Clinical Procedures

By
Assist. Prof /Nawal Kamal Abd Elkhalek
Assist. Prof /Mervat Mahamed Hassan

Faculty of Nursing
South Valley University

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 Clinical Procedures

Abdominal Examination

Procedure Checklist: Leopold's Maneuver

No. STEPS 2 1 0
1. Wash hands with warm water

2. Prepare equipment
3. Explain the procedure
4. Prepare the woman by: and instruct the woman to empty
her bladder then instruct her to lie on her back, with
knees flexed slightly (dorsal recumbent position). Place a
small pillow or rolled towel under client's right hip.

5. Close the door or close the curtains. Properly drape the

patient.
6.
First Maneuver or fundal grip:

- Perform abdominal palpation (Determine fundal

level)
Stand at the foot of the bed facing the face of the woman
and measured in centimeters from the top of pubic bone
to the top of fundus, correllates with the current weeks of
pregnancy.

7. - Determine the fetal lie and presentation:

Stand at the foot of the bed, facing the patient and
gently place both hands flat on the abdomen palpate
upper abdomen with both hands (Use palms not
fingertips). Palpate gently but with firm motions
,determine if the mass palpated is the head or buttocks
by observing the relative consistency ,shape ,and
mobility

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 Clinical Procedures

8 Second maneuver: Umbilical Grip

Still facing the woman, the health care provider palpates

the abdomen with gentle but also deep pressure using
the palm of the hands. First the right hand remains
steady on one side of the abdomen while the left hand
explores the right side of the woman's uterus. This is
then repeated using the opposite side and hands. The
fetal back will feel firm and smooth while fetal
extremities (arms, legs, etc.) should feel like small
irregularities and protrusions. The fetal back, once
determined, should connect with the form found in the
upper abdomen and also a mass in the maternal inlet,
lower abdomen.
9 Third maneuver: Pawlick's Grip

In the third maneuver the health care provider attempts

to determine what fetal part is lying above the inlet, or
lower abdomen. The individual performing the
maneuver first grasps the lower portion of the abdomen
just above the pubic symphysis with the thumb and
fingers of the right hand. This maneuver should yield
the opposite information and validate the findings of the
first maneuver. If the woman enters labor, this is the part
which will most likely come first in a vaginal birth. If it
is the head and is not actively engaged in the birthing
process, it may be gently pushed back and forth. The
Pawlick's Grip, although still used by some
obstetricians, is not recommended as it is more
uncomfortable for the woman. Instead, a two-handed
approach is favored by placing the fingers of both hands
laterally on either side of the presenting part.

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 Clinical Procedures

10 Fourth maneuver: Pelvic Grip

The last maneuver requires that the health care provider

face the woman's feet, as he or she will attempt to locate
the fetus' brow. The fingers of both hands are moved
gently down the sides of the uterus toward the pubis.
The side where there is resistance to the descent of the
fingers toward the pubis is greatest is where the brow is
located. If the head of the fetus is well-flexed, it should
be on the opposite side from the fetal back. If the fetal
head is extended though, the occiput is instead felt and
is located on the same side as the back.

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 Clinical Procedures

Immediate Care of the Newborn Baby

Outlines

 Introduction
 Immediate care of new born baby
1. clearing the air way
2. Assessment of baby's condition using Apgar score
3. Clamping and cutting the cord
4. Thermal adaptation
5. Identification
6. Care of the eyes
7. Vitamin K

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Introduction
• Definition of neonatal period:

The time from birth though the twenty eight day of life.

During this time the neonate must make many adjustments to extra -
uterine life.
• The following measures are designed to assist the infant in
accomplishing the adaptations to extra uterine life.
1- Clearing the air way
• As soon as the head is born, and before the baby takes its first
breath, the pharynx (mouth) and Nasopharynx (nose) must be
suctioned to prevent aspiration of mucous, blood and meconium
and debris into the trachea when breathing begins. This should be
done using mechanical suction to minimize the risk of virus
transmission.
• Once the baby is born it should be held down for a few moments to
promote drainage of mucous and to facilitate the drainage of liquid
material from pharynx by gravity. Then, the infant is transferred to
a warmed bassinet.

