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Oby and Gyn notes for Nurses

Introduction

Care of the mother and child is a major focus in health. It is also a major issue in nursing

practice. To have healthy children, it is important to promote the health of childbearing

women and her family from the time before conception until the child is a grown up.

The first recorded obstetric practice are found in Egyptian records dating back to 1500

B.C. Practices such as vaginal examination and the use of birth aids are referred to in

writings from the Greek and Roman Empires.

Magnitude of maternal health practice in Ethiopia

Maternal mortality ratio: number of maternal deaths in pregnancy, child birth or during

Puerperium due pregnancy related causes per 100,000 live births in a year. It is an indicator

of the status of the health care provided to pregnant mothers, i.e. access to health care

facilities like ANC, delivery care and PNC. It is about 700 deaths per 100,000 live births in

our country. The most important obstetric causes of maternal deaths in developing countries

are heamorrhage, sepsis, obstructed labour, abortion and hypertension. The coverage of

ANC in Ethiopia is about 35% and attended delivery is about 15% in the year 2005

Nursing is about ensuring healthy antenatal period followed by a safe normal delivery with

a healthy child and a postpartum period.

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Obstetric terms

Maternal - pertaining to mother

Maternal mortality- Death due to pregnancy or child bearing

Fetal- pertaining to fetus

Obstetrics- The branch of medicine that concerns themanagement of pregnancy,

childbirth, and the puerperium

Gynaecology: - The study of women‘s health care, esp. diseases and conditions

that affect reproduction and the female reproductive organs.

Conception/ fertilization: - the union of a single egg & sperm. It is the bench

mark of the beginning of pregnancy.

Pregnancy: - the condition of having a developing embryo or fetus with in the

body.

- The state from conception to delivery of the fetus.

- The normal duration is 280 days counted from the 1st day of last menstrual

period.

- Prenatal- occurring before birth

- Intranatal- occurring within birth

- Postnatal- occurring after birth

- Primigravida- a women pregnant for the 1st time

- Primipara- a women having born one child

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Anatomy of the Female Reproductive System

Pelvis Bones

Main function is as organ in the locomotory system. It serves as a bridge between the two

femur bones and helps distribute the upper body weight. It is involved in sitting and

motion. It is well adapted to childbearing & delivery.

Four pelvic bones:

Innominate (hip) bones: one on each side

Sacrum: wedge shaped, consisting of 5 fused vertebrae

Sacral promontory which is the body of S1

Coccyx: vestigial tail

Each innominate bone has three parts:

Ilium: large flared out part

Ischium: thick lower part with

Large prominence: ischial tuberosities

Behind and a little above the tuberosities is an inward projection---ischial spines

Pubic bone: with the obturator foramen

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Fig 1: Bony pelvis, anterior view

Joints

Symphysis pubis: between the two pubic bones anteriorly along the midline.

Sacroiliac joints (2)

Sacrococcygeal joint

There is little movement in these joints during pregnancy which is brought about by the

endocrine changes.

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Fig 2: Ligaments and joints of the pelvis

Fig 3: Lateral view, Bony pelvis

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Ligaments

Interpubic ligament: at the symphysis pubis

Sacroiliac ligament (2)

Sacrococcygeal ligament

Sacrotuberous ligament (2)

Sacrospinous ligament (2)

True Pelvis:

Is a bony canal through which the fetus must pass during birth. It has a brim, cavity and

outlet.

Pelvic Brim:

Bordered by the sacral promontory, superior ramus of pubic bone, upper inner border

of the body of the pubic bone & upper inner border of the symphysis pubis.

Outlet:

Bordered by the inferior pubic rami, sacrotuberous ligament, ischial tuberosities,

inferior border of symphysis pubis and tip of coccyx.

Mid cavity: the area between the inlet and outlet of the pelvis with an imaginary liner

passing through the symphysis pubis and the S3 denoting the center of the cavity.

Table 1: Measurement of the pelvic canal in cm

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Anteroposterior Oblique Transverse

Brim 11 12 13

Midcavity 12 12 12

Outlet 13 12 11

Important diameters of the bony pelvis

Inlet:

Diagonal conjugate: from the sacral promontory to the lower border of the symphysis

pubis=12.5 cm

Measured by digital vaginal examination

Anatomical conjugate: from the sacral promontory to the upper border of the

symphysis pubis=12 cm

Obstetric conjugate: from the sacral promontory to the inner border of the symphysis

pubis=11.5 cm

Represent the actual space available for the passage of the fetus during delivery. It can

be estimated by subtracting 1 to 1.5 cm from the diagonal conjugate. Remember that the

diagonal conjugate can be measured by digital pelvic examination.

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All the above three are anteroposterior diameters at the pelvic inlet, & the later two are

also known as true conjugates.

Oblique diameter: from the sacroiliac joint to the ileopectineal eminence, 12 cm

Transverse diameter: between the two ileopectineal lines on both sides, 13 cm

Midcavity

Circular in shape

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Interspinous diameter: between the two ischial spine, 10-11 cm

Outlet: three important measurements

Angle of pubic arch: 90o or above is favourable

Intertuberous diameter: between the ischial tuberosities, 10-11 cm

Anteroposterior diameter: between the symphysis pubis and the sacrococcygeal joint,

13 cm

Four types of female pelvis

Gynecoid (female type): rounded brim, blunt ischial spines, sub pubic angle of 90o,

incidence of 50%

Android (male type): heart shaped brim, prominent ischial spines, sub pubic angle

<90o, incidence of 20 %

Anthropoid: Long oval brim, blunt ischial spines with sub pubic angle > 90o, and

incidence of 25%

Platypelliod: kidney shaped brim, blunt spines, sub pubic angle >90o and incidence of

5%.

Pelvic floor/Pelvic diaphragm

A muscle layer that demarcates the pelvic cavity and the perineum

Its strength is enforced by its associated condensed pelvic fascia

Supports the weight of the abdominal and pelvic organs

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The muscles are responsible for the voluntary control of micturation, defecation &

play an important role in sexual intercourse.

Influence the passive movement of the fetus through the birth canal & relaxes to allow

its exit from the pelvis.

The main muscles are pubococcygeus (each muscle arises from the pubic bone

pass backward sourrounding urethra, vagina & rectum and insert in the pubic

bone), ileococcygeus & puborectalis muscles forming the levator ani muscle.

Fetal Skull

The head is the most difficult part of the fetus to deliver whether it comes first or last. It

is large in comparison to the rest of the body (>25% of the total body length) & the true

pelvis. Thus some adaptation must take place during delivery for the safe expulsion of

the fetus.

An understanding of the land markings and measurements of the fetal skull enables you

to recognize normal presentations and positions & to facilitate delivery with the least

possible trauma to mother and child.

The skull is divided into three parts: vault, face and base.

Base: Comprised of bones which are firmly united to protect the vital centers in the

medulla. It is found below an imaginary line between the glabella and the lower end of

the suboccipital region.

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Face: 14 small bones which are firmly united and non-compressible.

Vault: composed of bones ,sutures & fontanelles

Bones

Occipital bone: at the back of the head forming the occiput

Parietal bone (2): lie on either side of the skull

Frontal bone (2): at the front of the head above the glabella

Sutures: cranial joints

Sagittal suture: between the parietal bone

Coronal suture: separates the frontal bones from the parietal bones

Lambdoidal suture: separates the occipital bone from the parietal bones

Frontal suture: between the frontal bones

Fontanelles: where the sutures meet

Anterior fontanelle: also called the bregma, diamond shaped, between the frontal,

sagittal and coronal sutures, closes 18 months after delivery.

Posterior fontanelle: also called the lambda, triangular in shape, between the sagittal

and lambdoidal sutures, closes 8 weeks after delivery.

The sutures and fontanelles allow a certain degree of movement during labour &

delivery.

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Fig 4: The vault of fetal skull with bones and sutures

Regions of the Skull

Occiput: between the foramen magnum and the posterior fontanelle

Vertex: between the two fontanelles and the parietal eminences

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Sinciput / Brow: from the anterior fontanelle and the coronal suture to the orbital

ridges

Face: between the orbital ridge and the chin

Other land marks:

Mentum: the chin

Glabella: where the orbital ridge meet at the center.

Diameter of the skull

Suboccipitobregmatic----9.5 cm

Suboccipitofrontal-------10 cm

Occipitofrontal-----------11.5 cm

Mentovertical--- --------13.5 cm

Submentovertical-------11.5 cm

Submentobregmatic----9.5 cm

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Female External Genitalia

The Vulva: the term applies to the external female genital organs. It consists of the

following structures:

The mons pubis

o pad of fat over the symphysis pubis

o covered with pubic hair from the time of puberty

The labia majora (greater lips)

o Two folds of fat and areolar tissue covered with skin and pubic hair on the outer

surface.

o arise in the mons pubis and merge into the perineum behind

The labia minora (lesser lips)

o two folds of skin lying between the labia majora

o anteriorly divides to enclose the clitoris and posteriorly form the fourchette

The clitoris

o small rudimentary organ corresponding to the penis

o extremely sensitive and highly vascularised

The vestibule

o Area enclose by the labia minora in which the urethral orifice and vaginal opening

are situated.

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Bartholin’s glands

o two small mucus secreting glands lying in the posterior part of the labia majora

o lubricate the vaginal opening

The urethral orifice: 2.5 cm posterior to the clitoris

The vaginal orifice / Introitus

o partially closed by the hymen

o Occupies the posterior 2/3 of the vestibule

Blood Supply: branches from the external pudendal artery and small amount from the

inferior rectal artery. The blood drains through the pudendal veins.

Lymphatic drainage: inguinal glands

Nerve supply: branch of pudendal nerve.

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Figure 5- Anatomy of female external genitalia

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The Vagina

a canal running upwards and backwards from the vestibule to the cervix

a passage which allows the escape of the menstrual flow

receives the penis and ejected semen

Provides exit for the fetus during delivery.

Relations

Anterior---Urinary bladder and urethra

Posterior—rectum, perineal body

Lateral--ureters

Superior--uterus

Inferior—vulva

The posterior wall is longer than the anterior wall (10 cm Vs 7.5 cm); the walls are

thrown into folds called rugea which allow the vagina to stretch during intercourse and

child birth. The epithelium is lined by squamous cells. The vagina has an acidic

environment (PH =4.5). This is due to the existence of bacteria known as lactobacilli

which convert glycogen to lactic acid. The acidic PH deters the growth of pathogenic

bacteria.

Blood supply: vaginal artery. The blood drains via the corresponding veins.

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Lymphatic drainage: via the inguinal, internal iliac & sacral nodes.

Nerve supply: Pelvic plexus

The Uterus

shelters the fetus during pregnancy

Prepares every month for menstrual shading

expels its contents at the end of pregnancy

situated in the true pelvis

It leans forward which is called anteversion, and bends forward on itself which is

known as anteflexion.

Relations:

Anterior--- urinary bladder

Posterior---rectum

Lateral---fallopian tubes, broad ligament, ovaries

Superior---intestines

Inferior---vagina

It is supported by the pelvic floor and several ligaments like:

Transcervical ligament

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Uterosacral ligament

Pubocervical ligament

Broad ligament

Round ligament

Ovarian ligament

Structure

hollow, muscular, pear-shaped organ

7.5 cm long, 5 cm wide, 2.5 cm deep, each wall is 1.25 cm thick

cervix forms the lower third

Parts

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Body / Corpus---upper 2/3 of the uterus

Fundus---domed upper wall between insertions of the fallopian tubes

Cornua—upper outer angle where the fallopian tubes join

Cavity---the potential space between the anterior & posterior walls

Isthmus---narrow area between the cavity & cervix, 7mm long

Cervix---lower third which protrudes into the vagina, it has internal and external

Os (openings)

Layers

Endometrium: inner most lining which sheds every month

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Myometrium: muscle coat, thick in the upper part and sparse in the isthmus and cervix

Perimetrium: outer most layer with double serous membrane extension of the

peritoneum.

Blood supply: Uterine artery, and the blood drains via the corresponding veins.

Lymph: via internal iliac and pelvic glands

Nerve: pelvic plexus

The Fallopian Tubes / Uterine tubes

Propels the ovum towards the uterus

receives the spermatozoa

provide fertilization site

supplies the fertilized ovum with nutrition

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It extends laterally from the cornua & arch over the ovaries. It is 10 cm long. The lumen

of the tube provides an open pathway from the outside to the peritoneal cavity. It has

four portions:

Interstitial: within the wall of the uterus

Isthmus: also narrow part

Ampulla: wider portion where fertilization usually occur, 5 cm long

Infundibulum: funnel shaped composed of many finger like projections called fimbriae.

It is lined by ciliated cells and goblet cells which contain glycogen.

Blood supply: Ovarian and uterine arteries, vein drainage via the corresponding vessels.

Lymph: lumbar glands

Nerve: ovarian plexus

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Ovaries

produce ova and hormones (progesterone and estrogen)

attached to the back of broad ligament in the peritoneal cavity

Has two parts: the medulla where the supporting framework and blood vessels lie.

The other part is the cortex where the follicles lie at different stages of development. It is

the functioning part.

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Figure: - 6 ovary

Blood supply: ovarian vessels

Lymph: lumbar nodes

Nerve: ovarian plexus

Other contents of the pelvic cavity

Urinary bladder

Urethra

Ureter

Breast

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Also known as mammary glands, accessory glands of reproduction

One on each side of the sternum, extending from the 2nd

to the 6th

rib.

Lie on the superficial fascia of the chest wall over the pectoralis major &

stabilized by the suspensory ligament. The part extending to the axilla is known as the

axillary tail.

Areola is a loose, pigmented skin around the nipple. It contains sebaceous glands.

The nipple lies in the centre of the areola at the level of the 4th rib. The surface is

perforated by small orifices which are the openings of the lactiferous ducts.

The breast interior is composed of largely glandular tissue. Each has 18-20 lobes

each having several lobules. The lobules drain via lactiferous tubules; these join and

form lactiferous ducts.

In the lobules situated are alveoli containing milk-secreting cells and

myoepithelial cells. The myoepithelial cells are used for ejection of the produced milk

from the alveoli into the lactiferous tubules.

Ampulla: a widened-out portion of the duct where milk is stored. It lies under the

areola.

Blood supply: internal mammary, external mammary & upper intercostal arteries.

Venous drainage is via the corresponding vessels.

Lymph: largely by axillary glands

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Nerve: function is largely controlled by hormones, few fibers to the areola and nipple.

Branches of thoracic nerves

The Menstrual Cycle

Many changes recur periodically in the female during the years between the menarche &

menopause in the uterus giving menstruation except during pregnancy. Menstruation is

the outward sign of changes in the endometrium.

The average age for menarche (the first menses) is 12-13 years of age. But it may come

as early as 9 years or be as late as 18 years of age.

Four body structures are involved in the physiology of the menstrual cycle. These are the

hypothalamus, the pituitary gland, the ovaries and the uterus. Inactivity of any part of

this structure will result in an incomplete or ineffective cycle. Some women have

symptoms in premenstrual period like anxiety, fatigue, abdominal bloating, headache,

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appetite disturbance, irritability and depression. Some experience pain during ovulation.

This pain is called Mittelschmerz.

There are different phases of the menstrual cycle in the uterus and ovary.

Phases of the menstrual cycle in the ovary

The ovary has two main functions. These are production of ovum (Oogenesis) and

hormones. At birth, a female‘s ovaries contain an estimated 2-4 million eggs, and no

new ones appear after birth. Only a few, perhaps 400 are destined to be ovulated. All the

others degenerate at some point in their development.

Follicle growth: eggs exist in structures known as follicles in the ovaries. At the

beginning of each menstrual cycle, 10-25 follicles are recruited for development. Then

of these only one, the dominant follicle, would continue to develop. The others undergo

degenerative process called atresia. The dominant follicle continues to develop and

eventually ruptures to release its content in the peritoneal cavity i.e. ovulation. After

ovulation the remaining of the follicle undergoes important changes and becomes a

corpus luteum. If the ovulated ovum is not fertilized, the corpus luteum dies usually in 7-

10 days post ovulation. This ceases the production of sex hormones. Only in 1-2% of all

cycles, two or more follicles reach maturity and more than one egg may be ovulated

giving multiple birth.

