REPRODUCTION SYSTEM CLINICAL SKILLS MANUAL

For Students

Given to the 4th Semester Students of Hasanuddin University Medical Faculty

REPRODUCTION SYSTEM
Medical Faculty Hasanuddin University

2012

REPRODUCTION SYSTEM CLINICAL SKILL MANUAL

For Students

LIST OF CONTENT

NO.
1.

TOPICS
OBSTETRIC EXAMINATION SKILL

2.

GYNECOLOGIC EXAMINATION SKILL

3.

IUD COUNSELLING SKILL & INSERTING IUD (INTRA UTERINE DEVICE) ARM IN TO A STERILE PACKAGE

BREAST FEEDING TECHNIQUE

INTRODUCTION

This Reproduction System skill manual provides 4 main skills which are Obstetric examination skill, Gynecologic Examination Skill, IUD Counselling Skill & Inserting IUD (Intra Uterine Device) Arm in to a Sterile Package, and Breast Feeding Technique.

Obstetric Examination Skill includes Antenatal Care (e.g.communication skill which emphasize on the pregnant woman complaints), Physical Examination of the pregnant women; inspection, palpation based on Leopold assessment and monoaural auscultation of the fetus heart beat using Laenec sthetoscope. Gynecologic Examination Skill includes performing a correct and safe vaginal speculum insertion and a comprehensive bimanual examination.

It is very much expected that upon completing this clinical skill training, the students will be able to comprehend the obstetric and gynecologic examination, performing IUD counselling as well as inserting the device in to a steril package and the brest feeding techinque correctly.

This skill manual is also completed with guidance for every activities along with its activities assessment sheets allowing both students and instructors to monitor the students progress in performing the corresponding skill.

In order to perfect this skill manual, we are welcome for every constructive critics and sugesstions.

Makassar, March 2012

Reproduction System Skill Lab Coordinator

CLINICAL SKILLS MANUAL

For Students

OBSTETRIC EXAMINATION SKILL

Given to the 4th Semester Students of Hasanuddin University Medical Faculty

Edited By:
Dr. dr. Mardiah Tahir, Sp.OG dr. Retno Budiati Farid, Sp.OG(K)

REPRODUCTION SYSTEM
Medical Faculty Hasanuddin University

2012

OBSTETRIC EXAMINATION SKILL

PREFACE
Obstetric Examination includes several interconnected procedures. For basic assessment, generally its divided into Antenatal Care, Physical Examination of the Pregnant Women; inspection, palpation and auscultation. Antenatal care only focuses on important things that are easily identified and particularly assesses certain changes as the mother goes older. Physical examination of palpation and auscultation are aimed to identify gestational age, fetal lie, fetal presentation, numbers of fetus, fetus condition and the compatibility of the passage and passenger (in conjunction with correct assessment of the shape of the maternal pelvis, thus, can indicate whether the delivery is going to be complicated or further intervention is needed e.g. Cesarian section)

INDICATION
Antenatal Care Early detection of pathologic condition during pregnancy Labor planning Prepare for labor finishing Conception progressiveness Identifying the fetus lie, position, presentation and condition Managing any revealed problem during pregnancy

ANTENATAL CARE
(HISTORY TAKING AND PHYSICAL EXAMINATION)

STUDY OBJECTIVES:
After completing this study skill, students are expected to have the ability to: 1. conduct a complete anamnesis to a pregnant woman 2. perform a comprehensive physical examination to a pregnant woman or anatomic model

STUDY TOOLS AND MATERIALS :

1. Study manual for anamnesis at the first antenatal visit 2. Study manual for physical examination at the first antenatal visit 3. Stethoscope (monoaural/Laenec and biaural), length scale, termometer, weight scale, reflex Hammer, anatomic model, a pair of hand gloves, blanket, a bucket for medically decontaminated fluid, soap and a basin for washing hands 4. Pieces of papers, pencils, pens, and mothers card

STUDY METHODS :
1. 2. 3. 4. 5. Skill demonstration based on the provided manual Lecture Discussion Active participation in conducting the skill (simulation) Evaluation using provided check list with scoring system

