ONE: INSTRUMENTATION

Gauze pack

Gauze is a type of thin medical fabric with a loose open weave used in wound care.

Uses of gauze.

Gauze can be used for cleansing, packing, scrubbing, covering, and securing in a variety of
wounds. Closely woven gauze is best for extra strength or greater protection, while open or
loose weave is better for absorbency or drainage.

Types of Gauze

Gauze Trach Sponge, Sterile Gauze Swab, Gauze Bandage With Woven Edges, Gauze
Combine Dressing, Gauze eye pad, Non-Sterile Gauze Swabs and Paraffin Gauze Dressings.

Seven tips in terms of applying the gauze on the wound.

• Wash hands before doing anything to your wound.
• Be sure the gauze cover beyond the wound.
• Hold the gauze by the edges and then put gauze dressing on the wound.
• No contact with the part of the gauze that touches the wound.
• Use adhesive tape to secure the gauze.
• If no medical dressing gauze available, use clean cloth as a substitute.

How to remove gauze from wound

• Wash hands before removing the old gauze.

• In case of infection, sterile gloves can be used. Remember wash hands before and after.
• For the gauze applied in hairy areas, remove gently in the direction of hair growth.
• If the absorbent cotton gauze is struck to the wound, wetting the gauze or apply a saline
solution: 1/4 teaspoons of table salt for every quart of water.
• Soak the wound covered with gauze in the saline solution. After several minutes, you can try
to remove the gauze.
• Use a clean towel to pat dry the wound, or just leave it air dry.
• Cover the wound with fresh woven gauze.
 Uses of Forceps

Medical forceps are grasping-type surgical instrument used during surgeries and other

medical procedures. Forceps are used for tweezing, clamping, and applying pressure. They

can be used as pincers or extractors. They are used in emergency rooms, exam rooms,

operating rooms and to render first aid. Similar to articulating tongs, forceps are often used

for holding or removing tissue or for placing or removing gauze, sponges, or wipes. These

handheld instruments have been in use for over 3 thousand years.

Crile Hemostatic Forceps 5 1/2 inch

Mckesson Stainless Steel Tissue Forceps

Halstead Curved Mosquito Hemostatic Forceps - 5 in. Stainless Steel

MckessonHemostat Forceps Stainless

Types of Forceps

Forceps come with a hinge on one end or with the pivot towards the middle. When hinged at

the end, forceps look similar to tweezers. When hinged toward the center, they look more like

scissors.

Tweezer Style

Tweezer style forceps are also known as pick-ups, thumb forceps, tissue forceps, or dressing

forceps. Closure activates by depressing your thumb upon one side of a forcep's shank while

a finger is on the opposite shank. By compressing both shanks together, these surgical

tweezers grasp and hold tissue or other surgical instruments. The spring tension regulates

how wide the device can open and the amount of tissue you can grip. The fixed hinge at the

bottom is non-locking and non-pivoting.

"Thumb" forceps come with several different tip options, including flat, serrated, cupped,

ringed, grooved, teeth or diamond dusted. The tip shape may be straight, curved, or angled.

Serrations or teeth look more menacing for work with tissue, but cause less damage than flat

forceps, since they require less pressure to maintain a firm grip. Smooth or cross-hatched

forceps remove sutures, dressings, or drapes.

Scissor Style

The scissor type forceps, sometimes called "ring forceps" look similar to scissors because of

the rings at one end for the thumb and forefinger. Surgeons sometimes call them hemostats or

clamps. These hinged instruments connect two extensions with a hinge near the center of the

tool. When one end closes, the other opens. The working end of this instrument grasps and

holds while the other is used to open and close the working end of the tool.
The scissor style is available in locking or non-locking designs. The locking versions allow

the forceps to act as a latching clamp or to apply constant pressure. The most common

locking forceps employ a ratchet device for the lock.

What Are Forceps Made of?

Manufacturers make medical forceps with durable materials, including stainless steel, high-

grade carbon steel, titanium, plastic, polypropylene, or a combination of alloys. The alloy

versions can include chromium, nickel or cobalt. The tips of the alloy models have the added
advantage of high flexibility and offer superior performance. These materials can withstand

the harsh environments of sterilization and autoclaving. The plastic constructed models are

disposable, while the steel and alloy models are usually reusable.
 TWO: NURSING CARE PLAN

A nursing care plan (NCP) is a formal process that correctly identifies existing needs and

recognizes potential needs or risks. Care plans provide communication among nurses, their

patients, and other healthcare providers to achieve health care outcomes. Without the nursing

care planning process, the quality and consistency of patient care would be lost. Nursing care

planning begins when the client is admitted to the agency and is continuously updated

throughout in response to the client’s changes in condition and evaluation of goal

achievement. Planning and delivering individualized or patient-centered care is the basis for

excellence in nursing practice.

Types of Nursing Care Plans

Care plans can be informal or formal:

An informal nursing care plan is a strategy of action that exists in the nurses nurse‘s mind.

A formal nursing care plan is a written or computerized guide that organizes the client’s

care information. Formal care plans are further subdivided into standardized care plans and

individualized care plans:

Standardized care plans specify the nursing care for groups of clients with everyday needs.

Individualized care plans are tailored to meet the unique needs of a specific client or needs

that are not addressed by the standardized care plan.

Purposes of a Nursing Care Plan

The following are the purposes and importance of writing a nursing care plan:
 • Defines nurse’s role. It helps to identify the unique role of nurses in attending to

clients’ overall health and well-being without having to rely entirely on a physician’s

orders or interventions.

• Provides direction for individualized care of the client. It allows the nurse to think

critically about each client and develop interventions directly tailored to the

individual.

• Continuity of care. Nurses from different shifts or departments can use the data to

render the same quality and type of interventions to care for clients, therefore

allowing clients to receive the most benefit from treatment.

• Documentation. It should accurately outline which observations to make, what nursing

actions to carry out, and what instructions the client or family members require. If

nursing care is not documented correctly in the care plan, there is no evidence the care

was provided.

• Serves as a guide for assigning a specific staff to a specific client. There are instances

when a client’s care needs to be assigned to staff with particular and precise skills.

• Serves as a guide for reimbursement. The insurance companies use the medical record

to determine what they will pay concerning the hospital care received by the client.

• Defines client’s goals. It benefits nurses and clients by involving them in their

treatment and care.

Components

A nursing care plan (NCP) usually includes nursing diagnoses, client problems, expected

outcomes, and nursing interventions and rationales. These components are elaborated below:

1. Client health assessment, medical results, and diagnostic reports are the first steps to

be able to design a care plan. In particular, client assessment is related to the

 following areas and abilities: physical, emotional, sexual, psychosocial, cultural,

spiritual/transpersonal, cognitive, functional, age-related, economic, and

environmental. Information in this area can be subjective and objective.

2. Expected client outcomes are outlined. These may be long and short-term.

3. Nursing interventions are documented in the care plan.

4. Rationale for interventions to be evidence-based care.

5. Evaluation. This documents the outcome of nursing interventions.

Care Plan Formats

Nursing care plan formats are usually categorized or organized into four columns: (1) nursing

diagnoses, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation.

Some agencies use a three-column plan wherein goals and evaluation are in the same column.

Other agencies have a five-column plan that includes a column for assessment cues.

Writing a Nursing Care Plan

Steps for writing a nursing care plan (NCP)

Step 1: Data Collection or Assessment

The first step in writing a nursing care plan is to create a client database using assessment

techniques and data collection methods (physical assessment, health history, interview,

medical records review, and diagnostic studies). A client database includes all the health

information gathered. In this step, the nurse can identify the related or risk factors and

defining characteristics that can be used to formulate a nursing diagnosis. Some agencies or

nursing schools have specific assessment formats you can use.

Step 2: Data Analysis and Organization: Now that you have information about the client’s

health analyze, cluster, and organize the data to formulate your nursing diagnosis, priorities,

and desired outcomes.

Step 3: Formulating Your Nursing Diagnoses

NANDA nursing diagnoses are a uniform way of identifying, focusing on, and dealing with

specific client needs and responses to actual and high-risk problems. Actual or potential

health problems that can be prevented or resolved by independent nursing intervention are

termed nursing diagnoses.

Step 4: Setting Priorities

Setting priorities deals with establishing a preferential sequence for addressing nursing

diagnoses and interventions. In this step, the nurse and the client begin planning which

nursing diagnosis requires attention first. Diagnoses can be ranked and grouped as having a

high, medium, or low priority. Life-threatening problems should be given high priority.

A nursing diagnosis encompasses Maslow’s Hierarchy of Needs and helps to prioritize and

plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a

hierarchy based on basic fundamental needs innate to all individuals. Basic physiological

needs/goals must be met before higher needs/goals can be achieved, such as self-esteem and

self-actualization. Physiological and safety needs provide the basis for implementing nursing

care and nursing interventions. Thus, they are at the base of Maslow’s pyramid, laying the

foundation for physical and emotional health.

Maslow’s Hierarchy of Needs

• Basic Physiological Needs: Nutrition (water and food), elimination (Toileting),

airway (suction)-breathing (oxygen)-circulation (pulse, cardiac

monitor, blood pressure) (ABCs), sleep, sex, shelter, and exercise.

• Safety and Security: Injury prevention (side rails, call lights, hand hygiene,

isolation, suicide precautions, fall precautions, car seats, helmets, seat belts), fostering

a climate of trust and safety (therapeutic relationship), patient education (modifiable

risk factors for stroke, heart disease).

• Love and Belonging: Foster supportive relationships, methods to avoid social

isolation (bullying), employ active listening techniques, therapeutic relationship, and

sexual intimacy.

• Self-Esteem: Acceptance in the community, workforce, personal achievement, sense

of control or empowerment, accepting one’s physical appearance.

• Self-Actualization: Empowering environment, spiritual growth, ability to recognize

the point of view of others, reaching one’s maximum potential.

Step 5: Establishing Client Goals and Desired Outcomes

After assigning priorities for your nursing diagnosis, the nurse and the client set goals for

each determined priority. Goals or desired outcomes describe what the nurse hopes to

achieve by implementing the nursing interventions derived from the client’s nursing

diagnoses. Goals provide direction for planning interventions, serve as criteria for evaluating

client progress, enable the client and nurse to determine which problems have been resolved,

and help motivate the client and nurse by providing a sense of achievement.
Example of goals and desired outcomes.

One overall goal is determined for each nursing diagnosis. The terms goal,

outcome, and expected outcome are often used interchangeably.

According to Hamilton and Price (2013), goals should be SMART. SMART goals analysis

strategy stands for – Specific, Measurable, Attainable, Realistic, and Time-Bound goals.

• Specific. It should be clear, significant, and sensible for a goal to be effective.

• Measurable or Meaningful. Making sure a goal is measurable makes it easier to

monitor progress and know when it reaches the desired result.

• Attainable or Action-Oriented. Goals should be flexible but remain possible.

• Realistic or Results-Oriented. This is important to look forward to effective and

successful outcomes by keeping in mind the available resources at hand.

• Timely or Time-Oriented. Every goal needs a designated time parameter, a deadline to

focus on, and something to work toward.

Hogston (2011) suggests using the REEPIG standards to ensure that care is of the highest

standards. By this means, nursing care plans should be:

• Realistic. Given available resources.

• Explicitly stated. Be clear in precisely what must be done so there is no room for

misinterpretation of instructions.

• Evidence-based. That there is research that supports what is being proposed.

• Prioritized. The most urgent problems being dealt with first.

• Involve. Involve both the patient and other members of the multidisciplinary team

who are going to be involved in implementing the care.

• Goal cantered. That the care planned will meet and achieve the goal set.
Short Term and Long Term Goals

Goals and expected outcomes must be measurable and client-centered. Goals are constructed

by focusing on problem prevention, resolution, and rehabilitation. Goals can be short-

term or long-term. Most goals are short-term in an acute care setting since much of the

nurse’s time is spent on the client’s immediate needs. Long-term goals are often used for

clients who have chronic health problems or live at home, nursing homes, or in extended-care

facilities.

• Short-term goal. A statement distinguishing a shift in behaviour that can be completed

immediately, usually within a few hours or days.

• Long-term goal. Indicates an objective to be completed over a longer period, usually

over weeks or months.

• Discharge planning. Involves naming long-term goals, therefore promoting continued

restorative care and problem resolution through home health, physical therapy, or

various other referral sources.

Components of goals and desired outcomes in a nursing care plan.

• Subject. The subject is the client, any part of the client, or some attribute of the client

(i.e., pulse, temperature, urinary output). That subject is often omitted in writing goals

because it is assumed that the subject is the client unless indicated otherwise (family,

significant other).

• Verb. The verb specifies an action the client is to perform, for example, what the

client is to do, learn, or experience.

• Conditions or modifiers. These are the “what, when, where, or how” that are added to

the verb to explain the circumstances under which the behaviour is to be performed.
 • Criterion of desired performance. The criterion indicates the standard by which a

performance is evaluated or the level at which the client will perform the specified

behaviour. These are optional.

Step 6: Selecting Nursing Interventions

Nursing interventions are activities or actions that a nurse performs to achieve client goals.

Interventions chosen should focus on eliminating or reducing the etiology of the nursing

diagnosis. As for risk nursing diagnoses, interventions should focus on reducing the client’s

risk factors. In this step, nursing interventions are identified and written during the planning

step of the nursing process; however, they are actually performed during the implementation

step.

Types of Nursing Interventions

Nursing interventions can be independent, dependent, or collaborative:

Types of nursing interventions in a care plan.

• Independent nursing interventions are activities that nurse are licensed to initiate

based on their sound judgement and skills. Includes: ongoing assessment, emotional

support, providing comfort, teaching, physical care, and making referrals to other

health care professionals.

• Dependent nursing interventions are activities carried out under the physician’s orders

or supervision. Includes orders to direct the nurse to provide medications, intravenous,

diagnostic tests, treatments, diet, and activity or rest. Assessment and providing

explanation while administering medical orders are also part of the dependent nursing

interventions.
 • Collaborative interventions are actions that the nurse carries out in collaboration with

other health team members, such as physicians, social workers, dieticians, and

therapists. These actions are developed in consultation with other health care

professionals to gain their professional viewpoint.

Nursing interventions should be:

• Safe and appropriate for the client’s age, health, and condition.

• Achievable with the resources and time available.

• In line with the client’s values, culture, and beliefs.

• In line with other therapies.

• Based on nursing knowledge and experience or knowledge from relevant sciences.

Steps for writing nursing interventions

1. Write the date and sign the plan. The date the plan is written is essential for

evaluation, review, and future planning. The nurse’s signature demonstrates

accountability.

2. Nursing interventions should be specific and clearly stated, beginning with an action

verb indicating what the nurse is expected to do. Action verb starts the intervention

and must be precise. Qualifiers of how, when, where, time, frequency, and amount

provide the content of the planned activity. For example: “Educate parents on how to

take temperature and notify of any changes,” or “Assess urine for colour, amount,

odour, and turbidity.”

3. Use only abbreviations accepted by the institution.

Step 7: Providing Rationale

Rationales, also known as scientific explanations, explain why the nursing intervention was

chosen for the NCP. Rationales do not appear in regular care plans. They are included to

assist nursing students in associating the pathophysiological and psychological principles

with the selected nursing intervention.

Step 8: Evaluation

Evaluating is a planned, ongoing, purposeful activity in which the client’s progress towards

achieving goals or desired outcomes and the effectiveness of the nursing care plan (NCP).

Evaluation is an essential aspect of the nursing process because conclusions drawn from this

step determine whether the nursing intervention should be terminated, continued, or changed.

