Pregnancy Examination Clinical Procedure / Steps

PREGNANCY EXAMINATION (ANC) CLINICAL PROCEDURE / STEPS SCALE SCORING 1 1. Inspection approval a. Greetings therapeutic. b. Explain this examination to the mother. c. Explain the purpose and expected results of the examination d. If the mother understands what has been said, ask for verbal consent regarding the examination that will be carried out. 2. tools preparation a. Tensimeter set b. Thermometer c. Watch d. 3 bottles (for thermometer) e. Tissue in place f. Blanket 2 3 4 g. Flashlight h. Metline i. Pelvic extender j. Hammer k. Laenec stethoscope / funandoscope / doppler l. Bent m. Tongue spatula n. Gauze and cotton o. Scales p. LILA height measuring tape q. Dressing Car / trolley r. Client Status s. Stationery t. Handschoen u. Like an instrument v. Cover / room cover. Patient preparation a. The patient is informed of the action to be taken b. Install the sling c. Explain the purpose and objectives of the physical examination d. Adjust the client's position 3. Ways of working : Washing hands General inspection Examination of the client's general condition and consciousness a. The general condition and consciousness of the client b. Body shape (tall, short, thin, fat, kyphosis, lordosis, scoliosis) c. How to walk d. Weigh yourself and measure your height e. External pelvic measurement (If necessary) Check vital signs (BP, Pulse, Temperature and respiration in one minute) Physical examination : EXAMINATION OF THE HEAD, FACE, NECK, CHEST. Adjust the client's sleeping position a. Head Examination - Scalp Cleanliness - Hair Construction - Hair Distribution b. Facial Examination Check whether there is edema, chloasma gravidarum or hyperpigmentation on the face. - Examining the eyes: Conjunctiva, sclera, pupils and eyelids c. Ear Examination - Cleanliness Secretions/Cerumen) d. Nose Examination - Nose Cleanliness (Are There Any Secretions) - Are there polyps? e. Examining the mouth and teeth: - Lips - Oral mucosa - Dental caries - Stomatitis - Molar - Tongue f. Check the neck - Enlarged tonsils, thyroid gland, enlarged jugular veins, and enlarged lymph nodes. g. Check chest - Check breathing movements - Auscultation of breath sounds - Breast:Shape, size, and symmetrical or not - The nipples are protruding or inverted, is there pigmentation in the areola area? - Presence/absence of other fluids or cholostrum - When the client raises her arms above her head, examine her breasts to determine whether there is retraction or not - The client lies down with the left hand on top and systematically palpates the left breast (after that the right one too). from the direction of the breast, axial: is there a mass or enlarged lymph vessels Ear (Is There is ABDOMEN EXAMINATION a. Check whether the uterine enlargement is appropriate for gestational age, the shape of the uterine enlargement, striae, lines, presence/ absence of surgical scars. b. Leopold's palpation examination: Prepare the patient to bend his legs Leopold I - Look and feel whether the uterus is contracting or not then collect the uterus towards the center. - Determine the height of the uterine fundus with a finger or metline (Mc Donald) - Determine the part of the fetus in the fundus Leopold II - Both hands are moved to the left and right sides of the mother's stomach. - Determine the small part of the fetus and the location of the fetal back (longitudinal, hard, elongated) Leopold III - Determine the part of the fetus in the lower uterine segment. - Determine whether the lowest part of the fetus has entered PAP or not Head: Hard, round, bouncy Buttocks: Soft, less round, less elastic Latitude: Uterine fundus is empty. Leopold IV - The patient's legs are straightened. - The examiner looks at the patient's feet - Determine how far the lower part of the fetus is in the pelvis using both hands. - Bring both hands together on the surface from the bottom - Both handsconvergent: Only a small part of the lower part enters the pelvis Secondhands parallel:Part of the head or lower part of the fetus enters the pelvic cavity. - Both handsdivergent:The largest part of the head or lowest part of the fetus enters the pelvic cavity and the largest size of the head has passed the PAP AUSCULTATION EXAMINATION a. Determine the position of the fetal back and look for the maximum puctum. b. Place the laenec stethoscope / funduscope at the maximum puctum (uterus does not contract). c. Feel the mother's pulse at the same time to compare it with the fetus' heart rate. d. Comparing sounds: - Maternal side: Aortic pulsation, bowel sounds - Child's side: Fetal heart rate, fetal movements. - In twins, fetal heart sounds are heard in two places with the same clarity but with different frequencies. e. Calculate the frequency of FHR by listening to the fetal heart rate for one minute PELVIC EXAMINATION a. Carrying out measurements of Distancia Spinarum b. Carrying out measurements of Distancia Kristarum c. Perform measurements of external conjugates d. Take hip circumference measurements EXTERNAL GENETAL EXAMINATION (USING HANDS SCOEN) a. Examination of the Vulva, Vagina, Edema, Varices, Scars and Fistulas. b. Presence/absence of vaginal discharge (color, consistency, amount and odor) Extremity examination a. There is / is no edema, varices, scars b. There is/isn't a signHOMAN SIGN c. Percuss or check the patellar reflex 4 Tidy up the patient 5 Clean up the equipment 6 Washing hands 7 Notify the results of the examination and therapeutic greetings 8 Documentation