Counselling + Procedure for OBS and Gynaecology

Counselling Stations ............................................................................................................... 2

Gynecology ........................................................................................................................... 2
Myomectomy in a fibroid patient ..................................................................................... 2
Molar pregnancy ............................................................................................................... 3
OCP .................................................................................................................................... 4
IUCD and CU-T .................................................................................................................. 5
Norplant/Implanon ............................................................................................................ 6
Contraceptive for newly married couple ......................................................................... 7
Hysterectomy .................................................................................................................... 7
Obstetrics............................................................................................................................... 8
ANC .................................................................................................................................... 8
Placenta Previa ................................................................................................................10
IUD ....................................................................................................................................11
PNC ...................................................................................................................................12
Breast feeding and EBF ...................................................................................................13
Breaking bad news ..............................................................................................................15
CA Cervix..........................................................................................................................15
Procedure stations..................................................................................................................17
MVA ......................................................................................................................................17
Dilatation and curettage ......................................................................................................18
Mechanism of normal labor ................................................................................................19
2nd stage of labor management ..........................................................................................20
Immediate/Routine care of newborn ..................................................................................22
Active management of 3rd stage of labor ...........................................................................23
NVD ......................................................................................................................................23
Examination of newborn .....................................................................................................24
Resuscitation of a baby with perinatal asphyxia...............................................................25
Breast feeding .....................................................................................................................25
Counselling Stations
Gynecology
Myomectomy in a fibroid patient

1. Greetings + self-introduction
2. Inform about diagnosis
i. you have a benign tumor/fibroid in uterus
ii. this is causing heavy bleeding
iii. this may the cause of your infertility
3. inform about treatment options
i. medical management (only medicine)
ii. myomectomy (resection of only the tumor)
iii. hysterectomy
4. best option for her

we have determined that myomectomy is the perfect option for you

5. Inform about operation (myomectomy)
(only the tumor will be removed ➔ rest of the uterus will remain)
6. Advantage of procedure
(reproductive function + menstrual function will remain preserved/intact)
7. Disadvantage of the procedure
i. Myomectomy can convert into hysterectomy
ii. Fibroid may recur
iii. Infertility may persist
8. Exclude other factor of infertility
i. AUB
ii. PID (lower abd pain + purulent vaginal discharge)
iii. TB history
iv. Previous hx of DnC
9. Pre-requisite before procedure
i. Semen analysis of husband
ii. Keep blood ready
iii. Some other investigation needed for G/A fitness
10. Warning and consent
i. Myomectomy may turn into hysterectomy
ii. Consent taken with full information about the risks
11. Post-operative advice
i. Avoid heavy work: 6 weeks
ii. Avoid coitus/sexual intercourse: 6 weeks
iii. Avoid pregnancy: 3 moths (12 weeks)
iv. Next delivery must be in the hospital
12. Cost
i. Keep some money at hand (5-6k taka)
13. Query + thanks
Molar pregnancy

1. Greetings + self-introduction
2. Tell about diagnosis
You are having features of pregnancy ➔ but unfortunately you are not carrying a
baby ➔ instead there is benign tumor in your uterus ➔ causing excess nausea,
vomiting, P/V passage of grape like cluster and P/V bleeding ➔ it has been
confirmed by USG and other investigation
3. Tell about the treatment
For this condition you will need treatment ➔ called suction and evacuation ➔ we
will take out the mass from your uterus
4. Prerequisite for treatment
Admit in hospital ➔ keep blood ready
5. After S&E
In most cases (90-95%) it will be cured ➔ rarely (5-10%) become worse and
malignant ➔ so follow up is needed
6. Regular follow up ➔ at least 2 years
7. During follow up, doctor will ask about
➢ Irregular p/v bleeding / amenorrhea
➢ Cough, breathlessness, hemoptysis
➢ Hematemesis, melaena
➢ Examine abdomen and vagina
➢ Investigation: Beta HCG and Chest X ray
8. Come weekly ➔ will do Beta HCG test ➔ 3 consecutives normal ➔ then
come monthly for 6 month ➔ then come 3 monthly
9. If you had hemoptysis/chest pain ➔ you may need to do Chest x ray
10. Advice During 2 years follow-up
➢ Avoid conception
➢ Use barrier method
➢ Don’t use OCP, IUCD
OCP
1. Greetings + Self introduction
2. Contraceptive history
3. Mens + Obs hx
➢ number of child + Age of last child
➢ Menstrual cycle
➢ LMP
4. Ask about Past clinical history (and also mention the contraindication)
i. HTN
ii. DM
iii. Liver disease
iv. Migraine
v. Smoking history
5. OCP advantages
i. Highly effective
ii. Cheap
iii. Convenient to use
iv. No interference with sexual activity
v. Quick Reversibility after stopping use
vi. Additional non contraceptive benefits