Step 9: Putting it on Paper

The client’s care plan is documented according to hospital policy and becomes part of the

client’s permanent medical record which may be reviewed by the oncoming nurse. Different

nursing programs have different care plan formats. Most are designed so that the student

systematically proceeds through the interrelated steps of the nursing process, and many use a

five-column format.

Nursing Care Plan for Diabetes

Diabetes Mellitus

Diabetes mellitus (DM) is a chronic disease characterized by insufficient insulin production

in the pancreas or when the body cannot efficiently use the insulin it produces. This leads to

an increased concentration of glucose in the bloodstream (hyperglycemia). It is characterized

by disturbances in carbohydrate, protein, and fat metabolism. Sustained hyperglycemia has

been shown to affect almost all tissues in the body. It is associated with significant

complications of multiple organ systems, including the eyes, nerves, kidneys,

and blood vessels.

Classifications of diabetes mellitus include:

• Type 1 diabetes is characterized by destruction of the pancreatic beta cells.

• Types 2 diabetes involves insulin resistance and impaired insulin secretion.

• Gestational diabetes mellitus is when a pregnant woman experiences any degree of

glucose intolerance with the onset of pregnancy.

• Diabetes mellitus associated with other conditions is when specific types of diabetes

develop due to other causes (e.g., pancreatic diseases, hormonal abnormalities,

medications).

• Prediabetes (impaired glucose tolerance or impaired fasting glucose) is a new

classification of diabetes indicating a metabolic stage between normal glucose

homeostasis and diabetes.

Nursing Care Plans for Diabetes Mellitus

Nursing care planning goals for patients with diabetes include effective treatment to

normalize blood glucose levels and decrease complications using insulin replacement, a

balanced diet, and exercise. The nurse should stress the importance of complying with the

prescribed treatment program through effective patient education. Tailor your teaching to the

patient’s needs, abilities, and developmental stage. Stress the effect of blood glucose control

on long-term health. Blood glucose levels related to insufficient diabetes management or

adherence to diabetes management plan

 Outcome: The patient will achieve and maintain blood glucose levels within the normal

range.

Intervention Rationale

Assess for signs or symptoms of Hypoglycemic events are extremely dangerous and should be corrected as quickly as
hypoglycemia possible.

Assess for signs or symptoms of Being aware of signs and symptoms of hyperglycemia will allow for prompt administration
hyperglycemia of medication if necessary.

Monitoring the blood glucose level closely will prevent hypoglycemic and/or hyperglycemic
Monitor/perform blood glucose
events from occurring. Likewise, it will assist in determining if the medication regimen is
checks
appropriate or requires dosage adjustments.

Administer diabetic medications (oral Appropriate medication administration will assist in maintaining optimal blood glucose
and insulin) as prescribed levels.

When carbohydrates are metabolized in the body they are broken down into glucose and
Count carbohydrates for all meals and
therefore will cause a rise in the blood glucose level. Counting carbohydrates ensures the
snacks
appropriate dose of insulin can be given with each meal or snack.

Being aware of patient’s current knowledge level in the management of diabetes will assist
Assess patient’s level of
in determining additional education needs and allows for all education to be tailored to each
understanding/knowledge of diabetes
individual.

Diabetic education is vital to the patient’s overall treatment plan. Education on what diabetes
Educate patient on chronic condition of is, how it is managed, hypoglycaemia vs hyperglycemia, and signs and symptoms will assist
diabetes mellitus to empower the patient and allow him/her to feel more confident in his/her ability to manage
a chronic condition.

Educate patient on how to monitor Diabetic patients will need to be able to monitor blood glucose levels independently at home
blood glucose levels to ensure proper diabetic management and adherence to the treatment plan.

Educate patient on dietary Educating patients on dietary restrictions and carbohydrate counting will increase the
restrictions/carbohydrate patient’s understanding of the condition and assist in gaining confidence in the independent
counting/meal planning management of this condition.

Having a stable support system will assist patients in being able to monitor and manage
Assess patient’s support system
diabetes.
 Nursing Care Plan for Asthma

Asthma is a chronic inflammatory lung disease that causes airway hyperresponsiveness,

mucus production, and mucosal edema resulting in reversible airflow obstruction. Allergens,

air pollutants, cold weather, physical exertion, strong odours, and medications are common

predisposing factors for asthma. When an individual is exposed to a trigger, an immediate

inflammatory response with bronchospasm happens. This inflammatory process leads to

recurrent episodes of asthmatic symptoms such as cough, dyspnea, wheezing, and increased

mucus production.

Nursing Care Plans

The nursing care plan goals for asthma focuses on preventing the hypersensitivity reaction,

controlling the allergens, maintaining airway patency and preventing the occurrence of

reversible complications.

Nursing Interventions and Rationales.

Nursing Interventions
Rationale
Nursing Assessment

Assess the client’s vital signs as Increased BP, RR, and HR occur during the initial hypoxia and hypercapnia. And when it becomes
needed while in distress. severe, BP and HR drops and respiratory failure may result.

Assess the respiratory rate, depth, Changes in the respiratory rate and rhythm may indicate an early sign of impending respiratory
and rhythm. distress.

Assess the client’s level of anxiety. Anxiety may result from the struggle of not being able to breathe properly.

Assess breath sounds and Adventitious sounds may indicate a worsening condition or additional developing complications
adventitious sounds such as wheezes
and stridor.
Assess the relationship of inspiration
to expiration.
Assess for signs of dyspnea (flaring
of nostrils, chest retractions, and use
of accessory muscle).
Assess for conversational dyspnea.
Assess for fatigue.
Assess the presence of paradoxical
pulse of 12 mm Hg or greater.
Monitor oxygen saturation.
Monitor peaked expiratory flow
rates and forced expiratory volume
as taken by the respiratory therapist.
Monitor arterial blood gasses
(ABG).
such as pneumonia. Wheezing happens as a result of bronchospasm. Diminishing wheezing and
indistinct breath sounds are suggestive findings and indicate impending respiratory failure.
Reactive airways allow air to move into the lungs more easily than out of the lungs. If the client is
gasping for air, instruction for effective breathing is needed.
These indicate respiratory distress. Once the movement of air into and out of the lungs becomes
challenging, the breathing pattern changes.
Dyspnea during a normal conversation is a sign of respiratory distress.
Fatigue may indicate distress, leading to respiratory failure.
Paradoxical pulse is an abnormally large decrease in systolic blood pressure and pulses wave
amplitude during inspiration. The normal fall in pressure is less than 10 mm Hg. A paradoxical pulse
of 12 mm Hg or greater indicates a severe airflow obstruction.
Oxygen saturation is a term referring to the fraction of oxygen-saturated hemoglobin relative to the
total hemoglobin in the blood. Normal oxygen saturation levels are considered 95-100%.
The severity of the exacerbation can be measured objectively by monitoring these values. The peak
expiratory flow rate is the maximum flow rate that can be generated during a forced expiratory
maneuver with fully inflated lungs. It is measured in liters per second and requires maximal effort.
When done with good effort, it correlates well with forced expiratory volume in 1 second (FEV 1)
measured by spirometry and provides a simple, reproducible measure of airway obstruction.
During a mild to moderate asthma attack, clients may develop respiratory alkalosis. Hypoxemia
leads to increased respiratory rate and depth, and carbon dioxide is blown off. An ominous finding is
a respiratory acidosis, which usually indicates that respiratory failure is pending and that mechanical
ventilation may be necessary.
 THREE: BED MAKING

Closed bed
Occupied bed.
Post-operative bed

Bed Making
In most instances beds are made after the client receives certain care and when beds are

unoccupied. Unoccupied bed can be both open and closed.

Closed bed: is a smooth, comfortable and clean bed, which is prepared for a new patient

• In closed bed: the top sheet, blanket and bed spread are drawn up to the top of the bed and

under the pillows.

Open bed: is one which is made for an ambulatory patient are made in the same way but the

top covers of an open bed are folded back to make it easier of a client to get in.

Occupied bed: is a bed prepared for a weak patient who is unable to get out of bed.

Purpose:

1. To provide comfort and to facilitate movement of the patient

2. To conserve patient’s energy and maintain current health status

Anesthetic bed: is a bed prepared for a patient recovering from anesthesia

⇒Purpose: to facilitate easy transfer of the patient from stretcher to bed

Amputation bed: a regular bed with a bed cradle and sand bags

⇒Purpose: to leave the amputated part easy for observation

Fracture bed: a bed board under normal bed and cradle

⇒Purpose: to provide a flat, unyielding surface to support a fracture part

Cardiac bed: is one prepared for a patient with heart problem

⇒Purpose: to ease difficulty in breathing

General Instructions

1. Put bed coverings in order of use

2. Wash hands thoroughly after handling a patient's bed linen. Linens and equipment soiled

which secretions and excretions harbour micro-organisms that can be transmitted directly or

by hand’s uniforms

3. Hold soiled linen away from uniform

4. Linen for one client is never (even momentarily) placed on another client’s bed

5. Soiled linen is placed directly in a portable linen hamper or a pillow case before it is

gathered for disposal

6. Soiled linen is never shaken in the air because shaking can disseminate secretions and

excretions and the microorganisms they contain

7. When stripping and making a bed, conserve time and energy by stripping and making up

one side as completely as possible before working on the other side.

8. To avoid unnecessary trips to the linen supply area, gather all needed linen before starting

to strip bed

9. Make a vertical or horizontal toe pleat in the sheet to provide additional room for the

client’s feet.

Vertical - make a fold in the sheet 5-10 cm 1 to the foot

Horizontal – make a fold in the sheet 5-10 cm across the bed near the foot

10. While tucking bedding under the mattress the palm of the hand should face down to

protect your nails.

Order of Bed Covers

1. Mattress cover

2. Bottom sheet

3. Rubber sheet

4. Cotton (cloth) draw sheet

5. Top sheet
6. Blanket

7. Pillow case

8. Bed spread

Note

• Pillow should not be used for babies

• The mattress should be turned as often as necessary to prevent sagging, which will cause

discomfort to the patient.

A. Closed Bed

• It is a smooth, comfortable, and clean bed that is prepared for a new patient

Essential Equipment:

• Two large sheets

• Rubber draw sheet

• Draw sheet

• Blankets

• Pillow cases

• Bed spread

Procedure:

• Wash hands and collect necessary materials

• Place the materials to be used on the chair. Turn mattress and arrange evenly on the bed

• Place bottom sheet with correct side up, centre of sheet on centre of bed and then at the

head of the bed

• Tuck sheet under mattress at the head of bed and mitre the corner

• Remain on one side of bed until you have completed making the bed on that side

• Tuck sheet on the sides and foot of bed, metering the corners

• Tuck sheets smoothly under the mattress, there should be no wrinkles

• Place rubber draw at the centre of the bed and tuck smoothly and tightly

• Place cotton draw sheet on top of rubber draw sheet and tuck. The rubber draw sheet should

be covered completely

• Place top sheet with wrong side up, centre fold of sheet on centre of bed and wide hem at

head of bed

• Tuck sheet of foot of bed, metering the corner

• Place blankets with centre of blanket on centre of bed, tuck at the foot of beds and miter the

corner

• Fold top sheet over blanket

• Place bed spread with right side up and tuck it

• Mitre the corners at the foot of the bed

• Go to other side of bed and tuck in bottom sheet, draw sheet, metering corners and

smoothening out all wrinkles, put pillow case on pillow and place on bed

• See that bed is neat and smooth

• Leave bed in place and furniture in order

• Wash hands

B. Occupied Bed

Purpose: to provide comfort, cleanliness and facilitate position of the patients

Essential equipment:

• Two large sheets

• Draw sheet

• Pillow case

• Pyjamas or gown, if necessary

Procedure:

• If a full bath is not given at this time, the patient’s back should be washed and cared for
• Wash hands and collect equipment

• Explain procedure to the patient

• Carry all equipment to the bed and arrange in the order it is to be used

• Make sure the windows and doors are closed

• Make the bed flat, if possible

• Loosen all bedding from the mattress, beginning at head of the bed, and place dirty pillow

cases on the chair for receiving dirty linen

• Have patient flex knees, or help patient do so. With one hand over the patient’s shoulder

and the shoulder hand over the patient’s knees, turn the patient towards you

• Never turn a helpless patient away from you, as this may cause him/her to fall out bed

• When you have made the patient comfortable and secure as near to the edge of the bed as

possible, to go the other side carrying your equipment with you

• Loosen the bedding on that side

• Fold, the bed spread half way down from the head

• Fold the bedding neatly up over patient

• Roll dirty bottom sheet close to patient

• Put on clean bottom sheet on used top sheet centre, fold at centre of bed, rolling the top half

close to the patient, tucking top and bottom ends tightly and metering the corner

• Put on rubber sheet and draw sheet if needed

• Turn patient towards you on to the clean sheets and make comfortable on the edge of bed

• Go to the opposite side of bed. Taking basin and wash cloths with you, give patient back

care

• Remove dirty sheet gently and place in dirty pillow case, but not on the floor

• Remove dirty bottom sheet and unroll clean linen

• Tuck in tightly at ends and mitre corners

• Turn patient and make position comfortable

• Back rub should be given before the patient is turned on his /her back

• Place clean sheet over top sheet and ask the patient to hold it if she/he is conscious

• Go to foot of bed and pull the dirty top sheet out

• Replace the blanket and bed spread

• Mitre the corners

• Tuck in along sides for low beds

• Leave sides hanging on high beds

• Turn the top of the bed spread under the blanket

• Turn top sheet back over the blanket and bed spread

• Change pillowcase, lift patient’s head to replace pillow. Loosen top bedding over patient’s

toes and chest

• Be sure the patient is comfortable

• Clean bedside table

• Remove dirty linen, leaving room in order and wash hands.

Making a post-operative bed

• The entire bed need clean linen.

• Make the bottom of bed as you normally would. The post operative the bottom of bed

as you normally would. The post operative bed usually requires a draw sheet under

the client’s hips. Usually another draw sheet is placed under the client’s heard.

• In some cases, top liners are simply tan-folded to the foot of the bed. In others, a full

post operative bed is made.

• Have two or more pillows available, but do not put them on the bed. Rational: A

pillow may be contraindicated for a client, usually the physician or charge nurse will

determine when it is safe for the client to have one.

• Be sure all furniture is out of the way.

• Be sure the call light is available, but keep it on the bed side stand until the client is in

bed. The call light cord is kept out of the way, to facilitate the transfer of the client to

bed.

• Know what surgical procedure your client has had before you determine what special

equipment is needed. For the client’s convenience and safety, make the following

items available: tissue, an emesis basin, a blood pressure cuff and stethoscope, a

“frequent vital signs” flow sheet an intake and output record, and an intravenous (IV)

stand. Other items can be added according to the client specific requirements.

• Report to your charge nurse when you have completed the postoperative bed and

assembled the necessary equipment.

 FOUR: IMMUNIZATION

Immunization is the process of administrating a weakened or killed microorganism or its

product to stimulate the host’s immunologic response to that antigen.

Types of Vaccines:

Vaccines can be

- Killed microorganisms (pertussis),

- Live but weakened – attenuated – microorganisms (measles, polio TB)

- toxoids (tetanus and diphtheria).

Target group - all under one year children and women of childbearing age (15 - 49 years).
Side effects of vaccines

BCG

1. Normal reaction

- A small red, tender swelling about 10 mm across appears at the place of immunization after
about 2 weeks

- Abscess: due to injection errors

- Ulcer

- Scar

2. Severe reaction

- Sometimes there is severe local inflammation or deeper abscess.

