Mnh i - 3 Yrs Curriculum-1_104707
Mnh i - 3 Yrs Curriculum-1_104707
Mnh i - 3 Yrs Curriculum-1_104707
MATERNAL
NEWBORN HEALTH I
By Martha
Kairu
Module outcomes
• By the end of the module, the learner should:
Provide care to a woman before & during pregnancy
Provide care to a woman during labour
Provide care to a woman in puerperium
Provide care to the newborn
Maternal Newborn Health I Course
outline
• Preconception care • Normal Labour
• FANC • Normal Puerperium
• Essential Obstetric & • Normal Newborn
Newborn care
• Targeted post-natal care
• Physiological changes in
pregnancy
• Minor complications during
pregnancy
DEFINITION OF PRE-CONCEPTION CARE
This is a set of interventions that identify and modify
biomedical, behavioral, and social risks to a woman’s health and
future pregnancies.
It includes health promotion, prevention and management of
any pre existing conditions; emphasizing health issues that
require action before conception or very early in pregnancy for
maximal impact.
The target population for pre conception care is women of
reproductive age (15 to 49 years)
4
OBJECTIVES OF PRE CONCEPTION CARE
To provide Health promotion and education to
improve knowledge attitudes and behavior of men
and women with regard to pregnancy
To provide Evidence - based Screening for
pregnancy risks
To provide Interventions to address identified risks
and conditions
To Achieve universal coverage of Essential
Obstetric Care
5
REPRODUCTIVE HEALTH RISKS INCLUDE THE
FOLLOWING:
Age: Very young (16yrs and below); Elderly (35 yrs
and above)
Parity :Primigravida, Grand multiparity, short inter-
pregnancy interval
Nutritional status: Under nutrition, obesity,
malnutrition
Low Socio-economic status: poverty
Previous adverse pregnancy outcome: Recurrent
spontaneous abortions, Stillbirths, Early neonatal
deaths (first one week), Previous baby with
6
Preconception care has a positive effect on a range of
health outcomes including:-
Reducing maternal and child mortality
Preventing un-intended pregnancies
Preventing complications during pregnancy and delivery
Preventing still-births, pre-term births and low birth
weight
Preventing birth defects
Preventing neonatal infections
Preventing vertical transmission of HIV
Lowers the risk of acquiring type II diabetes and other
life style related illnesses
7
AREAS ADDRESSED BY THE
PRECONCEPTION CARE PACKAGE
Nutritional conditions
Vaccine preventable diseases
Genetic conditions
Infertility/ sub-fertility
Female genital mutilation
Too early unwanted & rapid successive pregnancies
STIs & HIV
Interpersonal/ gender based violence
Mental health
Psychoactive substance use, including alcohol and tobacco
use 8
PRECONCEPTION CARE PROTOCOL
1. Comprehensive HISTORY should be taken to include:
Family history: hereditary conditions, Medical conditions, congenital
abnormalities
Medical history: Diabetes, hypertension, HIV, TB, RT cancers e.g.
Breast cancer, cervical cancer
Surgical history : Previous C/section, Obstetric fistula repair
Obstetric/gynaecological history: Pregnancy wastage, previous
preterm deliveries, STIs, menstrual disorders, prolonged sub fertility
Environmental history: exposure to radiation, Chemicals
Nutritional history : diet
9
2. PHYSICAL EXAMINATION
Should encompass a general head to toe examination, vital signs, weight,
e.t.c.
Systematic examination of the thyroid glands, heart, breasts, abdomen, pelvis
and other relevant systems will be based on the history obtained from the
woman
3. INVESTIGATIONS:
The investigations to be done include:
Full blood count, random blood sugar, Syphilis test, HIV test, Blood group and
rhesus, Urinalysis
Additional investigations are based on the history and examination findings
10
4. INTERVENTIONS
Health education and counseling on nutrition, psycho-
socio counseling, weight control, e.t.c.
Administration of prophylactic drugs such as folic acid,
iron, zinc, vitamin A and calcium
Promoting exercise
Management of pre-existing medical problems:
Stabilize medical conditions and ensure that medical
control is optimal
Screen for anaemia and treat appropriately
11
Check that any drugs or treatments used are
safe for use in pregnancy and do not affect
sperm function( cytotoxic and radiation,
smoking and alcohol etc)
Where appropriate, refer women for
specialized care.
12
DIAGNOSTIC METHODS
13
DEFINITION
Normal pregnancy:-
It is a state in which a fertilized ovum continues to grow and
develop inside the uterus, within a period of 40 weeks, or 280
days ,or 9 months and seven (7) days.
DIAGNOSTIC FACTORS
Are basic experiences, that occurs to the woman, and suggests
pregnancy.
14
CLASSIFICATION
1. PRESUMPTIVE/POSSIBLE FEATURES
Rated to be 50% suggestive, because same feature occurs in non-
pregnancy state. They are:-
i) AMENORRHOEA
Observed as from the 4th week onwards and it’s the first sign of
pregnancy to the victim.
However, menses can fail , due to emotional stress, severe illness and
hormonal imbalance.
15
ii) MORNING SICKNESS
Observed between the 4th to the 14th week.
Characterised by either nausea only, or nausea and vomiting on
waking up in the morning, thereafter wears off as day gets old.
Occurs to approximately 75% of women.
Same can occur due to G.I.T. conditions e.g ulcers, pyrexial
illness, cerebral irritation etc.
16
iii) FREQUENCY OF MICTURITION
Also referred to as bladder irritation.
Observed as from the 6th to the 12th week because the enlarged
uterus compresses the urinary bladder.
Same condition can occur due to pelvic tumour, e.g fibroids.
Urinary tract infection brings same features.
17
iv) SKIN CHANGES
Observed between 8th to 16th week.
It includes hyperpigmentation and development of
stretch marks.
Same occurs due to melanin disorder and rapid
deposition of fat respectively.
18
v) QUICKENING
Generally observed between 16 th – 20th week as the uterus
comes into contact with the abdominal muscle.
The sign is unreliable because it can be confused with
intestinal movements (wind) due to anxiety.
Misinterpretation is common among the infertile women.
19
vi) BREAST CHANGES
Includes fullness due to enlargement/tissue growth, as well
as tingling sensation from increased blood supply.
Noted between 3rd to 5th week, and more significant to a
primigravida.
Same occurs due to hormonal contraceptives especially
C.O.Cs.
20
2.PROBABLE FEATURES
Rated to be 95% suggestive because other
conditions bringing same features are always
within the reproductive system. They
include:-
i) POSITIVE PREGANANCY TEST.
Blood sample; diagnostic levels are available
as from the 6th day of pregnancy to the 12th
week.
21
contd
In a urine specimen, diagnostic levels are present from
2nd to 10th week.
Basically the test is positive only in the first (1st)
trimester.
Same hormone is noted in gynaecological conditions such
as hydatidform mole and choriocarcinoma.
22
ii) HEGAR’S/GOODELL’S SIGN
Also referred to as ; Softening of the Isthmus
Noted between the 6th to the 8th week in that, the entire
isthmus is softened.
On bimanual compression the fingers on the abdomen and
those placed through the vagina almost meet.
Same can occur due to hydatiform mole.
23
iii) CHADWICK’S/JACQUEMIER’S SIGN
Known as blueing of the vagina.
Observed as from the 8th week onwards.
The vagina/vulval membranes becomes dark purplish or
violet blue discoloured because of increased vascularity.
Same occur due to gynaecological conditions leading to
pelvic congestion, e.g, retroversion and pelvic cellulitis.
24
iv) OSIANDER’S SIGN
Also referred to as Pulsation of fornices.
Present from the 8th week onwards.
Results from increased pulsation in the uterine arteries because
of increase of blood supply.
The pulsation is felt by the fingers placed on the lateral fornices
Same occurs due to gynaecological conditions,e.g pelvic
inflammatory disease & fibroids.
25
v) UTERINE GROWTH
Noted as from the 12th week of pregnancy onwards, as the
uterus progressively becomes an abdominal organ.
Same can occur due to uterine myomas as well as other pelvic
tumour.
vi) UTERINE SCOUFFLE
These are soft blowing sounds, heard as from the 16 th week of
pregnancy onwards, on abdominal auscultation.
26
contd
Are of the same rate with maternal pulse.
Brought about by pressure, as blood passes through the
enlarged and increasingly coiled uterine arteries at the
placental site.
Same sounds are present due to large fibroids or ovarian
tumuors.
27
vii) BRAXTON HICKS CONTRACTIONS
Present as from 16th week onwards.
Experienced as painless waves of uterine contractions ,or
as tightening of the lower abdomen.
They intensify at about 35 weeks gestation because of the
rapid fetal growth and development between 32-40 weeks.
28
contd
Their main role is to increase blood supply to placental bed
and bring about development of lower uterine segment.
Same occur due to uterine tumours.
29
contd
Basically it involves placing a finger on anterior and posterior
fornix respectively.
Palm of the other hand is on the fundus abdominally.
Make the fetus float upwards and the gentle impact is felt by the
hand on the fundus.
Thereafter same impact is perceived as the fetus sinks back by the
fingers at the fornices.
Same procedure is positive incase of a pendiculated submucuous
(subendometrial) fibroid.
30
3.POSITIVE FEATURES
Are true features hence rated to be 100% suggestive, since
there is no alternative diagnosis.
They include:-
i) VISUALISATION OF THE SAC
Gestation sac and presence of heart activities, are identified
through ultrasonograpy.
31
contd
A highly powered machine reveals/picks the gestation
sac and cardiac activities as from 4th-5th week.
An ordinary machine does so as from 8th-15th week.
The routes are either transabdominal or transvaginal,
the former being more common.
32
ii) AUSCULTATION OF FETAL HEART SOUNDS
Commonly used instruments are:-
Doppler, as from 11th – 12th week.
Sonicade machine as from 14 th week.
Pinard fetalscope as from 20 -22 weeks.
Normal rate ranges between 120-160 B/m and are always regular
in rhythm.
33
iii) PALPATION OF FETAL PARTS
Possible from a gestation of 24 weeks
Confirmed by locating the head ,which is ballotable, back
felt as a smooth contour and limbs on the opposite side .
The site of fetal heart is estimated and F.H.S auscultated
for confirmation.
34
iv) FETAL MOVEMENTS
Visible in late pregnancy.
Noted on palpation, as fetal limbs slips away from the site of
pressure.
NB: * Fetus can be visualized as from 16 th week onwards through
X-ray, but it’s safe as from 30weeks.
*However, ultrasound is safe throughout pregnancy.
END
35
PHYSIOLOGICAL
CHANGES in
pregnancy
36
welcome
ct
Also referred to as, changes and adaptation in
pregnancy.
Generally results from effects of oestrogen
and progesterone hormones.
37
GOAL OF STUDY
Facilitates diagnosis of:-
Pregnancy , induced alterations.
Abnormalities in presence of a chronic
illness(es) hence prompt interventions.
38
AIMS (OBJECTIVES) OF THESE CHANGES
To enable her body nurture and protect the
fetus.
To prepare the body for labour process.
To develop her breasts hence prepare for the
lactation.
39
CHANGES PER SYSTEM
1. REPRODUCTION SYSTEM
i. Uterus
Growth is in size, weight as well as the decidua.
This facilitates nourishment, accommodation and
protection of the embryo/fetus.
40
Size growth:- Results from effects of high oestrogen
& progesterone levels in early pregnancy.
Then, hyperplasia (increase in the number of cells)
and hypertrophy of myometrial cells occurs.
During the 1st , four months ,wall thickness
increases from 1cm to 2.5cm.
41
Later the wall becomes less firm, to allow
longitudinal growth as products of conception
continues to develop.
From the 2nd trimester, thickness reduces gradually to
a range of 0.5 – 1cm or less, hence easy palpation and
identification of fetal parts.
Length increase:- Determined by fetal growth.
At term, uterus measures 30cm x 23(22.5)cm x
20cm.