6. Side effects
i. Nausea
ii. Vomiting
iii. Weight gain
iv. Breakthrough bleeding
7. Procedure
i. Start white pill from the 1st day of menstruation
ii. Take one pill at night at the same time for 21 days
iii. Take the red pill (iron pill) for the next 7 days
iv. Withdrawal bleeding will occur during these 7 days
v. After 7 red pill ➔ start new strip again
8. Missed pill
i. miss 1 pill ➔ take it as soon as you remember ➔ continue rest as
usual
ii. miss 2 pills ➔ take both as soon as you remember ➔ continue the
rest + barrier method for next 7 days
iii. miss 3 pills ➔ discard the current strip ➔ use barrier method ➔
period starts again, ➔ start a new strip

9. danger sign/when to stop and return

i. Chest pain
ii. Respiratory distress
iii. Leg pain
iv. Hypertension
v. Jaundice
Return immediately ➔ consult ➔ choose another method
10. Ask for query + thanks
IUCD and CU-T
(1st 4 points same)
1. Greetings + Self introduction
2. Contraceptive history
3. Mens + Obs hx
➢ number of child + Age of last child
➢ Menstrual cycle
➢ LMP
4. Ask about Past clinical history
i. PID
ii. Past ectopic pregnancy
iii. Genital malignancy
iv. DM
v. Liver disease
5. Show patient the IUCD device
i. Advantage of IUCD
ii. Long acting + reversible (LARC)
iii. CU-T-380A: 10 year duration of action
iv. High efficacy
v. No interference with sexual intercourse
vi. Fertility return immediately after removal

6. mechanism of action
i. foreign body reaction
ii. prevents implantation of zygote
iii. copper has spermicidal action
7. disadvantage/ complication
i. lower abd pain
ii. dysmenorrhea
iii. irregular p/v bleeding
8. contraindication
i. suspected pregnant
ii. past h/o ectopic pregnant
iii. AUB
iv. PID hx/present
9. time of insertion
i. post abortal
ii. NVD: within 48 hours of delivery
iii. If not within 48 hour then after 6 weeks of delivery during LUCS
10. Instruction
i. Check for thread during each menstruation
ii. Come back immediately if thread not found
11. Follow up
i. Come back once in next 1 month
ii. Then once in next 3 months
iii. Then once in next 6 months
iv. Then once yearly
v. Remove after expiration/wish to remove
12. Ask for any query + give thanks
Norplant/Implanon

1. Greetings + Self introduction

2. Contraceptive history
3. Mens + Obs hx
➢ number of child + Age of last child
➢ Menstrual cycle
LMP
4. Ask about Past clinical history
i. DM
ii. Liver disease
iii. Thromboembolism
5. Show her the Implanon/Norplant device
6. Advantage of Implanon
i. LARC (long acting reversible contraceptive)
ii. Duration of action: 3 years
iii. High efficacy
iv. No interference with sexual intercourse
v. Prompt return of fertility after removal
7. Mechanism
i. Inhibition of ovulation
ii. Inhibits implantation
iii. Thickens cervical mucus
iv. Decreases tubal motility
8. Disadvantage/side effects
i. Irregular p/v bleeding
ii. Headache
iii. Weight gain
iv. Acne
9. Contraindication
i. Suspected pregnancy
ii. AUB
iii. Liver disease
iv. Thromboembolism
10. Procedure

Small incision made on skin ➔ tube inserted ➔ later taken out by same procedure
11. Instruction
Check for local pain ➔ consult if any discomfort/side effects
12. Query + thanks
Contraceptive for newly married couple
Greetings + introduction ➔ Contraceptive hx ➔ obs and mens hx ➔ past clinical history (mainly
like OCP) ➔ options for them: Condom/barrier method + OCP (since newly married) ➔
Condom: advantage disadvantage ➔ OCP: advantage, disadvantage, contraindication,
how to take pill, what to do in missed pill ➔ query + thanks

