Mnh i - 3 Yrs Curriculum-1_104707

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12/23/2024

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)

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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
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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
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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
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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

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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.

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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.

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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.

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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.

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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.

viii) INTERNAL BALLOTTEMENT


Ballottement of the fetus is possible between 16 th to 28th
week because space is an important factor.

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.

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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
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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.

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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.
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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

Normally, numerous alterations occur.


 In a woman, who has a pre-existing C.V.S disease, they
lead to severe impact.
Specific changes are:
Enlargement of the heart.
 Chambers distends due to myocardial hypertrophy as well
as increase of the blood volume.

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

Needed for fetal bone mineralization and breast milk


production, hence it’s absorption is greatly increased.
Maternal bone loss may occur in late pregnancy ,since
the daily transfer of calcium from mother to fetus is
250mg, as compared to 2-3mg daily in the first trimester.
 Therefore, the mother is at risk of osteoporosis later in
life, especially where balanced dietary intake is
inadequate.
103
WEIGHT GAIN
Comprises of :
Grown products of conception.
Hypertrophy of various maternal tissue.
High fat deposition generally, but more is on the
breasts, thighs and gluteal region as well as in the
fetal body.

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

psychological adjustment to childbearing.

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

when physically and psychological prepared for the child


birth.
To help and support the woman/mother in her choice of

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

have a physically and psychologically healthy


mother and neonate.

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

come, 1st served basis).


 Working environment, in terms of physical facilities and

professionalism level.
 Community motivation, in terms of awareness of the services,

literacy level and physical location of the clinics.

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

the inner wear to prevent unpleasant oduor.

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

afternoon nap if possible.


 As from 36 weeks to increase resting period during the day.

116
3.EXERCISES

 Refer to Myle’s , prenatal exercises chapter 14.


 They are best taught/handled by physiotherapists in some

institutions.
 Encourage her to remain active as long as she doesn’t

strain.

117
4.DRESSING

 Have to be loose, fitting and of absorbable material.


 Aim is to ensure free air movement, good circulation and

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.

whole grain products, soya, dairy products, red meat, liver


and egg yolk.
 The later is best absorbed in presence of ascorbic acid ,

from fresh fruits e.g. oranges etc.

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

restriction or premature birth.

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,

renal failure etc.

123
6 . ELIMINATION

 Emphasis on high intake of fruits, vegetables and free fluids


except alcohol.
 Aim is to prevent constipation and facilitate continuous

bladder drainage.
7. SOCIAL HABITS
 Includes smoking of cigarettes ,drinking of alcohol and

general abuse of hard substances.


124
SMOKING: Leads to constriction of blood vessels because of
nicotine.
 Therefore either abortion, low birth weight or congenital

malformation.
 Postnatally, the infant may suffer respiratory problem in which

sudden death may occur.


NB: Smoking of spouse/other members, inside the house leads
to passive smoking ,and affects the fetus.

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,

irrespective of being maintained comfortable.


 Reluctancy to feed.
 Microcephaly and some degree of mental retardation, leading

to learning difficulties later in life.

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

which may lead to loss of pregnancy.


128
Postnatally
The new born suffers/demonstrates withdrawal

features such as:-


 Voracious/greedy feeding pattern = vomiting.
 Sometimes reluctancy to feed.
 Fever in absence of an infection.
 Sometime diarrhoea.

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

nipple highly indicative of intraductal carcinoma.


Discolouration, mostly yellowish , associated with

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

spouse understand the procedure ,about to be


carried out.
NB: First impression is often lasting and determines
the rest of the experience.
136

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

past pregnancy (ies) and finally the current pregnancy.


 So it’s taken in a friendly discussion to acquire

accurate data.
137

I. BIOGRAPHIC-SOCIAL/PERSONAL DATA
 Enquire of:
 Name, age, marital status
 Level of education, address and telephone number, occupation

and that of next of kin, as well as religion.


 Alcohol use , smoking and the living set up i.e. who lives with

her.
 This is to assess for the physical and psychological support.
138

2.MEDICAL AND SURGICAL

 Major childhood diseases e.g. polio and rickets, because of the


effect on pelvic development.
 Rheumatic heart disease, childhood illness that affects heart

valves.
 Vascular disorder e.g. hypertension, cardiac disease, chronic

anaemia etc.
 Their control measures and/ or complication(s).
139

 Endocrine disorders e.g. diabetes mellitus .


 Malignancy conditions e.g. cancer.
 Psychiatry disorders/ mental illness.
 Tuberculosis because of its mode of transmission.
 Surgical procedures/accidents involving the reproductive

system and vertebral column except caesarean section.


 Aim is to anticipate for;
 Uterine rupture.
 Neurological complications.
140
 Accident :- Fall from a height. Involvement in a road traffic
accident.
 Assault & specific areas involved.
 Post accident/assault care and follow up.
 Blood transfusion ,ie, indication(s) year / date, unwanted effects

experienced and care given.


 Drug allergies and current use of medicine, in terms of type of

drug, allergic reaction and treatment given.


 Food allergies .
141

3.GYNAECOLOGICAL

Comprises of:-
Menstrual
Age at menarch.
Menstrual cycle:
 Average length, regularity, duration of flow and
consistency.
142

 Related complaints e.g. dysmenorrhoea &severity.


 Metrorrhagia and Menorrhagia.
Procedure ever carried out along the genital tract

e.g. curettage, cervical cauterisation – erosion.


143

Family planning methods


Type(s) ever used.
Duration of use.
Its effectiveness ,whether maintained the intended

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

Grouped into 2(two), namely:-


Past Obstetric hx.
Provides information regarding previous procreation
experiences.
 Date (year) each pregnancy was terminated.
 To assess the health of siblings and mother.
146

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

 Major illness encountered during each pregnancy.


 It could be a pregnancy induced or a medical

condition associated with pregnancy.


 Helps to determine the cause of pregnancy loss, or

neonatal death, hence closely monitor for


reoccurrence.
 Duration of labour in (hrs) in each pregnancy.
 Gives a clue on the expected type of labour, hence

intervene.
148

 Place where each previous delivery occurred, e.g.


health facility, home ,on the way.
 Provides data on the type of labour she is likely to

undergo.
 Information helps to determine sources of some

neonatal conditions e.g. Tetanus, omphalitis etc .


149

 Mode of delivery with each of the pregnancy.


 Normal ie spontaneous vertex delivery ,commonest.
 Abnormal because of fetal factors , or due to maternal

factors hence delivery is assisted with instruments e.g.


vacuum extractor.
 Caesarean section, due to a complication.
150

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

/estimated date of delivery (EDD) and maturity by date


(MBD) respectively.
NB: LMP date unknown, quickening date help in the
estimation of dates respectively.
Disorders so far experienced and major illnesses.
153

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

Calculate MBD i.e. age of pregnancy at a particular


date, using the following rule:-
 To date is always indicated.
 Exclude the L.M.P. date and the todate because:
Pregnancy couldn’t have started on the LMP day.
There is no proof that pregnancy will last for the

todate (24 hours = day).

EXERCISE
155

II. SREENING TESTS/GENERAL EXAMINATION.


 Starts as the client enters the facility.
 Gait is noted and height approximated.

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

renal disease or hypertension.


 As from 26 weeks, indicates pre-eclampsia or pregnancy

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

induced hypertension & large fetus.


 Static or weight loss, indicates either poor nutrition, malabsorption

or, illness currently or in the recent past.


 So, closely follow up/intervene as necessary

Assignment, procedure manual .


158

3. HEIGHT

Taken once throughout the entire period and recorded in


centimetres.
 Aim: To anticipate for pelvic adequacy although pelvic

assessment is done later.


 Height below 150cm ,is highly suggestive of Justo

minor pelvis.
159

4.URINALYSIS

Carried out during every visit.