- Sometimes the lymphatic glands near the elbow or in the axilla swell. This may be because:
• You used a needle that was not sterile

• You injected too deeply under the skin by mistake

• You gave too large a dose of vaccine.

DPT

- Fever
- Soreness at the injection site

- Abscess - Convulsion (rare)

Polio

- Usually none Tetanus Toxoid (TT)

- Pain, redness and swelling at the infection site.

Measles

- Fever 5 – 8 days late

- Occasional rash

Contraindications of vaccines

• DPT should not be given if the child has developed severe reactions like shock,
convulsions, anaphylactic reaction, etc. to the previous dose of DPT. This is a rare side effect
due to the pertussis component of DPT vaccine.

• Infants with clinical AIDS should not receive BCG vaccine and oral polio, but should be
given the other EPI vaccines.

. For those who start at birth:

Contact Age of Child Vaccines

1st At birth BCG and Polio 0

2nd 6 weeks OPV1 and DPT1

3rd 10 weeks OPV2 and DPT2

4th 14 weeks OPV3 and DPT3

5th 9 months Measles

For those who start later

Age of child Antigens

Less than 6 weeks BCG and OPV1

Above 6 weeks BCG if not given previously

OPV (3 doses)

DPT (3 doses)

Above 9 months BCG if not given previously

OPV

DPT

Measles

Tetanus toxoid vaccine schedule for women (15 - 49 years)

Dose Minimum interval Duration of

protection
TT1 0 0
TT2 4 weeks 3 years
TT3 6 months 5 years
TT4 1 year 10 years
TT5 1 year Life long

Note: If a woman was given 3 doses of DPT vaccine when she was a child, provided that a
written document of her immunization is available, and the doses are given at the right
intervals, the 3 doses of DPT can be counted as two doses of TT.

The cold chain

The cold chain is the interconnection of equipment or people that ensure vaccine potency by
keeping vaccine cold all the way from the manufacturer to the mother/child.

Equipment

Materials that are used in the cold chain include:

Thermometers, ice packs, vaccine carriers, cold boxes, refrigerators and freezers.

Note: Skilled human power to maintain the cold chain is necessary.

Precautions for vaccines

- All vaccines have to be stored at 0o C to 8o C both at the health center and outreach unit.

- Storage time for all vaccines is up to a month at the health center/health station and up to 1-
2 days at the outreach unit.

- Measles and polio be kept frozen.

- Never freeze DPT or tetanus vaccine.

- Keep diluents with vaccine in refrigerator if there is space.

- If not, refrigerate at least the diluents needed for the following day.

EPI Delivery Strategies

Static: immunization performed as part of routine activity of the Health units.

Outreach: an immunization approach in which the staffs of health unit go out and administer
vaccine to mothers and children in their catchments areas.

Mobile: an immunization approach only single dose vaccination (measles, BCG) in nomadic,
settlement areas and mostly used for controlling epidemics of measles.

Campaign: an immunization approach conducted by mobilizing the community, example

polio and measles vaccination.

Indicators

The following are some indicators that show a successful immunization programme:

- BCG scar on the right shoulder.

- Completed immunization card.

- Vaccine storage times and temperatures at health centre and outreach level.

Immunization Problems

A. Drop Out

A drop out is defined as a child or a woman who failed to return for subsequent doses for
which he or she is eligible.

The possible causes of dropout rates are:

- Unsure of dates of return

- Long wait at the vaccination centre

- Vaccination centers open at inconvenient hours

- Some health workers do not explain the need of completing vaccination.

- Negative attitude of some health workers towards the program.

- Mothers usually busy on other engagements.

- Family left the place for a while.

- Child develops side effects or was sick on the appointed date.

- Sick on the appointed date.

A child or a woman who discontinued the immunization program should not have to restart
the immunization. There is no maximum interval between two immunizations.

B. Missed opportunities

Current policy is that all children and mothers at the health facility for any reason should be
screened for immunization status and vaccinated if eligible.

Common causes of missed opportunities are:

- Health workers do not know the policy

- Health workers screen but tell patients to return later

- Health workers only vaccinate women with TT if they are pregnant

- Health workers only vaccinate the index child, miss the siblings.
- Health workers only open a vial if there are enough clients who need it

- False contraindications to immunization, example not giving polio vaccine to a child with
diarrhea.

- Logistical problems, such as vaccine shortages, poor clinic organization, and inefficient
clinic scheduling

- The failure to administer simultaneously all vaccines for which a child was eligible

- Accessibility; time (women carry household responsibilities), distance, cost of

transportation

- Acceptability: culture, rumors, beliefs, etc.

Dropouts and missed opportunities are causes of low vaccination coverage, and have
potential solutions. These are:

- Social mobilization

- Dropout tracing mechanisms

- In service training to community health workers and utilization of other motivation

mechanisms.

- High level advocacy. - Get commitment by the local leaders.

- Monitoring and supervision the program

- Ensure financial and logistics support for the health institutions.

- Monitor coverage periodically.

- Daily integrated health service for all women and children attending the health units.

Immunization Monitoring Chart: It shows the progress you are making in raising
immunization coverage in your catchment areas. This chart enables the number of people you
actually immunize each month with your coverage targets.
 FIVE: ORAL REHYDRATION THERAPY

Oral Rehydration Therapy is the giving of fluid by mouth to prevent and/or correct the

dehydration that is a result of diarrhoea. As soon as diarrhoea begins, treatment using home

remedies to prevent dehydration must be started. If adults or children have not been given

extra drinks, or if in spite of this dehydration does occur, they must be treated with a special

drink made with oral rehydration salts (ORS).

Oral rehydration therapy, (also called ORT, oral rehydration salts or solutions (ORS),

or oral electrolyte), is a simple, cheap, and effective treatment for diarrhea-

related dehydration, caused by e.g. cholera. It consists of a solution of salts and other

substances such as glucose, sucrose, citrates or molasses, which is administered orally. It is

used around the world, but is most important in the Third World, where it saves millions of

children from diarrhea still their leading cause of death.

History

ORT was developed in the late 1960s by researchers in India and International Centre for

Diarrhoeal Disease Research in Bangladesh (then East Pakistan), for the treatment of cholera.

The Indo-Pakistani War of 1971 provoked a public health emergency in the refugee camps

set up to house those fleeing the violence. With cholera spreading rapidly and death rates

rising, the head of a medical centre in one of the camps instructed his staff to distribute Oral

Rehydration Salts (ORS). In the refugee camps where ORS was being used the death rate was

only 3%, compared to 20–30% in those camps using only intravenous fluid therapy. In 2002,

Drs. Norbert Hirschhorn, Dilip Mahalanabis, David R. Nalin, and Nathaniel F. Pierce were

awarded the first Pollin Prize for Pediatric Research, in recognition of their work in

developing ORT. Between 1980 and 2000, ORT decreased the number of children under five

dying of diarrhea from 4.6 million worldwide to 1.8 million—a 60% reduction. ORT is
"potentially the most important medical discovery of the 20th century". Today, the total

production is around 500 million ORS sachets per year, with the children's

rights agency UNICEF distributing them to children in around 60 developing countries. ORS

represents a cheap and effective way of reducing the millions of deaths caused each year by

diarrhea.

Reduced osmolarity grams/litre Reduced osmolarity mmol/litre

ORS ORS
Sodium chloride 2.6 Sodium 75
Glucose, anhydrous 13.5 Chloride 65
Potassium chloride 1.5 Glucose, anhydrous 75
Trisodium citrate, 2.9 Potassium 20
dehydrate
Citrate 10

Total Osmolarity 245

The Oral Rehydration Therapy

Oral rehydration therapy with an inexpensive glucose and electrolyte solution as promoted by

the World Health Organization has reduced substantially the number of deaths from

dehydration due to diarrhea. In addition, recent research suggests that these solutions have

advantages over conventional therapy. Yet, oral rehydration therapy has not been used

extensively in developed countries.

Oral rehydration therapy (ORT), using a simple, inexpensive, glucose and electrolyte solution

promoted by the World Health Organization (WHO) has reduced the number of deaths from

dehydration due to diarrhea by about a million per year.

Oral rehydration and maintenance solutions presently in use, although effective in

rehydration, do not decrease stool volume because of the relatively high osmolarity of the

glucose which they contain. The challenge, therefore, is to provide adequate glucose to the

sodium pump without increasing the osmolarity of the rehydration solution.

There are certain contraindications to the use of ORT:

• Protracted vomiting despite small, frequent feedings

• Worsening diarrhea and an inability to keep up with losses

• Stupor or coma

• Intestinal ileus.

Preparation of ORS

WHO and UNICEF have jointly developed official guidelines for the manufacture of oral
rehydration solution and the oral rehydration salts used to make it (both often abbreviated as
ORS). They also describe acceptable alternative preparations, depending on material
availability. Commercial preparations are available as either prepared fluids or packets of oral
rehydration salts ready for mixing with water. A basic oral rehydration therapy solution can
also be prepared when packets of oral rehydration salts are not available. The molar ratio of
sugar to salt should be 1:1 and the solution should not be hyperosmolar. The Rehydration
Project states, "Making the mixture a little diluted (with more than 1 litre of clean water) is
not harmful."

The optimal fluid for preparing oral rehydration solution is clean water. However, if this is
not available, the usually available water should be used. Oral rehydration solution
should not be withheld simply because the available water is potentially unsafe; rehydration
takes precedence. When oral rehydration salts packets and suitable teaspoons for measuring
sugar and salt are not available, the WHO has recommended that homemade soups may be
considered to help maintain hydration.
Formula for the WHO standard and low-osmolar-oral rehydration solution

Standard Low-osmolar

Component

grams/L oz/L grams/L oz/L

NaCl (salt) 3.5 0.123 2.6 0.092

Trisodium citrate dehydrate 2.9 0.100 2.9 0.100

KCl (NoSalt) 1.5 0.053 1.5 0.053

Anhydrous glucose 20 0.705 13.5 0.480

Total 27.9 0.981 20.5 0.725

Molar composition for the WHO standard and low-osmolar-oral rehydration solution

Standard Low-osmolar Acceptable range

Component

mmol/L mmol/L mmol/L

Glucose 111 75 <111

Sodium 90 75 60–90

Potassium 20 20 15–25

Chloride 80 65 50–80

Citrate 10 10 8–12

Total 311 245 200–310

ORS can be administered easily by a properly instructed parent, because dehydration can be
corrected quickly, it lends itself well for use in an outpatient department or nursing station. At
the end of 4 hours, the child can either be sent home on maintenance therapy or, if
dehydration persists, be observed for further therapy. Intelligent use of ORT can decrease
hospital admissions, an important consideration in a time of decreasing hospital budgets.
Although in our society intravenous therapy is often considered more convenient than ORT,
clinicians should feel more comfortable as they become more accustomed to the use of ORT.

Administration

ORT is based on evidence that water continues to be absorbed from the gastrointestinal
tract even while fluid is lost through diarrhea or vomiting. The World Health
Organization specify indications, preparations and procedures for ORT.

WHO/UNICEF guidelines suggest ORT should begin at the first sign of diarrhea in order to
prevent dehydration. Babies may be given ORS with a dropper or a syringe. Infants under two
may be given a teaspoon of ORS fluid every one to two minutes. Older children and adults
should take frequent sips from a cup, with a recommended intake of 200–400 mL of solution
after every loose movement. The WHO recommends giving children under two a quarter- to
a half-cup of fluid following each loose bowel movement and older children a half- to a full
cup. If the person vomits, the caregiver should wait 5–10 minutes and then resume giving
ORS. ORS may be given by aid workers or health care workers in refugee camps, health
clinics and hospital settings. Mothers should remain with their children and be taught how to
give ORS. This will help to prepare them to give ORT at home in the future. Breastfeeding
should be continued throughout ORT.

Oral Rehydration Therapy (ORT)

Physiology

Oral rehydration therapy is widely considered to be the best method for combating

the dehydration caused by diarrhea and/or vomiting. Various diseases cause damage to

the intestine, allowing water to flow from the blood into the intestine, depleting the body of

both fluid and electrolytes. This may be

 • a direct destruction of the cells lining the intestine (the enterocytes),

• a toxic effect causing them to lose their microvilli (the brush border),

• a toxic effect (by an enterotoxin) causing them to secrete water.

In the human body, water is absorbed and secreted passively; it follows the movement of

salts, based on a principle called osmosis. So, in many cases, diarrhea is caused by intestine

cells secreting salts (primarily sodium) and water following passively along. Simply drinking

water is ineffective for 2 reasons: (1) the large intestine is usually secreting instead of

absorbing water, and (2) electrolyte losses also need compensating.

An inexpensive home-made solution consists of

• 1 litre of water, mixed with

• 8 teaspoons of sugar,

• 1 teaspoon of table salt.

The amount of rehydration that is needed depends on the size of the individual and the degree

of dehydration. Rehydration is generally adequate when the person no longer feels thirsty and

has a normal urine output. A rough guide to the amount of ORS solution needed in the first 4-

6 hours of treatment for a mildly dehydrated person is:

• Up to 5 kg (11 lb): 200 – 400 ml

• 5-10 kg (11-22 lb): 400 – 600 ml

• 10-15 kg (22-33 lb): 600 – 800 ml

• 15-20 kg (33–44 lb): 800 – 1000 ml

• 20-30 kg (44-66 lb: 1000 – 1500 ml

• 30-40 kg (66-88 lb): 1500 – 2000 ml

• 40 plus kg (88 lb): 2000-4000 ml

Technique

Adults and children with dehydration who are not vomiting can be allowed to drink these

solutions in addition to their normal diet. People who are vomiting should be fed small

frequent amounts of ORS solution until dehydration is resolved. Once they are rehydrated,

they may resume eating normal foods when nausea passes. Vomiting itself does not mean

that oral rehydration cannot be given. As long as more fluid enters than exits, rehydration will

be accomplished. It is only when the volume of fluid and electrolyte loss in vomit and stool

exceeds what is taken in that dehydration will continue. When vomiting occurs, rest the

stomach for ten minutes and then offer small amounts of ORS solution. Start with a

teaspoonful every five minutes in children and a tablespoonful every five minutes in older

children and adults. If output exceeds intake or signs of moderate to severe dehydration

occur, medical assistance should be sought.

 SIX: CERVICAL CANCER

Cervical cancer is cancer of the cells in the cervix. Receiving regular gynecological exams,
getting Pap tests and practicing safe sex are the most important steps that you can take toward
the prevention of cervical cancer. Surgery, radiation and chemotherapy are the main
treatments for cervical cancer.

Cervical cancer, or cancer of the cervix, begins on the surface of your cervix. It happens
when the cells on your cervix begin to change to precancerous cells. Not all precancerous
cells will turn to cancer, but finding these problematic cells and treating them before they can
change is critical to preventing cervical cancer.

Types of cervical cancer

There are two main types of cancer of the cervix:

Squamous cell carcinomas and adenocarcinomas. About 80% to 90% of cervical cancers are
squamous cell carcinomas, while 10% to 20% are adenocarcinomas.

Cervix

The cervix is the lowest part of your uterus (where a baby grows during pregnancy). It looks
a little bit like a donut and connects your uterus to the opening of your vagina. It's covered in
tissues made up of cells. These healthy cells are what can grow and change to precancer cells.

How common is cervical cancer?

About 14,000 people in the United States are diagnosed with cervical cancer each year.
People between the ages of 35 and 44 are most frequently diagnosed with cervical cancer.
The average age at diagnosis is 50. Around 4,000 people die of cervical cancer per year. This
rate is on the decline due to screenings and the HPV vaccine.