ANTENATAL CARE
(HISTORY TAKING AND PHYSICAL EXAMINATION) ACTIVITIES DESCRIPTION: Activities # 1. Introduction # 2.Role Play: asking and answering question Time 2 minutes 30 minutes Introduction Speech 1. Arranging the students seat 2. Two instructors (an instructor and co- instructor) give examples on how to do a complete anamnesis, at the first antenatal visit, and Leopold maneuvers. One instructor acts as a doctor and the other as the patient/the mother. Students thoroughly observe. 3. Students are given opportunity to ask questions; instructors explain important aspects related to the topic 1. Students are grouped in pairs. A mentor is required to observe every 3 pairs 2. In each role play, every pair (all at once) practices on doing antenatal care and Leopold maneuvers, One student acts as a doctor who is helping the patient and the other as the patient 3. Mentors supervise the performed procedures using check lists 4. Every mentor should provide feedback for each of the pair 1. Brain storming/discussion: Which part that is easy to perform?, what are the difficult parts?, What are the patients-act students feel? What can a doctor improve to make the patients more comfortable? 2. Instructors summarize by explaining the last question and giving necessary enlightenment Description

# 3. Role play with feed back

100 minutes

# 4. Brain storming/ Discussion

15 minutes

Total allocated time

150 minutes

ANTENATAL CARE
{Includes Leopold palpation maneuvers and Laenec monoaural auscultation } Mark every clinical step using the following scoring categories: 1. Need to be improved: Steps that are not correctly performed, un-organized chronologically, or for some missed/left over steps 2. Able: Steps that are performed correctly, chronologically based, but not efficiently conducted 3. Master: Steps that are performed correctly, chronologically based, and efficiently conducted NS (Not suitable): Steps that are unnecessarily conducted due to the situation NO.

CLINICAL STEPS
1

CASES 2 3

A. CHIEF COMPLAIN 1. 2. Greets the patient,

Politely Introduce your self by shaking hand and ask the patients name, age, address B. ANAMNESIS 1. Ask about:

Pregnancy history (GPA), marriage history (how long) Menstrual history, first day of the last menstrual period The patients and her familys past diseases history, her past labor history (ever experienced any difficult labor before?) 2. Define the gestasional age based on menstrual anamnesis, and set the estimated time of labor C. EXAMINATION 1. GENERAL General Condition Body weight and height Vital signs (Blood Pressure, pulse, heart rate, respiratory rate, body temperature) SPECIFIC a. Explain the procedure to the patient by describing the overall picture. Do not forget to mention that some parts of it may induce uncomfortable feeling,

2.

but assure that it is not going to bring any harm to do fetus. b. Position the patient in a comfortable laying position c.Cover the lower body parts (the two legs) with provided blanket d. Wash hands thoroughly with soap, rinse with clean warm water then wipe them dry using towel e.Stand at the right side of the mother facing the right lateral aspect f.Notify the patient that the examination will be started g. Leopold 1: Position the lateral side of the left index finger at the top of fundus utery to define the fundus utery upper level. Carefully not to slightly push the womb with the finger (whenever required, grasp and restraint the lowest part of the uterus using right thumb and index fingers by placing them at the right and left front sides (of the lower abdomen area) just above the symphisis pubis. Lift the left index finger (along with the two restraining fingers), then reposition your self facing the mothers head. While facing the woman, palpate the woman's upper abdomen (fundus utery) with both hands. Repeatedly, apply gentle pressure on to the area using both hands. Feel the fetus body part(s) on that side i. Leopold 2: Position the left palm on the right lateral side and the right palm at the left lateral side of the mothers abdominal wall, parallel at relatively similar level Starting from the upper side down to the bottom, apply gentle pressure on to the areas with both palms either simultaneously or interchangeably (First the right hand remains steady on one side of the abdomen while the left hand explores the right side of the woman's uterus) This is then repeated using the opposite side and hand. Feel the presence of flatten part (fetus back) or small parts (extremities: legs and arms) j. Leopold 3: Position your self at the right side of the mother

