SANDRA SHROFF ROFEL COLLEGE OF

NURSING

SUBJECT – clinical speciality , obstetrics & gynecological nursing

Practice teaching on psychiatric disorder during pregnancy

SUBMITTED TO SUBMITTED BY
Mrs. Dipa M R Ms. Mehzbeen Navsariwala
Professor 1 st yr M.Sc. Nursing
S.S.R.C.N. S.S.R.C.N.
Vapi. Vapi.

Date of submission – 20/3/’11

Identification
Title of course : obstetrics & gynecological Nursing
Topic : psychiatric disorder during pregnancy
Level of student : 4 th yr B.Sc. nursing
No. of student : 47
Date :
Time
Venue
Teaching method : Lecture cum discussion
AV AIDS : white board, Flow chart, OHP, LCD
Name of evaluator : Mrs. Dipa M R

Name of the student teacher : Ms. Mehzbeen navsariwala

1 st yr M.Sc.Nursing

GENERAL OBJECTIVE
At the end of the class the student will acquired knowledge about psychiatric disorder during pregnancy , and able to develop a skill &
attitude to apply this knowledge in clinical practice.

SPECIFIC OBJECTIVE
At the end of the class the student will able to
 define psychiatric disorder in pregnancy
 describe psychiatric society
 explain common psychological disorder
 discuss high risk women for psychiatric disorder
 enlist incidence of psychiatric disorder
 enumerate mental illness in pregnancy
 describe mental illness in puerperium
 explain psychological aspects of gynecology
 educate the patient with psychiatric disorder
Specific Time CONTENT AV ACTIVITY Evaluation
Objective AIDS Teaching Learning
Introduction Being pregnant is a very personal Teacher will Student will
experience for each patient. This period in her life explain and think and
poses many new challenges and possible problems. ask question answer the
How she responds to these challenges is dependent
question
on her emotional maturity or lack of it. It is the
responsibility of the practical nurse to help her
understand and meet these challenges
appropriately. You can help the patient, her mate,
and significant others in their understanding of the
physiologic changes that may occur during
pregnancy
Student Definition
will be able Teacher will Student will What is
to define It is a disturbance of explain and think and psychiatric
psychiatric i. cognition [thought] ask question answer the disorder?
disorder in ii. conation [action] question
pregnancy iii. affect [feeling]
any equilibrium between the three during
pregnancy is known as psychiatric disorder in
pregnancy