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Hormone production by the ovarian follicles especially the dominant follicle, secrete

estrogen mainly, and small amounts of progesterone. The corpus luteum secretes

progesterone mainly, and moderate amount of estrogen. Thus, in terms of the ovarian

function, the menstrual cycle can be divided into

Follicular phase: from start of follicle development to ovulation, when the

follicles are the important structures in the ovary.

Luteal phase: after ovulation up to menstruation, when the corpus luteum is the

dominant structure in the ovary.

Control of Ovarian Function

This constitutes a hormonal series made up of GnRH, the anterior pituitary

gonadotropins follicle stimulating hormone (FSH) & luteinising hormone (LH), and

gonadal sex hormones progesterone and estrogen. The entire sequence of basic controls

depends on the secretions of GnRH from the hypothalamic neuroendocrine cells in

episodic pulses.

Hypothalamus

↓GnRH

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Anterior Pituitary

↓FSH & LH

Ovaries

↓Progesterone and estrogen

Uterus

In the follicular phase, there is constant stimulation of the ovarian follicle by FSH & LH

to develop and mature an ovum. Some 18 hours prior to ovulation, there is a sharp

increase in the level of LH. This is said to be what ignites the ovulation to take place.

During the luteal phase, there is high level of sex steroids produced by the corpus

luteum. This forces the level of GnRH FSH and LH to decrease by negative feedback.

But the level of the sex steroids also decreases after 10 days due to the demise of the

corpus luteum. Following this the uterus starts to bleed giving menstruation. Then after

the hypothalamus and anterior pituitary gland start producing hormones which develop

and mature an ovum for another reproductive cycle.

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Phases of the menstrual cycle in the Uterus

Proliferative phase: between cessation of menstruation and occurrence of ovulation. It

has an average duration of 10 days. In this phase the endometrium begins to thicken as it

regenerates. The endometrial glands and arteriole grow longer and more coiled. There is

high level of estrogen in the body which brings about these changes, so also called

estrogenic phase. It corresponds to follicular phase in the ovary.

Ovulation: rupture of mature follicle with expulsion of its ovum into the pelvic cavity.

Secretory phase: between ovulation and onset of menses. The endometrium secrets

various substances, the glands become more coiled and contain glycogen. There is high

level of progesterone which brings about these changes. It is also called progesteronic

phase. It corresponds to luteal phase in the ovary.

Menstrual phase: the entire period of menstruation. Average length of 3-5 days (1-9

days is normal), volume of 80 ml (50-150 ml is normal) and typical of 28-30 days cycle

(21-35 days is normal). During this period the endometrium degenerates resulting in the

menstrual flow.

There are also changes on the cervix brought about by the sex hormone. The cervical

secretion from the cervical glands becomes abundant, clear and non viscous in the

proliferative phase (estrogenic phase). This helps in the support and transport of

spermatozoa in the vagina, but it becomes thick and sticky in the secretory phase

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(progesteronic phase) to prevent the ascent of bacteria and spermatozoa from the vagina

to the uterine cavity.

Fertilization

Fertilization is the union of the ovum and spermatozoa. Following ovulation, the ovum

passes into the fallopian tube and is moved along towards the uterus. The ovum has no

power of locomotion, thus is moved along the cilia and by the peristaltic muscular

contraction of the tubes. At this time the cervix secrets alkaline mucus which support

and transport spermatozoa from the vagina to the uterus via the cervix. Fertilization of

the ovum usually occurs soon after ovulation (in 24 hours) at the distal end of the tube,

usually the ampullary part.

The fertilized ovum now containing 23 paired chromosomes starts to multiply once

every 12 hours forming 2, 4, 8 & so on cells. This process continues until a mass of cells

called Morula is formed. It takes 3-4 days until the fertilized ovum reaches the uterus.

After the morula, a fluid filled cavity (blastocele) appears in the morula now called a

blastocyst. Around the outside of the blastocyst there is a single layer of cells known as

the trophoblast, while the remaining cells are clumped together at one end forming the

inner cell mass. The trophoblast will form the placenta and chorion. The inner cell mass

will become the fetus and amnion. Trophoblast becomes sticky and adherent to the

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endometrium. It begins to secret substances which digest the endometrial cells, allowing

blastocyst to become embedded in the endometrium, which completes by the 11th

day.

Decidua is the name given to the endometrium during pregnancy. Estrogen brings about

the continuous growth of the endometrium; progesterone stimulates the secretory

activity of the endometrial glands & increase in the size of the blood vessels. The

decidua underneath the blastocyst is called basal decidua, the part which covers the

blastocyst is known as capsular decidua and the remainder is the parietal (true) deciduas

.

Figure: - Diagrammatic representation of the development of the fertilised ovum.

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Trophoblast: forms small projections from the blastocyst especially at the area of

contact. These differentiate into layers

Syncitiotrophoblast (Syncitium)

o Capable of breaking down tissue as in the process of embedding.

o Erodes the blood vessels of the decidua, making nutrients in the maternal blood

accessible to the developing organism.

o produce human chorionic gonadotropin (HCG) hormone

Cytotrophoblast

o single cell layer

Mesoderm (primitive mesenchyme): loose connective tissue

Inner cell mass:‘ cells differentiate into three layers

Ectoderm: form the skin & nervous tissue

Mesoderm: form bones, muscles, heart, blood vessels & other organs

Endoderm: form mucous membranes & glands

Also two cavities emerge from the inner cell mass. These are the amniotic cavity and

yolk sac. The yolk sac provides nourishment for the embryo until the trophoblast is

sufficiently developed to take over.

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Embryo: period until 8 weeks of gestation at which time organ and systems of the body

are laid down. Then the conceptus is called the fetus at which time maturation of the

organs and systems of the body take place.

The Placenta

It is completely formed from the 10 weeks after fertilization. It has different function.

Respiration: excrete CO2 and absorbs O2

Nutrition: absorbs amino acids, glucose vitamins minerals water, fatty acids and

others

Storage: glucose in the form of glycogen & reconverts it as required. Also stores iron

& fat soluble vitamins A, D & E.

Excretion: CO2, bilirubin

Protection: good against bacteria (except in for few like Syphilis), poor against

viruses. Protection by the passage of IgG from maternal circulation to the fetus which

would work for up to 9 months after birth.

Endocrine

o HCG: keeps the corpus luteum alive

o Estrogen: develops the endometrium

o Progesterone: enriches the endometrium

o HPL (human placental lactogen): role in glucose metabolism

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The placenta is 20 cm in diameter, 2.5 cm thick, 1/6 the weight of the fetus at term. It

has two surfaces: the maternal side which dark red with 20 lobes and the fetal part which

is clear whitish with blood vessels running in membrane.

Read: The different anatomical variations of the placenta and umbilical cord.

Anatomical variations of placenta

Succenturiate lobe of placenta: small extra lobe, separate from the main part &

joined by membrane which harbors blood vessels. It has risk of being retained post

delivery with further complications of hemorrhage & infection. Upon examination, the

placenta looks torn or the blood vessels run beyond the edge of the placenta.

Battledore insertion of the cord: cord inserted at the very edge of the placenta.

Velamentous insertion of the cord: vessels run some distance through the

membranous (cord inserted into the membrane) from the edge of the placenta.

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Bipartite placenta: two complete & separate lobes, each with a cord leaving it.

Circumvallate placenta: an opaque ring seen on the fetal surface formed by a

doubling back the chorion and amnion.

The Amniotic fluid

It allows growth & movement of the fetus, maintains constant temperature,

provides small amount of nutrients, equalizes pressure & protects the fetus from

injury, aids in effacement & dilatation of the cervix during labour, and protects the

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placenta & umbilical cord from pressure of the uterine contraction. Fetal urine

contributes to the volume after the 20th

week. It has an average volume of 1000

ml, 99% water, 1 % dissolved solid matter. It is clear pale-straw colored.

Umbilical Cord (funis)

It contains two arteries and one vein in a gelatinous substance known as

Wharton‘s jelly covered by the amnion. Average size of 50 cm. If it is too long,

the fetus may knot the cord and die; and if it too short, vaginal delivery could be

difficult in a high implantation of the placenta.

Time scale of development

For the first 3 weeks following conception the term fertilised ovum or zygote is used. From

3-8 weeks after conception it is known as the embryo and following this it is the fetus

until birth, when it becomes a baby. Although when speaking to mothers the fetus in

utero is usually referred to as a baby, the midwife/Nurse should use the correct

terminology during professional discussions and in records.

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Development within the uterus is summarise as follows

0-4 weeks after conception

Rapid growth

Formation of the embryonic plate

Primitive central nervous system forms

Heart develops and begins to beat

Limb buds form

4-8 weeks

Very rapid cell division

Head and facial features develop

All major organs lay down in primitive form

External genitalia present but sex not distinguishable

Early movements

Visible on ultrasound from 6 weeks

8-12 weeks

Eyelids fuse

Kidneys begin to function and the fetus passes urine from 10 weeks

Fetal circulation functioning properly

Sucking and swallowing begin

Sex apparent

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Moves freely (not felt by mother)

Some primitive reflexes present

12-16 weeks

Rapid skeletal development - visible on X-ray

Meconium present in gut

Lanugo appears

Nasal septum and palate fuse

16-20 weeks

'Quickening' - mother feels fetal movements

Fetal heart heard on auscultation

Vernix caseosa appears

Fingernails can be seen

Skin cells begin to be renewed

20-24 weeks

Most organs become capable of functioning

Periods of sleep and activity

Responds to sound

Skin red and wrinkled

24-28 weeks

Survival may be expected if born

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Eyelids reopen

Respiratory movements

28-32 weeks

Begins to store fat and iron

Testes descend into scrotum

Lanugo disappears from face

Skin becomes paler and less wrinkled

32-36 weeks

Increased fat makes the body more rounded

Lanugo disappears from body

Head hair lengthens

Nails reach tips of fingers

Ear cartilage soft

Plantar creases visible

36-40 weeks after conception (38-42 weeks after LMP)

Term is reached and birth is due Contours rounded

Skull firm

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The fetal circulation

The key to understanding the fetal circulation is the fact that oxygen is derived from the

placenta. In addition, the placenta is the source of nutrition and the site of elimination of

waste. At birth there is a dramatic alteration in this situation and an almost instantaneous

change must occur. Therefore all the postnatal structures must be in place and ready to

take over. There are several temporary structures in addition to the placenta itself and the

umbilical cord and these enable the fetal circulation to take place while allowing for the

changes at birth.

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The Umbilical vein

This vein leads from the umbilical cord t the underside of the liver and carries blood rich

in oxygen and nutrients. It has a branch that joins the portal vein and supplies the liver.

The ductus venosus (from a vein to a vein)

This connects the umbilical vein to the inferior vena cava.

At this point the blood mixes with deoxygenated blood returning from the lower parts of

the body. Thus the blood throughout the body is at best partially oxygenated.

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The foramen ovale (oval opening)

This is a temporary opening between the atria that allows the majority of blood entering

from the inferior vena cava to pass across into the left atrium. The reason for this

diversion is that the blood does not need to pass through the lungs to collect oxygen

The ductus arteriosus (from an artery to an artery)

This leads from the bifurcation of the pulmonary artery to the descending aorta, entering

it just beyond the point where the subclavian and carotid arteries leave.

Adaptation to extra uterine life

At birth the baby takes a breath and blood is drawn to the lungs through the pulmonary

arteries. It is then collected and returned to the left atrium via the pulmonary veins,

resulting in a sudden inflow of blood.

The placental circulation ceases soon after birth and less blood returns to the right side

of the heart. In this way the pressure in the left side of the heart is greater while that in

the right side of the heart becomes less .This results in the closure of a flap over the

foramen ovale, which separates the two sides of the heart and stops the blood flowing

from right to left.

With the establishment of pulmonary respiration, the oxygen concentration in the

bloodstream rises. As a result the ductus arteriosus constrict and close. For as long as the

ductus remains open after birth blood flows from the high pressure aorta towards the

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lungs, in the reverse direction to that in fetal life.

The cessation of the placental circulation results in the collapse of the umbilical vein, the

ductus venosus and the hypogastric arteries.

These immediate changes are functional and those related to the heart are reversible in

certain circumstances. Later they become permanent and anatomical.

The umbilical vein becomes the ligamentum teres

The ductus venosus the ligamentum venosum and

The ductus arteriosus the ligamentum arteriosum.

The foramen ovale becomes the fossa ovalis and

The hypogastric arteries are known as the obliterated hypogastric arteries except for

the first few centimetres, which remain open as the superior vesical arteries.

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Maternal Physiological Changes during Pregnancy

The physiologic biochemical and anatomic changes that occur during pregnancy are

extensive and may be systemic or local. Physiologic alterations during pregnancy

maintain healthy environment for the fetus without compromising the mother‘s health;

although, sometimes determine small discomfort to the mother.

Gastrointestinal Tract

During pregnancy, nutritional requirements, including those for vitamins and minerals,

are increased, and several maternal alterations occur to meet this demand. The mother‘s

appetite usually increases, so that food intake is greater, some women have a decreased

appetite or experience nausea and vomiting. These symptoms may be related to relative

levels of human chorionic gonadotrophin (HCG).

Oral Cavity

Salivation may seem to increase (ptyalism) due to swallowing difficulty associated with

nausea, and the gums may become hypertrophic, hyperemic and friable; this may be due

to increased systemic estrogen. Vitamin C deficiency also can cause tenderness and

bleeding of the gums. The gums should return to normal in the early puerperium

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Gastrointestinal Motility

Gastrointestinal motility may be reduced during pregnancy due to increased levels of

progesterone, which in turn decrease the production of motilin, a hormonal peptide that

is known to stimulate smooth muscle in the gut. Transit time of food throughout the

gastrointestinal tract may be so much slower that more water than normal is reabsorbed,

leading to constipation.

Stomach and Esophagus

Gastric production of hydrochloric acid is variable and sometimes exaggerated,

especially during the first trimester. More commonly, gastric acidity is reduced.

Production of the hormone gastrin increases significantly, resulting in increased stomach

volume and decreased stomach PH. Gastric production of mucus may be increased.

Esophageal peristalsis is decreased, accompanied by gastric reflux because of the slower

emptying time and dilatation or relaxation of the cardiac sphincter. Gastric reflux is

more prevalent in later pregnancy owing to elevation of the stomach by the enlarged

uterus. Besides leading to heartburn, all of these alterations as well as lying in the

supine lithotomy position make the use of anesthesia more hazardous because of the

increased possibility of regurgitation and aspiration.

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Small and Large Bowel and Appendix

The large and small bowels move upward and laterally, the appendix is displaced

superiorly in the right flank area. These organs return to the normal positions in the early

puerperium. As noted previously, motility is generally decreased and gastrointestinal

tone is decreased.

Gallbladder

Gallbladder function is also altered during pregnancy because of the hypotonia of the

smooth muscle wall. Emptying time is slowed and often incomplete. Bile can become

thick, and bile stasis may lead to gallstone formation.

Liver

There are no apparent morphologic changes in the liver during normal pregnancy, but

there are functional alterations like increased production of blood proteins but their

concentration is not elevated because of more increase in the plasma volume.

Kidneys and Urinary Tract

Renal Dilatation

During pregnancy, each kidney increases in length by 1-1.5cm, with a concomitant

increase in weight. The renal pelvis is dilated. The ureters are dilated above the brim of

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the bony pelvis. The ureters also elongate, widen, and become more curved. Thus, there

is an increase in urinary stasis, this may lead to infection. The absolute cause of

hydronephrosis and hydroureter in pregnancy is unknown; there may be several

contributing factors, which include elevated progesterone levels.

Renal Function

The glomerular filtration rate (GFR) increases during pregnancy by about 50% .The

renal plasma flow rate increases by as much as 25-50%. Even thought the GFR

increased dramatically during pregnancy, the volume of the urine passed each day is not

increased. Thus, the urinary system appears to be even more efficient during pregnancy.

With the increase in GFR, there is an increase in endogenous clearance of creatinine.

The concentration of creatinine in serum is reduced in proportion to increase in GFR,

and concentration of blood urea nitrogen is similarly reduced.

Glucosuria during pregnancy is not necessarily abnormal, may be explained by the

increase in GFR with impairment of tubular reabsorption capacity for filtered glucose.