42
ct
Weight:- Estimated to range between 1000-1100gm by term.
NB:-
Specific uterine growth depends on the age and parity.
Size is estimated through digital fundal height assessment
in which 1 finger breadth=1 week ,after 36 weeks 1
finger= 2 weeks.
43
CHANGES IN UTERINE SHAPE & SIZE
During the first (1st) 6 weeks uterus maintains its original
shape.
Thereafter, shape and size changes as follows:-
Before 12 weeks
It is still a pelvic organ, but, between 10-12 weeks the
shape is midway between globular and pear, in
anticipation for fetal growth.
44
At 12 weeks
Fundus ,is palpable abdominally just above symphysis pubis.
Dextrorotation is initiated since the uterus is upright.
It rotates to the right side of the body, such that, it’s left margin
faces anteriorly.
Rationale of rotating to the right is due to presence of recto-
sigmoid colon on the left side of the pelvis.
It’s shape is Globular.
45
At Eighteen (18) weeks
Fundus is midway between the symphysis
pubis and the umbilicus.
At Twenty(20) weeks
The fundus is just 2 fingers below the
umbilicus.
Uterus is ovoid in shape and the fundus is
thicker, more round and dome-shaped.
46
At Twenty two and Twenty four (22-24 ) weeks
Fundus is at the umbilicus level.
Difference in gestation is determined by genetical
link.
Right obliquity (Dextrorotation) is complete, since
the uterus is quite heavy and also has completely
risen out of the pelvic cavity.
47
At Thirty (30) weeks
Fundus may be palpated midway between
umbilicus and xiphisternum (sternal process)
Lower uterine segment can be identified,
though still incomplete anatomically.
48
At Thirty six (36) weeks
Fundus is in contact with Xiphisternum
/Xiphoid cartilage. So, it is at the highest level
and no finger can be fitted.
Mother reports difficulties in breathing and
digestion.
49
At Thirty eight (38) weeks
Fundus is palpable at the level of 34 weeks
because lightening have occurred.
In a primigravida normally ,engagement
occurs , while it is not the case for
multipara due to poor tone of uterine
muscle.
Finally , lower uterine segment is
50 completely developed.
Indicators of correct gestation for late booking.
H/o difficulty in breathing and digestion sometimes
ago.
Frequency of micturition currently.
C/o low backache due to widening of pelvic joints.
At 34 weeks head is quite small and far from the
brim.
51
At Forty (40) weeks
Uterus is ready to go into
labour.
Mother feels and looks
tired ,experiences backache
and joint pains, particularly
when walking.
52
ii) Ovaries and Uterine tubes.
Becomes progressively vertically positioned, hence
increased tension on the broad and round ligaments.
On movement, sharp groin pain on the right side is
experienced ,due to spasms of the round ligaments.
NB: Ovaries are only active in the 1st trimester.
53
iii) Isthmus.
Softens and lengthens such that, by the tenth (10 th)
week, it measures 25mm from 7mm in non-
pregnancy state.
So it has grown three (3 )times in length.
In late pregnancy, lower uterine segment
develops from it.
54
iv) Cervix.
Remains firmly closed throughout, hence provides a
seal against contamination, and holds-in the uterine
contents until term.
Specific changes
Bluish or purple coloured (appearance) because of
increased vascularity.
Oestrogen hormone is highly responsible.
55
Formation of operculum
This is a thickened plug of mucus, brought about by the effect
of progesterone hormone on the endocervical cells.
Its role is to provide a barrier from ascending infectious
organisms.
Erosion appearance (ectropion).
Oestradiol (oestrogen) hormone, stimulates growth in
columnar epithelium of the cervical canal.
56
The infravaginal portion becomes softer , swollen
and its length is approximately 2.5cm.
Ripening of the cervix.
Refers to preparation/ readiness of the cervix for
labour process.
It is brought about by enzyme collagenase and
prostagladins.
Effacement.
Refers to taking up of the cervix which occurs
during the last two (2) weeks prenatally.
57
v) Vagina.
General hypertrophy of the muscle layers is influenced by
oestrogen hormone.
Relaxation of the connective tissues results from effects of
progesterone hormone.
Specific changes are:-
Increased elasticity, hence easily dilates during 2 nd stage.
58
ct
Violet or red-purple coloration and becomes warmer, due
to increased vascularity.
Increase of Leucorrhoea, because of increased
desquamation (peeling) rate, on the superficial vaginal
mucosa cells.
Lower vaginal media (discharge) P.H ,due to presence of
more glycogen.
Aim is to provide protection against some micro-organisms.
59
ct
Unfortunately organisms e.g. Candida albican , a
fungi, thrives best in such an environment.
So candidiasis / moniliasis/monilial vaginitis is
very common.
NB: Candida albican is a normal flora of the nose,
throat, bowel and skin.
60
vi) Breasts.
Generally enlargement occurs due to fat deposition
around the glandular tissues.
Number of glandular ducts and acini cells increase
because of influence, from oestrogen hormone.
Progesterone and human placental lactogen hormone
facilitates budding of the alveoli to match the number of
acini cells.
61
NB: Despite gradual rise of prolactin levels, lactation is
inhibited ,due to high levels of oestrogen, felt at the
alveoli receptor.
Specific changes are:-
Prickling, tingling sensation around the nipple due to
high vascularity.
Noted around 3rd-4th week.
62
Thickening of the alveoli, occurs between 6th -8th
week, so breasts become painful, tense and
nodular.
For light coloured woman ,superficial veins are
visible.
Prominency of Montogomery’s tubercles on the
areola between 8th -12th weeks,.
These are hypertropic sebaceous glands openings.
63
They produces sebum to keep nipple soft and flexible.
Hyperpigmentation of the areola in terms of :
Development of primary areola at 8-12 weeks. The
darkened area enlarges and becomes more erectile.
Development of secondary areola at 16 weeks. It’s
characterised by extension of the pigmented area and it is
often mottled in appearance.
Basically hyperpigmentation toughens the area for
breastfeeding.
64
ct
Production of little colostrum as from the 16 th week.
Occurs due to slight stimulation of acini cells despite of the
antagonists.
Prominency, mobility of the nipple and sometimes leakage
of some colostrum.
This occurs in late pregnancy due to the effect of
progesterone hormone.
Assignment:- The chronological order of breast changes.
65
2.SKIN
Generally,darkening of varying degree is observed
to almost all the prenatals as from the 3rd month
until term.
This is brought about by the melanocyte-
stimulating effects of oestrogen and progesterone
hormones.
It is more marked on dark-skinned women.
66
Specific changes are:-
Hyperpigmentation on the following areas.
Face , it’s referred to as chloasma or melasma or “mask of
pregnancy”.
Caused by melanin deposition into epidermal or dermal
macrophages.
Epidermal melanosis regresses postnatally ,while dermal
melanosis may persist up to 10 years, in 1/3 of women.
67
ct
Darkening of linea alba, and it’s referred to as linea
nigra. Breasts as earlier discussed.
Development of striae gravidarum
These are stretch marks, brought about by rapid
deposition of fat, growth of the uterus and high levels
of adrenocortical hormones.
68
contd
As the skin stretches, thin lines occurs in the dermal
collagen, hence the stretch marks, which appears as
red stripes prenatally.
Six (6) months postnatally they appear as
sparkling/ glistening, slivery, white lines.
* Affected areas are breasts, abdomen, hips and
thighs.
69
ct
Increase of the growing hair compared to resting hair.
Results from the hormonal stimulation, particular oestrogen.
By the end of pregnancy, the amount of overaged hair is high.
So, postnatal the ratio is reversed such that, excess hair falls off
leading to some degree of anxiety.
Fortunately normal hair growth occurs within 6-12 months
postnatally.
70
ct
Rise in temperature by a range of 0.2-0.4 0c.
Results from effect of progesterone hormone and increased basal
metabolic rate.
The high BMR is from the maternal, placental and fetal tissues.
So, for comfort the activity of the sweat glands is increased, in order to
have excess heat lost.
Peripheral vessels also dilates hence loss of some core heat through
cooling of blood to some extent.
71
3.CARDIOVASCULAR SYSTEM
72
ct
Increase in cardiac output.
In non- pregnancy state, estimated cardiac output in a
minute is 5 litres.
By the 20th week prenatally, it is estimated to be 7
litres.
The increase is brought about by rise in plasma
volume and Red blood cells.
73
contd
Maximum levels are achieved by about 24th week and
it is maintained until term.
Aims of increased output is to:-
Provide extra blood flow for placental supply.
To match the increased blood vessels capacity hence
cure (combat) hypotension and fainting attacks.
74
ct
Slight increase in pulse rate.
This is by approximately 15 B/M.
Stroke volume also increase from 64ml to 71ml/beat.
Finally the heart rate increase from 75 B/M in non
pregnancy state to maximum 90 B/M.
The aim is to maintain systemic circulation.
75
ct
Hypotension (Low Blood Pressure)
Results from the effect of progesterone hormone.
Peripheral vascular resistance reduces as from the 5 th week , up to the
first (1st) half (1/2) of the second (2nd) trimester.
Thereafter, as cardiac output increase, BP stabilizes to non-pregnancy
state levels by term.
During 3rd trimester, prolonged supine position, leads to compression of
inferior vena cava, hence supine hypotension or supine hypotensive
syndrome.
76
ct
Occult Oedema
Noted around the ankles at term, as fluid slips into the
tissues of the feet.
Brought about by poor venous return hence increased
venous pressure in the legs.
The other cause is lowered osmotic pressure since
haemodilution has occurred.
77
ct
Increase of blood volume
Results from increase of major blood components.
Total volume increase, ranges between 30-50% by term in a
singleton pregnancy.
Plasma increases by approximately 50% (1200ml) by term.
Aim is to reduce blood viscosity (thickness) hence
improves capillary flow.
78
ct
Increased iron metabolism
Daily increase during early pregnancy ranges between 2-
4mg .
In late pregnancy it ranges between 6-7mg daily.
Total requirement in the entire prenatal period is about
1000mg.
79
ct
High risk of thrombosis and embolism
Effects of oestrogen hormone on the clotting factor
reduces prothrombin time index to less than 10
seconds.
The main aim (purpose) is to prevent PPH, after
placental separation.
80
ct
Poor immunity
The immune response is generally suppressed by human
chorionic gonadotrophin, prolactin hormone and depression
of lymphocytes functions.
This leads to decreased resistance against some specific
viral, bacterial and parasitic infections.
81
4.RESPIRATORY SYSTEM
Generally, increased cardiac output leads to increased
pulmonary blood flow.
Specific changes are:-
Hyperaemia, oedema and hypersecretion of mucus.
This occurs on the upper respiratory tract mucosa.
The mother presents with, nasal congestion,
sometimes epistaxis (nose bleeding) and changes in
voice.
82
ct
Alteration in thoracic anatomy
The aim is to improve air flow along the bronchial
tree.
Generally, as uterine enlargement continues, the
diaphragm is elevated hence total lung capacity
is reduced.
Shape of the chest changes, due to increase of
the chest circumference by approximately 5-
7cm.
Progesterone hormone and relaxin proteins are
83 responsible.
ct
Increase in oxygen tension and consumption
This leads to hyperventilation, brought about by the effect of
progesterone hormone on the respiratory centre.
It becomes highly sensitive to 02 demand, at the slightest
stimulation.
Hyperventilation is highly marked at 36 weeks due to severe
reduction of the lung field.
84
5.RENAL SYSTEM
Changes include:-
Increased excretion (activity).
It is brought about by the high increase of blood supply to
the kidneys, by 70-80% as from the 16 th week.
Aim, is to excrete most of the wastes from the mother and
the fetus.
85
ct
86
contd
Frequency of micturition
Occurs in 2 episodes
Early pregnancy between 10 th -12th week
Late pregnancy following lightening.
Relaxation of ureters
Results from the effect of progesterone hormone.
The lower third , just above the brim kink, hence decrease in
size ,while the upper two-thirds (2/3) dilates.