Symptoms and Causes

Early stages of cervical cancer don't usually involve symptoms and are hard to detect. The
first signs of cervical cancer may take several years to develop. Finding abnormal cells
during cervical cancer screenings is the best way to avoid cervical cancer.
Signs and symptoms of stage 1 cervical cancer can include:

• Watery or bloody vaginal discharge that may be heavy and can have a foul odor.
• Vaginal bleeding after intercourse, between menstrual periods or after menopause.
• Menstrual periods may be heavier and last longer than normal.

If cancer has spread to nearby tissues or organs, symptoms may include:

• Difficult or painful urination, sometimes with blood in urine.

• Diarrhea, or pain or bleeding from your rectum when pooping.
• Fatigue, loss of weight and appetite.
• A general feeling of illness.
• Dull backache or swelling in your legs.
• Pelvic/abdominal pain.

Causes cervical cancer

Most cervical cancers are caused by the virus HPV, a sexually transmitted infection. HPV
spreads through sexual contact (anal, oral or vaginal) and can lead to cancer. Most people
will get HPV at some point in their lives and not realize it because their bodies fight the
infection. However, if your body doesn't fight the infection, it can cause the cells of your
cervix to change to cancerous cells.

HPV and cervical cancer

There are more than 100 kinds of HPV and about a dozen of them have been shown to lead to
cancer. Early detection of these types of HPV is the key in preventing cervical cancer.
Regular screenings with your healthcare provider can help identify cell changes before they
become cancer. The HPV vaccine can help prevent HPV infection by protecting you against
the HPV that causes up to 90% of all cervical cancers.

Diagnosis and Tests

Cervical cancer develops slowly and over many years. Before turning to cancer, the cells in
your cervix go through a lot of changes. The once normal cells in your cervix start to appear
irregular or abnormal. These abnormal cells may go away, stay the same or turn into cancer
cells. Regular gynaecological screenings with a Pap test can detect most cases of cervical
cancer. A Pap test, or Pap smear, is a test that collects cells from your cervix. These cells are
examined for signs of precancers or other irregularities. If your Pap comes back as abnormal,
further testing is necessary. This could include an HPV test, which is a specific test that
checks the cells of your cervix for HPV infection. Certain types of HPV infection are linked
to cervical cancer.

If the biopsy confirms cancer, further tests will determine whether the disease has spread
(metastasized). These tests might include:

• Liver and kidney function studies.

• Blood and urine tests.
• X-rays of your bladder, rectum, bowels and abdominal cavity.

Tests for Cervical Cancer

The tests used to detect cervical cancer are the Pap test and the HPV test. These cervical
cancer screenings can find irregular or problematic cells in their earliest form before they
have a chance to turn into cancer. When these cells are found early, cervical cancer is highly
treatable and less likely to become serious.

Screening for cervical cancer

The goal of cervical cancer screening is to detect cell changes on your cervix before they
become cancer.

• Pap test: This test detects abnormal or irregular cells in your cervix.
• HPV test: This test detects the high-risk types of HPV infection that are most likely
to cause cervical cancer.

Stages of cervical cancer?

• Stage I: Cancer is found only in the cervix. It hasn't spread and is small.
• Stage II: Cancer has spread beyond the cervix and uterus but hasn't yet spread to the
pelvic wall (the tissues that line the part of the body between your hips) or your
vagina.
 • Stage III: Cancer has spread to the lower part of the vagina and may have spread to
the pelvic wall, ureters (tubes that carry urine) and nearby lymph nodes.
• Stage IV: Cancer has spread to the bladder, rectum or other parts of the body like the
bones or lungs.

Management and Treatment

The cervical cancer treatment team includes a gynaecologic oncologist (a doctor who
specializes in cancers of female reproductive organs). Recommended treatment for cervical
cancer is based on many factors including the stage of the disease, age and general health,
and if you want children in the future. The treatments for cervical cancer are radiation,
chemotherapy, surgery, targeted therapy and immunotherapy.

Radiation

Radiation therapy uses energy beams to kill cancer cells on your cervix. There are two types
of radiation therapy:

• External beam radiation (EBRT): Aims high-powered radiation at cancer from a

machine outside your body.
• Brachytherapy: Puts the radiation in or just near cancer.

Chemotherapy

Chemotherapy (chemo) uses drugs that are injected through your veins or taken by mouth to
kill cancer cells. It enters your blood and is effective for killing cells anywhere in your body.
There are several drugs used for chemo and they can be combined. Chemo is often given in
cycles. The length of the cycle and the schedule or frequency of chemotherapy varies
depending on the drug used and where cancer is located.

Surgery

Different kinds of surgery are used to treat cervical cancer. Some of the most common kinds
of surgery for cervical cancer include:

• Laser surgery: This surgery uses a laser beam to burn off cancer cells.
• Cryosurgery: This surgery freezes cancer cells.
 • Cone biopsy: A surgery in which a cone-shaped piece of tissue is removed from your
cervix.
• Simple hysterectomy: This surgery involves the removal of your uterus but not the
tissue next to your uterus. Your vagina and pelvic lymph nodes aren't removed.
• Radical hysterectomy with pelvic lymph node dissection: With this surgery, your
uterus, surrounding tissue called the parametrium, your cervix, a small portion of the
upper part of your vagina and lymph nodes from your pelvis are removed.
• Trachelectomy: This procedure removes your cervix and the upper part of your
vagina but not your uterus.
• Pelvic exenteration: This is the same as a radical hysterectomy but includes your
bladder, vagina, rectum and part of your colon, depending on where cancer has
spread.

Targeted therapy

Targeted drug treatment destroys specific cancer cells without damaging healthy cells. It
works by targeting proteins that control how cancer cells grow and spread. As scientists learn
more about cancer cells, they're able to design better-targeted treatments that destroy these
proteins.

Immunotherapy

Immunotherapy uses medicine to stimulate the immune system to recognize and destroy
cancer cells. Cancer cells can also avoid being attacked by the immune system by sending off
a signal. Immunotherapy helps to target these signals so the cancer cells can't trick the body
into thinking it's a healthy cell.
Prevention

Some risk factors can be avoided, while others cannot. Some risk factors within your control
are:

• Screening history: Those who haven't had Pap tests are regular intervals are at
increased risk of cervical cancer.
• HPV infection: Certain types of HPV are linked to cervical cancer. Lowering the risk
for HPV can also lower the risk for cervical cancer.
• Sexual history: Having sexual intercourse before the age of 18 and having many
sexual partners puts you at higher risk of HPV infection and chlamydia. Preventing
these diseases reduces the risk of cervical cancer.
• Smoking: Cigarette smoking is associated with an increased risk of cervical cancer.
• HIV infection: Those who've been infected with HIV have a higher-than-average risk
of developing cervical cancer.
• Birth control pills: There is evidence that long-term use of oral contraceptives can
increase the risk of cervical cancer.
• Multiple children: Having three or more full-term pregnancies may increase your
risk for developing cancer of the cervix.
• Having a weakened immune system: Having a weak immune system makes the
body unable to fight infections.

Some risk factors you can't change are:

• DES (diethylstilbestrol): DES is a hormonal drug that was given to people between
1938 and 1971 to prevent miscarriage.
• Family history: Cervical cancer may have a genetic component.

Receiving regular gynecological exams and getting Pap tests are the most important steps to
take toward preventing cervical cancer. Other things you can do are:

• Get the HPV vaccine (if you are eligible).

• Use condoms or other barrier methods when you have sex.
• Limit your sexual partners.
• Stop smoking and using tobacco products.
Cervical Screening Cancer Guidelines:

Most people should have regular cervical cancer screenings. Screenings include Pap tests,
testing for HPV or a combination of both tests.

These are the cervical screening cancer guidelines:

• Cervical cancer screening should begin at age 21 years, regardless of sexual history.
Some healthcare providers are willing to delay this until age 25.
• For those 21 to 29 years of age, screening is recommended every three years with
only a Pap test (no HPV test).
• For people 30 years and older, co-testing with Pap and HPV should be done every
five years, or Pap test alone every three years.
• Routine Pap testing should be discontinued (stopped) in those who have had a
total hysterectomy for benign conditions and who have no history of CIN (cervical
intraepithelial neoplasia) grade 2 or higher.
• Cervical cancer screening can be discontinued at age 65 in those who have two
consecutive normal co-test results or three consecutive normal Pap test results in the
past 10 years, with the most recent normal test performed in the past five years.
• People who have been adequately treated for CIN grade 2 or higher will need to
continue screening for 20 years, even if it takes them past the age of 65.
• People 65 to 70 years of age or older who have had three or more normal Pap tests in
a row and no abnormal Pap test results in the last 20 years should stop having cervical
cancer screening. Those with a history of cervical cancer, DES exposure before birth,
HIV infection or a weakened immune system should continue to have screening as
long as they are in good health.
• Those who have had a total hysterectomy (removal of the uterus and cervix) should
also stop having cervical cancer screening unless they have a history of cervical
cancer or precancer. People who have had a hysterectomy without removal of their
cervix should continue to follow the guidelines above.

Cervical Cancer Vaccine

The HPV vaccine is approved for children and adults ages 9 to 45 and protects against the
development of cervical cancer. The vaccine works by triggering your body's immune system
to attack certain human papillomavirus (HPV) types, which have been linked to many cases
of cervical cancer. It is best to get the vaccine before the start of sexual activity. The vaccine
is given in a series. The number of shots you need varies depending on the age you are at
your first dose.
 SEVEN: EPISIOTOMY

Definition, indications, types and principles of Episiotomy

Definition

An episiotomy is a surgical cut in the muscular area between the vagina and the anus (the
area called the perineum) made just before delivery to enlarge your vaginal opening.
Obstetricians used to do episiotomies routinely to speed delivery and to prevent the vagina
from tearing, particularly during a first vaginal delivery, in the belief that the “clean” incision
of an episiotomy would heal more easily than a spontaneous tear. Many experts also believed
that an episiotomy might help prevent later complications, such as incontinence.
Indications:-
1. Large size baby:-a baby estimated to be 4000gm or more may cause need for an
episiotomy either to prevent laceration or in anticipation of a possible shoulder dystocia.
2. Preterm or small for gestational age baby
3. Fetal malpositions & malpresentations.
4. A thick perineum which is rigid & resistant to distention.
5. Prior to an assisted delivery such as forceps & vacuum extraction.
6. To speed up delivery if there is fetal distress.
Types of episiotomy:-
1. Medline or median episiotomy:-
The episiotomy incision is given in the midline, extending from the vaginal opening towards
the anus.
The advantages are:
• Less blood loss with this procedure.
• Less pain.
• An easier to perform procedure.
• Wound repair is done easily.
• Better cosmetic results due to less scarring.

2. Mediolateral episiotomy:-
In a mediolateral episiotomy, the incision begins in the middle of the vaginal opening and
extends down toward the buttocks at a 45-degree angle.
The primary advantage of a mediolateral episiotomy is that the risk for anal muscle tears is
much lower. However, there is much more disadvantages associated with this type of
episiotomy, including:
• increased blood loss
• more severe pain
• difficult repair
• higher risk of long-term discomfort, especially during sexual intercourse

Principles:-
The following principles should be observed regardless of which types of episiotomy is cut:-
1. The presenting part of fetus is protected from injury.
2. A single cut in any direction is far preferable to repeated snipping because the latter will
leave jagged.
3. The episiotomy should be large enough to meet the purpose for deciding to cut it.
4. The timing should be such that lacerations are prevented & unnecessary blood loss
avoided.
 EIGHT: ANTENATAL CARE

The aim of antenatal care is to assist the woman to remain healthy and thus aid the health of
the unborn baby. Antenatal care should also provide support and guidance to the pregnant
woman and her partner or family, to help them in their transition to parenthood. This implies
that both care and education are required from care providers.

During this important time the role of the health care worker is to:

• promote health activities;

• prevent ill health;
• provide curative services;
• liaise with other services such as specialist care and antenatal education;
• teach the woman both knowledge and skills regarding her own health care;
• become a supportive provider who is approachable and willing to listen to the
woman’s needs and to assist with any concerns she or her family may have about the
pregnancy, birth or postpartum period.

There are a number of important issues around the provision of antenatal care. These include
determining what kind of care should be offered to all women and what is needed by women
with difficulties or complications arising during pregnancy or birth. Other issues include the
frequency of visits, what should actually be offered in terms of care for the woman at each
visit and what screening tests are necessary. Quality of care is important and women’s
perceptions of their care should be sought and considered at all stages.

Aspects of care

Pre-pregnancy and inter-pregnancy care

The first 12 weeks of embryonic/fetal life are a period of tremendous cellular organization
and development (organogenesis), which even today is not fully understood. By the end of
this period, the major anomalies that can affect the fetus are usually already present; the
earlier they occur the more profound the damage. There are many factors in both the
environment and the individual that can affect fertility. It is, therefore, worth considering
factors external to the man/woman (external variables), factors internal to the couple (internal
variables) and factors that can affect both male and female fertility. Consideration should be
given to providing folic acid for potentially pregnant women as well as iron supplements, if
these are indicated. Recent evidence has indicated that folic acid reduces the risk of some
serious defects of the central nervous system in early pregnancy, including anencephaly and
spina bifida. The incidence of these problems has been shown to be reduced by 50% when
women take the folic acid supplements (0.4–1.0 mg/day) before getting pregnant and during
the first six weeks of pregnancy (equivalent to the first eight weeks of pregnancy dated from
the last menstrual flow). Women who have had a fetus with a neural tube defect should be
counselled about the increased risk in subsequent pregnancies and offered a folic acid
supplement (4 mg/day) if they intend to have another pregnancy.

Encouraging early antenatal care for all women

The purpose of antenatal care is to:

• support and encourage psychological adjustment to pregnancy, childbirth,

breastfeeding and parenthood;
• promote awareness of the social and psychological components of childbearing and
their influences on the family;
• monitor the progress of pregnancy to ensure the health and wellbeing of mother and
fetus; monitor all women for signs of obstetric difficulties through close personal
attention and diagnostic tests where essential and indicated;
• recognize deviations from the normal, and treat or refer as required;
• recognize that women who develop warning signs may return to normal following
treatment and might not necessarily be continued to be regarded or treated as at risk;
• build a trusting relationship between the woman and her care givers;
• provide the woman with information with which she can make informed decisions;
• actively involve relevant members of the woman’s family or friends in the experience
of pregnancy, encouraging the supportive role that they might play and recognizing
that they too might need support.

It is accepted that all women should seek antenatal care early in pregnancy. Many do, but
there are frequently women who do not present for care until very late in the pregnancy or
even in labour itself. Women from culturally marginal groups who have not had the
educational opportunities which encourage preventive health care, who do not have adequate
access to health care services because of lack of transport and the distance they live from the
health care facility, with few financial resources to meet the expectations or requirements of
the health care services or providers for payment, with restrictive home situations where other
members of the family prohibit attendance at health care services, to name only a few
reasons, are less likely to seek appropriate and timely care.

Calculation of the expected date of delivery

The duration of pregnancy is usually taken to be 40 weeks, with normal labour occurring
between 38 and 42 completed weeks of gestation. Issues of premature and prolonged labour,
therefore, surround the period before 38 weeks and after 42 weeks. The expected date is
awaited with anticipation by the woman, who often becomes very disappointed if delivery
does not occur around this date. The typical formula for calculation is nine calendar months,
and seven days are added to the first date of the last menstrual period. This assumes that
ovulation occurred 14 days after the first day of the last period, and that the last period of
bleeding was a true period.