Increased levels of urinary glucose also contribute to increased susceptibility of pregnant

women to urinary tract infection.

Proteinuria changes little during pregnancy and if more than 300mg/24h is lost, a disease

process should be suspected

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Bladder

As the uterus enlarges; the urinary bladder is displaced upward and flattened in the

anterior-posterior diameter. Pressure from the uterus leads to increased in urinary

frequency.

Hematologic System

Blood Volume

Perhaps the most striking maternal physiologic alteration occurring during pregnancy is

the increase in the blood volume. The magnitude of the increases varies according to the

size of woman, and whether there is one or multiple fetuses. The increases in blood

volume progress until term; the average increase in volume at term is 45-50%. The

increase is needed for extra blood flow to the uterus, extra metabolic needs of fetus and

increased perfusion of others organs, especially kidneys. Extra volume also compensate

for maternal blood loss during delivery. The average blood loss with vaginal delivery is

500-600ml, and with cesarean section is 1000ml.

Red Blood Cells

The increase in red blood cell mass is about 25%. Since plasma volume increases early

in pregnancy and faster than red blood cell volume, the hematocrit falls until the end of

the second trimester, resulting in a state of physiological anemia. When the increase in

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the red blood cells is synchronized with the plasma volume increase, the hematocrit then

stabilizes or may increase slightly near term.

Iron

With the increase in red blood cells, the need for iron for the production of hemoglobin

naturally increases. If supplemental iron is not added to the diet, iron deficiency anemia

will result. Maternal requirements can reach 5-6mg/d in the latter half of pregnancy. If

iron is not readily available, the fetus uses iron from maternal stores. Thus, the

production of fetal hemoglobin is usually adequate even if the mother is surely iron

deficient. Therefore, anemia in the newborn is rarely a problem; instead, maternal iron

deficiency more commonly may cause preterm labour and late spontaneous abortion,

increasing the incidence of infant wastage and morbidity.

White Blood Cells

The total blood leukocyte count increases during pregnancy from a prepregnancy level

of 4,000-11,000 to 10,000-15,000 in the last trimester, although counts as high as

16,000/mL have been observed in the last trimester. Lymphocyte and monocyte numbers

stay essentially the same throughout pregnancy; polymorphonuclear leucocytes are the

primary contributors to the increase.

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Clotting Factors

During pregnancy, level of several essential coagulation factors & the count of platelets

are increased. There are marked increases in fibrinogen and factor 8. Factors XI & XIII

decrease in during pregnancy. Understanding these physiologic changes is necessary to

manage two of the more serious problems of pregnancy: hemorrhage and

thromboembolic disease, both caused by disorders in the mechanism of hemostasis.

Cardiovascular System

Position and Size of Heart

As the uterus enlarges and the diaphragm becomes elevated, the heart is displaced

upward and somewhat to the left with rotation on its long axis, so that the apex beat is

moved laterally. The size of the heart increases due to the increase in the workload.

Cardiac Output

Cardiac output increases approximately 40% during pregnancy, reaching its maximum at

20-24 week‘s gestation and continuing at this level until term. The increase in output can

be as much as1, 5L/min over the non-pregnant level. Cardiac output is very sensitive to

changes in body position. This sensitivity increases with lengthening gestation,

presumably because the uterus impinges upon the inferior vena cava, thereby decreasing

blood return to the heart.

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Blood Pressure

Systemic blood pressure declines slightly during pregnancy. The obstruction posed by

the uterus on the inferior vena cava and the pressure of fetal presenting part on the

common iliac vein can result in decreased blood return to the heart. This decreases

cardiac output, leads to a fall in blood pressure, and causes edema in the lower

extremities.

Peripheral Resistance

Peripheral resistance is decreased owing to the vasodilatation effect of progesterone the

blood vessels.

Pulmonary System

Pregnancy produces anatomic and physiologic changes that affect respiratory

performance. Early in pregnancy, capillary dilatation occurs throughout the respiratory

tract, leading to engorgement of the nasopharynx, larynx, trachea, and bronchi. This

causes the voice to change and makes breathing through the nose difficult. Respiratory

infections and preeclampsia aggravate these symptoms. Chest X-rays reveal increased

vascular makings in the lungs.

As the uterus enlarges, the diaphragm is elevated as much as 4cm, and the rib cage is

displaced upward and widens, increasing the lower thoracic diameter by 2cm and the

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thoracic circumference by up to 6cm. Elevation of the diaphragm does not impede its

movement. Abdominal muscles have less tone and are less active during the pregnancy,

causing respiration to be more rather than less diaphragmatic.

Lung Volumes and Capacities

Alterations occurring in lung volumes and capacities during pregnancy include the

following: Dead volumes increases owing to relaxation of the musculature of conducting

airways. Tidal volumes increases (35-50%) gradually as pregnancy progresses. Total

lung capacity is reduced (4-5%) by the elevation of the diaphragm. Functional residual

capacity, residual volume, and respiratory reserve volume all decrease by about 20%.

Larger tidal volume and smaller residual volume cause increased alveolar ventilation

(about 65%) during pregnancy. Inspiratory capacity increases 5-10% and a progressive

increase in oxygen consumption of up to 15-20% above non-pregnant levels & enhanced

CO2 excretion by term.

Metabolism

As the fetus and placenta grow and place increasing demands on the mother,

phenomenal alterations in metabolism occur. The most obvious physical changes are

weight gain and altered body shape. Weight gain is due not only to the uterus and its

contents but also to increase breast tissue, blood and water volume in the form of extra

vascular and extra cellular fluid. Deposition of fat and protein and increased cellular

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water are added to the maternal stores. The average weight gain during pregnancy is

12.5Kg. About 2kg increase in the first 20 weeks, and 0.5 kg per week until delivery.

Reproductive Tract

After conception the uterus develops to provide nutritive and protective environment in

which the fetus will develop & grow. The decidua becomes thicker, richer and more

vascular at the fundus and corpus. The myometrium hypertrophy and hyperplasia takes

place. These are the effects of estrogen on the muscles. The weight of the uterus

increases from 60 gm to 900gm at term, volume changes from 10 ml to 1000ml at term.

Painless (usually) contractions in the uterus could occur during pregnancy from as early

as 8 weeks lasting 60 seconds; these are called Braxton-Hicks contraction. The isthmus

elongates and the cervix continues to produce the cervical plug. The vagina and cervix

become more elastic and more vascularised.

Skin

There is increased melanocyte stimulating hormone secretion (MSH) which may result

in hyperpigmentation of the skin over the cheeks (chloasma), linea nigra and

hyperpigmentation of the nipple area. Increase in maternal size could bring about

stretching of collagen fibres in the breast, abdomen & increased fat deposition areas

giving rise to striae gravidarum. This regresses in 6 months postpartum. Pregnants also

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experience increased sweating during pregnancy due to raised basal body temperature

together with vasodilatation.

Skeletal Changes

Relaxation of ligaments and muscles with posturing like exaggerated lumbar curve.

Endocrine

Production of HPL, progesterone, estrogen, ACTH, MSH, TSH & oxytocin increased.

The levels of FSH & LH is Suppressed.

Could there be goiter during pregnancy? If so please explain the pathophysiology.

Minor Disorder of Pregnancy

Minor disorders are only minor as long as they are not life threatening. A minor disorder

may escalate & become a serious complication of pregnancy. Exa: simple nausea and

vomiting may progress to hyperemesis gravidarum. The role of the nurse is to educate

the mother and be always alert to any developing complication & refer appropriately.

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Most of the minor disorders are due to hormonal, metabolic and postural changes.

1. Digestive System

a. Nausea & vomiting: usually between 4-16 weeks of gestation. The most likely cause

is increased level of HCG. It is also referred as early morning illness, but it is not

confined to the morning. It gets precipitated by smell of food, so understanding the cause

is a key in the treatment of the condition.

b. Heart burn: due reflux gastric content into the esophagus via the lax lower

esophageal sphincter. It is most troublesome at 30-34 weeks of gestation because it the

time the stomach becomes under pressure from the growing uterus. If the condition is

occasional, advice the mother to avoid bending over, take small meals and sleep with

more pillows. If it is persistent, you can treat it with antacids.

c. Excessive salivation (ptyalism): starts from the 8th week, & improves with

regression of the nausea and vomiting..

d. Constipation: can improved by intake of increased water, fresh fruits & vegetable. A

glass of warm water in the morning before breakfast may activate the gut & help regular

bowel movements. Exercise like walking is also helpful. The condition may aggravate

hemorrhoids and full rectum can cause non engagement of the fetal head at term.

2. Musculoskeletal System

a. Backache: due to softening of the ligaments with increased lumbar curve. Giving

support to the back and sleeping on hard board may help.

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b. Cramp: usually leg cramp, unknown cause. Advice the mother to raise the leg with

dorsiflexion of the foot, take warm bath before bed & vitamin B complex.

3. Genitourinary System

a. Frequency of micturition: it is problem usually at early and late pregnancy. These

are due to the competing of the growing pelvis and the descending fetal head for space in

the pelvis during early and late pregnancy respectively. Your major responsibility is to

rule out the existence of UTI.

b. Leucorrhea: increased white, non irritant vaginal discharge. So advice on personal

hygiene like washing the area twice a day.

4. Circulatory System

a. Fainting: in early pregnancy due to vasodilatation before compensatory increase in

blood volume, & later due to impinging of the enlarged uterus on the inferior vena cava.

Both result in decreased venous return, leading to decreased cardiac output. Advice the

mother to avoid standing for long periods and lying on her back. Also advice her to sit or

lie down quickly when she feels dizzy.

b. Varicosities: peripheral vasodilatation with sluggish circulation predisposes to valve

incompetence. Usually occurs in the legs, hemorrhoids and vulva. Family history & jobs

which demand long periods of standing/sitting also predispose to the condition. Advice

the mother to elevate the legs & rest, do calf exercises by moving the toes, use tights on

her extremities and avoid constipation. Sanitary pads give support to vulvar varicosities

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5. Nervous System

a. Insomnia: could be due to nocturnal frequency, discomfort in bed, anxiety, etc.

Advice the mother in accordance with the condition you suspect is the likely cause.

Diagnosis of Pregnancy

Pregnancy is mainly diagnosed on the symptoms reported by the woman and the signs

elicited by the health care provider. There are three categories in the diagnosis of

pregnancy.

1. Presumptive (Possible) criteria

a. early breast changes: increase in size, darkening of the areola

b. Amenorrhea: without use of contraceptives, and in a woman with regular cycles

c. Morning sickness

d. Bladder irritability

e. Quickening: the date of the first movement of the fetus felt by the mother

i. primigravid---18-20 weeks

ii. multigravid---16-18 weeks

2. Probable Signs

a. Presence of HCG in the urine or the blood

b. Uterine growth

c. Braxton hicks contractions

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d. Ballottement of the fetus

3. Positive Signs

a. Visualization of the fetus by

i. ultrasonography: as early as 6 weeks of gestation via the abdomen

ii. X-ray: after 12 weeks of gestation

b. Fetal heart beat by

i. ultrasonography

ii. Fetal stethoscope (fetoscope): usually between 20-24 weeks

c. Fetal movement by

i. palpation

ii. visible

Definitions of terms

Gravidity: refers to pregnancy irrespective of the outcome

nulligravid, primigravid, multigravid

Parity: refers to delivery. The fetus could be dead or alive. Nullipara, primipara,

multipara, grandmultipara.

Lie: the relationship of the long axis (spine) of the fetus to the long axis of the mother‘s

uterus and normal lie is longitudinal. Abnormal lie could be transverse or oblique.

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Attitude: the relationship of the fetal parts to one another (head and limbs to its trunk)

and the normal attitude is flexion, abnormal includes deflection and extension.

Presenting part: part which lies over the cervical OS during labour and on which the

caput forms

Presentation: refers to the part of the fetus which lies at the pelvic brim or in the lower

pole of the uterus.

Vertex, brow, Face-----------Cephalic

Breech

Shoulder

Compound

Position: relationship between the denominator pf the presentation and six area in the

pelvis. Anterior position is favourable than posterior.

Crowned: biparietal diameter passes the ischial spines

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Denominator: part of the fetus which determines the position.

Vertex----Occiput

Breech----Sacrum

Face-------Mentum

Engaged: when the widest diameter (biparietal diameter for cephalic presentation)

passes the pelvic brim

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Antenatal Care, ANC

Antenatal care is the care given to a woman during her pregnancy.

Objectives

1. promote & maintain the good health of the mother & fetus during pregnancy

2. ensure that the pregnancy result in healthy infant & healthy mother

3. detect early & treat appropriately ‗high risk‘ conditions

4. Prepare the woman for labour, lactation & subsequent care of the baby.

ANC should be started as early as possible.

History Taking

Social Hx: Name, age, occupation, residence, etc

General health: ask about her general health and stress on importance of restricting

alcohol and nicotine, and exercise is helpful.

Menstrual hx: ask about the LMP and try to ascertain whether it is reliable i.e. was with

normal duration and amount, is sure of the date, no use on contraception for at least three

cycles prior to the LMP. Then calculate the EDD (expected date of delivery) by

LMP + 9 months + 7 days --- when you use G.C.

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LMP + 9 months + 10/5/4 days ---- when you use E.C.

This formula assumes that conception occurred 14 days after 1st day LMP and last period

of bleeding was true mensus.

If the woman does not know/ remember the LMP, use fundal height, quickening and

early ultrasound to estimate the gestation age of the conception and calculate the EDD.

Obstetric Hx: record previous pregnancies and labour i.e. the outcome, any problem

during labour and pregnancy, etc.

uterine efficiency is better after the first labour

primigravid: more risk of PIH, obstructed labour, etc

Grandmultipara: more risk of PPH

previous abortion: be sympathetic and non judgmental

hx of Rh isoimmunization, abortion D & C, APH/PPH, PIH, etc.

Medical and surgical hx: could be mild or severe

UTI—pyelonephritis--- premature labour

pregnancy predisposes to DVT

essential hypertension predisposes to PIH

asthma, epilepsy, etc may need drug therapy which may affect early fetal

development

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Operation to the any part of the body especially to the genital tract is of great

importance.

Family hx: gives a clue to familial, racial, genetic diseases.

Diabetes mellitus, hypertension, multiple pregnancy, sickle cell anemia, etc.

Physical examination

First Visit

Objective

to diagnose pregnancy

to identify high risk pregnancy

to give advice to pregnant mother

General appearance: as she walks in observe any deformity, stature, mood

Height =< 150 cm need special care

Weight: average weight gain of 12-14 kg

0.4 kg/month in the 1st trimester, 0.4 kg/week in the 2

nd & 3

rd trimesters

Sudden weight gain may suggest fluid retention

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Take the vital signs

Blood pressure: to ascertain normality & provide baseline reading for comparison

throughout pregnancy. It may get falsely elevated if the woman is anxious or nervous.

Use the brachial artery.

Clinical signs of anemia

Breast examination: assess the size, lumps, and the nipples; and teach the mother on self

examination of the breast.

Examine the hearts, lungs as well

Abdominal examination: to observe signs of pregnancy, assess the fetal size & growth,

assess fetal health, diagnose the location of fetal parts and detect any deviation from

normal

Steps: inspection, palpation and auscultation

Inspection

o Shape: the uterus is longer than broader, longitudinal and ovoid in primi,

round in multi, broad in transverse lie

o correspond the size with the stated gestational age

o look at the skin for changes in pregnancy

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palpation

o Fundal height & fundal palpation

Clean and warm hands

12 week---symphysis pubis

20 week---umbilicus, one finger breadth above the umbilicus

corresponds to 2 weeks, and to 1 week below the umbilicus.

38 week---xiphisternum

40 week---4 cm lower because of lightening

Purpose is to know what occupies the fundus and fundal height.

o Lateral palpation

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know the lie & identify the side of the back

Do the examination facing the mother

Note irregularities which denote extremities

o Deep pelvic palpation

know the presentation and attitude

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Pwlick’s grip Helps you identify whether the head is engaged.

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Auscultation: check the FHB, rate and rhythm. Count for a full minute, and hands

don‘t touch the abdomen.

Pelvic Assessment: may be done depending on special indications, but usually deferred

until labour ensues. This can be done clinically or by X-ray pelvimetry.