87
contd
This leads to stagnation (stasis) of urine at the renal
pelvis ,hence high chances of pyelonephritis.
Increase of glomerular filtration rate:
Renal threshold is lowered, hence glycosuria and high loss of
other solutes e.g, urea as well as creatinine.
So, it’s difficult to diagnose gestational D/M and renal
disorders respectively.
88
ct
Retention of urine
Mostly in 2nd trimester hence cystitis.
This is due to increased bladder capacity, since uterus is
an abdominal organ.
The relaxation effect of progesterone on smooth
muscles is responsible of the laxity of bladder .
89
ct
Stress incontinence
Observed in the 3rd trimester.
Occurs due to reduction in bladder capacity since
uterus is enlarged and lightening has occurred.
Simultaneously, urethra is straightened and urethra
sphincter relaxed, so incontinence is unavoidable in
most cases.
90
6.GASTRO-INTESTINAL SYSTEM
Specific changes are:-
Easy bleeding of the gum ; when mildly hurt by a toothbrush.
Results from the effect of oestrogen hormone which makes them soft,
oedematous and spongy.
Sometimes epulis contributes to easy bleeding.
Fortunately all these regresses spontaneously postnatally.
91
Dietary changes
Basically associated with high hormonal levels which are
thought to dull the sense of taste.
It leads to compulsive appetite on certain foods and sometimes
to non-food substances.
This is generally known as craving (fading) and pica
respectively.
92
Appetite
During the 1st trimester, it’s generally poor to some women
due to morning sickness.
Thereafter appetite increases, due to effect of hypothalamus
under the stimulation of progesterone hormone.
This leads to daily food increase by 200kcal= one (1) extra
meal daily.
93
contd
By the beginning of the 3rd trimester there should be 3.5 kg of fat
store in the maternal body ,since no more is laid down thereafter.
It’s purpose is to provide energy for the labour process and
facilitate initiation of lactation.
Most prenatals experience increase in thirst due to the slight fluid
retention and osmotic resetting, hence high fluid intake.
94
Marked reduction of gastric and intestinal tone.
It is accompanied by relaxation of lower oesophageal
sphincter due to combined effects of oestrogen and
progesterone hormones.
This predisposes to heartburn, constipation, development
of haemorrhoids and mendelson’s syndrome, incase G/A
is required.
95
ct
Displacement of the stomach and intestines
Occurs gradually as the uterus enlarges.
Appendix is displaced upward and laterally hence appendicitis can be
confused with pyelonephritis due to the site of pain and tenderness.
Stomach acquires a vertical position at term, hence oesophageal
reflux leading to psyrosis, because of change of gastro-oesophageal
angle.
96
7.MUSCULO-SKELETAL SYSTEM
The core factor is relaxation which is generally brought about by:
o Oestrogen hormone , acts on the connective tissue causing joint
capsules to relax and pelvic joint mobile.
o Progesterone hormone , relaxes pelvic ligaments specifically.
o Relaxin generally acts on the collagen, softens pelvic joints and
ligaments, in preparation for delivery.
97
ct
Specific changes are:
Progressive Lordosis Posture:
Occurs as a compensation for the enlarging uterus ,particularly
if, abdominal muscle tone is poor.
The centre of gravity shifts backward over the legs.
Rolling/waddling Gait:
Noted as from a gestation of 34 weeks onwards, due to increased
mobility of pelvic joints.
98
ct
Backache
Mostly among multiparous due to exaggerated, and relaxed
pelvic joints, as well as lordosis posture.
Lightening
Due to increased pelvic capacity.
99
ct
Occasional aching, numbness and weakness experienced
in the arms.
They are brought about by traction on the ulnar and
median nerves.
Traction results from marked lordosis, accompanied by
anterior flexion of the neck, and slumping of the shoulder
girdle.
100
Proteins
For the first 20 weeks, maternal storage of protein is
increased.
Most of it is transferred to the fetus in form of amino acids.
In the last 20 weeks more protein is conserved in the
maternal body through, reduced nitrogen excretion in urine.
This facilitates the rapid fetal growth and rebuilding of the
maternal tissue in puerperium.
101
Fat/Lipid
Accumulation of maternal fat stores, during the first and
2nd trimester, enhances fat mobilisation in late pregnancy
without affecting the maternal health.
However fats are used by maternal tissues as an
alternative energy source as insulin resistance increases.
102
Calcium
104
contd
Increase of intravascular and extracellular fluid.
Therefore ,average total gain for a normal single fetus
pregnancy is 12.5kg or 12500gm.
First 20 weeks gain, accounts for 4kg, so approximately 200gm
or 0.2kg per week.
The last 20 weeks gain, is 8.5kg ,hence approximately 0.4-0.5kg
per week i.e. 400gm-500gm.
105
contd
Generally the total gain is basically influenced by maternal
health prior to conception, prenatally and genetic make up.
Therefore the total gain can be 11kg or as high as 16kg in
one who is healthy.
END : QUESTION?
106
PRENATAL (ANTENATAL) CARE
107
OBJECTIVES/AIMS
To monitor the progress of pregnancy hence ensure maternal
health and normal fetal development.
To identify risk factors, which can endanger the life of both.
To support and encourage the family to have healthy
108
CONTD
To promote awareness of the sociological aspects of
childbearing and the influences they may have on the
family.
To ensure that the woman reaches the end of pregnancy
infant feeding.
109
CONTD
To offer the family advice on parenthood either
manually, on one to one bases or in a planned
audio-visual programme.
The care is aimed at allaying fear/worries hence
110
PROMOTERS OF ANTENATAL
ATTENDANCE
Service providers attitude to the individual client.
Timing of services i.e. served as they come (principle of 1 st
professionalism level.
Community motivation, in terms of awareness of the services,
111
CONTD
Culture and traditional orientations; General attitude
towards the services.
So if any of the above is overlooked, the clients default
the services.
Remedy; Find out the reason(s) of default in
collaboration with community leaders and other
appropriate sectors .
112
PRIME HEALTH MESSAGES
Aims at deliberately, empowering the client through:
Sharing appropriate information in simple and clear
terms.
Increasing awareness of their own feelings.
Imparting skills to help them make informed choices.
113
1.HYGIENE
Aims :
To prevent infection
To endorse self esteem
To refresh her
Personal hygiene
Daily or twice a day bath and change of clothing, particularly
114
Oral toilet to prevent dental carries and gum disease which
results from;
Higher demand of calcium and phosphorous by the fetus.
Easy injury of the gum.
Environmental hygiene
To prevent accidents and communicable diseases.
Food hygiene
To prevent food poisoning.
115
2.REST
Enquire on her specific occupation, whether is the only bread
winner and also regarding presence of a house help.
The aim is to determine whether she has ample time for total
rest.
Emphasis on eight (8) hours of sleep at night and 2 hours of
116
3.EXERCISES
institutions.
Encourage her to remain active as long as she doesn’t
strain.
117
4.DRESSING
comfort.
A dress or trouser can do, as long as the top is loose and
fitting.
Shoes; flat or low heeled to reduce straining of the back
muscle.
118
5.NUTRITION
Based on the locally available, affordable foods as well as
the craving/ fadding.
Emphasis on a well balanced diet which has extra proteins
and vitamins.
To increase the quantity in order to cater for all.
Highlight on cooking methods to preserve nutrients by
discouraging:-
Washing of vegetables after they are chopped.
119
Addition of bicarbonate of soda during cooking of green
leafy vegetables, because of destroying folic acid.
Overcooking of vegetables
Mention best sources of protein which also provide iron e.g.
120
HINDRANCES OF GOOD NUTRITION
o Poverty; Unavailability and un-affordability of certain foods.
o Food craving.
o Pica e.g. soil which leads to intestinal worms.
o Ignorance:- Due to inadequate knowledge or just
misconception .
o Food taboos:- Certain foods should not be consumed
prenatally through community consent.
o Superstition:- That the outcome is disastrous, if certain food
is consumed prenatally.
121
EFFECTS OF POOR NUTRITION
Prenatally
o Development of anaemia and poor clotting mechanism.
o High probability to infection.
o Loss of pregnancy.
Intrapartum
o Prolonged labour due to general weakness.
o Low birth weigh baby because of either intra-uterine growth
122
o Postpartum haemorrhage.
o Stillbirth.
Postnatally
o Puerperal complications.
o Inadequate lactation leading to early weaning.
o Chronic condition e.g. congestive cardiac failure,
123
6 . ELIMINATION
bladder drainage.
7. SOCIAL HABITS
Includes smoking of cigarettes ,drinking of alcohol and
malformation.
Postnatally, the infant may suffer respiratory problem in which
125
ALCOHOL: Discouraged at all amounts.
It specifically leads to:-
Maternal poor appetite.
Accidental fall, so possibility of placental separation.
Fetal alcohol syndrome.
Sometimes, immorality hence S.T.I.
126
Characteristic of fetal alcohol syndrome are:-
Growth restriction in the infant.
Child is irritable (hang over), characterized by restlessness,
127
HARD SUBSTANCE ABUSE
General behavior depend on the social class, and exact
substance being abused.
General presentation :-
Sometimes poor appetite.
Neglect of hygiene.
Immorality, may lead to loss of pregnancy.
Obstetrical complication because of poor ANC attendance
129
8 . BREAST CARE
Emphasis on daily self breast examination after
teaching the skills. Aims are to assess for:-
Normal occurrence/developments such as;
Skin changes.
Patency of lactiferous tubules.
Nipple prominency.
130
Abnormal occurrences such as:
Lumps(abnormal growths)
Nipple fissure/cracks, characterized by erosion of the
breast cancer.
131
Encourage to wear a well fitting brassiere to
prevent sagging and compression of the nipple.
Towards term, share on breastfeeding if
appropriate i.e. have purposed to breastfeed.
END
132
133
FI
RS
T
/B
O
O
KI
N
G
VI
134
AIMS/OBJECTIVES
To assess health and offer screening opportunity.
To ascertain baseline records, of various
examinations for future comparison as the care
continues.
To educate the woman in planning for safe birth.
135
GENERAL
Establish rapport as you welcome her/them in a
friendly manner. This leads to relaxation.
Ensure privacy, comfort, and that client as well as
SPECIFIC ACTIVITIES
I. HISTORY
Definition. It’s a systematic procedure of gathering
subjective data, about the client’s general health and
status of pregnancy.
Aim/Objective:
To assess her health, that of her immediate Fx, the
accurate data.
137
I. BIOGRAPHIC-SOCIAL/PERSONAL DATA
Enquire of:
Name, age, marital status
Level of education, address and telephone number, occupation
her.
This is to assess for the physical and psychological support.
138
valves.
Vascular disorder e.g. hypertension, cardiac disease, chronic
anaemia etc.
Their control measures and/ or complication(s).
139
3.GYNAECOLOGICAL
Comprises of:-
Menstrual
Age at menarch.
Menstrual cycle:
Average length, regularity, duration of flow and
consistency.
142
purpose.
Complications encountered.
Date of termination /change of use and reason.
144
4.FAMILY
Presence of hereditary diseases e.g. diabetes,
hypertension, heart disease, blood disorder e.g sickle
cell disease & haemophilia, cancer particularly that
of breast etc.
Twinning history specifically ,own mother or a close
relative.
TB because of its mode of transmission.
145
5.OBSTETRICAL
CT
Duration/maturity of fetus by termination.
Helps to diagnose, abortion, preterm, term and post
term labour.
NB: Abortion, enquire of after care e.g. D&C.
147
intervene.
148
undergo.
Information helps to determine sources of some
CONTD
Birthweight of each baby.
Helps to anticipate the size of the current fetus.
Sex/gender and fate of each of the baby.
Helps to keenly evaluate for possibility of BOH.
So the current fetus is termed to be precious.
Thus, optimal planning of prenatal, labour and delivery care.
151
CONTD
Puerperal complications and events after each
delivery.
