a key role successful continuation of exclusive breastfeeding

INTERNATIONAL ACT

International code of marketing of breast milk substitute (the code) was adopted by the World Health Assembly (WHA). The code set out simple, basic rule to regulate harmful marketing practice

• No advertising of breast milk substitutes feeding bottles and teats
• No free samples to mothers
• No promotion in healthcare facilities, including no free or low cost formula
• No company personnel to contact mother
• No gifts or personal samples to health workers
• No pictures of infants or words idealizing artificial feeding on the labels of the products
• Information to health workers should be scientific and factual
• Information on artificial feeding, including that on labels, should explain the benefits and superiority of breastfeeding and the associated with artificial feeding

ULTRASOUND IN OBSTETRICS – ULTRASOUND WORKING, USE OF ULTRASOUND IN OBSTETRICS, TRANSVAGINAL ULTRASONOGRAPHY, DOPPLER ULTRASOUND AND MIDWIFE’S RESPONSIBILITY REGARDING PRENATAL SCREENING (Maternal and Child Health Nursing)

The ultrasound is a sound wave beyond the audible range of frequency greater than 2 MHz cycles per second). The commonly used frequency range in obstetrics is 3.5-5 MHz.  SONAR stands for “Sound, Navigation and Ranging”. In clinical practice, two main varieties of ultrasound (sound that is produced at a very high pitch) are used depending upon whether the reflected waves give audible or visual signals

• The apparatus, which interprets the audible signals – doptone and sonicaid are easy to carry and simple to use even with batteries. It can detect fetal heartbeats are early as 10 week of gestation
• The apparatus for interpretation of visible signals – the sonar system, which is a much more sophisticated and bulky apparatus, issued in three forms

The A-scan, that gives a one-dimensional picture

The B-scan, that gives a composite two-dimensional picture

The real-time scanner that depicts movements – to display cardiac and breathing activity

HOW DOES ULTRASOUND WORK?

Scanners are used to produce static pictures. The picture is built up as a single crystal transducer (a thin disk to which a wire is attached) is moved backward and forward across the area scanned. When the transducer is placed on the body and as it encounters a structure, a fraction of that sound is reflected back. The echo is detected electronically and transmitted on to the screen as dots. The amount of sound from the each organ varies according to the type of tissue encountered:

• Strong echoes give bright dots, e.g. bone
• Weaker echoes give various shades of gray according to their strength
• Fluid-filled areas cause no reflexion and give rise to a black image

The real-time scanners are so called because it produces a moving picture on the screen as opposed to scanner that gives static picture. The real-time scanner can have several types of transducers attached to it, which are interchangeable and are used according to the type of image needed and the part of the anatomy to be examined. Types of transducers in common use include the linear array, the curved linear array, the sector and the vaginal probe. Instead of a single crystal, all these types of transducers have many crystals that fire off electrical energy and collect the echoes very rapidly, thus producing the moving picture.

USE OF ULTRASOUND IN OBSTETRICS

Sonography is a noninvasive procedure and has been proved safe to the conceptus, even with repeated exposures at any stage of pregnancy.  Routine sonography in early months is used for:

• Diagnosis of pregnancy: detects gestational ring at 5^th week, fetal poles and gestational sac at 6^th week, cardiac pulsation at 7^th week and embryonic movements at 8^th week of gestation
• Detection of abnormal conceptus prior to clinical manifestations, and fetal malformations
• Accurate determination of gestational age is possible, which is helpful later in pregnancy when IUGR is suspected. For this, crown-rump length (CRL) at 10-11 weeks gives the best predictive value
• Diagnosis of twins can be made early in pregnancy for effective management
• To diagnose unsuspected placenta previa: because of the possibility of placental migration to the upper segment, repeat scanning should be performed later-around 34^th week

Selective sonography is done when indicated at any time during pregnancy for the following reasons:

• To determine the maturity of the fetus: crown-rump length (CRL), biparietal diameter (BDP) and femur length (FL) are the measurements of choice for assessment of gestational age. Determination of the maturity is important in cases of:

Uncertainty gestational age

Discrepancy between amenorrhea and uterine size

Prior to elective induction of postmaturity or elective cesarean section

Suspicion of fetal and/or placental abnormalities such as:

