Document 19320

I - Medical Part
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General Physical Examination touf&SKvrf;a=umif; [email protected]&mwGif
Management in Airway Obstruction
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Supra-pubic catheterisation
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Digital Per rectal Examination
Vaginal or Pelvic Examination
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Management in Breech Presentation
Tooth Extraction
Scaling Teeth
II - Obstetric and Gynaecological Part 38
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III - Dental Part
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Cement filling for tooth cavities
IV - Orthopaedic Part
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Management in Shoulder joint dislocation 95
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Management in Temporo-Mandibular joint
dislocation 103
Quizz Answer
Instrumental Delivery- forceps and vacuum 55
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ptkdpyfjzwfnSyf'%f&mrsm;ukd pDrHukojcif;
Suture of Perineal tears and Episiotomies 65
The procedures, explanations and treatments provided in this publication are based on research and consultation with medical and
nursing authorities. They all reflect accepted medical practices. Nevertheless they cannot be considered as absolute and universal
recommendations. The authors, the editor and the publisher disclaim responsibility for any adverse effects resulting directly or
indirectly from the suggested procedures, from any undetected errors, or from the reader’s misunderstanding of the text.
Aide Médicale Internationale
21/22-26 Maetao Road, Maesot, Tak 63110 Tel: (66) 055 54 32 31 / 08 78 48 60 15 Mail: [email protected]
Health Messenger
Issue No 39 vol.2 | Technical Cards
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[email protected] aqmif;yg;&Sifrsm;ESifh pmzwfy&dowfrsm;tm; aus;Zl;
Oyum& wif&Sdyga=umif;/ //
A technical card is practical course intended to
assist a medical or paramedical personnel to operate a basic, specific and clearly identified type of
health care.
We already received much positive feedbacks
from our readers, and as a result, we have been
much enthusiastic to continue working on the similar medico- technical procedures as an additional
volume to our previous health messenger issue.
But this time, we have introduced some more
specific clinical procedures on dental, orthopaedic,
obstetric and gynaecological fields. In each and
every article, our article countributors present step
by step instruction for those common procedures
and documentations, with many clear and easy-tounderstand illustrations to enhance comprehension
of our readers.
Some procedures may be unfamiliar with our
medic readers, but we would like to keep them
in this issue as our aim is to alleviate the medical
knowledge as well as to widen the scope of our
camp-based medical personnel.
We hope this issue will help our medical personnel fulfill their responsible duties properly and
systmatically. Moreover, we would like to thank all
our contributors and readers for these two consecutive volumes.
Publishing Manager: Augustin Remay Medical Editor: Dr. Min Editorial Committee: Dr. Ioana
Crestescu-Kornett, Dr. Nadia Trifonova Kancheva Landolt, Dr. Folaranmi Ogunbowale, Dr. Rose
McGready, Dr. Zaw Win, Dr. Claudia Turner, Dr. Aung, Dr. Marcus Rijken, Dr. Myo, Dr Htwe, Dr. Ei Ei,
Dr.Bo Bo, Erika Pied Distributor: Manit Tipbanjongsuk Graphic Designer: Patrice Leroy Illustrator:
Anchalee Areewong, Proof reader: Hannah Mundy, Dr. Khin Cho Printer: JCC
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
General Physical
Dr. Aung (Chulalongkorn University)
I. Physical Examination of the
patient (General view)
Physical examination is the evaluation of the
body and its functions using inspection (looking with the eyes), palpation (feeling with the
hands), percussion (tapping with the fingers),
and auscultation (listening with the ears). A
physical examination usually starts at the head
and proceeds all the way to the toes. However,
the exact procedure will vary according to the
needs of the patient and the preferences of the
examiner. The patient should be comfortable
and treated with respect throughout the examination.
1. Inspection
The visual examination of the body using the
eyes and a lighted instrument if needed.
2. Palpation
The examination of the body using the sense of
touch. There are two types: light and deep.
3. Percussion
An assessment method in which the surface of
the body is struck with the fingertips to obtain
sounds that can be heard or vibrations that can
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
General Physical Examination
be felt. It can determine the position, size, and
consistency of an internal organ. It is done over
the chest to determine the presence of normal
air content in the lungs, and over the abdomen
to evaluate air in the loops of the intestine.
4. Auscultation
The process of listening to sounds that are produced in the body. Direct auscultation uses the
ear alone, such as when listening to the grating of a moving joint. Indirect auscultation involves the use of a stethoscope to amplify the
sounds from within the body, like a heartbeat.
The examiner observes the patient’s appearance, general health, and behavior, along with
measuring height and weight. The vital signsincluding body temperature, pulse rate, respiratory rate, and blood pressure-are also recorded.
The following systems are reviewed from head
to toe of the patient:
• Head: The hair, scalp, skull, and face are examined.
• Eyes: The external structures are observed.
The internal structures can be observed
using an ophthalmoscope (a lighted instrument) in a darkened room.
• Ears: The external structures are inspected. An otoscope (an instrument with a
light for examining the internal ear) may
be used to inspect internal structures.
• Nose: The external nose is examined. The
nasal mucosa and internal structures can
be observed with the use of a penlight and
a nasal speculum.
• Mouth and pharynx: The lips, gums,
teeth, roof of the mouth, tongue, and
pharynx are inspected.
• Neck: The lymph nodes on both sides of
the neck and the thyroid gland are palpated (examined by feeling with the fingers).
• Breasts and armpits: A woman’s breasts
are inspected with the arms relaxed and
then raised. In both men and women, the
lymph nodes in the armpits are felt with
the examiner’s hands. While the patient is
still sitting, movement of the joints in the
hands, arms, shoulders, neck, and jaw can
be checked. The breasts are palpated and
inspected for lumps.
• Chest: The area is inspected and also examined by using palpation and percussion. A stethoscope is used to listen to the
breath sounds from the airway and sounds
from the heart.
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
General Physical Examination
Back: The spine and muscles of the back
are palpated and checked for tenderness.
The upper back, where the lungs are located, is palpated on the right and left
sides and a stethoscope is used to listen
for breath sounds.
Abdomen: Light and deep palpations are
used on the abdomen to feel the outlines
of internal organs including the liver,
spleen, kidneys.
Rectum and anus: With the patient lying on the left side, the outside areas are
inspected. If necessary, internal digital
examination (using a finger), is done. In
men, the prostate gland is also palpated.
Reproductive organs: The external sex
organs are inspected and the area is examined for hernias (The bulging of an
organ, or part of an organ, through the
wall containing it). In men, the scrotum is
palpated. In women, a pelvic examination
is done using a speculum and a (Pap test)
may be taken.
Legs: The legs are inspected for edema
(swelling). The joints and muscles are
observed. Pulses in the knee, thigh, and
foot area are palpitated. The groin area is
palpated for the presence of lymph nodes.
The presence of varicose veins (abnormally enlarged and twisted veins), usually in
the legs, is noted.
Skin: The exposed areas of the skin are
observed; the size and shape of any lesions
are noted.
5. Additional screen of the nervous
The patient’s ability to take a few steps and do
deep knee bends is observed. The strength of
the hand grip is felt. With the patient sitting
down, the reflexes (automatic response to a
stimulus) in the knees and feet can be tested
with a small hammer. The sense of touch in
the hands and feet can be evaluated by testing
reaction to pain and vibration.
Sometimes additional time is spent examining
the 12 nerves in the head (cranial) that are connected directly to the brain. They control the
sense of smell, strength of muscles in the head,
reflexes in the eye, facial movements, and muscles in the jaw.
II. Specific Procedures in
General Examination
1. Measurement of Temperature
It is to measure the amount of heat inside the
patient’s body by using the thermometer.
Axillary temperature
Health Messenger Magazine Issue 39 Vol.2
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) / ykd;0ifjcif;ukd qJvfrsm;[email protected]_a=umifh tzsm;wufjcif;/
ukd,fcHtm;ykdif;qkdif&mpepf aESmifh,SufcH&jcif; [email protected][kwf
jrpfyGm;emjzpfjcif;[email protected]=umifh jzpfEkdifonf?
vkdtyfaom ypPnf;rsm;
ao;i,faom xnfhcGuf
aqmif&Gufcsuf tqifhqifh
t&ufysH pdrfxm;aom tylcsdefwkdif; ud&d,mukd
xkwf,l+yD; *Grf;pvkH;i,frsm;ESifh okwfyGwfvkdufyg?
tylcsdefwkdif; ud&d,mukd cgcsvkdufjcif;jzifh ud&d,m
wGif;&Sd jy'g;onf 35 'D*&D pifwD*&[email protected]&muf&Sd
vlemukd yg;pyfzGifhckdif;xm;+yD; tylcsdefwkdif; ud&d,m.
jy'g;buftqkH;ukd vlem. vSsmtv,fykdif;atmuf
wGif xm;&Sd+yD; vlem. yg;pyfxJwGif rukdufrdapbJ
xkdtaetxm;wGif tylcsdefwkdif;ud&d,mukd 3 - 5
[email protected] xm;vkdufyg?
tylcsdefwkdif; ud&d,mukd xkwf,l+yD; ukd,fylcsdefukd
zwfI vlemrSwfwrf;[email protected][kwf vJrm;pmtkyfxJwGif
tylcsdefwkdif;ud&d,mukd 35 'D*&D pifwD*&[email protected]
jyefcgcsyg? t&ufysHxnfhxm;aom cGufi,[email protected]
jyefxnfh xm;yg?
touf&SKjcif;pepfzdpD;r_. vuQ%mrsm;qkdonfrSm oufjyif;
&SKoHrsm; xGufaejcif;/ aoG;wGif; atmufqD*sif"mwfavSsmh
enf;aejcif; ( Elwfcrf;rsm; jymaejcif;/ vufonf;rsm;
jymaejcif;/ rsufESmjymESrf;aejcif;/ pojzifh) ESmacgif;xdyfv_yf
um;I touf&SKaejcif;/ &ifbwfatmufykdif; csdKifh0ifaejcif;/
touf&SKE_ef; jrefaejcif;)
ykHrSef touf&SKE_ef;rsm;rSm- &ifaoG;i,fwpfa,muftwGuf wpfrdepf vSsif 30 - 50 }udrf
- uav;wpfa,muftwGuf wpfrdepf vSsif 20 - 30 }udrf
- vl}uD;wpfa,muftwGuf wpfrdepfvSsif
14- 20 }udrf
vkdtyfaom ypPnf;rsm;
aqmif&Guf&onfh tqifhqifh
vlem. touf&SKE_ef;ukd rppfaq;rSDwGif vlemtm;
tu,fI vlemonf vl}uD;jzpfaeygu prf;oyfrnfh
ta=umif;}udKodaevSsif rSefuefaom touf&SKE_ef;ukd
r&Ekdifaoma=umifh }udKwif+yD; ajymr xm;ygESifh?
2? touf&SKE_ef;ukd wkdif;wmjcif;
touf&SKonfh t}udrfta&twGufjzpfonf?
touf&SKjcif;ukd prf;oyf&mwGif aq;rSL;rS ppfaq;&
rnfrSm- touf&SKE_ef; (rnfrSs jrefaeonfukd)
- [email protected] rSefrSef&SKaeraeukd
- vlemonf touf&SK&ef cufcJr_ &Sdr&Sdukd
- touf&SKjcif;pepfzdpD;r_. vuQ%mrsm; &Sdr&Sd qkdonf
[email protected]?
Health Messenger Magazine Issue 39 Vol.2
General Physical Examination
The normal oral or ear temperature is 37 C but
the range is between 35.8 and 37.2˚ C. Rectal temperature is usually about 0.5˚ C higher
than in the mouth, which in turn, is 0.5 ˚ C
higher than the axilla, but the axilla is not the
reliable site for measurement. Body temperature is usually taken beneath the tongue, or in
Rectal temperature
the rectum or the external auditory meautus.
Shake the thermometer down so that the
mercury inside is about 35˚ C.
Ask the patient to open mouth, place the
mercury end of the thermometer under
the middle part of the tongue and let him/
her keep it in her mouth without biting.
Keep the thermometer in position for 3- 5
Take the thermometer out, read the temperature and report it on the patient’s
chart or lema.
Shake the thermometer back down to 35˚
C. Put it in the small container with savlon antiseptic solution.
2. Respiratory Rate Measurement
Increase in body temperature- high oral temperature above 37.2˚ C is an important physical sign. It may be due to humid environment
(heat illness), fever by cellular reponse to infection, immunological disturbance or malignancy.
Signs of respiratory distress are wheezing, cyanosis (blue lips, blue nails, blue face, etc…),
flaring nose, chest indrawing, fast respiratory
A small container
Cotton wool balls
The respiratory rate is the number of breaths
taken by the patient within a minute.
While checking the respiration, the medic
should check: - respiratory rate (how fast it is)
- how regular it is
- if the pateint has difficulty in breathing
- Signs of respiratory distress (+) or (-).
Remove the thermometer that has been
soaked with Savlon antiseptic solution
and wipe it with the cotton wool ball.
Normal respiratory rates are:- 30 - 50 per minute for a baby
- 20 - 30 per minute for a child
- 14 – 20 per minute for an adult
Health Messenger Magazine Issue 39 Vol.2
vlemtm; ukd,fcE<mykdif;qkdif&m prf;oyfppfaq;jcif;
tu,fI vlemonf uav;jzpfaeygu ikda=uG;jcif;
[email protected][kwf tvGefv_yf&Sm;aejcif; rvkyfapbJ +idrfouf
aeap&ef vkdtyfonf?
&ifbwfv_yf&Sm;r_ukd =unfh&SKyg [email protected][kwf vlem.
&ifbwftay:ykdif;wGif vufwpfzufukd wifxm;+yD;
&ifbwfazmif;=uGvmjcif; (touf&SKaepOftwGif;
tqkwfwGif;[email protected])ESifh &ifbwf
tqkwfwGif;rSavrsm;jyefxGufoGm;jcif;)ukd [email protected]
cHpm;Iprf;oyfEkdifonf? &ifbwfwpf}udrfjrifhwuf+yD;
wpf}udrfjyefusoGm;jcif; wpfausmukd touf&SKE_ef;
wpf}udrf[k owfrSwfa&wGuf&onf?
vlemrS toufp&SLvkdufaomtcg touf&SKE_ef; ukd
pwifa&wGufvkduf+yD;tjcm;vuf wpfzufjzifh em&Dukd
wpfrdepftwGif; v_yf&Sm;r_rsm;ukd a&wGufyg?
vJrm;pmtkyf [email protected][kwf twGif; vlemrSwfwrf;xJwGif
rSefuefpGm a&;rSwfyg?
3? aoG;ckefE_ef;ukd wkdif;wmjcif;
aoG;ckefE_ef;qkdonfrSm wpfrdepftwGif; ESvkH;ckefonfh
aoG;ckefE_ef;ukd wkdif;wm&mwGif ppfaq;&rnfrSm- aoG;ckefE_ef; (rnfrSsjrefaeonfukd)
- aoG;ckefE_ef;. pnf;csuf (pnf;csufrSef rrSef)
- aoG;ckefE_ef;. yrm% (yrm% rsm; rrsm;) ESifh
- aoG;ckefE_ef;ykHpH
xkd;xkd;usoGm;jcif; pojzifh)
vkdtyfaom ypPnf;rsm;
aqmif&Gufenf; tqifhqifh
aoG;ckefE_ef;ukd rwkdif;wmrSD vlemukd 10 [email protected] tem;,l
ap&rnf? vufxJwGif em&DwpfvkH;ukd a&[email protected];yg?