facing the feet. Place the left palm at the lower left side and the right palm at the lower right side of the mothers abdominal wall. Gently apply slight pressure on to the areas either simultaneously or interchangeably to identify lower fetus parts (the stiff round homogenous sensation is most likely a head, while the smooth crushed to bit unsymmetrical part is a buttock) k. Leopold 4: Position the left and right hands at the left and right lateral sides of the lower uterus, respectively. The tip of the fingers of both hands are place just above the symphisis. Match the right and left thumbs together, and and put the other fingers close to each other.. Pay attention to the angle formed by the left and right fingers (convergent or divergent) Next, move the left thumb and index fingers to the lower part of the fetus (for head presentation: hold on to the part close to the neck; for breech presentation: try to grasp the fetus waist) Fix either of those two parts to the upper pelvic brim, and place the right hand fingers in between the left ones and symphisis to evaluate how far is the fetus lowest part has entered the upper pelvic brim. AUSCULTATION : 1. Lift both hands, then take the monoaural stethoscope with left hand. Place the tip on the mothers abdominal wall at the fetus back (the long regular part) Place the left ear on the mothers abdomen, then listen to the fetal heart beat (should the beat is hardly heard on this first spot, change the spot, try to locate the maximum punctum). In the case where the mothers abdominal wall is thick enough and harden the heart beat calculation, place the stethoscope tip to the relatively thinner part which is about 3 cm below the umbilicus. Listen to the heart beat, then calculate it within the whole 60 seconds. Normally, it should be 120 160 bpm Restore all the used equipment to its original places. 1 2 3

2.

3. 4.

5. 6.

7.

Whenever necessary, perform some further additional examination e.g. USG, laboratorium Notify the patient that the examination procedure has been completed. Remove the covering blanket, then help the mother to regain her comfortable position. Note down the result of examination on the provided status 1 2 3

D. EXPLAINING EXAMINATION RESULT Explain results yielded from palpation and auscultation, which include: Gestational age The fetal lie (longitudinal, transverse, or oblique ) The fetal position ( left / right back, inferior /superior) The fetal presentation (head, crowning, footling, breech) The fetal condition (in accordance with auscultation result) E. ANTENATAL CARE PLANNING 9. 10. 11. 12. 13. Inform the mother about her clinical status and the pregnancy condition Explain about the antenatal care planning in accordance to the previous examination result Note down on the mothers pregnancy control card the further required schedule and clinical care. Should the mother experience any complain, encourage her to visit the health providers (even hen unscheduled) Hand in the control card back to the mother, and greet her. 8.

REFERENCES 1. Saifuddin AB (editor), Buku Acuan Nasional Pelayanan Kesehatan Maternal dan Neonatal. Jakarta: Yayasan Bina Pustaka Sarwono Prawirohardho, 2001 2. Winkjosastro H, Saifuddin AB, Rachimhadhi T. Ilmu kebidanan. Third edition. Jakarta. Yayasan Bina Pustaka Sarwono Prawirohardho. 1997.

CLINICAL SKILLS MANUAL

For Students

GYNECOLOGIC EXAMINATION

Given to the 4th Semester Students of Hasanuddin University Medical Faculty

Edited By:
Dr. dr. Mardiah Tahir, Sp.OG dr. Retno Budiati Farid, Sp.OG(K)

REPRODUCTION SYSTEM
Medical Faculty Hasanuddin University

2012

GYNECOLOGIC EXAMINATION
PREFACE
Gynecology Examination is a bimanual clinical procedure to assess woman genital organs condition as a method to confirm any abnormality of the sites. This examintion is just part of a complete thorough procedure, therefore it focuses marely on the external genitalia organs in terms of defining the size, uterus and cervix consistency, adnexa condition, parametrium and the surroundings internal genitalia organs.

INDICATION
Examination of the size, position, shape, and consistency of the uterus Examination of the uterus adnexa and parametrium Examination of the ballotement Confirming intra or extra uterine pregnancy Confirming infection or inflamation status Examination of vaginal discharge, bleeding, pelvic tumor

GYNECOLOGIC EXAMINATION
(VAGINAL SPECULUM INSERTION & BIMANUAL EXAMINATION)

STUDY OBJECTIVES:
After completing this study skill, students are expected to have the ability to: 1. perform a correct and safe vaginal speculum insertion 2. perform a comprehensive bimanual examination

STUDY TOOLS AND MATERIALS :

3. Study manual for vaginal speculum insertion 4. Study manual for bimanual examination 5. Graves speculum, antiseptic solution and cotton an instruments table, flood lamp/head lamp, a pair of gloves, soap and flowing tap water (for hand washing), a dry and clean towel, a basin for washing hands 6. Pieces of papers, pencils, pens, and mothers card

