NSC 403: MATERNAL AND CHILD

HEALTH NURSING.
CREDIT: 4 UNITS

BY

O.ADEBIMPE FATILE MRS

 GOAL OF MCH

• GOAL OF MCH is to equip the student Midwives with knowledge, skills

and attitude that will assist them in assessing, planning, implementing
and evaluating care that will be provided during natural process of
maternity circle and child development as well as identifying any
negative influences on normal progress thus preventing or mitigating
their negative impact.
 OBJECTIVES OF MCH 1
• At the end of this course the students should have acquired sound
theoretical and practical knowledge and skills of midwifery to enable
them:

1. Describe history, scope and professional roles and ethics for nurses in
maternal and child health (MCH) nursing.

2. Discuss the mutual effect of nursing process, evidence-based practice

and nursing theory on the future of MCH nursing practice.

3. Apply concepts of family-centered care to MCH nursing.

 OBJECTIVES OF MCH 2

4. Provide comprehensive maternity care that is family-centered and goal

directed towards the total health of mother, child and the family.

5 Match knowledge of current mode of MCH with the nursing process to

achieve quality MCH nursing care.

6. Utilize critical thinking to identify areas of care that could be beneficial

from further research or application of evidence-based practice.
COURSE DESCRIPTION
• This course is designed to build knowledge, skills and positive attitude
of students to be able to provide comprehensive and integrated
sexual and reproductive care with emphasis on practical service
delivery for maternal and child health care throughout maternity
cycle within the family framework.
• The course covers the sociology and physiology of reproduction,
introduction to midwifery practice, fundamentals of midwifery
practice theories applied to midwifery practice, basic concept of
practice, quality care, applied anatomy & physiology of female
reproductive organs & associated organs as well as applied
pharmacology.
 COURSE SCHEDULE
• WEEK 1 -4: INTRODUCTION TO MATERNAL AND CHILD
HEALTH NURSING / FUNDAMENTALS OF MIDWIFERY
PRACTICE
• UNIT I: History & Ethics of Midwifery, Ethico -legal
issues / the law & the Midwife and Rules and regulations
governing Midwifery practices
• Week 5- 6- Unit II: Theories applied to Midwifery
practice
• Week 6-7- Unit III: Basic concept of practice
• Unit IV: Quality Care
 COURSE SCHEDULE
• Week 8 -9- Unit V: Applied anatomy and physiology
• 1. Anatomy & physiology of female reproductive organs
• 2. Anatomy & physiology of male reproductive organs
• 3. Associated organs of reproduction
The Female Breast
The Urinary system
COURSE SCHEDULE
• Week 10 – 11- Foetal development
• The Foetal skull
• Unit vi: Physiology
• Week 12 - Unit vii: Applied pharmacology
• Week 13- Revision
INTRODUCTION 1
• Maternal and child health (MCH)Nursing is an aspect of Nursing which
deals with the care of mother and child before birth (prenatal), during
birth (intra-natal) after birth (post-natal).

• It includes family planning service

• As well as pre-conception care i.e. adolescent reproductive health.

• It is a special area of practice that is referred to as “Midwifery”.

INTRODUCTION 2
• The course may run for a minimum of three semesters or more in
universities.
• It is designed to impart knowledge, skills and positive attitude to
students with a view to providing;
1. Comprehensive and integrated sexual and reproductive health care
• Base on practical service delivery for maternal and child health
• Throughout the maternity circle within the family framework.
 FUNDAMENTALS OF MIDWIFERY
PRACTICE
HISTORY OF MIDWIFERY 1
• Midwifery is an ancient profession, mostly practised by elderly women in the
community.
• This is evidenced archeologically by a woman who was said to have squatted
and supported by another from rear in 5000 BC.
• Traditionally, midwifery practice was not regulated.
• Practices were mainly based on oral illusion of knowledge, no written
document.
• The women were taken initiatives based on their communities inquiries (Leap
and Hunter, 1993; Marland and Rafferty, 1997 as cited by Barnawi, Richter
and Habib 2013).
HISTORY OF MIDWIFERY 2
• They played the role of primary caregivers, nutritionists and spiritual
advisors in the communities.
• The profession has gone through a lot of changes in the past centuries
• Presently, Midwifery now has regulated scope of practice.
• A Midwife is an individual who has completed a three-year basic
midwifery programme
• While a Nurse-Midwife is a professional who had a 18-months
midwifery course in addition to three-year general nursing
programme in recognised institution.
HISTORY OF MIDWIFERY 3
• History of preliminary nursing education could be traced back to
the end of 19th century in England and few of the countries of
continental Europe where nursing apprenticeship commenced
(Ajibade 2012).
• This was brought about by courageous attitude of lady Florence
Nightingale.
• Graduates of Florence Nightingale school led campaigns for
organized and formal training for nurses worldwide particularly in
the British colonies and protectorates in which Nigeria is one.
HISTORY OF MIDWIFERY 4
• Training of nurses and midwives started by 1930 in Nigeria mostly in
mission hospitals and few government hospital.
• Midwives board in Nigeria was established by the midwives ordinance
in 1930.
• First meeting of the board took place in June 1931.
• The significance of midwifery education and scientific practice in
Nigeria was underscored by the Midwives decree of 1966 (Ajibade
2012).
 SOME LANDMARKS IN HISTORY OF MIDWIFERY 1
• In 460 BC, Hippocreates father of scientific medicine trained and
supervised midwives.
• Discovered foetus’ struggling on its way out of womb during birth.
• In the 15th century, physcians made some significant discoveries and
invention that opened opportunities for technological development which
assisted in improving hospital deliveries.
• This led to decline in home deliveries by midwives who did not have
access to such technological development.
• The first book of midwifery based on Soranus teaching was printed in
Germany language. He was the first physician to specialise in Obstetrics
and Gynecology.
• The book was translated to English in 1540 and was the only book for a
century.
 SOME LANDMARKS IN HISTORY OF MIDWIFERY 2
• Ambrose Pear (1510 – 1590 AD)began modern obstetrics by performing
internal podalic version and skilfully delivered women with mal-presentations.
• He was the first to assist women in delivering in bed instead of bathing stool
and sutured lacerations.
• Established school of Midwifery in Paris and one of his students was Louis
Bourgeois who warned midwives against getting infected and transmitting
syphilis.
• In 1726, John Leake replaced obstetric stool with special delivery bed.
• Fielding Ould (1710 – 1789 AD) described mechanism of normal labour and
performed the first episiotomy.
SOME LANDMARKS IN HISTORY OF MIDWIFERY 3
• In 1818, Francois first recognised foetal heart sound in pregnant women.
• In 1862, Florence Nightingale in collaboration with Kings college hospital
started midwifery training.
• Spencer and Ballantyne promoted ante natal care (ANC) during pregnancy.
• First ANC began about the time of first world war.
• Caesarean section for obstructed labour was dated back to 715 BC
• It derived its name from a Roman law called Lex Caesarea enacted during
Caesar's reign. Also related to a Latin word “carda” that means “to cut”.
• First CS was performed by a French Obstetrician Francois Mauriocaus in 1668
 ETHICS IN MIDWIFERY 1
• Various professional groups are conferred with the responsibility to adhere
the standard of practice and conduct set by their profession.
• The primary responsibility of Midwives is to the people who are in need of
their care that is expected to be qualitative.
• To provide this, midwives are increasingly facing uncertainties causing them
to make decisions in absence of adequate evidence.
• Thus need for daily tool (like ethics) to support decision making to make
midwifery practice possible.
• ETHICS is a code of moral principles, it is a philosophy of moral behaviour
• Riddick-Thomas in Fraser and Cooper (2009) stated that ethics is often about
exploring values and beliefs and clarifying what people understand , think and
feel in a given situation.
 ETHICS IN MIDWIFERY 2
• Ethics is also described as the basic concepts and principles that guide
human beings in thought and action (Jones as cited by Riddick-Thomas in
Frazer and Cooper, 2009) .
• Ethics is expected to liberate and empower midwives to move towards
being an autonomous practitioner.
• It promotes professional growth and development.
• Ethics in midwifery focuses on how midwives (i) practice midwifery,
• (ii)Assume professional responsibilities and duties’
• (iii) Carry out their duties to assure the integrity of the midwifery
profession and
• (iv) Relates to other people.
 ETHICS IN MIDWIFERY – Framework and theories
• Exploration of ethics of any situation require having framework to work with
• There are different frameworks that have been utilised in clinical areas.
• One of them is that of Edwards (1996) who advocated for four-level system
based on Melia (1998)’s work (Riddick-Thomas in Fraser and Cooper 2009).
• Edward stated that there are four levels of moral thinking that assist in
expressing arguments and discussion which will eventually help to resolve
moral dilemmas (Riddick-Thomas in Fraser and Cooper 2009).
• These are:
• Level one Judgements
• Level two Rules
• Level three Principles
• Level four Ethical theory.
ETHICS IN MIDWIFERY: Framework and theories 2
1. JUDGEMENT:
• Base on available information on any phenomenon, people make judgement
that is usually in line with individual’s values, belief and past experience.
• This might be biased because it lacks foundation, it is an instant judgement.
• However, reflection on past judgements can be helpful if an individual can
examine such judgements retrospectively to determine whether they are
based on prejudice.
2. RULES:
Rules are to steer our practices and control our actions, they differ base on
culture and society where we live.
 ETHICS IN MIDWIFERY – Framework and theories 3
There are different forms of rules,
(i) substantive rules for phenomena like confidentiality / truth telling or privacy.