1? vufaumuf0wf aoG;ckefE_ef;
‡ vufaumuf0wf aoG;ckefE_ef;ukd ykHrSeftm;jzifh zvufpf
qm umyDa&'D;&,fvpf t&Gwfa=umab;wGif prf;oyf
[email protected]&SdEkdifonf?
‡ vlem. vufaumuf0wfay:&Sd nmbufvuf
aumuf0wfaoG;a=umay:wGif oif. tv,f
vufacsmif; okH;acsmif;ukdwifxm;yg? (vlem. vufr
atmufajcteD;&Sd ae&mbufwGif)
‡ tvGefnifompGmzdxm;+yD;aemuf ckefaejcif;ukd cHpm;
&vSsif 4if;onfaoG;ckefE_ef;jzpfonf? vufacsmif;
rsm;. vufxdyfjyifukdokH;I aoG;ckefE_ef;/ pnf;csufESifh
yrm%[email protected] cHpm;=unfhyg?
‡ em&Dukd =unfh&if;jzifh wpfrdepfjynfhatmif aoG;ckefE_ef;
ukd a&wGufyg?
‡ xkd;xkd;usoGm;aom aoG;ckefE_ef;ukd od&SdEkdifap&ef
vlem. vufarmif;ukd ajrSmufxm;vkduf+yD; oifh
vufacsmif;rsm;ESifh aoG;ckefE_ef;ukd prf;oyfyg?
Radial pulse examination
Taking a Pulse
ykHrSefaoG;ckefE_ef;rsm;rSm- &ifaoG;i,f wpfa,muftwGuf wpfrdepf vSsif 120 - 150 }udrf
- uav;wpfa,muftwGuf wpfrdepfvSsif 90- 120 }udfrf
- vl}uD;wpfa,muftwGuf wpfrdepfvSsif 60 - 100 }udrf
Health Messenger Magazine Issue 39 Vol.2
General Physical Examination
Patient should be taken at rest before
checking their respiratory rate.
If the patient is an adult, do not tell him/
her because he will be aware of it and it
will not be the correct respiratory rate.
If the patient is a baby or a child, he needs
to be kept quiet without crying or many
Look at the chest movement or place one
hand on the patient’s upper chest to feel
as it rises (as air goes inside the lungs during inspiration) and as it falls (air goes out
of the lungs during expiration). Each rise/
fall cycle is counted as one respiration.
Start counting the rate when the patient
breathes in by holding the watch in the
other hand.
And count the movements during one
Record it correctly on the Lema or IPD
3. Pulse rate Measurement
Pulse character (slow-rising, collapsing,
The patient must take test for 10 minutes
before checking the pulse. Hold the watch
in one hand in front.
1. Radial Pulse
‡ For radial pulse, it is usually found at the
wrist, lateral to flexor carpi radialis tendon.
‡ Place three middle fingers over the right
radial pulse over the patient’s wrist (on the
side near the thumb base of patient).
‡ Press very slightly and may feel a beat and
this is the pulse rate. Use the pad of fingers
to access the rate, rhythm and volume.
‡ Count the pulse for a full minute, looking
at the watch.
‡ To detect a collapsing pulse, raise the patient’s arm and feel across the pulse with
your fingers.
Pulse rate is the number of heart beats per
When measuring the pulse, check:- Pulse rate (how fast it is)
- Pulse rhythm (regular or irregular)
- Pulse volume (high or low) and
Normal pulse rates are:- 120- 150 per minute for a baby
90- 120 per minute for a child
60- 100 per minute for an adult
Health Messenger Magazine Issue 39 Vol.2
vlemtm; ukd,fcE<mykdif;qkdif&m prf;oyfppfaq;jcif;
‡ [email protected] b,fbuf vufaumuf0wf aoG;ckef
E_ef;ukdprf;oyfyg? tu,fI aoG;ckefE_ef;onf
wpfbufbufwGif yrm%avsmhonf[kcHpm;&ygu
xkduGJjym;aejcif;ukd vlem. b,fnmvufaumuf0wf
ESpfbufvkH;ukd w+ydKifwnf; prf;oyf+yD; twnfjyKyg?
2? wHaqmifqpf aoG;ckefE_ef;
‡ wHawmifqpf aoG;ckefE_ef;onf }wd*HykHvufarmif;
pGef;=uGufom;t&Gwf. ukd,fcE<mbufwGif&Sdaom
wHawmifqpfa&[email protected];ae&mwif
‡ vufr (vlem.nmvufarmif;twGuf oifhnm
vufrukdtokH;jyK+yD; b,fbufukdvnf; b,fvufjzifh
prf;oyfyg)okH;I vufacsmif;ukd wHawmifqpf
aemufbufwGif cGufykHpHywfI prf;oyfyg?
‡ aoG;ckefE_ef;ukd [email protected]&ef }wd*HykHvufarmif;pGef;=uGuf
om;t&Gwf. ukd,fcE<mbufjcrf;ukd prf;oyf=unhf+yD;
oabmobm0ykHpHukd qkH;jzwfyg?
Brachial pulse examination
‡ [email protected];a=umifh
avsmhusjcif;ukd jzpfay:vmEkdifjcif;a=umifh vlemukd
ckwifay:wGif vJavSsmif;aeapyg?
‡ vnfyif;ykdif; aoG;v$wfa=um ESpfbufpvkH;ukd
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‡ vllem. nmbuf vnfyif;ykdif; aoG;ckefE_ef;twGuf
oifhb,fvufrukd tokH;jyK+yD; b,fbuftwGuf
‡ toHtkd;ESifh &[email protected]&kd;/ nSyf&kd;ESifh em;aemufbuf&dS
=uGufom;rsm;. ta&[email protected] ae&m=um;
wGif vufrxdyfykdif;ukd wifvkdufyg?
‡ aoG;ckefE_ef;ukd prf;oyf&ef [email protected]
nifompGm zdcsvkdufyg?
‡ em&Dukd =unfh&if;jzifh wpfrdepfjynfhatmif aoG;ckefE_ef;
ukd a&wGufyg?
‡ vJrm;pmtkyf [email protected][kwf twGif;vlemrSwfwrf;wGif
rSefuefpGm rSwfwrf;wifyg?
txl;ojzifh vlemonf touf 65ESpf txufjzpfaeygu
vlem. vnfyif;ykdif;aoG;ckefE_ef;ukd prf;oyf&mwGif owd}uD;
pGmxm;&ef vkdtyfonf? oifjyif;xefpGm zdESdyfvkdufygu
vlemonf aoG;a&mufenf;+yD; vJusoGm;Ekdifonf?
4? aoG;aygifcsdef zdtm;ukd wkdif;wmjcif;
aoG;a=umrsm;. eH&Hrsm;ay:[email protected] oufa&mufaom zdtm;
3? vnfyif;ykdif; aoG;ckefE_ef;
‡ &[email protected]&kd;/ nSyf&kd;ESifh em;aemufbuf&Sd=uGufom;
rsm;. a&[email protected]&Sd ar;&kd;. axmifhpGef;wGif vnfyif;ykdif;
aoG;ckefE_ef;ukd vG,fulpGmprf;[email protected]&SdEkdifonf?
aoG;aygifcsdefwGif wefzkd; 2 rsdK;&Sdonf?
- yxrqkH; qlnHoHukd =um;odEkdifaom tjrifhqkH;
aoG;aygifcsdefzdtm;onf ESvkH; aoG;nSpfonfh
aoG;aygifcsdefjzpf+yD; (tay:aoG;)
- oifaemufqkH;=um;&aom
tedrfhqkH; aoG;aygifcsdefzdtm;onf ESvkH;nSpfem;csdef
aoG;aygifcsdefzdtm; (atmufaoG;) jzpfonf?
Health Messenger Magazine Issue 39 Vol.2
General Physical Examination
‡ Then palpate the left radial pulse. If either
pulse feels diminished in volume, confirm
any difference by simultaneous palpation.
2. Brachial Pulse
‡ The brachial pulse is found in the antecubital fossa medial to the biceps tendon.
‡ Use thumb (right thumb for right arm
and vice versa) with finger cupped round
the back of elbow.
‡ Feel medial to the tendon of biceps muscle
to find the pulse and assess its character.
3. Carotid pulse
‡ The carotid pulse is most easily palpable
at the angle of the jaw, anterior to sternocleidomastoid muscle.
‡ Let the patient lie on a bed in case reflex
bradycardia is induced.
‡ Never compress both carotid arteries simultaneously.
‡ Use left thumb for the right carotid pulse
and vice versa.
Carotid pulse examination
‡ Place the tip of thumb between the larynx
and the anterior border of the sternocleidomastoid muscle.
‡ Press thumb gently backwards to feel the
‡ Count the pulse for a full minute, looking
at the watch.
‡ Record it correctly on the Lema or IPD
Need to be careful when checking pulse in the
patient’s neck, especially if he is older than 65.
If you press too hard, he may become lightheaded and fall.
4. Blood Pressure Measurement
Blood pressure is the force exerted by circulating blood on the walls of blood vessels.
Blood pressure has two values:- Peak value where the first noise can be
heard is systolic blood pressure and
- Minimal value where the last noise you
hear is diastolic blood pressure.
Sphygomanometer with correct size of
Normal values- Systolic blood pressure – 100 – 140 mmHg
- Diastolic blood pressure – 70- 90 mmHg
Health Messenger Magazine Issue 39 Vol.2
vlemtm; ukd,fcE<mykdif;qkdif&m prf;oyfppfaq;jcif;
- ESvkH;aoG;nSpfonfh aoG;aygifcsdef (tay:
aoG;)onf 100 - 140 jy'g;rDvDrDwmjzpf+yD;
- ESvkH;nSpfem;csdef aoG;aygifcsdefzdtm; (atmufaoG;) onf 70 - 90 jy'g;rDvDrDwm
vkdtyfaom ypPnf;ud&d,mrsm;
aoG;aygif csdefwkdif; ud&d,m
aqmif&Guf&rnfh enf;tqifhqifh
pwifraqmif&GufrSD vlemukd 5 [email protected];,lae
rwfwwf&yfEkdifaom vlemrsm;wGif xkdifaepOftwGif;
aoG;aygifcsdefwkdif;wm &,lEkdifonf? vlem. rnfonfh
vufukdrqkd tokH;csprf;oyfEkdifonf?
[email protected];ckdif;xm;+yD;
ESvkH;tdrfESifh wwef;wnf;avmufwGif oufawmifh
oufom wifxm;apyg?
vufarmif;txufbufykdif;&Sd vufarmif;aoG;v$wf
a=umtay:ukd vufywftv,fae&mESifh ywfxm;
vkdufyg? vufarmif;. twGif;bufykdif;wGif &mbm
ykdufESpfacsmif;ukd rSefuefpGmae&mcs xm;yg?
vufywfatmufbufwGif&dSaom vufarmif;aoG;ckef
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aoG;ckefE_ef; prf;oyf&&Sdaomae&mwGif em;usyfukd
aoG;ckefE_ef;ukd prf;oyfr&onftxd aoG;aygifcsdef
wkdif;ud&d,mrS zdtm;ukdjrSifhwifvkdufyg? ud&d,m&Sd
aoG;zdtm;ukd rSwfom;xm;yg? 4if;onf ESvkH;
aoG;nSpfonfh aoG;aygifcsdefukd t=urf;zsif;[email protected]
[email protected] aemufxyf 10 jy'g;rDvDrDwm zdtm;ukd
jrSifhwifvkduf+yD; vufarmif;aoG;v$wfa=umay:ukd
em;usyfwif+yD; em;axmifvkdufyg?
ykHrSeftoHrsm; yxrqkH; jyef=um;&onftxd zdtm;ukd
ajz;nSif;pGm avSsmhcsvkdufyg? [email protected]&Sdcsufzdtm;ukd
a&;rSwfxm;+yD; 4if;rSm tay:aoG; (ESvkH; aoG;nSpfonfh
aoG;aygifcsdef) jzpfonf?
toHrsm; aysmufuG,foGm;onftxd zdtm;ukd
ajz;nSif;pGm qufvufavSsmhcsyg?
toH vkH;0aysmufuG,foGm;onhf zdtm;ae&mukd
ESvkH;nSpfem;csdef aoG;aygifcsdefzdtm; (atmufaoG;)
[k rSwfwrf;wifxm;yg?
vufarmif;ywfzdtm;ukd vkH;0avSsmhcsvkduf+yD; vuf
aoG;aygifcsdefukd vJrm; [email protected][kwf twGif;vlem
rSwfwrf;wGif rSefuefpGm rSwfwrf;wifyg?
Brachial artery
Health Messenger Magazine Issue 39 Vol.2
General Physical Examination
Let the patient rest for five minutes before
the procedure.
In ambulatory patients, measurements
can be made while keeping the patient
seated. Either arm can be used.
Ask the patient to stretch out the arm and
support it comfortably at the heart level.
Apply the cuff to the upper arm with the
centre of the bladder over the brachial artery. Put correctly the two rubber tubes on
the internal part of the arm.
Use two fingers to palpate the brachial
pulse just below the cuff.
Place the stethoscope on the place where
the pulse is felt.
Inflate the cuff until the pulse is impalpable. Note down the pressure on the
manometer. This is rough estimation of
systolic pressure.
Then inflate the cuff for another 10
mmHg and listen through the stethoscope
over the brachial artery.
Deflate the cuff slowly until regular sounds
are first heard. Note the reading down and
this is the systolic pressure.
Continue to deflate the cuff slowly until
the sounds disappear.
Record the pressure at which the sounds
completely disappear as diastolic pressure.
Deflate the cuff completely and remove
the armband.
Record it correctly on the Lema or the
IPD chart.
Health Messenger Magazine Issue 39 Vol.2
touf&SLvrf;a=umif; [email protected]&mwGif
a'gufwmrsdK; (attrftkdif)
touf&SKvrf;a=umif;wGif tpkdiftcJ0wWK/ t&nf [email protected][kwf
vSsmaemufykdif;ESifh [email protected] touf&SKvrf;a=umif;
[email protected]; [email protected][kwf touf&SKusyfjcif; jzpfyGm;onf?
4if;tajctaeonf vnfacsmif;[email protected][kwf av&SKjyGefukd
[email protected];a=umifh aemufqkH;wGif toufaoqkH;jcif;[email protected];w
nfoGm;Ekdifaomtouf&SK&yfqkdif;apjcif;ukd jzpfay: aponf?
wGif;[email protected] t&m0wWKukd z,f&Sm;ypf&ef aqmif&Guf
aomenf;vrf;tqifhqifhjzpfonf? 4if;ukd ESvkH;aoG;[email protected]
jcif;/ wufjcif;/ owdvpfjcif; ponfhtajctaersm;ESifh
a&maxG;rSm;jcif; r&Sdap&ef ta&;}uD;onf?
