NORMAL PREGNANCY.pptx

NORMAL PREGNANCY
DEFINITION:
pregnancy, process and series of changes that take place in a woman’s
organs and tissues as a result of a developing fetus.
• Pregnancy occurs when the male and female reproductive cells unit to form a
zygote or a fertilized ovum.
• The fertilized ovum embeds in the maternal tissues to develop into a fetus and
finally expelled as a baby at the end of pregnancy.

DURATION
• Pregnancy last averagely for a period of 280 days 40weeks or nine months and
seven days
• During this period the fertilized ovum embeds and develop in the lining of the
uterus called decidua.
• while the fetus lies in a fluid called liquor amini.
• The fetus is surrounded by two membranes called the chorion and amnion.
• it is attached to the placenta by umbilical cord through which the fetus derives
its nutrients and oxygen from maternal blood via the placenta and waste
products also excreted

SIGNS OF PREGNANCY
POSSIBLE (PRESUMPTIVE) SIGNS
• Early breast changes 3-4 weeks
• Amenorrhoea
• Morning sickness 4-14 week
• Bladder irritation
• Quickening 16 -20week

SIGN CONT.
PROBABLE SIGNS
• Presence of HCG in urine and blood
• Softened isthmus (Hegars sign)
• Blueing of the vagina (Chadwicks sign)
• Pulsating of the fornices (Osianders sign)
• Skin pigmentation
• Braxton Hicks contractions
• Ballottement of fetus

SIGNS CONT.
POSITIVE SIGNS
• Visualisation of gestational sac
• Fetal heart sounds
• Fetal movement
• Palpable fetal parts

PHYSIOLOGICAL CHANGES DURING
PREGNANCY
THE BODY OF THE UTERUS
• The decidua occurs after embedment of the blastocyst under the
influence of estrogen and progesterone.
• There is thickening and increased vascularity of the lining of the
uterus especially the fundus and the upper boarder of the uterus.

PHYSIOLOGICAL CHANGES DURING OF
PREGNANCY
• The decidua is thought to play a role in the establishment of
spontaneous labour i.e. release of prostaglandin which aids cervical
ripening.
• The decidua and trophoblast release relaxin that causes relaxation of
the myometrium.

PHYSIOLOGICAL CHANGES DURING PREGNANCY
Myometrium:
• under the influence of oestrogen, there is uterine muscle growth i.e.
hyperplasia (increase in number) due to division and hypertrophy
(increase in size) of the myometrial cells.
• The muscle cells expand due to distension by the growing fetus,
liquor and placenta.
• The uterus increase in weight from 57-60g to 900g (1000g).
• It increases in size from 7.5x5x2.5cm to 30x23 x 20cm.

• The hypertrophy and hyperplasia of the muscle cells causes the 3
layers to become clearly defined.
• The muscle fibres become prepared for their respective functions
during and after delivery.
• The myometrium is both contractile and elastic

Perimetrium:
• This is a layer of peritoneum.
• It does not totally cover the uterus, but deflect over the bladder
anteriorly and over the rectum posteriorly.
• The anterior and posterior folds open out allowing the enlarging
uterus to rise unrestricted.

• The blood supply to the uterus increases to meet the growing needs
of the functioning placenta and uterus.
• Oestrogen causes development of new blood vessels.
• The arteries, veins and lymphatic's are enlarged.
• The richly supplied uterine arteries straightens out as the uterus
grows.
•

CHANGES IN UTERINE SHAPE AND
SIZE
• For the first few weeks, the uterus maintains its original pear shape but
later the upper part enlarges and it becomes globular in shape.
• The lower part softens and elongates.
• This is the beginning of the differentiation between upper and lower
part of the uterus.

CHANGES IN UTERINE SHAPE AND SIZE
12th WEEK OF pregnancy
• The uterus is about the size of a grape fruit.
• It is no more anteverted and anteflexed as it has risen out of the
pelvis and become upright though often it inclines and rotates to the
right (right obliquity of the uterus).

CHANGES IN UTERINE SHAPE AND
SIZE
• The uterus becomes more globular and the isthmus opens out.
• The fundus may be palpated abdominally above the symphysis pubis.
16th WEEK
• The uterus becomes spherical in shape, and can be palpated midway
between the symphysis and umbilical.
• The cervix and isthmus develop into the lower uterine segment which
is thinner and contains less muscle and blood vessels (site of incision
for caesarean section).

20th WEEK
• At 20 weeks the fundus of the uterus can be palpated at the level of the
umbilicus.
• From this period until term the uterus becomes ovoid in shape.
30th WEEK
• The lower uterine segment can be identified but still not complete.
• The fundus may be palpated midway between the umbilicus and
xiphisternum.

36th WEEK
• The uterus now reaches the level of the xiphisternum
38th-40th WEEK
• The softening of the tissues of the pelvic floor, the good uterine tone
and the formation of lower uterine segment encourages the fetus to
sink into the lower pole of the uterus.
• This is known as engagement and causes reduction in the fundal
height described as lightening.