(ii) Authority rules as determined by government and enforced on the governed.

(iii) Procedural rules meant for determining a set course of action to be followed
(Beauchamp & Childress (2001) as cited by Riddick-Thomas in Fraser and Cooper
2009)

Example is Nursing and Midwifery Council of Nigeria (N&MCN) rules &

regulations.
 ETHICS IN MIDWIFERY – Framework and theories 4
• Ethical principles
There are four (4) main ethical principles that are expected to guide
professional practice and decision making. These are
• autonomy,
• non-maleficence,
• beneficence and
• justice.
These principles are germane in health care services because they enhance
advocacy which is a significant tool in caring for others.
• AUTONOMY is individual independence and capacity to make and act on
moral decision.
 ETHICS IN MIDWIFERY – Framework and theories 5
• The principle expresses the significance of respecting the patient’s right to
decide on a course of action for his or her treatment.
• The focus of modern health care is based on the professional duty of
respecting individuals’ autonomy (as practice in issue of informed consent).
• Midwives should ensure women are encouraged to exercise this right while
receiving maternity services.
• BENEFICENCE i.e. doing good, it encourages health care givers to take active
steps in helping others.
• It helps to guide one in balancing the benefits of any procedure/ action
against it’s harms.
•
ETHICS IN MIDWIFERY – Framework and theories 6
• This is sometimes difficult for health professionals in maternity services when
a client chooses an action that may not be in her best especially when
considering the effect on both mother and foetus.
• NON-MALEFICENCE: Means avoidance of harms,
Aim of this principle is to reduce harm to the barest minimum, most importantly
in this era of new and controversial technologies.
The principle wants midwives to consider risks in a procedure in relationship to
the benefit of the procedure.
• JUSTICE: Fair treatment- Health professionals are expected to be fair to
everybody regardless their race, gender, religion, status etc.
• All patients and clients should be treated equally.
 ETHICS IN MIDWIFERY – Framework and theories 7
4TH LEVEL: ETHICAL THEORIES:
body of rules, ideas, principles and techniques that are applied to a subject
especially when they are distinct from actual practice.
• There many theories that could be applied to midwifery / health care
• However, the two main ethical theories are the

1. Utilitarianism and
2. Deontology.
ETHICS IN MIDWIFERY – Framework and theories 8
Utilitarianism theory (benefits of an action and its consequences)
is based on balancing the consequences of following certain actions or
rules.
• It focuses on a very large pair of scales,
i. e with benefits of an action on one side and its consequences on the
other side.
(Riddick-Thomas in Fraser and Cooper 2009).
DEONTOLOGY THEORY refers to logic of moral obligation permissible,
right or wrong actions.
• It describes health professionals’ duties to their patients and explore their
other duties somewhere else with a view to balancing the competing
demands of the duties.
ELEMENTS OF CODE OF ETHICS 1

Relationship in midwifery, midwifery practice, The professional responsibilities of

midwives & Advancement of midwives’ knowledge and practice
• 1. Relationship in midwifery: (i) Development of a partnership with women where
both will share information that will enhance informed decision making, consent to
care plan and acceptance of responsibility for the outcomes of their choice.
• (ii) Support women/ families’ rights to active participation in making decision on
their care.
• (iii) Empowerment of women/ families in speaking for themselves on matters
affecting their health within the society / culture.
• (iv) Working together with women, policy and funding agencies to define women’s
needs for health services and means of ensuring fair allocation of resources based
on priorities and availability.
 ELEMENTS OF CODE OF ETHICS 2

(v) Midwives are to support and sustain each other in their professional roles
and be active in nurturing their own and other’s sense of self-worth.
(vi) Respecting working with other health professionals, consulting and
referring women’s health needs for further care where such needs are beyond
the midwives’ expertise.
(vii) Midwives are to recognise the human interdependences within the field
of practice and actively strive in resolving inherent conflicts.
(viii) Midwives are accountable to themselves as persons of moral worth as
well as duties of moral self-respect and maintenance of integrity.
 ELEMENTS OF CODE OF ETHICS 3

2. Midwifery practice
• (a) Provision of care for women and their families with respect for cultural diversity as
well as ensuring elimination of harmful practices within those cultures.
• (b) Encouragement of realistic expectations of childbirth from women within their
communities, with the minimum expectation of harmless conception or childbearing.
• (c) Utilisation of recent evidence-based professional knowledge to provide safe
midwifery services in all communities and culture.
• (d) Prompt response to psychological, physical, emotional and spiritual needs of women
seeking health care at any situation.
• (e) Acting as desired role model of health promotion for women, families and other
health professionals.
• (f) Actively seeking for personal, intellectual and professional growth and fitting such
growth into their practice throughout their midwifery career.
 ELEMENTS OF CODE OF ETHICS 4
3. The professional responsibilities of midwives
• (a) Midwives are expected keep clients’ information in confidence so as to
protect their right to privacy and share such information only when mandated
by law.
• Midwives are responsible for their decisions and actions and accountable for
the related outcomes while caring for their clients.
• Midwives may not participate in any activities that are against their moral
values, however, they should ensure such value will not prevent women from
having essential health care.
• Midwives are expected to comprehend and ensure elimination of harmful
effects of violation of ethical and human rights on the health of women and
infants.
• Midwives are to take part in the development and implementation of health
policies that promote the health of women and children.
ELEMENTS OF CODE OF ETHICS 5
• 4. Advancement of midwives’ knowledge and practice
• Development and sharing of midwifery knowledge through processes
such as peer review and research.
• Participation in the formal education of student midwives and
development of continue education.
• Ensuring that the advancement of midwifery is based on activities that
protect the human rights of women.
ETHICO- LEGAL ISSUES
• THE LAW AND THE MIDWIFE
• MIDWIFE – means “with woman” or wise woman as described in France
(Riddick-Thomas in Fraser and Cooper 2009).
• International confederation of Midwives in 2005 defined a midwife as “ a
person who, having regularly admitted to a midwifery educational
programme, duly recognised in the country in which it is located, has
successfully completed prescribed course of studies in midwifery and has
acquired the requisites qualifications to be registered and /or legally
licenced to practice midwifery”
THE LAW AND THE MIDWIFE - ICM 2005 1

• The midwife is recognised as a responsible and accountable professional who

works with women, gives necessary supports, cares and advices during pregnancy,
labour and post partum period, conducts births on his or her responsibility and
provides care for the newborn and the infants.
• Such care include preventive measures and promotion of normal birth, detection
of complications in mother and child, accessing of medical care or other assistance
and carrying out of emergency measures.
Other important roles of midwives are;
1. Health counselling and education for the women, family and the community.
2. Ante-natal education and preparation for parenthood.
THE LAW AND THE MIDWIFE - ICM 2005 2

3. Women’s health
4. Sexual or reproductive health
5. Child care.
6. Midwives can practice in many settings including hospital, clinics, home and
community.
7. She is expected to have attended two refresher courses within three years of
practice as pre-requisite for renew of license.
8. Education and training
• The law permits a midwife to establish a school under the authority of Nursing
and Midwifery Council of Nigeria.
THE LAW AND THE MIDWIFE - ICM 2005 2
9. Assignment / delegation of duties to others.
•The law frowns at midwife delegating midwifery duty to a non midwife.
•She is expected to be responsible for all her actions.
FUNCTIONS OF MIDWIFERY LAW

• It provides framework for midwifery practice

• It distinguishes the nurse midwives from other health workers.
• It enhances maintenance of standard of nurses and midwives
• It institutes boundary of independent nursing action.
LEGAL PRECAUTIONS FOR MIDWIVES