Physiological adaptations to pregnancy

A woman’s body adapts and adjusts to the needs and demands of a growing fetus in
remarkable ways. Knowledge of the physiology of pregnancy provides an insight into the
foundations and rationale of antenatal education.

Physiological adaptations to pregnancy

Management of pregnancy

Antenatal care is necessary to observe maternal health and fetal wellbeing. The timing and
number of antenatal visits depends on the individual. The traditional regime is monthly from
the booking visit to 28 weeks’ gestation, fortnightly to 36 weeks’ gestation and then weekly
until delivery. Recent knowledge has led to an understanding that in a normal pregnancy a
woman does not need to make so many antenatal visits. At each visit, the midwife will
examine the woman using a systematic approach. Good communication is essential; the
woman should be able to communicate how she is feeling and if she has any problems. Her
general appearance and demeanour will alert the midwife to recognize a number of
complaints such as stress, anxiety, concern, illness, disability or lack of sleep. Careful
observation of the woman’s general appearance, her demeanour and the manner in which she
communicates can provide vital information and should not be overlooked.

Examinations

There is still some debate about which tests and procedures should be carried out during
pregnancy and when these should be done. Recent research has revealed that many tests
routinely performed until now have been unnecessary. Unless there is some treatment that
can be offered, or some preventive care that would be instituted, tests should not be carried
out just to record the results. This thinking has led to a questioning of routine practice and a
reduction in the number of unnecessary tests routinely performed during pregnancy. Also,
treatment of most disorders during pregnancy should be conducted on an outpatient basis.
Removing a woman from her home environment should only be undertaken if absolutely
necessary. Some tests do, however, remain vital during pregnancy.

Blood pressure

Most antenatal regimes require the woman’s blood pressure to be taken at each visit to
identify signs of hypertension. Hypertension is only a sign and does not always indicate pre-
eclampsia. However, a rise in the diastolic reading to above 90 mmHg or of more than 10
mmHg from the baseline reading taken before the twentieth week of pregnancy may require
evaluation and referral to a doctor.

Other tests may include the following:

Urinalysis: This should be tested at booking for the presence of bacteria to screen for
asymptotic bacteriuria. If a high level of bacteria is found (greater than 100 000 colonies per
ml), treatment with a suitable antibiotic is required. It is important to retest the urine for
bacteria after completion of the treatment. At subsequent visits the urine should be tested for
the presence of protein. The definitive test for proteinuria in pregnancy is determination of
total protein excretion in a 24-h urine collection, using a reliable quantitative method (e.g.
Esbach’s). This is too complicated to be used for screening therefore a random urine
specimen (with clinically significant cut-off 0.3g/l or 1+) could be considered.

Weight

Recent findings suggest that there is little value in assessing weight gain at each visit and
provide no justification for telling women to restrict their diet in an effort to limit weight
gain.

Fundal height

The measuring of fundal height has been shown to vary a great deal between individual
health workers. Therefore, for these measurements to be of value the same person should
record the fundal height at every visit. This is only one of many reasons for promoting
continuity of care during pregnancy. Several studies have shown quite good sensitivity and
specificity of fundal height for predicting low birth weight for gestation. The ability to predict
low birth weight is not the same as ability to detect growth restriction, but fundal height may
be useful as a screening test for further investigation. Abdominal girth measurement has not
been adequately evaluated at all. When measuring fundal height, the use of a tape measure
has been found to provide more accurate information. The measure should be placed at the tip
of the symphysis pubis and should measure the distance from the symphysis pubis to the
fundus. In normal singleton pregnancies the measurement in centimetres approximates the
gestational age after 24 weeks of pregnancy.
Abdominal palpation

The lie and presentation are usually noted at each visit. Towards term (from 36 weeks in the
primigravida) the degree of engagement is noted and sometimes a note is made of the actual
position of the presenting part, despite importance of such kind of intervention (four Leopold
manoeuvres) up to date is out of known value.

Pelvimetry

Neither X-ray nor clinical pelvimetry are been shown to predict cephalopelvic disproportion
with sufficient accuracy to justify elective Caesarean section with cephalic presentation
therefore are out of value for routine antenatal care practice. Cephalopelvic disproportion is
best diagnosed by a carefully monitored trial of labour.

Fetal heart/fetal movements

In the early stages of pregnancy the woman should be asked about the movements of the fetus
at each visit, although some women do not feel the baby move until after 16 weeks gestation.
Sometimes the woman will be anxious if she feels the baby is not moving as much as she
thinks it should. As pregnancy progresses, listening to the fetal heart becomes possible and
the midwife can assure the woman that the fetal heart is heard and is at a normal rate and
rhythm. Doppler ultrasound as a means of assessing the fetal heart appears to have little, if
any, effect on pregnancy outcome when used as a screening test in unselected pregnancies.
On the other hand, research into its use in high risk pregnancies (complicated mainly by fetal
growth retardation or maternal high blood pressure) shows that there are fewer stillbirths and
neonatal deaths among normally formed babies when Doppler is available to clinicians.
Similar findings have emerged regarding the value of counting fetal movement as a measure
of fetal wellbeing. The logic behind this is that a reduction in, or cessation of, fetal
movements may precede fetal death by a day or more. Two randomized trials have been
undertaken (the larger one involving more than 68 000 women) to assess whether clinical
action taken on the basis of fetal movement counting improves fetal outcome. These trials
provide no evidence that routine formal fetal movement counting reduces the incidence of
intrauterine fetal death in late pregnancy. Routine counting results in more frequent reports of
diminished fetal activity, greater use of other techniques of fetal assessment, more frequent
antepartum admission to hospital, and an increased use of elective delivery for decreased
movement, and thus increased use of resources without compensating benefit. Routine
Doppler imaging and routine fetal movement counting for normal pregnancy is, therefore, not
supported by available evidence.

Legs

At each visit it is useful to examine the legs for varicosities. Women who stand for long
periods or who do heavy manual work may benefit from advice on exercises for their legs.
However, the presence of oedema (except severe or rapidly developed swellings of face or
lower back) should not be taken as a sign of disease since lower limb oedema is present in the
majority, up to 50–80% of normal pregnancies.

Blood tests

Blood should be taken early in pregnancy to ascertain the blood group and type, if this is not
known. Haemoglobin is estimated at least once during pregnancy, preferably around 32
weeks’ gestation when the haemodynamics are at a peak. Sometimes a repeat estimate is
ordered at 36 weeks’ gestation, particularly if the haemoglobin is low. Studies show that
routine iron supplements are not essential in well nourished populations but may be helpful in
areas of high anaemia or where malaria is endemic. WHO recommendations for such
supplements are: one tablet of 60 mg elemental iron with folic acid 0.5 mg twice a day for at
least 90 consecutive days. It should be noted that the normal haematological adaptations of
pregnancy are frequently misinterpreted as evidence of iron deficiency that needs correcting.
Routine iron supplements raise and maintain serum ferritin above 10 µg/litre and result in a
substantially lower proportion of women with a haemoglobin level below 10 or 10.5 g per
cent in late pregnancy. As yet, neither iron or folate supplementation after the first trimester
have shown any positive effect on a number of substantive measures of maternal or fetal
outcome, including proteinuric hypertension, antepartum haemorrhage, postpartum
haemorrhage, maternal infection, preterm birth, low birth weight, stillbirth or neonatal
morbidity. Women do not feel any subjective benefit from having their haemoglobin
concentration raised. There is also no evidence to support the claim that women might be in a
stronger position to withstand haemorrhage. In fact, the contrary might be true in that women
with a low haemoglobin might better withstand a loss of blood due to a higher circulating
blood volume. Evidence suggests that except for genuine (severe) anaemia (below 70 g/l), the
best reproductive performance is associated with levels of haemoglobin that are traditionally
regarded as pathologically low. Unless there is evidence of iron deficiency from other
measures, low haemoglobin should not necessarily be regarded as sufficient grounds for
routine supplementation.

Rhesus

Rhesus factor and antibodies should be checked and preparations made to provide anti-D for
Rh negative to non-sensitized women following any procedure/event that could result in
fetomaternal transfusion, also on 28th week of gestation and after delivery.

Ultrasound scans

Visualization of the fetus to assess fetal wellbeing using an ultrasound scan is possible in
some countries, but the equipment is expensive and requires expert skilled technicians. There
is no doubt about the value of ultrasound in specific clinical situations such as establishing
whether a fetus is alive or dead, estimating gestational age (if performed before 22 weeks of
pregnancy), establishing the pattern of fetal growth, localizing the placenta, confirming a
suspected multiple pregnancy, assessing amniotic fluid volume in suspected polyhydramnios
or oligohydramnios, confirming fetal position and assisting in other procedures such as
cervical cerclage or external cephalic version. It may also assist in visualizing fetal
malformation, although not always with total accuracy. More importantly, routine use of
scans for all pregnancies has not been shown to be clearly beneficial. Research has shown
that the benefits expected of routine ultrasound in early pregnancy, such as better gestational
age assessment, earlier detection of multiple pregnancies, and detection of clinically
unsuspected fetal malformation at a time when termination of pregnancy is possible, have
been largely unfulfilled. In this regard a satisfactory inspection of fetal anatomy to detect
malformation cannot be performed before 18 weeks, and if an examination of the heart is to
be included, examination closer to 22 weeks may be necessary. Research trials of routine
ultrasonography in late pregnancy suggest an increased incidence of antepartum admissions
to hospital and of inductions of labour with no improvement in perinatal outcome. In
conclusion, ultrasound equipment can be part of an intensive care area where antenatal
services are provided for high risk pregnancies or for referral if problems arise, but they are
not recommended for routine surveillance in normal healthy pregnancies.

Non-stress cardiotocography

Data available from RCT provide no support for the use of antepartum non-stress
cardiotocography as a supplementary test of fetal wellbeing in “high risk” pregnancies.
Antepartum cardiotocography is essentially an assessment of immediate fetal condition.
Unless evidence emerges to the contrary its clinical use would seem best restricted to
situations in which acute fetal hypoxemia may be present e.g. sudden reduction of fetal
movements or antepartum haemorrhage.

Records

All findings should be recorded on the antenatal records. The records should be accurate and
contain the signature of the person making the record so that anyone who may be called upon
to examine the woman at a later stage in the pregnancy knows whom they can contact for
further information if it should be necessary.

Discussion time

It is important to allocate sufficient time to talk to the woman (and her accompanying family,
if any) at every visit. This opportunity should be offered when the woman is dressed and
sitting up rather than while she is lying naked or partially covered on an examination bed. It
is very difficult, psychologically, for women to address difficult questions to you (such as
fears about the baby’s wellbeing, difficulties with their partners or sexual practice issues)
when they are in a psychologically disadvantaged position. It is important to offer them an
opportunity to ask questions and request assistance when they are comfortable to do so.
Exploring stressful social situations in women’s lives during the pregnancy may help to
prevent severe negative outcomes in the postpartum period. Factors such as depression,
violence in the home or experience of being abused as a child may contribute to difficulties
with the birth or with breastfeeding in addition to postpartum adjustment problems. The care
giver who detects these concerns and experiences early in pregnancy may be able to provide
more sensitive care during pregnancy and birth and to arrange for referrals for specialist
support for those who need it. It is possible that sensitivity to such problems may reduce the
incidence of postpartum depression, child abuse and marital disharmony after delivery
(ALPHA: Antenatal Psychosocial Health Assessment Scale). While husbands and partners
should be encouraged to attend antenatal visits with their wives it is important to ensure that
at least one visit (and opportunity for discussion) is offered to the woman alone in case the
source of her problems is a member of her family. The woman may not be free to discuss
these problems in the presence of her partner or friends.
Emergency obstetric care

It is most important that antenatal care providers strengthen women’s knowledge about
warning signs of complications during pregnancy and ensure that they know where to get
help if these occur and have the means (financial, transport, help, communication) to do so if
the need arises. While many of these difficulties may seem insurmountable at first, discussing
the problem with the family and explaining the reasons for the importance of such help and of
seeking it quickly when complications occur may motivate them to find solutions in case of
problems arising. Simply giving instructions to the family that emergency action must be
taken is not enough; the family needs to understand why action is important and what can go
wrong if they do not make the necessary arrangements. In many situations it may be essential
to collaborate with traditional birth attendants who customarily offer primary care in some
cultures and in some regions. Doing without such care givers on the grounds that they are
unskilled will not change local people’s trust in and reliance on their services. There is a need
to cooperate with them, to involve them in the health care service, to educate them about
emergency signs and what can be done to help at this time and why and their role in this
event, and to ensure their acceptance and support by the health care services.

Prioritizing care in emergency situations

In addition to the need to identify high risk pregnancies, it is also important for a midwife to
learn to prioritize care and take action in an emergency. The term “triage” is widely used to
describe prioritization in emergencies. In maternity care triage translates to: mother first,
baby second, i.e.: first, assess the mother’s condition: (A,B,C in English)

Airway

Breathing

Circulation

Second, the fetal condition: cardiac activity (fetal heart rate) gestational age

Triage is particularly relevant to some of the complications. The foundation of effective

actions is:

• plan first
• implement quickly
• communicate effectively
 • act correctly.

Midwives need to be familiar with the prioritizing framework, as part of their role is to take
appropriate emergency action when complications arise and to refer without delay to a
medical practitioner. “The midwives’ role is to monitor the high risk condition, implement
physician-prescribed care as well as midwife-prescribed interventions to minimize fetal and
maternal complications.”
 NINE: BREASTFEEDING

Breastfeeding

The World Health Organization (WHO) recommends breast milk as the only food or drink
offered to infants during the first 6 months of life. To promote breastfeeding, mothers should
be empowered to initiate skin-to-skin contact with their infant immediately after birth for at
least one hour. Exclusive breastfeeding is recommended for the first 6 months, with
continued breastfeeding for 2 years or more, with the appropriate introduction of solid foods.
Forty thousand children die each day (28 every minute) in developing countries, the victims
of malnutrition and frequent illnesses made worse by malnutrition. In many developing areas,
25% of all children die before reaching their fifth birthday. In the last few years, it has
become clear that seven simple techniques can be effective in saving millions of these
children’s lives:

These techniques, known by the acronym GOBI-FFF, form the core of the child
survival strategy.

Growth monitoring and promotion

Oral rehydration therapy

Family planning

Breastfeeding

Female education

Immunization

Food distribution

Why we need to promote breastfeeding

Beneficial to the infant’s health

Beneficial to the mother’s health

Beneficial to bonding of mother and baby

Economic advantages

Ecological advantages .
Breastfeeding has important psychological benefits for both mothers and babies.

Breastfeeding helps a mother and baby to form a close, loving relationship, which makes
mothers feel deeply satisfied emotionally. Close contact from immediately after delivery
helps this relationship to develop. This process is called bonding. Babies cry less and they
may develop faster, if they stay close to their mothers and breastfeed from immediately after
delivery. Mothers who breastfeed respond to their babies in a more affectionate way. They
complain less about the baby’s need for attention and feeding at night. They are less likely to
abandon or abuse their babies.

Psychological benefits of breastfeeding

Emotional bonding

• close, loving relationship between mother and baby

• mother more emotionally satisfied
• baby cries less
• mother behaves more affectionately
• less likely to abuse or abandon baby.
Benefits to society

• The cost of an adequate diet for the mother is less than the cost of feeding a baby
artificial formula.
• Mothers can use food money for other family members. There is no need to purchase
breast-milk substitutes or feeding equipment and no need for extra fuel or water.
• Family time is not needed for food preparation and extra health care visits.
• The costs of medical consultation, medicine, lab tests and hospitalization are reduced.
Mothers and babies are healthier.
• Mothers can space pregnancies with the Lactation Amenorrhea Method which
improves the health of mothers.