Student Psychiatric society Teacher will Student will What

will be able 1. the marce society - “An international show and think and psychiatric
to describe society for the understanding , prevention explain answer the society are
psychiatric and treatment of mental illness related to question there?
society childbearing.”
The marce society was formed at an international
conference in 1980. The purpose of the conference
was to being together different stands of research in
puerperal mental disorder. It was recognized that
there needed to be a forum to discuss puerperal
mental illness in its broadest sense and a society
was formed. The society was named after Louis
victor marce, a french psychiatric who wrote the
first treatise entirely denoted to puerperal mental
illness, published in 1958.
Aims
- to promote facilitate & communicate about
research in o all aspect of mental health of
woman , their infants, and parents around
the time of child birth.
The society multidisciplinary and encourages
involvement from all disciplines including
psychiatrist, psychologist, pediatrician,
obstetrician, midwife, ect. It also involve
consumers and cares groups
The society hold an international meeting every 2
year hosted by president of society . there are lively
meeting with a high quality scientific content
brings together researcher , clinician , from around
the world
The society was originally established in the UK
but it has grown and is now truly international
society with members from all part of the world.
Regional group now has been formed that also have
regular meeting discuss more regional issues as
well as to exchange ideas about all aspects of
mental health of woman their infant and parents.
NASPOG- the north american society for
psychosocial obstetrics and gynaecology
The society was formed in 1979. As an
independent body after existing as a special interest
group the American college of obstetricians and
gynecologist [ACOGs].in the early 1960s. the
society remains as affiliate organization of
ACOGs.the relationship is identified as apart of
ACOGs goal to
1. interrelate with the other organization and
special interest with in obs/gyn
2. improve communication among
organization and ACOGs in order to
establish more collaborate relationship and
create a more renified voice within the
speciality of obs/gyn
3. provide cost effective services to
organization so that might further the over
all mission of full filling the educational
need of the society.
The society compresses of approximately 200
member drown from the field of obs & gynec ,
psychiatry, psychology , nursing, social work, ect.
Aim
To foster scholarly scientific and clinical study of
biopsychosocial aspect of obs & gyn . primary
focus is often on woman but they involve men with
women in couple communication, sexual,
 reproduction & parenting behavior. The aim is
brodly divided into the psychological &
psychophysiological , public health, social culture
and other aspects of such functioning &behavior.
NASPOG conduct annual meeting on February
each year holding abstract presentation poster
session , symposia with invited speakers. The
annual meeting serves as a forum for scientific and
clinical discussion .
Student Teacher will Student will What are
will be able Common Psychological Disorders: Mental show and think and the
to explain Health during Pregnancy explain answer the common
common question psychologi
Broadly classified under maternal depression,
psychologi perinatal mood disorders are a result of the cal
cal disorder physiological and hormonal changes the body disorder?
undergoes and the stressors involved in pregnancy.
There are various gestational or antepartum
disorders that affect women during pregnancy and
postpartum or postnatal mood disorders that occur
after pregnancy. Anxiety and depression constitute
the major emotional disturbances in the perinatal
stage. However the clinical classification of
perinatal mood disorders falls in three major groups
of mental disorders during pregnancy.
Major Depression - Gestational and Postpartum
Depression: Referred to as 'baby blues', depression
is a common and self-limiting mood disturbance,
that can severely affect the lives of the mother and
child. It affects nearly 10% of pregnant women and
poses a risk to the mother and the fetus. The
condition referred to as postpartum depression can
develop and worsen after the birth of the baby. The
trigger factors could be, the rapid rise in hormone
levels during pregnancy or the change in the levels
of chemicals in the brain, which govern moods. A
disruption in either of these, can lead to depression.
The other causes of depression could be stressful
life events, financial troubles, or a death in the
family.
The symptoms of major depression in pregnant
women include:
• Difficulty in sleeping or oversleeping
• Weight loss or change in appetite
• Irritability or mood swings
• Constant fatigue or lack of energy
• Restlessness or feeling slowed down
• Unpredictable, uncharacteristic, or bizarre
behavior

• Recurrent thoughts of self-harm or suicide

• Feeling of guilt or worthlessness

Untreated depression may lead to substance abuse,

self harm or suicide and could even cause the death
of the baby. Most pregnant women with
depression, experience preterm birth, spontaneous
abortion and low birth weights. It may also impair
a mother's ability to promote the infant's cognitive
 and emotional development.

Clinical Mood and Anxiety Disorders: They can

occur during pregnancy and following childbirth,
usually within six months to a year later and often
necessitate treatment. Usually as common as
depression, anxiety disorders are characterized by
panic attacks, hyperventilation and obsessive
compulsive disorders. The woman may have
repeated thoughts or images of frightening things
happening to her baby.

Postpartum Psychosis: This is the most extreme

form of perinatal mental illness, usually occurring
within a few weeks of childbirth and constituting a
medical emergency. This form of maternal
depression may lead to poorer neonatal outcomes
Student and even infanticide. Teacher will Student will What are
will be able show and think and the high
Psychiatric disorders are high risk during
to discuss pregnancy and following delivery are common explain answer the risk cases?
high risk in : question
women for
psychiatric • For the majority of women who develop
disorder mental health problems during pregnancy, this is
usually a mild depressive illness, often combined
with anxiety.

• Pregnancy protects against developing a

serious mental illness (schizophrenia, bipolar
disorder and severe depressive illness) but is not
protective against relapses of pre-existing serious
 mental illness, especially where usual medication
has been stopped at the outset of pregnancy.

• Women who have had a previous episode of

a serious mental illness, either following childbirth
or at other times, are at an increased risk of
developing a postpartum onset illness even where
they have been well during pregnancy and for
many years previously. This risk is estimated as at
least 50%.