STUDY METHODS :
1. 2. 3. 4. 5. Skill demonstration based on the provided manual Lecture Discussion Active participation in conducting the skill (simulation) Evaluation using provided check list with scoring system

GYNECOLOGIC EXAMINATION
(VAGINAL SPECULUM INSERTION & BIMANUAL EXAMINATION) ACTIVITIES DESCRIPTION:
Activities # 1. Introduction # 2. Role Play: asking and answering question Time 2 minutes 30 minutes Description Introduction Speech 1. Arranging the students seat 2. Two instructors (an instructor and coinstructor) give examples on how to do a gynecologic examination using vaginal speculum and bimanual examination. One instructor acts as a doctor and the other as the patient/the mother. Students thoroughly observe. 3. Students are given opportunity to ask questions; instructors explain important aspects related to the topic 1. Students are grouped in pairs. A mentor is required to observe every 3 pairs 2. In each role play, every pair (all at once) practices on doing the examination. One student acts as a doctor who is helping the patient and the other as the patient 3. Mentors supervise the performed procedures using check lists 4. Every mentor should provide feedback for each of the pair 1. Brain storming/discussion: Which part that is easy to perform?, what are the difficult parts?, What are the patients-act students feel? What can a doctor improve to make the patients more comfortable? 3. Instructors summarize by explaining the last question and giving necessary enlightenment

# 3. Role play with feed back

100 minutes

# 4. Brain storming/ Discussion

15 minutes

Total allocated time

150 minutes

SKILL MANUAL

GYNECOLOGIC EXAMINATION
Mark every clinical step using the following scoring categories: 1. Need to be improved: Steps that are not correctly performed, un-organized chronologically, or for some missed/left over steps 2. Able: Steps that are performed correctly, chronologically based, but not efficiently conducted 3. Master: Steps that are performed correctly, chronologically based, and efficiently conducted NS (Not suitable): Steps that are unnecessarily conducted due to the situation NO. CLINICAL STEPS A. INFORMED CONSENT 1. Explain the examination procedure 2. Explain the purpose of the examination 3. Explain that the examination might provoke some uncomfortable feelings, however the examiner will do the best to minimize the complaint, and the procedure will not bring any harm to the mother. 4. Ensure the patient fully understands the examination purpose and the procedure 5. Ask for oral informed consent prior to the examination. B. PREPARATION 1. INSTRUMENTS & MATERIALS Antiseptic solution and some spool of cotton Tampon tweezers Graves speculum Instruments table Gynecologic bed with stirrups Flood lamp/head lamp 2. EXAMINER A pair of hand gloves An apron and examination coat Soap and streaming down source of water/tap water A dry and clean towel C. PATIENT PREPARATION 1. Ask the patient to empty her bladder and disrobe (undo the clothes) 2. Ask the patient to lay down on the provided gynecologic bed 3. Set the patient in lithotomy position 4. Turn on the flood lamp, then properly direct it to the field of examination D. WEAR A PAIR OF GLOVES 1. Wash hands thoroughly then wipe them dry using a clean towel 2. Unfold the gloves, pick the inner surface of the left glove with the CASES 1 2 3

thumb and index fingers of the right hand, then fit the left hand inside the glove ensuring all fingers are inserted in proper holes correspondingly. Next, stretch the wrist part a bit to tighten the hand placement. 3. Take the right glove with the gloved left hand; by inserting the left fingers underneath the gloves fold, and then restrain the wrist part with the left thumb. 4. Fit the right hand inside the glove, ensure all fingers are inserted in proper holes. At the end, stretch the wrist part a bit to tighten the hand placement. E. PROCEDURE 1 1. Sit down on the provided chair, facing the patient external genitalia organs. 2. Wet a spool of cotton with antiseptic solution then carefully wipe off the vagina, vulva and perineal surfaces. 3. Inspect the vulva and perineal sites. 4. Separate both labia majoras with the gloved fingers to look for any surface lesions, redness, or swellings. Pay attention to the urethra opening and the vaginal introitus, note any discharge coming from the urethral opening (should the bladder has not been emptied, insert a catheter). 5. Using both thumb and index fingers of the right hand, thoroughly touch and then explore the right and left labia majora (particularly Bartholini gland) Note down any reveal abnormality(s) 6. Grab a vaginal speculum with the right hand. To easy the opening, place the left index finger into the introitus (at the posterior aspect of the introitus), and then insert the tip of the speculum parallel to the introitus floor (ensure there is no snared structure in between). Gently insert the speculum in to the vaginal cavity. 7. After being inserted half way, turn the speculum 90 until the handle is facing downward. Set the thumbscrews by slightly loosen it, so the upper and lower speculum blades touch the upper and lower vaginal wall, respectively. 8. Lock the thumbscrews and organize the blades into the open position, so vaginal and cervix lumen can be clearly observed (pay attention to the size, color and contour of the porsio, vaginal secrete and wall, as well as the fornices) 9. After completing the inspection, release the thumbscrews, and withdraw the speculum out. 10. Place the used speculum in the provided tray 11. Stand up for vaginal touch procedure. Uncover the right and left labia majora with the left hand thumb and index fingers, then insert the middle and index fingers of the right hand in to the vagina. 12. Position the tip of the left fingers on to the suprasymphysis, locate the top of the fundus utery (only if the size of the womb allows this