The economics of breastfeeding

If the mother is the only person who feeds the baby, then the time taken to breastfeed is
generally less than the time required to shop for the milk powder, sterilize the feeding bottle
and teat (and in rural areas of some countries go in search of firewood to boil the water),
prepare the feed and give it to the baby.

On the other hand, an “advantage” of bottle-feeding is that someone else could feed the baby
allowing the mother to earn income. The time required for breastfeeding each day is probably
no more than two hours, so in theory there is a loss of two hours worth of income.1 In
practice, given that maternity legislation does not always provide for breastfeeding breaks,
the decision to breastfeed may mean foregoing any work in a formal job, so the loss of
income may be higher. Nonetheless, in most developing countries, a large percentage of
income would have to be spent on the baby’s milk, so the advantage of working would
rapidly disappear.

Bottle-feeding: a waste of money, a waste of natural resources, a waste of time?

We “often forget or trivialize a key resource, breast-milk, which contributes to the

conservation of life on many different levels”. Breast-milk is not the only valuable natural
resources which is wasted by bottle-feeding. In many parts of the world water and firewood
are precious resources which are disappearing at an alarming rate.

To prepare 6 feeds correctly every day, bottles and teats must be boiled for 10 minutes and
the water for each separate feed must be boiled for at least 10 minutes. This brings the boiling
time up to 90 minutes per day. It takes 200 g of wood to boil one litre of water, so in one year
feeding a child artificially requires 73 kg of wood.

Breastfeeding, on the other, is the best way of using scarce resources. By eating a little extra
food, by drinking a little extra water, a woman produces the highest quality food for her baby:
“The lactating mother is an exceptional national resource, for not only does she process
coarse cheap foods to produce a unique and valuable infant food, but also the production
process of lactation provides measurable benefits to health and contributes to fertility
reduction.”
Benefits of breastfeeding to infant’s health

Breast-milk provides many health benefits for the baby. When babies are exclusively
breastfed, these benefits are highest. Overall, there is less illness requiring health care among
exclusively breastfed babies. Exclusive breastfeeding provides the best infant nutrition and
growth, with continued growth if other foods begin at around six months.

Protection against infection

• Breastfed babies have less diarrhoea, less gastrointestinal (GI) infection and less
respiratory infection than artificially-fed babies.
• A substance called the bifidus factor helps special bacteria to grow in the baby’s
intestine and prevents other harmful bacteria from growing.
• Dozens of anti-inflammatory agents reduce the harm caused by uncontrolled
inflammation.
• Lymphocytes and macrophages, which are living cells, fight disease.
• Each mother’s milk has antibodies to protect her baby against diseases to which she
has been exposed.
• Growth factors enhance the baby’s development and maturation of the immune
system, the central nervous system and organs such as skin.
Protection against infection

Breast-milk is not just a food for babies. It is a living fluid, which protects a baby against
infections. For the first year or so of life, a baby’s immune system is not fully developed and
cannot fight infections as well as an older child’s or adults. So a baby needs to be protected
by his mother. Breast-milk contains white blood cells and a number of anti-infective factors,
which help to protect a baby against infection. Breast-milk also contains antibodies against
infections which the mother has had in the past.

This picture shows the special way in which breast-milk is able to protect a baby against new
infections which his mother may have, or which are in the family’s environment now.
Colostrum, foremilk and hindmilk

The composition of breast-milk varies according to the age of the baby and from the
beginning to the end of a feed. It also varies between feeds and may be different at different
times of day. Colostrum is the thick, yellowish or clear milk that women produce in the first
few days after delivery.

Now we will speak about the special properties of colostrum and why it is important.

Property Importance

Antibody rich protects against infection and allergy

Many white cells protect against infection

Purgative clears meconium helps to prevent jaundice

Growth factors help intestine to mature, prevents allergy, intolerance

Vitamin A rich reduces severity of infection prevents eye disease

It contains more antibodies and other anti-infective proteins than mature milk. This is part of
the reason why colostrum contains more protein than mature milk.

It contains more white blood cells than mature milk.

These anti-infective proteins and white cells provide the first immunization against the
diseases that a baby meets after delivery. Colostrum helps to prevent the bacterial infections
that are a danger to newborn babies. The antibodies probably also help to prevent a baby
from developing allergies.

Colostrum has a mild purgative effect, which helps to clear the baby's gut of meconium (the
first rather dark stools). This clears bilirubin from the gut and helps to prevent jaundice.

Colostrum contains growth factors, which help a baby's immature intestine to develop after
birth. This helps to prevent the baby from developing allergies and intolerance to other foods.

Colostrum is richer than mature milk in some vitamins – especially vitamin A. Vitamin A
helps to reduce the severity of any infections the baby might have.

Mature milk is the milk that is produced after a few days. There is a larger amount of milk
and the breasts feel full, hard and heavy. Some people call this the milk “coming in”.

Foremilk is the bluish milk that is produced early in a feed.

Hindmilk is the whiter milk that is produced later in a feed.

What differences are there between these different kinds of breast-milk?

Colostrum contains more protein than later milk

Hindmilk contains more fat than foremilk.

The extra fat in hindmilk makes it look whiter. This fat provides much of the energy of a
breastfeed, which is an important reason not to take a baby off a breast before he has had all
he wants.

Foremilk is produced in larger amounts and it provides plenty of protein, lactose, water and
other nutrients. Because it looks watery, mothers sometimes worry that their milk is “too
thin”. Milk is never “too thin”. It is important for a baby to have both foremilk and hindmilk
to get a complete “meal”.

There is no sudden change from “fore” to “hind” milk. The fat content increases gradually
from the beginning to the end of a feed.
There are important differences in the quality of fat in different milks.

• Human milk contains essential fatty acids that are not present in cow’s milk or
formula. These essential fatty acids are needed for a baby’s growing brain and eyes,
and for healthy blood vessels.
• Human milk also contains an enzyme lipase which helps to digest fat. This enzyme is
not present in animal milks or formula.
• Digestive enzymes, lactase and lipase, and many other important enzymes, protect
babies born with immature or defective enzyme systems.
• So the fat in breast-milk is more completely digested and more efficiently used by a
baby’s body than the fat in cow’s milk or formula.

Protection from allergy

• The baby’s GI tract develops more quickly when fed breast-milk, preventing foreign
proteins from entering his system.
• A lower exposure to foreign proteins creates tolerance rather than allergic response.
• Nutrients such as zinc and the long-chain polyunsaturated fatty acids help the
development of the baby’s immune response.
• Giving babies even a single bottle of artificial formula in the first days of life can
increase the rates of allergic disease. All formulas, including soy formulas, carry a
risk of allergy.

Vitamins in different milks

Cow’s milk contains plenty of the B vitamins. But it does not contain as much vitamin A and
vitamin C as human milk.
Health workers often recommend giving babies fruit juice from a very early age, to provide
vitamin C. This may be necessary for artificially fed babies, but it is not necessary to apply
the rule to breastfed babies.

Breast-milk contains plenty of vitamin A, if the mother has enough in her diet. Breast-milk
can supply most of the vitamin A that a child needs even in the second year of life.

If you are worried about a woman’s diet and you think that there may not be enough vitamins
in her breast-milk, give extra vitamins to the mother.

Summary of differences between milks

• Breast-milk contains important anti-infective factors and growth factors which are not
present in animal milks or formula.
• Breast-milk contains the most suitable protein, in the right amount for a baby and it is
easily digestible.
• Animal milks contain too much indigestible casein. Neither cow’s milk nor formula
milks contain the ideal balance of amino acids.
 • Breast-milk contains the most suitable fat, with enough essential fatty acids for a
baby’s developing eyes and brain; and it contains lipase to help to digest the fat.
Animal milks and formula lack essential fatty acids and lipase.
• Breast-milk contains the correct amounts of minerals. Animal milks contain too much
of some minerals. In formula, the amounts are less than in cow’s milk and formula is
not well absorbed, though extra iron is added to formula.
• Breast-milk contains enough vitamins, provided the mother is not deficient. Animal
milks may not contain enough vitamins A and C. Vitamins are added to formula
milks.

So animal milks and formulas can never adequately replace breast-milk for babies.

Other benefits to the baby:

• A lower incidence of cot death (sudden infant death syndrome).

• A lower risk of childhood diabetes, cancer and ear infection.
• A better response to vaccinations and a faster ability to fight disease.
• Fewer orthodontic and dental problems (no bottle-associated tooth decay).
• Better psychomotor, emotional and social development.

Health benefits for mothers:

• Oxytocin that is released while breastfeeding contracts the uterus and helps to stop
bleeding after delivery. This makes it important that breastfeeding begin immediately
after birth and continue frequently.
• Breastfeeding women are energy efficient; they can produce milk even with limited
caloric intake.
• There is a lower risk of breast and ovarian cancer.
• Frequent breastfeeding delays the return of menses and helps to protect against
another pregnancy. This conserves iron stores and spaces children.

Breastfeeding to delay a new pregnancy

• Breastfeeding can delay the return of ovulation and menstruation, so it can be a useful
way to help space pregnancies.
• Breastfeeding can give effective protection against a new pregnancy if the mother
breastfeeds in the following way.
She should breastfeed exclusively and frequently, whenever the baby wants, both night and
day.

She should breastfeed at least 8–10 times or more in 24 hours with no interval longer than 6
hours between feeds.

When a baby is more than 6 months old, breastfeeding is less effective for family planning. A
baby of this age needs complementary foods, so breastfeeding can no longer be exclusive.
However, breastfeeding still provides partial protection against a new pregnancy if the
mother breastfeeds frequently. She should breastfeed the baby each time before she gives
complementary foods. This partial protection can be useful for a mother who cannot use any
other method of family planning.

After a child is a year old, protection is less. The child now needs to have food before
breastfeeding, to ensure that he eats enough. However, frequent breastfeeding may still give
some protection, if menstruation has not returned.

When menstruation returns, the woman is fertile again. Breastfeeding will not protect her,
even if her baby is still less than 6 months old. She needs another family planning method.

In most women, menstruation returns before conception. So menstruation is the main sign
that a woman is fertile again. However, a few women ovulate and can conceive BEFORE
they start to menstruate again. This is more likely to happen when the baby is more than 6
months old.

Physiology of Lactational Infertility

The effect of breastfeeding on fertility is mediated by a complex hypothalomic-pitutary-

ovarian feedback mechanism.

Breastfeeding regulation of both menstrual cycle and milk production begins with suckling
and its effect on the hypothalamus. The changes in the hypothalamic production of hormones
are caused by nipple stimulation. This in turn alters pituitary hormone production and as a
result, the ovary does not receive pulsatile stimulation for ovum development and release and
concurrently, milk production is stimulated.

Terms for Infant Feeding

Exclusive breastfeeding: means giving a baby no other food or drink, including no water, in
addition to breastfeeding (except medicines and vitamin or mineral drops; expressed breast-
milk is also permitted). Studies show that most babies who are exclusively breastfed for the
first 6 months grow well and are healthy. It is important for health workers to know how and
how often mothers are breastfeeding their babies. Health workers can help mothers to
understand the importance of breastfeeding their babies exclusively for the first 6 months.

Any of the following interferes with exclusive breastfeeding:

A baby is given any drinks or foods other than breast-milk.

A baby is given a pacifier or dummy.

Limits are placed on the number of breastfeeds.

Limits are placed on suckling time or the length of a breastfeed.

Predominant breastfeeding: means breastfeeding a baby, but also giving small amounts of
water or water-based drinks, such as tea.

Full breastfeeding: means breastfeeding either exclusively or predominantly.

Bottle-feeding: means feeding a baby from a bottle, whatever is in the bottle, including
expressed breast- milk.

Artificial feeding: means feeding a baby on artificial feeds and not breastfeeding at all.

Partial breastfeeding: means giving a baby some breastfeeds and some artificial feeds,
either milk or cereal, or other food.

Timely complementary feeding: means giving a baby other food in addition to

breastfeeding, when it is appropriate, around the age of 6 months.
Recommendations

Start breastfeeding within one-half to one hour after birth.

Breastfeed on demand day and night and no less than 8–12 times a day.

No time limits during one feeding.

Breastfeed exclusively from 0 up to around 6 months.

Complementary foods can begin around 6 months (exact age varies).

Give complementary foods to all children from 6 months of age.

Continue breastfeeding up to 2 years of age or beyond.

 TEN: CARE OF THE HEALTHY NEWBORN

Preparation for delivery in a maternity unit

Careful preparation of the delivery area and provision of suitable equipment are important for
the health of the newborn at birth.

In a maternity unit there should always be the provision of the following:

• a resuscitation table with an overhead heater manually controlled;

• resuscitation equipment (infant face mask, ventilating bag);
• cord-cutting/cord-clamping kit;
• suction apparatus;
• suction catheters;
• low-reading infant thermometers (down to 25°C/77°F) – an ordinary thermometer
only reads down to 35°C (95°F) and will not detect significant hypothermia;
• baby weighing scale;
• heat source to warm the delivery room;
• blanket (to wrap the infant);
• air-heated incubators or water filled mattresses to warm the infant (for internal or
external transport).

The following principles of cleanliness should be carefully observed:

• clean hands (in health facilities, sterile gloves)

• clean perineum
• clean delivery surface
• nothing unclean to be introduced into the vagina
• cleanliness in dividing the umbilical cord and taking care of the newborn baby
• instruments, gauze and ties used for delivery and cord care should be sterile
• nothing should be applied either to the cutting surface or to the stump
• the stump should be left uncovered to dry and mummify.

Drying the infant

The evaporative heat loss from the skin results in a lowering of skin temperature within
seconds after birth. This is the most intense of the sensory stimuli provoking spontaneous
breathing at birth. This heat loss is both physiologic and impossible to avoid. But if cooling
continues in the minutes that follow, the body temperature will drop below 36°C and
hypothermia will occur. Thus immediate drying of the baby is necessary; it is also important
to change the first wet towel to a dry one.

Assessment of the infant

As soon as the infant is born, while drying him/her, the health professional should
immediately assess the wellbeing of the child in order to identify an infant that requires
special care and a healthy infant that can be given immediately to the mother.

The assessment of the infant is made by looking for:

• Spontaneous breathing and heart rate in order to identify babies who need immediate
resuscitation. This is the most important thing and must be done within 30 seconds
from delivery.
• Birth weight/gestational age in order to identify a LBW/preterm infant who needs
special care.
• Birth defects/birth trauma in order to ensure appropriate and adequate treatment as
soon as possible.

Definitions

Breathing: normal breathing of an infant means initiation of spontaneous breathing within 30

seconds after delivery.

Heart rate: a heart rate (HR) >100/min is considered acceptable at birth and should be well
over 120/min after the first few minutes.

Birth weight: the first weight of the newborn obtained after birth. This weight should be
measured preferably within the first hours of life.

Gestational age: the duration of gestation is measured from the first day of the last normal
menstrual period. Gestational age is expressed in completed days or weeks. An at-term
delivery occurs after 37 to less than 42 completed weeks of gestation (259–293 days). This
information should be available before birth.