Examine the vuvla: exa—for wart, discharge

Examine urinary system, the lower limbs and the nervous system.

Booking for confinement:

WHO recommends minimum of 4 visits for a low risk pregnancy

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High risk pregnancies would have frequent ANC visits depending on the specific

problem they have.

Laboratory Investigations

Hct, blood group & Rh,

Urinalysis

VDRL

Stool examination as indicated

Advice

Advantage of ANC

Use of tetanus toxoid vaccine

danger of lifting heavy loads

importance of exercise

diet should be rich in Fe & protein

Breast care and rest.

Report the following

vaginal bleeding

frontal / recurring headache

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sudden swelling

Rapture of membrane.

premature onset of contractions

The first visit

The first ANC visit should occur in the first trimester, around or preferably before 16

weeks of gestational age.

Objectives of first visit

To determine patients‘ medical and obstetric history with a view to collect evidence of

the woman's eligibility to follow the basic component or need special care and/or referral

to a specialized hospital (using the classifying form).

To do pregnancy test to those women who come early in pregnancy,

To identify and treat symptomatic STI

To determine gestational age

+

To provide routine Iron supplementation

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To Provide advice on signs of pregnancy-related emergencies and how to deal

with them including where she should go for assistance

To provide simple written instructions in the local language that gives general

information about pregnancy and delivery, HIV as well as any specific answers to

the patient‘s questions.

To give advice on malaria prevention

To provide routine Provider-initiated HIV counseling and testing

To provide PMTCT services

The second visit

The second visit should be scheduled at 24-28 Weeks. It is expected to take 20 minutes.

Objectives of the second visit is to

address complaints and concerns perform pertinent examination and laboratory

investigation (BP, uterine height), proteinuria for those who are nulliparous and or those

who have history of hypertension or preeclampsia/eclampsia, determine hemoglobin if

clinically indicated

� assess fetal well being

design individualized plan

advice on existing social support

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decide on the need for referral based on updated risk assessment

The third visit

The third visit should take place around 30 – 32 weeks and is expected to take 20

minutes.

Objectives of the third visit is to

address complaints and concerns

perform pertinent examination and laboratory investigation (BP, uterine height,

multiple dipstick test for bacteruria, determine hemoglobin for all, proteinuria for

nulliparous women and those with a history of hypertension, pre-eclampsia or

eclampsia

assess for multiple pregnancy, assess fetal well being

review individualized birth plan and complication readiness including advice on

skilled attendance at birth, special care and treatment for HIV positive women

according to the National Guideline for PMTCT of HIV in Ethiopia

advice on family planning, breastfeeding

decide on the need for referral based on updated risk assessment

The fourth visit

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The fourth should be the final visit of the basic component and should take place

between weeks 36 and 38.

Objectives of the fourth visit is to:

review individualized birthplan, prepare women and their families for childbirth

such as

selecting a birth location,

identifying a skilled attendant,

identifying social support,

planning for costs,

planning for transportation

preparing supplies for her care and the care of her newborn.

complication readiness: develop an emergency plan which include

transportation,

money, blood donors,

designation of a person to make a decision on the woman‘s behalf and

person to care for her family while she is away.

re-inform women and their families of the benefits of breastfeeding and

contraception, as well as the availability of contraceptive methods at the

postpartum clinic.

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perform relevant examination and investigations

review special care and treatment for HIV positive women according to the

Guidelines for PMTCT of HIV in Ethiopia.

At this visit, it is extremely important that women with fetuses in breech

presentation should be discovered and external cephalic version be considered.

All information on what to do and where to go (which health facility) when labor

starts or in case of other symptoms should be reconfirmed in writing and shared

with the patient, family members and/or friends of the patient.

Normal Labour

During pregnancy the fetomaternal unit nourishes and protects the growing fetus. the

body of the uterus remains relaxed & the cervix closed. As parturition approaches the

non progressive Braxton hicks contractions experienced during pregnancy alter to

become the progressive form of labour.

Labour: the process by which the fetus, placenta, & membranes are expelled through

the birth canal.

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Normal labour: occurs at term, spontaneous onset, vertex presentation, process

completed within 24 hrs & no complication arisen.

Three stages of labour

1st

Stage of labour: begins with regular rhythmic contractions and ends when the

cervix is fully dilated i.e. 10 cm wide.

2nd

Stage of labour: begins with fully dilated cervix and ands with complete

expulsion of the fetus

3rd

: Stage of labour separation and expulsion of the placenta and membranes & involves

control of bleeding.

4. Fourth Stage: the first 1-2 hours after delivery of placenta – recovery stage.

Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.

Onset of Labour Stage of labour

The most important diagnosis in obstetrics since it is on the basis of this finding that the

decisions are made which will affect the management of labour.

Lightening: 2-3 weeks before the onset of labour, the lower uterine segment expands and

allow the fetal head to sink lower, it may engage. Fundus is no longer crowds the lungs,

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breathing is easier. Symphysis pubis widens, & pelvic floor more relaxed & softened.

She may complain of frequency of micturition.

The exact cause of onset of labour is not known, but appears to be multifactorial. It

involves estrogen, oxytocin, prostaglandins and overstretching of the uterus itself.

Physiology of the first stage of labour

Uterine action:

Fundal dominance: each uterine contraction starts at the fundus near one of the

cornua and spreads downwards. Fundal contraction is most intense and lasts

longer.

Polarity: upper pole contracts strongly and retracts to expel the fetus; lower pole

contracts slightly and dilates to allow expulsion to take place. If polarity is

disorganized the progress of labour is inhibited.

Lower segment: developed from the isthmus & is about 8-10 cm long.

Retraction ring: land mark between the upper & lower uterine segments

Cervical effacement: muscle fibres surrounding the internal OS are drawn upward

by the retracted upper segment & the cervix merges into the lower uterine

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segment. External OS opens after effacement in primi, but it may open earlier in

multi.

Cervical dilatation: process of enlargement of the external OS from a tightly

closed aperture to an opening large enough to permit the passage of the fetal head.

This is achieved by uterine contraction and counter pressure applied by the bag of

membrane & presenting part.

Duration

Length of labour varies widely and influenced by;

Partity

Birth interval

Psychological state

Presentation and position of the fetus

Maternal pelvic shape and size

Character of uterine action .

Diagnosis of Labour

Rhythmic, regular, painful uterine contractions associated with progressive

cervical dilatation +/- ROM, passage of show.

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True labour: uterine contractions are always present, rarely exceeding 60 seconds, recur

with rhythmic regularity. It begins irregularly but become regular and predictable. It is

felt first in the lower back & sweep around to the abdomen in a wave usually & often

doesn‘t disappear with level of activity like ambulation.

1st Stage of labour: has 3 phases

latent phase: cervical dilatation 0-3 cm, usually <=8 hrs

Active phase: then upto full cervical dilatation. The mean length of active phase is

7.7hours innulliparous woman (but up to 17 hrs) . Themean length of the active

phase in multiparous woman is 5.6 hrs (again upto 13.8hrs).(Albers 1999)

Tranitional phase cervical dilatation from8-10 cm

The uterus contracts 2-5 times per 10 minutes, increasing in strength, & each usually

lasting >40 seconds[3 -10cm (fully dilated)]

Admission:

All women with diagnosis of labour (latent and active) for high risk or ruptured

membrane

For low risk and intact membrane: active 1st Stage of labour Greet, warm and

comfort the mother, inform relatives to wait outside.

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Take appropriate history: gravidity, parity, abortion, LMP, EDD, GA, about ANC,

duration of contraction, duration of ROM/bleeding, any complaint.

P/E:

General appearance: exhaustion, pain, dehydration, edema

V/S:

o PR:

>100: infection, ketosis, hemorrhage, ruptured uterus, etc

½ hourly,

o BP: Q 4 hr (Q ½ hr if PIH)

Labor elevates BP

Hypotension: supine position, shock or epidermal anesthesia

o T: Q 4 hr, increases due to infection or ketosis

o RR: Q 4 hr

Do P/E to the thorax i.e. examine the cardiovascular and the respiratory systems

Abdominal palpation (obstetric palpation)

o Fundal height, lie, attitude, engagement, descent (fifths of the fetal

head which can still be felt above the brim)

o FHB: 120-160/min after contraction

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o Assess contraction

1. frequency of contraction per 10 minute

2. duration of contraction

3. strength of contraction (intensity)

Do – PV

o Pelvic assessment: Cavity, sacral promontory, Curve of the sacrum, ischial

spines & the Lateral pelvic sidewalls

o Cervix: dilatation, Effacement, Consistency, Edema

o Membranes: intact or ruptured, & if ruptured check the color of amniotic

fluid

o Presenting part: Position, Station (from -3i.e./ the inlet to +3 i.e. the pelvic

floor, 0 is the ischial spines), Molding (grading 0 to +3), Caput

Finish by examining the other system

Record all finding and then determine the stage of labor and decide if the woman

is a high risk (i.e. any abnormality picked up)

Bladder care

o Empty her bladder Q 2hrs

o Full bladder may initially prevent the fetal head from entering the pelvic

brim and later impedes descent of the fetal head. It also inhibit effective Ux

action

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Nutrition: - controversial

o Small dry biscuits with sips to prevent dehydration and hypoglycemia

o Risk of aspiration if general anesthesia is needed

Position

- Avoid supine position

- Ambulation is good except for woman with APH or ROM

Keep aseptic condition, remember that the vagina is not sterile, but the uterus is.

Keep personal and environmental hygiene at all time (mothers as well)

Pain relief

o Pain exhausts the woman physically and emotionally

o Pethidine can be used

Emotional support and reassurance

o A good nurse will give comfort, relieve pain, make strength, prevent

exhaustion, and maintain cleanliness during labor.

o Prevent complications, recognize early and promptly act when

complications occur until the arrival of the doctor

Enema: the membrane should be intact

Shaving - not recommended nowadays

Investigation - Hct, Bld group, Rh, VDRL, U/A (glu, Pr, ketones).

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Use the partograph

Reassessment: - Q 4 hr in 1st Stage of labour but Q1/2 hr in late first of labor (BP, T,

Abdominal Examination, PV, U/A)

- Q 1/2 hr: FHB, Uterine contraction, Pulse Rate

- Q2 hr: bladder

Second Stage of labour

Usually less than 1/2hr in multi (as little as 5min) & average 45min in prim but as long

as 2hr

No cervix felt on PV, contractions are much stronger & last 30-50sec, there is

urge to push (feels sense to defecate) & sometimes head can be seen at the vulva

Mechanism of labor

-descent – Engagement

-flexion (smaller presenting diameter )

- internal rotation of the head .

85

- extension of the head

– restitution (untwisting movement)

- internal rotation of the shoulder.(in to the widest diameter of pelvic out let i.e AP) At

the same time there is external rotation of the shoulder

-lateralflexion

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Once in the 2nd

Stage of labour the mother should never be left alone

Give constant and careful observation on:

- General condition, pulse, ux, FHB: Q 5 minute or after each

contraction

- Bladder should be empty

- Descent of the presenting part and progress of labor

- Membrane should be ruptured

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Preparation for delivery

*Equipment

- Delivery set: 2 clamps, scissors, sterile towel, cord tie, bowel and kidney

dish

- Ergometrine 0.5 mg in a syringe with swab, ready to give

- Section apparatus should be ready and in working condition

- Antiseptic lotion

- Empty container

- Identification with name and number of the mother

*Patient

-Position the mother, encourage to push, sterile gloves on, and keep constant

contact with mother

Conduct of delivery

1. Swab the vulva, Drap delivery area with sterile towels. Use a sterile pad to cover

the anus.

2. Do episiotomy on contraction if necessary

88

3. When the head is seen / the perineum and the head is crowned , place one hand

over it to control it and prevent it coming out quickly .The other hand is on a pad

or gauze over the rectum to ease the perineum to release the face and keep away

stool.

4. When the head is born, keep one hand on it and clean the eyes with the other hand

using dry cotton swab. Remove excess mucus from mouth, with gauze wrapped

around finger, look for cord around the neck, and if there is try to reduce it. If that

is not possible, clamp and cut it.

5. Wait for rotation of the shoulders. Then grasp the head and neck with two hands,

deliver the anterior shoulder first bending downwards, and then the posterior

shoulder .And slide one hand under the body and lift it out .

6. Lay baby down/ hold upside down

o Clear airways

- Cord clamped (4 – 5 cm) and cutting

- Dry baby well and wrap in a fresh warm towel

7. Place the new born in warm area and continue with 3rd

Stage of labour

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Third stage of labor

Third stage of labor

A. Uterine wall partially retracted but not sufficiently to cause placental separation

B. Further contraction and retraction thicken the uterine wall, reduce the placental site

and aid placental separation.

C .Complete separation and formation of retroplacental clot.

1. Expulsion of the placenta

Methods

o CCT oxytocic drugs (AMTSL)

o CCT without oxytocic drugs (Brandt Andrew Maneuver)

o Fundal pressure

90

o Traditional method /bearing down by the mother

Active management of third stage of labor (AMTSL):

AMTSL is the administration of uterotonic agents (preferentially oxytocin) followed by

controlled cord traction and uterine massage (after the delivery of the placenta).

Who should get AMTSL?

Every woman who come for delivery to the health facility. AMTSL is a standard

management of third stage of labor.

Benefit of AMTSL

• Duration of third stage of labor will be short

• Less maternal blood loss

• Less need for oxytocin in post partum

• Less anemia in the post partum

Drugs used for AMTSL

• Oxytocin is the preferred drug for AMTSL and 1st line drug for PPH caused by uterine

atony

91

• Ergometrine is the 2nd line drug for PPH though associated with more serious adverse

events

• Misoprostol has the advantage that it is cheap and stable at room temperature. It can be

distributed through community-based distribution systems.

• Uterotonics require proper storage:

• Ergometrine: 2-8°C and protect from light and from freezing.

• Misoprostol: room temperature, in a closed container.

• Oxytocin: 15-30°C, protect from freezing

Active Management of the Third Stage of Labor to Prevent Post-Partum

Hemorrhage

Use of uterotonic agents

Within one minute of the delivery of the baby, palpate the abdomen to rule out the

presence of an additional fetus(s) and give oxytocin 10 units IM.

• Oxytocin is preferred over other uterotonic drugs because it is effective 2-3 minutes

after injection, has minimal side effects and can be used in all women.

92

• If oxytocin is not available, other uterotonics can be used such as: ergometrine 0.5 mg

IM, syntometrine (1 ampoule) IM

or

• misoprostol 400-600 mcg orally. Oral administration of misoprostol should be reserved

for situations when safe administration and/or appropriate storage conditions for

injectable oxytocin and ergot alkaloids are not possible.

Steps in controlled cord traction

• Clamp the cord close to the perineum (once pulsation stops in a healthy newborn) and

hold in one hand.

• Place the other hand just above the woman‘s pubic bone and stabilize the uterus by

applying counter-pressure during controlled cord traction.

• Keep slight tension on the cord and await a strong uterine contraction (2-3 minutes).

• With the strong uterine contraction, encourage the mother to push and very gently pull

downward on the cord to deliver the placenta. Continue to apply counter-pressure to the

uterus.

• If the placenta does not descend during 30-40 seconds of controlled cord traction do

not continue to pull on the cord:

93

• Gently hold the cord and wait until the uterus is well contracted again;

• With the next contraction, repeat controlled cord traction with counterpressure.

• As the placenta delivers, hold the placenta in two hands and gently turn it until the

membranes are twisted. Slowly pull to complete the delivery.

• If the membranes tear, gently examine the upper vagina and cervix wearing

sterile/disinfected gloves and use a sponge forceps to remove any pieces of membranes

that are present.

• Look carefully at the placenta to be sure none of it is missing. If a portion of the

maternal surface is missing or there are torn membranes with vessels, suspect retained

placenta fragments and take appropriate action.

Uterine massage

• Immediately massage the fundus of the uterus until the uterus is well contracted.

• Palpate for a contracted uterus every 15 minutes and repeat uterine massage as needed

during the first 2 hours of the postpartum period.