For example, P.P.H ,inversion of uterus, sepsis etc.
So, closely monitor for reoccurrence and manage it
appropriately.
Period of exclusive breastfeeding ,to establish her
experience.
152
PRESENT OBSTETRIC.
Enquire on:-
Last normal monthly period (LMP) date i.e. onset date.
Then record it for later calculation of expected
CONTD
Drugs taken and exposure to radiation since pregnancy began.
Information facilitates anticipation for congenital abnormalities.
Use the Naegele’s rule to calculate the EDD as follows:-
Add seven (7) days to the date of LMP.
Either add nine (9) months to or subtract three (3) months from ,
month of LMP.
154
EXERCISE
155
1.Blood pressure
The initial findings provides record for future
comparison.
Monitored during every visit
Aim is to ascertain normality and diagnose
deviations.
156
CONTD
Results of 140/90mmHg and above indicates hypertension.
Interpretation
During 1st 20 week, high BP indicates either an existing
induced hypertension.
Both cases refer to the DR for future management.
157
2.WEIGHT
Purpose, is to monitor fetal and maternal health.
Taken on every visit.
Interpretation
Excess gain is highly associated with, gestation diabetes, pregnancy
3. HEIGHT
minor pelvis.
159
4.URINALYSIS
CT
Abnormal; fishy , accompanied by cloudiness
is indicative of urinary tract infection.
So send a specimen to lab for microcopy
5.BLOOD TESTS
neonatal jaundice.
Khan test/VDRL: for possibility of syphilitic
organisms.
162
CONTD
Haemoglobin levels; because of the increased iron
demand.
So repeated at 28 and 36 weeks respectively.
Rapid test for HIV antibodies.
To prevent mother to child transmission incase of
positive results.
Malaria parasite smear; for those in endemic areas.
163
positive history.
The spouse is also screened for the same.
Thereafter the couple is referred for genetical
counselling.
164
OBJECTIVES
BROAD:
To make most appropriate management plan.
SPECIFICS:
To confirm some of the information obtained through
history and screening tests.
To confirm pregnancy and the gestational age.
To determine abnormalities hence plan for the appropriate
interventions.
166
PREPARATION
MOTHER(CLIENT)
CT
ENVIRONMENT
Ensure cleanliness of floor and surface.
Well ventilated and quiet environment.
Adequate working space and well lit.
A sink with running water or provide for hand
washing.
Hang or ensure a label at the door indicating no entry
EQUIPMENT/REQUIREMENT
Since it’s a clean procedure, either a tray or a
trolley is cleaned.
Assemble the following:
Fetalscope.
Pair of clean disposable gloves .
Clean gauze and cotton wool in containers.
Vital signs apparatus .
169
CT
SELF (MIDWIFE)
Remove the wrist watch and wash hands socially
Ask the client to:-
Lie in supine position comfortably
Place the arms alongside the trunk
To avoid crossing of legs in order to relax
170
CONTD
Cover her with the draw sheet.
Warm hands by rubbing them together while
PROCEDURE
Taken earlier,and recorded are, weight, height and
vital signs.
Aim is to get baseline data, identify deviations and
intervene PRN.
Determine general hygiene and obvious deformity.
172
HEAD
Through inspection and palpation appropriately.
Note the shape, colour and distribution of hair, to
determine nutrition/health.
Hygiene, specifically for any infestation.
Palpate the scalp for swellings and hair for texture.
FACE
Inspect for hyperpigmentation .
173
EYES
Enquire for vision problem and associated factors.
Inspect conjunctiva and sclera for colour
Normally : pinkish and white respectively.
Abnormal: whitish / pallor on the conjuctiva, indicates
anaemia .
174
CT
Yellowish sclera, = jaundice, a liver disease.
Abnormal discharge, e.g yellowish/pussy which
indicates infection.
Excessive tearing, problem with lacrimal glands.
175
EARS
NOSE SINUSES
Enquire for : epistaxis, sense of smell and its
associated factors.
Inspect for discharge and nasal congestion.
For growths e.g. polyps .
177
MOUTH
CT
Gum for:
Bleeding .
Signs of inflammation,e.g, excessively red and
NECK
Inspect for:
Musculature, to evaluate for emaciation.
Range of motion, by asking her to move the head from
side to side.
Enlargement of thyroid gland and lymph nodes.
Distension of jugular veins and estimate jugular venous
pressure PRN .
181
CONTD
Palpate for:-
Thyroid gland and lymph nodes enlargement
Indicates goiter or URTI respectively.
Enlargement of lymph nodes may also indicate TB
of the glands.
Carotid arteries, for heart condition.
182
UPPER LIMBS/EXTREMITIES
Ask her to stretch them forward, hence assess for
medical condition(s) and examine for equality.
Inspect for:
Muscle atrophy (wastage), size as well as presence of
tremors.
Tremors, suggests either pernicious anaemia, nerves
disorder or alcoholism.
183
CONTD
Nails for pallor and koilonychia (spoon-shaped nails; a sign of
BACK
Assist her to sit up.
Inspect through, posterior and lateral view of thorax for.
Thyroid gland enlargement, ask her to swallow and see
whether it bulges.
Spine for:
Scoliosis ,lateral curvature of the spine.
Kyphosis, excessive backward curvature of the spine.
185
CHEST
Expose the chest and inspect for:
Condition of the skin to include colour.
Expansion on air entry, normally symmetrical.
Swellings of the lymph nodes.
Size and shape of the breasts, there equality and
physiological changes.
State of the nipple, i.e. whether flat, inverted, prominent or
bifid.
187
CONTD
Breast examination
Aims, are:
To detect abnormalities e.g. lumps ,early
CT
NB
Current recommendation is to use circles instead of
quadrants.
Palpate the each breast starting with the outer circle
ABDOMINAL / OBSTETRICAL
EXAMINATION
Objectives:-
To diagnose pregnancy.
To assess fetal size and growth.
To determine number of fetuses.
To determine the amount of liquor amnii.
Therefore, expose the abdomen, from lower ribs to
symphysis pubis.
190
I. INSPECTION
For the 4 “s” ,that is:-
Shape
Globular, between 12-18 weeks.
Ovoid, thereafter and indicates single fetus.
Round, indicates multiple gestation.
Pendulous, due to extreme relaxation of abdominal
muscles.
191
Size:-
Normally distended ,by either of the 4”Fs” or “T”.
Fetus, fat, flatus, feaces or tumours.
Scars:-
Curative or cosmetic , latter depends on cultural
background.
Skin changes:- Discusssed.
Note the abdominal musculature and fetal
movements.
192
II. PALPATION
Organomegally i.e. enlargement of the liver and spleen
respectively.
Uterus , using Leopold manoeuvre which comprises of
CONTD
To estimate fundal height, use the physical
landmarks.
So, determine the number of finger breaths, that
uterine fundus.
194
CONTD
Interpretation
Buttocks at the fundus:
Feels soft, irregularly outlined and large, hence cephalic
Presentation.
Head at the fundus:
Feels more distinctive in outline than buttocks, hard and
breech presentation.
In both situations lie is longitudinal.
195
umbilicus level.
Gentle pressure is applied with alternate hand in order to note
CONTD
So,firmly support the uterus on one side.
Then, slide the hand on the opposite side, using rotary
deeply.
197
CONTD
Interpretation
Fetal back:
Suggested by presence of a continuous smooth resistant
mass.
Limbs:
Identification of Small parts, on the opposite side, that
CT
Note the fetal part, at that area as well as its size.
Determine ballottement of the fetal part between thumb
and fingers.
Establish whether, its floating above the brim or dipping
CONTD
Face presentation, attitude of complete extension.
The head feels large , hard, round and unballotable.
Brow presentation, in a military attitude.
The head feels neither large, nor small, though hard, round
CONTD
While facing her legs, grasp the lower pole of the
uterus between palmar surface of hands, placed on
each side of the abdomen.
The tips of the fingers points downwards and
CT
Interpretation
On locating the head, determine how many finger breadths,
can be fitted on the part of the head, above the brim.
This helps to diagnose descent, i.e. level of presenting part.
At term ,locate the occiput and sinciput.
Establish which of them is higher, to determine attitude and
position.
204
111. AUSCULTATION
Aim: To assess the fetal well-being.
The fetal heart sound is a double sound, but more rapid.
Place pinard fetalscope on the mother’s abdomen at right
them correctly.
Then count for one(1) minute.
Normal, are between 120-160B/M, regular.
205
GENITALIA
Mainly through inspection of the vulva for:-
ABNORMAL VAGINAL DISCHARGE such as:-
Thick-yellowish and purulent, may indicate gonorrhea.
Greenish-yellow, frothy, and foul smelling.
Indicates trichomoniasis which is a protozoan infection.
206
CT
Curd-like, whitish and accompanied by pruritus vulvae.
Indicates moniliasis or candidiasis, a fungal infection.
Blood stained and foul smelling, mainly indicates bacterial
vaginitis.
NB: Specimens of discharge, are sent to laboratory for
microcopy, culture and sensitivity.
207
CT
ULCERATION, in terms of:-
Genital herpes. Characterised by vesicular eruption around
Ulcer is very painful, deep, easily bleeds and edges are not
swollen.
208
CONTD
Chancre: Indicates primary syphilis.
The ulcer is painless, shallow, clean, doesn’t bleed,
CT
Warts: Also referred to as condylomata accuminata.
Occurs on mons veneris, along the labia majora, around the
vaginal introitus, on the perineum and around the anus.
Varicosity:- Occurs along the labia majora and perineum.
Can easily rupture during the 2nd stage.
210
CONTD
Oedema:
Generally on the labia majora and mons veneris.
Highly associated with severe pregnancy induced
hypetensive disease.
Infestation:
On the pubic hair ,with lice.
Hygiene:-
Due to increased activity of sweat gland and
increased leucorrhoea.
211
LOWER LIMBS
Expose both legs up to mid-thighs. Inspect for:-
Equality in terms of length and size.
Muscle atrophy on one limb.
Obvious deformities e.g congenital talipes etc.
General hygiene.
Varicosity.
212
marked elsewhere.
Size of the foot.
Infestation with jiggers.
Between toes for fungal infection and tinea pedis
Palpate for:-
Varicosity on the thighs and behind the knees.
Deep venous thrombosis, on the calf muscle.
It is indicated by presence of tenderness and pain on gentle
application of pressure.
Oedema on the feet dorsum, ankles and along the tibia.
214
Aim is to confer passive immunity to the baby for the first six (6)
weeks.
Dose is 0.5ml intramuscular at the left deltoid muscle.
4th pregnancy.
215
IntermittentProphylaxis treatment:
Antimalarial specifically, sulfa based drugs, for
designated areas per ministerial directives.
Commonly used is sulfadoxine pyrimethamine(SP) i.e.
CONTD
Haemanitic /blood forming medications.
Are iron and folate, particularly to those who are at a
Anti-helmiths:
Dueto some water borne organisms and pica.
Mebendazole 500mg stat is commonly used.
END
FOCUSED ANTENATAL
CARE(FANC)
12/23/2024 219
ct
Introduction
It’s a model of ANC services, among the pillars of safe
motherhood, for those undergoing (N) pregnancy.
Definition
It’s a personalised service, which emphasizes on overall health,
preparation for child birth and complication /emergency
readiness.
NB: Non-health benefits are:- It’s friendly, timely and goal
oriented.
12/23/2024 220
ct
SPECIFIC OBJECTIVES/ GOALS/ ELEMENTS
1.Early detection and treatment of problems
Detection/diagnosis is of:-
Existing medical, surgical or obstetrical conditions.
Pregnancy induced conditions.
Identification methods are:-
History taking, specifically accompanied by active listening ie,to
the words, tone of voice and observe non-verbal cues.
12/23/2024 221
Various screening tests.
Physical examination in which, the data is correctly
interpreted.
Active and supportive treatment offered accordingly.
E.g, for HB level below 7gm/dl, refer, and haematinics are
administered as well as blood transfusion if necessary.