Give the baby to the mother

Every birth attendant should be aware of the fact that a newborn baby is a person with neuro-
sensory behaviour; the capability to see, feel (pain, warmth, cold), smell, taste and cry out
(happily or unhappily). Bearing this in mind we should treat every newborn baby as a human
being. Several studies have shown that for the mother the first few hours after birth are a
special and sensitive period, and that this period is important for the promotion of maternal
bonding. Separation of the child from the mother even for a day or two disturbs this sensitive
period and may have a detrimental effect on the mother’s care of the baby and on
breastfeeding.

When the baby has been dried, he/she should be wrapped in a cloth to avoid heat loss and
given to the mother. She may put him/her to the breast, which will give her the opportunity to
watch the baby and to touch him/her. Within 15–30 minutes most babies will start to try to
find the nipple of the mother’s breast.

The baby should stay with her/his mother as long as desired (night and day), without any
schedule for feeding and the mother should be able to participate actively to the care of the
infant (rooming-in). Sadly, separation is the routine in many hospitals and much effort should
be made to promote a different plan of organization of the nursery to facilitate early
breastfeeding and maternal-infant bonding.

In some instances either the mother, who might have to recover from an operative delivery or
suffer from complications or the baby who might be in need of special care, may not be
available for early contact. In these cases the separation between mother and infant should be
restricted to a period as brief as possible. As soon as the mother is feeling better or the child
is recovering, frequent visits to the neonatal unit should be permitted in order to enable the
mother to take care of her child as soon as possible.

When transporting the baby from the delivery room to the nursery, always bear in mind the
need of preventing hypothermia. The baby should therefore be wrapped in a soft blanket
either with his/her mother or within the arms of another person (father, nurse, relative) if the
mother is not ready for transport. A heated cradle or incubator can also be used for transport.

The principles of the “warm chain”should be always kept in mind.

Preventing heat loss at birth: drying, wrapping, weighing, breastfeeding

The “warm chain” is a concept introduced to describe a set of interlinked procedures which
will minimize the likelihood of hypothermia and will assure the wellbeing of the baby.
Failure to implement anyone of them will break the chain and increase the possibility of
undesirable cooling of the infant. The links in the “warm chain” include:
 • training all persons involved in the birth and subsequent care of the baby; preparation
of the place of delivery, by ensuring a clean, warm, draught-free room;
• provision of a clean and warm surface, drying and wrapping warm materials;
• immediate drying of the newborn baby;
• wrapping the baby and giving it to the mother quickly after birth;
• putting the baby to the mother’s breast;
• putting a warm cap on the baby’s head;
• covering the baby and mother together;
• ensuring warm, safe transport, if necessary.

If this cannot be done, a satisfactory arrangement is to dry and wrap babies and keep them as
close as possible to the mother. Ensure that the room is warm. It is difficult to warm infants
who become hypothermic, wrapping a baby who is already cold may simply keep him/her
cold. It is much easier to keep the infant warm in the first place.

Cleaning the airways

Aggressive prolonged suction can delay the onset of spontaneous breathing in the healthy
newborn and cause prolonged spasm and is not indicated unless the amniotic fluid is severely
stained with thick meconium or blood. If suction is required, a 10 FG (or if preterm an 8 FG)
soft suction catheter should be connected to a suction source not exceeding 100mmhg. This
should not continue for longer than 5 seconds in the absence of meconium. The catheter
should normally not be inserted further than 3cm from the baby’s lips at term.
The conditions mentioned above (healthy infant, asphyctic and low-birth-weight infant or
with a birth defect or trauma) can be variably associated and therefore need integrated
procedures for care. This session deals with the healthy infant.

The following with other conditions requiring special care.

Cord care

There is no need to rush to clamp and divide the cord except in an emergency situation. The
baby could be dried and given to the mother first and the cord cut when the pulsation stops.
The cutting of the cord and handling the placenta may be bound by tradition in different
cultures. It is important that health personnel is aware of these traditions and of the mother’s
own requests and that they try to fulfil these as far as possible if they are safe for the mother
and baby.

When to clamp the cord

In vaginal delivery the expulsion of the placenta results in an increase in pressure that could
cause a passage of blood from the placenta to the baby.

Early clamping of the cord (i.e. immediately after birth) results in low haemoglobin values
and may result in anaemia after 1–2 months. On the other hand, too late clamping of the cord
results in hypervolaemia and possibly hyperviscosity of the blood (packed red cell volume >
70 per cent in central venous blood), which may lead to respiratory difficulties and volume
overload of the heart.

If the newborn baby is placed on the mother’s breast, the cord could be left unclamped until
the pulsations have disappeared, without an increase of the haemoglobin value of the infant.
Thus, clamping of the cord at approximately 1 minute after birth seems to be most
advantageous.

How to clamp and cut the cord Inelastic tying material such as strings or bands are commonly
used. However, this old, widely used procedure results in a very temporary closing of the
vessels. As early as 1/2 to 1 hour after birth the shrinkage of the cord loosens the band and
reopens the vessels, increasing the risk of both bleeding and infection.

The most accurate method of clamping the cord is to use a rubber band. After clamping the
cord with a forceps and cutting it, the rubber band is applied around the cord with the help of
a forceps. In many developed countries a plastic cord clamp is used. This is expensive, is not
reusable and thus inappropriate for use in countries with limited resources.

How to clean the cord

The cord stump remains the major means of entry for infections after birth. Principles of
clean cord stump care (keep it dry, clean and do not apply anything) apply at home as well as
in the health facility. The stump will dry and mummify if exposed to the air without any
dressing, binding or bandages. It will remain clean if it is protected with clean clothes and is
kept from urine and soiling. No antiseptics are needed for cleaning. If soiled, the cord can be
washed with clean water and dried with clean cotton or gauze.

Local practices of putting various substances on the cord stump, whether in health facilities
or homes should be carefully examined, discouraged if found harmful and substituted with
acceptable ones if necessary. If the umbilical stump is draining pus, the skin around it is
becoming red and it has a foul smell, these may be signs of umbilical infection that requires
treatment with antibiotics.

The First Feed

Immediately after delivery the healthy baby instinctively searches for food. In the first couple
of hours of life, the baby is alert, active and ready to feed. If the mother has been given
certain drugs during labour then the baby may not be so alert.

Placed on the stomach of the mother, a healthy, term baby is able to crawl towards the breast.
If it has not been disturbed or sedated, the baby can find the breast without any help, usually
within the first hour. The birth of the placenta is facilitated by increased maternal oxytocin
production, stimulated by the baby’s contact with the nipple. Some babies need a couple of
hours or more and some may not be ready to feed until they wake up after their first sleep.
The process of childbirth is not finished until the baby has safely transferred from placental to
mammary nutrition.

What the health professional can do

• Support the woman during labour and delivery in a way that minimizes the need for
interventions.
 • Encourage the woman to try measures of pain relief which will not interfere with
breastfeeding. Avoid, if possible, medication which will eventually have a sedative
effect when passed on to the baby transplacentally.
• Allow the baby to remain with the mother, skin-to-skin, from immediately after birth
until the baby has finished the first feed.
• Let mother and baby interact at their own pace. Assist only when you believe it to be
absolutely necessary or when the mother asks for assistance.
• Postpone any routine procedures following birth that can safely wait until mother and
baby are ready, i.e. for at least one to two hours. Examples are the measuring and
dressing of the baby.
• Separate mother and baby only if absolutely necessary. The preliminary observation
of the baby can usually be done while it stays close to its mother. Even a brief
separation before the first feed can disturb the process.
• If the mother is sedated or feels too tired, help the searching baby to have the first
feed, at the breast, without any effort from the mother.
• Encourage and help the mother to have skin-to-skin contact with her baby as much as
possible during the first days after delivery. If their interaction in the first hours was
disturbed for some reason, it can be “re-enacted” at any time during the first days and
even weeks after the birth.
• Discourage the use of pacifiers and bottles during the establishment of lactation when
the baby is learning to breastfeed. When some babies are fed with an artificial teat
they develop a preference for it and this can reduce their enthusiasm for the breast.
• Let the baby start to feed when it shows that it is ready.

Prophylactic procedures

a) Vitamin K

A neonatal deficiency of vitamin K exists in at least 0.5% of all newborn babies. The risk of
gastrointestinal or other types of neonatal bleeding is especially high in preterm babies and
small for gestational age babies. To prevent early bleeding and the later haemorrhaegic
disease of the newborn, vitamin K prophylaxis is suggested.

The oral administration of two doses of 2 mg, one on the first day and one on the 7th day of
life has been shown to be almost as effective as one single dose of 1 mg intramuscular
injection. Although the oral administration is easier and cheaper, it presents the disadvantage
of a more complicated schedule of administration.

b) Ocular prophylaxis

In regions with a high frequency of gonorrhoea the prophylactic treatments with 1% silver
nitrate, 1% tetracycline and 0.5% erythromycin ointment have a similar efficacy. We
recommend the use of 1% tetracycline ointment which is harmless, affordable and effective.
The main disadvantage of silver nitrate is that it frequently causes chemical conjunctivitis.

c) BCG vaccination

In every country where there is a significant risk of acquiring tuberculosis and therefore
national policy for immunizations include BCG. Since the only contraindication is the
symptomatic HIV infection, a situation which never occurs in the neonatal period, BCG
vaccination should be given intra-dermally to all babies before discharge from the hospital.

Bathing the infant

It is best to postpone bathing of the infant or cleaning the vernix with oil. If cultural practices
in some areas demand bathing, or if the baby is particularly soiled with blood or meconium,
washing 2–6 hours after birth is permissible as long as the baby’s temperature is normal.
When the bath is given the midwife or nurse should:

• warm a small area or corner of the room;

• use warm water tested with the elbow, sit close to the heat source and undress the
infant on her lap;
• bath the infant quickly and gently;
• immediately wrap the infant in a dry warm towel and dry thoroughly from head to
toe;
• quickly dress and wrap the infant, remembering to place a cap on the baby’s head;
• place the infant close to the mother and allow breastfeeding.

When nursing care is given, such as changing the nappy (diaper), care should be taken not to
unduly expose infants to a cold environment but to do all procedures rapidly and keep the
baby covered as much as possible.
Swaddling

Sometimes after bathing, the procedure of swaddling the baby tightly is practised. It used to
be thought that swaddled babies were protected from external infections. There is no
scientific evidence that this is the case. It is preferable to wrap the baby loosely in a cotton
cloth or a warm shawl, or, as a compromise, to swaddle only the lower part of the body,
leaving the arms and head free to move.

The mother should not hesitate to keep the baby with her in bed, if she thinks this is more
comfortable. There is no risk of “smothering” or “infecting” the baby.

• Tight swaddling should be discouraged for several reasons:

• blockage of diaphragm’s movement reduces the lungs’ ventilation;
• blood circulation is decreased in different parts of the body;
• lack of air space between body and swaddling sheets prevents baby from keeping
warm;
• restriction to free movement of limbs prevents the development of neuro-muscular
coordination;
• tight swaddling with head swaddling can discourage breastfeeding as baby cannot
move its head and open mouth properly for correct breast-attachment;
• swaddled baby is more sleepy and less responsive to frequent breastfeeding, which
interferes in the stage of breastfeeding and lactation-establishment.
 ELEVEN: DISEASES PREVENTION AND CONTROL

Tuberculosis

Tuberculosis (TB) is a chronic infectious disease caused in most cases by mycobacterium

tuberculosis, but rarely by mycobacterium bovis and avium.

TB affects:

- The lungs (called pulmonary TB) which account for 80% of all TB cases.

- Other organs (called extra pulmonary TB) account for 20 % all TB cases.

Sources of TB:

- Untreated pulmonary TB patients

- Milk from infected cows (source of M. bovis)

Mechanism of Transmission

- Inhalation of droplets containing bacilli expelled from pulmonary TB patients by coughing

and sneezing. Person living in the same house or frequent contacts are at risk of Pulmonary
TB.

- Consumption of raw milk containing M. Bovis

Risk groups:

TB affects people of all ages and sexes. However, it is commonly found in people with:

Poverty and Crowded living conditions

- Poverty is the root cause of malnutrition and crowded living condition, both of which are
risk factors to TB infection. Moreover, poverty enhances the spread of HIV infection which
decreases the immunity of the body and increases the chance of TB infection.

Malnutrition- malnutrition decreases the defense of the body and predisposes the person to
TB infection.

HIV/AIDS- Infection with HIV destroys the immune mechanisms of the body and makes the
individual susceptible to the development of TB. HIV infected people have about 10 times
higher risk of infection by TB.
Signs and symptoms

Pulmonary TB can be suspected in people presenting with:

- Persistent cough for 3 weeks or more

–Cough with productive of sputum, with or without blood, shortness of breath and chest pain
- Loss of weight, intermittent fever, night sweats, loss of appetite and fatigue.

Diagnosis

- signs and symptoms suggestive of TB

- Examination of sputum by direct microscopy out of 3 sputum examined if two are positive
for Acid Fast Bacilli (AFB) or one positive sputum plus x-ray finding suggestive of
Pulmonary TB is defined as smear positive TB.

- Sampling and microscopic examination of tissues in Extra- Pulmonary TB., etc. - Chest x-
ray

- Culture of sputum

Management and Treatment

DOTS ( Directly Observed Therapy Strategy) is an effective & safe treatment of TB. It has
two phases. - Intensive phase (the 1st 8 weeks)

- Drugs are collected and swallowed daily under the supervision of health workers.

- Continuation phase (the next 6 months)

–Drugs are collected monthly and swallowed daily at home.

TB treatment Categories

The number of drug combinations given to a patient differs depending on treatment

categories. There are 4 treatment categories of TB grouped based on: .

Sputum smear positivity

.Seriousness of the disease .

Previous treatment history & types of drug combination given

Default from DOTS

. Children

. Pregnant women

Prevention

- Prophylaxis:

Isoniazid is given for children below the age of 6 years having a family member with smear
positive PTB.

- Vaccination: BCG (Bacillus calmette Gurrein) is a vaccine made from live attenuated strain
of bovine tubercle bacilli and mostly given at birth and for children with tuberclin test
induration less than 6mm diameter if BCG is not given previously.

It protects children from severe forms of TB and leprosy. It is not given for children with
AIDS.

Health Education

- Cover mouth with handkerchief or a piece of clean cloth during coughing & sneezing

- Collect sputum in a cupped container & bury the sputum, and advice not to spit
everywhere.

- Allow adequate ventilation of living rooms

- Drink boiled milk

Practical approach

- Counseling of TB patients & their households

- Counsel TB patients & their family

- discuss the main points for counseling

- Steps of counseling & frequency of counseling

Training & counseling of defaulters:

- Practice how to trace defaulters and advice them to continue treatment. The patient should
be asked why treatment was discontinued, and clearly counseled about the necessity of
regular treatment, & dangers of discontinuation. During counseling the family members
should be involved.
Organizing awareness session in the community:

Active community participation is essential for TB prevention and control to do this the
community should receive the appropriate information. The health education should include
the following points:-

- TB is an infectious disease caused by bacilli, not by a curse or witch craft

- Close contacts can be infected by TB, and they should be checked for symptoms & signs of
TB

- The bacilli are killed by DOTS if taken regularly with the recommended doses, and cures
the disease

- During DOTS, patients are no longer infectious & therefore not a danger to the family or
community

- Tablets are taken once a day

- Keep drugs out of the reach of children

- Never give your drugs to anyone else

- Methods of prevention

- The dangers of untreated or partially treated TB

Malaria

Introduction

Malaria is one of the leading causes of morbidity and mortality in Nigeria. About 75% of the
areas in Nigeria are malarious and 67% of the population is at risk of getting malaria
infection. It has been reported that cyclic, large scale and devastating epidemics of malaria
have occurred in Nigeria. Natural and human made disasters, and developmental activities
such as irrigation have also contributed to this situation. Effective preventive and control
measures with early diagnosis and treatment of cases can significantly reduce the morbidity
and mortality from malaria.