Modes of testing are:-
Inspection for abnormal colour e.g. deep amber

, dark brown, cloudiness/ turbid & blood


stained.
Smell, normally, ammonia.
160

CT
 Abnormal; fishy , accompanied by cloudiness
is indicative of urinary tract infection.
 So send a specimen to lab for microcopy

culture and sensitivity.


Biochemical strips testing, for presence of

proteins, glucose, acetone etc


Aim, to diagnose UTI, pre-eclampsia &

diabetes mellitus respectively.


161

5.BLOOD TESTS

Most of them are carried out only once, though a


repeat may be necessary.
They are:-
Grouping and Rhesus factor; because of possibility of

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

OTHERS:- Determined by resources and history.


Hepatitis B virus: - To prevent perinatal transmission.
German measles/Rubella immune status ; where there

is history of contact with a sufferer.


Sickle cell disease and Thallasaemia , where there is

positive history.
 The spouse is also screened for the same.
 Thereafter the couple is referred for genetical

counselling.
164

III. PHYSICAL EXAMINATION


DEFINITION
It is a systematic evaluation of the health status ,which

involves accurate collection of both objective and


subjective data from head to toe.
Tools are; inspection, palpation & auscultation

NB: Carried out during every visit, but more detailed


in the booking.
165

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)

Explain to the client briefly, regarding the examination.


Ask her to empty the bladder and remove inner clothing.
If appropriate, provide an examination gown for easy

accessibility of various body parts during the procedure.


Assist the client to the examination couch as necessary,

to lie in lateral position.


167

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

or screen the couch for privacy.


168

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

standing on the right hand side of the client.


 Simultaneously engage the client into a talk

to make her relax.


171

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

Enquire for hearing problems & associated factors.


Inspect for excessive wax, discharge = infection

and general hygiene.


176

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

Note the breath oduor to assess for hygiene as well as


other medical conditions.
Inspect :
Lips for:
 Excessive dryness indicates dehydration.
 Cyanosis due either a heart or lung disease.
178

CT
Gum for:
 Bleeding .
 Signs of inflammation,e.g, excessively red and

swollen hence recedes from the teeth.


Teeth; Note the oral hygiene
 Dental formula i.e. whether all are intact, presence

caries and extraction.


179

Tongue: Ask her to stick the tongue out.


 Inspect for abnormal colouration e.g. pallor,

yellowish and whitish which indicates anemia,


jaundice and dehydration respectively.
 Snail tract ulcer, characterized by painless and shiny

grey patches = 20 syphillis.


180

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

hypochromic anaemia), which indicates iron deficiency anaemia.


 Hygiene on the palms and nails.
 Fingers for clubbing = either heart or lungs disease.
 Palpate the joint for musculo skeletal conditions.
 Nail bed for capillary refilling status.
 Finger and around the wrist for oedema due to,

either a minor disorder = carpal tunnel syndrome, or major


complication = pre-eclampsia.
184

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

Lordosis, exaggerated forward convex


curvature of the lumbar spine.
Hump/hunch back, results from excessive

muscle growth, common, on the cervical


region leading to a protrusion appearance.
Palpate for Sacral oedema.
Its presence indicates either congestive

cardiac failure or severe preeclampsia.


186

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

engorgement of axillary lymph nodes hence


intervene.
Prepare her for breastfeeding.
Teach client self breast examination .
Refer to procedure manual .
188

CT

NB
Current recommendation is to use circles instead of
quadrants.
Palpate the each breast starting with the outer circle

and through to the axillary tail.


Then the inner circle and finally the nipple area.
189

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

four (4) steps:-


i) FUNDAL (FIRST MANOEUVRE)
Aims are to;
 Estimate gestational period.
 Diagnose presentation and lie.
193

CONTD
 To estimate fundal height, use the physical
landmarks.
 So, determine the number of finger breaths, that

can be accommodated, below or above a landmark.


 Using both hands, note the fetal part located at the

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

has a round contour.


 Its ballotable because of the free neck movement So,

breech presentation.
 In both situations lie is longitudinal.
195

ii) LATERAL( 2ND MANOEUVRE)


Aims are to:
 Diagnose position by locating the fetal back.
 To confirm lie and presentation respectively
 Hands are placed on either side of the abdomen at the

umbilicus level.
 Gentle pressure is applied with alternate hand in order to note

which side of uterus offers the greater resistance.


196

CONTD
 So,firmly support the uterus on one side.
 Then, slide the hand on the opposite side, using rotary

movements from breech to neck.


 Repeat the same on the opposite side in order to locate fetal

back and limbs.


 Alternatively, “walk or move” the fingertips on each side, still

from breech to neck.


 The fingertips should be dipped into the abdominal wall

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

slip about under the examining fingers.


 Failure to locate fetal back at term, indicates posterior

position in which limbs are on both lateral aspects.


198

iii) SHALLOW PELVIC PALPATION/3RD


MANOEUVRE/PAWLICKS MANOEUVRE
Aim:
Diagnose, attitude and engagement at term
Confirm presentation.
 Therefore, gently and firmly hold the lower portion

of the abdomen, just above symphysis pubis, between


thumb and spread out fingers.
199

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

into the pelvis.


Interpretation
 vertex presentation, attitude of good flexion.
 The fetal part in the lower pole feels hard ,round,

ballotable and small= head


200

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

and limited ballottement.


 If head is floating above the brim, it means that

engagement has not occurred.


 If dipped into the pelvis and immobile, signifies
engagement.
201

iv) DEEP PELVIS (FOURTH MANOEUVRE)


 Aims are:- To diagnose descent and Confirm presentation
as well as position.
NB;i) Forewarn the client of possible discomforts, in terms
of tightening of the uterine muscles.
ii) Instruct her to bend the knees slightly hence relax the
abdominal muscles.
iii)To breath normally through the open mouth.
202

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

inwards, towards the upper border of symphysis


pubis.
203

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

angle to the fetal back.


 Compare the beats with maternal pulse initially, to identify

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

and on the external genitalia.


 Causative organism is herpes simplex virus type 2 (HSV2).
 Chanchroid:- Signifies sexually transmitted infection.

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,

indurated (hard) and heals within a month spontaneously.


NB: The last two (2) also occurs extragenitally at the anus.
 Genitally, occurs at inner aspect of labia majora, labia

minora, clitoris and vaginal introitus.


209

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

 Swelling e.g on ankles and feet.


 Normal at term and referred to as occult oedema.
 Abnormal, if it extends to the lower leg as well as

marked elsewhere.
 Size of the foot.
 Infestation with jiggers.
 Between toes for fungal infection and tinea pedis

(ringworm of the foot).


213

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

IV. DRUGS(PREVENTIVE SERVICE)


 Refers to the routine medications, such as:-
 Tetanus Toxoid injection:-

 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.

 For primigravida, two (2) doses at 4 weekly interval.


 Thereafter a booster (single dose) before 38 weeks gestation up to the

4th pregnancy.
215
 IntermittentProphylaxis treatment:
 Antimalarial specifically, sulfa based drugs, for
designated areas per ministerial directives.
 Commonly used is sulfadoxine pyrimethamine(SP) i.e.

Fansidar, 2-4 doses at 4 weekly interval.


 Each dose comprises of three (3) tablets, swallowed in the

clinic for compliance purposes as a D.O.T (directly


observed therapy approach).
216

 The first dose is given at first contact as long as pregnancy is


above 16 weeks, rest after every 4 weeks until 40th week.
Note:
 More than 2 doses are highly recommended because they reduce

parasitimea effectively leading to normal pregnancy.


 Within the first 2 weeks of S.P administration, folate, should be

withheld because it reduces the efficacy of Fansidar.


217

CONTD
 Haemanitic /blood forming medications.
 Are iron and folate, particularly to those who are at a

high risk of developing anaemia due to:-


 Poor dietary intake of iron
 Multiple pregnancy
 To treat mild anemia, characterised by a haemoglobin

level ranging between 9-10.9mg/dl.