Dietary advise; on balanced diet, and to ovoid food items
that inhibit iron absorption.
12/23/2024 222
2.Prevention of complications
Achieved through preventive services as follows.
Tetanus toxoid,to inhibit maternal and neonatal tetanus. A
total of 5 doses is administered during the entire procreation
period.
Haematinics ie, iron and folate supplementation to prevent
anaemia.
Intermittent presumptive treatment (IPT) and insecticide
treated nets (ITNs), hence prevent malaria.
12/23/2024 223
The nets are provided free of charge to all prenatals and
under 5s(fives) in the designated areas.
Anti-helminths. It’s a presumptive treatment for
prevention of hookworm infestation. Mebendazole
500mg stat is preferred.
Teach regarding good practices of environmental hygiene
and share concerning pica to prevent intestinal worms.
12/23/2024 224
3. Birth preparedness and complication readiness
For birth preparedness discuss on:-
Components of birth plan in regard to:-
Place she expect to deliver her baby. Inform her of the EDD, as
you share on suitability of her choice.
Importance of a skilled attendant, in case of a home delivery
choice.
Transportation means. To reach the chosen place of birth
safely .
12/23/2024 225
Funds for clearing the professional bill. Perhaps from
government scheme e.g NHIF, family savings or a community
revolving fund.
Birth companion/ partner. To accompany her throughout the
labour process.
Mother-baby package. Comprises of items for a clean delivery,
and for keeping the neonate warm.
Encourage her to have the bag ready as she awaits labour, since
delivery may be too fast.
12/23/2024 226
The stored items are;
i. Pair of sterile gloves, or improvised clean plastic bags.
ii.Soap and clean cotton wool.
Sanitary towels, preferably pads.
iii.
iv.Kiberiti kit; consists of, new razor blade(s) and at least 2
clean, boiled strings/threads. All stored in an empty
matchbox.
v. Clothings for baby & mother + money.
12/23/2024 227
For complication / Emergency readiness
12/23/2024 228
4. Health promotion
Through sharing on:-
Various ways of infections and conditions control.
Hygiene, balanced diet & to be delivered by a skilled attendant.
To avoid habits that would be disastrous to the fetus as well as
her health.
Importance of exclusive breastfeeding , postnatal care and child
spacing in future.
12/23/2024 229
5. Provision of skilled care at birth
Maternal as well as neonatal morbidity and mortality is
highly predisposed by self delivery, together with unskilled
attendants.
So, currently delivery in a health facility is highly
recommended.
Due to some inevitable shortcomings, TBA are used.
Therefore, to be efficient in their services, they should be
integrated & upgraded, to comprehend, at what level to refer
to hospital.
12/23/2024 230
VISITS
World health organisation (WHO) states that:-
A healthy prenatal client should have at least 4(four) visits, during the
entire period.
Each visit to be thorough/comprehensive and personalised.
To use the acronym, GATHER for establishment of rapport and to
appropriately serve the client.
G= Greet, A= Ask, T= Tell, H= Help, E= Explain, R= Remind.
12/23/2024 231
SPECIFIC ACTIVITIES
First (1st) visit:- Expected to occur before a gestation of 16
weeks(< 16 weeks).
Activities are;
Those of a first(booking) visit, which includes: history taking,
screening tests,physical examination and preventive services.
Share on appropriate prime message(s), teach on various danger
signs and emergency preparedness.
Sensitise on individual birth plan, use of ITNs & HIV testing
Conclusion as usual.
12/23/2024 232
Second (2nd) visit
Occurs between 16th to 28th week.
Establish rapport and enquire of complains since the last
visit e.g. intercurrent disease, injury and use of medicine.
Examine as usual , but dwell more on signs of infection,
oedema, anaemia , fetal growth & development.
Review birth plan, remind on the need to know her HIV
status.
12/23/2024 233
Administer 1st dose of sulphadoxine pyrimethamine as usual, the
1st tetanus toxoid if not given in the first visit and replenish
haematinic supply PRN.
Give the next return date , record findings and discharge.
Third (3rd) visit
Occurs between 28th- 32nd week.
Basically as in second visit.
12/23/2024 234
Give 2nd dose of SP and TT for a primigravida.
May recheck HB level, since haemodilution is at the maximum
particularly, in presence of anaemia features.
Discharge as previously done.
Fourth (4th) visit
Occurs between 32nd - 40th week
Generally, the visit takes place any time before the onset of
labour
12/23/2024 235
After establishing rapport, enquire of any complains,
concerns or clarification.
Review the birth plan updates and help her to finalise
on the issue PRN.
Administer the 3rd dose of prophylaxis antimalarial.
At 36 weeks and thereafter, reassess HB and perform
pelvic evaluation for adequacy respectively.
The rest of the care is as usual.
12/23/2024 236
NB: Those who either develop a pregnancy
induced condition or are diagnosed to have a
medical condition, cannot continue with FANC
program.
END . QUESTION!
THANKYOU
12/23/2024 237
MINOR DISORDERS
IN PREGNANCY
FINALLY………………
12/23/2024
238
Are generally known as inconsequential disorders, but if
overlooked may become health hazards.
Caused by high hormonal levels and pressure from the grown
uterus.
Specifics are:-
Morning sickness
Characterised by either nausea, vomiting or both on waking
up in the morning.
Occurs between 4th -14th week , to about 50% of the prenatals
due to sudden rise of oestrogen hormone.
12/23/2024 239
Management
To take starchy food of her choice, before waking up
and a sweetened drink.
To have small frequent meal and adequate fluid to
prevent dehydration.
Fainting / syncope attacks
Results from either vasodilatation in early pregnancy,
faulty position in late pregnancy or cardiac problems.
12/23/2024 240
ct
Management
Conservatively:-
To avoid long periods of standing and overcrowded areas.
To adopt a lateral position in late pregnancy.
Curative, to seek medical attention for anaemia and heart problems.
Heart burn ( psyrosis )
Experienced as a burning sensation in the medial sternum, because of
reflux of stomach contents to the oesophagus.
12/23/2024 241
contd
Results from relaxation of cardiac sphincter, as well as pressure
exerted by the uterus as from 30th week.
It’s worsened, if she adopts a recumbent position.
Management
To take easily digestible foods .
To avoid bending after meals.
To sleep while propped up comfortably.
To take milk regularly ,if it persists.
For no relieve, administer antacids e.g. Actal 2 every 8 hourly.
12/23/2024 242
Itching
Mostly, experienced on the abdomen due to rapid uterine growth.
Sometimes, it results from poor hygiene and allergic reaction to
certain materials as well as detergents.
Management
Advise on hygiene, particularly of the vulva.
To avoid the material allergic to and the detergent, or rinse the
latter properly.
To apply a soothing cream on the respective areas.
12/23/2024 243
Frequency of micturition
Experienced in two(2) episodes.
Early pregnancy between 10-12 weeks.
Late pregnancy when lightening occurs.
Management
Reassure that, it will resolve spontaneously as long as
pain or discomfort are absent.
12/23/2024 244
ct
Excessive salivation ( ptyalism )
Brought about by high hormonal levels.
Occurs to quite a small group of prenatals and it is worse
between 8th -16th week.
Thereafter, it may subside or disappear, but in very few
occasions it persists all through.
Management
Reassure by educating on the cause and possible prognosis.
Advise on hygienic measures.
12/23/2024 245
contd
Constipation
Results from relaxation of intestinal tissues, hence
decrease of peristaltic movements.
The growing uterus also contributes, as it leads to
displacement of GIT structures.
Management
Advise on increasing fluid , fresh fruits and vegetable
intake.
12/23/2024 246
contd
To take some warm water, before breakfast, to
activate the guts hence regular bowel movements.
Exercise regularly.
In severe cases, refer to the doctor for prescription of
a mild laxative e.g. milk of magnesium 30 ml nocte.
12/23/2024 247
Pica
Refers to craving for unnatural food substances .
Exact cause is unknown, though highly associated with
hormonal and metabolic changes.
Management
Create a relaxed environment, so that she can confidently
disclose .
Assess for it’s potential harm and take appropriate measures.
Advise on alternative foods to abandon the habit.
12/23/2024 248
Varicosity
Refers to dilatation of some veins due to inefficiency of valves , as
an effect of progesterone hormone.
The respective veins overfill, hence bulge or protrudes.
Affected areas are:- Legs , anus( haemorrhoids /piles) and vulva.
Management
Legs
To avoid long periods of standing and sitting, because muscle
contraction from walking improves venous return.
12/23/2024 249
contd
To wear support tights, such as stockings or crepe bandage before
standing, after resting with legs elevated.
Anal
Advise on preventing constipation.
Painful, refer to the doctor for anaesthetic suppositories.
Vulval
Are quite rare, but if present, are very painful.
12/23/2024 250
contd
Advise on wearing a sanitary towel to give support and
ease pain.
Should always deliver in a hospital setting , because of the
probability of rupture during 2 nd stage.
Generally reassure that, varicosity sometimes resolve
spontaneously after delivery.
If it persist and is symptomatic, then surgery is done
postnatally.
12/23/2024 251
Leg Cramps
Characterised by tightening of the affected muscles into a hard knot,
causing intense pain.
It’s highly associated with ischaemia and electrolytes status changes
i.e, low calcium and sodium.
Affected muscles are those of the thigh , calf and foot.
Management
Exercise in terms of : Massage of the affected area and dorsoflexion
of the foot.
To increase milk intake, since it’s rich in calcium.
Severe cases, refer to the doctor for prescription of calcium
supplements and vitamin B complex.
12/23/2024 252
Backache
Brought about by softened ligaments and change of centre of
gravity, as uterus enlarges.
Management
Advise: - To wear low healed shoes.
12/23/2024 253
Occult oedema
Common in late pregnancy due to haemodilution &
compression of the lower limbs, leading to delay of venous
return.
Characterised by pitting oedema of the ankles, normally less
in the morning and increases as the day wears off.
Management
To rest with legs elevated.
To avoid long periods of standing and walking.
12/23/2024 254
Insomnia
Occurs in late pregnancy ie from 36 weeks.
Genuine associated factors are:-
Discomfort due to the enlarged uterus, so comfortable
position is not easily acquired.
Lack of exhaustion during the day.
Nocturnal frequency , because of reduced bladder capacity.
False labour, due to intensified Braxton Hick’s contractions
and lightening has occurred.
12/23/2024 255
cont
Increased anxiety because of, perhaps poor perception of
labour process or uncertain status of the fetus.
NB: Sometimes it’s accompanied by fear, common mood
swings, so may predispose to psychosis after delivery.
Therefore it should not be dismissed lightly.
Management
Listen sensitively and reassure as necessary to achieve a health
pregnancy.
12/23/2024 256
Advise on, good ventilation of bedroom, afternoon nap, warm
bath before retiring to bed and going to bed early.
Above interventions don’t help, then, refer to doctor and a mild
sedative is prescribed e.g. Valium 2 mg nocte.
Carpal Tunnel syndrome
Occurs in the 3rd trimester to a very small group.
Caused by fluid retention, which creates oedema and pressure
on the median nerve.
So, commonly noted in the morning, but in severe cases occurs
at any time.
12/23/2024 257
Major complains are, numbness, pins and needles
sensation(peripheral paraesthesia) on the fingers as well as
hands.
Management
Reassure that spontaneous resolution occurs postnatally.
To rest with hands and arms elevated above the chest.
Severe cases refer, for diuretic therapy and special splint that
resembles gloves.