Suspected ectopic pregnancy

Blighted ovum (empty sac)

Incomplete abortion

Hydatidiform mole

Localization of placenta as in placenta previa

Abruptio placentae

Intrauterine growth retardation

Intrauterine death

Malpresentations, such as breech, transverse or face

Structural defects, such as neural tube defects, absent or abnormal limbs

Defects of gastrointestinal and urinary system and heart defects

• Prior to invasive procedures such as chorion villus biopsy, amniocentesis, cordocentesis, photocopy and intrauterine fetal therapy
• As a part of antepartum or intrapartum fetal surveillance a biophysical profile
• Integrity of a previous cesarean scar – a weak scar or placental implantation over the scar can be detected
• Postpartum period

Secondary PPH

Retained placental bits

Subinvolution due to fibromyoma

• Neonatal head screening to diagnose:

Intraventricular hemorrhage

Hydrocephalus

TRANSVAGINAL ULTRASONOGRAPHY

Transvaginal ultrasonography (TUS) is usually done during the first trimester of pregnancy. As the transducer is closer to the object, the images are of enhanced quality. A full bladder is not required. Transvaginal sonography is superior to transabdominal sonography in diagnosing placenta previa

DOPPLER ULTRASOUND (AUDIBLE SIGNAL)

Ultrasound transmitted into the body in a narrow beam is transferred back at the same frequency when the object is still. When moving, there is a change in frequency known as the Doppler shift. The frequency increases or decreases according to whether the movement is toward or away from the source of energy

It is used for monitoring the fetal heart rate, which can be picked up as early as 10^th week of gestation. Uterine and fetal blood flow can be assessed and the fetus at risk of compromise could be identified. Leg vein thrombosis can be diagnosed by noting the absence of hissing sound of blood flow through the veins

MIDWIFE’S RESPONSIBILITY REGARDING PRENATAL SCREENING

Midwives take care of pregnant women in different stages of their pregnancy. They often need to involve themselves in preparing and counseling women through the process. When giving information about the screening tests available or prescribed, it is important to include information regarding;

• Why the test is offered
• What the test involves and
• When and how the results will be given

In order to advise women regarding the tests that are available, the midwife needs to keep up-to-date with current technological advances

Information given to women should also include how the woman needs to prepare herself, e.g. by attending with a full bladder for a scan

POSTNATAL CARE – Objectives of Postpartum Care, Postpartum Examination, Postnatal Assessment, Postnatal Care and Attention, Complications of Postnatal Period and Role of Nurse in Postnatal Care (MATERNAL AND CHILD HEALTH NURSING)

Care of the mother after delivery is known as postnatal or postpartum care or puerperium. Puerperium is a 6-week period following birth in which the reproductive organs undergo physical and physiological changes – a process called involution

OBJECTIVES OF POSTPARTUM CARE

• To prevent complications of postpartum period
• To provide care for the rapid restoration of the mother
• To provide family planning services
• To check adequacy of breastfeeding
• To provide basic health education to mother/family

POSTPARTUM EXAMINATION

Examining postpartum mother to rule out any fever, tachycardia, laceration and erosion of cervix, rectocele, cystocele, displacement of uterus and inflammatory swellings in the abdomen, examining the neonates to rule out birth injuries, congenital defects and low-birth weight

POSTNATAL ASSESSMENT

It is to Assessing weight changes of the neonates and the nature and extent of birth injuries and congenital defects. Assessing the temperature and pulse rate of the mothers

POSTNATAL CARE AND ATTENTION

Provide for the care of the perineum, care of the breast, prevention of infection, early ambulation, immunization and psychological support to mothers. It is also provided for prevention of infection and care of the cord stump of new born. Postnatal education and counseling includes breat-feeding, dietary intake, danger signals, and family planning

COMPLICATIONS OF POSTNATAL PERIOD

•  Puerperal sepsis: this is infection of the genital tract within 3 weeks after delivery. This is accompanied by rise in temperature and pulse rate, foul smelling lochia, pain and tenderness in lower abdomen, etc. this can be prevented by attention to asepsis before and after delivery
• Thrombophlebitis: this is an infection of the vein of the legs, frequently associated with varicose vein. The leg may become tender, pale, and swollen
• Secondary hemorrhage: bleeding from vagina anytime from 6 hours after delivery to the end of puerperium (6 weeks) is called secondary hemorrhage and may be due to retained placenta or membranes
• Others: urinary tract infection and mastitis, etc