Definition

Malaria is an acute infection of blood caused by protozoa of the genus plasmodium through
the bite of an infected female anopheles mosquito. The mosquito breeds in sunlight with
small clean water collection. Plasmodium Falciparum, Vivax, Ovale and Malariea are the
main species of genus plasmodium that causes malaria. Among these Plasmodium
Falciparum and Vivax are the most common in Ethiopia.

Methods of Transmission

Malaria is a vector borne disease. It is mainly transmitted from infected person to the healthy
person by the bite of female anopheles mosquito. The bite takes place during the dark and
cool hours of the day. Although rare, malaria can be transmitted through blood transfusion,
placenta and inoculation accidents. Mosquitoes breed in sunlight, small stagnant water
collections in the residential areas e.g. Plastic materials, broken glasses and clay posts).

Signs and Symptoms

- high grade fever

- Malaise, headache

- Sweating and shivering

- Muscle ache, joint pain

- Nausea, vomiting, loss of appetite, abdominal pain, diarrhea and thirst.

The symptoms and signs of malaria may be confused with other diseases that cause fever
such as measles, pneumonia, tonsillitis, otitis media (middle ear infections) and upper
respiratory tract infections. In children failure to feed and fever should be considered
seriously

Danger signs of Malaria

- altered consciousness

- Not able to drink or feed

- Frequent vomiting

- Convulsion

- No urine output in the last 24 hrs.

- Bleeding

- Jaundice (yellowish discoloration of sclera)

- Difficulty in breathing

Risk Factors

Young children, travellers who are non-immune, refugees, displaced people, pregnant women
(malaria causes Abortion, Maternal and fetal death, Premature labour and anemia during
pregnancy) and labourers entering malarious areas are groups which are at risk of getting
malaria. People in rural areas with limited access of health services are the most affected.

Malaria Diagnosis and Treatment:-

Diagnosis Malaria diagnosis should be based on the patient's symptoms, signs and history;
and/or result or Rapid Diagnostic Test (RDT). For suspected clinical malaria with negative
RDT results, other cause of fever should be suspected.

In malarious area, a patient with fever or a history of fever at least within the past two days is
assumed to have clinical malaria.

In a non-malarious area, a patient with fever or history of fever at least within the past two
days and with a history of travel to malarious area within the last two weeks is assumed to
have clinical malaria. However other common causes of fever such as measles, pneumonia,
meningitis, upper respiratory tract infections should also looked for.

Treatment:

Drug therapy: Artemether-lumefantrine (administered orally 2 times a day for 3 days) is the
first-line drug for the treatment of all uncomplicated clinical malaria cases and for RDT
confirmed falciparum malaria cases (except pregnant women and infants under 5 kg body
weight).

Malaria Epidemic Precipitating Factors;

1. Climatic change:- Rain fall: When there is abnormal rain fall in the form of excess or
deficit, mosquito breeding sites are created in abundance. Similarly, when the numbers of
rainy days in a specified period becomes few and also in dry seasons water on rivers and
streams decrease and creates small intermittent pools of stagnant water ideal for mosquito
breeding sites.

Temperature: When there is increase of air temperature in high and temperate areas the life
cycle of mosquitoes and malaria parasites within the mosquito host is shortened. These
phenomena will lead to high mosquito density within short periods of time and leading, of
course, to high malaria transmission.

Humidity:

1. Humidity affects transmission by increasing the longevity of adult vectors:

2. Water resource development: the development of dams, and irrigation; programmes create
conducive situations for malaria epidemic;

3. Reduced or weakened vector control activities;

4. Development of insecticide resistance;

5. Death of cattle due to disease and drought makes mosquitos exclusively feed on humans.

6. Migration of non-immune people from high to low land and vice versa; and

7. Resistance to anti malaria drugs.

Contribution by individuals and groups in Malaria Prevention and Control

Programme:

Individual and household:

It is possible to protect oneself and family from the bites of mosquitoes. The protective
measures are:

• Carefully cover your body to reduce areas exposed to mosquito bites in the night; • Apply
to your skin repellent creams:

• Use insecticide treated mosquito nets;

• Protect windows and doors with wire mesh or made of local material; (e.g. sisal; grass etc);
• Spray in the night mosquito killer insecticide (Aerosol).

• Mosquitos more in the night, hence don't often open doors; and

• Keep domestic animals in stable outside the house to reduce mosquito movement into the
house.

Community, government organizations and NGOs:

Community:-

• It is possible to control malaria by carefully identifying places for human dwelling. As the
flight range of mosquito is limited to 2 km., it is advisable to locate human dwellings at least
2 km. away from the breeding location. In addition, houses must be built against the wind
direction so that mosquito will not reach the houses with the push of the wind;

• Participate and demonstrate in action, education provided on malaria prevention and

control measures; and

• Communities should participate in vector control activities in terms of labor and materials;
and

• Communities should participate in residual house spraying by selecting spray men and
providing them the necessary support.

Government Organization:

• When water collections in ponds and other structures are under way, it is essential to see
that no mosquito breeding sites are created in the surrounding;

• Organizations engaged in road construction should see that ditches areas are filled and
levelled to eliminate water collections;

• Development organizations employ a large number of daily labourers during harvest

seasons, but the organizations should select places that are not highly exposed to malaria
risks and should always apply control measures in collaboration with the health extension
worker.

Non Governmental Organizations:-

• NGOs and other international organizations are expected to participate and collaborate in
the national and local malaria prevention and control efforts in terms of training, materials
and finance.

Prevention And Control Of HIV/AIDS And Other Sexually Transmitted Infections

HIV/AIDS

HIV is the virus that causes AIDS. HIV destroys a certain type of blood cells known as T-
cells or CD4 cells that help the body fight off infection, and gradually weakens the immune
system and exposes to other communicable diseases or cancer. It is a virus that attacks only
human beings. HIV has two main species. They are known as HIV-1 and HIV-2. HIV has
many sub-species. The virus that is wide spread in Nigeria is the HIV-1C sub-species.

AIDS is an advanced stage of HIV infection that occurs when the immune system cannot
fight off infections that the body is normally able to withstand. At this stage, the infected
person becomes more susceptible to a variety of infections, known as opportunistic infections
and other conditions (e.g. chronic diarrhea, toxoplasmosis, TB, pneunocystis pneumonia,
etc). A person can be infected with HIV for many years before any symptoms occur, and
during this time, an infected person can unknowingly pass the infection to others. HIV/AIDS
is a fast spreading disease that does not have any cure. It does not discriminate in terms of
age, sex, colour, level of social status, etc. It is a disease which can stay in the body a long
time(3-20 years) without any symptom.

Transmission

Sexual contact:

- Heterosexual

- Anal sex

- Oral sex

Blood contact:

- Injections/needles (sharing needles, IV drugs, or injury from contaminated needles or other

sharp objects)

- Cutting tools (using contaminated skin-piercing instruments, such as scalpels, needles, razor
blades, circumcision instruments)

- Transfusions (receiving infected blood or blood products) or transplantation of an infected

organ.

- Contact with broken skin (exposure to blood through cuts or lesions).

Mother to child transmission (MTCT):

- During pregnancy

- During delivery

- During breast feeding

HIV is not transmitted through:-

- Ordinary social or casual contact

- Shared clothing

- Touching

- Shared food or dishes

- Dry kissing

- Shaking hands

- Toilet seats

- Insect bites

- Massaging another person

- Living with a person with HIV

Risk behaviours related to HIV/AIDS:

- Promiscuity

- Extra marital sexual practices

- Harmful traditional practices

- Alcoholism and drug use (e.g. chat chewing, hashish)

Signs and Symptoms

Major Signs and symptoms:

- Weight loss (>10% of body weight)

- Prolonged fever (>one month)

- Chronic diarrhea for one month

Minor signs and Symptoms:

- Swelling of the lymph nodes

- Persistent cough greater than one month

- Skin diseases (rashes, generalized pruritic dermatitis)

- Pulmonary and/or disseminated TB.

- Recurrent Hepes zoster

- Pneumonia

- Chronic herpes simplex

- CNS derangement

- Night sweats and general body weakness

- Kaposis sarcoma

- Silky hair

Management and Treatment.

Early identification and management of signs and symptoms of HIV/AIDS is very important
in the prevention and control of HIV/AIDS in the community. Actions taken at home during
opportunistic infections

Skin problems (open sores)

- Wash with soap and water

- Keep the area dry and apply 1% gentian violet solution

- Dressing can be made of cloth strips that have been washed and dried in the sun

- Dressings with pus or blood should be handled the way body fluids are handled

Sore mouth and throat :

- Rinse the mouth with warm water mixed with a pinch of salt

Care and Support of people living with HIV/AIDS (PLWHA) at home

PLWHA need special attention from their family and should not be isolated within the home
since isolation aggravates the problems, lower their self esteem and initiate them to revenge
others.
The advantage of HBC services are:

- To help prevent contamination and cross infection

- To refresh PLWHA

- To establish state of cleanliness

Components of home based care HBC are:

General hygienic measures:

- Bed bath should be given regularly by using mild soap and rinse well. The patient can use
body lotions or creams to restore moisture to dry skin. While giving bed bath the care giver
should always be gloved.

- Mouth care- maintain good dental hygiene by brushing teeth with a soft tooth brush after
meals

- Turning patient in bed- encourage change of position to bed ridden PLWHA to prevent
pressure sores caused by lying on one side of the patient for long periods. Turning should be
done at least every four hours.

- Maintain food safety

- Cook food thoroughly

- Eat cooked foods immediately

- Store cooked foods carefully

- Wash hands repeatedly

- Keep all kitchen surfaces clean

- Reheat cooked foods thoroughly

- Use pure water

- Avoid contamination of foods with insects, rodents, etc

Careful handling of body fluids-

PLWHA are at a greater risk of contracting various infections. Body fluids are often a source
of infection to both PLWHA and their families. Therefore, wash hands with soap and water
before and after contact with contaminated materials, contact with own body fluids (semen,
mucus, blood, pus, vomitus ).

- Do not share razors.

- Keep finger nails and toe nails clean, keep nails short.

- Unwashed hands should be kept away from eyes, nose and mouth.

Nutrition (serving food): The purpose of nutrition services to PLWHA is to provide a diet
that can compensate the catabolic losses due to the illness as well as for the patient to live a
relatively comfortable life. Food preparation and serving should stimulate the patients
appetite, encourage ingestion and usually provide small, frequent meals of favourite foods.
Symptomatic care of opportunistic infections:

The main objectives of home based care (HBC) of opportunistic infections are to reduce
suffering and to promote recovery of those infections.

Home Based Care

- Identify PLWHA that need home treatment

- Identify the conditions for which PLWHA require home treatment

- If drug is prescribed make, sure that it is taken according to prescription.

- Refer PLWHA who need medical treatment

- PLWHA often have health problems that cannot be managed at home .Therefore, the home
based caregiver is to be able to recognize such conditions and provide referrals for medical
treatment.

Other Sexually Transmitted Infections (STIs)

The traditional method of diagnosing STIs is by laboratory tests. However, these tests are
unavailable or too expensive in the community. For this reason, syndromic approach has been
suggested by the WHO for use in low resource countries like Nigeria. Syndromic approach
relies on signs and symptoms of STIs and risk assessment but not laboratory tests. The health
extension worker should take proper history regarding STIs and refer suspected cases to the
health institutions. HIV/AIDS and other STIs management should involve partner
notification and individuals should be encouraged to refer their partners. Free discussion and
cooperation between partners is essential to prevent the spread of STIs including HIV/AIDS.
Syphilis (Hard Chancre)

A sexually transmitted disease characterized by a primary lesion, a later secondary eruption

on the skin and mucous membranes, then a long period of latency, and finally late lesion of
the skin, bones, viscera, CNS and cardiovascular systems. Treponema pallidum, a spirochete
is the infectious agent.

Clinical manifestations

The clinical presentation is divided in to three groups:

- Primary syphilis – Consists of hard chancre, the primary lesion of syphilis, together with
regional lymphadenitis. The hard chancre is a single, painless ulcer on the genitalia or
elsewhere (lips, tongue, breasts, anus) and heals spontaneously in a few weeks without
treatment. The lymph glands are bilaterally enlarged and not painful. There will not be
suppuration (pus formation).

- Secondary syphilis: After 4-6 weeks of the primary infection, a generalized secondary skin
eruption (including palms and soles) appears often accompanied by mild fever and sore
throat. These early skin lesions are not itchy but they are highly infective.

- Tertiary syphilis- This stage is characterized by destructive, non- infectious lesions of the
skin, bones, viscera and mucosal surfaces. Other disabling manifestations occur in the
cardiovascular and central nervous systems.

Chancroid (soft chancre)

An acute bacterial infection localized in the genital area and characterized by single or
multiple painful necrotizing ulcers at the site of infection. Haemophilus ducrey bacillus is the
infectious agent.

Signs and Symptoms

- Soft painful sore on penis, vagina or anus

- Swollen lymph nodes in the groin that contain pus, may open and drain pus and scar up.

Lymphogranuloma venereum

A veneral disease caused by chlamydia trachomatis, most commonly manifested by acute

inquinal lymph adenitis
Signs and symptoms

- Swollen lymph nodes in the groin that may open and drain pus

- Painful oozing sores around the anus

- Enlarge genitals, abscesses around the anus, narrowed rectum , anal fistula.

Candidiasis

A fungal infection usually confined to superficial layers of skin or mucous membranes,

presenting clinically as oral thrush or vuluovaginitis.

Signs and symptoms

- intense vaginal burning and itching

- clumpy white fluid in and around the vagina

- itchiness of the genitals in men

Gonorrhea

An acute or chronic purulent infection of the urogenital tract.

Sign and symptoms

In woman

- unusual vaginal discharge

- unusual vaginal bleeding

- lower abdominal pain

In man

- painful urination

- drops of pus from the penis

Trichomoniasis

A common and persistent protozoal disease of the genito- urinary tract caused by
Trichomonas virginals

Signs & symptoms

Woman

- Vaginal burning and itching, Foamy, green- yellow fluid with a bad smell from the vagina,
Pain or burning when urinating

Man

- Watery white fluid from the penis and pain or burning when urinating

Prevention

Household members and other close contacts with AIDS patients should be the main focus of
the prevention and control program. Besides they are part and parcel of the HIV/AIDS
treatment because, for the time being, health sector resources that can provide services for
this situation are so minimal that home care of patients will continue to be the mainstay of
treatment.

The following are the main methods for the prevention of HIV/AIDS and other STIs:-

-Abstain from sexual intercourse before marriage

- Remain faithful to partner after marriage

- Use condoms in cases of extra marital sexual inter course

- Avoid sharing piercing objects (blades, needles etc)

-Avoid harmful traditional practices such as uvula cutting, circumcision, tooth extraction,
tattooing, skin incision, etc

- Prevent mother to child transmission of HIV.

Mother to child transmission can be prevented by advising:

• women to do HIV testing before marriage and during pregnancy

• Women with HIV to use contraceptive condoms

• Pregnant women to take the drug that prevent mother to child transmission. They should be
referred to health facility where the necessary drugs are available.

• Advising and encouraging women to deliver to a nearby health facility.

• After the child is born, if possible try to give cow’s or artificial (formula) milk, if not
possible give breast milk for not more than four months and advice to completely stop breast
feeding after four months.