END 258
INTRODUCTION TO
NORMAL LABOUR
Ms
By Kair
u
COURSE OUTLINE- 3RD & 4TH MONTHS
1. THE NORMAL LABOUR:
Concepts
First stage of labour
Transition and 2nd stage of labour
Physiology & management of 3rd stage of labour
The 4th stage of labour
2. NORMAL NEONATE:
APGAR scoring
Immediate care of the neonate
Physiology of the normal neonate
First/initial examination
Daily/routine examination
Minor disorders of the neonate
3. NORMAL PUERPERIUM:
Physiology
Prime health messages
Daily/ six weeks examination
Targeted post-natal care
Minor disorders in puerperium
DEFINITION OF NORMAL LABOUR
• Normal labour is a physiological process, which commences
spontaneously at term (after 37 completed weeks of
gestation) with rhythmic regular uterine contractions of
increasing intensity and frequency, accompanied by
progressive cervical effacement and dilatation, and descent of
the presenting part (cephalic), resulting in expulsion of a
healthy foetus, a complete placenta and membranes and a
healthy mother.
CHARACTERISTICS OF NORMAL LABOUR:
• Normal labour has several important characteristics. These
are:
Duration - completed within 18 hours (from 1st stage to 4th
stage)
Occurs at term between 38 and 40 weeks of gestation
Is spontaneous, i.e. not induced
The foetus presents by the vertex
Has no complications to either mother or baby
The newborn child requires minimal or no resuscitation at
birth
CLINICAL FEATURES OF NORMAL
LABOUR
• Contractions of the uterus, which are increasingly strong,
painful and regular
• The cervix is taken up into the lower uterine segment
causing dilatation of the cervix
• There is a mucoid blood stained discharge, which is called
show
• Sometimes there is rupture of membranes with drainage of
liquor amnii (amniotic fluid)
Spurious labour
• Refers to false labour symptoms experienced by most
women commonly 2-3 weeks prior to onset of true labour
• Many women experience contractions prior to onset of
labour which may be painful and may even be regular for
some time, causing the woman to think that labour has
started
• The two features of true labour that are absent in spurious
labour are effacement and dilatation of the cervix
• Reassurance should be given to the woman
DIFFERENCES BETWEEN TRUE &
FALSE LABOUR
FACTORS TRUE LABOUR FALSE
LABOUR
Contractions Regularly spaced Irregularly spaced
Interval Gradually shortens Remains long
between
contractions
Intensity of Gradually increases Stays the same
contractions
Location of Back and abdomen Mostly lower abdomen
pain
Effect of Do not abolish Often abolish the pain
analgesics the pain
Cervical Progressive No changes
FACTORS INFLUENCING THE
ONSET OF LABOUR
There are many theoretical explanations as to why labour
starts.
It appears to be as a result of a combination of factors.
Medical researchers describe hormonal and mechanical
muscle contractions.
The rise in oestrogen levels meanwhile triggers the release of
of labour
This explains why patients with certain conditions tend to go
extremities
o Increased vaginal secretions, due to congestion in the
vaginal mucosa
2)Frequency of Micturition
The descent of the foetal head increases pressure
STAGE OF LABOUR
INTRODUCTION.
OBJECTIVE
To equip the learner midwife with the relevant knowledge
on normal labour so as to be able to diagnose and
manage any abnormal findings in the course of care of
the laboring woman.
1. DURATION:
• Length of labour varies widely & is influenced by the parity,
birth interval, psychological state, presentation & position of
the fetus, maternal pelvic shape and size and the character
of uterine contractions.
• A greater part of labour is taken up by first stage.
• Active phase is completed within 6-12 hrs. Duration of latent
phase of labour should not be longer than 8hrs.
• During active phase, it is expected that a multiparous ought
to dilate at a rate of 1.5cm per hr & a primigravida at a rate of
1cm per hr.
2. UTERINE ACTION
i) CONTRACTION & RETRACTION
• Uterine muscle has a unique property. During labour, the
contraction does not pass off entirely, but the muscle
fibers retain some of the shortening of contraction instead
of becoming completely relaxed. This is called retraction.
• It assists in progressive expulsion of the fetus; the upper
segment of the uterus becomes gradually shorter & thicker
& its cavity diminishes
• The contractions of the uterus are coordinated by two
pacemakers in the region of the cornua. These are located
where the fallopian tubes join the uterine body.
• The muscle contractions start at the top corner of the uterus,
spread to the fundus, and then downward. During normal
pregnancy, the uterus contracts intermittently but the
contractions are not strong enough to overcome the
resistance of a normal cervix and do not lead to its dilation.
• The contractions of pregnancy become more frequent
towards term and get more painful and noticeable.
• When talking about contractions, you as a midwife are concerned
with three factors, namely:
– The strength,
– The duration and
– The frequency of the contraction.
• When you talk of the strength of a contraction, you identify it as
one of three categories: Mild, moderate & severe.
• The strength of a contraction is measured according to the time it
has taken.
• Thus, a contraction which takes <20 seconds is said to be mild,
one that takes 20 to 40 seconds is said to be moderate or fairly
strong and one that lasts for 40 to 60 seconds is said to be strong
or severe contraction.
• The duration refers to the time taken by a contraction
(time between the start and end of the same
contraction), for example a mild contraction lasts for 10
to 20 seconds.
• Frequency, on the other hand refers to the number of
contractions per 10 minutes duration. The frequency is
low at the start of 1st stage but increases at the end of 1st
stage (normally 3-4 contractions in 10 minutes). If a
mother has three contractions in every 10 minutes, the
frequency is written as 3:10.
(ii) POLARITY
• Polarity describes the neuromuscular harmony between
the two poles or segments of the uterus throughout labour.
• The upper pole contracts strongly and retracts to expel the
fetus. The lower pole contracts slightly and dilates to allow
expulsion of the fetus to take place.
• If polarity is disorganized, then the progress of labour is
inhibited.
(iii: ) FUNDAL DOMINANCE
• During a contraction the uterus feels hard to touch. At the
beginning of the process, contractions are painless and
involuntary, and are controlled by the nervous system under
the influence of endocrine hormones.
• The contraction starts at the upper part of fundus, spreading
across, and by the time they reach the lower fundus, they
last longer and are very intense. The peak of the contraction
is reached simultaneously over the whole uterus and fades
from all parts together. This pattern allows the cervix to
dilate and the contracting fundus to expel the foetus.
iv) FORMATION OF THE UPPER &
LOWER UTERINE SEGMENTS
fingers (90˚)
Withdraw the fingers slowly and note the discharge on
them
Assess the intertuberous diameter by fitting four
knuckles of the closed fist of the gloved hand
Clean and dry the mother and leave her comfortable
Check the foetal heart rate
Communicate the findings to the mother
Unscreen the bed, open the windows, remove the
episiotomy
Note any discharge or bleeding from the vaginal orifice
If membranes have ruptured, colour & oduor of any
the skull bones. The parietal bone overrides the occipital bone
& the anterior parietal bone overrides the posterior
During a vaginal examination this is how you should check for
moulding:
In cephalic presentation, run the finger on the head feeling for
the sutures
Judge the degree of moulding by feeling the amount of
labour
Take blood for haemoglobin and cross matching if the
woman and just after birth for the infant, can reduce
MTCT by as much as 50%
PERINEAL SHAVE
Not a routine procedure as research has shown that perineal
shaving is unnecessary and does not improve infection rates
Bath or shower
For women in normal labour, a warm bath( or birthing pool) can
C = clear
M= meconium stained
B= blood stained
Descent O
......
Dots = mild contractions
......
< 20 seconds
......
Diagonal Lines = Moderate
Contractions
contractions 20 - 40 seconds
Completely filled in = strong
contractions > 40 seconds
BP
341
PARTOGRAPH
Definition of partograph
A tool developed by the World Health Organization (WHO) to
labour process
Increase the quality and regularity of all observations of mother and
foetus
Recognize maternal or foetal related health problems as early as
possible
NOTE:- The partograph, if correctly and
accurately charted, can be a highly effective
tool in reducing the complications related to
prolonged labour for the mother ( PPH,
puerperal sepsis, uterine rupture and its
sequelae) and for the newborn ( neonatal
infections e.t.c.)
CONDITIONS FOR STARTING A PARTOGRAPH
A Partograph chart must only be started when a woman is in
hospital gown
COMMUNICATION
The culmination of pregnancy is an event with great
psychological, social & emotional meaning for the
mother and her family. The woman may experience stress
and physical pain.
The MW should display tact and sensitivity, respect the
open mouth
Verbal coaching and relaxation to help draw her attention
END
THE 2 STAGE OF
ND
NORMAL LABOUR
THE TRANSITION & SECOND
STAGE OF LABOUR
DEFINITION OF 2ND STAGE
• This is the stage that begins with full dilatation of the cervix (10
cm) & ends with complete expulsion of the foetus.
• It is the stage of descent and expulsion of the baby.
• The contractions become stronger, lasting 40 to 60 seconds,
with a one minute recovery interval.
DURATION OF 2ND STAGE
• It normally lasts from 1 to 2 hours on average in primigravida,
and half an hour in multipara (but can be as litle as 5 minutes).
If this stage goes beyond two hours, it is considered abnormal.
DEFINITION OF THE TRANSITION PERIOD
• The period between full cervical dilatation and the time
when active maternal pushing efforts begin
• It is considered as part of the last phase of the active 1 st stage
of labour & marks the shift to the 2nd stage of labour.
• It’s characterized by maternal restlessness, discomfort, desire
for pain relief, a sense that the process is never ending and
demand to the attendants to end the whole process hence
regarded as the most intense part of active labour
• This period lasts for 30 minutes- 1.5 hrs.
PHYSIOLOGY OF SECOND STAGE
OBJECTIVES OF LEARNING
1. To be ready to conduct the delivery on time
2. To conserve maternal energy which is only needed during the
perineal phase
3. To prevent occurrence of intracranial injury thru’ accurate
timing of 2nd stage + early intervention thru’ proper control of
the head during delivery
4. Prevent/ minimize the soft tissue trauma
SPECIFIC CHANGES
1. CONTRACTIONS: strengthen, become more frequent and expulsive
in nature. Strengthening results after the membranes rupture becoz;-
– Fetal head is directly applied to the vaginal tissues
– The uterus is closely applied to the fetus (uterus moulds around
the fetus)
• Finally the contractions intensify i.e. strengthen & become more
frequent (lasting between 40- 60 seconds)
• Expulsive nature occurs as descent continues, whereby pressure from
the presenting part stimulates nerve receptors in the pelvic floor
leading to Ferguson reflex
• The mother then experiences a great urge to bear down
• Initially, the reflex is controllable to some extent but later
becomes compulsive (irresistible) during each contraction
2. Abdominal muscles and diaphragm become active:
• Are also referred to as secondary powers/ maternal efforts
• This is in response to the compulsive and expulsive uterine
actions which come into action on order to reinforce the
contractions which are already in place
• Finally, the pelvic outlet and floor resistance is overcomed
3. Displacement of the pelvic floor
Also referred to as soft tissue displacement. Occurs as follows as the
fetal head continues to descend:-
• Anteriorly; the urinary bladder is pushed upwards into the abdomen
to prevent its injury, while the urethra is stretched & thinned out,
reducing its lumen. This makes catheterization difficult
• Posteriorly; the rectum is compressed alongside the sacral curve.
Pressure of the advancing head leads to expulsion of the residual
fecal matter
• Laterally; levator ani muscles are pushed sideways as they dilate and
thin out. The perineal body is flattened, stretched and thinned to
allow maximum opening of the vagina and the fetal head becomes
visible
4. Expulsion of the fetus
• The fetal head advances gradually as contractions continue,
receeds between contractions until crowning occurs.
• Finally the head is born, followed by the shoulders and the
body. The hind fluid drains out and second stage is
completed
PRESUMPTIVE SIGNS OF 2ND STAGE OF
LABOUR
Expulsive uterine contractions-the woman feels the urge to
bear down as the contractions are expulsive in character
Trickle of blood through the vagina- from slight laceration of
the cervix when fully dilated, laceration from vaginal mucosa
caused by the advancing head
Anus dilatation/ gaping-due to pressure exerted by the head
as it reaches the pelvic floor\woman feels the urge to open
bowels as the head exerts pressure on the rectum
• Appearance of anal cleft line: also called the ‘purple line’
appears as a pigmented mark in the cleft of the buttocks
which creeps up the anal cleft as the labour progresses
• Appearance of the rhomboid of michaelis: this is sometimes
noted when a women is in position where her back is visible.