• Midwives should be knowledgeable, skillful, confident and accept responsibility

in their practice.
• They must communicate with their clients effectively when carrying out
procedures.
• They must take informed consent from their clients before embarking on any
procedure.
• They should be able to provide appropriate alternative if clients refuse treatment.
 FELONY RELATED CASES (CRIMES PUNISHABLE BY LAW)
Nurses can be prosecuted for various crimes committed on the job.
• some nursing-related crimes, including felonies such as murder,
• misdemeanors like stealing
• misuse of resources,
unintentional acts that may be treated as crimes of medical negligence. Updated:
11/02/2021
Felonies include crimes involving serious bodily harm or violence, though not all felonies are
violent.
• Felonies are punishable by a year or more in prison, with some even eligible for the death
penalty in those states that allow capital punishment.
• Nurses who commit felonies are typically no different than other felons—except that they
target patients.
• Their reasons for committing crimes are complicated and varying.
• However, the majority of the nursing cases take place in hospitals and nursing homes, where
victims are accessible and defenseless.
Stealing can be a misdemeanor offense, meaning a less serious crime than a
felony,
depending on the jurisdiction and the value or quantity of the item stolen.
• Nurses steal drugs for a variety of reasons. Some have addiction problems, such
as an addiction to prescription pain medication.
• Others sell the drugs for a profit. A small percentage of nurses, use stolen drugs
to harm others.
• Access to drugs, syringes, and other medical equipment can be troublesome for
healthcare providers.
• Hospitals, pharmacies, and care facilities have increased security in recent years
to prevent the theft and misuse of drugs and other medical equipment.
Medical Negligence
• However, nurses don't have to intentionally commit a crime in order to end up
in criminal trouble.
• Prosecutions for medical negligence are increasingly common. Criminal
medical negligence requires that the nurse:
• Committed a ''gross or flagrant deviation from the standard of care,‘’
what would have been expected from a similarly skilled nurse performing in a
similar situation, and Negligent nursing errors can result in criminal charges
for assault,
FELONY RELATED CASES
Midwife Convicted on Felony Charges After Failed Home Birth
• An unlicensed North Carolina midwife entered a guilty plea to charges filed as a result of
a failed home birth for which she worked as a midwife in July 2012. The woman, who
was initially charged with
1. murder of an unborn child,
2. assault inflicting serious bodily injury,
3. obtaining property by false pretense,
4. obstruction of justice,
She filed in a guilty plea later to reduce charges of obstruction of justice and
unauthorized practice of midwifery.
• According to news and as a result of the controversial plea agreement.
The murder and other charges were dismissed,
leaving the deceased child’s parents angered and upset by the proceedings,
although they did know the woman was not licensed when they agreed to her services.
The charges were filed based on the woman’s involvement in a home birth in
Asheville, in which she acted as a midwife. the child was brought to a hospital
four days after Delivery.
1. she was pronounced dead as a result of prolonged rupture of membranes with
acute chorioamnionitis and meconium aspiration,
which occur when a fetus breathed in fluid during delivery.
2. The woman allegedly told the mother the birth had gone well and to disregard
the symptoms of meconium aspiration.
3. The woman was not licensed to practice midwifery in that state
4. she did attended a non-accredited midwifery school,
5. The mother was aware that she was not using a state licensed and certified
midwife.
• The Standard of Care for Home Births Remains High

• North Carolina, as well as Maryland and other states, has laws requiring midwives to
obtain a license to legally attend to births in the state.
• The license requires midwives to be registered nurses certified in midwifery and to
hold a national certification.
• Midwives who attend to home births have a legal duty to provide care that meets or
exceeds the professional standard, and this includes a duty to address possible
complications and know when to seek emergency help.
• If a licensed midwife is negligent or reckless and violates the professional standard of
care, and a baby is injured or killed as a result, the victims of the negligence can seek
damages through a birth injury or medical malpractice lawsuit and hold the
responsible parties accountable for their loss
• . Midwives, as well as doctors and nurses, can be held accountable for medical
negligence and birth injuries. Whether a birth is performed at home or in a hospital,
• The parents and baby have the right to be cared for competently.
Good Samaritan Law
A law that provides protection against claims of malpractice for medical practitioners
who render emergency care at the scene of an accident
• except when gross negligence or willful misconduct can be proved
• . Most states have passed such laws; all the laws cover doctors, and about half the laws
cover nurses.
• The term “good Samaritan” comes from the biblical parable of a traveler who was robbed,
beaten, and left on the side of the road to die. While others passed by, a man from Samaria
stopped to help him. He applied ancient “first aid” and brought him to a place to heal,
covering all expenses.
• In modern language, a good Samaritan is “
anyone who renders aid in an emergency to an injured or ill person.” If the person
experiences further injury as a result of the aid being rendered, the state’s Good Samaritan
law often protects the helper from liability.
• Good Samaritan laws vary from state to state, but common features include:
• Consent: A person must consent to receiving a rescuer’s help.
• Implied consent: If the person is unconscious or incapable of making decisions on their own
behalf, rescuers may act as if consent has been given.
•Reasonable level of care: If a rescuer believes an action should be taken that is
outside their scope of practice (such as emergency surgery), they should not perform that
action.
•Compensation: Services provided by a rescuer must be completely voluntary. The good
Samaritan may not require or accept compensation.
•Good Samaritan laws may differ in certain aspects, including the following areas:
•Untrained care attempt: If a rescuer provides medical aid without official training to do so
(for example, a lay person performing CPR without certification), the rescuer may be liable
for damages that occur.
Medical Professionals: Physicians, nurses, firefighters, and EMTs are protected in most states
by Good Samaritan laws. In other states, they may be liable because of their profession.
•Imminent Peril: In some states, if a rescuer provides unnecessary aid that results in the
further injury of a victim, the rescuer may be liable. For example, if a victim is trapped in a
vehicle, they are not in imminent peril unless other factors further endanger them, like a fire.
In this case, removing the person is not necessary and could result in further injury.
Discharge against medical advice (DAMA)

• is defined as when a patient chooses to leave a hospital before the healthcare team
recommends discharge from the hospital
• . With a significant and increasing prevalence of up to 1–2% of all hospital admissions, leaving
against medical advice (AMA) affects both the patient and the healthcare provider .
• This action leaves the patient with inadequately treated medical problems and increased risk
for readmissions
• . Even though no hospital is willing to allow DAMA due to its adverse consequences, this issue
has become one of the most common problems in our current healthcare system.
• Choi et al., in a retrospective matched cohort study of 656 patients, found that the risk of
readmission was 12 times more in patients who leave ,
• the increased mortality and rate of readmission to hospitals certainly impose an economic
burden
• This problem affects both patients and physicians, but there may be solutions to this
prevalent issue.
 Common hospital practice for an AMA discharge involves the patient
being asked
• to sign a form stating that they are aware that they are leaving the facility
AMA,
• the hospital is generally not legally required to use it.[5]
• Rather, the legal and ethical requirement is that the authorized health care
professional has an informed consent discussion with the patient regarding
their choice to leave the hospital before it has been recommended.
• This discussion which includes disclosure of the risks, benefits, and
alternatives to hospitalization, as well as the patient's understanding,
should be documented in the patient's chart
• . Many physicians incorrectly believe that insurance denies payment for
the hospitalization of patients leaving AMA, leaving such patients
financially responsible
ASSIGNMENT

• Rules and regulations governing midwifery practice

• Norms and standard of practice
• Midwife’s legal coverage
• Nursing & Midwifery Council decree
• Inter-sectoral and inter-professional relationship to midwifery
• The role of national & international organizations in midwifery practice.

SPECIAL ASSIGNMENT
• ETHICO LEGAL ASPECT OF HIV/AIDS AND PLWH/AIDS
THEORIES APPLIED TO MIDWIFERY PRACTICE

• THE SELF-CARE MODEL

• Dorothea Orem (1980) developed self-care model to describe nursing as
related to concept of self-care.
• Orem was a popular nurse theorist from USA, her theory is recognized as a
valid description of nursing anywhere.
• Orem’s general theory of self-care deficit nursing delineates when patients
are unable to care for themselves, even with the assistance of family
members.
• When the patient or family members are unable to provide the necessary
care, there is a self-care demand that can be met by a nurse.
 THE SELF-CARE MODEL

• The general theory is composed of three interrelated theories: the theory of

self-care, the theory of self-care deficit, and the theory of nursing systems.
• The theory of self-care explains why people care for themselves.
• The theory includes the concepts of self-care agency, basic conditioning
factors, and therapeutic self-care demand.
• Self-care requisites are also incorporated into the theory and provide the
basis for undertaking self-care.
The three classifications of requisites are:
1. Universal selfcare requisites or activities of daily living, such as eating,
resting, sleeping, and social interaction.
2. developmental requisites associated with adjusting to events, such as
attending college, getting a job, marriage, and old age.
 THE SELF-CARE MODEL