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 Clinical Procedures

2-Assessment of baby's condition using Apgar score

Apgar score is scoring system used to assess cardiopulmonary function of

newborn baby
• Assessment by Apgar scoring is carried out at 1 minute and at 5
minute after birth for rapid evaluation of early cardiopulmonary
adaptation.
A score of
7 to10 is normal,
3 to 6 indicates mild to moderate distress,
• 0 to 2 sever distress and the infant needs resuscitation and I.C.U
• The infant is assigned a score of 0 to 2 in each of the five items and
the scores are totaled.
A Appearance (color)
P Pulse (Heart rate)
G Grimes (Reflexes)
A Activity (muscle tone)
R Respiration

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 Clinical Procedures

Sign 0 1 2
Heart rate Absent < 100 b.p.m ≥ 100 b.p.m
Weak cry,
Respiratory effort Absent Good, crying
hypoventilation
Cry or active
Reflex irritability No response Grimace
withdrawal
Some flexion of
Muscle tone Limp Active motion
extremities
Body pink,
Color Blue, pale Completely pink
extremities blue
NOTE:-
Bradypnea: less than 15 breath /min
Tachypnea: more than 60 breath /min
3-Clamping and cutting the cord
• The cord consists of 2 arteries and one vein, covered by substance
called Wharton’s jell.

The length of cord is about 50 cm.

• Separation of the infant from the placenta is achieved by dividing

the umbilical cord between two clamps which should be applied
approximately 8-10 cm from the umbilicus of the fetus.
• The cord is clamped and divided, as soon as pulsations have
ceased. If ligation is done carelessly the baby may loss a great deal
of blood very quickly.
• The cord ligation is applied 2-2.5 cm from the umbilicus.
The cord is ligated with a special clamp or rubber bands or tapes. The
blood volume of a term newborn infant is 80-100ml per kg body weight.

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 Clinical Procedures

4-Thermal adaptation

Characteristics of newborns that predispose them to loss heat.

• The skin is thin.
• The blood vessels are close to the surface.
• Heat is readily transferred from the warmer internal areas of the
surrounding air.

To conserve heat, the healthy full- term infant remains in apposition of

flexion. This reduces the amount of skin surface exposed to the
surrounding temperatures and decreases heat loss .
Methods of heat loss in the neonate:-

A-Evaporation

Occurs when wet surfaces are exposed to air

• At birth the infant loses heat when amniotic fluid on the skin
evaporates.

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 Clinical Procedures

• Evaporation also occurs during bathing. Thus drying the infant as

quickly as possible at birth and after bathing helps prevent
excessive heat loss.
B-Conduction

• Occurs when new born come in direct contact with objects that are
cooler than their skin.

• Placing infants on cold surfaces such as (scales or touching them

with cold hands or a cold stethoscope causes this type of heat loss).

• The reverse is also true, that is wrapping newborns in warm

blankets or placing them against the mother's skin can protect them
against heat loss.

C-Conviction

Occurs when heat is transferred to air surrounding the infant by

currents of cool air passing over the surface of this body.

• Maintaining warm environmental temperatures help to prevent this

type of heat loss.

• Oxygen should be warmed before administration.

• Newborns are often placed in incubators for a short time after birth
so that the surrounding temperature can be controlled to prevent
convective heat loss.

D-Radiation
Is the transfer of heat to cooler objects that are not in direct contact with
the infant. For examples:-
• Infants placed near cold windows loss heat by radiation.

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 Clinical Procedures

• Infants should be kept away from windows and outside walls to

minimize radiant heat loss.
• Small amounts of heat are lost through respiration and in urine and
faces.

• It is important for the midwives to ensure that they employ

measures to minimize heat loss at delivery by ensuring that the
delivery room temperature is 21-24 C and encouraging skin to skin
contact with the mother to promote heat gain.