• Pregnancy was thought to have a protective

effect on maternal suicide rate but Confidential
Enquiries into Maternal Deaths have shown that
whilst suicide during pregnancy remains relatively
uncommon, suicide is a leading cause of maternal
death. The majority of suicides occur following
childbirth. Over half of women who died from
suicide had a previous history of serious mental
Student Teacher will Student will What are
illness.
will be able show and think and the
to enlist Incidence explain answer the incidence
incidence question of
of In first trimester of pregnancy – high as 15 % , psychiatric
from that 5% of woman suffered from previous
psychiatric disorder?
history / episodes of mental illness.
disorder
In second & third trimester 5%
Student Teacher will Student will What are
will be able In puerperium 16% show and think and the mental
to explain answer the illness in
Mental illness in pregnancy
enumerate question pregnancy?
mental
illness in 1. minor mental illness
pregnancy
2. major mental illness

1.minor mental illness

The majority of episodes of mental illness during

pregnancy are minor condition or neuroses. The
commonest condition is the depressive neuroses
with anxiety, but phobic anxiety states and
obsessional compulsive disorder may also occur.
In most cases neurotic mental illness may resolve
in second trimester and seems to be no risk of
women getting post natal depression.

A] minor mental illness in first trimester

Minor mental illness are more likely to have in

women , who have marked neurotic traits, history
of neurotic disorder, social tension other factor
such as previous abortion ect

The majority of these illnesses resolve by second

trimester. Women require support, counseling
reassurance, information which communicate in a
caring, intelligible way, rarely drugs are prescribed
instead of therapy help women to relax & reduce
anxiety counseling & support by midwife work
effectively.

B] minor mental illness in late pregnancy

 The onset is usual during 3rd trimester which is
less common in 1st trimester. If it occur the risk of
developing postnatal depression increased . the
midwife in this case plays an important role in
giving counseling support to treat this condition
postnatal depression detection scale is used for high
risk group. Listening intervention with PND has
been found effective.

2. Major mental illness

It includes manic depression severe depression &

schizophrenia. The risk of an women developing a
episodes of those condition in pregnancy is lower
than at other time in her life. Although the reduce
in pregnancy it is greatly increased in 1st 3 month
after delivery.

Women who have had single episode in past ,

advised them to stop their medication for some
time throught the pregnancy. The problem is more
complex in the women had a serious episode of
major mental illness , in this case the drug are
adjucted to minimize effect on fetus eg.
Phenothiazines , antiparkinsones, butyrophenones
etc. to prevent a risk of major depression relapse
may take conventional tricyclic anti depressant
such as anti triptylin, imipramine & dothiopine .
Student the dose of anti depressant drug may reduce in 3rd Teacher will Student will What are
will be able trimester & gradually withdrawn before delivery . show and think and the mental
to describe because adverse reaction on newborn which explain answer the illness in
mental question puerperium
illness in ?
puerperium includes irritability,convulsion .

Mental illness in puerperium

It includes post natal depression , minor mental

illness, purperial psychosis. In 1992, the WHO
include puerperial mental disorder in ICD

ICD - 10 classification of puerperal disorder

F53 – mental & behavior disorder associated with

the pueroerium , not else where classified . this
classification should be used only for mental
disorder associated with puerpeurim

F53.0 – mildmental & behavioral disorder

associated with the puerperium not else where
classified include postnatal depression

F53.1 – severe mental & behavioral disorder

associated with the puerperium not else where
classified include puerperal psychosis.

F53.8 – other mental & behavioral disorder

associated with the puerperium not else where
classified

F53.9 – puerperal mental disorder , unspecified.

Depressive disorder – is characterized by mood

swings in to protected period of low mood that
return to normal functioning.

Criteria for major depression , a person must have

2 wk or more of a depressed mood or loss of
interest accompanies by additional symptos of
depression . it includes

1. Major depression

it is a cluster of psychologic & physical symptoms

that induse for 2 or more wk & that interfere with
the person ability to function or enjoy life.

Causes

Artifact hypothesis – the women perceive event to

which they are exposed as having a greater impact
on their life then the men& articulate their
perception in depressive terms.

Biologic hypothesis – as women move in their life

cycle they are subjected to changing hormones that
modulate the expression of emotion. These shifting
hormonal levels derive affective states in woman
and are responsible for disorder such as
premenstrual dysphoric disorder and post partum
depression

Psychologic hypothesis – sex role stress may

explain the higher prevalence of depression in
women. Poor job opportunity, pressure to fulfill
financial as well as career or vocational
responsibility undoubtedly contribute depression in
women. Violence against women reduce selfesteam
impaires interpersonal functioning & is often
associated with recurrent depression.