• Ensure that the uterus does not become relaxed (soft) after you stop uterine massage

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APPROXIMATE FUNDAL HEIGHTS DURING THIRD STAGE

(A)Beginning of 3rd

stage (B)Placenta in lower segment (C) End of 3rd stage

Examination of the placenta, membrane & Umbilical cord

Placenta

- Inspect the fetal side

95

- Location of insertion of blood vessel

- Trace blood vessels to the periphery to detect any torn vessels ----

succenturiate/ extra lobe

- Inspect maternal side

- Check the cotyledons

- Observe areas of abruption -- infarction or calcification

Cord

-length ,number of blood vessel true knots

Memberane

- Full / not

4. Control of bleeding

Methods

- Living ligatures:- Oblique muscle fibers of the uterus run in & out b/n

the blood vessels, when the uterus contracts & retracts, they

continuously clamp the blood vessel

- Extra clotting power

96

- At the end of the 3rd Stage of labour

- Uterus should be below the umbilicus

- Hard, round & movable

- Minimal bleeding

- Empty bladder

Prolonged 3rd stage

- Weak uterus contraction

- Adherent placenta

- Full bladder.

The Fourth Stage of labour

4. Fourth Stage: the first 1-2 hours after delivery of placenta – recovery stage.

Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.

Check placement of fundus at level of umbilicus.

If fundus above umbilicus, deviation of fundus

1.) Empty bladder to prevent uterine atony

2.) Check lochia

a. Maternal Observations – body system stabilizes

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b. Placement of the Fundus

c. Lochia

d. Perineum –

R – edness

E- dema

E - cchemosis

D – ischarges

A – approximation of blood loss. Count pad & saturation

Fully soaked pad : 30 – 40 cc weigh pad. 1 gram=1cc

e. Bonding – interaction between mother and newborn – rooming in types

IMMEDIATE CARE OF MOTHER AND NEW BORN

Mother -: expel clot from the uterus with massage and administration of oxytocin

drug

- Swab the vulva, put sterile pad in position

- Buttocks should be dry and any wet sheet is removed

- Monitor her V/S: PR and BP Q ½ hr

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- Encourage to void

Baby: observe the general well being

- Prevent hypothermia

- Check the security of the cord clamp

- Check APGAR score (1st and 5th min)

Appearance

Pulse rate

Grimace

Muscle tone (Activity)

Respiratory effort

Each given a score of 0 / 1 / 2. The maximum score is ten. Good score is 7 – 10. And <

7 need resuscitation.i.e APGAR 5-7 modratly depressed

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>> 0-4 Severly

If the infant is moderately depressed APGAR 5-7 - Need tactile stimulation,

But in severely depressed APGAR 0-4 consider asphyxiated thus immediate intubation

is indicated.

The 1st minute APGAR is used to Evaluate cardio respiratory function

The 5 minute APGAR is more useful in predicting long term out come.

Clearing the airway: Oropharynx first

Take weight, length and head circumference

Give neonatal eye prophylaxis: 1% TTC eye ointment, 0.5% erythromycin

Give Vitamin K 1 mg IM

100

Promote bonding & breast-feeding

Put in ID: name of the mother, sex, length, wt, head circumference,

APGAR score, date & time of delivery

Record keeping

- Mode of delivery, Episiotomy

- Use of an anesthetic and other drug

- Amount of blood loss

- Any lacerations

- Placenta & membranes: completeness

- Baby records

Postnatal Care

Mother

- Minimum of 6 hrs of observation before discharge for an uncomplicated

vaginal delivery.

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- Transfer from labour ward to post natal ward after 1 - 2 hours,

welcome her & help her to settle in the ward. Observe her general

condition, palpate the uterus to note whether it is contracted well or not

- Help the mother sleep and rest: quite room +/- sedation

- Ambulation gives a filling of well being and reduce the incidence of

thromboembolic disorder

- Give her a cup of tea and something light to eat.

- Take the V/S and clean the perineum.

Normal newborn

Establish feeding

Assess the general well being

Initiate immunization

* Discharge instruction

All women should avoid heavy work (lifting or straining) for at least six weeks

following delivery.

The women should limit the number of stairs she climbs for the first week at

home. Beginning the second week, if her lochia discharge is normal, she may start

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to expand her activity. She should continue with muscles strengthening exercise

such as sit ups and leg rising.

Post partum exercises

- strengthen the muscle of the back, pelvic floor & abdomen

- postponed heavy exercises for at least 3 wks of terdelevery

the pelvic floor exercise is known as hegle‘s exercise by contraction & relaxation

of the muscle 10-20 x/hr

The women should take shower, and continue to cleanse her perineum from the

front to back.

At 12th

week sexual respons patterns return to the pre pregnant stat

The women should begin contraception measures with the initiation of coitus. If

she wishes an IUD, this may be fitted immediately after delivery or at the first

postnatal check up. A diaphragm must be refitted at a 6-week check up. Oral

contraceptives are begun after about 2-3 weeks postnatal.

The women should notify her physician or nurse/midwife if she sees an increase,

not decrease, in lochia discharge, or if lochia serosa or alba becomes rubra.

Postnatal appointment: 1st visit after 1 week, and 2

nd visit after 6 weeks.

The Normal Puerperium

103

The puerperium is the period of adjustment after pregnancy and delivery when the

anatomic and physiologic changes of pregnancy are reversed and the body returns to the

normal non-pregnant state.

Characterized by the following features

reproductive organ and other physiological changes return to non -pregnant stage

lactation is established

the foundation of the relationship between the infant and his parents are laid

Mother recovers from stresses of pregnancy and delivery, & assumes

responsibility for the care and nurture her infant.

The care which is required during the puerperium should be based on

promoting the physical well being of mother and baby

encouraging sound method of infant feeding and promoting the development of

good maternal and child relationship

Supporting and strengthening the mother‘s confidence in herself and enabling her

to fulfill mothering role within her particular personnel, family and cultural

situation.

PHYSIOLOGY OF THE PUERPERIUEM

104

Immediately after delivery the uterus weighs about 1kg

Uterus: - involution: decrease in size- end of labour-------20 week[ at the level of

umbilicus]

1 week post labor----12 week[at symphsis pubis]

6 week post labour----prepregnant state

- By continuous uterus contraction and autolysis, at which time the organ weighs

< 100gm.

Cervical change – internal os is converted in to transvers slit

- complete healing occur after 6-12 wks

Vagina – Retern to anteparterm condition by 3rd

week

Lochia: discharge from the uterus in the puerperiuem. It is alkaline and favors

growth of microorganisms. Amount varies with each woman, odour is heavy but

not offensive. It undergoes sequential changes as involution progresses

a) Lochia rubra: red in color lasts 1 - 4 days consisting of blood debris &

shade of decidua

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b) Lochia serosa: pallor, lasts 5 - 9 days containing less blood, more serum and

WBC

c) Lohia alba: creamy white, contains WBC, Cx mucus and debris from

healing tissue, during 2nd

& 3rd

post partum wk

Persistent lochia rubra: - Retained product of conceptus tissue

Offensive: - infection

Endocrine system

More oxytoxin and prolactin - suppress FSH

- Prolactin acts on breast alveoli to produce more milk

- Rapid fall of estrogen, progesterone, HCG.

- First ovulation is delayed by breast feeding

- Non lactating (only 10 - 15 %) ovulate by six weeks and approximately

30%Ovulate by 90 days

Urinary tract: - more urine due to decrease blood volume & Autolysis at 1st

week

- RFT & glucosuria

Blood volume: decreases to pre pregnant level by 3 weeks. From 6 lit to 4 lit

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Fluid loss – 2L during the 1st wk & 1.5L during the next 5 wks

MSS: return to normal over a period of approximately 3 months

Psychological - emotional liability, mania followed by depression

Post partum reaction syndrome

Management

- Important role is to educate or advice the mother about the care for her

self and for her baby in hygiene, nutrition, immunizations, family

planning, etc.

- Diet as in pregnant, more protein if she is breast feeding.

- Increased daily fluid take to 2.5 - 3 liter

- Iron and vitamin to control anemia, fiber to aid excretio

Multiple pregnancies

Definition -existence of two or more fetuses in uterus

Twin pregnancy occurs approximately 1:80 pregnancy, triplet 1:802 quadruplets 1:80

3

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* Two types of twins

- Monozygotic (identical twins): - 30%

- Dizygotic (Fraternal twins)-70%

* Monozygotic twins

Result of the division of a single fertilized ovum

Constant incidence in all races not affected by age, etc.

The twins have same physical characters (skin, hair, eye color, body build) and

same genetic feature (blood group, etc) they are often mirror image of one

another, their fingerprints differ.

Dizygotic twins

- Product of 2 ova and two sperms

- Same or different sex, but usually same sex (70%)

- Bear only the resemblance of brothers or sisters

- May or may not have same blood type

- Most common in blacks and least common in Asia and more in females

between 30 -40 years of age

108

- may follow rebound increase GnRH post OCP or clomiphene (artificial

ovulation)

Super fecundation : 2 ova with 2 sperms from different men

More Morbidity & mortality rates due to preterm labor, hemorrhage, UTI and PIH

Placenta and cord

- Twins could have separate placenta, chorion and amnion depending on

the time of separation.

- They could also have fused placenta

- Twin to twin transfusion: same chorion

N.B Monochorionic are monozygotic

* Effect of twins gestation

Exacerbation of minor disorder of pregnancy

- Increase nausea and vomiting leading to hyper emesis gravidarum

- Increase tendency for edema of ankle and varicose veins

- More heart burn and indigestion

- More backache

109

Pressure is more due to the big uterus.

Big placenta with more HCG

Anemia: due to increased demand

Poly hydramnios: usually in monozygotic twins and with fetal abnormalities

PIH: big placenta & more hormones

Dx : - could be difficult

Hx - family Hx of multiple gestation in her side

- exacerbation of minor disorder of pregnancy

P/E - big uterus by inspection and palpation

- Presence of two fetal poles (head and breech)

- Multiple limbs

- Two backs

- Hearing two FHB by two observers simultaneously, the heart beats

differing by at least by 10 BPM

- Ultra sound and X- ray:

DDx – Polyhydraminos, Hydatidiform, Abdominal tumor, Inaccurate date

110

Management

Early diagnose is important so as to provide dietary advice on iron, folic acid and

vitamin which help keep her Hgb at normal level

Frequent ANC to detect abnormalities like PlH

Labor usually starts earlier b/c of overstretching of the Ux, or others. So admit if

she has labor, leakage of liquor or bleeding

Expect preterm labor and malpresentation

Manage the 1st stage of labour normally and preparation should be made for the

reception of two immature babies.

Two suctions

Warm room with two sections

Management of Second stage of labour

Make sure that you have an obstetrician by your side.

- Resuscitation equipment should be ready

- If twin A is non vertex, C/S is the mode of delivery.

- Prepare delivery set with two cord clamps, forceps, cordite,

- Episoitomy could be done depending on the need.

- Induction & Agumentation are contraivdicated in twins

- If twin A verlex / twins B non vertex vaginal delivery

111

- After delivery of the first baby, cut the cord as far out side the Vx as

possible, and do abdominal examination to ascertain the lie & do PV to

see the presentation and position of the 2nd fetus, and presence of cord.

- Auscultate the FHB

- If the 2nd twin is non vertex, ECV is tried if the membrane is intact

- If the fetal presenting part is not engaged it should be pushed into the

pelvis by fundal pressure.

- Contraction usually restarts in 5minutes and the baby is usually

delivered with in 15-30 minutes

- Label the babies.

Management of 3rd stage of labour

L

- Active management

- Examine the placenta for completeness, and the cord

Complication

* Anemia ( 2-3 x) common

* Delay in the birth of the second twin: due to

- Poor uterine action

112

- Malpresentation of twin B

Dangers are:

- Intra uterine hypoxia, IUFD ( 3x) common

- Birth asphyxia following premature separation of the placenta

- sepsis secondary to ascending infection

PPH

PROM

Prolapse of the cord

Prolonged labor: malpresentation, poor uterine action

Abortion

Polyhydramnios

Conjoined twins

Locked twin

o Twin A non vertex (breech) with twin B vertex

o Both vertex: - Obstructed labor – C/S

Management of Puerperium

- Same general care

- Uterine involution could be slow

113

- Care of babies on body temperature and hygiene maintenance

Hyperemesis gravidarum

Excessive nausea and vomiting in pregnancy

1in 500 pregnancies

Associated with dehydration, ketoacidosis and serum electrolyte imbalance.

Cause is unknown but associated with

o multiple gestation

o Hydatidiform mole, etc.

* Assessing the mother

- Take hx

Frequency of nausea and vomiting

Tolerance of food

Any events that may produce stress or anxiety

Accompanying pain or fever

- Do P/E

- General appearance

- V/S: - PR could be fast and weak in severe dehydration

114

- BP: - low

- Assess dehydration

- Do general P/E

- Investigation: - check HCT

- Do U/A for glucosuria, ketonuria, pr- , & WBC

Admit to the hospital

Calm and reassure the mother

Give IV fluids: N/S or DNS in 3 lts / 24hr after correction of dehydration

Add dextrose and vitamins to the infusion

Observe V/S Q 4 hr

Monitor input and out put

Daily U/A until the ketones disappear

Give antiemetics / sedation

Once vomiting has subsided for 24 hrs, encourage oral fluids (not to sweet) &

administer light food step by step

Breech Presentation

115

Is diagnosed when fetus assumes a longitudinal lie with cephalic pole in the uterine

fundus & caudal pole at pelvic brim

Incidence 3-4 % of delivery

Dx – Hx – Fetal kick, low in the abdomen

- Maternal sub costal discomfort

P.E – Abdominal palpation

. Round, global, smooth head occupying the fundus

. FHB heard move easily of or above the umbilicus

116

P.V – presenting part – soft & irregular out line with out suture line

- In labor – Soft irregular mass with anal orifice

External genitalia

- The sacrum is the denominator

D.Dx – Face presentation – hard maxilla & sucking

- Compound presentation

Dx . Ultra sound confirm the Dx,

Management

1) Antenatal – External cephalic version (ECV) – to achieve

Vaginal delivery with vertex delivery

- Contra indication for ECV

– multiple pregnancy

- suspected IUGR

- Aminotic fluid abnormality

- APH

- , cardiac disease of the mother

117

- Scarred uterus

Risk of ECV – Placental reparation

- cord entanglement & sudden fetal death

- PROM

- Precipitation of preterm labor

- Rh sensitization

Pt selection – should have completed 36 wks of question with out

contraindication

Preparation & technique

- Ultra sound to confirm Dx

- should be carried out in a labor unit

- Check FHB

- Administer Anti – D immunoglobulin if the mother is Rh –

ve

Choice of mode of Delivery

1. Absolute indication for C/S

118

- Fetal wt > 3500 - Sever IUGR

- Pelvic contraction - Primigravida over the age of 35 yrs

- Footling breech

- Breech with extended head

2. Vaginal Breech delivery

- Fetal wt with 3500 gm

- Presentation with frank or complete breech

- head should be flexed

- Adequate pelvic

N.B The most experienced medical attendant should available around

PREGNANCY INDUCED HYPERTENSION

Hypertensive states in pregnancy include pre-eclampsia, eclampsia chronic

hypertension, chronic hypertension with superimposed pre-eclampsia and transient

hypertension.

119

- Pre-eclampsia is a triad of edema, hypertension and proteinuria. It usually occurs in

nulliparus after the 20th

gestational week, and most frequently near term.

- Eclampsia is the occurrence of seizures that can't be attributed to other causes is a pre

eclamptic patient

- Chronic hypertension is defined as hypertension that is present before 20 weeks

gestation, before conception or that persists beyond 6 weeks after delivery.

o Hypertension: BP >= 140 / 90 mmHg in at least two occasions 6 hours apart, or a

single measurement of DBP >=110 mmHg

- Proteinuria: excretion of 300mg or more in 24hours via the urine.

- Transient HPN development of HPN after mid pregnancy or in the first 24hrs

postpartum with out other signs of Pre-eclampsia or preexisting HPN.

Pre-eclampsia

- occurs in 6% of Pregnant

- predisposing factors: null parity, black race, maternal age <20 or > 35, low

socioeconomic status, multiple gestation, hydatidiform mole, polyhydramnios,

chronic HPN and underlying renal disease

120

- categorized into :

o mild - blood pressure < 160/110mmhg, and no sign of severity

o Severe:

BP> 160/110 mmHg

proteinuria > 5 gm/24hr or >=3+ on two random urine specimens

Oliguria < 500 ml/ 24hrs

deranged RFT or LFT

Thrombocytopenia

Pulmonary edema

IUGR / Oligohydramnios

cerebral /visual disturbances, epigastric pain, etc

The cause of PE is not known. It is called disease of theories.