• Covering the baby head is of particular importance

5-Identification

• When babies are in hospital, it is necessary that they are readily

identifiable one from another.
• Various methods of indicating identity can be employed.
• e.g.:- Name bands are applied usually one on the infant's wrist and
one on the ankle. Each contain the family name, sex of the infant,

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 Clinical Procedures

and date and time of birth .name bands should remain on the baby
until his discharge from hospital.
6-Care of the eyes

• Before the baby is transferred to the nursery the eyes must be

receive prophylactic treatment to prevent ophthalmic neonatorum.
• The most common medication for eye prophylaxis is: tetracycline
and erthromycin ointment.
7-Vitamin K

• Hemorrhagic disease of the new born is acumination which

results from a deficiency of vit-K one dose of vit-K prevents
bleeding problems until the infant is able to produce it on his
her own.
Vitamin K is given to the neonate within the first hour after birth
intramuscularly injection of 0.5 mg to 1 mg of water soluble vit.K. This
can be prevent hemorrhagic disease.

Note:
Post natal bleeding tendency occurs as a result of:
• In ability of synthesize vit. K
• Immaturity of liver in terms of production of prothrombin and
other clotting factors

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 Clinical Procedures

Breast self Examination

Procedure Checklist: Breast Exam

No.
STEPS 2 1 0

1. Welcome the woman and, introduce yourself.

2. Define the procedure: It is a technique by which a thorough

inspection and palpation of the breast is made during
antenatal and postnatal period in order to collect data about
the breast condition of the mother.

3. Identify the Objectives:

 To discover any abnormalities that causes harm or

problem as early as possible.
 To detect early any breast lesion.
 To learn how to examine breast for self and for others.
 To encourage BSE practice.
 To reinforce the woman's confidence in BSE ability.
 To assess the breast size, shape, contour, elasticity and
symmetry. (in antenatal period)
 To assess the nipple for type, size and secretions.
 To examine the areola and nipple for evidence of
blisters, cracks or fissures
 To assess the breast for signs of engorgement, mastitis
or abscess (in postpartum period)
 To check the beast tissue for presence of lump or cyst
that may require further medical evaluation.
 To detect and treat early any abnormalities or
complication.

4. Place the woman on the examination couch and Explain the

procedure to her.
5. Drape the woman and keep the doors and curtain closed.

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 Clinical Procedures

6. Wash your hands.

7. Inspection:
a) On sitting position: Ask the client to sit in comfortable
position facing the examiner
 With arm relaxed at sides.
 With arms held over head.
 With hands on hips ,pressing in to contract the chest
muscles
b) On the supine position: Ask the client to assume the
supine position and put her right arm over her head and
inspect the right breast (Reverse this step for the left
breast).

8. Palpation :examine the right breast on the supine position:

 Put right hand behind head. Use pads of fingers of left
hand, held flat together, gently press on the breast tissue
using small circular motion, imagine the breast as a face
of a clock. Beginnings at the top (12 O' clock position)
make a circle around the outer area of the breast.
 Move in one finger width, continue in smaller and
smaller circles until you have reached the nipple (cover
all areas including the breast tissues leading to the
axilla)
 Reverse the procedure to the left breast.

Underarm Examination:
9.
 Examine the left under arm area with arm held loosely at
side. Cup the finger of the opposite hand and insert them
high into the underarm area. Draw finger down slowly,
pressing in circular pattern, covering all areas.
 Reverse the procedure for the right underarm

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10. Nipple Examination

Gently squeeze the nipple of each breast between the thumb

and index finger to check for discharge.

11. Assist the woman to get down from examination table and
redress her clothes, then wash hands

12. Report abnormality.

13. Record findings and woman's reaction.

Total mark

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 Clinical Procedures

Examination of the placenta

Checklist for examination of the placenta

No. STEPS 2 1 0

1. Wash hands; wear an apron and gloves

Explain the procedure to the parents and ask if they want to
2. observe.

3. Ensure that there is adequate lighting to check the placenta

4. Prepare a flat surface with protection to avoid blood spillage

5. Prepare syringe and needle if cord samples are required

Lay out the placenta with the fetal surface uppermost - noting
6. shape, size, colour and smell.