2. Seasonal affective disorder

Women are more likely to experience seasonal

affective disorder then men , it is a syndrome
characterized by recurrent depressive episode that
occur most commonly in winter & these
characterized by features as overeating,
oversleeping, weight gaining

Incidence is 4.3% - 10% in general population ,

male female ratio is1:6.3

3. Premenstrual dysphoric disorder

Incidence is 3-8% in ovulating women .

The criteria emphasized the emotional symptoms

is more in luteal phase the pattern of symptoms is
depression , irritability, mood swings .

4. Depression during pregnancy & the

puerperium

Treditionally , pregnancy has been viewed as a

period of well being that makes a women feel
biologically ‘complete’ and provide protection
against psychiatric disorder the factor such as
history of depression, younger age, limited social
support, living alone, a greator no of children,
marital conflict increases the risk of depression
during pregnancy & puerperium.

Anxiety disorder – community survey shows that

anxiety disorder are the most common medical
illness. The anxiety disorder in women include
social phobia, panic disorder, with or without
agoraphobia, generalized anxiety disorder, OCD, &
post traumatic disorder.

1. Panic disorder,without agoraphobia

Panic disorder typically found in female than in

male . age of onset is between adolescent to 30 yrs.
Patient refer panic attack as anxiety attack. It occur
suddenly over the course of several minutes & are
characterized by a variety of physical sensations &
cognisions [shortness of breath , hyperventilation,
palpitation, feeling of die ] patient usually go crazy
in behavior have less impairment.

2. panic dispoder, with agoraphobia

Agoraphobia is unlike social phobia in that fear of

variety of places and are not concerned with being
noticed and drawing attention. Approximately 7%
women sustain

3. generalized anxiety disorder

it is the most common anxiety disorder. The
prevalence rate is nearly 7 % in women & 4% in
men. It is characterized by anxiety & worry
experienced most of time for at least 6 month and
restlessness, fatigue, difficulty in consentration,
irritability, difficulty in sleeping. It is associated
with day to day circum stance.

4. Social phobia

It is also known as social anxiety disorder is a

persistence fear of one or more situation that may
lead to embarrassing scruting by other such as
speaking, eating, writing, in front of other people.
Patient avoide social setting eg. Classroom, parties,
or group activities. The risk factor may include
female gender, single status, growing age etc.

5. Obsessive compulsive disorder

Is found in 3% women & 2% of men. Obsession

are recurrent thought or images that are
inappropriate & are not simply about real life the
patient attempt to suppress them or neutralize them
by the compulsion which is repetitive behavior to
decrease the anxiety. One study found that women
tends to be compulsive washes then checking.

6. Post traumatic stress disorder

It is an anxiety disorder that develops after

exposure to a traumatic stressors that involves
actual or threaten death or serious injury to own
self or to other. In women PTSD can occur as result
of sexual assault , or early child hood abuse . 31%
of women have PTSD after trauma. Sometimes it
turn in to personality disorder . symptoms include
dissociative experiences, anger, depression self
abusing, multiple suicidal attempts.

7. Anxiety related to post partum period

The postpartum seems to be time of increase

vulnerability. It is very vulnerable to OCD even if
attempt of medication is their the cause of anxiety
is unknown.

Other disorder

1. Psychological problem in pregnancy

Throughout a patient's pregnancy, her emotional

reactions have been described as ambivalence, fear
and anxiety, introversion or narcissism, and
uncertainty. These feelings predominate at different
periods of the pregnancy; other tends to fade in and
out as the pregnancy progresses.

a. Ambivalence. This refers to the patient's

simultaneous attraction for and against the
pregnancy. The negative response to the pregnancy
does not mean that she doesn't want the baby. She
may simply have doubts as to whether she will be a
good parent, wonder if she is ready for a baby, how
a new baby will affect her family and her lifestyle,
and so forth. This is not to say that she doesn't feel
good about the pregnancy. Even though she may be
doubtful in some ways, she may be experiencing
joy and excitement as well as happiness and
anticipation.

b. Fear and Anxiety. This refers to the patient being

concerned for her own health and the health of her
baby.

c. Introversion or Narcissism. The patient becomes

concerned for herself. She may be preoccupied
with her own thoughts and feelings.

d. Uncertainty. Before the patient can accept the

fact that she is pregnant, she must ask herself "Am
I really pregnant?" This may last until a positive
diagnosis of pregnancy is confirmed by a
physician. "Quickening" is usually a big milestone
in the process of accepting the pregnancy.