ROLE OF NURSE IN POSTNATAL CARE

• Care during postpartum period to the mother-enquire and observe her condition generally and with reference to sleep, diet, after the pain subsides. Check vital signs, inspect perineum for discharge and inspect breast and nipples
• Care of newborn is an interwoven activity along with the care to mother. It involves taking body temperature, checking skin, color, eyes, bowel movements, urination, watching the cry, checking the sleeping and feeding

MEASUREMENT OF FUNDAL HEIGHT – Methods and Procedures (MATERNAL AND CHILD HEALTH NURSING)

METHOD AND PROCEDURES

• Ask the woman to completely empty her bladder immediately before proceeding with the abdominal examination. This is important as even a half full bladder might result in an increase in the fundal weight
• Ask the woman to lie on her back with the upper part of her body supported by cushions. Never make a pregnant woman lie flat on her back as the heavy uterus may compress the main blood vessels returning to the heart and cause fainting (supine hypotension). Ask her to partially flex her hips and knees
• Stand on the right side of the woman to examine her in a systematic manner
• The attention of the woman may be diverted by conversation
• Your hand must be warm and should be placed on the abdomen till the uterus is relaxed before the palpation is actually begun. Poking the abdomen with the fingertips should be avoided at all costs
• To measure the fundal height, place the ulnar (medial/inner) border of the hand on the woman’s abdomen, parallel to the symphysis pubis. Start from the xiphisternum (the lower end of the sternum/breastbone), and gradually proceed downwards towards the symphysis pubis, lifting you hand between each step down, till your finally feel a bulge/resistance, which is the uterine fundus
• Mark the level of the fundus. Using a measuring tape (a tailor’s tape measure which is made of non-stretchable material), measure the distance (in cm) from the upper border of the symphysis pubis to the top of the fundus. After 24 weeks of gestation, the fundal weight (in cm) corresponds to the gestational age in weeks (within 1-2 cm deviation). Remember, at the time of measuring the fundal height in cm, the legs of the woman should be kept straight and not flexed
• The supine position in late pregnancy and labor has also been shown to be associated with higher fundal height readings; therefore, this can give to false readings and an inaccurate estimate of the gestational age. It is therefore, recommended that the woman lies down in a half-lying position when measuring the fundal height
• When the same operator is measuring the fundal height at each visit, this technique has been shown to have good predictive values, especially for identifying major intrauterine growth retardation (IUGR) and multiple pregnancies
• The normal fundal height is different at different weeks of pregnancy. To estimate the gestational age through the fundal height, the abdomen is divided into parts by imaginary lines. The most important one is the one passing through the umbilicus. Then divide the lower abdomen (below the umbilicus) into 3 parts with 2 equidistant lines between the symphysis pubis and the umbilicus. Similarly, divide the upper abdomen into three parts, again with two imaginary equidistant lines, between the umbilicus and the xiphisternum
• Look where the fundal height is and judge as given below:

At 12^th week: just palpable above the symphysis pubis

At 16^th week: lower one-third of the distance between the symphysis pubis and umbilicus

At 20^th week: two-thirds of the distance between the symphysis pubis and umbilicus

At 24^th week: at the level of the umbilicus

At 28^th week: lower one-third of the distance between the umbilicus and xiphisternum

How to Determine Fetal Lie and Presentation

• At 32^nd week: two-thirds of the distance between the umbilicus and xiphisternum
• At 36^th week: at the week of the xiphisternum
• At 40^th week: sinks back to the level of the 32^nd week, but the flanks are full, unlike that in the 32^nd week

The pelvic grips (four in number) are performed to determine the lie and the presenting part of the fetus

• Fundal palpation/fundal grip

This palpation helps determine the lie and presentation of the fetus

Palpate the uterine fundus gently by laying both hands on the sides of the fundus in an attempt to determine which pole of the fetus (the breech or the head) is occupying the uterine fundus. The head feels like a hard globular mass which is ballotable (moves between the fingertips of the two hands), whereas the breech is of a softer consistency and has an indefinite outline