&[email protected]&Sd&onfh vuQ%mrsm;
• vlemonf pum;rajymEkdifjcif; [email protected][kwf toHrjyK
Ekdifjcif;[email protected] &SdEkdifonf/
• aoG;xJwGif atmufqD*sif"mwfenf;yg;jcif;a=umifh
vlem. rsufESmonf tjyma&mifajymif;aeonf?
• vlemonf [email protected];ukd owd}uD;pGmjzifh nSpfxm;
• vlemonf tm;aysmhpGm acsmif;qkd;ae+yD; tiftm;okH;
touf&SKjcif;a=umifh qlnHoHjrifhrsm; xGufay:ae
• ukor_r&vsif vlemonf vsifjrefpGm owdvpfoGm;
aqmif&Guf&rnfh enf;vrf;tqifhqifh
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wpfzufukd xm;+yD; tjcm;vufwpfzuf. vufzaemifhukd
vlemh&ifbwfay:wGif wifxm;yg/ [email protected] &ifbwfykdif;
zdESdyfay;jcif;ukd 5 }udrf cyfqwfqwfzdESdyfay;yg?
Health Messenger Magazine Issue 39 Vol.2
Management in Airway
Dr. Myo (AMI)
Airway obstruction or choking occurs when
the airway becomes blocked by a solid object,
liquid, or by the back of the tongue. This can
cause hindrance of breathing, finally leading to
death due to obstruction of the throat or windpipe. The Heimlich Maneuver is the technique
used in order to dislodge the obstruction. It is
important not to confuse airway obstruction
with a heart attack, seizures or fainting.
support and place the heel of the other hand on
the chest. Then give 5 chest thrusts sharply.
Symptoms and Clinical Signs
The patient cannot speak or cry out.
The patient’s face turns blue (cyanosis)
due to lack of oxygen.
The patient desperately grabs at his or her
The patient has a weak cough, and labored breathing produces a high-pitched
Without treatment, the patient will quickly become unconscious.
Chest thrusts
First, apply chest thrusts as follows:- place
one hand in the middle of the patient’s back for
If unsucessful to clear the blockage,
Apply up to the back blows as follows:1. Stand to the side and slightly behind the
Health Messenger Magazine Issue 39 Vol.2
touf&SLvrf;a=umif; [email protected]&mwGif pDrHukojcif;
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ykdif;ukd ywf+yD;zufxm;vkdufyg?
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taetxm;wGif qkyfukdifxm;vkdufyg?
7— vlem.0rf;Akdufukdtay:[email protected];wnf+yD; cyfjyif;jyif;
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8— nSpfIzdESdfyfay;csuf t}udrfwkdif;ukd jyifyrS t& jyKwf
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10— tu,fI pDrHukocsuf ratmifjrifygu vlemonf
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11— jyifyrSt&m0wWK tjyifjyefa&mufonftxd [def;rf
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pDrHaqmif&Gufcsufonf toufu,fq,fa&;enf;pepf
Health Messenger Magazine Issue 39 Vol.2
Management in Airway Obstruction
2. Support the chest with one hand
3. Give up to five sharp blows between the
shoulder blades with the heel of the other
Abdominal thrusts lift the diaphragm and force
enough air from the lungs to create an artificial
cough. The cough is intended to move and expel an obstructing foreign body in airway. Each
thrust should be given with the intention of
removing the obstruction.
1. Ask the choking patient to stand if he or
she is sitting.
2. Place yourself slightly behind the standing
3. Reassure the patient by explaining the procedure and that you are going to help.
4. Place both of your arms around the patient’s upper part of abdomen.
5. Clench your fist with one hand and place
your thumb toward the victim, just above
his or her umbilicus.
6. Grab your fist with the other hand.
Back blow
If it fails, continue to the following method of
abdominal thrusts (Heimlich Maneuver).
Heimlich Maneuver
Abdominal thrusts also known as the Heimlich
Maneuver are a series of under-the-diaphragm
abdominal thrusts.
Abdominal thrusts are recommended
to clear a blocked airway in conscious
adults and children over one year of age.
They are not recommended for choking in
infants under one year old.
Health Messenger Magazine Issue 39 Vol.2
touf&SLvrf;a=umif; [email protected]&mwGif pDrHukojcif;
jzpf+yD; Tenf;pepfukd oif=um;xm;aom rnfolrqkd
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[email protected][kwf [email protected] t+idrft&m0wWK
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&&SdapEdkfif+yD; owd}uD;pGm xm;&ef vkdtyfonf?
jyifyrS t&m0wWKrsm;onf yg;pyfem;[email protected]
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[email protected]/ tu,fI vlemonf owd&Sdaeygu
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aeyguvnf; aq;rSL;rS vlemukd tajctaejyefaumif;onfh
[email protected]
t&m0wWKonf urBmhqGJtm;jzifh tvkdvkfd xGufusvm
&ifaoG;i,frsm;ESifh uav;rsm;wGif
&ifbwfykdif; zdESdyfay;jcif;
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rsufESmarSmufvSsuf taetxm;jzifh OD;acgif;ukd
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bufrS zdESdyfay;jcif; 5 }[email protected] aqmif&Gufyg?
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onfht&mukd oifhvufnSd;wpfacsmif;jzifh z,f&Sm;
ypfyg? Remove the object with your finger
• [email protected]&Guf&ef ratmifjrifygu uav;ukd
[email protected] arSmufcsvkdufyg? uav;.
aemufausmukd oifhvufwpfbufrS vufzaemifhjzifh
tiftm;okH;zdESdyfay;yg [email protected][kwf uav;. &[email protected]&kd;
tv,fem; ay:wGif oifhvufnSd;ESpfacsmif;ukd
wifxm;+yD; 5 }[email protected] [email protected] vSsifjrefpGm
Health Messenger Magazine Issue 39 Vol.2
Management in Airway Obstruction
7. Deliver five upward squeeze-thrusts sharply
into the abdomen.
8. Make each squeeze-thrust strong enough
to dislodge a foreign body.
9. Try to ensure that your thrusts make the diaphragm move air out of the patient’s lungs,
resulting in a kind of artificial cough.
10. Keep a firm grip on the patient, since he or
she can lose consciousness and fall to the
ground if the maneuver is ineffective.
11. Repeat the Heimlich maneuver until the
foreign body is expelled. If necessary, alternate five back blows with five abdominal
Heimlich maneuver on oneself
Choking is common. Deaths due to choking
occur most commonly in children less than 3
years and in elderly people, but can occur at
any age. The Heimlich maneuver is a life-saving technique and can be administered by anyone who has learnt the technique. When no
one else is around, the Heimlich maneuver can
be self performed.
recovery position so that the object should fall
out due to gravity.
Chest thrusts for Infant and
If the baby is distressed or stops coughing,
lay face down on your forearm with the
head low and support his back and chin.
- Give up to 5 back slaps between the shoulder blades.
- Check the mouth. Remove any noticeable
obstruction with one finger.
- If this fails, turn the baby on to his/her
back. Give up to 5 forceful blows on the
infant’s back with the heel of your hand or
place two fingers in the middle of the infant’s sternum and give five quick downward thrusts with two fingers.
If the baby is unconscious, try up to 5 mouthto-mouth breaths.
A person may also perform abdominal thrusts
on himself by using a fixed object such as a
railing or the back of a chair to apply pressure
where his hands would normally do the procedure. But this may cause internal injuries and
so requires great caution.
The medic can use his finger to sweep foreign objects away once they have reached the
mouth. However, if the patient is conscious, he
will be able to remove himself, or if they are unconscious, the medic should place the patient
Health Messenger Magazine Issue 39 Vol.2
touf&SLvrf;a=umif; [email protected]&mwGif pDrHukojcif;
tu,fI uav;onf owdvpfaeygu yg;pyfcsif;awhI
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uav;i,f toufjyef&SKEkdifonftxd puf0ef; tywf
vnfatmif qufvufaqmif&Gufyg? - aemufausmukd
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vkH;0 rzdrdygapESifh?
Health Messenger Magazine Issue 39 Vol.2
Management in Airway Obstruction
Continue the cycle of back slaps, chest thrusts,
mouth checks and breathing attempts until the
baby restarts breathing.
Tips & Warnings
If patient is coughing strongly or able to
talk, let him try to expel the foreign body
using his own efforts.
• If the choking patient seems to have a weak
or ineffective cough, this indicates that air
exchange is minimal and you should start
the Heimlich Maneuver. .
• To avoid bone fracture, never place your
hands on the patient’s sternum or lower rib
cage during the Heimlich Maneuver.
Health Messenger Magazine Issue 39 Vol.2
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ta&jym; aumfwdwfrsm; [email protected][kwf csKyftyfxdef;
tygt0if EkdifvGefcsKyf}udK;rsm; 3-0
Health Messenger Magazine Issue 39 Vol.2
Dr. Htwe (Chulalongkorn University)
Equipments/Materials needed
Suprapubic urinary bladder catheterization is a
commonly performed procedure to relieve urinary retention when transurethral catheterisation presents difficulties or is contraindicated,
and when there is a risk of damage to the urethra with the catheter.
Urethral injuries
Urethral obstruction
Bladder neck masses
Benign prostatic hypertrophy (BPH)
Prostate cancer
Management of pelvic surgery
Unable to palpate distended bladder
Gross haematuria or clot retention
Previous abdominal or pelvic surgery
Known or suspected carcinoma of bladder
Recent cystostomy
Sterile gloves
Antiseptic solution
Gauze squares, 4 X 4
Sterile drapes
Anesthetic solution without epinephrine
Syringe, 10 mL
Needles, 18 and 25 gauge
Scalpel blade, No. 11
Syringe, 60 mL
Percutaneous suprapubic catheter set
(Pediatric: 8F, 10F; Adult: 12F, 14F, 16F)
• Trocar or obturator
• Malecot catheter
• Connecting tube
• One-way stopcock
Urine leg bag
Drain sponges
Skin tape or nylon suture (3-0) with a
needle driver
Suture needle
1. Place the patient supine on the bed with
his or her legs spread apart.
Health Messenger Magazine Issue 39 Vol.2
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aqmif&Guf&rnfh enf;vrf;tqifhqifh
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onftxd qD;ykdufukd ajz;nSif;pGm jyefqGJyg?
19— [email protected];ykdufukd qD;okdavSmiftdwfESifh csdwfquf
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ta&jym;ESifh uyfwGJxm;vkdufyg?
20—vlemay:rSm t0wfumrsm;ukd z,f&Sm;vkduf+yD; ta&
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jzifh aq;a=umay;yg?
21— qD;ykdufazmuf0ifxm;aom qD;ykdufywf0ef;usifukd
[email protected]&;twGufaqmif&Gufyg?
Health Messenger Magazine Issue 39 Vol.2
Supra-pubic catheterisation
2. Obtain informed consent from the patient
or guardian.
3. Provide adequate parenteral analgesia with
or without sedation.
4. Clean the lower abdominal wall with a
5. Shave and disinfect the suprapubic area
with polyvidone iodine.
6. Palpate the distended bladder and mark the
insertion site at the midline and 2 fingers
(4-5 cm) above the pubic symphysis.
7. Apply an antiseptic solution from the pubis to the umbilicus.
8. Repeat the application of the antiseptic solution 2 more times and allow the area to
9. Apply sterile drapes and confirm the insertion site again by palpating the anatomic
10. Fill the 10-mL syringe with a local anesthetic agent and use the 25-gauge needle to
raise a skin wheal or bubble at the insertion
11. Advance the needle through the skin, subcutaneous tissue, rectus sheath, and retropubic space, while alternating injection and
aspiration, until urine enters the syringe.
Note the direction and depth required to
enter the bladder.
12. Using the No. 11 scapel blade, make a 4mm incision at the insertion site with the
blade facing inferiorly.
13. Insert the trocar or obturator into the Malecot catheter and lock it into the port.
14. Connect the 60-mL syringe to the port of
catheter unit.
15. Place the tip of the catheter–unit into the
skin incision and direct it caudally from
Suprapubic catheterization- position of trocar
Peritoneal cavity
Symphysis Pubic
Prostate Gland
Health Messenger Magazine Issue 39 Vol.2
qD;ckHrSwqifh qD;tdrfwGif; qD;ykdufxnfhjcif;
Peritoneal cavity
Suprapubic track
Symphysis Pubic
22—qD;ykdufukd ta&jym;ESifh wGJuyfxm;yg [email protected][kwf
qD;ykdufukd ta&jym;ESifh wGJcsKyfay;yg?
23— qD;ykdufpD;qif;r_pepf wpfckvkH;ukd tenf;qkH; [email protected]
wpf}udfrf [email protected]&Sif;a&;vkyfyg?
24— qD;ckHrS wqifh qD;ykdufxnfhxm;aom vlemrSeforSsukd
ta=umif;&if;cH a&m*grsm;tm; ukor_&Ekdif&ef qD;ESifh
ausmufuyfq&m0efxH v$Jajymif;ay;yg?
25—qD;ckHrS wqifhxnfhxm;aom qD;ykdufrsm;ukd 4
ywfxufykd+yD; qufrxm;oifhyg?
• qD;ykdufukd ae&mrSm;xm;jcif; [email protected][kwf taetxm;
• tlaygufjcif;ESifh 0rf;AkdufwGif; ukd,ft*Fgrsm; xdckduf
• c%wm jzpfyGm;aom jrifomxif&Sm;onfh qD;wGif;
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• [email protected];a=umifh jzpfyGm;aom qD;oGm;rsm;vmjcif;
• ta&jym;atmuf wpfoSsL;v$ma&mif&rf;jcif; [email protected]
r[kwf jynfwnfemjzpfjcif;
• qD;ykdufwGif; [email protected];
Health Messenger Magazine Issue 39 Vol.2
Supra-pubic catheterisation
true vertical towards the patient’s legs.
-The medic’s nondominant hand should
be placed on the lower abdominal wall,
and the unit should be stabilized between the thumb and index fingers.
- The dominant hand should be used to
advance the unit for 10- 15 cm, while aspirating, until urine enters the syringe.
- Once urine enters the syringe, advance
the unit 5 additional cm into the bladder.
16. While securing the unit with the nondominant hand, withdraw the trocar or obturator from the catheter.
17. Advance the catheter approximately 5 additional centimeters and then completely
remove the trocar or obturator needle.
18. Gently withdraw the catheter to lodge the
wings against the bladder wall.
19. The catheter is then connected to the
drainage bag, which should be secured to
the skin to prevent dragging.
20. Undrape the patient and apply skin preparatory solution (eg, benzoin) to the skin.
21. Apply drain dressings around the catheter
at the insertion site.
22. Tape the catheter to the skin or stitch the
catheter to the skin.
23. Clean the drainage system at least once a
24. All patients who undergo suprapubic tube
placement should be referred to urologist
for the treatment on underlying disease.
25. Suprapubic tubes should not be left in
place for more than 4 weeks.