procedure to be taken from outside) The inner hand evaluates the vagina wall, and then bimanually defines the uterus size, consistency and position direction. Cervix consistency and parameterium condition are also assessed. Place both inner and outer hands to the isthmus part (Hegar sign identification) and then match the fingers all together. 13. While restraining the uterus at the suprasymphysis part with the left hand, take the right middle and index fingers out. 14. Lift the left hand restraint, then wipe clean the spot and the vulva/perineal sites from any vagina secrete / fluid with antiseptic solution. 15. Notify the patient that procedure has been completed, and help her regain her comfortable sit. F. INFECTION PREVENTION 1 1. Collect the used instruments then place them all in a basin filled with 0,5% chlorine solution for about 10 minutes 2. Dispose all the used/contaminated materials in the provided medical bins. Wipe clean all the contaminated surfaces with 0,5% chlorine solution. 3. Place both gloved hands inside 0,5% chlorine solution, clean the gloves from any secrete/fluid trace, then undo the gloves with inside surfaces exposed out. Leave them inside for about 10 minutes. 4. Wash hands with soap and streaming down water/tap water 5. Wipe them dry with a clean towel G. RESULT EXPLANATION 1 1. Explain the result obtained to the patient 2. Explain the diagnosis and treatment planning 3. Ensure the patient understands the explanation 4. Ask for written informed consent (signed by the patient) should the patient required further examination 5. Ask the patient to wait in the waiting room if the examination has been completed. For patient needs further examination, show her the designated room.

REFERENCE
-------------Pemeriksaan Obstetri dan ginekologi. Buku Acuan Nasional Pelayanan Kesehatan Maternal dan Neonatal, Yayasan Bina Pustaka Prawirohardjo, 2001

CLINICAL SKILLS MANUAL

For Students

IUD COUNSELLING SKILL & INSERTING IUD (INTRA UTERINE DEVICE) ARM IN TO A STERILE PACKAGE

Given to the 4th Semester Students of Hasanuddin University Medical Faculty

Edited By:
Dr. dr. Mardiah Tahir, Sp.OG dr. Retno Budiati Farid, Sp.OG(K)

REPRODUCTION SYSTEM
Medical Faculty Hasanuddin University

2012

IUD COUNSELLING SKILL & INSERTING IUD (INTRA UTERINE DEVICE) ARM IN TO A STERILE PACKAGE
PREFACE
The IUD counselling skill & inserting IUD (Intra Uterine Device) arm in to a sterile package is designed to develop capable and skilful front liners of health providers in performing counselling as well as inserting a Copper T380 A IUD.

STUDY OBJECTIVES
After completing this study skill, students are expected to have the ability to: Improve positive behaviors on the benefit of a correct IUD insertion. Select the client based on the live history and physical examination Perform the suggested infection prevention procedures to diminish post insertion infection as well as B hepatitis/HIV AIDS spreading Carefully insert the Cu T 380 A IUD arm; embracing the non touching insertion technique Provide prior and after insertion counseling

STUDY TOOLS AND MATERIALS :

1. 2. Study manual for IUD insertion and removal Cu T 380 A IUD, Graves Speculum, Tenaculum, Sound Uterine, scissors, tampon tweezers, a pair of gloves, covering blanket, anatomic model, a basin for decontaminated fluid, and soap

