Maternity 2013

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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.

43
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.

44
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

45
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

47
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

49
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

54
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

55
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

56
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.

57
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.

58
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

59
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.

61
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 2nd
& 3rd
trimesters
 Sudden weight gain may suggest fluid retention

66
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.

70
 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

73
 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

74
 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.

76
 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,

78
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 .

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- 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

86
 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

89
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

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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.

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• 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

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- 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

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 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

102
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 2nd
visit after 6 weeks.
The Normal Puerperium

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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

105
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

106
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 1:803

107
* 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

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- 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

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- 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

125
- 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

126
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

127
- 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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