218

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.
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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

Entails discussion on various danger signs, which includes:-


Vaginal bleeding, difficulty in breathing & fever.
Severe abdominal pain, severe headache and blurred vision,
mostly occurs in severe pre-eclampsia.
Reduced / absence of fetal movements, leakage of clear liquor in
absence of labour &persistent vomiting.
Labour onset before 37 weeks and convulsions.

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.

-To stoop when picking articles instead of


bending.
-To avoid long distance walks.
-To use a firm surface or mattress at night.
 For other causes of backache, refer to the doctor.

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

factors as the chief factors which influence onset of labour.


◦Hormonal factors
◦Mechanical factors
◦Other factors
HORMONAL FACTORS INFLUENCING THE ONSET OF SPONTANEOUS
LABOUR
The hormones include:
◦ Oxytocin
◦ Progesterone & Oestrogen
◦ Prostaglandins
 Close to term, progesterone levels in the body fall, while at the same

time levels of oestrogen (which is responsible for sensitizing the


uterine muscles) rise.
 The fall in progesterone levels is important because it has effect on

muscle contractions.
 The rise in oestrogen levels meanwhile triggers the release of

oxytocin, from the posterior pituitary gland, which causes uterine


contractions, hence contributing to maintenance of labour.
 Oxytocin stimulates the release of prostaglandins from
the myometrium which facilitate in initiation of labour
by causing the cervix to soften (cervical ripening) in
preparation for normal labour.
 The foetal hypothalamus produces releasing factors,

which stimulate the anterior pituitary gland to


produce adrenocorticotrophic hormone (ACTH). ACTH
stimulates the foetal adrenal glands to secrete cortisol,
which causes relative levels of placental hormones to
rise. These cause further uterine contractions.
MECHANICAL FACTORS
1.Increased contractility of the uterus
 As the pregnancy advances, there is an increase in

contractibility of the uterus which becomes more


susceptible to stimulation as term approaches
2.Pressure of the presenting part
 The presenting part stimulates nerve endings in the cervix

resulting in initiation of labour


3.Over distention/overstretching of the uterus
 It increases contractility of the uterus thus prompting onset

of labour
 This explains why patients with certain conditions tend to go

into premature labour eg. Polyhydramnious and multiple


pregnancy
Other factors
 that have been associated with onset of labour:-

hyperpyrexia, cyanosis, emotional upset


PRE-LABOUR OR PREMONITORY SIGNS
OF LABOUR
 Synonym: Warning signs indicating the onset of labour
 This is the period two to three weeks prior to the onset of labour

when a number of changes take place;


1)Lightening
 Two to three weeks before labour (at around 38 weeks in

primigravida), the lower uterine segment expands allowing the


foetal head to sink deep into the pelvic cavity. The descent of the
head and the body of the baby gives space to the maternal lungs,
heart and stomach, which enables these organs to function easily.
 The symphysis pubis widens and the pelvic floor softens and

becomes more relaxed, allowing further descent of the uterus into


the pelvis
Factors that bring about lightening
 The symphisis pubis widens
 The softened pelvic floor relaxes
 The lower uterine segment stretches and foetus sinks

further down in the uterus


 Lightening may also bring the following maternal
symptoms:
o Leg cramps or pains
o Increased pelvic pressure
o Increased urinary frequency
o Increased venous stasis, causing edema in the lower

extremities
o Increased vaginal secretions, due to congestion in the

vaginal mucosa
2)Frequency of Micturition
 The descent of the foetal head increases pressure

within the pelvis. This limits the capacity of the urinary


bladder, which can cause irritation. The laxity of the
pelvic floor muscles gives rise to poor sphincter control
causing a degree of stress incontinence.
 This pressure results in the congestion of circulation to

the lower limbs. Additionally, the relaxation of the


pelvic joint may give rise to backache
3. Weight Loss – A slight decrease in weight (about 0.5 to 1.5
kg) occurs around 1-2 days before onset of labor due to
decreased water retention as a result of decreased
progesterone
4. Increased Activity Level= ENERGY SPURT
 - Toward the end of the pregnancy, some women experience

a sudden increase in energy coupled with a desire to


complete household preparations for the new baby.
- Increased secretion of adrenaline in preparation for much
work ahead = labor.
- Should be reserved for labor
 5.Increased Braxton Hick’s Contractions
- B-H is irregular painless practice contractions,
which may appear even on 6th month. Usually felt
in the abdomen or groin region and patients may
mistake them for true labor
- It may reach an uncomfortable level.
- Will not dilate cervix but ripen it, in preparation
for spontaneous labour onset.
6. Cervical changes.
- Ripening of Cervix: Cervix becomes butter-soft and may

dilate 1-2 cm.


 The cervix softens (“cervical ripening”), stretches, and thins,

and eventually is taken up into the lower segment of the


uterus. This softening and thinning is called cervical
effacement.
7. Backache due to fetal descent, as a consequence of
lightening.
8. Gastrointestinal disturbances: diarrhea, nausea, vomiting
or indigestion occur as a result of increased nerve
innervation due to descent of the presenting part.
FIRST STAGE OF LABOUR
• This is known as the stage of cervical dilatation.
• This stage begins when regular, painful uterine contractions
start and is detected clinically by the thinning and
effacement of the cervix, followed by its dilatation.
• The normally thick cervix becomes thinned out and
stretched over the presenting part.
• The first stage is completed when the cervix is fully dilated
and the presenting part starts being expelled.
• This stage has two phases;
 Latent phase

Latent phase
- Slow period of cervical dilatation from 0-4cms
- It is the period of gradual shortening of the cervix
(cervical effacement) where the cervix shortens from 3
cm to <0.5 cm long.
- Lasts for 6-8 hours in primigradivae
Active phase
-Faster/rapid period of cervical dilatation from 4-10cms or
full cervical dilatation, with rhythmic regular uterine
contractions.
PHYSIOLOGY OF 1
ST