Pathology

- Generalized vasoconstriction (i.e. hypertension) & capillary leak (i.e. edema): - these

would result in reduced plasma volume.

- Decreased placental blood flow and abruptio placenta.

- hemorrhage and necrosis of the liver, impaired liver function, increase

bilirubin(jaundice)

- pulmonary edema

121

- brain hemorrhage

- reduced Glomerular filtration rate

- thrombocytopenia, haemolysis

Effects to the mother

worsening to eclampsia

placental abruption

multi organ damage

Effect to the fetus

IUGR

IUFD

premature delivery

fetal distress

Diagnosis:-

symptom from the Hx

B/P measurement, proteinuria, edema

Clues in detection

122

-ANC period gives you the opportunity to pick a high risk mother likely to develop

PIH, though PIH is not preventable.

-Taking careful hx and particularly noting the following is important

family hx of HPT

mother age and parity

any hx of renal dx

past hx of pre-eclampsia

adverse social circumstance or poverty

Weight measurement at each visit

BP measurement at each visit

Anticipation and early detection of PIH is a major input for the good outcome of the

disease

Management

The objectives are to prevent progression to eclampsia, preserve the health of the mother

and fetus, & delivery of an alive, healthy and mature fetus. Rx depends on degree of

PIH, GA, maternal and fetal condition. The definitive management is delivery. It is

conducted in a tertiary setup where there is facility for close fetal & maternal follow up

and neonatal ICU.

123

Mild:

If the mother is term, no fetal jeopardy and no contraindication for vaginal

delivery, then effect delivery by induction of labor.

Same condition as above, but if it is preterm, ambulatory management is

preferred. it includes bed rest at home, twice weekly visit, Bp & random urine

measurement twice weekly, daily fetal movement counting and she should report

immediately for any worsening i.e. occurrence of danger signs.

Severe: prevent convulsion, control BP & effect delivery immediately for GA >=34

weeks, but expect until maturity is reached for those <34 weeks ( but responsive to your

medication)

Admit to the hospital, daily Hx and physical examination,

and follow BP Q 4 - 6 hrs, weight daily, dip stick urine

measured Q 48 hrs, weekly organ function tests, serial U/S,

daily fetal movement counting, daily FHB auscultation. The

mother takes regular diet.

During Labor

-The nurse should always remain with the mother throughout the course of labour

124

- document BP, urine output, edema

- make sure that she is comfortable, avoid supine position

- BP and PR Q 30 min

- FHB Q 15 min

- call obstetrician / physician when the second stage commences

- A short second stage may be effected by instrumental delivery

POST DELIVERY

- continue recording BP every 4 hours for 24 -48 hrs, urine dipstick daily, urine

output recorded, and continue anticonvulsant because she might have new attack

of seizure postpartum especially in 48 hrs, etc

Anticonvulsant: MgSO4, diazepam (10 mg IV bolus over 2 minutes, then 30 mg/100 ml

5% D/W over 24 hrs after the control of seizure to prevent recurrence), phenytoin

Antihypertensive: for severe hypertension. The drugs are hydralazine, Nifedipine,

Labetolol. The control of Hypertension is to bring the DBP between 90 - 100 mm Hg

ECLAMPSIA

- Occurs in 0.2 -0.5% of all deliveries

- 75% occur before delivery

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- About 50% of postpartum eclamptic seizures occur in the first 48 hrs after delivery

- signs of impending eclampsia

- severe headache

- visual disturbance blurring on fleshing lights

- epigastric pain

- Sharp rise in BP, etc.

If any of the above signs are picked, seek assistance to prepare necessary equipment,

medication and call for obstetrician / physician

Stage in Eclamptic fit

Premonitory phase: 10 -20 sec, mother is restless with REM , head drawn to one side

with twitching of facial muscle

Tonic stage: 10 - 20 sec, muscles go in to spasm, teeth clenched, eyes staring .

Clonic phase: 60 -90 sec, violent contraction with intermittent relaxation, salivation with

foaming at the mouth

Stage of coma: breathing continues and coma may persist for min/hrs, further

convulsion may occur before the mother regains consciousness

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Management: the objectives are to control convulsion & hypertension, and effect

delivery once the patient is stable.

The patient must be under constant observation. Avoid unnecessary external stimuli &

injury; prepare essential equipment & medications for intervention.

- use anticonvulsant like MgSO4 and diazepam in the control of seizures and

antihypertensive to control of Hypertension

Emergency care of the mother with eclampsia

- clean and maintain the mothers airways

- semi prone position i.e. left lateral position

- suction

- administer oxygen and prevent severe hypoxia

- prevent the mother from being injured during the clonic stage

- monitor the V/S: BP Q 15 min

- maintain adequate hydration & monitor input and output

- labour is not allowed and C/s is done directly if there is severe PE, GA <34 weeks, &

unfavorable Cx

- continue the intensive care for 48 hrs post partum

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- All the usual postpartum care is given & as soon as the mother's conditions permits

she should be taken to her bed and see her child.

- Avoid disturbance (noise, light, etc.)

- keep emergency drugs ready

Complication of eclampsia

Includes cerebral hemorrhage thrombosis & mental

confusion, acute renal failure, hepatic liver necrosis, cardiac

myocardial failure, respiratory asphyxia, pulmonary edema,

pneumonia, temporary blindness, bitten tongue, fractures,

fetal hypoxia and still birth.

Polyhydramnios

- Amniotic fluid quantity exceeding 1500ml. May not be clinically apparent until it

reaches 3000ml. It occurs in 1 in 250 pregnancies.

- The cause is unknown in 1/3 of cases, it could be due to placental abnormality,

multiple gestation, maternal DM, fetal anomalies, or iso immunization.

- It usually has gradual onset with chronic course from about 30 weeks of pregnancy.

Rarely, it accumulates acutely over 3-4 days, Ox reaching the xiphisternum at about

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20 weeks. This is frequently associated with monozygotic twins or severe fetal

abnormality.

Sign and symptom

- mother may complain of breathlessness and discomfort

- exacerbation of heartburn , constipation and indigestion

- edema and varicosities

Dx - abdominal examination

- big Ux

- Skin on the abdomen stretched and shiny.

- Tense Ux, difficult to feel fetal parts.

- Fluid thrill.

- FHB difficult to hear

Management

- determine cause if possible

- refer for obstetrician‘s evaluation

- Subsequent care will depend on the mother‘s condition, cause of

Polyhydramnios, stage of pregnancy and fetal condition.

- mother should rest in bed

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- treat exacerbated symptoms like heartburn

- labour is usually normal, get prepared for possibility of PPH

Complication

- increased fetal mobility leading to unstable lie and malpresentation

- cord presentation and cord prolapse

- PROM

- placental abruption when the membranes rupture

- premature labour

- PPH

ANTEPARTUM HAEMORRAGE

- bleeding from the genital tract after the 28th

week of gestation & before delivery

- Occurs in 2-3% of pregnancies, and it needs careful evaluation & management to in

order to avoid poor maternal and perinatal outcome.

- causes: abruption placenta, placenta previa,

- effect on the fetus

- increased morbidity &mortality

- still birth, perinatal or neonatal death

- severe hypoxia with insult to the brain

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- effect on the mother

- severe bleeding may lead to shock DIC & renal failure, even death

Abruptio placenta

Separation of the whole or part of the placenta before delivery of the fetus from the

normal implantation.

Predisposing factors: hypertension, advanced age, multiparity, multiple gestation,

polyhydramnios, trauma, smoking, poor nutrition, low socioeconomic status, ECV, etc

The blood loss from a placenta abruption may be defined as concealed or revealed.

Concealed hemorrhage is the blood retained behind the placenta; the mother will have

all the signs and symptoms of hypovolemia. There is uterine enlargement and pain. In

revealed hemorrhage, the blood flows to the external and no blood is accumulated

behind the placenta.

Dx: the mother with concealed bleeding is difficult to pick. She exhibits signs of

hypovolemia with no obvious bleeding externally and the abdomen feels hard & tender

with guarding. Fetal part are unlikely to be felt, difficult to hear the FHB. Ultrasound is

also helpful in diagnosis.

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Placenta previa The placenta is partially / wholly implanted in the lower Ux segment

before the presenting fetal part.Predisposing factors:scarre uterus,advanced age,

multiparity,multiple pregnancyRh incompatibility, etc.

- generally there are four types of PP:

o Type 1-Low lying placenta: placenta in the lower uterine segment but

not over the internal cervical OS

o Type 2-PP marginalis: placenta touches the internal cervical OS

marginally

o Type 3-PP partialis: placenta partially covers the internal cervical OS

o Type 4-PP totalis: placenta covers the whole of the internal cervical OS

- Dx: painless, bright red bleeding usually small in amount occurring at rest, the fetal

presenting part is situated high (remains unengaged), the uterus feels normal,

transverse or oblique lie, etc. Ultrasound will confirm the diagnosis and the degree.

-

Management: General

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Admit & call for obstetrician

V/S q 15 minutes

Resuscitation

Determine Hct and Blood group

Monitor fetal and maternal condition

Prepare at least 2 units of cross matched blood, and anticipate

PPH

Never do PV

Abruptio Placenta

Mild bleeding may stop spontaneously and the pregnancy could be left to reach term and

delivery effected by labour induction or C/S.

Moderate or severe bleeding requires hourly input / output monitory, frequent Hct

determination, and do C/S for uncontrolled bleeding and obstetric indications.

Placenta previa

Depends on the amount of bleeding, the conditions of mother & fetus, location of the

placenta, and stage of the pregnancy.

If the bleeding is slight & the mother and fetus are in good condition, the woman could

rest in bed, and wait until term if no bleeding occurs subsequently.

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Effect delivery if there is active bleeding, fetal distress, term, etc. C/S is done all except

in cases of low lying PP & anterior PP marginalis, in which case vaginal birth could be

possible.

Complications

Hypovolemic shock and death to the mother and fetus

Acute renal failure

Coagulation defects

Post partum hemorrhage

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Post Partum Hemorrhage

Definition:-Post partum hemorrhage is bleeding from the genital tract in excess of 500

ml following normal delivery (>1000ml following C/S) during/after the 3rd

stage of

labour. Or a bleeding that has resulted in change of hematocrit by 10% or more.

It is responsible for about 25% of maternal deaths world wide, and is one of the

emergencies in which if the nurse/midwife does not know how to play the part, the

doctor may be unable to save the mother‘s life. Shock may develop quickly and can

become irreversible. It complicates 5-8% of pregnancies. The rate of flow is more

important than the amount. Clinically it may be evidenced by change in vital signs,

pallor and need for blood transfusion. Anemia is a predisposing cause.

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If bleeding occurs with in 24 hours after delivery it is called primary while after 24 hours

of delivery is secondary PPH

Cause of primary PPH

- Uterine atony

- Retained placenta

- Retained cotyledon

- Genital trauma

- Disseminated intramuscular coagulation (DIC)

- Inversion of uterus

Cause of secondary PPH

- Chorioamnioitis

- Retained products

- Endometritis

Type of PPH

1. Atonic postpartum hemorrhage

2. Traumatic postpartum hemorrhage

3. Hypofibrinogenaemia(DIC)

Management of PPH

Three basic principle are applied

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1. Call an obstetrician

2. Stop the bleeding

3. Resuscitate the mother

Atonic postpartum hemorrhage

This is bleeding from the placental site when the uterus is not well contracted. This is a

failure of a myometrium at the placenta site to contract and retract and to compress torn

blood vessels and control blood loss by a living ligature action

Cause

- Incomplete separation of placenta

- Retained cotyledon. Placental fragments of membranes

- Prolonged labour & obstructed labour resulting in uterine inertia

- Polyhydramnios, multiple pregnancy: – over strewing the uterus

- Full bladder

- Fibroids

- Grand multipara

Management of Atonic PPH

Massage the Uterus

Give pitocin or Ergometrine

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Empty the bladder

Empty the uterus

Bimanual Compression

Bimanual Compression

It can be done externally or internally

Method

Place one hand on the fundus and the other above the symphysis pubis (externally) or in

anterior fornix (internally) and squeeze until clotting occurs. Usually clotting takes place

7-10 minutes later. Remove the external hand to check whether the bleeding is stopped

or not.

Dangers

Hemorrhage

Shock

Infection

Traumatic PPH

This is bleeding from a laceration of the cervix, vaginal wall and perineum episiotomy

or even ruptured uterus.

Cause

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Delivery through partially dilated cervix

Instrumental delivery

Difficult delivery: - face to pubes, after coming head of the breech

Management of traumatic PPH

When bleeding is due to the tear, explore the area for the tear, clamp the bleeding point

and suture. Make sure that the uterus is not ruptured. If the laceration is sutured &

bleeding stopped, make sure that the uterus is well contracted.

If bleeding is from bruised cervix, the cervix can be sutured and bleeding controlled.

If bleeding is from ruptured uterus, transfer to the hospital as soon as possible; go

with patient or send a full written report with date, time of departure and signature

Hypofibrinogenaemia

This is bleeding due to a clotting defect and patient has continuous hemorrhage

Causes

- Placental abruption

- Intrauterine death which is prolonged

- Pre-eclampsia, eclampsia

- Intra uterine infection

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- Hepatitis

Management of hypofibrinogenaemia (DIC)

The best treatment is

- fresh blood transfusion

- Give Oxygen and resuscitate with IV drip

- Drugs as prescribed

E.g. Morphine for pain

- IV syntocinon if uterus is lax

The patient will respond quickly to this treatment if given quickly. Advice hospital

delivery for the next time and warm her to explain to doctor or nurse

It is important to be able to differentiate between atonic and traumatic postpartum

hemorrhage.

Atonic Traumatic

Uterus is lax or soft Uterus is contracted firmly

Bleeding starts after a few Bleeding starts immediately

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minutes of birth after delivery and continues

Blood is dark red in color Blood is bright red in color

Management of severe PPH in a health center

1. Massage the uterus to stimulate contraction and expel the placenta if possible

2. Stay with your patient and shout for help

3. Empty bladder

4. Give ergometrine 0.5 ml I.V and put up a drip

5. If placenta is already expelled, expel clots. If not, try to expel it with contraction

caused by ergometrine. If not and she is still bleeding severely in order to save the

patient‘s life, manual removal is done

6. If still the uterus is lax as a last reason, bimanual compression method is done

Consequences of PPH

1. Shock and collapse-death

2. Puerperal anemia: - weakness & low resistance to infection

3. Fear of the further pregnancy

4. Sheehan‘s syndrome-due to anterior pituitary necrosis

5. Infection

Prevention of PPH

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Good antenatal care

- Careful history taking to find out if she had PPH in previous delivery

- Bring hemoglobin as high as possible and treat anemia. Book high risk for hospital

delivery - Group and cross match high-risk mother in labour

- Try to prevent prolonged or obstructed labour

-Make sure that the mother rests as much as possible during 1st stage and prevent

dehydration.

- Keep bladder empty.

- Delivery head slowly and control it

- Active management of third stage

ABNORMAL LABOUR

Abnormalities of labor is based on

1. Abnormalities of expulsion force [power]

2. >> of presentation & position & fetus ( passenger)

3. >> bony pelvic (passage)

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4. >> birth canal ( passage)

5. Maternal anxiety

Malpresentation and Malposition

Malpresentation: - A presentation other than vertex

E.g. Shoulder, face, brow and breech

Malposition and mal-presentations have ill fitting presenting parts compared to a well

flexed vertex presentations in a normal pelvis.

Cause – Polyhdraminose, Abnormal pelvis, Abnormality of uterus Shape

Laxed muscle

- multiple pregnancy

All ill fitting part is associated with (results in)

1. Early rupture of membrane with risk of cord prolapsed

2. Premature labour

3. slow, irregular, short-lived contractions

4. Uncoordinated and excessively painful labour after rupture

5. Prolonged and obstructed labour

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6. post partum hemorrhage

7. Fetal and maternal distress

Breech Presentation

Definition: When the fetus assumes longitudinal lie with the cephalic pole in the uterine

fundus and caudal pole in the pelvic brim..