Gross hematuria transient condition is
Post obstruction diuresis
Cellulitis and abscess formation
Obstructions in catheter
Displacement or malposition of catheter
Bowel perforation and intra-abdominal
visceral injuries
Health Messenger Magazine Issue 39 Vol.2
ptkdwGif; prf;oyfppfaq;jcif;
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ptkdwGif; prf;oyfppfaq;jcif;qkdonfrSm aq;ukoa&;
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• emusifjcif;ESifh ,m;,Hjcif;
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• tlvrf;a=umif;qkdif&m trltusifhrsm; ajymif;vJ
• 0rf;xJwGif tcGsJ [email protected][kwf aoG;ygjcif;
• 0rf;Akdufykdif; ta&;ay: emusifjcif;
• 0rf;Akdufatmufykdif; t}udwfwnfonf[k oHo,
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• qD;usdwfuifqmjzpfjcif;
• rdef;rukd,fwGif; prff;oyf&mwGif cufcJaejcif;
Health Messenger Magazine Issue 39 Vol.2
Per-rectal Examination
Health Messenger
Per rectal examination is an internal examination of the rectum by medical personnel.
There are two steps in per-rectal examination,
- Digital per-rectal examination as ordinary procedure
- Protoscopic examination,additional procedure for further pathological lesions
Gastro-intestinal indications
persistent diarrhoea or constipation
altered bowel habits
mucus or blood in the stool
acute abdomen
suspected lower abdominal mass
Genito-urinary indications
This procedure should be done with high caution as rectal area is very easily damaged in case
of malpractice.
Before this examination, the medic should take
complete thorough history of the patient,
During this conversation, the medic should pay
more attention to the complaints of patients in
history of present illness (HOPI). The patient’s
complaint may be directly linked with the following indications.
In male,
Benign prostatic hypertrophy (BPH)
acute or chronic prostatitis
carcinoma prostate
In female,
difficult vaginal examination
Unexplained prolonged backache due to
nerve root pain or bone pain
Pyrexia of unknown origin (PUO)
Following trauma to abdomen, pelvic,
spinal and perineal regions
Peri-anal indications
pain and itchiness
Health Messenger Magazine Issue 39 Vol.2
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wwd,=um;vltaejzifh olemjyKwpfOD;yg&Sdaeapoifh
+yD; trsdK;om; jzpfygu [email protected]&Guf&ef rvkdyg?
2— aqmif&Guf&rnfh enf;vrf;onf &Sufp&mjzpf+yD; tqif
odyfrajyaomfvnf; emusifr_ukd tvGefcHpm;&rnf
r[kwfa=umif; vlemukd &Sif;vif;ajymjyI tm;ay;yg?
3— ckwifpGef;wGif wifyg;/ 'l;rsm;ukd &[email protected]
auG;xm;+yD; ajczaemifhrsm;onf aygifcG=um;om;
ae&mrS uif;vGwfaeap&atmif vlemtm; b,fbuf
wapmif;taetxm;jzifh jyifqifae&mcsxm;yg?
4— vuftw
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(oefaumuf/ wkwfaumif) pGJaejcif;/ tjyifvdfyfacgif;/
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ptkdqufjyGef/ ptkduGJem [email protected] ta&jym;qkdif&m
tajctaersm;ukd ptkd0ef;usifae&mwGif =unfh&SK
Symphysis Pubis
Health Messenger Magazine Issue 39 Vol.2
Per-rectal Examination
References: needed
hand gloves
protoscopes of various sizes
water soluble lubricant (KY Jelly)
local anesthesia
rectal swabs
tissue papers
1. There should be good light and total privacy. A nurse should be present if the patient
is female for third party and if male, there
is no need to do so.
2. Reassure the patient by explaining that the
procedure may be embarrassing and uncomfortable, but not painful.
3. Prepare the patient. Lie them down in left
lateral position with buttocks at the edge of
the bed, knees drawn up to the chest and
heels clear from the perineum.
Position of the patient in PR examination
4. Put on the gloves. Separate the patient’s
buttocks and inspect the perianal skin for
dermatological conditions like perianal
warts, scabies, worms’ infestations, external
haemorrhoids, signs of trauma, rectal prolapse, fistulae and fissures. Don’t’ forget to
observe the anogential region carefully.
5. Ask the patient to strain during external
inspection and check –
- Rectal prolapse on straining
- Haemorrhoid prolapse
- Incontinence
- Whether straining is painful
6. Lubricate your finger with water-based gel.
Place the pulp of the finger on the anal
margin with the palm facing posteriorly.
The patient should be assured just before
putting in the finger. Pass the finger gently
through the anal canal into the rectum by
using steady pressure on the sphincter.
7. If anal spasm is present, ask the patient to
breathe out and relax. In case of anal spasm
and pain due to anal fissure, apply local
anesthetic gel to the anal margin for a few
minutes and retry again.
8. Ask the patient to strain and squeeze your
finger to access anal sphincter tone. Round
the finger around the walls of rectal mucosa through 360˚ to detect mass, stricture or
any tenderness. Note the proportion of the
rectal circumference and its distance from
the anus involving in any disease process
or lesion.
9. Palpate and identify the cervix in females
and prostate in males. Assess the size, shape,
consistency and note any tenderness when
examining prostate gland.
Health Messenger Magazine Issue 39 Vol.2
ptkdwGif; prf;oyfppfaq;jcif;
ppfaq;yg? ptkdESifh vdift*Fgae&mrsm;ukd aphpyfpGm
=unfh&SKppfaq;&efvnf; rarhavsmhygESifh?
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ptkdwGif;[email protected] vufnSd;ukd rxnfhrSDwGif vlemukd
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7— tu,fI ptkdnSpftm;jyif;aeygu vlemukd touf
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[email protected];rsm;ae+yD; emusifaeygu xkHaq;qDukd
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jy\em&Sdaomae&mrsm;ESifh ptkd0 rnfrSs uGma0;
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9— trsdK;orD;rsm;wGif om;tdrfacgif;ESifh trsdK;om;
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vuftdwfay:rS rpiftenf;i,fukd &,l+yD; "mwfcGJcef;
[email protected] [email protected] a[rkdatmuyfhwfac: rpifwGif;
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rygukd ppfaq;yg? ykd;arG;&ef ptkdwGif;rS jcpf,lxm;onfh
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12— vlem. ptkd0ukd wpf&SK;puULjzifh okwfypfyg?
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&kdufjcif;[email protected] vlemukdv$Jajymif;ay;yg?
Health Messenger Magazine Issue 39 Vol.2
Per-rectal Examination
Symphysis Pubis
10. Withdraw finger gently to avoid sudden
spasm, and inspect the glove at the fingertip for blood, pus, mucus, and stool colour.
11. Investigations- Apply a small amount of
stool from your glove and sent it to laboratory for faecal occult blood test by using
Haemoccult test cards. Take also rectal
swabs and rectal discharge for bacteria,
Chlamydia and viral infections.
12. Wipe the patient’s anus with tissue paper.
Protoscopy is done after digitial examination
unless sexually transmitted disease is suspected. But this procedure is usually rare to be performed.
If needed, refer the patient for further investigations like stool culture, sigmoidoscopy,
colonoscopy and barium enema.
Protoscopic Examination
Protoscopy is the way of additional examination to inspect the anal canal and rectal mucosa
and is adequate for detection of haemorrhoids,
fissures, rectal prolapse, and mucosal disease.
Health Messenger Magazine Issue 39 Vol.2
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• vdifykdif;qkdif&m apmufum;cH&onfh oHo,jzpfp&m
tr_rsm;wGif taxmuftxm;tjzpf &,l&ef
Health Messenger Magazine Issue 39 Vol.2
Vaginal or Pelvic
SMRU Doctors
It is hard to describe how to carry out a vaginal
or pelvic exam in a book. This is partly because
you will “see” with your fingers and not your
eyes. Health workers need training from an experienced person before trying a vaginal digital
examination themselves.
of Douglas such as in an ruptured ectopic
Gynaecological Indications
Obstetrical Indications
1. Pre-natal - To access the size of uterus in
order to determine gestational age in the
absence of ultrasound
2. During child delivery-To perform artificial rupture of membranes
- Check onset and progress of labour by
assessment of:
i. cervical dilatation, length and effacement
ii. station of the head
iii. presentation and position of the presenting part
iv. caput, molding
3. Determine if there is fluid or abnormal
uterine bleeding e.g. blood in the Pouch
to take a cervical smear
vaginal or pelvic infection- Determine if
there is cervical irritability (a sign of STI
or intra-abdominal irritation due to inflammation or infection such as bacterial
menstrual dysfunction
to evaluate lower abdominal or pelvic
urogenital prolapse
confirm presence or absence of pelvic mass
or pelvic organ abnormalities (uterine fibriods, ovarian cysts or uterine prolapse,
To collect evidence in cases of suspected
sexual assault
1. You cannot proceed unless you obtain the
patient’s consent
2. Suspected or proven placenta previa (when
placental site is not known)
Health Messenger Magazine Issue 39 Vol.2
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[email protected][kwfatmufa&mufonfhtaetxm;ukd
Health Messenger Magazine Issue 39 Vol.2
Vaginal or Pelvic Examination
3. Preterm rupture of membranes without
Technique of vaginal digital
‡ Explain the procedure to the patient, and
the reason why it is necessary.
‡ Obtain the patient’s consent and let keep
one female assistant with you as a third
party in the case of male medics.
‡ Ask the patient to lie on her back. Ask her
to bend her knees and let them relax open
to the side. If she holds her knees together
it is hard to examiner her. Make an effort
to relax the patient and respect her modesty
External Examination or Inspection:‡ Under sufficient light, check the vulva
and vaginal opening for signs of redness,
irritation, discharge, cysts, genital warts
and other abnormal conditions.
Inspection of the vulva
Vaginal or Pelvic Examination
Positioning the patient
Obstetrical aspect- in pregnancy
Internal Examination: -
‡ Always wash your hands well with a proper scrub before putting on sterile gloves.
‡ It is easier to insert your fingers if you put
some clean water on the gloves. Spread
the labia with your non dominant hand
(not the hand you write with) and use
your dominant hand to make the internal
‡ Gently insert two gloved fingers in the vagina, being aware of the position of your
fingers and the woman’s clitoris. Be sure
not to catch any pubic hair or the delicate
lips of the vagina as this hurts. You usually
have to reach inside as far as your fingers
will go to reach the cervix.
Health Messenger Magazine Issue 39 Vol.2
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oyf&yfpGm 0wfqifygap?
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Pubic bone
Health Messenger Magazine Issue 39 Vol.2
Vaginal or Pelvic Examination
‡ Check inside the vaginal canal for any abnormal mass, cysts, or pus coming from
the Bartholin glands.
Gynaecological aspect- in non-pregnant
In early pregnancy, vaginal examination is performed to establish the gestational age if ultrasound is not available. The pregnant uterus is
equivalent to the size of an:
- apple at 6 weeks
- orange at 8- 10 weeks
- grapefruit at 12- 14 weeks
‡ In case of additional speculum examination for gynaecological problems, apply
some lubricants to the speculum and gently insert into the vagina. Do not forget to
notify the patient of what you are doing.
‡ The speculum spreads apart the vaginal
walls, allowing the inside of the vagina
and the cervix to be examined. Examine
the walls of vagina and cervix for damage, growths, inflammation, unusual discharge, bleeding or discoloration.
‡ If you suspect STD, a sample of the cervical mucus may also be obtained with
In late pregnancy, vaginal examination is done
to access cervical status before induction of labour. Feel the dilatation and length of cervix, it
consistency and position and the station of the
fetal head above or below the ischial spine.
Speculum examination: -
Speculum Examination
Health Messenger Magazine Issue 39 Vol.2
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Bimanual Examination
Pubic bone
Peritoneal cavity
Health Messenger Magazine Issue 39 Vol.2
Vaginal or Pelvic Examination
Make it a habit to be consistent.
• Vaginal examination in labour: Always report on the presenting part, cervix dilatation and effacement, station, position and
• Vaginal examination in a non-pregnant
woman: Always report on the size of the
uterus, the feel of the cervix, the presence
or absence of pelvic mass/es, tenderness in
the cervix or fornices (e.g. pouch of Douglas) and the discharge on the glove when it
is removed from the vagina.
a cotton swab and tested for sexually
transmitted diseases such as gonorrhea or
‡ After the exam is finished, let the patient
use a washcloth or tissue to wipe vaginal
area in order to remove any discharge resulting from the exam, and then let them
dress in privacy.
Bimanual Examination: ‡ Insert one or two gloved fingers of one
hand into the vagina while placing the
other hand on the lower abdomen of the
‡ Press down on the abdomen and move the
fingers around inside vagina to locate and
determine the size, shape, and consistency
of the uterus and ovaries. Any unusual
growths, tenderness, or pain can also be
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
Management in Breech
SMRU Doctors
In a breech presentation, the buttocks of the
baby present first in the birth canal. Breech
presentation can be diagnosed during the antenatal consultation by abdominal palpation and
/or vaginal examination.
A breech presentation can have specific complications during delivery. The risk of these
complications occurring increases if the doctor or midwife is not trained in performing a
breech delivery. In many countries, a Caesarean section is performed for breech presentation, although Caesarean section delivery also
Complete Breech
has complications and risks. Check what your
NGO’s policy is for the management of breech
Some doctors might attempt an external cephalic version at 36 weeks of gestation to convert the breech to head presenting. However,
anyone who is carrying out deliveries should
know the management of a breech presentation, as unexpected or undiagnosed breech
presentations could happen any time.
Frank Breech
Health Messenger Magazine Issue 39 Vol.2
Footling Breech
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ukd,fcE<m tvkdavsmuf arG;zGm;Ekdifjcif; r&Sdaom &Sm;yg;onfh
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nifompGm qGJcsay;yg? pdwfcsvkH+cKH&aom taetxm;rSm
uav;ausm ta&[email protected] &SdaepOftwGif; oifhvufronf
uav;wifyg;ay:[email protected] a&muf&Sdae+yD; vufacsmif;rsm;onf
ajcaxmufrsm;ukd qkyfukdifxm;&rnf? uav;ajcaxmuf
Health Messenger Magazine Issue 39 Vol.2
Management in Breech Presentation
Every mother with a breech baby should be informed about the diagnosis and a delivery plan
should be made before the contractions start.
Types of Breech Presentation
There are 3 types of breech:
1. Complete (folded legs)
2. Frank (Straight legs)
3. Footling (feet first)
ii) Nuchal arms: when one or both arms are
raised behind the neck and head of the baby,
making delivery more difficult. If you touch
the baby too early during labour, the risk of
nuchal arms increases.
iii) Head entrapment: if the body of the
baby delivers and the head remains stuck in
the pelvis, there could be serious damage to
both mother and baby, including injuries to
the brain and skull of the infant.
Management during labour
The midwife or nurse always needs to ask herself: Why is this baby breech? Some possible
explanations are: • Pelvic mass e.g fibroids
• Excessive amount of amniotic fluid
• Multiple pregnancy (twins, triplets or
• Placenta previa
• Fetal anomalies: hydrocephaly, anencephaly, prematurity and other congenital abnormalities
• Abnormalities of uterine and maternal
pelvis bones
Most of these causes can be identified by ultrasound examination.
All the complications of a normal vaginal
delivery are possible in a breech presentation, but you should also be aware of the
specific complications that could occur.
i) Umbilical cord prolapse: especially prevalent in footling breech, or in premature labour
A vaginal delivery can be attempted for a baby
in the breech position if:
- The baby is in a frank breech position its
hips are bent and its legs extend up.
- The baby is small enough (usually under
8 pounds) to pass easily through the vagina.
- The pregnant woman has no obstetrical
problems, such as placenta previa, that
might complicate the delivery.
- The pregnant woman’s pelvis is of normal
or above average size.