3. health deviation requisites, such as trauma, surgical interventions, and the need
for crutches after fracturing a leg.
• The theory of self-care deficit describes and explains when people need nursing
care.
• Orem specifies five methods that nurses use to help meet the self-care needs of
the patient:
a) acting for or doing for another (relates to the three requites mentioned)
b) guiding and directing
c) providing physical or psychological support
d) providing and maintaining an environment that supports personal development
e) teaching.
 Neuman’s system model
• Neuman’s system model (1980):- This model is philosophically consistent with
the perspectives of family system approach and can be largely modified to include
the family as client.
• Members of the family influence themselves in their interactive behaviours thus
creating basic structure of the family.
• All interactions within the structure targeted towards keeping the structure stable
as it moves between stability (wellness) to instability (illness).
• The main goal of the nurse is to assist the family system to get stabilized within its
environment. Neuman’s 1980’s model offers an interdisciplinary approach and
pulls together the goals and emphases many disciplines concerned with health
care.
• It stresses the complementary work of nurses and doctors within the society, it
also encourages nurses to broaden their input rather than restricting it.
Neuman’s system model
• Basic survival factors identified by Neuman are physiological, anatomical and
genetic feature
• Basic core structure:- person’s energy resource if compromised leads the
individuals to risk, core is made up of basic survival factors.
• The range of unique variables within the common care giving individual his/her
baseline.
• For instance it is basic that each person require sufficient pressure to circulate
blood, the actual degree of pressure may vary from person to person.
• Lines of resistance protect the core structure to make it stable. The lines may be
immune system coping behaviours or physiological mechanisms.
•
 Neuman’s system model

• They can also vary from person to person depending on stage of development, life
style & past experience. They are to help and maintain internal & external factors
in their environment.
• The totality of lines of resistance forms and individuals normal line of defense
which is relatively stable. It is developed over a period of time.
• Partly through the responses or previous experienced adaptation e.g. previous
measles attack VS present attack
• The flexible line of defence likened to accordion, vary from day to day and can be
affected by things like amount of rest, the nutritional state or number of
interactions that are occurring at a particular point in time e.g. association between
stressful life events e.g. divorce, change of job & physical illness or a late night
leading to less tolerant behavior the following day.
Neuman’s system model

• Variables arising from physiological, psychology, socio cultural & developmental

sources can affect the line of defense.
• Each person is subject to stressors throughout life and these are seen as stimuli
that produce tension within the system. This can cause disequilibrium or
disturbance in the harmony of the individuals & they require response
• The line of defence responds to the stressors to prevent them from reaching the
central energy resource. If this is impinged upon, life is threatened
• Stressors can be intra personal, inter personal & extra personal.
IMOGENE KING'S GOAL ATTAINMENT THEORY
• King first published her conceptual framework in 1971 and further developed it
into the theory of goal attainment in 1981 King’s open system model (1981)
• King’s systems framework is based on the assumption that human beings are the
focus of nursing.
• The goal of nursing is health: its promotion, maintenance, and/or restoration; the
care of the sick or injured; and the care of the dying (King 1992).
• King’s theory evolved from the General Systems Theory of Von Bertalanffly.
• The components of a system theory are:
• (a) goal; (b) structure; (c) functions; (d) resources; and (e) decision making’
IMOGENE KING'S GOAL ATTAINMENT THEORY

• King (1996) further stated that the ‘nursing domain involves human beings,
families, and communities as a framework within which nurses make transactions
in multiple environments with health as a goal’ (Norris and Frey 2001).
MASLOW’S HIERARCHY OF NEEDS

• Abraham Maslow developed a theory of behavioral motivation based on needs.

• There are five levels in this hierarchy in which the first which is the basic
physiological need must be met to maintain life.
• The rest of the needs are related to quality of life and they are safety and security,
love and belonging, self-esteem, and selfactualization.
• The needs of the lower levels must be met before a person is motivated to meet the
needs of the next higher level.
• Many nursing programs use Maslow’s Hierarchy of Needs as a basis for planning
the care of clients.
• This ensures that basic physiological needs as well as the other needs are assessed
and addressed in individualized care plans.
MASLOW’S HIERARCHY OF NEEDS

Physiological Needs
• Are generally accepted to be the needs for oxygen, water, food, elimination,
rest /sleep, activity (exercise), and sex.
• With the exception of sex, all of these needs must be met for the life of the
individual to be maintained.
Safety and Security Needs
• Encompasses the needs for shelter, stability, security, physical safety, and freedom
from undue anxiety.
• Safety needs include both physical and emotional aspects.
• Illness is often a threat to safety because the stability of life is disrupted.
MASLOW’S HIERARCHY OF NEEDS

Love and Belonging Needs (Social)

• This third level of the hierarchy incorporates not only giving but also receiving
affection.
• Having friends and participating with others in groups and organizations are two
ways to meet these needs.
• Meeting these needs is extremely important for mental health.
Self-esteem Needs
• The needs of the self-esteem level are met by achieving success in work and other
activities.
• Recognition from others increases self-esteem and feelings of pride in one’s
accomplishments.
MASLOW’S HIERARCHY OF NEEDS

• SELF-ACTUALIZATION NEEDS
• Self-actualization is the highest level of the Maslow hierarchy.
• A person who has met these needs is confident, self-fulfilled, and creative; looks
for challenges; and sees beauty and order in the world.
QUALITY CARE-
DEFINITION AND ELEMENTS OF QUALITY MIDWIFERY
PRACTICE.
Background
• The medical science and technology has rapidly advanced,
• The healthcare delivery system has been struggling in its ability to provide
consistently high quality care to all.

• Implication of this is that advanced know-how and increased resources in

themselves, will not translate into the high quality of health care which
populations and individuals rightly expect.

• Organization of the delivery of care has become very important.

QUALITY CARE- DEFINITION AND ELEMENTS OF QUALITY
MIDWIFERY PRACTICE.
• Health expenditure in advanced countries has doubled in the last 30 years (WHO
2006).

• However, the highest-spending countries are not always those with the best results
(WHO 2006).
• One reason is the fragmentation of their health care delivery systems.

• The midwife is central to high quality maternity care, and

• the principle that ‘all women need a midwife and some need a doctor too should
be widely accepted in our country.
QUALITY CARE- DEFINITION AND ELEMENTS OF QUALITY
MIDWIFERY PRACTICE.
• Quality simply means degree of excellence.
• It is a distinguishing attribute.
• It is described as a general term applicable to any trait or characteristic.
• Quality is described as the totality of features or characteristics of a product or
service that bears on its ability to satisfy a given needs
• It is used to describe a good or service that satisfies customer.
• Quality of care is 'the extent to which health care services provided to
individuals and patient populations improve desired health outcomes (WHO
2006).'
ELEMENTS OF QUALITY
Shaw (1998) identified the following as elements of quality:
• 1. Appropriateness
• 2. Equity
• 3. Accessibility
• 4. Effectiveness
• 5. Acceptability
• 6. Efficiency
HIGH QUALITY MATERNITY CARE

• The Royal College of Midwives (2014) stated that;

• High quality maternity services must produce a healthy mother, healthy baby
and family integrity.
• High quality care should be safe, effective, woman-centred, timely and
equitable.
• It should also be evidence-based and delivered as close as possible to the
communities where women live or work.
• It should continue to be free and accessible to everyone at the pointo need.
QUALITY ASSURANCE

• This a process in which the achievable and desirable levels of quality are
described, the extent to which these levels are achieved is measured and actions
that will enable the level to be reached are taken.
• It is a way of preventing mistakes or defects in manufactured products and
avoiding problems when delivering solutions or services to customers.
• It is part of quality management focused on providing confidence that quality
requirements will be fulfilled.
• QA is an assessment of the effectiveness of health care provision,
• It is the efforts made to improve care through monitoring of the care and the desire
to ensure quality care is maintained.
GOALS OF QUALITY ASSURANCE
• To ensure evidence based nursing care and accountability of services rendered in
compliance with standards of practice.
• To have a defined mechanism for identification, measurement, and resolving
clinical issues related to practice.
• To produce a defined mechanism for collection of data, evaluation of quality
indicators and development of corrective action and assessment of outcomes.
COMPONENTS OF QUALITY ASSURANCE PLAN
• A quality assurance plan contains the foundation and framework of all control
activities, these include;
• 1. Clearly stated goals.
• 2. Measurable objectives.
• 3. Designated accountability for the objectives
• 4. methods of quality assurance activities
• 5. Stated responsibilities for conducting QA activities.
• 6. Mechanism of data reporting
• 7. Mechanism of corrective actions
• 8. Clear statement of confidentiality.
COMPONENTS OF QUALITY ASSURANCE PLAN 2
• Quality assurance comprises administrative and procedural activities implemented
in quality system so that requirements and goals for a product, service or activity
will be fulfilled (Quality Assurance vs Quality control- Learning Resources in
Wikipedia 2018).
• QA operates on two principles:
• 1. Fit for purpose- the product or service should be suitable for the intended
purpose.
• 2. Right first time – elimination of mistakes.
COMPONENTS OF QA ACTIVITIES