It occurs in 3-4% of term gestations. It has higher incidence as gestational age decreases.

1. Breech with extended legs or frank breech: - in this type of breech the hips are

flexed and the legs are extended on the fetal abdomen.

2. Complete breech: - the fetus lies in a flexed attitude and the legs are flexed on the

abdomen. The presenting part is bulky and consists of buttocks, external genitalia

and both feet.

3. Footling-one or both feet present because neither hips nor knees are fully flexed.

Causes: often no cause is identified, but the following circumstances favor breech

presentation

- Polyhydramnios

- Prematurity

- Multiple pregnancy

- Placenta previa

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- Contracted pelvis

- Uterine abnormalities

- Hydrocephaly

- Extended legs

Diagnosis

History: fetal kick felt low in the abdomen, maternal subcostal discomfort (due to the

hard head)

On palpation

- Lie is longitudinal

- The fundus contains a hard, regular and rounded mass which is ballottable.

On pelvic palpation no head is palpated

On auscultation

The fetal heart beat is heard above the umbilicus if the breech is not engaged; below the

umbilicus if it is engaged.

Vaginal examination

No sutures and fontanels are felt. When the membrane is ruptured the anal sphincter

grips the finger, fresh meconium seen on the examining finger.

Antenatal management

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The presentation may be confirmed by ultrasound scan or x-ray of abdomen. The

obstetrician may decide to do an external cephalic version after 36 weeks of gestation.

The principle of Management

- intelligent observation

- Avoidance of unnecessary interference

- Prompt action carried out with manual dexterity when assistance is needed

Mechanism of breech delivery

1 Descent takes place by increasing compaction due to increased flexion of the limbs.

Bitrochanteric

diameter which is 10cm enters the pelvis in the oblique diameter.

2. Internal rotation of the buttocks

3. Lateral flexion of the body

4. Restitution of the buttocks

5. Internal rotation of the shoulder

6. Internal rotation of the head

7. External rotation of the body

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8. Birth of the head the chin face and incipit sweep the perineum and the head is born in

born in a flexed attitude

N.B Labor in breech is always considered as a trial

Management of labor in Breech Delivery

It is managed depending on types of presentations

TYPES OF DELIVERY

1. Spontaneous breech delivery: fetus is delivered entirely spontaneously without

any help (traction or manipulation) other than support

2. Assisted breech delivery: - assistance is necessary for delivery of extended legs or

arms and the head

3. Breech extraction: this is the manipulative delivery to extract the breech when the

mother is unable to deliver in an emergency situation

First stage

- Careful observation

- Warn mother not to push

- Vaginal examination when membrane ruptures (to rule out cord prolapse)

- Be prepared for the delivery

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1. Delivery of flexed breech

-Full dilatation of the cervix should be confirmed by vaginal examination before

allowing the woman to push to prevent the breech slipping through incompletely dilated

and the head may be trapped by the cervix

- Active pushing is not commenced until the buttocks are distending the vulva

- Encourage her to push with the contraction and the buttocks are delivered

spontaneously. Episiotomy may be necessary (on the side of the lower extremities of the

fetus)

- Get mother to push; when the buttocks are born, pull down a loop of cord, feel for

pulsation, put into the hollow of the sacrum to prevent pressure and traction

- Feel for the elbows on the chest, the shoulder should be born easily with the arms

flexed across the chest if not help them out by flexing the arm

-Grasp the baby by iliac crest with the thumbs held parallel over his sacrum and tilt the

baby towards the maternal sacrum to free the anterior shoulder

- Wrap small towel around the baby hip to preserve the warmth and improve the grip on

the slippery skin

- When the anterior shoulder is born, lift the buttocks towards the mother‘s abdomen to

enable the posterior shoulder and arm to pass over the perineum

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2. Delivery of the head

i. Delivery of flexed head (Burn’s Marshall Method)

After the shoulder is born the baby is allowed to hang unsupported. With in 1 or 2

minutes the nape of the neck (hairline) appears .The baby is now grasped by the ankle

and maintains traction while supporting the head on the perineum with the right hand

.Hold the baby on a stretch and slowly bring the feet up to an angle of 180 degrees

When the face appears, get someone to clean the air ways then delivery the head very

slowly taking 2 to 3 minutes to allow the vault of the head to be expelled. The mother

should breathe out the head

ii. Delivery of extended head (Mauricio Smellie Veit method)

. When the baby is allowed to hang the neck and hair line is not visible, it indicates that

the head is extended

Pick up the baby by the feet and lie him astride on the right forearm put the middle

finger of the right hand in the babies mouth far back to the roof of the tongue. With

the other hand on the head and flex it down towards the floor applying traction. When

the head is down, bring it up gently to deliver.

3. Delivery of extended legs

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Encourage the mother to push, when legs are seen it may be necessary to apply slight

pressure in the

popliteal space beyond the knee. This will flex the legs and then they can be easily

delivered. Pull

down a loop of cord to prevent traction, feel for pulsation, and place it in the hollow of

the sacrum to

prevent pressure.

4. Delivery of extended arm

Get the mother to push, when the axilla is seen it means that the arms are extended .So

place the cord in sacrum and fingers below the iliac crest, rotate shoulder into the

anterior posterior diameter of the pelvis, then rotate the posterior shoulder in to the

anterior keeping the back on top, now flex the arm over the face and deliver it, and now

bring the other arm interiorly, and deliver it by flexing it across the chest. Now the

shoulders are born.

Manage third stage actively, and look for cervical and genital tract tear.

Dangers of breech presentation

Delay of the after coming head

Cerebral damage due to hypoxia

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Asphyxia (fetal or neonatal): prolapse of cord or pressure on cord.

Prematurity

Intracranial hemorrhage due to trauma

Injuries to liver, spleen, adrenal glands or kidney

Erb‘s palsy due to damage of the brachial plexus

Fracture to femur, tibias, humerus or clavicle, dislocation of shoulder/hip

Damage to spinal cord due to wrong handling

Facial nerve paralysis due to twisting of the neck

Pneumonia due to premature inspiration

A. Brow Presentation

Definition: - When the sinciput or the area between the face & vertex is in the lower pole

of the uterus.

Attitude- Between flexion and extension (mid way) engaging diameter Mentovertical

13:5cm it occurs 1 in 1000 deliveries head is b/n anterior fontanel & orbital ridges,

laying at pelvic brim.

Causes:

1. Lax uterus, multiple pregnancy, polyhydramnios

2. Deflexed fetal head

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- Hypotony of the neck muscle

- Thyroid tumor

3. Anencephaly – because absence of vertex

4. Abnormal shape of pelvis

Diagnosis – Is not detected before the onset of labor

On palpation the head is big and high & does not enter the pelvis despite good uterine

contraction

On Vaginal examination

- it is difficult to reach the presenting part is high

- A smooth hair less area is felt, with part of the bregma at one side

- The orbital ridges may be felt & ant.fontanell may be felt one side of the pelvis.

Management - The Nurse has to inform the doctor b/c the vaginal delivery is extremely

rare

If brow presentation is diagnosed early in labour, it may be converted to a face

presentation by fully extension or it may be flexed to a vertex presentation, however,

brow presentation will lead to obstructed labour except in large pelvis & small baby.

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Thus - Caesarian section is the management for alive baby

- Craniotomy if baby is dead

Complications – Obstructed labor - Facial edema & bruising

- Cerebral Hemorrhage - Maternal trauma & uterine rupture

B. Shoulder Presentation

Definition – When the shoulder of the fetus lies in the lower pole of the uterus in labour.

A transverse lie becomes a shoulder presentation in labour.

Incidence – occurs once in 250-300 deliveries.

Causes

- Maternal Laxity of uterus

- Placenta previa, polyhydramnios.

- Multiple pregnancy

- Fetal Uterine abnormality laced uterine muscle, contracted Ux

- Preterm pregnancy -amount of amniotic fluid in relation to the fetus is greater

- Macerated fetus –lack of muscle tone

Diagnosis

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- The uterus appear broad and the fungal height is less than expected for the period of

gestation

- Neither the head nor breach if felt , mobile head is found to one side of abdomen

- Easily seen on abdominal examination when labour progresses, the hand can be felt

or the ribs on

VIE , but placenta previa has to be excluded

- Arm may prolapse when membrane rupture

- Ultrasound to confirm the lie/presentation

Management

- When diagnosed at antenatal clinic after 36 weeks external version may be

attempted

- In labour caesarian section is done to avoid obstructed labor & uterine rupture

- When membranes have ruptured, look for prolapse of the cord.

Complications

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Maternal Fetal

- Obstructed labour - Fetal death (cord prolapse) & arm

prolapse

- Uterine rupture - Prematurity

- Death

- Puerperal sepsis

- PPH

C. Face Presentation

Definition: When the attitude of the head is extension and the face lies in the lower pole

of the uterus.

– the occupant of the fetus contact with its spine

- The denominator is centum, & presenting diameter is SIB ( 9.5cm)

Cause - Lax uterus slack abdominal muscle & pendulus abdomen alter uterine axis this

form the fetal

buttock lean forward & extension of head that lead chin ( mentum) to the

denominator

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multiple pregnancy

- Contracted pelvis e.g Android pelvis

- polyhydramnios

- Deflexed fetal head: thyroid enlargement or tumor of the neck

- Anencephaly because of absent vertex

- Abnormal shape of pelvis

Diagnosis|

Abdominal examination

Inspection – irregular abdomen and the shape of the fetal spine is that of an ―S‖.

Palpation

- Prominent occipital is felt. A deep groove is felt between fetal back and head.

Auscultation of the - fetal heart is heard clearly at midline on the same side of the

limbs

Vaginal examination

- The presentation part is high

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- A soft irregular mass is felt, the gums are felt and the fetus may suck examining

finger –

diagnostic the direct ridge nose & eye may felt but the face become

edematous, become more

difficult to differentiate from breech

- Locating the position of mentum is important i.e. anterior, transverse or

posterior

Mechanism of face delivery

- Instead of an increase in flexion there is an increase in extension

- The chin rotate instead of occiput

- The engaging diameter is submentobregmatic 9.5 cm face presentation can be

born normally ] ]

except when the chin is posterior and gets caught in the hollow of the sacrum,

when it develops

into obstructed labour.

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Management in labour – The Nurse should inform the obstetrician

- When membranes ruptures do vaginal examination to make sure no cord

prolapsed and to note

the position Q 4hrs

- Rotation occurs below the level of spines

- If the chin is anterior let labour continue, if transverse, watch that it rotates

anteriorly. When the

face distends the perineum, perform an episiotomy, then hold back the

sinciput and allow the ]

chin to be born, when the chin is born flex the head and allow the occipital

to be born.

- Always be careful not to damage the baby‘s eyes with fingers or antiseptic

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- If the head has become impacted or any suspicion of disproportion C/s will

be necessary

Complication

- Obstructed labour b/c of pelvic contraction & face do not mould unlike the

vertex

- Cord prolapse b/c of the face is ill filting the presenting part

- Facial bruising with edematous eye lid & lips – so reassure the family this

occur only for 1-2

days

- Cerebral hemorrhage & maternal trauma b/c of lack of molding of the face

lead to excessive

compression of the fetal skull

Compound or complex presentation

Definition: When a hand or occasionally of foot, lies along side the head, the

presentation is said to be compound. This tends to occur with a small fetus or

roomy pelvis, seldom is difficulty encountered except in cases where hand and

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foot are felt in the vagina a serious situation which usually occurs with a dead

fetus

If diagnosed during the first stage of labour, attempt could be made to push the

arm upwards over the baby‘s face. If during the second stage hold the hand

back directing it over the face.

Occipitoposterior Position

It occurs in 13% of the vertex presentations. Head is deflexed-larger diameter

present OF= 11.5 cm

Causes

Direct cause is unknown but associated with

- Pendulous abdomen

- Abnormal pelvis, Android, Anthropoid, flat sacrum

- The placenta is in anterior wall

Diagnosis

Inspection

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There is a saucer-shaped depression at or below the umbilicus this depression or

deep hollow is created by between head and lower limbs

The back is not anterior

Palpation

The fetal head is found on one side

The limbs are in front and give hollowing above the head

There is a saucer like depression around the umbilicus. There is bulge like full

bladder, limbs are found on both sides, the back is difficult to palpate.

Auscultation

Fetal heart is heard in the flanks and descends down

Vaginal examination

2. Membranes may rupture early

3. Due to deflection , anterior fontanelle is the anterior part of the pelvis near

ileopectineal eminence

Outcomes of labour

1. Long internal rotation

2. Short internal rotation

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3. Deep transverse arrest

- If the flexion of the head increases the occipital strikes the pelvic floor and

rotates anteriorly (ROP) to 45o then to 90

o rotation and delivered normally.

- If the flexion remains incomplete, the rotation of the head takes place

posteriorly brings the occiput into the sacrum. This is known as short rotation.

In this case the body is born by face to pelvis.

- Sometimes the loop rotation of occipitoposterior is arrested and the head is

left in the occipital- lateral position in the cavity of the pelvis.

Occipitofrontal diameter is caught at the narrow interspinous diameter of the

midpelvis. This is known as deep transverse arrest. The delivery could be by

rotation of the head to anterior or by cesarean section.

Management

Encourage the mother to lie on the side where the fetus lies.

Patient may have severe back pain, analgesics may be given.

Retention of urine is common catheterization is necessary.

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Patient feels the need to bear down before fully dilation. Two-third of cases will

deliver normally 12% will deliver face to pubis. If the ischial spines are prominent

the internal rotation may be interrupted, & caesarian section is recommended

(DTA).

Identifying the ear by the root of the pinna (right or left), manual rotation can be

done. Keep the right hand on the head and left on the abdomen and rotate than

forceps delivery is performed.

Expect bleeding in the third stage, so manage it actively and inspect for genital

tract lacerations.

Prolapse of cord Loop or slip down of cord in front of the

presenting part

Prolapse of umbilical cord can be classified as:

1. Occult presentation in which the cord lies over the face or head of the fetus

but cannot be felt on vaginal examination

2. Fore lying presentation in which the cord precedes the presenting part and

usually palpated through the membranes if the cervix is dilated

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3. Complete prolapse in which the cord found in to the vagina in front of the

presenting part with ruptured membranes.

Obstetric factors

- High head or ill fitting presenting part

- Abnormal presentation (Face, Breech, Shoulder, Brow and Transverse) &

compound

presentation

- Multiple pregnancy especially 2nd

twins

- Multiparty The presenting part may not be engaged lead to PROM

- Premature rupture of membrane prior to engagement of the presenting part

- Contracted pelvis

- polyhydramnios The cord is swept down with gush of liquor if the membrane

rupture

- Low implantation of placenta

- Abnormally long cord

- Prematurity – small size of fetus ( </1500 gm) relation to the pelvis the uterus

allows the cord to prolaps

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Dx – Visible cord, Brady cardia

Management: It depends on the fetal condition and presentation

If the fetus is alive:

- Position the mother in the knee chest position or deep trendelenberg position

- Manually pushing the presenting part backward by gloved finger vaginally to

relieve off the

pressure on the cord till the baby is delivered, especially during uterine

contraction

- The best method of delivery in this case in caesarean section

- If the fetus is not alive and the presentation and position is normal vaginal

delivery is possible

Complications

Fetal

- Birth trauma

- Prematurity

- Metabolic acidosis

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- Hypoxia & death

Maternal

- Lacerations of birth canal if rapid vaginal delivery is carried out

- Rupture of uterus (malpresentation )

- Uterine atony (prolonged labour)

Prolonged labour

Traditionally, prolonged labor is defined retrospectively when all the stages of

labor (from onset of true labor to delivery) last more than 24 hours. One of the

main objectives of monitoring labor is to detect abnormal progress of labor before

it is prolonged. Clinically, abnormal progress of labor is entertained whenever

there is ‗failure to progress‘ in labor; i.e., progress of labor not following the

normal course. ‗Poor or failure to progress‘ is a symptom of abnormal labor. It is

not the cause for the abnormal labor.

The indication for any interventions (e.g. CS) should be the cause of the ‗failure to

progress‘ rather the symptom.