- The baby has already descended well into
the pelvis as labor begins.
- The baby’s head is tucked down toward its
chest - not extended.
Be sure, as in any delivery that the cervix is
fully dilated and the bladder empty before the
woman starts pushing. Sit the woman up on a
bed – NOT flat on the floor.
Consider an episiotomy when the buttocks are
visible. The safest way is do nothing until the
neck of the baby is born. Remember- Hands
off the breech! Do not touch the baby un-
Health Messenger Magazine Issue 39 Vol.2
wifyqkHykdif;jzifh uav;arG;&mwGif pDrHukoay;jcif;
Delivery of Shoulders - Loveset’s manoeuvre
xGuf+yD;csdefwGif ajcaxmufESifh wifyqkHykdif;ukd [email protected]
jzifh ywfxm;oifhonf?
uav;yckH;ukd arG;xkwfjcif;
tu,fI uav;yckH;onf tvkdavSsmuf arG;xGufrvmygu
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ausm&kd;cGufonf wapmif;taetxm; a&mufoGm;atmif
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ausmbufonf tpOft+rJ tay:bufwGifom &dSae
&rnf? tu,fI uav;vufarmif;onf tvkdavsmuf
xGufrvmygu vufarmif;ukdxkwf&ef }udK;pm;yg? wHawmif
qpfukd auG;xm;vkduf+yD; uav;.rsufESmESifh &ifbwfay:
ukdausmfI vufarmif;ukd t+rJwrf;ywfxkwfvkdufyg? [email protected]
Health Messenger Magazine Issue 39 Vol.2
Management in Breech Presentation
til you see the first bit of hair on the babies’
of legs
Delivery of legs
If the legs of the baby do not spontaneously
deliver, flex the baby’s knee to deliver the legs.
In the rare case that the body of the baby does
not deliver spontaneously: give gentle traction at 45º downwards. The safe position for
your hands is thumb on buttocks and fingers
wrapped around the legs with the baby’s back
anterior. After delivery of legs, a towel should
be wrapped around the legs and pelvis.
Shoulder Delivery
If the arms do not spontaneously deliver: DO
NOT PULL ON THE BABY. Rotate the baby
so the scapula is in the oblique position and
one shoulder under the symphysis. Rotate the
fetus 180 degrees until the other scapula is in
the oblique position, but make sure the back of
the baby is always upward. If the arm does not
deliver spontaneously, try to deliver the arm.
Always flex the elbow and sweep the arm down
over the face and chest of the baby. The fetus
is then rotated 180 degrees in the opposite direction, the back being kept uppermost. Then
deliver the other arm.
Delivery of Head
Controlled, slow delivery of the after-coming head is essential. The fetal head should be
maintained in a flexed position to allow delivery of its smallest diameter.
Delivery of the head must be with assisted and
can be accomplished by:
• Mauriceau-Smellie-Veit manoeuvre -Lay
the baby face down with the length of
its body over your hand and arm. Place
the first and third fingers of this hand on
the baby’s cheekbones and place the second finger in the baby’s mouth to pull
Health Messenger Magazine Issue 39 Vol.2
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ukdqGJukdifxm;yg? xkdvufrS vufnSd;ESpfacsmif;jzifh
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OD;acgif;ukd nifompGm qGJxkwfyg? rSwfcsuf- tulaq;0efxrf;ukd uav;acgif;xGuf
vmap&ef rdcif. qD;ckH&kHtay:rS zdxm;ay;apyg?
[email protected];ap&ef
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vGwfoGm;onftxd vufarmif;twkdif; uyfI
uav;ukd ajrSmufxm;ay;yg?
• nSyfqGJtuljzifh arG;xkwfjcif;
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ajcaxmufrsm;ukd qkyfukdifxm;+yD; tarh0rf;Akdufay:
[email protected];nSif;aom rsOf;auG;vrf;a=umif; twkdif;
nifompGm qGJxkwfvkdufyg?
uav;ukd,fcE<mukd tvGeftrif; qGJajrSmufxkwfjcif;onf
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ykHrSefxkH;pH aqmif&Gufonfhtwkdif; uav;arG;jcif; wwd,
tqifhukd axmufyHhaqmif&Gufay;+yD; [email protected];rsm;rS
uav;ukd jyKpkapmifha&Smuf&rnf?
Forceps Delivery
Health Messenger Magazine Issue 39 Vol.2
Management in Breech Presentation
Mauriceau - Smellie - Viet Manoeuvre
the mother’s pubic bone as the head delivers. This helps to keep the baby’s head
flexed. Raise the baby, still astride the arm,
until the mouth and nose are free.
• Forceps delivery
• Burns-Marshall method- the feet are
grasped and with gentle traction swept in
a slow arc over the maternal abdomen.
Avoid extreme elevation of the body as this may
cause hyperextension of the cervical spine.
Finally, as routine practice, use active management of the third stage of labour, and your
team should take care of the baby.
the jaw down and flex the head. Use the
other hand to grasp the baby’s shoulders.
With two fingers of this hand, gently flex
the baby’s head towards the chest, while
applying downward pressure on the jaw
to bring the baby’s head down until the
hairline is visible. Pull gently to deliver the
head. Note: Ask an assistant to push above
Burns-Marshall Method
Health Messenger Magazine Issue 39 Vol.2
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rsufESmjzifh qif;vmjcif;- avpkyfcGufjzifh rarG;&yg?)
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uav; arG;&mwGif uav;onf oaE<umv 35
• uav; wifyg;ykdif; [email protected][kwf ezl;jzifharG;jcif;
• uav; [email protected]@jzpfaejcif;
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avpkyfcGufjzifh uav;arG;jcif;onf nSyfqGJarG;jcif;xuf
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rSefuefvkHavmufaom qGJtm;ay;jcif; vkdtyfonf? avpkyf
Health Messenger Magazine Issue 39 Vol.2
Instrumental DeliveryForceps and Vacuum
SMRU Doctors
In some births, although the cervix is fully dilated, the baby has difficulty passing through
the vagina. Vacuum and forceps can be used
to help the baby through the vagina, but there
are risks, and all users should be trained fully
in instrumental delivery. Medics should be prepared for complications, such as increased risk
of shoulder dystocia and post partum hemorrhage.
Indications for instrumental
1. Maternal problems
• Prolonged 2nd stage of labour
• Maternal exhaustion
• Drug induced analgesia
• Soft tissue resistance with failure to
• Maternal illness e.g. cardio-respiratory failure, intracranial haemorrhage
2. Maternal-fetal problems
• Relative cephalopelvic disproportion
• Malpostion e.g occipito posterior
• Malpresentation e.g face presentation
(not for vacuum)
3. Fetal problems
• Fetal distress heard by auscultation
Severe prematurity (for vacuum must be
>35 weeks gestation)
Breech or brow presentation
Transverse lie
Incomplete cervical dilation
Unengaged head
Delivery requiring excessive traction
How to decide between Vacuum and
Vacuum delivery may take longer than forceps;
it requires patient cooperation (the woman
must be able to push) and minimal CPD. The
vacuum cup must be placed correctly and correct traction (pull) is necessary to avoid losing
vacuum. With a vacuum delivery, there is a
small increase in the risk of the baby having a
When using forceps, there is a higher risk of
causing trauma to the mother and to the baby.
You should consider a forceps delivery only
when the baby needs to be delivered quickly
Health Messenger Magazine Issue 39 Vol.2
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twkdaumufrSwfenf;rSm----- ABCDEFGHIJ
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uav;acgif;onf [email protected] wnfhauG;
qif;oGm;+yD; ab;[email protected]; apmif;aeonf?
Vacuum Extractor- Determine position
Metopic suture
Anterior fontanelle
Coronal suture
Coronal suture
Sagittal suture
Posterior fontanelle
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Health Messenger Magazine Issue 39 Vol.2
Instrumental Delivery- Forceps and Vacuum
(for example with severe bradycardia) and the
mother is not able to push (for example, unconscious).
Technique for using a Vacuum
Extractor (ALSO© AAFP)
Severe: cannot be reduced. Often deflexed & asynclitic
- Equipment and Extractor ready
In emergency medicine or obstetrics, the use of
pneumonics helps to structure the care. Several
“advanced life support” organizations have developed methods to organize emergency care.
One method is the ALSO (advanced life support obstetrics) pneumonics for instrumental
deliveries: ABCDEFGHIJ
- Ask for help
- Address the patient
- Anaethesia adequate?
- Abdominal palpation 0/5 or head deep-
ly engaged
- Bladder empty? Use a urinary catheter to empty the bladder.
C - Cervix fully dilated? Can only perform an instrumental delivery when the cervix is fully dilated
- Determine position and think Shoulder Dystocia
Anterior fontanelle larger, forms a cross
Posterior fontanelle smaller, forms a Y
Assess for bend in ear
Molding makes assessment difficult
• Mild: parietal bones touching but not
• Moderate: overlapping but reduced
by finger pressure
F - Apply cup over Flexion point = sagittal suture in midline and 3 cm in front of posterior fontanelle.
“Flexion point” – proper application results in
flexion of fetal head on traction.
Ideally centre of cup should be over flexion
point and edge of cup will be on edge of
posterior fontanelle.
Wipe the vertex clean of blood, spread the labia
and the cup is compressed and inserted. A finger is swept around the cup to make sure not
maternal tissue is trapped. Increase the dial to
yellow (10 mm Hg) and a further check made
for maternal tissue. Increase to green area (50
mm Hg) for traction until delivery.
Health Messenger Magazine Issue 39 Vol.2
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D - uav;taetxm;ukd qkH;jzwf+yD; uav;yckH; wpfjcif;ukd pOf;pm;yg?
Health Messenger Magazine Issue 39 Vol.2
Instrumental Delivery- Forceps and Vacuum
- Gentle traction at right angles to the plane of the cup, pull only during con
tractions. Bending or twisting applica-
tion will cause the cup to come off.
- Halt traction after the contraction – re-
duce pressure between contractions.
- Halt procedure if disengagement of cup (pop offs) 3 times or if no progress in 3 consecutive pulls.
- Max pulling for 20 minutes (fetal inju
ries increase >10 minutes)
- Evaluate for Incision (episiotomy) when head being delivered.
- Not necessary just for vacuum but may be needed for shoulder dystocia or diffi-
cult delivery.
- Remove vacuum when Jaw reached.
Complications of Vacuum
These can be divided into maternal and foetal
Subgleal Haemorrhage
Intracranial Haemorrhage
Retinal Haemorrhage
Scalp bruising and lacerations
Vacuum Extraction
perineal lacerations
stress urinary and anal incontinence
Method for forceps delivery
- Ask for help
- Address the patient
- Anaethesia adequate?
- Abdomen palpation (0/5 or head fully engaged)
- Bladder empty? Use urinary catheter to empty the bladder
Health Messenger Magazine Issue 39 Vol.2
ud&d,mtuljzifh uav;arG;jcif;- nSyfqJarG;jcif;ESifh avpkyfcGufjzifh arG;jcif;
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Apply Right blade
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wGif tokH;& vG,fulap&ef nSyftoGm;rsm;ukd acsmqDjzifh okwfvdrf;yg?
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Health Messenger Magazine Issue 39 Vol.2
Instrumental Delivery- Forceps and Vacuum
Apply left blade
C - Cervix fully dilated? Can only perform an instrumental delivery when the cervix is fully dilated
- Determine position and think Shoulder Dystocia
Anterior fontanelle larger, forms a cross
Posterior fontanelle smaller, forms a Y
Assess for bend in ear
Molding makes assessment difficult
• Mild: parietal bones touching but not
• Moderate: overlapping but reduced
by finger pressure
• Severe: cannot be reduced. Often deflexed & asynclitic
E - Equipment ready
A pair of forceps consists of two parts, each a
mirror image of each other. There are for components: blade, shank, lock and handle. Each
blade has a cephalic (to fit the bay’s head) and
a pelvic (to fit the mother) curve.
- Forceps ready – coat the forceps blades with lubricant for ease of use.
- Articulate (put together) and hold in po
- Disarticulate (take apart), place the left blade in the left hand
• Apply to the left side of the mother
• Cephalic curve toward vulva
• Shank vertical at start
• Apply to left side of fetal head
• Right hand protects maternal tissue,
applies force
- Repeat for right side
- Articulate handles and lock
Posterior fontanelle midway between shanks, 1cm above plane of shanks.
Fenestrations admit no more than one finger
Sutures: lambdoidal above and equidistant from upper surface of each blade, sagittal suture is midline.
G - Gentle traction =Pajot’s Manoeuver
‡ Axis traction follows pelvic curve
‡ Initial traction downward, then sweeping
in large, J-shaped arc
‡ Unused hand exerts downward traction
causing 2 vectors of force: horizontal outward and vertical downward at right angles to the plane of the curves
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
Instrumental Delivery- Forceps and Vacuum
H - Handle elevated vertically to follow J shaped pelvic curve
- Evaluate for Incision (episiotomy)
- Remove forceps when Jaw is reachable
Complications of forceps
These can be divided into maternal and foetal
1. Intracranial haemorrhage
2. Direct trauma to head and face
1. Trauma to the vagina
2. Uterine rupture
3. increased risk of a post partum haemorrhage
Health Messenger Magazine Issue 39 Vol.2
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(rpiftdrf tcGsJajrS;) wavSsmuf yg0ifonf? ptkd0
Health Messenger Magazine Issue 39 Vol.2
Management of Perineal
Tears and Episiotomies
SMRU Doctors
During the delivery of a baby, the perineum
or vaginal wall can sometimes tear. The tear is
graded by degrees of severity; the type of treatment will depend on the grade of the laceration.
1. The most superficial, or first-degree, or
simple perineal tears involve the skin of
the area between the vagina and the anus
(perineum) and the tissue around the
opening of the vagina. No muscles are involved. These tears are often so small that
no stitches are required. They usually heal
quickly and cause little or no discomfort.
2. Second-degree or complete perineal
tears or lacerations involve the skin, vaginal mucosa and the muscles underneath.
These tears need to be stitched carefully,
layer by layer. They will cause discomfort
and generally take some weeks to heal. (If
you use vicryl or catgut, the stitches dissolve during the healing period.)
3. Some women who deliver vaginally will
end up with a more serious tear in their
perineum. This can also occur when an
episiotomy is cut and the tissue then tears
further on its own. These severe tears are
called third- or fourth-degree lacerations.
A third-degree or complicated perineal
laceration is a tear in the vaginal tissue,
perineal skin and muscles that extend into
the anal sphincter (the muscle that surrounds anus).
4. A fourth-degree perineal tear goes
through the anal sphincter and the tissue
(rectal mucosa) underneath it. Damage to
the anal sphincter could result in stool incontinence.
Note: Some women will have a tear at the top
of the vagina near the urethra. These tears are
often quite small and mostly only a few or no
stitches are needed. Upper vaginal tears or tears
in the labia heal more quickly and are less painful than perineal tears. However, most women
will complain of burning sensation when urinating for a few days.
Materials needed
Sterile abscess suture box containing scissors, tooth dissecting forceps, needle holders and needles
Resorbable and non-resorbable suture
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
Management of Perineal tears and Episiotomies
Sterile drapes and gloves
Prepare a sterile tampon-gauze tied with
a suture and then place in the vagina to
collect uterine secretions.