In the case of a transverse lie, the fundal grip will be empty

• Lateral palpation/lateral grip

This palpation is used to locate the fetal back to determine the fetal lie

Place the hands on either side of the uterus at the level of the umbilicus and apply gentle pressure. The back of the fetus is felt like a continuous hard, flat surface on one side of the midline and the limbs are felt as irregular small knobs on the other side

In the case of a transverse lie, the back is felt transversely, i.e. stretching across both sides of the midline

• First pelvic grip/superficial pelvic grip

The third maneuver must be performed gently, or it will cause pain to the woman. Spread you right hand widely over the symphysis pubis, with the ulnar border of the hand touching the symphysis pubis. Try to approximate the finger and thumb, putting gentle but deep pressure over the lower part of the uterus. The presenting part can be felt between the fingers and the thumb. Determine whether it is the head or the breech (in the case of a longitudinal lie)

The mobility of the presenting part can also be determined by gripping the presenting part and trying to move it. If it cannot be moved, it indicates that the presenting part is “engaged”. The fetal head is said to be engaged if the widest diameter of the fetal head has passed through the brim of the pelvis, or only two finger-breadths are felt above the pelvic brim

In the case of a transverse lie, the third grip will be empty

• Second pelvic grip/deep pelvic grip

To perform this grip, you must face the foot end of the mother. Keep both the palms of your hands on the sides of the uterus, with the fingers held close together, pointing downward and inward, and palpate to recognize the presenting part

If the presenting part is the head (felt like a firm, round mass, which is ballotable, unless engaged), this maneuver, in experienced hands, will also be able to tell us about its flexion

If the woman cannot relax her muscles, tell her to flex her legs slightly and to breathe deeply. Palpate in between the deep breaths

• How to auscultate for fetal heart sounds (FHS):

Use a fetoscope or the bell of the stethoscope for this. Remember, the FHS is best heard on the side where the spine/back of the fetus is. For a normal vertex presentation, the FHS is best heard midway between the line joining the umbilicus and the anterior superior iliac spine, on the side where the back is

In a breech presentation, the fetal heart is usually heard above the umbilicus

Count the FHR rate for one full minute

INTRANATAL CARE – Aims of Good Intranatal Care, Objectives of Intranatal Care, Intranatal Examination, Intranatal Assessment, Intranatal Care and Attention, Intranatal Education and Counseling and Role of the Nurse in Intranatal Care (MATERNAL AND CHILD HEALTH NURSING)

NURSING PROCEDURES LIST CLICK HERE

Childbirth is a normal physiological process but complications may arise. The need for effective intranatal care is therefore indispensable, even if the delivery is going to be a normal one. The emphasis is on the cleanliness. It entails clean hands and finger nails, a clean surface for delivery, clean cutting and care of the cord and keeping the birth canal clean by avoiding harmful practices

AIMS OF GOOD INTRANATAL CARE

• Thorough asepsis
• Delivery with minimum injury to the infant and mother
• Readiness to deal with complications such as prolonged labor, antepartum hemorrhage, convulsions, malpresentations prolapse of the cord, etc
• Care of the baby at delivery – resuscitation, care of the cord, care of the eyes, etc

OBJECTIVES OF INTRANATAL CARE

• To maintain the health and well-being of pregnant women and their off-springs during the intranatal period
• To keep the women in labor under close observation and avoid interference with the natural process of delivery unless there is a valid reason to do so
• To encourage and support women in labor and extend personal attention to them
• To ensure a safe delivery; outcome in the form of healthy mothers healthy babies

INTRANATAL EXAMINATION

Examining mother is to rule out any rise in temperature and blood pressure intrauterine bleeding and maternal distress. Examining fetuses for observing heart rate, fetal movements and color of the liquor

INTRANATAL ASSESSMENT

Assessing birth weight and also the Apgar score of the new-borns on the basis of heart rate, muscle tone, respiratory effort, response to nasal stimulation and cyanosis, if any undertaking the follow-up action

INTRANATAL CARE AND ATTENTION

Provided for prevention of infection to birth canal, establishment of respiration of the newborn prevention of heat loss, care of the eyes and cutting the umbilical cord