Examine the cord, noting the length, insertion point and

7. presence of true knots or thrombi.

Inspect the umbilical cord vessels at the cut end at the

furthest point from the placenta as the arteries can be fused
8. around the insertion site making it difficult to differentiate
them.

Count the vessels in the cut end of the cord; the absence of
9. one of the arteries can be associated with renal agenesis

Observe the fetal side for irregularities such as

succenturate lobes, missing cotyledons, fatty deposits or
10.
infarctions

Observe the membranes and inspect for completeness.

11. There should be a single hole present where the baby has
passed through the membranes.

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 Clinical Procedures

Report abnormality. Separate the amnion from the chorion

12. by pulling the amnion back over the base of the umbilical
cord to ensure both are present.

13. Turn the placenta over to inspect the maternal side.

Examine the cotyledons, ensuring all are present, noting

the size and any areas of infarction, blood clots or
14.
calcification.
Take cord blood samples if required
15.
Weigh, swab or take samples if indicated
16.
Where there is suspicion that the placenta and/or
17.
18. Clean membranes
away equipment
are incomplete, they should kbe kept for
19. Wash hands
further inspection and referred to the duty
Total marks obstetrician.

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 Clinical Procedures

IUD insertion

Procedure:

1- Explain the procedure including advantages, dis advantages,

effectiveness and side effects of IUCD.

2- Arrange the equipment's on examination table.

3- Instruct woman to empty her bladder.

4- Position woman on her back with knees flexed and buttocks at the
edge of the table.

5- Provide privacy and drape patient appropriately.

6- Wash hands and don sterile gloves.

7- Load IUCD inside applicator as per manufacturer's instruction.

8- Inspect external genitalia, urethra and vagina for signs of infection,

lesions or discharge.

9- Explain to the women that there will be slight discomfort during

speculum insertion.

10- Insert the speculum gently and observe the cervix for signs of
infection and erosion.

11- Clean the external cervical os with an antiseptic soaked swab by

using sponge holding forceps.

12- Instruct the patient that there will be discomfort (pinching pain)
when applying the vulsellum. Apply vulsellum at the 120 clock
position on the cervix; grasp the lip of the cervix.

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13- Pass the uterine sound into the cervical canal and insert carefully
into the uterine cavity while pulling steadily downward and
outward on the vulsellum. (a slight resistance indicates that the top
of the uterine sound has reached the fundus), and remove the
uterine sound.

14- Measure the length of the device to be inserted into the uterine
cavity. The depth of gauge on the inserter-tube is used to mark the
depth of the uterus. Pull the loaded inserter tube gently until the
distance between the top of the folded "T" and edge of the depth
gauge closest to the "T" is equal to the depth of the uterus as
measured on uterine sound.

15- Carefully peel the clean plastic cover of the package away from the
white packing. Lift the loaded inserter keeping it horizontal os that
neither the "T" nor the white rod falls out.be careful not to push the
white rod towards the "T"

16- Grasp the vulsellum and pull firmly downwards and outwards to
align the uterine cavity and cervical canal with the vaginal canal.

17- Gently introduce the loaded inserter assembly through the cervical
canal. keeping the depth gauge into a horizontal position

18- According to the position and direction of the uterine cavity gently
and carefully advance the loaded inserter assembly until the depth
gauge comes in contact with the cervix or resistance of the uterine
fundus is felt.

19- Hold the vulsellum and the white rod in one hand.
20- Gently and carefully push the inserter tube upwards, towards
resistance.

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21- Remove the while rod while holding the inserter tube stationary.
22- Gently and slowly withdraw the inserter tube from the cervical
canal and check for the strings protruding from the uterus .cut the
strings shorter so that they protrude only 3 cm outside the cervix.
23- Remove the vulsellum. If there is excessive bleeding from the
vulsellum site, press a sterile cotton ball to the site using forceps
until the bleeding stops.
24- Remove speculum and drapes.
25- Instruct patient to stay in bed for some time.
26- Wash perineum with soap and water speculum and drapes.
27- Remove gloves and discard.
28- Instruct the woman on follow-up measures
1- To confirm presence of IUCD periodically by feeling the presence
of threads in vagina.
2- instruct patient to visit clinic whenever she experiences the
warning signs of problems related to IUCD such as:

PAINS

P: delayed periods, spotting, bleeding or missing period.