Condom advantage Condom disadvantage

Cheap High failure rate
Simple Interference with intercourse
Easy to use Latex allergy
Non contraceptive benefit: against STD, PID,
HPV, Ca Cervix

Hysterectomy

1. Greeting and self introduction 0.5

2. Explanation about disease 1

There is a malignancy/…./anything that is mentioned in the scenario

3. Treatment options 1
i. There is conservative treatment
ii. There is definitive treatment (hysterectomy)
4. Best available option for her 1
i. We have determined that the best option for you is hysterectomy
ii. Because you have completed your family
iii. Without this treatment your health condition will worsen
iv. After this treatment you will be cured
5. Pre-requisite of the operation 1
i. Keep blood ready
ii. Pre-operative investigations needed (blood, urine, Chest xray, ECG)
6. Complication during operation (may happen, but we will do our best to 1
avoid)
i. Hemorrhage
ii. Injury to structure
iii. Complication due to anesthesia
7. Immediate post-operative complication (may occur, we will try our best to 1
avoid)
i. Bleeding
ii. Urinary infection
8. Consequences of the operation 1
i. No more menses
ii. No future pregnancy
9. Treatment cost: 7-10 k taka 1
10. Hospital stay: 14 days
11. Query + thanks giving 0.5
Total 10
Obstetrics
ANC
A mother has come to you for her 1st ante natal visit. How will you counsel her, regarding her
ante natal care? (ANC counselling)

1. Greetings and self-introduction

2. Schedule future ante natal visits
You will come to us minimum 4 times. Please take this card:
1st at 16 weeks
2nd at 24-28 weeks
3rd at 32 weeks
4th at 36 weeks

3. Advice

Rest
a.

⮚ Sleep 8-10 hours at night and 1-2 hours at noon

⮚ If you don’t feel sleepy during the day, lie down and rest
Diet
b.

⮚ You have to eat high calorie nutritious diet containing: meat, fish, egg,
milk, fruits, vegetables
⮚ Drink plenty of water

Personal
c. hygiene

⮚ Always stay clean

⮚ Bathe regularly
⮚ Wear clean and comfortable dress
⮚ Take care of your breasts, clean them during bathing properly

Sexual
d. Aintercourse:
Avoid sexual intercourse during
➢ 1st 3 months (upto 12 weeks)
➢ the last 2 months (7 months/28 weeks onwards)

Care
e. of bowel bladder

⮚ Drink adequate water

⮚ Frequent evacuation of bladder
⮚ Eat fiber containing foods to avoid constipation
Comfort
f. of mother
 ⮚ Don’t do heavy work
⮚ Don’t wear high heels
⮚ Don’t travel further distance

Immunization
g.
Are you vaccinated for Tetanus➔ if not we will vaccinate you. Once at 5
months, once at 6 months

Drugs
h.
Regularly take
➢ Iron
➢ Calcium
➢ Folic acid tablet
Don’t take any medications without doctor’s prescription
Plan
i. of delivery

⮚ Decide place of delivery: home/hospital

⮚ If you decide to deliver at home, arrange for a skilled birth attendant
⮚ If hospital arrange:
a. Money
b. blood donor
c. transportation
d. attendant who will care for you
Danger
e. 2 sign: Please note the following danger signs
➢ Headache
➢ Blurring of vision
➢ Convulsion
➢ Per vaginal bleeding
➢ Severe lower abdominal pain, fever (chorioamnionitis)
➢ Dysuria
If you note these problems, urgently consult the doctor

4. Thank the mother and ask for queries

Placenta Previa
28 years, 2nd gravida, at 36 weeks of pregnancy with placenta previa, diagnosed by USG, family
anxious and worried, counsel her about the condition

1. Greetings + self introduction

2. Details about current pregnancy
i. Age of pregnancy
ii. Any complications other than the presenting problem
iii. Whether any/How many ANC she had
3. Obstetric + menstrual history
i. Para, gravida, ALC, past delivery details
ii. LMP
iii. Menstruation prior to pregnancy
4. Inform about the current diagnosis