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

• By the end of pregnancy, the uterus is divided into two


anatomically distinct segments, known as the upper and
the lower uterine segments.
• The upper uterine segment is a thick muscular, contractile
area from where the contractions begin. The longitudinal
fibres retract, pulling on the lower segment and causing it
to stretch, pushing the head down.
• The lower uterine segment is thinner and develops from the
isthmus of the uterus about eight to ten centimeters in
length and is prepared for distension and/or dilatation. The
lower segment stretches when being pulled by the
longitudinal fibres.
• When labour begins, the retracted longitudinal fibres in the
upper segment pull on the lower segment causing it to
stretch.
• The force applied by the descending head or breech also aids
the stretching.
v) THE RETRACTION RING
• A retraction ring which is an imaginary ridge, forms between
the upper and the lower uterine segment. It is present in every
labour and is perfectly normal as long as it is not marked
enough to be visible above the symphysis pubis.
• When retraction ring is seen above the symphysis pubis, it
indicates obstructed labour when lower segment thins
abnormally. May also indicate fetal compromise.
• The physiological ring gradually rises as the upper uterine
segment contracts and retracts and the lower uterine segment
thins out to accommodate the descending fetus. Once the
cervix is fully dilated and the fetus can leave the uterus, the
retraction ring rises no further.
vi) CERVICAL EFFACEMENT
• ‘Effacement’ refers to the inclusion of the cervical canal
into the lower uterine segment.
• This process takes place from above downward; i.e. the
muscle fibres surrounding the internal cervical os are
drawn upwards by the retracted upper segment and the
cervix merges into the lower uterine segment
• The cervical canal widens at the level of the internal os
whereas the condition of the external os remains
unchanged
• Effacement may occur late in pregnancy, or it may not take
place until labour begins
vii) CERVICAL DILATATION
• Dilatation of the cervix is the process of enlargement of the
os uteri from a tightly closed aperture to an opening large
enough to permit passage of the fetal head
• Cervical dilatation is measured in centimeters & full dilatation
at term is 10 cm
• Cervical dilatation occurs as a result of uterine action & the
counterpressure applied by either the intact bag of
membranes or the presenting part, or both.
• A well flexed fetal head closely applied to the cervix favours
efficient dilation. Pressure applied evenly to the cervix causes
the uterine fundus to respond by contraction & retraction.
viii) SHOW
• Throughout pregnancy the cervical canal is sealed by a
plug of mucus known as an operculum. Together with
the intact membranes this prevents organisms ascending
into the uterine cavity.
• When labour starts, the internal Os is pulled away from
the fetal membranes and the canal is opened up. This
releases the mucous plug which oozes out of the vagina
mixed with a little blood. This is called the 'show'.
FURTHER DESCRIPTION OF TERMS
Contraction:-The uterine muscles contract repeatedly,
becoming progressively shorter and thicker.
Retraction:-A unique property of uterine muscle fibre
• it means the contraction does not pass over entirely;
• the muscle fibre does not return to its original length;
• it retains some of the contraction, thus becoming
progressively shorter and thicker
• this progressively reduces the capacity of the uterine cavity
• NB: The muscle fibre of the upper segment mainly contracts
and retracts-relaxes slightly
• Relaxation:-relaxation of the muscle fibres of the lower
segment results in progressive thinning and lengthening of
this segment and subsequent dilation of the cervical os
• When these processes are normal, the result is good
outcome of labour in that:-
– Contraction and retraction provide sufficient force to
expel the foetus without overtiring the uterus
– Relaxation-Ensures an adequate oxygen supply to the
foetus since during a contraction the blood supply is
diminished as the placenta is squeezed
3. MECHANICAL FACTORS
a) FORMATION OF THE FOREWATERS:
• As the lower uterine segment forms & stretches, the chorion
becomes detached from it & the increased intrauterine pressure
causes this loosened part of the sac of fluid to bulge downwards into
the internal os to the depth of 6-12 mm.
• The well flexed head fits snugly into the cervix & cuts off the fluid in
front of the head (forewaters) from that which surrounds the
body(hindwaters)
• The effect of separation of the forewaters prevents the pressure that
is applied to the hindwaters during uterine contractions from being
applied to the forewaters. This may help keep the membranes intact
during the 1st stage of labour and be a natural defence against
ascending infections.
b) GENERAL FLUID PRESSURE
• While the membranes remain intact, the pressure of the
uterine contractions is exerted on the fluid & as fluid is not
compressible, the pressure is equalized throughout the uterus
& over the foetal body. This is known as general fluid pressure
• When the membranes rupture & a quantity of fluid emerges,
the placenta, fetal head, and umbilical cord are compressed
between the uterine wall & the foetus during contractions &
the oxygen supply to the foetus is thereby diminished.
Preserving the integrity of the membranes, therefore,
optimizes the oxygen supply to the foetus & helps prevent
intrauterine fetal infection especially in longer labours.
c) RUPTURE OF THE MEMBRANES

• The optimum physiological time for the membranes to


rupture spontaneously is towards the end of the first stage
of labour after the cervix becomes fully dilated & no longer
supports the bag of forewaters. The uterine contractions are
also applying increasing expulsive force at the time.
• Occasionally, the membranes do not rupture even in the
second stage & appear at the vulva as a bulging sac covering
the foetal head as it is born. This is known as the ‘caul’
d) FOETAL AXIS PRESSURE
• During each contraction, the uterus rises forward & the
force of the fundal contraction is transmitted to the
upper pole of the foetus, down the long axis of the
foetus & applied by the presenting part to the cervix.
This is known as ‘foetal axis pressure’ & becomes more
significant after rupture of the membranes & during
second stage of labour
SPECIFIC MANAGEMENT OF 1ST STAGE
OF LABOUR
INTRODUCTION
 The aim of management is to prevent/ detect complications as

early as possible so that the necessary interventions are put into


place to deliver a healthy neonate and end up with a healthy
mother.
 The proper management of labour is essential, if you are to

avoid problems or to detect them early when they occur. The


patient will come to you believing she is in labour. You should
be able to assess and decide whether she is in labour or not. The
patient may be in early labour, but often she might arrive in the
late second or even third stage.
 Ifyou are sure she is not in labour send her home to wait.
If she is in labour, keep her in the ward and continue
monitoring her progress.
Note: No labour should be assumed normal until the
fourth stage has successfully concluded
ADMISSION
 Activities to be carried out on admission;
 History Taking
 A detailed personal history should have been taken during

pre-natal care. However, if this has not been done, this is


a good time to get it recorded. Make sure the names are
correctly spelled because this can eventually result in
problems when registering the baby.
Review the last date of menstruation to calculate the
expected date of delivery.
Check her age, parity and contraceptive history.

Assuming that a detailed personal history had been


taken during pre-natal care, you should now take
information about the following:
Any presence of show
Presence or absence of contractions
Onset of contractions and their characteristics
Activity of the foetus
Rupture of the membranes
Any treatment given
Food taken in the last four hours
HEAD TO TOE PHYSICAL EXAMINATION
 Start by explaining to the mother that you want to
examine her. The health care provider should appreciate
the psychological aspect of a woman in labour, respect her
feelings and the need for company or privacy. They
should support the woman and her partner or family
during labour, birth and the immediate postpartum period
How to Examine the Mother Systematically
When examining her, check on her general condition.

Check if she is exhausted, anaemic, in great pain,


dehydrated, or with generalized oedema. You should
also check her height. This will enable you to exclude
any risk factors.
You should also take her vital measurements including

her blood pressure, pulse, temperature, and respiratory


rate
Conduct an abdominal examination checking for:
 Height of fundus
 Over-distension of the abdomen, scars or other
abnormality
 Over-distension of bladder
 Possible presence of twins or multiple pregnancy
 Contractions - frequency, length, type and strength
 Lie of foetus - this is the relation of the long axis of the

foetus to the long axis of the uterus (it can be longitudinal,


oblique or transverse)
 Rate and rhythm of the foetal heart
VAGINAL EXAMINATION IN LABOUR
 This is an important examination carried out in labour as it
can give you a lot of information, which you might not get
from an abdominal examination. On the other hand, if you do
it often it is uncomfortable for the woman and you might
introduce an infection into the uterine cavity, especially if the
membranes have ruptured.
Note: Do not do a vaginal examination if the mother has an
ante-partumhaemorrhage, because if there is placenta
praevia, severe haemorrhage will occur
INDICATIONS FOR A VE
These are to;
 Make a positive identification of presentation
 Determine whether head is engaged incase of doubt
 Ascertain whether the forewaters have ruptured or to

rupture them artificially


 Exclude cord prolapse after rupture of the forewaters

especially if there is an ill-fitting presenting part or the foetal


heart rate changes
Assess progress or delay in labour
Confirm full cervical dilatation
Confirm the axis of the foetus & presentation of

the second twin in multiple pregnancy


METHOD/PROCEDURE OF
PERFORMING A VAGINAL EXAM
VE during labour is an aseptic procedure
Explain procedure to the patient & give her an

opportunity to ask questions.


Observe patient’s privacy & avoid unnecessary

exposure by screening the bed & closing the nearby


windows
Ensure that her bladder is empty
Bring the trolley and dirty bin near
 Perform abdominal palpation to assess the fundal height,
lie, position & FHR
 Scrub your hands for at least five minutes & Glove

yourself methodically to prevent contamination.


 Explain the semi-lithotomy position that should be

maintained during the examination to the mother.