A: abnormal pain or pain during coitus.

I: infection, any vaginal discharge.

N: not feeling well, fever, or pelvic pain.

S: strings in vagina (feeling the device in vagina).

Side effects and complications:

1- Excessive bleeding.

2- Low back pain during menstruation.

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 Clinical Procedures

3- Pain during menstruation.

4- Pelvic infection.

5- Uterine perforation.

6- Ectopic pregnancy.

7- Expulsion of device.

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The fundus and lochia examination

Procedure:

1- Hand washing

2- Prepare the necessary equipment and taken to the bed side table (clean
gloves, sterile pad, and antiseptic solution)

3- Great the woman, and explain the procedure to obtain her consent.

4-ask the woman to empty her bladder before the procedure.

5- Maintain privacy through the procedure.

A- Fundus and Lochia Assessment Steps.

6- Wash hands and wear the clean examination gloves.

7-Ask the woman to lie on her back with her knees slightly bent.

8- Do fundal massage using one hand and the other gloved hand lowered
the perineal pad to assess the lochia flow in the bad.

9- Ask the woman since how many hours she changed her perineal pad.

10- Assess the fundal level, position, size and consistency first then
massage as needed.

11- Assess the lochia flow in the bad during massage.

12- Support the uterus by cupping one hand against the lower uterine
segment (just above the symphysis pubis)

13- Measure by finger breadth how far the fundus from the umbilicus.

14- Use anew-perineal pad to cover the perineum after perineal care.

B- Post procedure tasks.

12- Remove and dispose gloves according to procedure.

13- Inform the woman about the findings and document the procedure
accurately.

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 Clinical Procedures

Perineal care
Checklist of perineal care
No. Steps 2 1 0
1. Wash hands.
2. Prepare equipment and take to bedside.
3 Explain the procedure to woman and screen the bed.
4. Drape the woman cover and perineal area only exposed.
Put mackintosh and towel under the woman and place the
5. bed pan with the towel (lithotomy position).
Remove the soiled perineal pad from above to downward
6.
and wrap in paper and place in paper bag or kidney basin.
With forceps and cotton sponges clean as follows:

 From symphysis pubis upward to the umbilicus.

 The far thigh then, the near thigh.
 The far labia from above downward, then the near labia.
7.
 Center from clitoris downward to perineum and rectum
 Pour the rest of solution over the vulva and rectum.
 Dry and clean genitalia with cotton sponges by the same
technique.
Remove the bed pan and instruct the women turn on her
8. side and dry her buttocks with cotton.

9. Apply sterile perineal pad.

10. Rearrange bed & clothes to make women more comfortable.

Remove soiled equipment

11.

12. Remove gloves

13. Position patient for comfort and warmth

14. Wash hands

15. Charting

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 Clinical Procedures

Vaginal Examination
Checklist for vaginal examination
No. Steps 2 1 0
1. Wash hands

3 Prepare equipment and supplies

4. Explain procedure to the woman.

5. Screen the bed and drape the woman.

Position the women with her thighs flexed and abducted.
6.
Encourage the woman to relax her muscles and legs.
7.

8. Inform the woman before touching her. Be gentle.

9. Wash hands and Pull glove onto dominant hand.

Before the procedure if fluid leakage, use Nitrazine test
10. tape and Q- tip with slide for fern test before performing
the exam.
Insert your -well-lubricated second and index fingers of
11. the gloved hand gently into the vagina until they touch
the cervix.
12. If the woman verbalizes discomfort. Pause for a moment
and allow her to relax before progressing.
13. To determine the status of labor progress, perform the vaginal
examination during and between contractions.

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