STUDY METHODS :
1. 2. 3. 4. Skill demonstration based on the provided manual Lecture Discussion, active participation in conducting the skill (simulation) Evaluation using provided check list with scoring system

SKILL MANUAL
IUD COUNSELLING SKILL & INSERTING IUD (INTRA UTERINE DEVICE) ARM IN TO A STERILE PACKAGE ACTIVITIES DESCRIPTION
Activities # 1. Introduction # 2. Role Play: asking and answering question Time 5 minutes 30 minutes Description Introduction Speech 1. Arranging the students seat 2. Two instructors (an instructor and coinstructor) give examples on how to give IUD counselling and insert IUD Cu T 380 A arm in to a sterile package. One instructor acts as a doctor and the other as the patient/the mother. Students thoroughly observe. 3. Students are given opportunity to ask questions; instructors explain important aspects related to the topic 1. Students are grouped in pairs. A mentor is required to observe every 3 pairs 2. In each role play, every pair (all at once) practices on doing Cu T 380 A insertion and removal. One student acts as a doctor who is helping the patient and the other as the patient 3. Mentors supervise the performed procedures using check lists 4. Every mentor should provide feedback for each of the pair 1. Brain storming/discussion: Which part that is easy to perform?, what are the difficult parts?, What are the patients-act students feel? What can a doctor improve to make the patients more comfortable? 4. Instructors summarize by explaining the last question and giving necessary enlightenment

# 3. Role play with feed back

100 minutes

# 4. Brain storming/ Discussion

15 minutes

Total allocated time

150 minutes

SKILL MANUAL
IUD COUNSELLING SKILL & INSERTING IUD (INTRA UTERINE DEVICE) ARM IN TO A STERILE PACKAGE
Mark every clinical step using the following scoring categories: 1. Need to be improved: Steps that are not correctly performed, un-organized chronologically, or for some missed/left over steps 2. Able: Steps that are performed correctly, chronologically based, but not efficiently conducted 3. Master: Steps that are performed correctly, chronologically based, and efficiently conducted NS (Not suitable): Steps that are unnecessarily conducted due to the situation NO. CLINICAL STEPS INITIAL COUNSELING 1. Greet the patient politely, introduce your self and ask the purpose of the patient visit. 2. Give the patient some information about Familiy Planning 3. Provide the patient with information about the type of contraseption, the advantages and disadvantages for her, and also the differences between the irreversible (permanent) and reversible contraseption : - Show her how and where the contraseption is going to be used - Explain the principle of work - Explain the possible adverse effect and other medical condition that might occur 4. Explain what can be gained by the patient SPECIFIC COUNSELING METHOD 1. Give guarantee of the confidentiality of the process 2. Obtain as much information on the patient personal details (name, address, etc.,) 3. Ask the purpose of the contraseption using ; whether to organize the birth range, or to limit the number of children 4. Ask the about he patients believe/ religion that maight opposed one of the family planning methods. 5. Discuss the patients need, her consideration and worry 6. Help the patient to choose the best method for her 7. Should the patient requires IUD: Explain all the possible adverse effect of Cu T 380 A until she fully understands the information. PRE INSERTION COUNSELING AND CLIENT SELECTION 1. Conduct a thorough history taking ensuring no resistant condition, medically, that might be influenced by the IUD. 2. Ask about the patient reproductive health history; The last menstrual periode date, menstrual duration, and menstrual pattern The parity and the last birth history CASES 1 2 3

History of Ectopic pregnancy Severe pain during every menstrual period Severe anemic condition ( Hb < 9 gr % or Hm < 30 ) History of genital organs infection, sexually transmitted diseases or other pelvic infection cases Occupies more than one partner Cervix cancer 3. Explain that the procedure pre-requisites physical examination to be performed prior to inserting the device to assess the size, shape, depth and position of the uterus (including examination on the pelvic area), how it is going to be done, and give the patient opportunity to raise questions 4. Make sure the patient has emptied her bladder, and thorughly clean her external genital organs with soap. 5. Wash you hands with soap and streaming down water, and then dry them with a clean towel. 6. Help the patient to position her self on the bed. 7. Palpate the abdominal area, and identify any pain, lump, or other abnormalities on the supra pubic area. PELVIC EXAMINATION 1. Using the provided blanket, cover the patient body 2. Turn on the flood lamp, then properly direct it to the field of examination, which is the cervix 3. Wear a pair of DTT gloves 4. Set the instruments and materials on a sterilized tray 5. Inspect the external genitalia organs 6. Palpate the periurethral glands (Skene's glands) and Bartholini glands, locate any pain or discharge product 7. Insert the vagina speculum 8. Perform the following examination: - Identify any lesions or discharge on the vagina - Inspect the cervix 9. Carefully withdraw the speculum out, and place it back to the original position without touching any un-used instruments 10. Perform the following bimanual examination : - Ensure free movement of the cervix - Identify uterus size and position - Ensure no sign of pregnancy - Ensure no infection or adnexas tumor 11. Perform the retrovaginal examination due to the following indications: - Difficulty in defining the size of a retroversion uterus - Tumor in the cavum Douglassi 12. Place both gloved hands inside 0,5% clorine solution, clean the gloves from any secrete/fluid trace, then undo the gloves with inside surfaces exposed out.