You presented with p/v bleeding ➔ from assessment + USG we have confirmed you
have placenta previa ➔ it means your placenta is attached lower than normal
5. Reassure about the condition

This is unfortunate for you ➔ but we are well equipped to treat you ➔ please be
assured
6. Why you need treatment: complication of mother (complication is rare ➔ we
will try best to prevent any complication)
i. More p/v bleeding ➔ patient will worsen
ii. Preterm labor
iii. PPH
iv. Rarely, there is threat of life
7. Why you need treatment Complication of baby (complication is rare ➔ we
will try best to prevent any complication)
i. Low birth weight
ii. Premature
iii. Failure to breath
iv. Rarely, baby may die (IUD/stillbirth)
8. Some investigation necessary to monitor you + for treatment
i. Hb%
ii. Blood group
iii. USG
9. Plan of treatment: you are 36 weeks, only 1 week away from term ➔ so we
advise you to be admitted now

You are 36 weeks ➔ if you are healthy, baby healthy, no more bleeding, everything ok
➔ we will continue upto 37 weeks ➔ then terminate pregnancy ➔ based on USG ➔
we will determine whether NVD/CS will be needed

If you/baby are in danger or bleeding is severe ➔ we won’t wait till 37 weeks but
terminate immediately by NVD/CS according to USG
10. Advice during this time
i. Absolute bed rest
ii. Bathroom privilege (do toilet with potty in bed)
 iii. Arrange blood donor
iv. Avoid sexual intercourse
11. You must need delivery at hospital
12. Any query + thanks

IUD

1. Greetings + self introduction

2. Details about current pregnancy
i. Age of pregnancy
ii. Any complications other than the presenting problem
iii. Whether any/How many ANC she had
3. Obstetric + menstrual history
i. Para, gravida, ALC, past delivery details
ii. LMP
iii. Menstruation prior to pregnancy
4. Inform about the current diagnosis

You presented with absence/less movement of baby ➔ also you felt s/s of pregnancy
going away ➔ from assessment + USG we have found that ➔ your baby’s heart beat
and movement is absent ➔ we have diagnosed that your baby has died in utero
5. Reassure about the condition

This is very much unfortunate for you ➔ but it is fortunate that you are in great health ➔
but you need further treatment to ensure no complications occur
6. Cause explanation
This may have happened due to some health condition of you ➔ or due to some defect
of the baby ➔ we will assess you further to know cause ➔ so that we can prevent this
in future pregnancy
7. Why you need treatment: complication of mother (complication is rare ➔ we
will try best to prevent any complication)
i. Dangerous infection
ii. Blood coagulation (DIC)
iii. Severe bleeding (PPH)
8. Some investigation necessary to monitor you + for treatment
i. Hb%
ii. Blood group
iii. Blood test for coagulation (aPTT, fibrinogen)
iv. USG
v. X ray of abdomen
9. Plan of treatment:
The dead baby will be expelled spontaneously within 2 weeks ➔ if not we will deliver it
by NVD

We will insert a catheter in your genital tract ➔ please lightly pull on the catheter from
time to time ➔ this will help expulsion of baby [Intra cervical catheter]

10. Support
i. We will provide you with psychological support
 ii. After NVD, you can get pregnant again within 6 months
iii. We will assess you to prevent this in next pregnancy
iv. Do proper ANC in the next pregnancy
11. Any query + thanks

PNC
PNC counselling (advice on discharge

1. Greetings and self-introduction.

2. Advice

Rest
a)

⮚ You should sleep 10 hours per day

⮚ 7-8 hours at night
⮚ 1-2 hours during the daytime
⮚ It will be better if you sleep when the baby sleeps
⮚ Avoid heavy work for 6 weeks (NVD)/3 months (C/S)

Diet
b)
➢ You have to eat more than before (add 500 kCal if lactating)
➢ Eat nutritious diet containing: meat, fish, egg, milk, fruits, vegetables
➢ Avoid junk food
Personal
c) hygiene

⮚ Always stay clean

⮚ Bathe regularly
⮚ Wear clean and comfortable dress
⮚ Don’t wear high heels
⮚ Don’t travel further distance
⮚ Apply vulval pad and change regularly till lochial discharge occurs