 Check vaginal loss for its type and colour
 Swab the vulva with antiseptic lotion with the left hand
 Lubricate the 1st and 2nd fingers of the gloved hand with

hibitane obstetric cream


 Inspect the vulva and perineum for warts, varicose veins or
scars
 With the right hand, gently insert the lubricated fingers

obliquely inside the vagina with the thumb, facing the


symphysis pubis and note the condition of the following:
Vagina- check for texture and temperature
Cervix- check for position, length, texture and dilatation
Membranes- check whether intact or ruptured
Forewaters- whether formed, forming, already formed and shape
Check for level of presenting part
Confirm position, degree of moulding and caput succedaneum

NB: Your left hand should be on the mother’s abdomen during


The fingers to be introduced are held on a higher
level than the vaginal orifice during insertion to avoid
contact with the anus. Fingers should not be
withdrawn until the required information has been
obtained.
The fingers are directed along the anterior wall of the

vagina. The wall should feel soft and dilatable while


the vagina should be warm and moist.
The fingers are then directed upwards to the position

of the cervical Os.


 At times the Os is not felt readily, the fingers should then
be directed backwards and upwards
 Depending on the level of the presenting part, reach the

promontory of the sacrum


 Check the ischial spines: whether prominent or blunt
 Check the pubic arch: whether it can accommodate two

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

trolley and dirty bin for clearance.


IN SUMMARY, THE FOLLOWING ARE THE
FINDINGS OF A VE WHICH SHOULD BE
DOCUMENTED:
 Observe the labia for any sign of varicosities, oedema or
vulval warts or sores
 Note whether perineum is scarred from a previous tear or

episiotomy
 Note any discharge or bleeding from the vaginal orifice
 If membranes have ruptured, colour & oduor of any

amniotic fluid or discharge are noted


THE CERVIX
Is it bruised or oedematous?
Is it firm or soft?
Is it taken up, that is effaced?
How much is the Os dilated?
THE MEMBRANES
After deciding the state of the cervical Os, check

for presence of membranes. Note the following:


Are they ruptured or intact?
If intact are they bulging?
THE CORD
Is it presenting or prolapsed?
If prolapsed is it pulsating?
THE PRESENTING PART
Next, determine the level of the presenting part.
The station or level of the presenting part is the level

to which the presenting part has descended in the


pelvis.
When assessing vaginally, the level of the presenting

part is expressed in relation to the easily palpable


ischial spines. state if it is above the brim, at the brim,
in the cavity or at the outlet
POSITION
 Observe the position of the presenting part.
This is the position of the foetal parts in relation to the
parts of the pelvis. A point on the foetus, such as the
occiput in a vertex presentation, is usually used as
a reference point.
 To get the position right, you have to palpate the sutures

and fontanel to determine their position relative to the


pelvis.
In a cephalic presentation, you will feel the hard
head sutures and fontanel. Determine whether it is
the anterior or posterior fontanel by its shape. If it is
the posterior fontanel, then the position is
occipito-anterior. If it is the anterior fontanel
then the position is occipital-posterior
MOULDING
 Check for moulding or caput succedaneum
 Moulding is when the diameters of the foetal skull are reduced

in size. During labour the bones of the foetal skull tend to


overlap at the sutures so that the head can easily pass through
the birth canal
 Moulding is judged by feeling the amount of overlapping of

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

overlapping of skull bones & determine whether the skull


bones are:-
Not overlapping/ not touching each other = o
Just touching each other = +
Slightly overlapping = ++
Severely overlapping = +++
 Check for caput succedaneum
THE VAGINAL DISCHARGE
Withdraw the fingers and check if there is:
Any vaginal discharge
Any smell
Any liquor or meconium staining
Any bleeding
The following steps should further be taken as part of your
investigation:
 Take a urine sample for albumin and sugar
 Check for acetone, especially if the patient is in prolonged

labour
 Take blood for haemoglobin and cross matching if the

patient is anaemic or might need an operation


 By this time you will have gathered enough information as

to the stage of labour and whether the patient belongs to


the ‘at risk’ category and needs referral or not.
CLEANLINESS AND COMFORT
Bowel preparation
If there has been no recent bowel

action( depending on the woman’s normal


bowel habits), or the rectum feels loaded on
vaginal examination, the woman should be
consulted and asked if she would like an
enema or supporsitories. This is however
never done as a routine procedure
EMTCT DURING LABOUR
ELIMINATION of mother to child transmission of HIV during
labour and delivery
Goals of interventions: these are to:
 Identify HIV-positive women
 Provide adequate EMTCT coverage
 Continuity of care of prophylactic and treatment
antiretroviral regimens
 Reduce maternal nevirapine resistance
 Initiate neonates born to HIV-positive mothers with

antiretroviral prophylaxis immediately at birth


MEASURES TO BE TAKEN TO PREVENT
HIV TRANSMISSION DURING LABOUR:
1. Use universal precautions for all patients. These include:
Wearing of Protective gear e.g. sterile gloves, apron, boots
e.t.c
Safe use and disposal of sharps
Sterilization of equipment immediately after use
Safe disposal of contaminated materials
2. Minimize vaginal examinations by performing them only
when necessary (strictly 4 hourly) and recording all vaginal
examinations performed
3. Use of the partograph: Proper and consistent use of the
partograph in the monitoring progress of labour will improve
the management and reduce the risk of prolonged labour in
all women.
4. Avoid artificial rupture of membranes unless necessary
5. Avoid unnecessary trauma during delivery i.e.
Avoid invasive procedures, such as using scalp
electrodes or scalp sampling
Avoid routine episiotomy unless where absolutely
unavoidable
Minimize the use of forceps or vacuum extractors during
the delivery
6. Minimize risk of postpartum haemorrhage through:
 Active management of the third stage of labour
 Carefully remove all products of conception
 Carefully repair genital tract lacerations and tears

7. Use safe blood transfusion practices i.e


Minimize use of blood transfusions
Use only blood screened for HIV , Syphilis, malaria ,hepatitis
B and C
8. Elective C/S. Caesarean section performed before the onset
of labour or membrane rupture has been associated with
reduced MTCT of HIV.
HIV TESTING DURING LABOUR
 A woman of unknown HIV status at labour should be

offered HIV testing and counseling.


 ARV prophylaxis, when initiated during labour for 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

be an effective form of pain relief that allows increased mobility


with no increased incidence of adverse outcome for the mother
or baby
Clothing
 The woman should be given a clean, loose gown to wear or one

that she feels comfortable in immediately upon admission


RECORDS
 The
midwife’s record of labour is a legal document and must
be kept meticulously/accurately. The records may be
examined by any court for up to 25 years, they may go b4
the nursing council professional conduct or health
committee and may be examined
Half hourly- maternal pulse, contractions for length,
strength and frequency & the Foetal Heart Rate
(FHR)
Every 1½ - 2 hours check bladder
Every 4 hours – B/P. Temperature, abdominal

examination for descent, V.E, urine test acetone,


albumin
THE PARTOGRAPH
PARTOGRAPH SYMBOLS
FETAL
HEART
LIQUOR I = Intact

C = clear

M= meconium stained

B= blood stained

MOLDING O= Bones are separated & sutures can be felt easily

+= Bones are just touching each other.

++= Bones are overlapping but can be separated easily with


pressure from your fingers.

+++ = Bones are severely overlapping but cannot be separated


easily with pressure from your fingers 340
Partograph symbols ct’
Dilatation X

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

monitor, document and manage labour.