THE CERVIX
• The cervix acts as a barrier against infection, it also helps to retain the
pregnancy.
• Under the influence of progesterone, endocervical cells secrete mucus
which becomes thicker and more viscous during pregnancy.

THE CERVIX
• This thickened mucus forms a cervical plug called the operculum that
seals the cervix and provides protection from ascending infection.
• The cervix remains 2.5cm long but oestrogen causes it to increase in
width which exposes endocervical cells giving an appearance of
erosion.
• The vascularity increases and if viewed through a speculum the
cervix looks purple.
• In late pregnancy, softening of the cervix and effacement occurs

THE VAGINA
• Oestrogen causes the muscle layer to hypertrophy and there is changes
in the connective tissue which allow the vagina to be more elastic and
thus stretch during delivery.
• The vagina is more vascular, appearing reddish purple in colour.
• The mucosa have a marked desquamation of the superficial cells which
increases the amount of normal white vaginal discharge this is called
leucorrhoea.
•

THE VAGINA
• The mucosa cells also have an increased glycogen content which is
acted upon by the Doederlein’s bacilli to produce more lactic acid
which gives a more acidic medium.
• This provide extra protection but an increasing susceptility to other
microorganisms commonly Candida albicans.

CHANGES IN THE CARDIOVASCULAR
SYSTEM
• THE HEART: Due to increasing workload, the heart may slightly
increase in size and displaced upwards to the left.
• Cardiac output increases from 5 to 7 liters per minute.
• The resting heart rate is increased by 15 bpm by the end of
pregnancy.
• The increased cardiac output is balanced by reduced peripheral
resistance due to relaxation and dilatation of arterial walls by the
action of progesterone.

CHANGES IN THE CORDIOVASCULAR SYSTEM
• Blood pressure may remain the same or drop in the first trimester.
• But reaches its lowest level in the mid-trimester.
• Return to the level of the first trimester towards term.(end of
pregnancy)
• The fall in blood pressure during the mid-trimester can cause
fainting attacks

CHANGES IN THE CARDIOVASCULAR SYSTEM
• The supine position can decrease cardiac output by as much
as 25% due to compression of the inferior vena cava
• The pregnant woman may suffer supine hypotensive
syndrome characterized by fainting, dizziness light
headedness, nausea etc.

THE BLOOD
• The red cell mass increases to meet the extra oxygen requirement.
• The total amount of haemoglobin increase during pregnancy.
• Plasma volume increases from the 10th week and reaches a level 50%
above the non pregnant values by 32nd – 34th week.
• The increased plasma volume is much greater than that of the red
cell mass causing haemodilution.
• This is characterized by lowered haemoglobin level and is known as
physiological anaemia.

• Neutrophils increase, thereby enhancing the blood’s phagocytic and
bactericidal properties.
• The other white blood cells do not change.
• The increased blood flow is directed to the uterus and 80% goes to
the placenta.
• There is Poor venous return and increased venous pressure in the legs
contributing to dependent oedema, varicose veins of the legs, vulva
and haemorrhoids.

• Blood flow to the kidney is increased by 30-50% which helps to
enhance excretion.
• Blood flow is increased to the capillaries of the mucus membranes
and skin especially in the hands and feet.
• However, blood flow in the lower limbs is slowed especially in late
pregnancy.
• This helps to eliminate the excess heat produced by the increased
metabolism.
•

• The associated vasodilatation explains why pregnant women” feel
the heat”, sweat profusely and have clammy hands and feet.
• Blood flow to the breasts increases throughout pregnancy.
• Evidence of this is seen in the dilated veins, enlargement of the
breasts, heat and tingling sensation felt especially during early
pregnancy.

• IRON METABOLISM: The increased red cell mass and the needs of
the developing fetus and placenta lead to increased iron
requirement in pregnancy with an increase in iron metabolism and
absorption.
• PLASMA PROTEIN: The level of plasma proteins increase during
pregnancy but the haemodilution effect causes a fall in its
concentration especially albumin.
• This leads to a decrease in osmotic pressure which results in
Physiological oedema as a common feature of uncomplicated

• CLOTTING FACTORS: Fibrinogen, clotting factor 7, clotting factor 10
and platelets are increased leading to a change in clotting time-from
12 to 8.
• This predisposes to a higher risk of thrombosis, embolism and
disseminated intravascular coagulation.
• IMMUNITY: Human chorionic gonadotrophin and prolactin suppress
the immune system of the pregnant woman. Levels of IgG, and IgM
decrease.

CHANGES IN THE RESPIRATORY SYSTEM
• In late pregnancy, the ribs flare out maintaining the capacity of the thoracic cavity
by counteracting the effects of the enlarging uterus which presses on the
diaphragm.
• The respiratory rate does not alter but the amount of exhaled air per minute
increases as well as gaseous exchange and breathing is deeper.
• These changes make the pregnant woman often conscious of the need to breath.
• Increase vascularity to the nose can cause nasal congestion and nose bleeding
can occur.