Care
d) of bowel bladder

⮚ Drink adequate water

⮚ Don’t hold urine for long
⮚ Eat more vegetables
⮚ Eat fiber containing foods to avoid constipation
⮚ Use high commode
⮚ In case of presence of episiotomy wound due to NVD: wash the wound
after acts of defecation and micturition

Post
e) natal exercise
We will teach you some exercise. You should do them regularly
 Danger
f) signs
Please note the following danger signs:

⮚ Excessive bleeding
⮚ Seizure
⮚ Fever
⮚ Foul smelling per vaginal discharge
If you note these, urgently consult physician

3. Advice for newborn

a. Exclusive breast feeding

⮚ Feed the baby breast milk

⮚ Nothing else, not even a drop of water
⮚ Exclusive BF for the 1st 6 months
⮚ Feed baby as often as it wants
⮚ Maintain proper positioning and attachment
⮚ Start supplementary feeding from 6 months
⮚ Continue breastfeeding up to 2 years

b. Immunization

⮚ Give baby BCG vaccine within 14 days

⮚ Bring baby for vaccination when it is 6 weeks old

⮚ Continue your TT vaccination

4. Contraceptive advice

⮚ Avoid sexual intercourse for 6 weeks

⮚ If lactating ➔ avoid OCP and use POP from 6 months

⮚ Birth spacing for 2 years

5. Follow up

⮚ Post-natal care schedule

a. 1st visit: within 24 h of delivery
b. 3rd: 4th-7th day/during discharge
c. 3rd : after end of 6 weeks
6. Thank the mother and ask for queries

Breast feeding and EBF

1. Greeting and self-introduction

2. Directions for breastfeeding

⮚ Initiate breastfeeding within 1 hour

⮚ Exclusive breastfeeding for the 1st 6 month
⮚ Not even a drop of water
⮚ Feed baby as many times as it wants
3. Education about proper positioning and attachment
Please follow the positions that we have shown you

4. Benefit to mother

⮚ uterus will return to normal size

⮚ prevent excessive hemorrhage
⮚ natural contraceptive
⮚ protection from breast cancer, uterine cancer

5. Benefit to baby

⮚ complete and ideal food for baby

⮚ easily digestible
⮚ development of the brain and intellectual development
⮚ protect from infection
⮚ increase bonding

6. No need to buy artificial formula ➔ economic benefit

7. Weaning

⮚ Introduce supplementary food from 6 months

⮚ Such as: khichuri, rice, dal, vegetable, meet, egg etc.
⮚ Continue breast feeding up to 2 years

8. If you don’t follow EBF for 1st 6 months

⮚ difficulty in digestion
⮚ malnutrition
⮚ immunity will decrease
⮚ obesity
⮚ future ➔ diabetes
9. Ask about query + thanks
Breaking bad news
CA Cervix
The lady sitting in front of you is 52 years old. She came with complaints of foul smelling vaginal
discharge and post coital bleeding. You have examined the patient and taken biopsy from the
cervix. Report shows squamous cell carcinoma of the cervix. Now break the bad news and
counsel her regarding the treatment.

1. Greetings + self introduction

SPIKES = for
breaking bad
news
S = Set up 2. Want to speak alone/alongside a family member/close relative?
environment
P=Perception 3. What do you know about your current health condition?
of patient
about Did you consult any other doctor ➔ what did they tell you?
condition Did you discuss it with anyone ➔ what did they tell you?
Did you try to find out yourself ➔ what did you find out (books, internet
research)
I = If patient 4. Are you prepared and eager to know about the nature of your
want to know condition? What you hear may not be a happy news, so you need
about her mental preparation
condition
K= 5. We took a biopsy from your cervix (জরায়ু মুখ) ➔ we are very
knowledge to much sad to let you know that you have been diagnosed with
the patient Cervical cancer
about the
condition
E = Empathy 6. It is a very difficult situation for you ➔ please be patient and
+ emotional bear with us ➔ we are well equipped to deal with this condition
support and hopefully with your assistance ➔ we will overcome this
S = Strategy 7. Some further examination needed to assess spread
+ next plan i. Abdominal examination
ii. Vaginal examination
iii. Chest examination
8. Some further investigations needed to assess spread
i. USG
ii. Chest X ray
iii. CT scan of abdomen
iv. MRI of pelvis
9. Treatment modalities
i. Surgery: hysterectomy (radical)
ii. Radiotherapy
iii. Chemotherapy
10. Why you need treatment: complication