PRE INSERTION ACTIVITIES 1. Explain the general overview of an IUD insertion process, what the patient would experience during the insertion and after ward, and notify the patient to feel free to inquire on anything related to the process . 2. Insert the Cu T380A arms in to their sterile pack, initially by: Carefully tear some part of the plastic package and then fold the overhang backward Insert the inserter rod inside its tube without touching any unsterilized materials Place the package on a flat surface Place a scale card underneath the IUD arms Hold the both IUD arms, and then push the inserter tube until it reaches and folds the armpits. Whenever the arms have folded (until they touch the inserter tube ), pull the inserter rod out (from underneath the arms fold) Lift, push and turn around the inserter rod slightly, to insert the folded arms of the IUD in to its tube. POST INSERTION ACTIVITIES 1. For decontamination purpose, collect the used instruments then place them all in a basin filled with 0,5% clorine solution for about 10 minutes 2. Dispose all the used/contaminated materials in the provided medical bins. Wipe clean all the contaminated surfaces with 0,5% clorine solution 3. Place both gloved hands inside 0,5% clorine solution, clean the gloves from any secrete/fluid trace, then undo the gloves with inside surfaces exposed out. Leave them inside for about 10 minutes. 4. Wash hands with soap and streaming down water 5. Ensure the patient is not having severe cramp, observe for about 15 minutes before letting her leaving the hospital POST INSERTION COUNSELLING 1. Teach the patient how to self-check the IUD thread, and when it should be done 2. Explain to the patient about what to do should any diverse effect takes place 3. Notify the patient when to return to the clinic for controlling 4. Remind the patient that the Cu T 380A insertion application is for 10 years 5. Ensure the patient to visit the clinic anytime she required counsultation, medical check up, or IUD removal 6. Ask the patient to repeat all of the provided explanation 7. Complete the patient medical status and hand in an IUD card to her

REFERENCE
-------------- Pelatihan Keterampilan AKDR. JNPK-KS, Mei 2000

CLINICAL SKILLS MANUAL

For Students
BREAST FEEDING TECHNIQUE

Given to the 4th Semester Students of Hasanuddin University Medical Faculty

Edited By: dr. Dwi Bahagia, PhD., Sp.A

REPRODUCTION SYSTEM
Medical Faculty Hasanuddin University 2012

Breastfeeding Technique
Learning Goals General Aim:
Students are expected to be able to demonstrate the breastfeeding technique correctly and give the standardized instruction to the mother after delivery.

Specific Aims:
At the end of the session students will able to Prepare the mother Prepare all instruments Explain the mother about the benefits and the correct techniques of breastfeeding Position the mother and baby in an appropriate way Make sure that the baby is correctly attached Explain the correct technique of breaking the babys attachment Explain the correct way to burp the baby after breastfeeding

Learning equipments:
1. Baby Mannequin 2. Breast model

Preparation for Mother:

1. Ask the mother to do the handwashing using water and soap 2. Make sure that the mother is in her most comfortable and relaxed position: sitting, lying down or standing up. Be sure that the feet are not hanging down while doing the sitting position. 3. Ask the mother to release a small amount of her breast milk and use it to gently scrub the nipple and the area surrounded. This will disinfect and moisture the nipple.