Vigorously rub together all surfaces of
both hands with plain or antimicrobial
soap for 15–30 seconds and rinse under
running or poured water. Then put the
gloves on.
Provide emotional support and encouragement to the patient. Ask an assistant
to massage the uterus and provide fundal
Carefully examine the vagina, perineum
and cervix. If the tear is long and deep
through the perineum, check to exclude
third or fourth degree tear by : • Place a gloved finger in the anus;
• Gently lift the finger and identify the
• Feel for the tone or tightness of the
Change to clean, high-level disinfected
If the sphincter is injured, perform according to third or fourth degree tear. If
there is no sphincter injury, proceed with
Clean the perineum and vagina with antiseptic polyvidone iodine, place the sterile
drapes under the buttocks, on the abdomen and on the thighs.
Use local infiltration with 10 ml of 0.5 %
lignocaine beneath the vaginal mucosa,
beneath the skin of the perineum and
deeply into the perineal muscle except the
rectal mucosa. If necessary, use a pudendal
During local anesthesia infiltration, aspirate to be sure that no vessel has been penetrated. If blood is returned in the syringe
with aspiration, remove the needle. Recheck the position carefully and try again.
Never inject if blood is aspirated.
Wait for 2 minutes and then pinch the
area with forceps. If the woman feels the
pinch, wait 2 more minutes and then
Suturing the first and second degree
perineal tear
Vaginal mucosa
Repair the vaginal mucosa using a continuous 2-0 resorbable sutures:
Start the muco-cutaneous junction and
pass the first suture without producing a
knot in order to get a good joint of layers.
Suturing the vaginal mucosa
Health Messenger Magazine Issue 39 Vol.2
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rdef;rukd,f tcGsJajrS;ukd twGif;rS [email protected] csKyf&mwGif
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twGif; rD;aeaoG;rsm; vrf;a=umif;ay;pD;qif;Ekdif
atmif vkHavmufpGmapmufeuf&rnf jzpfaomfvnf;
tvGefeuf&efrvkdyg? rdef;rukd,f0 ae&[email protected] a&mufvm
onftxd csKyf&kd;ukd qufcsKyfyg?
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csKyftyfukd xm;&Sd+yD; aygifcG=um;om; pkwf+yJ'%f&m
jzwfcsKyfI csnfxm;yg?
t&nfaysmfEkdifaom 2 [email protected][kwf 3 csKyf}udK;rsm;ukd
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tu,fI pkwf+yJ'%f&monf apmufeufaeygu
ae&mvyfus,fukd ydwfrdaeap&ef tvm;wl csKyf}udK;
ukd aemufwpfxyf xyfcsKyfay;yg?
Subcuticular skin suture
wwd,qifhESifh pwkwÎqifh aygifcG=um;om;
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csKyf}udK;rsm;onf wpfckESifh wpfck tvGefeD;uyf+yD;
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r[kwfaom ([email protected][kwf ta&jym;tay:v$matmuf)
2-0 csKyf}udK;rsm;ukd tokH;jyK+yD; '%f&m.xdyfzsm;&Sd
ae&mwpfae&mrS pwifcsKyfvkdufyg? tu,fI
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csKyf}udK;rsm; a&mufraea=umif; aocsmap&ef
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aygifcG=um;om; pkwf+yJ'%f&mtwGuf rpiftdrfxJwGif
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jyifqifcsKyfvkyfyg? ptkdwGif; aq;0wfywfwD;xnfhI
rpifrsm;ukd umuG,fay;+yD; ay:vDAGD'kef; tkdiftkd'if;ykd;
owfaq;&nfjzifh aq;[email protected]?
ptkdwGif; tcGsJajrS;ukd 0 ² 5 pifwDrDwmjcm;I twlwGJ
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4- 0 csKyf}udK;rsm;ukd tokH;jyKjcif;jzifh rpiftdrfukd
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vkdufyg? wqufwnf;r[kwfaom 2- 0 csKyf}udK;ukd
Health Messenger Magazine Issue 39 Vol.2
Management of Perineal tears and Episiotomies
Suture the vaginal mucosa from inside
outwards, sufficiently close and deep
enough to allow the passage of lochia during the following days, but not too deep.
Continue the suture to the level of the
vaginal opening.
At the vaginal opening, bring together the
cut edges of the vaginal opening. Bring
the needle under the vaginal opening and
out through the perineal tear and tie.
Muscle layer
Repair the perineal muscles using interrupted 2 or 3 resorbable sutures. If the
tear is deep, place a second layer of the
same stitch to close the space.
make sure no stitches are in the rectum. In
case of second degree perineal tear, control the procedure with a finger placed in
the rectum.
Suturing the third and fourth degree
perineal tears
Repair these tears in the operating room.
Protect from the stool with a rectal tampon and clean with polividone iodine solution.
Repair the rectum using interrupted 3-0
or 4-0 sutures, 0.5 cm apart to bring together the rectal mucosa.
Suturing the muscular
layer of the rectal wall
Suturing the perineal muscular layers
Repair the skin ensuring that the sutures
are not too close together. Start at a point
at the apex of the wound using interrupted (or subcuticular) 2-0 sutures. If the tear
was deep, perform a rectal examination to
Place the suture through the muscularis
but not all the way through the mucosa.
Cover the muscularis layer by bringing
together the fascial layer with interrupted
sutures from the inside outwards, tying
knots on the rectal surface.
Health Messenger Magazine Issue 39 Vol.2
aygifcG=um;om;pkwf+yJjcif;ESifh rdef;rukd,fpGef;ptkdpyfjzwfnSyf'%f&mrsm;ukd pDrHukojcif;
ESpfcsuf [email protected][kwf okH;csufay;+yD; =uGufom;ukd
xkdae&mukd ykd;owfaq;&nfjzifh wzef jyefvdrf;ay;yg?
rpiftdrfESifh =uGufom;[email protected] rSefuefpGmjyKjyifcsKyfay;
xm;a=umif; aocsmap&ef vuftdyfpGyfxm;aom
vufacsmif;jzifh ptkdwGif; prf;oyfppfaq;yg? [email protected]
aemufwzef [email protected]&Sif;+yD;tqifhjrifh ykd;owfxm;aom
rdef;rukd,ftcGsJajrS;/ aygifcG=um;om; =uGufom;rsm;ESifh
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tajctaetm;vkH;wGif uvkd&kd[ufqif'if; tm;aysmh
&nfjzifh rdef;rukd,fukd aq;[email protected]+yD; '%f&mukd
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• rdef;rukd,fpGef; ptkdpyfjzwfnSyf'%f&mrsm;wGif trm
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rdef;rukd,fpGef; ptkdpyfjzwfnSyf
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onf wwd,[email protected][kwf pwkwˆqifhpkwf+yJ'%f&mrsm;
ukd vkH;0rumuG,fyg? 4if;ukdrjzpfrae pOf;pm;&rnfh tajc
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wGif;umvwGif ykd;0ifjcif;ESifh aemufqufwGJqkd;usdK;rsm;ukd
jyefvnfjyKjyif ukoay;jcif;
rdef;rukd,fpGef; ptkdpyfjzwfnSyf'%f&m teD;w0kdufukd
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tu,fI rdef;rukd,fpGef;ptkdpyfjzwfnSyf'%f&monf
ptkdxdef;=uGufom;[email protected][kwf rpiftdrf tcGJsajrS;ukdyg
jzwfazmufrdoGm;ygu wwd,qifhESifh pwkwÎqifh
pkwf+yJ'%f&mrsm;twkdif; aqmif&Gufyg?
wqufwnf;&Sdaom 2- 0 csKyf}udK;rsm;ukdokH;I
rdef;rukd,fwGif; tcGsJajrS;yg;ukd ydwfay;yg?
rdef;rukd,fpGef;ptkdpyfjzwfnSyf'%f&m xdyfzsm;. 1
pifwDrDwm txufem;rSpae+yD; pwifcsKyfvkyfay;yg?
rdef;rukd,f0 tqifhxda&mufonftxd csKyf}udK;ukd
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twl wGJcsKyfyg?
rdef;rukd,f0atmufbufwGif csKyftyfukdxm;&Sd+yD;
jzwfnSyf&mae&mukd csKyfausmf+yD; csKyf}udK;csnfay;yg?
Health Messenger Magazine Issue 39 Vol.2
Management of Perineal tears and Episiotomies
Apply antiseptic solution to the area frequently.
When the sphincter is torn, grasp each
end of the sphincter with an Allis clamp.
Repair the sphincter with two or three interrupted stitches of 2.0 sutures.
Repair of Anal Sphincter
Apply antiseptic solution to the area
Examine the anus with a gloved finger to
ensure the correct repair of the rectum and
sphincter. Then change to clean, high-level disinfected gloves.
Repair the vaginal mucosa, perineal muscles and skin as mentioned before.
In all cases, clean the vagina with diluted
solution of chlorohexidine and dry the
wound as soon as possible.
An episiotomy is an artificial cut in a mother’s
perineum to open the soft part of the birth canal. An episiotomy never prevents a third or
fourth degree tear. An episiotomy should only
be considered only in the case of:
Repair of Episiotomy
Breakdown of the suture
The scar may be long and unpleasant in
case of episiotomy
complicated vaginal delivery (bree- ch, shoulder dystocia, forceps, vacu- um delivery);
scarring from poorly healed third or fourth degree tears;
Fetal distress and head on pelvic floor.
The repair of an episiotomy should be done
layer by layer. A systematic and accurate closure of the wound prevents infection and complications in the post partum period.
Anal incontinence in case of complete or
complicated perineal tears
Post partum infection and purulent lochia
Recto-vaginal fistula
Apply antiseptic solution to the area
around the episiotomy.
If the episiotomy is extended through the
anal sphincter or rectal mucosa, manage as
third or fourth degree tears, respectively.
Close the vaginal mucosa using continuous 2-0 suture.
Start the repair about 1 cm above the apex
of the episiotomy. Continue the suture to
the level of the vaginal opening;
Health Messenger Magazine Issue 39 Vol.2
aygifcG=um;om;pkwf+yJjcif;ESifh rdef;rukd,fpGef;ptkdpyfjzwfnSyf'%f&mrsm;ukd pDrHukojcif;
wqufwnf;r[kwfaom 2- 0 csKyf}udK;rsm;ukd
tokH;jyK+yD; aygifcG=um;om;=uGufom;rsm;ukd csKyfydwf
atmuf) 2- 0 csKyf}udK;rsm;ukd tokH;jyKjcif;jzifh
ta&jym;ukd csKyfydwfay;yg?
Health Messenger Magazine Issue 39 Vol.2
Management of Perineal tears and Episiotomies
At the vaginal opening, bring together its
cut edges.
Bring the needle under the vaginal opening and out through the incision and tie.
Close the perineal muscle using interrupted 2-0 sutures.
Close the skin using interrupted (or subcuticular) 2-0 sutures.
Health Messenger Magazine Issue 39 Vol.2
usef;rma&; apwrmef
oGm;Ekwfjcif;qkdonfrSm qkd;&Gm;aom aemufqufwGJ
qkd;usdK;rsm;ukd a&Smif&Sm;&ef cGJpdwfjcif;qkdif&m wif;usyf
[email protected];atmufwGif
&aom cGJpdwfukor_ wpfrsdK;jzpfonf? Tukor_wGif
owdxm;&rnfrSm oGm;ukd qGJEkwfjcif;rsdK; r[kwf
aomfvnf; nifompGm Ekwfypfjcif;jzpfonf? emusif
ukdufcJaeaom oGm;wkdif;twGuf Elwfypf&ef rvkdtyfbJ
aemufqkH;tqifhtaejzifhom pOf;pm;xm;&rnf? oGm;rEkwf
rSDwGif oGm;ukd qufvufxdef;odrf;xm;&eftwGuf vkdtyf
[email protected]&Guf&ef vlemukd v$Jajymif;ay;a&;
twGuf aq;rSL;rS pOf;pm;oifhonf?
a,bk,stm;jzifh a&m*g&mZ0if
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2— ESvkH;a&m*grsm; &Sd r&Sd
3— xkHaq;ESifh aq;rwnfhjcif; &Sd r&Sd
4— qD;csdKa&m*g &Sd r&Sd
tu,fI tqkdyg tajctaersm; jzpfay:aeygu aq;rSL;
onf txl;owdjyK umuG,fr_ &,loifhonf?
aqmif&Guf&rnfh tajctaersm;
atmufazmfjyyg tajctaersm;wGif ta&;ay:aqmif&Guf
&rnfh jyKpka&;ESifh ukoa&; ta=umif;jycsufrsm;a=umifh
oGm;wpfacsmif;ukd rjzpfrae Ekwf&Ekdifonf?
1? oGm;atmufcH tom;Ekykdif; emwm&Snf
2? oGm;atmufcHtom;Ekykdif;wpf&SK;aojcif;
3? qkd;&Gm;pGmoGm;ykd;pm;I oGm;ykyfjcif; [email protected]
[kwf qkd;&Gm;aom ykd;0ifjcif; (oGm;jynfwnf
em/ oGm;atmuf wpfoSsL;a&mif&rf;jcif;)
4? tjrpfaorsm;jzpfaeaom oGm;
5? oGm;. axmufula&;wpf&SL;rsm;ESifh t&kd;
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jyGefusyfygaom aq;xkd;jyGef
2— ykd;owfxm;aom aq;xkd;tyfrsm;
3— 3 µ puef'Dudef; [email protected][kwf 2 µ vkdif'kdudef; [email protected]
aom xkHaq;rsm;
Health Messenger Magazine Issue 39 Vol.2
Dental Extraction
Health Messenger
Dental extraction is a procedure undergoing
strict surgical precautions in order to avoid serious complications. In this procedure, always
remember that a tooth is not pulled, but gently
extracted. As not all painful teeth should be extracted, this procedure should be kept as final
step. Before extraction, the medic should consider about referal for some treatment to save
the tooth.
General history taking and
physical examination
Search for the potential complications and contraindications, and check the patient’s medical
history for the following.
1. Excessive bleeding
2. Heart diseases
3. Allergy to anaesthesia
4. Diabetes
And if any of the above conditions are present,
the medic should take special precautions.