Appears as dome shaped curve in the lower back, & is held
to indicate the posterior displacement of the sacrum &
coccyx as the fetal occiput moves into the maternal sacral
curve
• Gaping of vulva-more pronounced in primigravida than
in a multigravida because it is distended by the
presenting part.
• Visible presenting part-visible at the vagina. It is almost
a positive sign except in excessive moulding and in
breech presentation
• Bulging of the perineum- a sign that delivery is
imminent/ about to occur
CONFIRMATORY EVIDENCE OF THE 2ND
STAGE OF LABOUR
Full cervical dilatation on vaginal examination.
Therefore, vaginal examination must always be
performed as a confirmatory evidence of onset of 2nd
stage.
PHASES OF THE SECOND STAGE OF LABOUR
• Two distinct phases:
The latent/ Passive phase
The active/perineal phase
1. The latent phase: the phase in which descent and rotation of
the fetal head occurs.
• In some women, the cervix may be fully dilated but the
presenting part may not have fully descended & there4
pushing at this phase does not yield much, apart from
exhausting & discouraging the mother
2. The active phase
• Also known as perineal phase or imminent 2nd stage
• Delivery is expected to occur in the next 5-15 minutes.
• is characterized by a compulsive urge to push once the head is fully
visible
• Specific features of the perineal phase are:
Contractions are expulsive and compulsive
Secondary powers become active i.e. mother pushes with each
contraction
Perineum bulges excessively becoz the presenting part is directly
applied on the pelvic floor
Excessive gaping of the anus, vagina and vulva due to severe pressure
on the pelvic floor
Presenting part is visible at the vulva
Positions for the 2 stage of labour
nd
• The second stage begins when the cervix is fully dilated, the
baby has moved deep into the pelvis, and the mother is ready
to push.
• During the tiring second stage of labor, effectiveness of pushing
can be aided with body positions such as kneeling, upright
squatting, and being on all fours.
MECHANISM OF THE SECOND STAGE
OF NORMAL LABOUR
DEFINITION
• The mechanism of labour refers to a series of
movements the foetus has to make to pass
through the birth canal.
COMMON PRINCIPLES
1. Descent takes place all through
2. Whichever part leads and 1st meets the resistance
of the pelvic floor will rotate forwards 1/8 of a
circle (45 degrees) until it comes under the
symphysis pubis
3. Whatever emerges from the pelvis will pivot
around the pubic bone
Common principles ctd’
4. Whichever mechanism/movement that the head
makes will be the same movement that the
shoulders will follow
5. Internal rotation of the shoulders will always take
place at the same time with external rotation of the
head.
BASIC FACTORS
1) LIE
• Lie means the relation of the long axis of the foetus to
the long axis of the uterus. It may be longitudinal, oblique
or transverse
• In cephalic presentation, the lie is longitudinal
2) PRESENTATION
• The presenting part of the foetus is that part which is in
or over the pelvic brim. Its position is examined in
relation to the cervix. It could be vertex, face, or a
breech.
• The presentation is cephalic, and the presenting part is
usually the posterior part of the anterior parietal bone.
3) POSITION
• The position describes the relationship of a selected part of the
foetus to the maternal pelvis. For example, in a vertex
presentation the selected part is the occiput. With face
presentation it is the chin, and with a breech presentation, it is
the sacrum
• The position in normal labour is right occipito-anterior (ROA) or
LOA (left occipito-anterior)
4) ATTITUDE
• The pelvis is a curved passage with different diameters at the
inlet, mid-cavity and outlet . The foetus, therefore, has to adapt
itself to the shape, size, and curve of the pelvis at different
levels as it descends. Therefore, ATTITUDE IS ONE OF
COMPLETE FLEXION
• To be able to manage labour skillfully, you need to
understand the natural movements made by the baby so
that, when assisting in delivery, you can follow the
movements rather than oppose them.
• The factors, which influence the mechanism of labour,
are known as the three 'Ps': power, passage, and
passenger.
5) DENOMINATOR
• Refers to the part of presentation that indicates the
position. Or
• Part of presentation, used when referring to a fetal
position.
**E.g , In vertex presentation, denominator is the occiput.
• In normal labour ( cephalic presentation), denominator is the
occiput
Therefore,
• The lie is longitudinal
• Presentation is cephalic
• Position is right or left occipitoanterior
• Attitude is one of complete flexion
• The denominator is the occiput
• The presenting part is the posterior part of the anterior
parietal bone
The mechanism of labour in a cephalic vertex presentation
includes the following steps (MAIN MOVEMENTS OF THE
FOETUS):
• Descent and flexion
• Internal rotation of the head
• Birth by extension of the head
• Restitution of the head
• Internal rotation of the shoulders & External rotation of
the head
• Lateral flexion of the body
ENGAGEMENT, DESCENT & FLEXION OF THE HEAD
• Engagement is the descent of the presenting diameter through
the pelvic brim.
• The head usually engages late in pregnancy in the primigravida
while in the multipara it does not engage till labour starts because
of laxity of the pelvic floor muscles.
• The head enters the pelvic brim in oblique diameter with sub
occipital frontal diameter (10cm)-The presenting diameter in a
cephalic presentation. With good uterine contractions, there is
more flexion of the head.
• The head engages with sub occipital bregmatic (9.5 cms) oblique
diameter of the pelvis brim and the occiput therefore becomes
the leading part.
INTERNAL ROTATION OF THE HEAD
• The occiput rotates 1/8th of a circle anteriorly, to lie under the
symphysis pubis. Such a rotation is achieved by the action of
the uterine muscles pushing downwards.
• The pointed vertex presents on the broad levator ani muscle.
When the vertex reaches the perineum, the occiput turns from
the posterior to the anterior position.
• Anteriorly there is more room for further descent. When the
occiput is below the symphysis pubis, crowning takes place,
whereby the occiput slips beneath the sub-pubic arch and no
longer recedes between contractions
• By now, the widest transverse diameter (biparietal) is born.
BIRTH BY EXTENSION OF THE HEAD
laterally.
The incision is not more than 3cm & is made at 45° to the midline.
sphincter
Advantages:
It is associated with less bleeding
excessive bleeding
Disadvantages
Bartholins duct may be involved
Convulsion
Circulatory collapse
Respiratory collapse
If the above signs are noted, call for medical help (anaesthetist)
and resuscitate the mother
Repair of the Episiotomy
The episiotomy should be repaired as soon as possible
(immediately after the third stage) before oedema sets in and
while tissues are still anaesthetised. You will need a good
source of direct light.
The patient is placed in the dorsal recumbent position. The
midwife should be seated comfortably during the procedure.
An aseptic technique must be maintained throughout the
procedure.
The vagina and the episiotomy site are cleaned with antiseptic
lotion and the midwife should have a sterile gown and gloves
on.
Sterile gauze is inserted into the vagina to absorb blood
and keep the operation site dry. Absorbable sutures are
used.
The repair begins at the apex of the vaginal wound. A
continuous or interrupted stitch is used, started from the
apex to the fourchette bringing the two edges of the
wound together. The perineal muscles are then sutured
and finally the skin is sutured= a total of three (3) layers
are sutured.
The stitches should just be firm enough. If they are too
loose, they may cause oedema and if they are too tight,
the mother will be very uncomfortable.
After suturing, remove the pack from the vagina and
note on the mother’s card that the pack has been
removed.
Insert the little finger into the anal orifice to make sure
the two orifices have not been stitched together and the
vaginal orifice is still patent.
Hints on repairing the perineum
Should be sutured with in one hour after local analgesia is
given
The area is cleansed with savlon solution
For any leakage from the uterus, vaginal tampon or pack
should be inserted
Good light is essential
The extent of the laceration should be determined
Layers to be repaired
Vaginal wound
a) Deep and superficial tissue
b) Vaginal mucosa
Perineal muscles and fascia
Perineal skin and subcutaneous tissue; thus a total of 3
layers.
The first stitch inserted at the apex of the incision
The most commonly used suturing material is 2/0 chromic
catgut.
Complications of episiotomy
Infections leading to broken episiotomy
Haematoma formation at the site of the episiotomy
haemorrhage
THE 3 STAGE OF
RD
LABOUR
PHYSIOLOGY AND MANAGEMENT OF 3RD STAGE OF
LABOUR
DESCRIPTION OF 3RD STAGE:
• This is the stage that commences immediately after the birth of
the baby & involves delivery of the placenta & the membranes
up to when bleeding is completely controlled.
• It includes the delivery of the placenta and membranes as well
as the complete control of hemorrhage from the placenta site.
DURATION:
• The third stage lasts between 5-15 minutes but any period upto
1 hour is normal. If it lasts more than 1 hr, it is considered as
retained placenta, hence prolonged 3rd stage of labour thus
posing a risk for possible postpartum haemorrhage (PPH).
• At this stage, the uterus contracts down to follow the body
of the foetus as it is being born.
• As the cavity of the uterus becomes smaller, the area of the
placental site is diminished. The placenta is then cut off
from the spongy layer of the decidua basalis.
• Further uterine contractions expel the placenta from the
upper segment into the lower segment and through the
vaginal vault.
• This process, whereby the placenta leaves the upper
segment to the lower segment and through the vagina, is
referred to as separation and descent of the placenta.
Principles of the Third Stage of Labour
Physiology of Third Stage
1. Separation of the placenta
2. Descent of the placenta
3. Expulsion of the placenta
4. Control of bleeding
SEPARATION & DESCENT OF
THE PLACENTA
The Mechanical Factors:
During the third stage, the following mechanical factors come into play:
• The uterus reduces in size 2.5cm below the umbilicus, or 15cm above
the symphysis pubis after the expulsion of the foetus
• The contraction and retraction of the uterine muscles continues. The
placental site is reduced to half
• The placenta becomes compressed & blood in the intervillous spaces is
forced into the spongy layer of the decidua.
• Retraction of the oblique uterine muscle fibres exerts pressure on the
blood vessels so that blood does not drain back into the maternal
system.
• Since the placenta is inelastic, it does not contract, so it
detaches from the shrinking uterine wall
• The placenta is pushed further to the lower uterine segment
by the weight of the retro-placental clot. This is the
accumulated blood from the separated placenta
• With the next contraction the placenta is pushed into the
vagina and expelled
METHODS OF PLACENTA SEPARATION
• There are 2 methods of separation of the
placenta:
–Matthew-Duncan method
–Schultz Method.
Matthew-Duncan method
• A method of placenta separation whereby the placenta is
expelled with the maternal side first exposed.
• The placenta slides down sideways & comes thru’ the vulva with
the lateral border first, like a button thru’ a buttonhole
• In this case, the placenta begins to detach unevenly at one of its
lateral borders so the placenta descends, slipping sideways,
maternal surface first
• Maternal surface is first seen
• In this method, the process of separation takes longer & blood
loss is greater than in Schultz method
Schultz Method
• The most common method of placenta separation whereby the
placenta is expelled with the fetal surface first exposed.
• Placenta detaches from a central point & slips down into the
vagina thru’ the hole in the amniotic sac
• The fetal surface first appears at the vulva with the membranes
trailing behind like an inverted umbrella as they are pilled off the
uterine wall
• The maternal surface of the placenta is not seen & any blood clot
is inside the inverted sac
Signs of placental separation
• Elongation of the cord at the vulva which does not recede
on pressing at the symphysis pubis
• A sudden gush of blood through the vulva
• The uterus contracts and feels hard like a cricket ball.
• Uterus rises in the abdomen as the placenta descends to the
lower uterine segment or vagina and displaces the uterus
upward
CONTROL OF BLEEDING
The control of bleeding is achieved through the following:
• Retraction of the oblique uterine muscle fibres exerts
pressure on the blood vessels so that blood does not drain
back into the maternal system.