Cause in 1st stage

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1. in-efficient uterine contraction (Power) is the most common cause of

prolonged labour, the cervix dilates slowly or not at all

2. pelvic abnormalities(passage): - a contracted pelvis and pelvic tumors

prevent normal progress in labour

3. The fetus (passenger): - a large fetus, malposition & malpresentation inhibit

the progress of labour.

4. Psychological cause: Abnormally tense or apprehensive women tend to have

prolonged labors. The primigravidae more often affected than

multigravidae.

Management

When progress in labour is slow the cause must be identified, weak uterine action

may be rectified with a syntocinon infusion, caesarian section if no progress

despite good uterine contraction obvious disproportion or malpresentation of the

fetus indicate the need for operative deliveries.

Nursing care

Maternal condition: She may be exhausted, dehydrated and ketotic and may be

suffering severe pain

- Encourage and reassure the mother

- Help to adopt a comfortable position

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- Adequate analgesia should be offered because it will enable her to rest.

- Administer IV infusion

- Empty bladder regularly

- Test urine for ketoses

- Record intake and output

- Allow sips of water

- If membrane ruptured 08 hours before high vaginal swab is taken for culture

and sensitivity and antibiotic is started

Fetal condition:

- Monitor the fetal heart beat

- Observe amniotic fluid (meconium)

- Avoid aspiration at delivery

The second stage

The exception in this phase should be continuous descent and advance of the

fetal head. It is prolonged if it stays > 2 hrs in primi & >1 hr in multi.

Causes of a prolonged 2nd

stage of labour

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1. Hypertonic uterine contractions

Management - syntocinon infusion is commenced in order to stimulate

adequate contraction

2. Ineffective maternal effort – voluntary effect

Fear, exhaustion or push and cause delay especially in primigravida.

3. A rigid perineum.

A forceps delivery is performed under local anesthesia.

4. Reduced pelvic outlet.

A forceps delivery is performed if possible or, in severs cases, caesarian

section

5. Large fetus

An operative delivery will be necessary.

Complications of prolonged labour

Maternal: -

- edema

- Laceration

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- Uterine prolapse, PPH

- Cystocele or rectocele –over stretching of pelvic floor muscles

- Retention of urine

- Urinary tract infection during puerperium.

Fetal:

- Difficult instrumental deliveries

- Hypoxia

- Intracranial hemorrhage

Cephalopelvic Disproportion

When the head of the fetus does not fit into the mother‘s pelvis or delivery

condition in which the mother‘s pelvis is too small to allow the fetal head to pass

through.

Causes

- Contracted pelvis

- Big baby

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- Occipitoposterior position

- Pelvic tumors

- Malpresentations :Face, brow

Contracted Pelvis

Signs of contracted pelvis

- In multigravida prolonged and difficult labour with history of still births,

instrumental delivery and neonatal deaths

- In primigravida- under 150 cm with short fingers and small feet

- Bony deformity of spine, hip and leg

- Pelvic assessment will reveal contracted pelvis

Management

Cesarean section is usually performed for severe CPD, sometimes instrumental

deliveries help in lesser degrees of CPD.

Retained Placenta

Definition: When the placenta remains undelivered after 30 minute of the delivery

of the fetus.

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Cause

- Poor uterine contraction

- Hours glass contraction: a contraction ring in the third stage caused by giving

ergometrine and

not expelling the placenta in time

- Full bladder

- Mismanagement of third stage of labour

- Abnormal placentation

- Extra lobe of placenta

Management of retained placenta

1. Careful observation –check pulse

- Vaginal bleeding

- Check bladder

2. Gently try to deliver by controlled cord traction

3. If not manual removal followed by antibiotics

Manual removal of placenta – This should be carried out by a Dr.

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- Open iv line, anesthesia ( Epidural)

Method: Place one hand on the fundus to support the uterus let the other hand

follow the cord until it reaches the placenta move hand up to the edge of placenta

and find where it is partiality separated (remember it would not be bleed if is not

separated) then move your hand up and down , until you have it completely

separated then bring it out in your hand ,examine it.

Adherent Placenta

When the placenta has penetrated beyond the decidua.

Management

- is usually hysterectomy

-sometimes doctors can remove it as a piecemeal under general anesthesia or leave

it to be absorbed

Rupture of the uterus

Definition; when there is a tear or cut in the uterus. It is one of the obstetric

emergencies

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Causes other cause

1 Weak caesarian section scar - High parity

2 Obstructed labour - Neglected labor with

previous c/s

3 The unwise use of oxytocic drug - Extension of sever Cx

laceration up wards

4 Trauma during operative manipulation per vagina.

1 Weak Caesarian Section Scar

Cause:-

-If another pregnancy occurs with in six months

-Over distension as in subsequent twin or polyhydramnios

Occurrence: - during 1st stage of labour or the last four weeks of pregnancy.

Sign and symptoms

-Constant abdominal pain accompanied by vomiting even when the pulse below

100.

-Vaginal bleeding

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-shock

Management

-Labour should be conducted in hospital

-Reduced abdominal palpation to a minimum and perform with great gentleness.

Observation: Record and Report

- Increased tenderness over the scar

- Constant pain in the abdomen

- Slight or no advance, with good contractions during 1st stage

- Insufficient advance during 2nd

stage

- A rise in pulse rate

- Vaginal bleeding

- Shock

2. Due to obstructed labour

Cause-when labour is obstructed it causes excessive thinning of the lower uterine

segment during labour. It is more common during 2nd

stage of labour

Signs and Symptoms

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1. Rising pulse rate

2. Tonic Contraction and Bandl‘s ring

3. Tenderness of the lower uterine segment

4. Vaginal bleeding

In case of actual rupture

- Mother feel separate mass & something has given way and contraction cease

- Cessation of FHB

- Abdominal or shoulder pain

Management: - An immediate c/s

On district:

- Lay the patient flat, put iv drip

- Methadone 50mg for pain reliving

- Treat for shock

- Transfer to the hospital quickly

On Hospital

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- Lie flat, prepare blood for transfusion

- Prepare for operation

3 Due to trauma

Cause:

- Operative procedure

e.g internal version, craniotomy

-Extraction of the after coming head of the hydrocephalus baby

e.g Cervical tear

4. Due to unwise use of oxytocic drugs – Especially in high parity

Cause- using intravenously or intramuscularly to induce labor

General Sign of rupture Ux Complication

1. Maternal tachycardia - Amniotic fluid embolism

2. Scar pain with Tenderness - Maternal shock

3. Abnormal FHB - Fetal distress

4. Poor progress in labor - Death of the mother & fetus

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5. Vaginal bleeding

Types of rupture – Especially in high parity

-Incomplete: - rupture the myometrium and endometrial are ruptured and the

perimetrium remains

intact

Complete: - all uterine layers are torn

General Management of a ruptured uterus away from hospital

1. Lie patient flat

2. Take blood for grouping and cross matching

3. Put up intravenous drip and give methadone 50mg

4. Transfer to the hospital

Management of a ruptured uterus in the hospital

1. Lie patient flat

2. Blood group and cross match

3. Put intravenous drip

4. Get patient to sign consent form

5. Give pre medication

6. Carry doctor‘s order & post op care

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Condition of the baby

-Usually still born , after complete rupture

-Incase of incomplete rupture and if it happens in the hospital it is

possible to have live baby.

Surgical Management

1. Hysterectomy

2. Repair of the uterus if it torn interiorly. Postoperative care is the like

other postoperative cases

Lacerations

A tear is called laceration. The tear can occur in the vaginal wall or in the perineum

or in the cervix. Tears of the perineum are graded according to their severity. Other

areas of trauma may be the cervix and extended tears of the vagina

Causes

1. Not controlling the head at delivery

2. Precipitate labour

3. Big baby

4. Face to pubis and after coming head of breech

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5. Instrumental delivery

6. Old scar tissue and face presentation

Type of perineal lacerations

First degree

Involves the vaginal mucous and the skin of the perineum

Second degree

Involves the deeper layer of perineal muscle

Third degree

Also called complete tear is a perineal laceration passing through/involves/ the

anal sphincter lying open the birth canal

Fourth degree

A tear extending from the vagina to the rectum leading to direct contact

between the two hollow organs

Mx - First and second degree laceration can be repaired by nurses midwife but

third & 4th degree or

complete tear is repaired/sutured by a doctor in hospital under anesthesia .

This type of tear is

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very serious and must be watertight. The repair will be done with in 24 hours.

Transfer patient to hospital after the repair, the laceration care should be taken in

order to avoid infection. The suture line must heal well. The patient is kept on low

residue diet and the doctor usually order liquid paraffin to keep the stool soft. Stool

shall not be passed for 7-8 days . Vulva swabbing should be done each time patient

passes urine and later stool.

Prevention of lacerations

1. Gain the woman‘s co-operation

2. Get patient to delivery at the end of a contraction

3. Control head, keep it flexed so small diameter is emerges

4. Get mother to breath the head out

5. Delivery the shoulder in anterior- posterior diameter and lift up the posterior

shoulder

6. Perform episiotomy when the perineum is very tight

OBSTETRIC OPERATIONS

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Maternal and fetal risk in the intra partum period may also be reduced by

modifying the mode of delivery. Common obstetric interventions that modify

mode of delivery include version, forceps and vacuum extraction and cesarean

birth or operative abdominal delivery. And also allows prompt emergency delivery

when either the mother or fetus is in danger.

Forceps Delivery

Forceps delivery is a means of facilitating the birth of the baby‘s head by providing

traction with the aid of obstetric forceps when it is impossible for the mother to

complete the delivery by her own effort. Forceps deliveries are classified by the

level of the head at the time the forceps were applied i.e. high-cavity mid-cavity or

low-cavity.

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Low-cavity or out let forceps application are done when the fetal head is visible on

the perineum.

Mid cavity: or mid forceps applications are for those in which the head is at the

level of the ischial spines.

High-cavity or High forceps applications are those in which forceps are applied

through the cervix before the head is engaged in the bony pelvis.

Pre requisites of forceps delivery

4. The fetal head must be engaged in the maternal pelvis

5. The cervix must be fully dilated

6. The membrane should be ruptured

7. The bladder should be empty & episiotomy done

8. Positive identification of presentation and position

9. Absence of significant cephalopelvic disproportion.

10. Adequate anesthesia must be used

Indication for forceps delivery

1. Fetal distress in the second stage of labor

2. Delay in the second stage of labor-

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3. Malposition: occipitolateral, occipitoposterior

4. Maternal exhaustion or distress

5. For the delivery of the after coming head of a breech presentation.

6. Conditions in which pushing is undesirable, such as cardiac conditions or

moderate to severe hypertension.

Complications

Failure-Undue force should never be used. If the head does not advance with

steady traction the attempt is abandoned and the baby is delivered by cesarean

section.

In the infant;

Bruising: Severe bruising will cause marked jaundice which may be prolonged

Cerebral irritability- A traumatic forceps delivery may cause cerebral edema or

hemorrhage.

Cephal haematoma- is a swelling on the neonate‘s skull, an effusion of blood

under the periosteum covering it, due to friction between the skull and pelvis

Tentorial tear- results from compression of the fetal head by the forceps. The

compression causes elongation of the head and consequent tearing of the tentorial

membrane

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Facial palsy- occasionally the facial nerve may be damaged since it is situated

near the mastoid process where it has little protection.

In the mother

Bruising and trauma to the urethra this may cause dysuria and occasionally

haematuria or a period of urinary retention or incontinence.

Vaginal and perineal trauma: the vaginal wall may be torn during forceps

delivery and the vagina must be inspected carefully prior to perineal repair. The

episiotomy may extend or be accompanied by a further perineal tear and these

must be repaired with care. As with any damaged perineum there may be bruising,

edema or occasionally hematoma formation.

Rupture of the uterus with increased risk of infection, increased risk of uterine

atony and excessive bleeding, fracture of the coccyx and bladder trauma

Implications for nursing care

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The nurse must be prepared to locate the appropriate types of forceps when

requested. The nurse must support the mother if she is awake, explaining what is

being done. Maternal comfort level should be observed closely forceps

applications should involve sensations of pressure but adequate anesthesia or

analgesia should be established so that no pain results.

The nurse should monitor the FHR closely during application and traction. Fetal

bradycardia may be observed as a result of head compression and is transient. The

neonate delivered with forceps should be carefully examined for cerebral trauma or

nerve damage.

The nurse must be alert for possible sequelae of forceps deliveries. The mother

should be observed carefully for excessive bleeding, severe perineal bruising and

pain, difficulty in voiding and cervical or vaginal lacerations.

Vacuum Extraction /Ventouse delivery/

Vacuum extraction is accomplished by use of a specialized vacuum extractor,

which has a cap like suction device that can be applied to the fetal head to facilitate

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extraction. Traction is applied by means of a chain and the fetal head is drawn out

of the vagina.

Indications

Indications for use of vacuum extraction are similar to those for forceps

application. In addition, vacuum extraction can be safely used through a partially

dilated cervix to shorten first stage labour in some cases.

1. Mild fetal distress

2. In late first stage.

3. Malposition: occipital lateral and occipital posterior positions

4. Maternal exhaustion

Contra indications

1. Profound fetal or maternal distress requiring rapid delivery

2. Evidence of cephalopelvic disproportion

3. Face or breech presentation

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The Procedure

1. The prerequisites are as for forceps delivery

2. The head must be engaged.

4. The woman is positioned and prepared as for forceps delivery.

5. The position of the fetal head is determined

6. An appropriately sized cup selected. The cup is placed against the fetal head

as near to the occiput as possible, ensuring that no cervix is trapped beneath

it.

The vacuum is then built up gradually, usually starting at 0.2 kg/cm2 reaches after

5-10 minutes 0.8 kg/cm2. Once this pressure has been obtained the operator exerts

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steady gentle traction on the fetal head, in conjunction with uterine contractions

and the mother‘s expulsive efforts.

Complications

1. Failure

2. Maternal – trauma to the mother is rare, if the cup is applied carefully.

3. Fetal - The most common complication of ventouse delivery is trauma to the

fetal scalp and some obstetricians prefer not to use it for this reason.

Chignon – this is an area of edema and bruising where the cup was applied.

Caesarean Section

Caesarean section is an operative procedure in which the fetus is delivered after 28

weeks through a surgical incision in the maternal abdominal wall and uterus. The

primary goal of caesarean delivery is the preservation of the life and well being of

both mother and fetus.

There are two major types of caesarean section: the lower uterine segment and

classical caesarean section.

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The lower uterine segment transverse caesarean section (LUSTCS): the lower

segment is less muscular, thus has less bleeding, better healing and lesser risk of

rupture in subsequent pregnancies. It is the most widely used type of C/S. It is

contraindicated in transverse lie with impacted shoulder, placenta previa & dense

adhesions over the segment.

Classical caesarean section is a vertical mid line incision over the upper uterine

segment which is highly muscular. Thus, it has higher blood loss, higher risk of

rupture in subsequent pregnancies. It is usually conducted in cases where the

LUSTCS are contraindicated.

Elective caesarean section – Decision to deliver the baby by caesarean section has

been made during the pregnancy and before the onset of labour. Patient is well

prepared, and the operator must ascertain fetal maturity.

Definite indications include

1. Gross Cephalopelvic disproportion

2. Previous C/S with other obstetric factors like Breech, DM, etc.

3. Two previous C/S

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4. Tumor praevia

5. Major degrees of placenta praevia

6. Multiple pregnancy with three or more fetuses

7. Previous classical C/S, repaired VVF

Emergency caesarean section: is performed when adverse conditions develop

during labour

Definite indications include:

1. cord prolapsed

2. Fetal distress

3. Footling breech

4. uterine rupture (dramatic) or scar dehiscence (may be less acute)

5. Cephalopelvic disproportion diagnosed in labour

Contra indications

1. The presence of dead fetus

2. An immature fetus that could not survive out side the uterine environment.

Complications

1. The immediate complications are hemorrhage from the placental site, or the

wound, infection, anesthesia risks, and thromboembolism.

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2. The late complications are abdominal (incisional) hernia, intestinal

obstruction due to adhesions, and vague abdominal pain

Patient Preparation

Hb, BG, Prepare two units of crossed match blood

Catheterization of the bladder

Informed consent

Psychological support and reassurance