CHANGES IN THE GASTROINTESTINAL SYSTEM
• The hygroscopic effect of oestrogen causes the gums to become spongy and
bleed easily. Dental problems may occur because of gingivitis.
• Increased salivation (Ptyalism) is common. There is a change in the sense of taste
leading to dietary changes and food craving.
• Some women crave for substances of no nutritional value such as coal, chalk and
clay, this is known as pica.
• The relaxing effect of progesterone has a major influence on the gastrointestinal
tract.

• Heartburn is common due to gastric reflux as a result of relaxation of the cardiac
sphincter.
• There is delayed gastric emptying which causes the woman not to feel hungry
often.
• The enlarging uterus displaces the stomach and intestines and this gives the
pregnant woman a feeling of fullness with the intake of meals and hours after.
• Peristalsis is slowed which results in constipation occurring frequently during
pregnancy

• Relaxation of smooth muscles affects those in the veins of the anus
and haemorrhoids can occur.
• Nausea and vomiting, often termed morning sickness occur
especially during early pregnancy due to raised oestrogen and HCG
levels.
• Vomiting can be excessive known as hyperemesis gravidarum.
•

CHANGES IN THE URINARY SYSTEM
• The kidneys increase in weight, progesterone causes the calyces and renal pelvis to
dilate.
• The ureters also dilate and lengthen and relaxation causes them to kink.
• Peristalsis movement slows down in the ureters and stasis of urine with reflux occur
which predisposes to pyelonephritis.
• The renal threshold is reduced and sugar may be present in the urine.
• The uterus presses on the bladder in early and late pregnancy causing frequency of
micturition.

SKIN CHANGES
• Increased activity of the melanin stimulating hormone causes deeper
pigmentation during pregnancy.
• Some develop deeper patchy colouring on the face which resemble a
mask and is known as choloasma.
• A pigmented line running from the pubis to the umbilicus and
sometimes higher is called linea nigra.

SKIN CHANGES
• The nipple becomes darker and tough in preparation for breast
feeding.
• The perineum darkens in order to enable it to stretch during delivery.
• As maternal size increase, stretching in the collagen layer occur
particularly over the breasts, abdomen and areas of fat deposition e.g.
thigh.

SKIN CHANGES
• The maximum stretched areas become thin and stretch marks called
striae gravidarum appear.
• Increased blood supply to the skin leads to sweating. Women feel
hotter due to progesterone induced rise in temperature of 0.5◦C
together with vasodilatation.

SKELETAL CHANGES
• Progesterone and relaxin courses relation of ligaments and muscles
especially during the latter week of pregnancy.
• The pelvic joints and ligaments relax which allows the pelvis to
increase in capacity.
• The symphisis pubis softens as well as the sacroiliac joints.
• The sacrococcygeal joint loosens allowing the coccyx to be
displaced backwards.

SKELETAL CHANGES
• Backache and ligamental pain is common as a result of this relaxation
especially in the multi gravid.
• Posture may alter to compensate for a change in the center of gravity
especially if the abdominal muscle tone is poor.
• The gravid uterus pulls the body forward and the woman leans
backwards in order to balance and she exaggerate the normal lumbar
curve (pregnancy pride).

MATERNAL WEIGHT
• Weight gain during pregnancy comprises the products of conception
(fetus, placenta and liquor) and hypertrophy of several maternal
tissues (uterus, breast, blood etc.)
• Many factors influence weight gain which include; The expected
increase is 2 kg in the 1st 20 weeks then 0.5 kg per week till term
making an approximate weight gain of 12 kg in the 40 weeks
gestation.
•

CHANGES IN THE ENDOCRINE SYSTEM
• Placental hormones:
• Since the fetus depends on glucose for body and brain growth,
human placental lactogen alters maternal glucose metabolism, free
fatty acids are mobilized and progesterone reduces muscle tone
thus conserving energy and also allows deposition of fat.

• Pituitary hormones:
• The anterior pituitary gland increases the production of ACTH, melanin stimulating
hormone and thyrotrophic hormone.
• The secretion of FSH and LH are inhibited and production of prolactin increases
but its action is withheld by oestrogen, however it stimulates production of
colostrum.
• The posterior pituitary produces oxytocin though it is not active until the level of
oestrogen and progesterone change.

• Thyroid hormones:
• The thyroid gland enlarges in response to a reduced level of plasma iodine though
its activity is not increased.
• High level of oestrogen cause the liver to produce more thyroid binding globulin
thus T4 is bound rather than free.
• Adrenal hormones:
• Corticosteroid production is increased and may be one of the reasons for
glycosuria in pregnancy.

• Striae and hypertension which occur in pregnancy is related to its
increased secretion.
• Aldosterone production increased which enhances the re-
absorption of sodium maintaining a balance in the Increased
Excretion of Sodium and Chloride by Progesterone.