• WHO (1983) in the document on principles of QA identified four components that

must be addressed in QA activities. These include;
• Performance i.e. technical quality
• Resources use – efficiency
• Risk management – identification and avoidance of injury or illness associated
with service provided.
• Patient satisfaction with the services provided.
APPROACHES TO QUALITY CARE 1
• Taylor, Lillis, LeMone and Lynn (2011) identified two approaches to ensuring
quality, these are “quality by inspection” and “quality as opportunity”.
• Quality by inspection is monitoring of workers to identify those who are
deficient with the aim of removing them.
• Workers and nurses who are in the setting where this approach is used are always
afraid to accept making errors and attempt to hide such error.
• This type of behavior is unacceptable and the outcome on patients are usually
fatal.
APPROACHES TO QUALITY CARE 2
• Quality as opportunity focuses on looking for opportunities to improve
services rendered and fosters on environment that supports teamwork.
• Workers/ nurses in this setting share skills and experiences.
• Mistakes made are not viewed as results of lack of motivation or effort by workers
but as a problem in the setting.
• Nurses in this setting are open and desire to learn because they are assured of
integrity and self-worth.
• Desire of nurses is to work in an environment in which quality measurements
encourage our best efforts.
MEASUREMENT OF QUALITY CARE- MODEL OF QUALITY-
ASSURANCE PROGRAMME
• In 1975, American Nurses Association (ANA) developed a seven-step model of
quality-assurance programme.
• Step 1 – Identification of values
• 2 – Identification of structure, process and outcome standards
and criteria
• 3 – Measurement of degree of attainment of criteria and
standards
• 4 – Making interpretations about strengths and weaknesses
based on such measurements.
• 5- Identification of possible courses of action
MODEL OF QUALITY-ASSURANCE PROGRAMME
• Step 6- Choosing of a course of action
• 7 – Taking action.
• The ANA model focuses on three essential components of quality care i. e.
structure, process and outcome.
• STRUCTURE – Structure evaluation or auditing looks at the environment in
which care is rendered.
Standards usually describe physical facilities and equipment,
organizational characteristics, policies and procedures fiscal and
personnel resources.
MODEL OF QUALITY-ASSURANCE PROGRAMME
• PROCESS – Process evaluation focuses on nature and sequence of activities
carried out by nurses implementing nursing process.
• Criteria would have explicitly described acceptable levels of
performance for nursing actions related to patient assessment, diagnosis ,
planning, implementation and evaluation.
• OUTCOME – Outcome evaluation is on measurable changes in the health status
of the patients or the end results of nursing care.
• Even though ideal environment and right nursing care are vital parts of quality
care, the critical element in evaluating care is demonstrable positive changes in
patient health status.
QUALITY IMPROVEMENT/ CONTINOUS QUALITY
IMPROVEMENT (CQI)/ TOTAL QUALITY MANAGEMENT
(TQM)

• Schroeder 1994 in Taylor et al (2011) defined QI/CQI/TQM as commitment and

approach used to continuously improve every process in every part of
organization, with the intent of meeting and exceeding the consumers’
expectations and outcomes.
• QI is usually internally driven, focuses on patient care rather than organizational
structure, focuses on processes rather than individuals and it is endless.
• It’s goal is to improve quality rather than assuring quality.
MAJOR PREMISES OF QI

• Focus on organizational structure

• Continuous improvement
• Leadership commitment
• Empowerment
• Collaboration / crossing boundaries
• Focus on process
• Focus on data and statistical thinking (Schroeder 1994 in Taylor et al, 2011).
• One of the most important outcomes of QI is recognition of patients’ satisfaction
as significant in health care services.
FACTORS INFLUENCING QUALITY MANAGEMENT

• Good organizational structure / function

• Good quality staff
• Continuing professional development
• Continuing structure/functional performance evaluation.
• Learning from failures and moving from low quality to high quality organization.
READING MATERIALS
• Fraser D. M. and Cooper M. A. Myles Textbook for midwives Churchill
Livingstone Elsevier Limited. Fifteenth edition
• Arenson J. and Drake P. Maternal and new born health. Jones and Bartlett
publishers Canada (current edition).
• Ojo and Briggs. Textbook for Midwives. Current edition
• Da Cruz V. and Adams M. Bailliere’s Midwives dictionary English language book
society and Bailliere Tindall London. Current edition.
HIGH QUALITY MATERNITY CARE

• The Royal College of Midwives (2014) stated that;

• High quality maternity services must produce a healthy mother, healthy baby and
family integrity.
• High quality care should be safe, effective, woman-centred, timely and equitable.
• It should also be evidence-based and delivered as close as possible to the
communities where women live or work.
• It should continue to be free and accessible to everyone at the point
• of need.
• NOTE: Download & read High quality midwifery care by This Royal of
Midwives 2014
BASIC CONCEPT OF PRACTICE

• BASIC CONCEPT OF PRACTICE – Nursing process, Primary health care,

Health illness continuum, Stress and crisis, Problem solving process.

• PROBLEM SOLVING PROCESS- Systematic identification of a problem,

determination of goals relating to the problem, identification and possible
approaches to achieve these goals, implementation of selected approaches and
evaluation of goal achievement (Burns and Groove).
STANDARDS OF CARE

• Standards are an agreed way of doing things; whether making or supplying

something, managing a process, or delivering a service, to make lives easier and
safer.

• Garner (2006) in Potter, Perry, Stockert & Hall (2011) defined standards of care
as legal guidelines for minimally safe and adequate nursing practice.

• Written policies and procedures of the nurse’s health care facility are specific
guidelines and directions for nursing care and are usually found in policy and
procedure manual of nursing department/unit.

• It is the responsibility of an employee to know this as it is the standard of care to

References
1. Ajibade B. L. 2012. A paper presented at the 6th biennial and 5th quadrennial delegate
conference of the National association of Nigeria Nurses and Midwives (NANNM) on
November 12, 2012 at Grayland cultural centre Yenogoa Bayelsa state.
2. Barnawi N., Richter S. and Habib F. 2013. Midwifery and Midwives: A historical Analysis.
Journal of research in Nursing and Midwifery. Vol. 2(8) pp. 114 – 121
3. Makinde O. Y., Oyadiran G. O. G. and Adeyemo M. O. A. 2013. Lecture notes on maternal
and child health nursing, module one, Dept of Nursing LAUTECH CHS, Isale Osun
Osogbo campus. Pp 1-7
4. Oyetunde M. O. and Nkwonta C. A. 2014. Quality issues in midwifery: A critical analysis
of midwifery in Nigeria within the context of the International of Midwives (ICM) global
standards. International journal of Nursing and Midwifery Vol. 6(3) pp 40 – 48.
5. Potter P. A, Perry A. G., Stockert P. A. & Hall A. Basic Nursing. Mosby Elsevier USA
Seventh edition 2011
6. Taylor C. R., Lillis C., LeMone P. and Lynn P. Fundamentals of Nursing – The art and
science of nursing care 7th edition 2011, Wolters Kluwer/ Lippcott Williams & Wilkins
 ANATOMY OF FEMALE PELVIS AND THE FETAL SKULL
Learning Objectives
At the end of this chapter the students will be able to:
- Describe anatomy of the Female pelvis and Female
external genitalia
- Mention parts of fetal skull with its features.
- Differntiat organs contained in the pelivic cavity.
- Describe characteristic of menustral cycle and its disorder
- List anatomy of female breast
- Define puberity and its featuers.
Female Pelvic Bones
• The female pelvis is structurally
adapted for child beaing and
delivery.
There are four pelvic bones
• - innominate or hip bones
• - Sacrum
• - Coccyx
A. Innominate bones
• Each innominate bone is composed of three parts.
• 1. The ilium the large flared out part
• 2. The ischium the thick lower part.
It has a large prominance known as the ischial tuberosity on which the body rests when sitting.
Behind and a little above the tuberosity is an inward projection, the ischial spine.
In labour the station of the fetal head is estimated in relation to ischial spines.
3. The pubis - The pubic bone forms the anterior part.
• The space enclosed by the body of the pubic bone the
• rami and the ischium is called the obturator foramen.

B. The sacrum - awedge shaped bone consisting of five fused vertebrae. The upper border of the
first sacral vertebra is known as the sacral promontary. The anterior surface of the sacrum is
concave and is referred to as the hallow of the sacrum.