 The partograph gives a complete picture of maternal and fetal

well-being and labour progress at a glance & provides guidelines


on when labour is no longer normal.
 The partograph is a graphic presentation of the progress of

labour, which outlines the progress of a woman in active labour


including the foetal and maternal condition.
The partograph serves as an ‘early warning system’
& assists in early decision on transfer,
augmentation & termination of labour.
It also increases the quality & regularity of all

observations on the fetus and the mother in labour


and aids in early recognition of problems with
either.
OBJECTIVES OF PARTOGRAPHING
These are to:
 Detect abnormal progress of labour as early as possible so that

appropriate intervention(s) are taken e.g. emergency caesarean section


 Monitor & prevent prolonged labour thru’ accurate charting and

interpreting the partograph


 Recognize cephalopelvic disproportion long before obstructed labour

 Assist in early decision on transfer, augmentation or termination of the

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

active phase of labour (from 4 cms)


Points to remember when starting a partograph:
1. The partograph is only started when the mother is in the
active phase of the first stage of labour, i.e. cervical dilatation
of 4cm & above
2. The latent phase is from 0-4cm dilatation & is accompanied by
gradual shortening of cervix. It should normally not last longer
than 8 hrs.
The active phase is from 4-10cms & dilatation should be at the rate
of at least 1cm/hr in a primigravida.
3. When labour progresses well, the dilatation
should not move to the right of the alert line.
4. When admission to hospital takes place in the
active phase, the cervical dilatation is immediately
plotted in the alert line
5. When labour goes from latent to active phase
plotting of the dilatation is immediately
transferred from the latent phase to the alert line.
Plottingthe partograph helps alert the provider
to problems and needed action in time for a
prompt life-saving intervention to occur.
OBSERVATIONS CHARTED ON THE
PARTOGRAPH
a) The progress of labour
- Cervical dilatation
- Descent of fetal head
 Descent: abdominal palpation of fifths of head felt above

the pelvic brim


 Uterine contraction

- Frequency per 10 min


- Duration /shown by different shading
b) The fetal condition
- Fetal heart rate & rhythm
- Membranes & liquor (whether ruptured or intact)
- Moulding of the fetal skull
c) The maternal condition
- Pulse, B/P temperature
- Drug and IV fluids given
- Urine /volume, protein, acetone/
- Oxytocin regimen

*** EXERCISE ON PARTOGRAPHING


SPECIFIC MANAGEMENT OF FIRST
STAGE OF LABOUR CNTD’
 Admit the patient to the waiting room, reassure her and
introduce her to other patients
 Reassure her and explain what is being done at every stage
 Give her an enema only if she is in early labour (this will

reduce the risk of faecal soiling and infection at delivery)


 The patient may have a warm bath and change into a clean

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

needs of the individual and provide an environment


within which each woman will deliver with dignity
ENVIRONMENT
It is important that the woman is welcomed and made to
feel at ease and that the mw spends time actively
listening as the woman recounts the details of the onset
of labour
She should be nursed in a clean environment
EMOTIONAL SUPPORT
 The MW has a traditional role to fulfil. i.e. being
‘with woman’ by monitoring the progress of labour
and assessing the physical state of mother and foetus
 Emotional support is provided by imparting

confidence, expressing caring, dependability and


being an advocate for the child bearing woman
COMPANIONSHIP IN LABOUR
 Research has shown that continous one to one support of
a woman during labour creates a strong feeling of
security & satisfaction & is associated with a reduction
in the length of labour, fewer perinatal complications
and a reduced incidence of oxytocin augmentation
 Admission to hospital is always a traumatic experience
& the company of a supportive companion can help
reduce the anxiety. Sometimes, the mw may double as
the companion since not all women are glad to have a
husband or companion present
MANAGEMENT OF FIRST STAGE OF LABOUR
CTND…
 Encourage her to walk about and empty her bladder
frequently
 Encourage the woman to take fluid diet soup, fruit

juice, salt lemon juice or plain water


 Do not allow any solid foods as the stomach takes a

long time to empty in labour


Check the following regularly:
 Check the foetal heart rate half hourly or more often if you

suspect foetal distress


 Check uterine contractions ½ hourly (strength, type, frequency

and duration) as well as maternal pulse.


 Four hourly, BP and temperature.
 Check the urine output and check for albumin and acetone.
 Every four hours check the level of the presenting part
and the degree of dilatation of the cervix
 Constantly check the woman's reaction to labour and be

aware of her needs, especially for pain relief.


 You can repeat pethidine 50 mg IM if cervical dilatation is

still 5 cm or less. Do not give more pethidine if delivery is


imminent as it depresses the baby's respiration
 Towards the end of the first stage, she can rest on her side,
or in any position she finds comfortable, for example,
squatting
 Discourage early pushing or bearing down before the cervix

is fully dilated. Early pushing only exhausts the woman and


will cause oedema of the cervix and interfere with normal
cervical dilatation
 If the bladder is full and she cannot empty it on her own,
catheterize her using aseptic technique
 When the membranes rupture, usually at the end of the

first stage, check the colour of the liquor for meconium


staining, the foetal heart rate and do a vaginal
examination to exclude prolapse of the foetal umbilical
cord
 The descent of the presenting part can be noted by abdominal
palpation or vaginal examination
 After conducting a thorough examination of the mother and

recording your observations in the partogram, there are a


number of things you can do to make her feel comfortable
during her labour i.e.. allow her to change position and move
around, use back massage, have a chosen companion with her
during labour, allow her to take fluids as required and return
the placenta to parents if so desired and directed by the
culture.
 However do not forget to check on the foetus especially if you

suspect foetal distress.


Control of pain may be achieved by:
Change of position/ moving around,
Touch and back massage from a companion or the MW
Breathing techniques e.g. breathing in/out through an

open mouth
Verbal coaching and relaxation to help draw her attention

away from labour pain (diversional mthds of pain mgt)


 Warm bath or shower
 Use of pharmacological agents e.g. tramadol 100mg IM or

slow IV 6-8 hourly, pethidine 50-100 mg IM or IV slowly 6-


8 hourly, inhalational nitrous oxide combined with 50%
oxygen (Entonox) or epidural analgesia where available,
however, exercise much caution when using
pharmacological agents for pain relief in labour becoz of
the risk of foetal distress
Note!
* Discourage supine position!
The supine position causes compression of the client’s aorta and
inferior vena cava by the fetus. This, in turn, inhibits maternal
circulation, leading to maternal hypotension and, ultimately, fetal
hypoxia
The other positions promote comfort and aid labor progress. For
instance, the lateral, or side-lying, position improves maternal and fetal
circulation, enhances comfort, increases maternal relaxation, reduces
muscle tension, and eliminates pressure points.
The squatting position promotes comfort by taking advantage of gravity.
The standing position also takes advantage of gravity and aligns the
fetus with the pelvic angle.
Role of the midwife in caring for a woman
in 1st stage of labour.
Admitting client to birthing area after determining that client is in labor
Determining if client's membranes have ruptured
Encouraging family participation as appropriate with the labor process
Performing Leopold maneuver and vaginal exams as appropriate
Monitoring maternal vital signs and fetal heart rate and patterns,
reporting any deviations or abnormalities
Applying electronic fetal monitor as appropriate
Assessing pain level, instituting positioning, breathing, relaxation, and
other methods for pain control; administering analgesics as ordered
Role of the midwife in caring for a woman in
1st stage of labour ct’
Encouraging voiding at least every 2 hours
Assisting with amniotomy with assessment of fetal heart rate, fetal
positioning, and fetal cord after amniotomy
Cleansing perineum and assisting with pad changes regularly
Monitoring progress including vaginal discharge, cervical dilation and
effacement, position, and fetal descent
Performing vaginal examinations as necessary
Preparing supplies and equipment for delivery
Verifying maternal and fetal heart rate response to uterine contractions
during intrapartal care
ARTIFICIAL RUPTURE OF THE
MEMBRANES
Also referred to as amniotomy & is abbreviated
as ARM (acronym)
DEFINITION
It is a procedure aimed at tearing the fetal
membranes resulting in drainage of liquor amnii
NOTE: the procedure is contraindicated in all HIV
positive clients becoz of the risk of increased
transmission of the virus to the fetus
INDICATIONS OF AMNIOTOMY:
To induce labour. Only recommended after ensuring
that the cervix is ready for labour but contractions fail
to start spontaneously as in a case of prolonged
pregnancy
To augment (accelerate) labour. Contractions are weak
in the active phase. Engagement must have occurred
Presence of caul. Failure for spontaneous rupture of
membranes to occur in early 2nd stage
To visualize the colour of liquor especially if fetal
compromise is suspected
To allow application of fetal scalp electrode hence
continous fetal heart rate monitoring
PREPARATION
MOTHER (CLIENT)
Explain the procedure briefly & obtain an informed verbal
consent
Instruct her to empty her urinary bladder and remove
inner wear if not in labour
Instruct her to lie on the couch in lateral position
EQUIPMENT
This is a sterile procedure
Have a sterile vaginal examination pack
Add a sterile pair of an amniohook/ amniotic hook
A sanitary towel
ENVIRONMENT
For any sterile exam
SELF (MIDWIFE)
Initially, handwashing, later surgical handscrubbing
and wear gloves correctly
PROCEDURE
While the client is in supine position, perform an
abdominal examination to assess soecifically;-
Presentation & engagement- whether it has
occurred. If not don’t do ARM
Auscultate the fetal heart sounds
Thereafter perform a VE & assess the following:
State of the cervix & its application to the
presenting part
The presentation and descent
Establish the state of membranes & shape of
the forewaters
Assess for cord presentation, if present,
abandon the procedure
If all factors are favourable, pick the amniohook
with the left hand and insert it into the vagina
while still closed
Open it near the membranes & guide the hook
with the 2 fingers in the vagina to pierce the
Confirm the presentation, position and
application of the presenting part to the
cervix. If poor, ask the mother to bear down
(push) during a contraction in order to
improve it hence prevent the hindwaters from
running out quickly
Make her comfortable
Instruct her to wear a sanitary towel &
change as soon as it gets soiled
Record the findings in terms of:-
1. Indication for ARM
2. Time and date carried out
3. State of liquor
4. State of cervix, dilatation, its application
5. Presentation, position and descent
6. Fetal heart sounds after the procedure
COMPLICATIONS OF ARM
1. Cord prolapse. Due to undiagnosed
malpresentation or if the head had not yet fully
engaged
2. Intrapartum haemorrhage. Premature
separation of the placenta, following fast
drainage of hindwaters
3. Fetal hypoxia. Due to severe compression of the
placenta during each contraction
4. Intra-uterine infection. From digital or
contaminated instruments due to failure to
strictly observe aseptic technique
ASSIGNMENT:
 Read& make notes on pain management in labour
 REFERENCE:

MYLES TEXTBOOK FOR MIDWIVES, AFRICAN


EDITION PG.485-500
COMPLICATIONS OF 1ST STAGE OF LABOUR
1. Prolonged labour
2. Obstructed labour
3. Fatal hypoxia/ distress
4. Maternal distress
5. Cord presentation/ prolapse
6. Uterine rupture
7. Sudden intra-uterine fetal death
8. Intrapartum haemorrhage
9. Pre-eclampsia/ eclampsia

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

Once the occiput has escaped from under


the symphysis pubis, the head extends
forward. The nape of the neck is pressed
firmly against the pubic arch.
This extension of the head causes the
anterior part to stretch the perineum
gradually.
Further extension allows the sinciput,
face and chin to sweep the perineum and
the head is born by extension.
Extension is the result of action from
two forces. The abdominal and thoracic
muscles exert downward pressure. The
pelvic floor and perineum resist this
pressure and push the head forward and
upward through the weak area, which is
the vagina.
RESTITUTION OF THE HEAD
• The twist in the neck of the fetus which resulted from
internal rotation is now corrected by a slight untwisting
movement.
• Therefore, the head turns 1/8 of the circle, back to where
it was before internal rotation of the head took place.
• This rotation takes place to undo the twist in the neck of
the fetus, which occurred during the previous internal
rotation of the head. This 'undoing of the twist' is known
as restitution.
INTERNAL ROTATION OF THE SHOULDERS
• The shoulders undergo a similar rotation to that of the head to lie
in the widest diameter of the pelvic outlet= AP diameter.
• When the head is passing through the level of the ischial spines
and the outlet in anterior posterior position, the shoulders enter in
the oblique diameter of the pelvis.
• The anterior shoulder reaches the pelvic floor first & therefore
rotates anteriorly 1/8th of a circle to lie directly below the
symphysis pubis
• The shoulders are now in the anterior posterior diameter of the
outlet.
• The anterior shoulder escapes the symphysis pubis while the
posterior shoulder sweeps the perineum.
EXTERNAL ROTATION OF THE HEAD

• As the internal rotation of the shoulders takes place, the head,


which has already been born, rotates externally 1/8 of a circle
in the same direction as restitution. The occiput of the fetal
head now lies in the lateral position.
LATERAL FLEXION OF THE BODY
• Following these movements the body bends sideways to
follow the curve of the birth canal.
The anterior shoulder escapes under the symphysis pubis
and the posterior shoulder sweeps the perineum. The body
of the baby is born by lateral flexion.
• To recap, the cardinal movements of labour in a vertex presentation are:
– Engagement
– Descent and
– Flexion
– Internal rotation of the head
– Birth of the head by Extension
– Restitution of the head
– Expulsion of the body=
• Internal rotation of the shoulders,
• External rotation of the head &
• Lateral flexion of the body
• An easy way to remember these movements is by use of the mnemonic
device -'Every Decent Family In Europe Eats Eggs'.
SPECIFIC MANAGEMENT OF THE
SECOND STAGE OF NORMAL LABOUR
Equipment needed during the second stage of labour:
( see procedure manual pg241)
• On the top shelf make sure you have:
– Sterile delivery pack( list the contents of a
delivery pack from procedure manual)
• On the bottom shelf you should have the following:
– Suturing pack
– Antiseptic solution
– Draw sheet and mackintosh
– Syntocinon drawn, in a receiver
– Lignocaine
– 5% dextrose solution 500mls
– Needles
– Branulars
– Syringes (for emergency)
– Sterile gloves
Extras
– Small bucket with 0.5% jik for decontaminating
instruments
– Bucket with 0.5% jik for
decontaminating linen
– A bucket with plastic bag for used swabs and
gloves
The role of nurse in caring 4 the woman in the second stage of labour

• Notifying the delivery team


• Setting up trays for delivery
• Providing a warm environment for the newborn
• Checking for the working condition of the neonatal
resuscitation
• Preparation of delivery room
• To assist in the natural expulsion of the fetus slowly and
steadily.
• To prevent perineal injures.
• To assist labour under aseptic precautions
• Vigilant monitoring of maternal vital sign and fetal heart
rate.
• Encouraging spontaneous bearing-down efforts for second
stage
• Evaluating pushing efforts and length of time in second
stage
THE FOLLOWING STEPS ARE SUGGESTED IN
THE MANAGEMENT OF THE SECOND STAGE
OF LABOUR:
• Explain the procedure to the mother and reassure her
• Ask your assistant to open and arrange the delivery pack while you
scrub up
• Gown and glove yourself methodically
• Swab the mother methodically
• Lubricate your two fingers and perform vaginal examination to confirm
second stage
• instruct your assistant to check the foetal heart beat after every
contraction, the mother's pulse after every ten minutes and to
administer syntocinon after the delivery of the baby
• Tell the patient to wait for a contraction. When it comes, she
should take in a full breath, close her mouth and bear down
as strongly as she can, then quickly take in another breath
and bear down again.
• She should be able to make at least two efforts during each
contraction and relax between contractions. Encourage her
all the time and explain the progress being made towards the
birth of her baby
• Place the baby towel on the bed, with the scissors and
two forceps for clamping the cord. Prepare two pieces of
cotton wool for wiping the newborn’s eyes, some gauze
for cleaning the airway and for a covering when cutting
the cord.
• At this stage the head might start distending the
perineum. The anus starts dilating and the head is seen at
the vulva. It keeps receding between contractions.
• When the head distends the perineum check if the
perineum is stretching well.
• Place the left hand on the advancing head with fingers
spread equally over the vertex towards the bregma to
stop any sudden explosive effort during and after
crowning of the head. With the right hand guard the
perineum, holding it with the pad.
• Check if the perineum is stretching. If not, give an
episiotomy at the height of a contraction if there is any
indication that the head is about to crown.
Crowning of the Head
• Next is the crowning of the head. The parietal eminences
pass through the bony outlet. At this stage the head no
longer recedes between contractions
-During crowning of the head,
• Tell the mother to stop pushing as this might lead to a
rapid delivery of the head and consequent brain damage.
• Ask her to pant thru’ an open mouth.
• Research has shown that a series of short pushes are
more effective than a long push. Encourage her as she
pushes
Extension of the head
• Assist the extension by gently grasping the parietal
eminences with your left hand. Let the head come out
slowly and naturally.
• Feel for the cord around the baby's neck. If it is there, slip
it from the baby's neck over the head. If it is too tight,
place two artery forceps on the cord and cut it between
them.
• When the nose and mouth come out, wipe away the
mucus with a sterile swab. By this point the whole head
should be out.
• The head will have restituted and rotated
spontaneously to face the mother’s left or right
thigh. This shows you that the shoulders have
descended and rotated to the anterior posterior
diameter of the pelvic outlet.
Delivering the Shoulders by Lateral Flexion of the Body