CHANGES IN THE NERVOUS SYSTEM
• Emotional instability is common in pregnancy.
• Anxiety, fear, irritability and depression may be manifested during
pregnancy.
THE BREAST
• The breast increases in size to 450-500g during pregnancy, hormone
activity causes changes in the breast.
• Oestrogen develops the duct system while progesterone the
glandular tissue.

THE BREAST
• The nipple and areola is prepared for breastfeeding.
• The breast enlarges and Montgomery tubercles are seen on the areola
which is darkened.
• Prolactin stimulates the production of colostrum.

SIGNS OF PREGANCY
POSSIBLE (PRESUMPTIVE) SIGNS
• Early breast changes i.e. prickling, tingling sensation, enlargement and fullness,
prominent and darkened areola can be used as an early sign.
• Women who take contraceptive pills may have such symptoms.
• Amenorrhoea: Absence of menses may be used as a suspicion of pregnancy but
use of contraceptive, hormonal imbalance, emotional stress, certain diseases e.g.
HIV can also cause amenorrhoea.

SIGNS OF PREGANCY
• Morning sickness: A feeling of nausea, vomiting, malaise,
weakness and tiredness may occur from 4-14 weeks.
However, gastrointestinal tract disorders, pyrexia illness and
cerebral irritation can result in these symptoms.

SIGNS OF PREGANCY
• Frequency of micturition: Pressure from the growing uterus during 6th -12th week
result in this but urinary tract infections and pelvic tumors can cause this to occur
in women who are not pregnant.
• Quickening: The first movement of the fetus felt by pregnant women may be an
indicator of pregnancy.
• A primigravida feels it at 18-20 weeks and a multigravida 16-18 weeks.
• However intestinal movement and gas in the intestines can give similar feeling.
•

PROBABLE SIGNS
• Presence of HCG in the blood and urine i.e. positive pregnancy test
(hydatidiform mole and choriocarcinoma may give similar results)
• Uterine growth and enlarged abdomen (tumours, ovarian cyst, and fibroid can
cause this).
• Hegar’s sign: This is a sign elicited when a bimanual examination is done.
• The softening and elongation of the isthmus causes two fingers inserted into the
anterior fornix to meet with a hand placed on the abdomen.

PROBABLE SIGNS
• Jacquemier’s (Chadwick’s) sign is a dark purplish discoloration of the
vaginal membrane caused by increase vascularity.
• Osiander’s sign is an increased pulsation of the uterine arteries felt in
the lateral vaginal fornices.
• The above signs may be present in pelvic congestion.

POSITIVE SIGNS
These are signs that do not have differential diagnosis with other
conditions and once they are present in a woman it can be concluded
that pregnancy has taken place. These include;
• Ballottement of the fetus on abdominal examination
• Palpation of fetal parts during abdominal exam.
• Fetal movement palpable or visible

POSITIVE SIGNS
• Fetal heart sounds heard on auscultation with a fetal stethoscope or
Doppler (Sonic aid which can detect FH at 11-12 weeks)
• Ultrasound scanning can be used to detect the presence of a fetal
sac as early as 4 weeks gestation
• Visualization of fetus by x-ray (not used nowadays)

DIAGNOSIS OF PREGNANCY
• The presumptive sings are used to suspect pregnancy.
• All the positive sings described above may be used to confirm
pregnancy
• A lot of biochemical pregnancy tests are available to help in the
diagnosis of pregnancy.
• These tests depend on the presence of HCG in the blood or urine.
• Early morning urine for pregnancy test gives accurate results if
instructions pertaining to the particular tests are followed.

DIAGNOSIS OF PREGNANCY
• examples of some test are;
• Gravindex test-drop of urine is placed on a slide and the reagent
added, an agglutination implies positive results
• Pregnosticon test is similar to the above but is more accurate
• The current Enzyme Linked Immunosorbent Assay (ELISA) can detect
very low levels of HCG in the urine.
• USG can be used to diagnose pregnancy as early as 4 weeks.
•

MINOR DISORDERS OF PREGNANCY
MORNING SICKNESS – NAUSEA AND VOMITING
• This is one of the earliest and commonest symptoms of pregnancy.
• The actual cause is not known but some attribute it to hormonal
influence during pregnancy.
• The woman feels nauseated on rising in the morning and may
actually vomit or have nausea with excessive salivation.

MINOR DISORDERS OF PREGNANCY
• As the name implies morning sickness but it can occur any time during the day
and impair the woman’s appetite.
• The smell of food substances can stimulate vomiting.
MANAGEMENT
• Reassure the expectant mother that is a normal process of pregnancy.
• The woman must avoid things that tend to nauseate her.
• She should be reassured that it is a temporal situation that may resolve during
12-16 weeks.