With prompt treatment ➔ you may remain healthy and live a better life ➔
but if untreated ➔ complication:
➢ Bowel, bladder problem
➢ Urinary fistula (VVF)
 ➢ Spread to distal organs
➢ Untimely avoidable death
11. Cost
We will try our best to provide best treatment with lowest cost ➔
however please keep in mind that in some cases treatment might
not be cheap ➔ for that family support is needed ➔ if unable let
us know ➔ we will arrange financial support from social welfare
ministry
12. Psychological support
13. Query + thanks
Procedure stations
MVA
30 year old woman para 2 presented to you with 9 weeks of pregnancy and per vaginal
bleeding. USG shows blighted ovum. You have decided to treat her with MVA. The patient has
been adequately counseled, consent taken, general anesthesia given, put in lithotomy position,
aseptic wash and draping complete. What are the next steps?

1. Check logistics
i. Cusco’s bivalve self-retaining vaginal speculum
ii. Vulsellum
iii. MVA cannula: 4 mm, 5mm, 6 mm (for cervical dilatation + aspiration)
iv. MVA syringe
v. Oxytocin
2. Prepare MVA syringe
i. Assemble it
ii. Close pinch valve
3. Create vacuum in the MVA syringe
4. Bimanual examination
Confirm size + position of uterus
5. Cusco’s speculum: retract vaginal walls
6. Vulsellum: catch anterior lip of cervix
7. Dilate cervix gradually: with MVA cannula
i. At 1st by 4 mm cannula
ii. Then by 5 mm cannula
iii. Lastly by 6 mm cannula
8. Insert cannula into uterine cavity through cervix
9. Attach MVA syringe to other end of cannula ➔ release pinch valve ➔
vacuum transferred into uterine cavity
10. Back and forth + rotatory movement of cannula ➔ evacuate contents of the
uterus
11. Ensure Complete evacuation, indicated by
i. Appearance of blood + bubbles
ii. No more aspiration occurring
iii. Gritty sensation (cannula is passing over uterine walls)
iv. Uterus feeling to be contracted around cannula
12. Close pinch valve ➔ slowly withdraw cannula and MVA syringe
13. Remove vulsellum ➔ remove cusco’s speculum
14. Examine evacuated mass
15. USG to confirm completion of aspiration
16. Oxytocin administration
17. Wash vulva + cover patient
18. Reassure the patient
Dilatation and curettage
(almost same as MVA, the differences are underlined)

1. Check logistics
i. Sim’s double bladed vaginal speculum
ii. Vulsellum
iii. uterine sound
iv. Hegar’s dilator/Cervical dilator
v. Curette
vi. Oxytocin
2. Patient anesthetized ➔ lithotomy position ➔ sponge holding forceps to clean
vagina and perineum ➔ draping with sterile sheet
3. Bimanual examination
Confirm size + position of uterus
4. Sim’s speculum: retract vaginal walls
5. Vulsellum: catch anterior lip of cervix
6. Uterine sound:
Measure length of uterine cavity (pass the sound into uterus)
7. Dilate cervix gradually: with Hegar’s dilator (8 mm) (metallic)
8. Introduce curette ➔ clockwise curettage of whole uterine cavity
9. Collect the curetted material
10. Ensure Complete evacuation, indicated by
i. Appearance of blood + bubbles
ii. Gritty sensation (cannula is passing over uterine walls)
iii. Uterus feeling to be contracted around curette
11. Gently withdraw curette
12. Remove vulsellum ➔ remove cusco’s speculum
13. Examine curetted mass
14. USG to confirm evacuation
15. Oxytocin administration
16. Wash vulva + cover patient
17. Reassure the patient
Mechanism of normal labor

1. Baby in left occipito-anterior position 1

Occiput is against the left pubic tubercle

Engagement of baby (bi-parietal diameter) along right oblique diameter
2. Engagement ➔ 1
3. Descent of head ➔
4. Flexion of head ➔
5. Head touches pelvic floor ➔ internal rotation ➔(anti-clockwise) occiput behind 1
symphysis pubis ➔ crowing
6. Delivery of head by extension 1