C. The Coccyx: - is avestigial tail. It consists of four fused vertebrae forming a small triangular
Pelvic Joints
There are four pelvic joints
• - One Symphysis pubis
• - Two Sacro illiac joint
• - One Sacro coccygeal joint
• - The symphysis pubis is a cartilgeous joint formed by junction of the two pubic
bones along the midline. ƒ
• The sacro iliac joints are the strongest joints in the body.
- The sacro coccygeal joint is formed where the base of the coccyx articulates
with the tip of the sacrum.
In non pregnant state there is very little movement in these joints but during
pregnancy endocrine activity causes the ligaments to soften which allows the
joints to give & provide more room for the fetal head as it passes through the
pelvis.
• Each of the pelvic joints is
held together by ligaments
• - Interpubic ligaments at the
symphysis pubis (1)
• Sacro iliac ligaments (2)
• - Sacro coccygeal ligaments(1)
• - Sacro tuberous ligament (2)
• - Sacro spinous ligament (2)
The false pelvis is formed by the iliac
portions of the innominate bones and is
limited above by the iliac crests. It has got
little obstetric significance except that its
measurements can to a certain extent,
predict the size and configuration of the
true pelvis. Its only obstetric function is to
support the enlarged uterus during
pregnancy. Its boundaries are: posteriorly
—
lumbar vertebrae, laterally—iliac fossa and
anteriorly—anterior abdominal wall.
The True Pelvis

The true pelvis is the bony canal through which the fetus must
pass during birth. It has a brim, mid cavity and an out let. The
pelvic brim is rounded except where the sacral promontory
projects into it. The pelvic cavity is extends from the brim
above to the out let below. The pelvic out let are two and
described as the anatomical and the obstetrical. The
anatomical out let is formed by the lower borders of each of
the bones together with the sacrotuberous ligament. It is diamond in
shape.
The obstretrical out let is of the space between the narrow pelvic strait and
the anatomical outlet.
Important land marks of female pelvis
A. Pelvic brim
- Sacral promentary posteriorly
- Superior ramus of the pubic bone antro lateral
- Upper inner boarder of the body of the pubic bone
- Upper inner boarder of the symphysis pubis anteriorly
B. Mid pelvis
- Ischial spine
C. Out let - Inferior pubic rami antero laterally
- Sacrotuberous ligament postro laterally
- Ischial tuberosity laterally
- Inferior border of symphsis pubis anteriorly.
- Tip of coccyx
Important diameters of the pelvis Inlet
Diagonal conjugate - a line from the sacral promontory
toward the lower boarder of the symphysis pubis and
measures 12.5 centimeter. It is measured by pelvic
examination.
Mid cavity
Interspinous diameter-a line between the two ischial spines
and measures 11 centimeter.
The pelvic out let
- Pubic arch
- Intertuberous diameter
PHYSIOLOGICAL ENLARGEMENT OF PELVIS DURING PREGNANCY AND LABOR

• Imaging studies show an increase in width and mobility of the symphysis pubis
during pregnancy which returns to normal following delivery.
• The pubic bones may separate by 5–10 mm. Similar changes also occur in
sacroiliac joints.
• There is gliding movement of the symphysis pubis near term. Relaxation of the
pelvic joints is due to progesterone and relaxin.
• There is increase of the anteroposterior diameter of the inlet during labor by the
rotatory movement of the sacroiliac joints.
• In dorsal lithotomy position, the anteroposterior diameter of the outlet may be
increased to 1.5–2 cm.
• Furthermore, the coccyx is pushed back while the head descends down to the
perineum.
 Measurements of the pelvic canal in centimeters
Anteropstrior Oblique Transverse

BRIM 11 12 13

CAVITY 12 12 12

OUT LET 13 12 11

The four types of female pelvis

• 1. The gynacoid pelvis (female type)
• 2. The android pelvis (male type)
• 3. The anthropoid pelvis
• 4 The platypelloid pelvis
Features Gaynacoid Android Antropald Platypelloid
Brim Round Heart Shaped Long Oval Kidney Shaped
Fore - Pelvis Genrous Narrow Narrowed Wide
Side Walls Straight Convergent Divergent Divergent
Isctial Spines Blunt Prominent Blunt Blunt
Sciatic Notch Rounded Narrow Wide Wide
Sub - Pubic Angle 90° < 90° > 90° < 90°
Incidence 50 % 20 % 25% 5%
Pelvic floor Or Pelvic diaphragm
• The pelvic floor or diaphragm is amuscular floor that demarcates the pelvic cavity and
perineum. Its strength is inforced by its associated condesed pelvic fascia, therefore,
it is important for pelvic organs protection.
Functions: -
• It supports the weight of the abdominal and pelvic organs
• The muscles are responssible for the voluntary control of micturation, defication and
play an important part in sexual intercourse.
• It infulences the passive movement of the fetus through the birth canal and relaxes to
allow its exit from the pelvis
• The main important muscels of pelivic floor are:
• Levater ani muscles arising from the lateral pelvic wall and decussate in the midline
between the urethra, the Vagina and rectum.
It contains pubococcygeous muscle, ileo coccygeus and pubo rectalis. Pubococygeous
muscle is constructed in such away that it can expand enough for child bith and
contract the pelvis supported
PELVIC FLOOR
(Synonym: Pelvic
diaphragm
PELVIC FLOOR(Synonym: Pelvic diaphragm)
Pelvic floor is a muscular partition which separates the pelvic cavity from the anatomical
perineum. It consists of three sets of muscles on eitherside—
1. pubococcygeus,
2. iliococcygeus and
3. ischiococcygeus collectively called levator ani.
Its upper surface is concave and slopes downwards, backwards and medially and is
covered by parietal layer of pelvicfascia. The inferior surface is convex and iscovered by
anal fascia.
T he muscle with the covering fascia is called the pelvic diaphragm.
ORIGIN: Each levator ani arises from the back of the pubic rami, from the condensed
fascia covering the obturator internus (white line) and from the inner surface of the
ischial spine.
INSERTION: From this extensive origin, the fibers pass, backwards and medially to be
inserted in the midline from before backwards to the vagina (lateral and posterior walls),
perineal body and anococcygeal raphe, lateral borders of the coccyx and lower part of
the sacrum (Fig. 1.10).
STRUCTURES IN RELATION TO PELVIC FLOOR
(1) P elvic organs from anterior to posterior are bladder, vagina, uterus and rectum. (2) P elvic
cellular tissues between the pelvic peritoneum and upper surface of the levator ani which fill
all the available spaces. (3) U reter lies on the floor in relation to the lateral vaginal fornix. The
uterine artery lies above and the vaginal artery lies below it. (4) P elvic nerves.
NERVE SUPPLY: It is supplied by the 4th sacral nerve, inferior rectal nerve and a perineal branch
of pudendal nerve S2,3
FUNCTIONS:
(1) To support the pelvic organs—The pubovaginalis which forms a “U” shaped sling, supports
the vagina which in turn supports the other pelvic organs— bladder and uterus. Weakness or
tear of this sling during parturition is responsible for prolapse of the organs concerned.
(2) To maintain intra abdominal pressure by reflexly responding to its changes.
(3)Facilitates anterior internal rotation of the presenting part when it presses on the
pelvicfloor.
(4)Puborectalisplaysanancillaryroletotheaction of the external anal sphincter.
(5) Ischiococcygeus helps to stabilize the sacroiliac and sacrococcygeal joints.
(6) To steady the perineal body.
PELVIC FLOOR DURING PREGNANCY AND PARTURITION:
• During pregnancy levator muscles undergo hypertrophy, become less rigid
and more distensible. Due to water retention, it swells up and sags down. In
the second stage, the pubovaginalis and puborectalis relax and the levator
ani is drawn up over the advancing presenting part in the second stage.
Failure of the levator ani to relax at the crucial moment may lead to
extensive damage of the pelvic structures. The effect of such a displacement
is to elongate the birth canal which is composed solely of soft parts below
the bony outlet. The soft canal has got deep lateral and posterior walls and
its axis is in continuation with the axis of the bony pelvis.
1. NATOMICAL PERINEUM:
• Anatomically, the perineum is bounded above by the inferior surface of the pelvic
floor, below by the skin between the buttocks and thighs. L aterally, it is bounded
by the ischiopubic ramus, ischial tuberosities and sacrotuberous ligaments and
posteriorly, by the coccyx.
• The diamond shaped space of the bony pelvic outlet is divided into two triangular
spaceswiththecommonbaseformed by the free border of the urogenital
diaphragm. The anterior triangle is called the urogenital triangle which fills up the
gap of the hiatus urogenitalis and is important from the obstetric point of view.
The posterior one is called t he anal triangle.
2. OBSTETRICAL PERINEUM: (Synonyms: Perineal body, central point of the
perineum).
• T he pyramidal shaped tissue where the pelvic floor and the perineal muscles and
fascia meet in between the vagina and the anal canal is called the obstetrical
perineum. It measures about 4 cm × 4 cm with the base covered by the perineal
skin and the apex is pointed and is continuous with the rectovaginal septum.
PELVIC FASCIAFor descriptive purpose, the pelvic fascia is grouped under the heading that
covers the pelvic wall, the pelvic floor and the pelvic viscera.
FEMALE URETHRA
• The female urethra extends from the neck of the bladder to the external urethral meatus
which opens into the vestibule about 2.5 cm below the clitoris. I t measures about 4 cm and
has a diameter of 6 mm.Its upper half is separated from the anterior vaginal wall by loose
areolar tissue and the lower half is firmly embedded in its wall. Numerous tubular glands
called paraurethral glands open into the lumen through ducts. Of these, two are larger called
Skene’s ducts which open either on the posterior wall just inside the external meatus or into
the vestibule. These glands are the sites for harboring infection and occasional development of
benign adenoma or malignant changes. While piercing the deep perineal pouch it is
surrounded by sphincter urethrae membranaceae which acts as an externBLOOD
SUPPLY:Arterial supply—Proximal parts are supplied by the inferior vesical branch and the
distal part by a branch of internal pudendal artery. T he veins drain into vesical plexus and into
internal pudendal veins.al sphincter.
• BLOOD SUPPLY:Arterial supply—Proximal parts are supplied by the inferior vesical branch and
the distal part by a branch of internal pudendal artery. T he veins drain into vesical plexus and
into internal pudendal veins.
FEMALE URETHRA
• The female urethra extends from the neck of the bladder to the external
urethral meatus which opens into the vestibule about 2.5 cm below the
clitoris.
• It measures about 4 cm and has a diameter of 6 mm.
• Its upper half is separated from the anterior vaginal wall by loose areolar
tissue and the lower half is firmly embedded in its wall.
• Numerous tubular glands called paraurethral glands open into the lumen
through ducts. Of these, two are larger called Skene’s ducts which open
either on the posterior wall just inside the external meatus or into the
vestibule. These glands are the sites for harboring infection and occasional
development of benign adenoma or malignant changes.
• While piercing the deep perineal pouch it is surrounded by sphincter
urethrae membranaceae which acts as an external sphincter.
• BLOOD SUPPLY: Arterial supply—Proximal parts are supplied by the inferior vesical
branch and the distal part by a branch of internal pudendal artery.
• The veins drain into vesical plexus and into internal pudendal veins.
• NERVE SUPPLY: It is supplied by the pudendal nerve.
THE URINARY BLADDER
• The bladder is a hollow muscular organ with considerable power of distension. Its
capacity is about 450 mL (15 oz) but can retain as much as 3–4 liters of urine.
• When distended it is ovoid in shape. It has —
• (1) an apex (2) superior surface (3) base (4) two inferolateral surfaces and (5) neck, which
is continuous with the urethra.
• The base and the neck remain fixed even when the bladder is distended.
• BLOOD SUPPLY: The blood supply is through superior and inferior vesical arteries.
• The veins drain into vesical and vaginal plexus and thence to internal iliac veins.
PELVIC URETER
It extends from the crossing of the ureter over the pelvic brim up to its
opening into the bladder. It
measures about 13 cm in length and has a diameter of 5 mm. Ureter is
retroperitoneal in course
BLOOD SUPPLY: It has got segmental supply from nearly all the visceral
branches of the anterior division of the internal iliac (uterine, vaginal, vesical,
middle rectal) and superior gluteal arteries. The venous drainage corresponds
to the arteries.
NERVE SUPPLY: Sympathetic supply is from the hypogastric and pelvic plexus;
parasympathetic from
he sacral plexus.
The fetal skull
• Fetal skull is the most important part of the fetus because it is the most common
presenting part.
• It contains the delicate brain which may be subjected to great pressure as the head
passes through the birth canal.
• It is the largest and least compressible and once born, generally ensures smooth
delivery of the body.
• An understanding of the landmarks and measurements of the fetal skull enables the
midwife to recognise normal presentation and positions and to facilitate birth with the
least possible trauma to mother and baby.
Ossification: Bones of the fetal head originate in two different ways.
• Face is laid down in cartilage and almost completely ossified at birth with the bones
being fused together
• The bones of the vault are laid down in membrane and are much flatter and more
pliable.
The fetal skull
• They ossified from the centre outwards and this processvis incomplete at birth
leaving small gaps which forms the sutures and fontanelles.
• The ossified centre on each bone appears as a boss or protuberance.
BONES OF THE VAULT
• There are five main bones in the vault of the fetal skull:
• The occipital bone: This lies at the back of the head and forms the region of the
occiput. Part of it forms the base of the skull as it contains the foramen magnum
which protect the spinal cord as it leaves the skull.
• The occipital protuberance is at the centre of the occiput
• Two parietal bones: These lies on either sides of the skull. The ossification centre
of each is called the parietal eminence.
DIAGRAM SHOWING BONES, SUTURES AND FONTANELLES
REGIONS AND LANDMARKS ON FETAL SKULL