MANAGEMENT
• Advice client to take easily digestible foods and snacks at bed time
to avoid hypoglycaemia
• Advice client to slowly get out of bed
• Dry biscuits also help before rising
• Avoid fatty and fried foods
• Monitor client’s vital signs.
• Promethazine theocolate (avomine) 25mg bd may be administered
•

HEART BURNS
• This occurs commonly in the last 12 weeks of pregnancy.
• The burning sensation in the throat and stomach is usually associated
with the action of progesterone causing relaxation of the cardiac
sphincter and reflux of gastric juice into the oesophagus

MANAGEMENT
• Reassure the expectant mother
• Advice mother to avoid fatty, spicy or indigestible food.
• She should have light easily digestible diet.
• She can have some peppermints which relieve the flatulence (air)
• A tea spoon full of milk of magnesia or mist magnesium Trisilicate
can also be taken orally.

MANAGEMENT
• Client should sit up after meals
• She should sleep with extra pillows at night.
• Client should eat little food at frequent intervals
• She should wear loose clothing in other not to put pressure on the
abdomen.

CONSTIPATION
• There is decreased muscle tone during pregnancy due to the action of
progesterone causing slow peristaltic action leading to constipation
MANAGEMENT
• Advice the client to take more fresh fruits and roughage
• Teach client exercises she can tolerate
• Take extra fluids first thing in the morning and last thing at night
• Serve prescribed laxities and discourage enema and purgatives

BACKACHE
Backache is usually caused by relaxation of the sacroiliac joint and over stretching of
the ligaments.
• It may also be an early sign of labour.
MANAGEMENT
• Reassure client and explain the cause of pain
• Ensure rest and sleep
• Advice client not to lift heavy objects
• Application of warm compresses and massaging relief pain
• Advise her to sleep on a hard firm surface or mattress

MANAGEMENT
• Explain the need to attend regular antenatal clinic
• She should maintain good posture when sitting or walking
• Avoid high heeled shoes
• Avoid standing for long periods
• Serve analgesics as prescribed
•

LEUCORRHOEA
• Leucorrhoea is excessive discharge of white mucus from the membrane lining the
genital organs of the female. It is due to increased blood supply to the genital tract
during pregnancy.
MANAGEMENT
• Educate the client on the importance of personal hygiene
• Bath at least twice a day
• She should avoid having unprotected sex
• She should avoid douching and insertion of foreign materials into the vagina
• Wash panties well and dry in the sun.

LEUCORRHOEA
• Encourage them to eat well balanced diet rich in proteins and
vitamins
• When cleaning the perineal area it should be from front to back
• She should wear cotton panties and avoid nylon panties
• Rule out the possibility of infection
• Maintain good vulva hygiene
• Prescribed Metronidazole (flagyl) 400mg tid for a week.
•

INSOMNIA
• Sleep disturbance in pregnancy is due to a lot of physical factors such as nocturnal
micturition, excessive fetal movement, thoughts about the outcome of pregnancy
and labour, unstable marriage and stress of marriage.
MANAGEMENT
• Reassure the client
• Take warm beverages last thing before bed
• Encourage her to have warm bath before going to bed
• Provide or prescribe mild sedatives
• Help in solving any domestic or social problems.
• Avoid sleeping too early during the night
• She should sleep in a well-ventilated and cool room.

PTYALISM
• This is excessive salivation which occurs from the 8th week of gestation.
• It is thought to be due to hormonal influence. This may accompany morning
sickness or heartburns
MANAGEMENT
• Chewing of sticks or gum sometimes help
• Some women prefer sour taste
• Advice the woman to avoid spitting around but get a container which should
be emptied frequently.
•

PICA
• This is the term used when pregnant women crave for unnatural
substances such as charcoal, clay, chalk etc. that has no nutritional
value.
MANAGEMENT:
• Advice the woman on the need to avoid the substances as they can be
potentially harmful. An alternative must be found if possible.

HAEMORRHOIDS
• These are varicose veins in the anus. They may be painful and cause bleeding. They
sometimes prolapse and become external.
MANAGEMENT
• Avoid constipation.
• Topical application may be prescribed e.g. xylocaine cream, anusol suppositories etc.
• Cold compresses can give relief.
• Drink lost of fluid.
• Eat more vegetables and fruits.

LEG CRAMPS
• Cramps are sudden gripping contractions of the calf muscle frequently occurring during
the third trimester.
• This usually wakes the woman up during the night and presents with painful calf the
following day.
• It is due to ischaemia and lowered serum calcium level.
MANAGEMENT
• Do leg stretching exercise be for retiring to bed
• Support legs on pillows or raise foot end of bed when sitting or sleeping
• Dorsiflex the foot when cramps occur.
• Encourage the intake of high calcium foods
• Calcium supplements can be prescribed.
•

FREQUENCY OF MICTURITION
• This occurs in early weeks of pregnancy when the growing uterus is still situated in the
pelvis and competes for space with the bladder.
• In the latter weeks it occurs when there is engagement and the presenting part enters the
pelvis and reduces the available space.
MANAGEMENT
• Reassure the woman and explain the cause to allay her anxiety
• Encourage her to sleep in the afternoon since her sleep will be disturbed at night
• Avoid fluid intake during the night
• Exclude other signs and symptoms of urinary tract infection
•

FAINTING
• This is as a result of vasodilatation occurring under the influence of progesterone
because there has been an increase in blood volume.
• Fainting may occur in late pregnancy when the mother lies on her back due to
supine hypotensive syndrome.
MANAGEMENT
• Avoid long periods of standing
• The woman should sit or lie down if she feels faint
• Avoid lying on her back
• Avoid getting up suddenly on rising but should lie for some time before rising
• She should turn on the side before rising slowly.