INTRANATAL EDUCATION AND COUNSELING

Provided on the desirability of colostrums feeding bonding personal hygiene, etc

ROLE OF THE NURSE IN INTRANATAL CARE

• The community health nurse should inspect perineum for any laceration or tear watch for bleeding
• Clean the mother fex napkin; demonstrates the perineal care
• Place the mother comfortably on the bed after delivery and provide some hot drink (coffee or tea)
• Provide the instructions to family, such as watch for bleeding in the mother as well cord bleeding in baby, to give normal diet to the mother, report to the health authorities about the birth

EXAMINATION OF PLACENTA – Examination of the Placenta, Membranes and the Umbilical Cord (MATERNAL AND CHILD HEALTH NURSING)

A one-minute examination of the placenta performed in the delivery room provides information that may be important to the care of both mother and infant. The findings of this assessment should be documented in the delivery records. During the examination, the size, shape, consistency and completeness of the placenta should be determined, and the presence of accessory lobes, placental infarcts, hemorrhage, tumors and nodules should be noted. The umbilical cord should be assessed for length, insertion, number of vessels, thromboses, knots and the presence of wharton’s jelly. The color, luster and odor of the fetal membranes should be evaluated, and the membranes should be examined for the presence of large (velamentous) vessels. Tissue may be retained because of abnormal lobation of the placenta or because of placenta accreta, placenta increta or placenta percreta 

Numerous common and uncommon findings of the placenta, umbilical cord and membranes are associated with abnormal fetal development and perinatal morbidity. The placenta should be submitted for pathologic evaluation if an abnormality is detected or certain indications are present

EXAMINATION OF THE PLACENTA, MEMBRANES AND THE UMBILICAL CORD

Examine the placenta and the membranes for completeness as follows:

Maternal surface of the placenta

• Hold the placenta in the palms of the hands, keeping the palms flat and the maternal surface facing you. Look for the following:

All the lobules must be present

The lobules should fit together

There should be no irregularities in the margins

• After rinsing the maternal side carefully with water, it should shine because of the decidual covering
• If any of the lobes are missing or the lobules do not fit together, suspect that some placental fragments may have been left behind in the uterus

Fetal surface

• Hold the umbilical cord in one hand and let the placenta and membranes hand down like an inverted umbrella
• The umbilical vessels will be seen passing from the cord and gradually fading into the edge of the placenta
• Look for free-ending vessels and holes which may indicate that a succenturiate lobe has been left behind in the uterus
• Look for the insertion of the cord, particularly the velamentous insertion (the point where the cord is inserted into the membranes and from where it travels to the placenta)

Membranes

• The chorion is the layer in contact with the uterus. It is rough and thick
• The amnion is the inner layer. It is thin and shiny
• The amnion can be peeled up to the level of insertion of the cord
• Both the layers can be seen at the edge of the hole where the membranes rupture and the fetus comes out
• If the membranes are ragged, place them together and make sure that they are complete

UMBILICAL CORD

The umbilical cord should be inspected. It has two arteries and one vein. If only one artery is found, look for congenital malformations in the baby

BLOOD PRESSURE MONITORING – Palpatory Method and Auscultatory Method (MATERNAL AND CHILD HEALTH NURSING)

Palpatory Method

This method is useful for measuring the systolic BP only. This is used in the absence of a stethoscope

• Ask the woman to sit or lie down comfortably and relax. If the woman has come walking, let her rest for 5-10 minutes before measuring her BP
• The woman should be titled to her left side using a cushion placed behind her back
• Place the sphygmomanometer on a flat surface, level with the woman’s heart
• Ensure that the pointer on the dial is at zero. If not, adjust it by rotating the knob attached to the dial
• Fix the inflatable cuff on the upper part of either arm, after removing all clothing from that arm. The lower border of the cuff should not be more than 2.5 cm from the cubital fossa (elbow)
• The dial/manometer is placed at the same level as your eye
• Feel for the brachial artery over the cubital fossa, just medial to the biceps tendon, or alternatively feel for the pulse at the wrist of the arm, to which the cuff is tied, with your left hand
• Tighten the screw of the rubber bulb and inflate the cuff by repeatedly squeezing the bulb with your right hand
• The pointer of the dial will show increasing deflections above zero as the pressure increases within the cuff
• Keep on inflating the cuff and increasing the pressure by squeezing the rubber bulb till you do not feel the pulse
• Note the manometer reading. Increase the pressure by 10 mm Hg above the level at which the pulse disappeared
• Deflate the cuff gradually till you feel the pulse appear again. The level at which the pulse reappears gives the systolic BP
• Deflate the cuff by loosening the screw of the rubber bulb, and remove the cuff from the woman’s arm