2. Postpartum blues/depression
Many new mothers experience what is called
“postpartum blues” between the third and tenth day
after childbirth. This is thought to occur due to the
rapid change in hormonal levels after birth. patient
experience feelings of depression or inability to
cope with the new demands being asked . Also,
patient have increasing doubts about ability to care
for baby. Patient experience unexplained crying,
mood swings, loss of appetite and a feeling of
being trapped. partner is also usually exhausted and
may resent the amount of time the baby takes up,
and at the same time, experience guilt for having
these feelings.
Such feelings are normal and usually go away after
one or two weeks.
3.Postpartum Adjustments
Having a baby is much more than a physical
experience. Feelings may range from joy,
fascination, and excitement to exhaustion. It is the
beginning of a parenting role that will continue for
a lifetime. A new little person has entered your life.
Things will never be quite the same.
Adjusting to such a big change does not happen
overnight. Parents may not be suddenly struck with
instant love for their baby. As with any
relationship, love for the new baby grows and
blossoms over time.
4.Postpartum depression
As mentioned above, after the baby is born, a large
change occurs in the amounts of certain hormones
in the mother’s body. This change in hormone
levels is believed to cause postpartum depression in
about 15 percent of new mothers. Unlike the “baby
blues,” postpartum depression symptoms continue
beyond the first six weeks after birth and are more
serious. If you have a history of depression, you
may be at greater risk of developing postpartum
depression. Be sure to discuss this with your health
care provider.
 Symptoms of postpartum depression may include:
• Anxiety
• Tiredness
• Sleeping problems
• Confusion
• Frequent crying
• Guilt feelings
• Frightening thoughts
• Low self-esteem
• Eating problems
• Decreased sex drive
• Mood swings
Student Teacher will Student will What are
will be able • Feelings of hopelessness show and think and the
to explain explain answer the psychologi
• Irritability
psychologi question cal aspect
cal aspects • Forgetfulness of
of • Feelings of being overwhelmed If any of the gynecology
gynecology above feelings last longer than the first two to four ?
weeks after the birth of your baby, contact your
health care provider. You may be experiencing
postpartum depression. It would be good to share
your feelings with family and friends. There are
also community resources and support groups
available to help you if you experience any of these
feelings.
Psychological aspects of gynecology
1. Puberty
The main task with physical changes , in this stage
are separation from the family, formation of
identity, & coming to term with sexuality, sexual
orientation, changing behavior is a natural process
not all adolescent complete this task & there fore
some remains dependent & insecure.
2. Premenstrual syndrome
A menstruation related mood disorder . various
mood disturbances , disorder of thought,
behavioral disorder somatic disease affect menses
in about 3 4 of cases.
Clinical picture
- Affection
- Cognitive
- Pain
- Psychological
- Physical
- Dermatological
- Neurological
- Behavioral
Etiology
- Ovarian
- Fluid & electrolyte
- Other hormonal
- Psychological
Management
 - Hormones
- Psychotropic drugs
- Other agents
- Psychotherapy
3.menstrual problem
Emotional problem can affect the menstrual cycle
-Amenorrhea & oligomenorrhea:- various
psychological stresses may precipitate these
condition
-dysmenorrhea:-hormonal & emotional factor are
associated with this.
-pseudocyesis:-the factor such as a wish for
pregnancy , to please the husband or to retain his
attention , wish to prove youthfulness.
-leucorrhea:-it is believed to be a result of various
psychological & emotional stress.
4. transition to parenthood
This parenthood causes loss of freedom, depression
and sexual difficulties are common following child
birth. women withdraw from her partner , both
emotionally & sexually may be an expression of
her extra responsibility
5.manopause:-
Clinical picture
Gynecological view – various symptoms like
depression , irritability, lack of confidence, poor
concentration,
Student Psychiatric view – the belief that the menopause is Teacher will Student will What
will be able a time of high risk for psychiatric disorder in show and think and nursing
to educate women. explain answer the advise you
the patient Etiology question will give to
with - Biologic factor patient?
psychiatric - Psychoanalytic view
disorder - Culture , social & family factor
- Illness behavior
Management
- Hormone replacement
- Psychotherapy

Nursing advise to the patient with psychiatric

disorder
• Get plenty of rest and sleep.
• Eat well. Do not try to diet too soon. Wait
at least six weeks before starting a weight-loss diet.
Eat sensibly to rebuild and maintain your energy.
• Drink plenty of fluids, especially if you are
breastfeeding.
• Try to do some sort of mild exercise every
day. Exercise is a great pick-me-up and a good
outlet for releasing tension and frustration.
• Arrange for short times away from the
baby.
• Get out of the house at least once a day for
a walk.