• Two frontal bones: These forms the forehead or sinciput, it has a frontal eminence
at the centre of each.
• The frontal bone fuse into a single bone by 8years of age
The skull is divided into the vault, the base and the face
• Vault is the large dome-shaped part above an imaginary line drawn between the
orbital ridges and the nape of the neck.
• The base comprised of bones that are firmly united to protect the vital centres in
the medulla
• The face is composed of 14 bones which are firmly united and non-compressible.
REGIONS AND LANDMARKS ON FETAL SKULL
The region of the skull are described as follows:
• Vertex: It is a quadrangular area bounded on one side by the bregma and coronal
sutures, behind by the lambda and lambdoidal sutures and literally by lines
passing through the parietal eminences.
• Brow: It is an area bounded on one side by the anterior fontanelle and coronal
sutures and on the other side by the root of the nose and supra-orbital ridges of
either side.
• Face: It is an area bounded on one side by root of the nose and supraorbital ridges
and on the other by the junction of the floor of the mouth with neck.
• Sinciput: Is the area lying in front of the anterior fontanelle and corresponds to
the area of brow
• The occiput : Is limited to the occipital bone.
SUTURES
• Flat bones of the vault are united together by non-ossified membranes attached to
the margins of the bones.
• These are called sutures and fontanelles.
There are four major sutures on the fetal skull:
• Sagittal or longitudinal suture: This lies between two parietal bones
• The coronal sutures: Run between parietal and fontal bones on either side
• The frontal suture: Lies between two frontal bones
• The lambdoidal sutures: separate the occipital bone and the two parietal bone
IMPORTANCE OF SUTURES
• It permits gliding movement of one bone over the other during moulding of the
head, a phenomenon of significance while the head passes through the pelvis
during labour.
• Digital palpation of sagittal suture during internal examination in labour gives an
idea of the manner of engagement of the head (synclitism or asynclitism) degree
of internal rotation of the head and degree of moulding of the head.
FONTANELLES

• The wide gap in the suture line is called fontanelle.

Of the many fontanelle (6 in numbers), two are of obstetric significance and they
are:
• Anterior fontanelle or bregma
• Posterior fontanelle or lambda
Anterior fontanelle
• It is formed by joining of these four sutures in the mid plane:
• Anteriorly, frontal suture
• Posteriorly, sagittal suture
• On either side, coronal suture
FONTANELLES (Anterior) CONTD

• The shape is like a diamond. It anterior- posterior and transverse diameters measure
approx. 3cm each.
• The floor is formed by a membrane and it becomes ossified 18mths after birth.
• It becomes pathological to ossify even after 24mths.
Importance
• Its palpation through internal VE examination donates the degree of flexion of the
head
• It facilitates moulding of the head.
• As remains membranous long after birth, it helps to accommodate the marked brain
growth (the brain becoming almost double its size during the first year of life)
• Palpation of the floor reflects intra-cranial status (depressed in dehydration elevated
in raised intracranial tension)
FONTANELLE(Posterior) CONTD
• It is formed by junction of three suture lines i.e:
• Sagittal suture anteriorly
• Lambdoidal suture on either side
• It is triangular in shape and measures about 1.2X 1.2cm.
• It donates the position of the head in relation to maternal pelvis’
DIAMETERS OF THE SKULL

• The engaging diameter of the fetal skull depends on the degree of flexion or
extension present
• ATTITUDE: This is the degree of flexion of extension of the fetal neck during
delivery.
• PRESENTATION: This is the part of the fetus that lies at the pelvic brim or in
the lower pole of the uterus.
DIAMETERS OF THE SKULL(anteroposterior diameters)
S/N DIAMETERS ATTITUDE PRESENTATION

1. Suboccipitobregmatic(9.5cm): Extends from the nape of the Complete flexion Vertex

neck to the center of the bregma.

2. Subboccipitofrontal(10cm): Extends from the nape of the Incomplete flexion Vertex

neck to the anterior end of the anterior fontanelle or center of
the sincipul
3. Occipitofrontal(11.5cm): Extends from the occipital eminence Marked deflexion Vertex
to the root of the nose(glabella)

4. Mentovertical(3.5cm): Extends from the midpoint of the chin Partial extension Brow
to the highest point on the sagittal suture

5. Submentovertical(11.5cm): Extends from junction of floor of Incomplete extension Face

the mouth and neck to the highest point on the sagittal suture

6. Submentobregmatic(9.5cm): Extends from junction of floor Complete extension Face

of the mouth and neck to the center of the bregma
DIAMETERS OF THE SKULL
The transverse diameters which are concerned with the mechanism of labour are:
• Biparietal diameter(9.5cm): It extends between two parietal eminences. Whatever may be the
position of the head, this diameter nearly always engages.
• Bitemporal diameter(8.2cm): It is the distance between the anteroinferior ends of the coronal
suture between two further points of the coronal suture at the temples
NOTE
Moulding: this is the term applied to the change in shape of the fetal head that takes place during
its passage through the birth canal.
• Alteration in shape is possible because the bones of the skull allow a slight degree of bending and
the skull bones are able to override at the sutures.This overriding allows reduction in the
presenting diameters.
• During the process, the parietal bones tend to overlap the adjacent bones, viz. the occipital bone
behind, the frontal bones in front and the temporal bones at the sides. In first vertex position, the
right parietal bone tends to override the left one and this becomes reverse in second vertex
position. Molding disappears within few hours after birth.
Moulding:
Grading: There are three gradings.
• Grade-1—the bones touching but not overlapping,
• Grade-2—overlapping but easily separated and
• Grade-3—fixed overlapping.