ITCHING
• Itching begins on the abdomen and areas of striae which is linked with the
liver’s respond to pregnancy hormones and with increased level of bilirubin.
MANAGEMENT
• Advise client to have warm bath
• Use local applications such as calamine lotion
• Antihistamines may be prescribed
• Other causes of itching such as heat rash, scabies etc. must be excluded
•
•

CARPEL TUNNEL SYNDROME
• The expectant mother may complain of numbness or pins and needles
in her hands and fingers which is usually worse in the mornings.
• It is caused by fluid retention which creates oedema and pressure on
the median nerve.
MANAGEMENT
• woman should be reassured and advised to avoid sleeping on her
hands
• Raising the hands up or on pillows can provide some relief.

FATIGUE
• Fatigue in the 1st trimester is due to hormonal changes.
• The woman has an overwhelming tiredness and looks sleepy even
when she wakes up in the morning after a night sleep.
• During the 3rd trimester it is due to increase in weight making
movement tiring. MANAGEMENT
• Reassure and explain cause to the woman
• She should be encourage to rest when necessary.

CONDITIONS THAT REQUIRE IMMEDIATE ACTION
• Vaginal bleeding however slight it is
• Severe frontal headache
• Oedema(massive)
• Premature rupture of membranes
• Severe abdominal or lower abdominal pains
• Excessive vomiting
• Pallor
• Fever

ANAEMIA
• Anaemia is a condition in which the number of red blood cells
or the haemoglobin concentration within them is lower than
normal
• INCIDENCE; 37% of pregnant women

TYPES OF ANEMIA DURING
PREGNANCY
Several types of anemia can develop during pregnancy.
These include:
• Iron-deficiency anemia
• Folate-deficiency anemia
• Vitamin B12 deficiency

Iron-deficiency anemia
• This occurs when the body doesn't have enough iron to produce
adequate amounts of hemoglobin. That's a protein in red blood cells
(FORMATION)
• the blood cannot carry enough oxygen to tissues throughout the body.
• Iron deficiency is the most common cause of anemia in pregnancy

Folate-deficiency anemia
• Folate is found naturally in certain foods like green leafy
vegetables.
• folate is use to produce new cells, including healthy red blood
cells.
• Folate deficiency can directly contribute to birth defects e.g.
neural tube abnormalities (spina bifida) and low birth weight.

Vitamin B12 deficiency
• vitamin B12 is use to form healthy red blood cells.
• SOURCES; meat, poultry, dairy products, and eggs
• EFFECTS; contribute to birth defects, such as neural tube
abnormalities, preterm labour

RISK FACTORS FOR ANEMIA IN PREGNANCY
• Multiple pregnancy
• Close pregnancies
• Hyperemesis gravidarum
• Teenage pregnancy
• Inadequate intake of iron rich diet
• anemia before pregnancy

CAUSES OF ANAEMIA IN PREGNANCY
• Inadequate intake of foods which contain the essential nutrients (
folic acid and iron) example:
• Poor method of cooking
• The demand for essential nutrients repeatedly outstrip the supplies
without adequate replenishment
• Chronic infections – e.g. UTIs and TB
• Sickle cell disease

CAUSES OF ANAEMIA IN PREGNANCY
• Infection. parasitic infections, tuberculosis
• Haemolysis ( as in malaria and sickle cell diseases)
• Recurrent bleeding, e.g. Threatened abortion.
• Hookworm infestation- as a result of pica.
• Acute blood loss, such as antepartum haemorrhage

Symptoms of Anemia During Pregnancy
• Pale skin, lips, and nails
• Feeling tired or weak
• Dizziness
• Shortness of breath
• Rapid heartbeat
• Trouble concentrating

PREVENTION OF ANAEMIA IN PREGNANCY
• Encourage patient to take a balance diet which is rich in folic acid and
iron
• The availability and cost of foodstuff must be considered
• Methods of cooking vegetable should be explained to patient so that
folic acid content is preserved
• Prescribed folic acid supplements (5mg) should be given daily
throughout pregnancy.

• Prescribed ferrous sulphate (200mg) or ferrous gluconate (325mg)
should be given thrice daily throughout pregnancy ( for iron deficiency)
• Prevention of malaria, where it is endemic.
• Discourage breeding of mosquitoes near her house. By having a good
drainage system.
• Encourage the use of insecticide treated net (ITN) at night
• Clear bushes around her house

• Routine haemoglobin estimation at each antenatal clinic visit makes it
possible for early recognition of patients who are at risk.
• Efficient replacement therapy following haemorrhages is necessary in
the prevention of subsequent anaemia
• Patients with sickle cell disease should have specialist care throughout
the pregnancy.