• Form relationships with other new moms.

Join a mother’s support group or postpartum

depression group. Share your experiences and

fears. The more you talk about your worries, the
more you will find that you are not alone.
• Ask others to help with housework,
babysitting and caring for other children you may
have so you can get away for awhile.
• Seek support from your family, friends,
church, health care provider, clinic or mental health
center. Keep their telephone numbers next to your
telephone.
• Try to postpone other major life changes,
such as moving to a new home, whenever possible.
• Organize and prepare as much as you can
the night before. This will help you wake up
feeling well organized and ready to face the day.
• Allow for more time than you think you
might really need. If you add 15 or 20 minutes to
your total expected time, you will have a much
better chance of being on time.
• Never compare your baby to another baby.
Each child is unique and each grows and develops
at his/her own rate.
• Keep a sense of humor. You can not always
be responsible for the behavior of your baby. If you
laugh at embarrassing moments, most people will
laugh along with you.
• Be good to yourself by trying to meet your
needs. Treat yourself to a good book, calming bath
or new hairstyle.

• Enjoy your baby. Relax and delight in every

moment possible. Hug, kiss, cuddle, laugh with and
love your baby.
Adjusting to parenthood is a major challenge. The
role of parenting is a constant learning experience.
As you discover more about your baby, it will be
easier to settle into a routine.
Remember, you are not only adjusting to a new 24-
hour-a-day job as a parent and a changing
relationship with your partner, but you are also
recovering from giving birth. These anxious
feelings usually go away after several weeks,
especially with understanding and support from
your partner and friends, and as you watch your
baby grow and develop.
Assignment
Write about nursing management of the pregnant
woman suffering from psychiatric disease
Summary
At the end of the topic we finished with the
psychiatric disorder during pregnancy, common
psychological problem, postpartum blue, post
partum depression.
Conclusion
 At the end of the topic we can conclude that mental
health problems can complicate pregnancy . child
birth and puerperium as well no single factor has
been isolated as being responsible to cause the
condition . the root cause should elicited to prevent
its interference with attachment to the new born , &
family and so as in care of the mother her self.

Bibliography :

1. Cunningham F G. Leveno Ks. Et. Al Williams obstetrics. 22 nd ed. Toronto : M. graw hill ; 2005 P 139 –187
2. Daftary SN, chakravartis Manual’s of obstetrics.2 nd ed. Delhi : Elsevier ; 2007. P 127 –130
3. Dawn CS. Textbook of obstetrics, Neonatology and reproduvtive and child health e3ducation. 16 th ed. Kolkata ; dawn book ; 2004 P.44
4. Dutta DC. Textbook of obstetrics 6th ed. New Delhi ; Central : 2004 P. 121 – 136
5. Fraser DM. Cooper MA.Myles textbook for midwives. 14 th ed. Toronto : chunchill livingstones;2003. P. 133 – 147
6. Jain V, Gopalan S. Mudaliar and Menon’s clinical obstetrics. 10 th ed. Chennai : 2005 . P. 124 – 136

Internet sources. :

1. www. Genesismission. 4 .com /Evolution/psychiatricdisorderinpregnancy. Html

2. http ; // www. Medterms. com /script lmaun art. asp ? article key =4918.
Student reference

1. Cunningham F G. Leveno Ks. Et. Al Williams obstetrics. 22 nd ed. Toronto : M. graw hill ; 2005 P 139 –187
2. Daftary SN, chakravartis Manual’s of obstetrics.2 nd ed. Delhi : Elsevier ; 2007. P 127 – 130
3. Dawn CS. Textbook of obstetrics, Neonatology and reproduvtive and child health e3ducation. 16 th ed. Kolkata ; dawn book ; 2004 P.44
4. Dutta DC. Textbook of obstetrics 6th ed. New Delhi ; Central : 2004 P.121 –136
5. Fraser DM. Cooper MA. Myles textbook for midwives. 14 th ed. Toronto : chunchill livingstones;2003. P. 133 – 147