Importance:
• Slight molding is inevitable and benefcial. It enables the head to pass more easily,
through the birth canal.
• Extreme molding as met in disproportion may produce severe intracranial disturbance
in the form of tearing of tentorium cerebelli or subdural hemorrhage.
• Shape of the molding can be a useful information about the position of the head
occupied in the pelvis.
• CAPUT SUCCEDANEUM: It is the formation of swelling due to stagnation
of fluid in the layers of the scalp beneath the girdle of contact. The girdle of
contact is either bony or the dilating cervix or vulval ring. The swelling is diffuse,
boggy and is not limited by the suture line. It may be confused with
cephalhematoma. It disappears spontaneously within 24 hours after birth.

Importance:
It signifes static position of the head for a long period of time.
Location of the caput gives an idea about the position of the head occupied in
the pelvis and the degree of fexion achieved.
In left position, the caput is placed on right parietal bone and in right
position, on left parietal bone.
With increasing fexion, the caput is placed more posteriorly.
DIAGRAM OF FETAL SKULL
THE BREASTS (MAMMARY GLANDS)
• The breasts are accessory glands of the female reproductive system.
• They are situated on the superficial fascia of the pectoralis major and seratus
muscles in the anterior chest wall
• The size and shape vary individuals depending on amount of fatty tissue
deposited
• They are usually hemispherical in the young nulliparous girl but are often flat and
pendulous in the multiparous woman.
• In childhood and in male they are present in a rudimentary form only.
• The female breasts begin to develop at puberty due to the influence of the ovarian
hormone.
• Oestrogen stimulates growth of the ducts while progesterone stimulates
development of the alveoli.
DIAGRAM OF FEMALE BREAST
THE BREASTS (MAMMARY GLANDS)

• Following puberty, the breast continue to enlarge due to deposition of fat and
connective tissue.
• Breasts remain incompletely developed until pregnancy occurs when there is
further growth of both the ducts and alveoli.
• It extends vertically from the second to the sixth rib
• Horizontally, it extends from the axilla to the lateral margin of the sternum
• The part of the breast which extends up into the axilla reaching as high as the third
rib is called the axillary tall of Spence.
Anatomy and physiology of Male Reproductive System/ Organs

The primary functions of the male reproductive system are:

• the production of male hormones,
• the formation of sperm cells (spermatozoa),
• and the placement of sperm cells in the female reproductive tract, where one
sperm can unite with a female sex cell.
The organs of the male reproductive system include:
• paired testes, which produce sperm and male hormones;
• ducts that store and transport sperm; (vas deferens and the urethra)
• accessory glands, whose secretions form part of the semen;
• and external accessory structures including the scrotum and penis.
Testes

• The paired testes or testicles are the male gonads, or sex glands.
• Each testis is protected and supported by a capsule of fibrous connective tissue.
• Septa (partitions) of connective tissue radiate into the testis from its posterior
surface, dividing the testis into internal subdivisions called lobules.
• Each lobule contains several highly coiled seminiferous tubules.
• Seminiferous tubules are lined with germinal epithelium,which is formed of
spermatogenic cells and supporting cells.
• Spermatogenic cells divide to produce sperm, while supporting cells support and
nourish the spermatogenic cells and help regulate sperm formation.
• Interstitial cells are cells that fill the space between the seminiferous tubules and
they produce male sex hormones.
Spermatogenesis
• Spermatogenesis is the process that produces sperm cells by the division of the
spermatogenic cells in the germinal epithelium.
• Sperm production begins at puberty and continues throughout the life of a male.
• Sexual maturity and sperm production are controlled by follicle-stimulating
hormone (FSH) and luteinizing hormone (LH).
• LH is often called interstitial cell–stimulating hormone (ICSH) in males.
• Once the sperm cells are completely formed, they are carried into the epididymis,
where they are temporarily stored while they mature.
• A mature sperm cell consists of a head, body, and flagellum.
DIAGRAM OF MATURED SPERM
Accessory Ducts
• Sperm cells pass through a series of accessory ducts as they are carried from the
testes to outside the body.
• These accessory ducts include the epididymis, vas deferens, ejaculatory duct, and
urethra.
• Epididymis: The epididymis appears as a comma-shaped organ that lies along the
superior and posterior margins of a testis.
• The epididymis is a long (6 m), tightly coiled, slender tube that is continuous with
the vas deferens.
• Vas deferens: It extends from the epididymis upward in the scrotum, passes
through the inguinal canal, and enters the pelvic cavity. It runs along the lateral
surface of the urinary bladder and merges with the duct from a seminal vesicle
under the urinary bladder.
• The duct formed by this merger is an ejaculatory duct.
Accessory Ducts
• Ejaculatory Duct: Each short ejaculatory duct is formed by the merger of a vas
deferens and a duct from a seminal vesicle.
• The ejaculatory ducts enter the prostate gland and merge with the urethra within
the prostate.
• During ejaculation, muscular contractions of the ejaculatory ducts mix seminal
vesicle secretions with sperm and propel them into the urethra.
• Urethra: The urethra is a thin-walled tube that extends from the urinary bladder
to the end of the penis.
• The urethra serves a dual role in the male.
• It transports urine from the urinary bladder during micturition and it also carries
semen, which includes sperm, during ejaculation.
• Control mechanisms prevent both fluids passing at the same time.
Accessory glands
• Three different types of glands produce secretions involved in the reproductive
process.
• These glands are the seminal vesicles, prostate gland, and bulbourethral glands.
Seminal Vesicles :These are paired glands located on the posterior surface of the
urinary bladder.
• The duct of each seminal vesicle merges with the vas deferens on the same side to
form an ejaculatory duct near the posterior surface on the prostate gland.
• The alkaline secretions of these glands help to keep semen slightly alkaline and
contain fructose sugar and prostaglandins.
• Secretions by the seminal vesicles compose about 60% of semen.
Accessory glands
Prostate Gland :The prostate gland is a doughnut-shaped gland that encircles the
urethra where it exits the urinary bladder.
• The ejaculatory ducts pass through the posterior portion of the prostate to join
with the urethra within the prostate.
• Prostatic fluid is forced through 20 to 30 tiny ducts into the urethra during
ejaculation.
• The secretion is an alkaline, milky fluid containing a mix of substances, including
prostate specific antigen (PSA).
• It forms about 30% of semen and contains substances that activate the swimming
movements of sperm.
Accessory glands
• Bulbourethral Glands
• The bulbourethral glands are two small, spherical glands that are located below
the prostate gland near the base of the penis.
• These glands secrete an alkaline, mucus-like fluid into the urethra in response to
sexual stimulation.
• This secretion neutralizes the acidity of the urethra and lubricates the end of the
penis in preparation for sexual intercourse
Scrotum
• The scrotum is the external sac of skin and subcutaneous tissue that contains the
testes.
• It hangs from the trunk midline posterior to the penis.
• A median partition(scotal septum) keeps each testis in a separate chamber within
the scrotum.
• Testes develop within the pelvic cavity but descend into the sac-like scrotum
through the inguinal canals near the end of the seventh month of fetal
development.
• The subcutaneous layer of the scrotum contains smooth muscle fibers that
reflexively contract or relax to shorten or lengthen the scrotum in response to
temperature.
• Through the actions of these muscles, the testes are raised closer to the body in
cold temperatures and lowered in warm temperatures.
• This maintains the testis at2- 40C (3°F) lower than the normal body temperature.
Penis

• The penis is the male copulatory organ that deposits semen in the female vagina
during sexual intercourse.
• It contains specialized erectile tissues that enable it to become enlarged and rigid
during sexual excitement.
• Three columns of erectile tissue compose the body of the penis.
• The corpora cavernosa are two columns of erectile tissue located dorsally, while
the corpus spongiosum is located ventrally.
• The urethra extends throughout the length of the corpus spongiosum.
• The corpora spongiosum expands at the tip to form the glans penis,which contains
numerous sensory nerve endings and the urethral opening.
• A loose sheath of skin, the prepuce,extends forward to cover the glans.
DIAGRAMS OF MALE REPRODUCTIVE SYSTEMS