BREAST FEEDING TECHNIQUES

Activities Description
Activities 1. Introduction 2. Role play demonstration, QA session Time allocated 2 minutes 23 minutes Description Introduction 1. Arranging the students seats 2. Two Instructors demonstrate an example on how to perform a correct breastfeeding technique using a mannequin. One istructor will act as a doctor while the other pne plays the babys mother Students are aske to observe 3. Allowing students to ask any questions they have regarding the demos. Instructor emphazises all important points. 4. Students are given opportunity to observe and ask anything that needs to be clarified. Instructor will provide them with answers 1. Students are divided into pairs 2. Each couple will perform the role play, one person will act as the doctor and the other will play the mother role 3. Students who play the doctor role will explain and demonstrate the breastfeeding technique 4. Instructor will supervise all the student activities using check list 5. Each students is expected to practice at least once during the day sessions. Brain storming/Discussion: students are given the opportunity to raise any issues that they might have including any difficulties during the sessions. Students are also allowed to mention any good things that they have experienced in the class. Ask their impression on playing the mother role

3. Practicing the role play

90 minutes

4. Brain Storming/ Discussion

15 minutes

Total time allocated

150 minutes

SKILL MANUAL

BREAST FEEDING TECHNIQUES

Mark every clinical step using the following scoring categories: 1. Need to be improved: Steps that are not correctly performed, un-organized chronologically, or for some missed/left over steps 2. Able: Steps that are performed correctly, chronologically based, but not efficiently conducted 3. Master: Steps that are performed correctly, chronologically based, and efficiently conducted NS (Not suitable): Steps that are unnecessarily conducted due to the situation NO. INFORMED CONSENT Welcome the patient. Introduce yourself in a warm, friendly manner. 2. Convince the mother that she has the ability to breasfteed her baby like every other mother. Assist her to overcome her hesitation due to previous unpleasant breasfeeding experiences. 3. Inform the mother about the benefits of breastfeeding 4. Involve the husband or other family members 5. Allow the mother to ask any questions she might have regarding the procedures PREPARATION OF THE MOTHER: THE BABY POSITIONS 6. Ask mother to place her babys head at her elbow so that the babys bottom can be attached to her lower arm. The babys head should not face upward and the bottom must be supported using one hand of the mother. 7. Ask mother to hold her baby using one arm 8. Ask mother to position the baby facing her abdominal side or the breast. The babystomach has to be attached to the mothers body. The babys head needs to face the breast of the mother. The babys ears and arms will then be located at one horizontal line. 9. Ask the mother to position one of the babys arms just under her axilary side while the other arm should be placed at the front. 10. Ask mother to maintain an eye contact to her baby expressing her love. THE ATTACHMENT OF THE BABY 14. Ask mother to hold her breast using one thumb at the upperside 1. CLINICAL STEPS CASES

while the other fingers will support the breast at the inferior side. Do not apply a pressure solely to the the nipple and the areola. 15. Ask mother to encourage the baby to open the mouth (rooting reflex) by: - Gently touch the babys cheek using the nipple or - Gently touch the nipple to the edge of the babys lips 16. When the babys mouth is wide open, ask the mother to bring her baby to her chest and insert the nipple and the areole inside the mouth: - Try to insert most of the areola into the mouth so the nipple will be placed just under the palateal side. The babys tongue will be able to pump the milk from its source which is located just under the areola. - When the baby starts to suck, it is not necesary to hold the breast. 17. You can tell when the baby is attached correctly to breast by looking at these signs: - Chin is attached to the breast - Most of the areola are inserted into the mouth. This consists of mostly the lowerside of the areola - The lips is wide open - The mouth is wide open Detaching the baby 18. Ask mother to use the other breast when the other one is empty. Ask mother to releasing the baby by: - Insert the little finger into the corner of the babys mouth or - Gently press the babys chin down 19. Ask the mother to start the next breastfeeding using the previous used breast that is not empty yet. 20. When it is done, ask the mother to pump a small amount of milk and scrub it to the nipples and the areola surrounded. Let it dry. HOW TO BURP THE BABY 21. Ask the mother to burp the baby by: - Sit the baby up or hold the baby to her shoulder and then gently pat the babys back - The baby could be lying down then gently rub or pat the babys back.

Picture 1. Several breast feeding positions

a. Position the baby

b. Hold the breast

Picture 2. Baby Positioning

C A L M

Chin Areola Lips Mouth

X
Picture 3. Attachment (Latching on position)

Picture 4. Burping Technique