• Avoid eating substances that have no nutritional value(pica)
• Report to clinic immediately you see bleeding ( for antepartum
haemorrhages)

ADVICE FOR CLIENT WITH VAGINAL DISCHARGE
• Report early for diagnosis and treatment.
• She should avoid douching and using antiseptic in the vagina.
• Under wear should be changed frequently, dry in sun and/or iron it
before wearing.
• Advise her to clean her anus from anterior to posterior.

ADVICE FOR CLIENT WITH VAGINAL DISCHARGE
• She should put on cotton underwears.
• Advise her to wash hands before and after touching her genitals.
• She should report with her husband for screening and treatment.
• She should also adhere to the treatment regimen to treat it
completely.

ANTENATAL CARE
• Antenatal care is the care, supervision, and attention given to a
pregnant woman till she delivers.
• Ideally antenatal care should commence from the time the woman
thinks she is pregnant or she is diagnosed as being pregnant and
should continue at regular interval till she delivers safely.

FOCUSED ANTENATAL CARE
• Focused antenatal care is the WHO new approach to antenatal care which is
based on scientific evidence .
• It seeks to improve upon the quality of the antenatal care provided to women
particularly in low resource settings.

PRINCIPLES OF FOCUSED ANC
• It looks at the quality of care rather than quantity of care.(4 visits for women
with normal pregnancy).
• Individualized care.
• Disease detection and not risk categorization(all pregnant women are at risk).
• Evidenced based practices during ANC provision.
• Birth preparedness and complication readiness.

RECOMMENDED SCHEDULE OF ANC VISITS
BOOKING VISIT
• This is the first or initial visit the pregnant woman makes to the health care
provider and should take place as soon as pregnancy has been confirmed.
• This visit is important because it helps to assess levels of health by history
taking, screening test as well as obtaining the individual’s baseline recordings.
• Booking visit; during first trimester(preferably before 14 weeks)

RECOMMENDED SCHEDULE OF ANC VISITS
• 1st scheduled visit at 16 -20 weeks
• 2nd scheduled visit in the sixth month(24 – 28 weeks)
• 3rd scheduled visit in the eighth month(28 – 32 weeks)
• 4th scheduled visit in the ninth month(about 36 weeks
• How ever more frequent visits or different schedules may be required based on the
woman’s needs andor national policies (eg.malaria or HIV)

ANTENATAL CARE CONT.
• Antenatal care should address both medical and psychosocial needs of the
pregnant woman. Within the health delivery context as well as the client’s
culture.
• Periodic visits to a health care provider are necessary for the following reasons
• Early detection and treatment of complications

ANTENATAL CARE CONT.
• Establishment of a supportive relationship between the pregnant woman and
the health care provider.
• Development of a birth preparedness and emergency plan with the woman.
• Provision of preventive measures.
• Provision of advice and counselling.

AIMS/BENEFITS
• To know baseline recordings of the woman’s physical health
• To monitor the condition of the mother and fetus to ensure good maternal and
fetal health throughout pregnancy.
• To monitor the progress of the pregnancy to ensure normal fetal development
and delivery of a normal term health baby.

AIMS/BENEFITS
• To recognize deviation from normal or early detection of abnormalities and
provide appropriate treatment or management.
• Certain complications can be prevented and the woman can also understand the
physiological changes and thus cope with minor disorders

AIMS/BENEFITS
• Preparation towards successful breast feeding can be done during
antenatal visits.
• To give health education on important topics
• To give prophylaxis treatment to conditions such as tetanus,
anaemia, malaria and worm infestation

AIMS/BENEFITS
• To build a trusting relationship between the family and their
caregiver.
• Antenatal clinic helps the prospective family to prepare
psychologically for childbearing and make adjustments to it.

RECEPTION
• First impressions are lasting, therefore the reception the woman receives during booking
can colour the rest of her experience.
• The midwife must be approachable, friendly and possess good communicative skills since
this visits involves a lot of interactions and exchange of information.
• The midwife should greet and welcome the woman with a smile and offer her a seat.
• She should establish rapport to ensure a smooth communication.

RECEPTION
• The midwife can gather much information by observing the woman as she
enters the room; whether she responds to a smile, looks angry, nervous or shy.
• A long wait or prospects of a previous interview, unresolved anger at home,
unwanted pregnancy etc. may have made her irritable.
• Observation of physical characteristics such as posture, gait, nutritional status,
feeling of unwell etc. can be done at a glance during the first contract with her.

HISTORY TAKING
Social history
• This involves taking history about the social aspect of the woman and assessing
the individuality of the woman.
• It involves personal information such as full name, address, husband’s name and
address and the next of kin, this helps in identification and tracing of patient or
relatives when the need arise.
• Her occupation as well as that of her husband will give an idea about her
socioeconomic status, if her work is strenuous, it can be identified and
appropriate advice given.