AUSCULTATORY METHOD

This method is used if a stethoscope is available. It measures both the systolic and the diastolic BP levels

• Follow the same initial steps as mentioned in the palpatory method, and note them the woman’s systolic BP
• Now raise the pressure of the cuff to 30 mm Hg above the level at which the radial pulse was no longer palpable
• Place the stethoscope on the cubital fossa, ensuring that the diaphragm is in contact with the fossa. Ideally, you should not hear any sounds. Ensure that you are using the stethoscope correctly, with the ear pieces facing forwards when placed in the ears
• Lower the pressure of the cuff slowly, about 2 mm Hg at a time, till you start hearing repetitive thumbing sounds. The reading at which the sound first starts is the systolic BP
• Continue lowering the pressure until the sound first muffles and finally disappears. The reading at which the sound finally disappears is the diastolic BP of the woman
• The blood pressure is noted down on paper as “systolic BP/diastolic BP”

ANTENATAL CARE – Objectives, Antenatal Examination, Antenatal Assessment, Antenatal Care and Attention and Role of Community Health Nurse at Antenatal (MATERNAL AND CHILD HEALTH NURSING)

Antenatal care began as a social service in Paris in 1788 for women who had committed the double inconvenience of being pregnant and destitute. Antenatal care to be provided to pregnant women to help them tide over the period of pregnancy successfully and to ensure a healthy pregnancy outcome

OBJECTIVES

• To maintain the health and well-being of pregnant women and their fetuses through the period of pregnancy
• To identify risk factors and apply appropriate measures of intervention as early as possible
• To identify complications of pregnancy and institute immediate remedial measures, including referral care
• To impart health education to women on pregnancy and childbirth, and to sensitize them on the desirability of family planning, fertility control and breastfeeding
• To lay the foundations of a healthy pregnancy outcome and good mother-child relationship

ANTENATAL EXAMINATION

Examining mother to record height, weight, blood pressure and to rule out anemia, jaundice, edema, varicosities, breast tumors, nipple deformities, hydramnios, multifetal pregnancy, anteversion or retroversion of the uterus and also to observe the height of fundus and presentation, position and attitude of fetus

ANTENATAL ASSESSMENT

Assessing maternal risk on the basis of gravidity maternal age, maternal weight, pregnancy weight gain, previous obstetric experience and accordingly placing mothers in low risk class for appropriate management

ANTENATAL CARE AND ATTENTION

The care provided for risk intervention, anemia prophylaxis and tetanus prophylaxis

Antenatal education and counseling provided about diet, work, exercise, travel, smoking, drinking, bathing, clothing, chemotherapy, family planning, breastfeeding, mental preparation, active participation and warning signals

ROLE OF COMMUNITY HEALTH NURSE AT ANTENATAL

• The community health nurse should assist the parents in understanding the anatomy and physiology of pregnancy, labor and birth
• Contact every expected mother early in pregnancy and help her seek adequate medical supervision
• Teach mother to monitor visual disturbances, edema of face, epigastric pain, signs of infection, burning on urination, any vaginal discharge and absence of or decrease in fetal movements after initial pressure
• Respond to mother’s questions about bathing, douching, work, sex, exercise, etc
• Help parents discuss and explore feeling related to child bearing and rearing
• Prepare mother for physical work of labour through the use of relaxation and breathing exercises for the various phases of labor
• Teach the mother to avoid over the counter or prescription drugs without checking with her care provider because many drugs considered harmless may be teratogenic to the developing fetus
• Teach the mother the importance of adequate fluid intake and moderate exercise to promote circulation and prevent stasis
• Demonstrating and teaching to mother and relatives on several aspects of maternity care
• The community health nurse acting as liaison between the hospital, health center, clinic and home in referring mothers to appropriate agency for safe delivery, when indicated
• Maintaining adequate records all mother in her area and recording relevant information adequately on follow-up visits
• Training midwives and dais and participating in training programs for nurses, midwives, village health nurses (health worker F/M)