• Criss-cross fibres in the uterus control bleeding by
compressing the blood vessels. These fibres are also known
as ‘living ligatures’
• Clotting of blood takes place in the sinuses thus sealing the
bleeding points a few hours later when uterine contractions
are less vigorous.
The time interval between the delivery of the baby and
delivery of the placenta is a dangerous period, in which one
of the greatest complications of pregnancy and labour can
occur.
This complication is excessive bleeding or postpartum
or actively.
The Passive or Natural Method of
Managing the 3rd Stage of Labour
The passive or natural method occurs naturally, that is
without any interference. For example, in a normal
delivery, if oxytoxic drugs are not used, the uterus
generally remains inactive for a few minutes after the
delivery of the baby, after which regular contractions then
begin again.
Physiology of the third stage takes place, the placenta is
ENSURE THAT:
• A uterotonic drug (syntocinon) has already been administered
• The uterotonic drug has been given time to act
• The uterus is well contracted
• Counter-traction is applied.
• Signs of placenta separation have already been observed-Not
mandatory so long as oxytocin has already been administered
and given at least 3-5 minutes to work
• After the syntocinon is given (with consent) –
intramuscularly, you MUST wait for signs of
placenta separation, this will be blood loss and
lengthening of the umbilical cord, use the clamps
as a guide to cord lengthening.
Complications of the 3 stage of labour
rd
POSTPARTUM HAEMORRHAGE(PPH)
• PPH can be defined as excessive bleeding of more than
500mls of blood from the genital tract after the birth of a
baby or any amount that may lead to deterioration in the
mother’s condition.
• If it occurs during the 3rd stage of labour or within 24hrs of
delivery, this is known as primary PPH
• If the condition occurs after 24 hours of, and within six
weeks after, delivery it is known as Secondary PPH.
Retained placenta
The placenta remains inside the uterus for longer than 30 minutes
after delivery of the baby, usually due to one or more of the
following:
• Uterine contractions may be inadequate to expel the placenta
• The cervix might have retracted too fast and partially closed,
trapping the placenta in the uterus
• The bladder may be full and obstructing placental delivery.
Acute Uterine inversion
End
FOURTH STAGE OF NORMAL LABOUR
DESCRIPTRION:
Rest • The women should plan at least one rest period a day and try to get a
good night sleep
Exercise • The women should limit the number of stairs she climbs to 1
flight/day for the first week at home.
• Beginning the second week, if her lochia discharge is normal, she
may start to expand this activity. She should continue with muscle-
strengthening exercise, such as sit-ups and leg raising
Hygiene • The women may take either tub baths or shower, and continue to
cleanse her perineum from front to back
Coitus Coitus is safe as soon as the woman’s lochia is over and if she
has an episiotomy, it is completely healed (about the fourth
week after delivery)
Follow up The women should notify her physician or midwife if she notices
an increase in lochia discharge, or if lochia serosa or lochia alba
becomes lochia rubra as these are signs of secondary P.P.H
THE NORMAL NEONATE
Welcome…
BROAD OBJECTIVE
To provide the learners with knowledge, skills and attitudes on
management of the normal neonate
SPECIFIC OBJECTIVES
By the end of this unit, the learners will be able to:-
Describe the immediate and subsequent care of the normal
neonate, including APGAR scoring, initial examination and daily
routine examination
Describe the physiology of the normal neonate
Describe the minor disorders of the normal neonate.
DEFINITION OF TERMS
a) A NEONATE:
Also known as a newborn, is a child from birth up to 28 days of
life.
b) A NORMAL NEONATE:
A neonate born at term ( at approximately 40 weeks
gestation)
Has no physical or physiological features suggestive
of an emergency or warranting immediate
resuscitation
Has got all the features/ characteristics expected of
a healthy neonate
GENERAL CHARACTERISTICS OF A
NORMAL NEONATE
A normal term baby weighs appx 2.5-3.5 kgs at birth
When fully extended, measures 45-55cm from the crown of
the head to the heels
Has an occipito-frontal head circumference of 34-37cm or
35-38cm
Appears plumpy and abdomen is prominent
Lies in an attitude of flexion, so as to prevent heat loss
When the arms are extended, their fingers reach the upper
thigh level
APGAR SCORING
The Apgar score was devised in 1952 by Dr. Virginia
Apgar as a simple and repeatable method to quickly and
summarily assess the health of newborn children
immediately after birth.
Apgar was an anesthesiologist who developed the score
in order to ascertain the effects of obstetric anesthesia
on babies
The Apgar score is determined by evaluating the
newborn baby on five simple criteria on a scale
from zero to two (2), then summing up the five
values thus obtained. The resulting Apgar score
ranges from zero to 10.
After delivering the baby, an assessment of the general
condition is done after one minute, after five minutes &
again after 10 minutes.
This involves the consideration of five specific signs and the
degree to which they are present or absent. The factors
assessed are:
Appearance – Colour of the neonate at birth
Pulse - Heart rate of the newborn
Grimace - good grimace =reflex response to stimulation
Activity - Muscle tone of the neonate
Respiratory efforts – vigorous crying or spontaneous
respiration
THE COMPONENTS OF THE APGAR SCORE
HEART RATE.
Is the priority assessment of the newborn after birth.
On auscultation or palpation, the nurse recognizes an absent heart
rate or heart rate less than 100 bpm as a signal for resuscitation.
RESPIRATORY EFFORT.
The newborn’s vigorous cry best indicates adequate respiratory
effort, the next most important assessment after birth.
A weak or absent cry is a signal for intervention.
MUSCLE TONE.
The nurse determines the newborn’s muscle tone by assessing the
response to the extension of the extremities. Good muscle tone is
noted when the extremities return to a position of flexion.
REFLEX IRRITABILITY. The nurse assesses reflex irritability by
observing the newborn’s response to stimuli such as a gentle
stroking motion along the spine or flicking the soles of the feet.
When this stimulation elicits a cry, the score is 2. A grimace in
response to stimulation scores 1, and no response is a score of 0.
COLOR. The nurse assesses skin color for pallor and cyanosis. Most
newborns exhibit cyanosis of the extremities at the 1-minute Apgar
check, and this normal finding is termed acrocyanosis. A score of 2
indicates that the infant’s skin is completely pink.
. Newborns with darker pigmented skin are assessed for pallor and
acrocyanosis
A score of 0, 1, 2 is awarded to each
of these signs in accordance with the
APGAR Score Chart.
THE APGAR SCORE TABLE
SIGN SCORE 0 SCORE 1 SCORE 2
Appearance( skin Pale or blue Body pink, extremities Pink all over
colour complexion) blue
Pulse/ heart rate Absent Less than 100/min More than 100/min
Grimace( reflex No response to Grimace/feeble cry Cry or pull away when
Response to stimulation when stimulated stimulated
stimuli)
Activity (muscle Limp Some Spontaneous
tone) flexion/movement movements/active(flex
ed arms and legs that
resist extension
Respiratory None Weak or slow/gasping Good/vigorous cry
effort( breathing)
Interpretation of APGAR score
A normal infant in good condition at birth will
achieve an APGAR score of 8 to 10.
Therefore, a score of;
1, 2 & 3 is severe birth asphyxia
4 & 5 is moderate birth asphyxia AND
6 & 7 is mild birth asphyxia
Thus, the above three will require immediate
resuscitation of the baby
IMMEDIATE CARE OF THE NEONATE
GOALS
To establish, maintain and support
respirations.
To provide warmth and prevent hypothermia.
To ensure safety, prevent injury and
infection.
To identify actual or potential problems that
may require immediate attention
i) Establish and maintain clear airway
The most important need for the newborn immediately after
birth is a clear airway to enable the newborn to breathe
effectively since the placenta has ceased to function as an
organ of gas exchange
Check breathing (Baby should be crying or breathing quietly
and easily)
To establish & maintain clear respirations:-
a) Wipe mouth and nose off secretions after delivery of the
head.
b) Suction secretions from mouth and nose. Suction mouth
first, then, the nose
c) Stimulate the baby to cry if baby does not cry
spontaneously, or if the cry is weak. The normal
infant cry is loud and husky. Observe for the
following abnormal cry:-
High, pitched cry – indicates hypoglycemia,
too warm.
It occurs when pores in the skin get clooged and
sweat cant get out hence, heat rash develops.
MANAGEMENT
The parents should be advised to:-
Loosen or remove extra clothing from the baby
Let him air dry rather than rubbing him with a
towel
NAPKIN RASH
More common in artificially fed babies.
It can be prevented by frequent care
and attention to the napkin area along
with immediate changes of the napkins
after each soiling.
Breast engorgement
The enlargement of breasts occurs in full term
babies of both sexes on 3rd or 4th day and may last
for few days or even weeks.
Lack of inactivation of progesterone and estrogen
after birth due to immaturity of neonatal liver,
leads to further rise in their levels thus resulting in
hypertrophy of breasts.
The local massage, fomentation should be curbed
and mother reassured.
PSEUDO MENSTRUATION
The development of menstrual like
withdrawal bleeding may occur in above ¼
of female babies after 3 to 5 days of
birth.The bleeding is mild and lasts for 2 to
4 days. The local aseptic cleaning of
genitals is advised.
Caused by the withdrawal of maternal
hormones
CONSTIPATION
End
THE NORMAL
PUERPERIUM
Finally
…
NORMAL PUERPERIUM & ITS SPECIFIC
MANAGEMENT
SPECIFIC OBJECTIVES:
At the end of these sessions, students will be able to:
Define normal puerperium
State physiological changes that take place in the
mother during peurperium
Describe the postnatal care given for mother and
baby.
Describe & manage the maternal minor disorders
during puerperium
Introduction;
Following the birth of the baby and
expulsion of the placenta, the
mother enters a period of physical
and psychological recuperation
Post natal period
Synonyms:
- Puerperium
- Post-partum period
Definition:
i) Puerperium is the period immediately following labour during
which, the reproductive organs return to their pre pregnant stage.
Lactation is initiated, and the mother recovers from the physical
and emotional experiences of parturition.
Puerperium begins as soon as the placenta is expelled and lasts for
6 weeks (42 days). It’s the process whereby the genital organs
revert back to their original pre-pregnancy state (involution).
The puerperium period covers six to eight weeks
following delivery or abortion and is characterized
by:
General organs return to their pre-gravida state(
involution)
Initiation of lactation
General recuperation (recovery) of the mother
ii) Post-natal care
The care given by a skilled attendant to meet the
needs of both the mother and the baby after birth
to reduce their risk of morbidity and mortality as
well as to promote the health and wellbeing of
the mother and baby.
Postpartum care is care given to the mother from
the time of placental expulsion up to 6 weeks
after delivery.
Incidence of maternal &
newborn mortality
Globally, over 500,000 women die as a result of
pregnancy related conditions. About 60% of these
deaths occur within the first week following
childbirth.
One million newborn deaths occur within the first
24 hours after birth and 75% of neonatal deaths
occur during the first week of life
In Kenya, most maternal and newborn deaths
occur in the early postnatal period.
Currently in Kenya, Neonatal mortality
rate is contributing to 60% of infant
mortality rate.
The above rates/incidences therefore
emphasize the importance of
midwives and other involved parties
to offer quality post natal care to the
clients.
THE CARE WHICH IS REQUIRED DURING
PUERPERIUM IS BASED UP ON THE FOLLOWING
PRINCIPLES:-
Promotion of physical well-being by good nutrition,
adequate fluid intake, comfort, cleanliness, and
sufficient exercises to ensure good muscle tone.
Early ambulation is insisted to prevent deep vein
thrombosis.
Establishment of emotional well-being.
Promotion of breast-feeding/ sound methods of
infant feeding.
Prevention of possible puerperal complications
CLASSIFICATION OF PUERPERIUM
Immediate: First 24 hours after
child birth
Early: Includes the first postpartum
week
Remote : Traditionally until the sixth
week post-partum
Anatomic changes during puerperium
END