HISTORY TAKING
Social history
• Knowing the age of the woman is also important since pregnancy occurring in the very
young and elderly women carry a risk.
• Marital status, educational background, tribe and religion should also be ascertained.
• General health and lifestyle should be assessed which include; smoking, alcohol intake,
exercise, nutritional pattern, sleep pattern and bowel and bladder habits.

HISTORY TAKING
Medical history
• Medical history provides an idea about the woman’s general health prior to pregnancy i.e.
whether there was any existing medical condition.
• This history is important because there are some medical conditions which affect pregnancy
adversely and there are some that are aggravated by pregnancy.
• Moreover women with these conditions may include diabetes mellitus, hypertension,
asthma, epilepsy, kidney disease, heart disease, tuberculosis, sickle cell disease and mental
illness.

HISTORY TAKING
Medical history
• It must be enquired whether patient is receiving treatment for the existing condition and what drugs
she is taking.
• Any history of accidents especially those involving the pelvis should be known.
• Enquiries should be made about any previous blood transfusion and their indications if known.
• Any history of STI should be noted and the midwife should find out the type of treatment used in
the treatment of the STI
• Enquire about allergies to food, drugs and other substances

SURGICAL HISTORY
• A history of operations on the pelvis, spine and reproductive tract, RTA,
e.g. myomectomy, salpingectomy etc. as well as operation pertaining to
pregnancy such as caesarean section.
• How long the operation lasted and if CS what was the indication for
the surgery and whether there were any complications.

FAMILY HISTORY
• This history is important because some conditions are genetic in origin and can
be passed on to the unborn fetus if there is the tendency.
• Other conditions are familial and so relations from such families are
predisposed to them, since pregnancy can increase this predisposition it is
essential to enquire about these conditions.
• Some of these conditions include epilepsy, HPT, DM, essential hypertension,
and mental illness.

FAMILY HISTORY
• Multiple pregnancies have a higher incidence in certain families and it’s
existence should be enquired.
• Enquire about recent infectious diseases especially TB in any family member.
• Any death of a family member or close relative and the cause of death.

MENSTRUAL HISTORY
• This talks about the age the mother attained menarche.
• Duration of the menstrual cycle e.g. 21, 24, 28 or 32 days.
• The first day of the last menstrual period to aid in the
calculation of EDD.
• Whether client experiences some disorders like
dysmenorrhea,

GYNAECOLOGICAL HISTORYRISKY SEXUAL
BEHAVIOURS
• Any history of STI should be noted and the midwife should
find out the type of treatment used in its treatment.
• Risky sexual behavior e.g. multiple sexual partners,
homosexuality, prostitution etc

PAST OBSTETRICAL HISTORY
• Details are taken of the following
• The history of previous pregnancies, labours, delivery and puerperium have an
important part to play in predicting the likely outcomes of the present
pregnancy.
• It also determines how the present pregnancy should be managed and where
the woman should deliver. The woman who is pregnant for the first time does
not have any past history and so the outcome cannot be predicted.

PAST OBSTETRICAL HISTORY CONT.
• Adequate pelvic capacity can be assumed after a successful vaginal delivery
and uterine efficiency is better after the first labour.
• An account of the previous pregnancies should be given including outcome i.e.
duration of pregnancies, minor or major disorders experienced during the
pregnancy.

• Any abortion should be known-duration of pregnancy before abortion, whether
it was induced outcome or spontaneous, if spontaneous whether it was
complete and whether evacuation was done or not.
• A sympathetic, non-judgment approach is required to gain this information
accurately.
• An account of previous labours should be given, whether the labour was
spontaneous, induced, preterm or post-term or c/s.

• If labour was induced possible indication should be known.
• The duration of the 1st, 2nd and 3rd stages of labour should be enquired.
• The mode of delivery whether vaginal delivery, vacuum extraction or
caesarean section should be known as well as the amount of blood loss during
delivery.
• History of retained placenta should also be noted. The midwife should enquire
about the size of babies and their conditions at birth

PRESENT OBSTETRICAL HISTORY
• The woman is asked of her last menstrual period (LMP) and the number of
days of flow and the nature of the flow, this helps to know if the last period of
bleeding was true menses.
• The estimated day of delivery (EDD) is then calculated by adding 9 calendar
months and 7 days to the first day of the woman’s LMP.
• This is for the average 28 days cycle,

• if the cycle is short e.g. 24 days then subtract 4 days from the calculated EDD,
• if the cycle is long e.g. 32 days then add 4 days.
• In case where the woman does not know her LMP the husband can be interviewed or
the woman asked to report on next visit with the right information.
• If this is not successful abdominal examination can help to estimate the gestational
age with the level of the fundal height and rough estimation or EDD done

• Ultrasound scan (USG) may be done to know gestation.
• The midwife should enquire about the general health of the woman
from the onset of this pregnancy. Assess for any danger signs or risk
factors.
• Ask of any bleeding since pregnant and any vaginal discharges.

NORMAL PREGNANCY.pptx

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