A tooth should be extracted for therapeutic
and curative reasons under the following conditions:
chronic inflammation of the pulp
necrosis of the pulp
Severe tooth decay or infection (tooth abscess, cellulitis)
teeth with dead roots
Severe gum diseases which may affect the supporting tissues and bone
structures of teeth
Instruments needed
For anaesthesia injection
1. A syringe with plunger to avoid intra-vascular injection
2. Sterilized needles
3. Local anaesthetic agents such as 3 % scandicaine or 2 % lidocaine
For tooth extraction
1. a spoon or probe instrument (hook) - to
separate gum from tooth
2. elevator- to mobilise and dislocate a tooth,
or lift out a broken root
• bayonnet elevator upper teeth
• right and left curved elevators for
lower teeth and upper molars
3. forceps- to pull the tooth
Health Messenger Magazine Issue 39 Vol.2
1— ZGef;o¿mef csdwfud&d,m [email protected][kwf owWKprf;wH oGm;ESifh oGm;zkH;ukd cGjJcm;ypf&ef
2— aumfwifay;onfhud&d,m- oGm;ukd v_yfay;&efESifh
v$Jz,fypf&ef [email protected][kwf usdK;yJhoGm;aom oGm;ukd r
(u) tay:oGm;rsm; twGuf bdkif,kdepf aumfwif
(c) atmufoGm;rsm;ESifh tay:tHoGm;rsm;twGufnmESifh b,ftaumufykHpH aumfwifud&d,mrsm;
3— oGm;EkwfwHrsm;- oGm;ukdEkwf&ef a&[email protected];/ pG,foGm;/
tHa&[email protected];/ tHoGm;ESifh tjrpfrsm; (b,fESifh nm/
tay:ESifh atmuf)[email protected] oD;[email protected]
ay;xm;aom rwlnDonfh oGm;EkwfwH ud&d,mrsm;
4— 0g*Grf;rsm;
vlemukd jyifqifae&mcsxm;jcif;
vlemukd ae&mcsxm;ay;jcif;
• atmufoGm;twGuf xkdifonfh ykHpH
• tay:oGm;twGuf xkdif&ufausmrSD ykHpH
• vlemh OD;acgif;ukd v_yf&Sm;r_r&Sdap&ef rsufESmjyif
rmay:wGif ae&mcsxm;yg?
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umtm; vlemvnfyif;ukd ywfay;yg?
aq;rSL;. ae&m,l ykHpH -
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ajz;nSif;pGm xkd;ESHyg? tay:ESifh atmufoGm;rsm;twGuf
atmufbufar;&kd;[email protected]
5-10 [email protected] apmifhqkdif;+yD;aemuf xkHaq;
tmedoifjya=umif;ukd aocsmygap? qkdvkdonfrSm
oGm;rsm;ukd acguf=unfh&mwGif vlemrS cHpm;r_r&Sd
a=umif; aocsmapjcif;jzpfonf?
4— cGJjcrf;xkwfjcif;- owWK csdwfwH. xdyfcGsefukd oGm;ESifh
oGm;zkH;ESifh oGm;usif;&kd;=um;[email protected] xkd;oGif;vkdufyg? [email protected]
aemuf ud&d,mukd a&[email protected];aemufiifv_yf&Sm;ay;jcif;jzifh
oGm;ukd oGm;zkH;rS cGJcGmxkwfay;yg? oGm;. rsufESmpm
ESpfbufpvkH;wGif [email protected]&Gufay;yg? [email protected]
aqmif&Guf&mwGif pma&;[email protected] *&kwpkduf
xdef;odrf;ay;+yD; acsmfxGufoGm;jcif;ukd umuG,f&ef
ab;uyf&uf&Sd oGm;ay:wGif rDSckd tm;,lxm;&rnf?
Separate the gum
from the tooth
- tay:oGm;rsm;ESifh b,fbufatmuf&Sd
oGm;rsm;twGuf vlemukd rsufESmcsif;qkdifyg?
- nmbufatmuf&Sd oGm;rsm;twGuf vlem
OD;acgif;aemufbufwGif ae&m,lvkdufyg?
Front side
aqmif&Guf&rnfh tqifhqifh
1— ud&d,mrsm; tm;vkH;ukd rukdifwG,frSD vufrsm;ukd
5— oGm;ukd ajrSmufwifay;jcif; [email protected][kwf v$Jxkwf
ay;jcif;- aumfwifay;onfh ud&d,m. toGm;
xdyfzsm;pGef;ukd ysufpD;aeaom oGm;ESifh a&[email protected]&Sd
Health Messenger Magazine Issue 39 Vol.2
Dental Extraction
There are different forceps specific for incisors,
canines, pre-molars, molars and roots, left and
right, upper and lower.
4. Cotton gauze
Preparation of the patient
Positioning the patient
• Sitting for lower teeth
• Lying for upper teeth
• Place the patient’s head on a firm surface to prevent movement
Surgical drapes- a clean drape around the
patient’s neck
Position of the medic :
1. Before touching all the instruments, wash
hands with soap and water and put the
gloves on.
2. Explain the procedure to the patient, and
tell them the number of teeth to be extracted. Always obtain the patient’s consent.
3. Injection- Inject local anaesthesia slowly
in the correct place (anaesthetic injections
for lower and upper teeth are quite different, for maxilla and mandible). Wait for
5-10 minutes to make sure the anesthetic
has taken effect - the patient may describe a
‘dead’ feeling on percussion of the tooth
4. Separation- Insert the point of the hook
instrument between the tooth and the
gum and the alveolar bone. Then separate the tooth from the gum by moving
the instrument back and forth. Do this on
both sides of the tooth. It should be controlled carefully like a pen and supported
on the adjoint teeth to prevent slippage.
For the upper teeth and teeth on left lower side, face the patient.
For teeth on lower right side, just
sit/stand behind the patient’s head.
Health Messenger Magazine Issue 39 Vol.2
Back side
Extract the teeth
with dental forcep
oGm;taumif;=um;wGif nifomaom ab;wkduf
v_yf&Sm;r_rsm;ESifh xnfhoGif;=unhfyg? ud&d,m
toGm; xdyfzsm;pGef;. taumufrsufESmjyifbufukd
ysufpD;aeaom oGm;bufwGifxm;yg? oGm;eH&H
wavSsmuf toGm;pGef;ukd avSsmwkdufxnfhyg?
Loosen or dislocate
the tooth with elevator
6— ud&d,mvufukdifukd v_yfray;vkdufjcif;jzifh toGm;
pGef;onf ysufpD;aeaom oGm;. xdyfykdif;ukd
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zkH;umay;+yD; aoG;wdwfoGm;ap&efESifh aoG;cJjcif;[email protected]
Health Messenger Magazine Issue 39 Vol.2
Dental Extraction
5. Elevation or dislocation of tooth- Insert the blade of elevator between the bad
and the good tooth in front by gentle lateral movements. Put the curved face of the
blade against the bad tooth. Slide the blade
down the side of the tooth.
6. Turn the handle so that the blade moves the
top of the bad tooth backward. While turning the handle, place the first finger against
the next tooth. A good mobilisation produces the suction noise due to the air entering between the tooth and the tooth socket.
7. When the tooth comes out, examine carefully to ensure that the roots have not been
fractured. Examine also the border of mucous membrane, alveolar bone and base of
the tooth socket.
8. Stop the bleeding- Compress the sides of
the tooth socket between the thumb and
index fingers. Then cover the socket with
the compress gauze and ask the patient to
bite firmly against it for 30 minutes to produce hemostasis and coagulation.
9. Recommend semi-liquid diet for the first
day. Tell the patient to avoid hot liquids
and frequent mouth rinsing.
Removal with dental forceps- Push the
forceps as far up the tooth as possible until the beaks of forceps must hold onto the
root under the gum. Use the other hand
to support the bone around the teeth. Use
see-saw and rotatory movements without
forcing the tooth to avoid fracturing the
roots or the bone.
After the procedure, dental instruments must
be cleaned and sterilised. Scrub and then place
them in a pot of boiling water for 20 minutes.
Then wrap them in a clean cloth or leave them
in disinfectant. Before using them again, wash
them with clean water to remove the taste of
Health Messenger Magazine Issue 39 Vol.2
jzpfay:vmap&ef vlemtm; rdepf 30 [email protected] wif;usyfpGm
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u¿wGif zwf&Skyg?
Health Messenger Magazine Issue 39 Vol.2
Dental Extraction
Stop the bleeding
1. Haemorrhage- If the first cotton gauze
does not stop the bleeding in the socket,
place more cotton gauze. Wait for 5 – 10
minutes to check if the bleeding stops. If
bleeding continues, suture the gum.
2. Alveolitis – this is due to poor inspection
and debridement of the tooth socket. After injection of local anesthesia, clean the
tooth socket with the curette, then ask the
patient bite on the cotton gauze.
3. Infection – can be due to aseptic extraction technique, sequestered bone, a residual nerve root or non-curetted cyst. Under
local anaesthesia, inspect and clean the
socket and prescribe ampicillin or erythromycin 500 mg q.i.d for 6-8 days.
4. Broken roots of tooth – Use the straight
or curved elevator. Slide the blade of the
elevator along the wall of tooth socket and
force it between the root and the socket.
Then move the root away from the socket
wall until is loose. Hold the loose tooth
and remove it.
Root pushed into sinus – Cover the tooth
socket with the cotton gauze and refer to
hospital. A special operation is needed to
open the sinus, locate and remove the root.
Meanwhile, ask the patient not to blow his
nose as forced air into the opening prevents
Bone chips – may cause bleeding and delay
healing. Gently pass the end of an elevator
or spoon instrument into the tooth socket.
Feel for the piece of bone and carefully lift
it up. Give local anesthesia if needed.
Swelling of face – Hold a cloth wet with
cold water against the face especially when
the tooth was difficult to extract or time
Painful socket – Prescribe acetaminophen
500 mg q.i.d until relieved. In case of dry
socket, place a dressing inside the socket,
change it daily until the pain stops.
Dislocated jaw – Refer to orthopedic
Health Messenger Magazine Issue 39 Vol.2
oGm;a=u;cGswfjcif;. &nf&G,fcsufrSm - oGm;zkH;atmufwGif
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Health Messenger Magazine Issue 39 Vol.2
Dental Scaling
Health Messenger
The objective of dental scaling is to remove
agents that cause inflammation, such as old
food, tartar, or objects caught under the gums.
Tartar forms when germs on the teeth harden,
causing the gums to become infected.
1. Two double-ended scalers or four singleended scalers For example- Ivory C 1 scaler- to remove tartar from
the tooth near the gum.
- G-11 and 12 curette - to remove tar tar
from the tooth under the gum.
Gum pocket
Root fibers
Note: If the patient suffers from bleeding
gums, wait for one week before proceeding
with the scaling. During that period, instruct
the patient to clean his teeth carefully and rinse
regularly with warm salt water.
After dental scaling, the patient should be
taught to clean his teeth properly to avoid the
return of tartar and related problems.
Probe explorer
Tweezers or cotton pliers
Sharpening Arkansas stone
Health Messenger Magazine Issue 39 Vol.2
pkyf,loGm;aomtcg oGm;acs;ausmufrsm;onf ykdkrkd
jrifom vmonf?
5— oGm;acs;ausmufrsm; atmufwGif oGm;acs;ausmuf
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Feel under the gum for tartar
Use the pointed tip
of the scaler
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the tooth
for a lower tooth
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Health Messenger Magazine Issue 39 Vol.2
Dental Scaling
down along the root surface under the
gum or press a corner of gauze between
the teeth. When the gauze lowers the gum
and soaks up the saliva, tartar may become
more visible.
5. Place the scaler under the tartar. Hold the
scaler as you would a pen. Always hold
the scaler tip on the tooth to avoid poking the gums and rest the third finger
against a tooth to keep the hand steady.
First use the pointed tip of the scaler to
remove the visible tartar. Then use the
rounded tip scaler to scrape away the remaining tartar. In this case, put the sharp
face of the blade against the tooth. Slide it
the tooth
the edge
the finger
rough taragainst
tar. Feel
the over
the bottom ofthe
the gum
1. Use a good light to see the teeth and gums
clearly. Seat the patient in a dental chair,
and sit next to the patient.
2. Explain the procedure to the patient, and
warn of any possible pain or bleeding.
3. Wash your hands and wear gloves.
4. Check for tartar on all sides of the tooth.
This will feel like a rough spot on the tooth
root. Slide the point of the probe up and
for an upper tooth
6. Hold the end of the scaler tight with fingers against the side of the tooth and pull
the scaler with a firm short stroke. Try to
break the tartar free with one stroke, as any
remaining tartar will become smooth and
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
Dental Scaling
more difficult to scrape. Wipe the end of
the scaler with cotton gauze. Press against
the gum to stop bleeding.
10. Keep all the scaling instruments sharp and clean. From time to time, feel the cutting edge to be sure it is sharp.
Scrape it against your fingernail. If the cutting
edge is unable to cut the nail, it will not be
suitable for scraping. Sharpen the cutting edge
of the scaler on Arkansas stone.
Use the rounded tip scaler to
scrape away the remaining tartar
7. Check with the probe and feel under the
gum for any roughness. When all the sides
of the tooth are smooth, move to the next
8. Finally, clean all the teeth using the
sharp edge of the scaler to scrape
away remaining dirt or plaque.
After the procedure,
9. After scaling, show the patient how to clean
their teeth properly:
- Clean teeth with a soft brush. Use the
brush to reach into the gum pocket, and
behind the front teeth.
- Clean between the teeth also.
- Rinse the mouth with warm salt water.
Start with 4 cups per day and then use one
cup per day to keep gums strong.
- Eat foods that can keep gums strongguava, oranges, fresh vegetables and dark
green leaves
Pour a few drops of water or oil on the stone so that the scaler can slide over it easily.
Rest second or third finger against the side of the stone for control.
Move the cutting edge of the scaler back and forth against the stone.
Turn the round scaler as you sharpen it to keep the scaler’s round
Scalers must be sterilised as they can be contaminated with blood. Mirror, probe and cotton tweezers do not need sterilization. Leave
them in disinfectant solution for 30 minutes.
Dry all the instruments with a towel. Then
wrap them inside a clean cloth and put them
in the scaling kit.
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
Cement filling for tooth
Health Messenger
Tooth cavities are the holes that tooth decay
makes in the teeth. Dental extraction is not
always needed when a tooth hurts due to cavities. A cement filling may be the solution to
treat it and keep the tooth.
In this case, the decay is deep enough for the
nerve to feel temperature changes, but there is
still no infection or abscess. The tooth can be
saved by filling the cavity as soon as possible.
A filling can help a person in four ways:1. It stops food, air and water from entering
the cavity. It will also stop much discomfort and pain.
2. It stops the growth of decay.
3. It will prevent a tooth abscess.
4. It can save the tooth from extraction.
There are two types of fillings.
‡ A permanent filling that needs an experienced dental surgeon and dental drill.
‡ A cement or temporary filling that helps
the patient feel more comfortable until he
can get a permanent filling.
The medic can fill the tooth cavity if there are
no signs of an abscess. There will be NO abscess when:1. there is no facial swelling or gum swelling
near the decayed tooth
2. the tooth hurts only after taking food or
cold drinks
3. the tooth feels more or less the same as others on tapping.
Types of fillings
A cement filling is only the first step to
save a tooth, and should be replaced with
a permanent filling as soon as possible.
1. Instruments needed
• Mirror
• Explorer probe
• Cotton pliers
• Spoon excavator
• Filling instrument
• Cement spatula
Health Messenger Magazine Issue 39 Vol.2
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aom*Grf;pukd z,f&Sm;yg? tu,fI *Grf;pkdaeygu
topfvJvS,f+yD; xyfrHokwfypfyg/
Remove decay from the tooth cavity
Health Messenger Magazine Issue 39 Vol.2
Cement filling for tooth cavities
2. Cement filling material
• Zinc oxide power or Interactive Restorative Material (IRM)
• Oils of cloves liquid (eugenol)
3. Cotton wool or gauze
4. Smooth glass to mix cement
5. In case of local anesthesia, syringe, needle and local anaesthetic agents
1. Keep the tooth cavity dry as cement stays
longer inside a dry cavity. Place some cotton between the cheek and gums to keep
the area dry. Put some cotton under the
tongue if the cavity is on a lower tooth.