(occiput under Symphysis pubis and nose on the side of buttock of mother)
7. Restitution 1

(baby’s head rotates clockwise in such way that nose now comes towards right thigh of
mother
8. External rotation of the head due to internal rotation of the shoulder 1

(clockwise…..along the same direction of restitution ➔ babies head now totally

horizontal ➔ nose against right thigh and occiput against left thigh ➔ shoulder now
along antero-posterior diameter of pelvic outlet……left shoulder under symphysis pubis
and right shoulder under buttock)
9. Delivery of anterior shoulder (left) ➔ delivery of posterior shoulder (right) 1
10. Delivery of rest of the body by lateral flexion 1
Total 10
2nd stage of labor management
(what doctor will do during each steps of the mechanism of labor)

A patient is in the 2nd stage of labor and about to deliver. Demonstrate delivery of the baby on
the model

Corresponding to
which step of labor

1. greeting, assurance & encouragement

2. Position:

Position of choice

dorsal position with 15 degree left lateral tilt

(preferable/recommended)

3. Prerequisite

i. Check logistics
ii. Ensure bladder is empty ➔ if full ➔
catheterize
iii. Aseptic preparation of doctor
iv. Sterile wash of vulva and perineum

4. Per vaginal examination ➔ check cervical dilatation ➔

check baby’s position, presentation

5. Perform episiotomy if required

6. Keep baby’s head flexed with 2 fingers ➔ controlled extension

delivery of the head
descent

flexion

internal rotation
crowning

7. Support the perineum ➔ head delivered by extension Delivery of the head

by extension
8. Suction + clean baby’s mouth and nose

9. Check if umbilical cord is around baby’s neck

➔ If loose ➔ take it over baby’s head

➔ If tight ➔ clamp in 2 places ➔ cut between them

10. Allow the baby's head to turn spontaneously Restitution

11. Head turned ➔ place 2 hands over each ear of baby ➔ tell +
mother to bear down with each contraction
External rotation of
head due to internal
rotation of shoulder

12. Press baby’s head downwards ➔ delivery of anterior delivery of anterior

shoulder shoulder

13. Lift baby’s head upwards ➔ delivery of posterior delivery of posterior

shoulder shoulder

14. Support the baby while rest of the body delivered Delivery of rest of the
body by lateral
flexion

15. Record the time of the delivery + sex of the baby

16. Immediate care of newborn (see below)

At least …place on abdomen ➔ dry baby ➔ wrap with dry

cloth ➔ clamp cord ➔ cut cord ➔ eye wash ➔ breast
feeding advice

17. Prepare for AMTSL

Immediate/Routine care of newborn

1. Place the baby on a dry sterile cloth over abdomen of mother 1

2. Dry baby with that cloth 1
3. Discard wet clot 1
4. Cover the baby with another dry sheet 0.5
5. Maintain skin to skin contact with mother 0.5
6. Check whether baby is crying/breathing spontaneously + color + 1
movement
7. Clamp the cord at three specific sites 0.5

(214)
1st tie: 2 finger from abdominal wall of the baby
2nd tie: 1 finger away from 1st tie
3rd tie: 4 finger away from 2nd tie

8. Cut the cord (with sterile blade/scrissor) between 2nd and 3rd tie ➔ after 1 0.5
minute but within 3 minutes

1 finger away from 2nd tie, between 2nd and 3rd tie
9. Apply 7.1% chlorhexidine solution to the umbilical stump 1

Empty 1 whole bottle over the stump

10. Clean the eye with Erythromycin 0.5

Swipe from medial to lateral aspect of the eye

11. Put the baby to mother’s breast + encourage early breastfeeding within 1 1
hour
12. Thanks, and assure the mother 0.5
Total 10
Active management of 3rd stage of labor

1. Assure + inform patient about what you are going to do

(you and your baby are going to be fine. Stay strong and we will be done in a few
minutes)
2. Clamp + cut the cord close to the vulva/perineum
3. Palpate abdomen of the mother to exclude 2nd baby
4. After exclusion of 2nd baby’s presence….