Change the cotton whenever it gets wet.
Wipe inside the tooth cavity with cotton
wool and leave a piece of cotton inside
while mixing the cement.
2. Using spoon tool, remove decay from the
bottom of tooth cavity. Then scrape clean
the walls and remove all decay from the
edge of the tooth cavity. Check closely
around the cavity edges with mirror. Use
cotton gauze to collect bits of decay. Leave
some cotton inside the tooth cavity.
3. Mix the cement on the smooth glass. Place
some zinc oxide powder and few drops of
eugenol separately on the glass slide. Then
mix a small amount of powder with eugenol liquid with the mixing tool. Add more
powder until the cement mixture becomes
thick and not sticky. Test it with your fingers. Take the cotton out of the cavity. If
the cotton is wet, change it.
4. Press some cement into the tooth cavity.
Put some cement on the end of the filling
tool and spread it over the base and into
the corners of the cavity. Then press more
cement against the other cement and the
sides of the cavity. Keep it until the cavity
is over-filled. Smooth extra cement against
the edge of cavity.
5. Remove the extra cement before it hardens. Press against the cement and smooth
it towards the edge by using the flat side
of filling tool. Shape the cement similar to
the top of a normal tooth. Check closely
around the tooth for loose pieces of cement
Press cement into the tooth cavity
Health Messenger Magazine Issue 39 Vol.2
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4— qD;[email protected] oGm;ayguftwGif;[email protected] zdoGif;ay;yg?
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Health Messenger Magazine Issue 39 Vol.2
Cement filling for tooth cavities
and remove them. With the probe, gently
lift out of any cement caught in the gum
pocket. Wipe
the probe
with cotton
gets hardened
gauze eachittime.
soap and water, and leave them for 20 minutes in disinfectant. Finally wrap all instruments together in a clean cloth.
A cement filling is a temporary treatment,
lasting up to 6 months. Advise the patient
to obtain a permanent filling from a dental
surgeon as soon as possible.
6. Remove all the cotton and ask the patient to bite normally. The teeth should
come together normally and not
hit the cement filling. Always check
whether the filling part is high or not:- If the cement is wet, the smooth place where
the opposite tooth bit into it can be visible,
then scrape the cement away from this site.
- In case of dry cement, let the patient bit
on a piece of carbon paper. If there is extra
cement, the carbon paper will darken it.
Scrape the extra cement.
7. Advise the patient not to eat anything for
one hour and not to use that tooth for biting or chewing for at least 24 hours.
8. Clean the instruments after the procedure.
First scrape the dried cement from filling
and mixing tools. Then scrub them with
Health Messenger Magazine Issue 39 Vol.2
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Normal shoulder joint
Rotator cuff muscle
Health Messenger Magazine Issue 39 Vol.2
Management in Shoulder
joint dislocation
Dr. Ei Ei (AMI)
The Shoulder joint is the most mobile joint in
the human body as it can turn in many directions. This advantage also makes the shoulder
most vulnerable to dislocation, accounting for
50% of all joints dislocations.
The shoulder joint is composed of three bones
which all come together at the top of shoulder
- the arm bone (humerus), the shoulder blade
(scapular) and the collar bone (clavicle). It is a
ball-and-socket joint type where the ball is the
head of humerus and the socket is the glenoid
cavity of scapular.
and lateral rotation of the humerus (in the
throwing motion)
Types of shoulder dislocation
Anterior Dislocation
A shoulder dislocation occurs when the top
part of the arm bone (humeral head) slips out
of its socket (glenoid cavity), and there is an
injury to the joint between the humerus and
scapula. It generally occurs after a traumatic
injury such as fall, assault, seizures or sport related accidents
Types of shoulder dislocation
1. Anterior dislocations- comprise about
95% of shoulder dislocations. The shoulder slips forward due to excessive extension
2. Posterior dislocationsAnterior less than 5%.
These are unusual
and seen after injuries
such as electrocution or after a seizure.
3. Inferior (downward) dislocation- 0.5%.
The shoulder is dislocated inferiorly by indirect forces hyper abducting the arm. This
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
Management in Shoulder joint dislocation
type of dislocation is commonly found in
road traffic accidents (RTA).
4. Multidirectional dislocation- This can be
a common problem in patients with generalised hyperlaxity (loose joints) caused by
connective tissue diseases. The dislocation
can be voluntary (the patient dislocating
the joint by himself ) or involuntary – due
to trauma.
Clinical Features
The symptoms include:• Severe Shoulder pain
• Reduced movement and inability to use
the joint (loss of function), due to muscle
• Arm held at the side usually slightly away
from the body with the forearm turned
• Loss of the normal rounded contour of
the deltoid muscle
• Swelling at the joint area
• Bruising if due to trauma or accident.
Complications of dislocation are based on types
of dislocation, anterior, posterior, etc.
1. Anterior dislocation may cause the following complications like:
• Tear of the anterior inferior labrum
(a piece of cartilage that stabilizes the
shoulder), known as Bankart lesion
• Nerve injuries – Damage to axillary
nerve and brachial plexus..
• Damage to axillary artery.
Joint stiffness leading to irreducibility
of the joint.
• Recurrent dislocation
2. In inferior dislocation- rotator cuff muscle tear, fracture of humerus, greater tuberosity…
3. Posterior type can become recurrent.
4. Fracture dislocation of shoulder is usually accompanied by several problems such as
• Joint stiffness due to soft tissue damage and hemorrhage in the joint,
• Damage of humerus head due to impact on vessel supplying the bone
• Increased requirement to carry out an
• Difficulty in repositioning of the
To establish a diagnosis, take the following action:
1. Ensure adequate history taking to find out
the cause of dislocation, time of dislocation, and the type of dislocation
2. Examine the joint for damage to bone,
muscle, nerves and blood vessels
3. X- ray to confirm the diagnosis and also to
rule out possible fracture around the joint.
Management involves non-operative and operative methods.
Non-operative methods –
1. Manipulation under anesthesia –
1. The shoulder can be reduced easily by this
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
Management in Shoulder joint dislocation
2. First check that there is no fracture of the
humeral head.
3. Put the patient under general anaesthesia.
4. Pull the arm of the patient gently.
5. Push the head of the humerus back over
the lip of the glenoid.
2. Hanging-arm technique –
1. Explain the procedure to the patient and
reassure him.
2. Place the patient face down on a couch
3. Position the affected shoulder off the edge
of the couch.
4. Intravenous pethadine or valium may be
needed to achieve adequate muscle relaxation.
5. Allow the arm to hang downward in 90˚ of
forward flexion.
6. The couch should be high enough to allow
the patient’s arm to dangle freely without
touching the floor.
7. The weight of the arm will then achieve
8. Instruct the patient to maintain this position for at least 20- 30 minutes until the
reduction is accomplished.
5. Finally rotate the arm inwards or medially
until the humeral head is replaced back.
6. After the completion of all reductions,
the shoulder should be immobilized in a
3. Kocher’s method –
1. Position the patient in seated upright posture.
2. Bend the affected arm of the patient at the
elbow relaxing the biceps tendon.
3. Press the arm against the patient’s body and
rotate it outwards until resistance is felt.
4. Lift the externally rotated upper part of the
arm slowly in the saggital plane as far as
forward as possible.
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
Management in Shoulder joint dislocation
For first time dislocations, a sling and activity
restriction is used for a few weeks (about three
weeks) to allow the swelling and inflammation around the shoulder to subside. The sling
that is used to treat most shoulder dislocations
holds the shoulder in internal rotation. This
means that the shoulder is turned inwards, and
the forearm is held against the body. Thereafter, progressive exercises are started until the
patient is able to resume their usual activities.
peated dislocations, surgery may be indicated.
The surgery involves repairing and tightening
the structures within the shoulder that were
damaged during the dislocation. The most
common procedure is an open reconstruction.
Rehabilitation is prolonged.
Signs of a successful joint reduction
Palpable or audible clunk
Return of rounded shoulder contour
Relief of pain
Increase in range of motion
Complications of Kocher’s method
Injury to the brachial plexus
Damage to the axillary vessels
Avulsion of the rotator cuff muscles
Fracture of the humeral head, neck or
shaft during manipulation
Contraindications for shoulder joint
‡ Subclavicular or intrathoracic dislocations
‡ Major arterial injuries
‡ Associated fractures of humeral neck
‡ Nerve injuries
‡ Presence of associated fractures
Operative methods
For young patients, there is a high risk of recurrent dislocation. For these patients with re-
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
Management of
Temporomandibular Joint
Health Messenger
The temporomandibular joint (TMJ) is located just in front of the lower part of the ear,
and allows the lower jaw to move. It is a balland-socket joint, similar to the hip or shoulder.
When the mouth opens wide normally, the ball
or condyle comes out of the socket and moves
forward, and goes back into place when the
mouth closes.
When a person yawns, shouts or laughs, temporomandibular joint can be dislocated when
the condyle moves too far and gets stuck in
front of bony prominence called articular eminence. Then the condyle cannot move back
into place, the jaw is stuck in open position
and unable to close mouth back. This happens
most often in elder people whose ligaments
keeping the condyle in place are loose or less
back teeth, allowing the condyle to move beyond the articular eminence. The surrounding
muscles often go into spasm and hold the condyle in the dislocated position.
unable to close teeth together
cannot close lips easily
fail to speak clearly
lower jaw looks longer and pointed
pain when the joint in front of the ear is
Clinical Features
The aim of the treatment is to move the
lower jaw back into its original normal
position, and then hold it until the muscles relax.
Try to keep the patient sit on the floor
with his head against the wall in order to
give support to his head.
Kneel down in front of him. Place your
fingers under his jaw, outside the mouth.
Put your thumbs beside his last molar teeth
on either side. Never put your thumbs on
his molars to avoid being bitten.
Press down hard on the lower jaw with the
ends of your thumbs. Use force to move
the lower jaw down, tip the chin upward to free the condyle, then guide the
ball back into the socket. Be sure to press
down before pressing back.
When the muscles surrounding the TM
joint are very tight, refer to the doctor or
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
Management of Temporomandibular Joint Dislocation
dental surgeon for an injection of local
anaesthesia or muscles relaxants.
Support the jaw with head-and-chin
bandage for 3- 4 days. Prescribe some analgesics to relieve pain.
Explain the problem to the patient and
advise him how to take care of his jaw:• After relocation of jaw, have mostly
soft or liquid diet for 2 weeks
• Avoid foods that are hard to chew
• Hold a warm wealth cloth against the
lower jaw
• Do not open the mouth too widely
in future
2. Let some patients have their jaws wired
shut for a period of time, causing the ligaments become less flexible and restricted.
3. In certain cases, a surgical procedure such
as an eminectomy, removal of articular
eminence or injection of medication into
TMJ ligaments may be necessary.
1. The medic should recommend the patient
to limit the range of jaw motion, for example by placing his fist under chin when
he yawns to keep his mouth open not too
Glenoid fossa
Mandibula condyle
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
Test your knowledge.
Answer to the following questions
and then check the correct answers on the next page.
Questions on part 1
1. Define Palpation.
2. List normal respiratory rates for different ages of a human.
3. Explain the mechanism of Heimlich Maneuver.
4. Name three indications of supra-pubic catherterisation.
5. How can you verify the insertion site for suprapubic catheter?
6. List genito-urinary indications in males for per rectal examination.
7. During per-rectal examination, if anal spasm is present, ask the patient to breathe and relax. True or False.
Questions on Part 2
8. List contraindications for vaginal examination.
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
9. How will you perform bimanual vaginal examination?
Name three types of breech presentation.
11. Explain the Mauriceau-Smillie-Veit Manoeuvre in head delivery of
breech presentation.
12. Give three foetal complications of vacuum delivery.
13. List four components of forceps.
14. Explain the difference between third and fourth degree perineal
15. List four complications of suturing on perineal tears.
Questions on Part 3
16. The patient should sit for extraction of upper teeth. True or False
17. How many scalers are needed for tooth scaling?
18. Define two types of cement fillings for tooth cavities.
Questions on Part 2
19. Describe the composition of shoulder joint.
20. List the signs of successful joint reduction.
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
Quiz Answers
Answers on part 1
Palpation is the examination of the body using the sense of touch.
There are two types: light and deep palpation.
2. •30 - 50 per minute for a baby
•20 - 30 per minute for a child
•14 – 20 per minute for an adult
3. Abdominal thrusts also known as the Heimlich maneuver are a
series of under-the-diaphragm abdominal thrusts. Abdominal thrusts lift
the diaphragm and force enough air from the lungs to create an artificial
cough. The cough is intended to move and expel an obstructing foreign
body in airway.
4. •Urethral obstruction
•Bladder neck masses
•Benign prosthetic hypertrophy (BPH)
5. Palpate the distended bladder and mark the insertion site at the
midline and 2 fingers (4-5 cm) above the pubic symphysis.
6. •benign prostatic hypertrophy (BPH)
•acute or chronic prostatitis
•carcinoma prostate
7. True
Answers on Part 2
•No patient consent
•Suspected or proven placenta previa (when placental site is not known)
•Preterm rupture of membranes without contractions
9. Insert one or two gloved fingers of one hand into the vagina while
placing the other hand on the lower abdomen of the patient. Press down
on the abdomen and move the fingers around inside vagina to locate and
determine the size, shape, and consistency of the uterus and ovaries. Any
unusual growths, tenderness, or pain can also be identified.
Health Messenger Magazine Issue 39 Vol.2
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Health Messenger Magazine Issue 39 Vol.2
Quiz Answers
10. •Complete (folded legs)
•Frank (Straight legs) •Footling (feet first)
11. Flex the head by pushing the head with a finger on the occiput and
with an assistant making suprapubic pressure, use the other hand to pull
the chin to the chest by placing a finger on each maxilla and deliver the
baby in an arc.
12. •Cephalohematoma
•Intracranial Haemorrhage
•Retinal Haemorrhage
13. Four components of forceps: blade, shank, lock and handle.
14. A third-degree perineal tear involves vaginal tissue, perineal skin
and the anal sphincter while a fourth-degree perineal tear goes through
the anal sphincter and the tissue.
15. •Breakdown of the suture
•Anal incontinence in complete or complicated perineal tears
•Post partum infection and purulent lochia
•Recto-vaginal fistula
Answers on Part 3
16. False
17. Two double-ended scalers or four single-ended scalers
18. •A permanent filling that needs an experienced dental surgeon and
dental drill.
•A cement or temporary filling that helps the patient feel more comfortable until he can get a permanent one.
Answers on Part 4
19. The shoulder joint is composed by three bones which all come
together at the top of shoulder - the arm bone (humerus), the shoulder
blade (scapular) and the collar bone (clavicle).
20. •Palpable or audible clunk
•Return of rounded shoulder contour
•Relief of pain
•Increase in range of motion
Health Messenger Magazine Issue 39 Vol.2
In Patient Department
Benign Prostatic Hypertrophy
History of Present Illness
Pyrexia of Unknown Origin
Sexually Transmitted Infections
Non Governmental Organization
Cephalo Pelvic Disproportion
Advance Life Support Obstetrics
Interactive Restorative Material
Road Traffic Accidents
Temporo Madibular Joint
Health Messenger Magazine Issue 39 Vol.2
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