Inj. IM 10 IU Oxytocin (5+5) on both thighs within 1 minute

5. Controlled cord traction with simultaneous counter traction

i. Right hand: hold cord + clamp (artery forceps) and keep pulling downwards
(traction) (pull while the uterus contracts, if contraction passes, wait for next
contraction)
ii. Left hand: palmar surface against symphysis pubis: push downwards and
backwards (counter traction)
6. Placenta visible ➔ cup with both hands ➔ rotate it ➔ delivery of placenta +
membrane
7. Uterine massage
8. Check placenta for missing bits/lobes/torn vessels
9. Check genital tract for tear and injury

NVD
(2nd stage + Immediate care of newborn + AMTSL)

1. Greeting + introduction + encouragement

2. Explain about the procedure and reassure
3. Mother placement:
i. Mother lies on sterile rubber cloth
ii. Sterile drape 3 pieces: 1 under buttock, 1 over abdomen, 1 to receive the
baby
iii. Doctor ➔ wash hands ➔ wear gloves
4. 2nd stage of labor (see above)
5. Immediate care of newborn (see above)
6. AMTSL (see above)
Examination of newborn
Sequence:
Greetings/Introduction ➔ consent to examine the baby ➔ color, appearance, respiratory rate,
heart rate, temperature (Vitals) ➔ Weight, length, Occipito-frontal circumference
(anthropometry) ➔ head ➔ eye ➔ ear ➔ nose ➔ mouth ➔ neck ➔ chest ➔ abdomen ➔
umbilicus ➔ hand ➔ leg ➔ genitalia ➔ anal canal ➔ back ➔ ask mother (breast feeding,
bowel bladder)
Things to note:

What abnormalities to look for

Color Jaundice
Cyanosis (central, peripheral)
Appearance Facies of cretinism, down’s syndrome, turner’s syndrome
Head Cephalhematoma
Caput
Bulged fontanelle
Anencephaly
Microcephaly
Eye Congenital cataract
Discharge
Ear Congenital anomaly
Low set ear (turner)
Nose Deformity
Mouth Cleft lip
Cleft palate
Tongue tie
Chest Ectopia cordis
Congenital anomaly
Auscultate precordium ➔ dextrocardia
Chest ➔ lung function
Abdomen Any lump/swelling
Hernia
Umbilicus Omphalocele
Omphalitis
Stump infection
Hand Polydactyli
Syndactyli
Amelia
Phocomelia
Leg DDH/CDH
Club foot
Genitalia Hypospadias
Epispadias
Undescended testis
Ambiguous genitalia
Anus Imperforate anus
Back Spina bifida
Meningocele
 Sacrococcygeal teratoma

Resuscitation of a baby with perinatal asphyxia

1. Dry the baby with clean cloth

2. Wrap the baby with another dry clothe
3. Suction
Clean the mouth + nose by sucker
4. Position: Neck extend + Chin lift + jaw thrust
(Place a folded cloth just under the back of the supine baby)
5. Again suction
6. Stimulation:

Baby left lateral ➔ rub back with ulnar border of right hand ➔ left hand to support
the baby
7. Place umbo bag mask in proper way (with right hand)
i. Thumb and index finger on the mask + middle finger on the chin
ii. Ring and little finger on angle of the jaw
8. Press UMBO bag with left hand 40 times per minute

1001…..1002….1003……………………………..1040
9. If not breathing still ➔ recheck ➔ suction ➔ position ➔ umbo bag press firmly
10. If not ➔ check HR (stetho/cord pulsation) ➔

If HR >100 ➔ continue UMBO bag until respiration returns

If HR <100 ➔ CPR + continue UMBO ventilation ➔ refer + arrange for consultation

CPR: for 3 breaths, 1 chest compression

Breast feeding
Greetings + introduction ➔ EBF (only breast milk, nothing else not even 1 drop of water, day
and night, as per demand of baby) ➔ continue breast feeding for 2 y + weaning from 6 months
➔ proper positioning ➔ proper attachment ➔ always ensure baby drinks fully from one breast
(foremilk + hind milk) ➔ query + thanks

Positioning Attachment
Body held close to mother Mouth wide open
Whole body supported Chin touching the breast
Head and body in a straight line Lower lip turned outward
Baby facing toward breast, nose opposite More areola visible above than below
nipple