The following procedure should be followed when


delivering the shoulders by lateral flexion of the body:
• Place one hand above and one below the foetal head
• Depress the head gently towards the anus/neck,
making sure it is neither twisted nor bent sideways till
the anterior shoulder is free under the syphysis pubis
• Remind your assistant to prepare to give syntocinon
10 I.U intramuscularly (in a single dose) after
delivery of the baby.
• Guide the head upwards in the direction of the
mother's abdomen to deliver the posterior shoulder
and the rest of the body.
• The posterior shoulder will sweep the perineum smoothly
and be born & the rest of the body will be born by lateral
flexion.
• Ask your assistant for the time and note the time of birth & to
administer syntocinon (oxytocin) to the mother 10 I.U
intramuscularly.
NOTE: -Syntocinon injection is provided as a sterile solution for
intravenous or intramuscular administration & is indicated to
produce uterine contractions during the third stage of labor and
to control postpartum hemorrhage.
• Place the baby on the mother’s abdomen at a slight slant to
drain the mucous
• Put the baby on the baby towel, clamp and cut the cord
• NB:
1) It’s encouraged to practice delayed cord clamping
(usually 2-4 minutes)unless under these circumstances:
– Where the mother is rhesus negative
– Where the mother is HIV positive
2) Delayed cord clamping enables the baby be born with a
high h.b, increases the iron stores in the newborn and lowers
the level of early childhood anaemia.
• Give the APGAR score to the baby a one minute.
• Show the baby to the mother & let her identify the sex of
the baby by saying loudly for the attendants in the labour
ward to hear and confirm.
• Ask your assistant to continue with the immediate care of the
neonate.
• Continue with the delivery of the placenta by using controlled Cord
traction (CCT).
• Check the placenta for completeness and/or malformation.
• Measure/estimate the blood loss and intervene where necessary.
• Do the first/initial examination of the baby
• Weigh the baby
• Do a post natal examination on the mother and record all the
findings
• Give the mother a free hot drink and transfer her to the postnatal
ward
EPISIOTOMY
Definition
This is an incision made through the perineal tissues
which is used to enlarge the vulval outlet during
delivery
This is a technique each midwife should master while
in the labour ward.
This competence is achieved through observing an
experienced midwife conducting the procedure. It is
an aseptic procedure
INDICATIONS OF AN EPISIOTOMY
 Rigid perineum, mostly in primigravidae
 Poor maternal effort or maternal distress in perineal phase of
second stage
 Prolonged 2nd stage of labour with foetal head bulging the
perineum
 In case of foetal distress in second stage, to hasten delivery
 When the perineum threatens to tear, for example, in persistent
occipito posterior position
 Prior to assisted vaginal delivery such as in low forceps or
vacuum delivery
 Pre-eclamptic mother- in order to hasten the delivery
 In mothers who have medical conditions such as cardiac
disease or diabetes mellitus, where rapid delivery is
required
 In delivery of preterm babies where the perineum Is tight to
minimize the risks of intracranial injury to the baby since
malpresentations are common in preterm labour & the fetal
head does not mould easily.
 In case the mother has had previous third degree tears
which had been repaired
 In malpresentations like breech delivery OR assisted
deliveries to prevent risks of intracranial injury to the baby
ADVANTAGES OF EPISIOTOMY
 Fetal acidosis and hypoxia are reduced since the delivery is
hastened.
 Over stretching of the pelvic floor is lessened due to timely
administration of the episiotomy
 Bruising of the urethra is avoided, hence prevents birth
complications e.g. VVF (Vesico-vaginal fistula).
 In severe pre – eclampsia or cardiac disease, episiotomy
reduces the effort of bearing down.
 A previous third degree tear which may occur again because
of the scar tissue which does not stretch well is prevented.
TYPES OF EPISIOTOMY INCISIONS
1. Mediolateral Episiotomy
 This is the most commonly performed episiotomy due to its safety

record. However, it is difficult to repair.


 It begins at the centre of the fourchette, directed posteriorly and

laterally.
 The incision is not more than 3cm & is made at 45° to the midline.

Move towards a point midway between ischio-tuberosity and the anus.


This is to avoid damaging the anal sphincter and the Bartholin’s glands
Advantages
 Bartholin glands are not affected

 Anal sphincters are not injured


2. Median Episiotomy
 This begins at the fourchette, is directed posteriorly for
approximately 2.5cms and stops just before the anal sphincter.
 It follows the insertion of perennial muscles and has minimal

bleeding due to few blood vessels in this area.


 It is easy to repair & less painful.

 However, there is the danger of the incision extending to the anal

sphincter
Advantages:
 It is associated with less bleeding

 More easily and successfully repaired

 Greater subsequent comfort for the women


3. J Shaped Episiotomy
 Not commonly performed.
 The incision begins at the centre of the
fourchette, is directed posterior for about 2cm
and then it is extended latero-posteriorly to
avoid damage to the anal sphincter.
 Suturing of this episiotomy is very difficult.
Disadvantages
 The suturing is difficult
 Shearing of the tissue occurs
 The repaired wound tends to be pucked
4. Lateral episiotomy
 Not used now.
 Unlike in all the other types, the incision does not begin at the

centre of the fouchette but on the side of the vaginal opening.


 The incision may extend leading to a severe vaginal tear and

excessive bleeding
Disadvantages
 Bartholins duct may be involved

 The levator ani muscle is weakened

 Bleeding is more profuse

 Suturing is more difficult

 The woman experiences subsequent discomfort


Performing an Episiotomy
 The timing of the incision is very important. It is best timed
when the presenting part is directly applied to the perineum
& the contractions are at their pick.
 An episiotomy involves incision of the Fourchette, the
superficial muscles and the skin of the perineum and the
posterior vaginal wall.
 If the episiotomy is performed too early, it exposes the
mother to a lot of bleeding. If performed too late, there will
not be enough time to infiltrate the anaesthesia. A tear may
already have developed before the midwife gives an
episiotomy.
 The main requirement for the procedure is a trolley with:
 Suture pack
 10mls syringes and needles
 Lignocaine also known as lidocaine ( 0.5% 10ml or 1% 5mls). The
advantage of the more concentrated sln is that a smaller volume
is needed. Lidocaine takes 3-4 minutes to take effect
 Chromic catgut (an absorbable suture).
 One Needle holder
 Artery forceps
 Toothed dissecting forceps.
 Mayo scissors for shortening the thread during the repair of the
episiotomy.
Procedure of performing an episiotomy
 Having prepared the above items, when the head reaches the pelvic
floor, two fingers of the non-dominant hand are inserted between the
perineum and the foetal head on the side of the proposed incision in
order to protect the fetal head.
 Lignocaine, 0.5% (10mls) or 1% (5 mls), is infiltrated into the area where
the incision has to be made, beneath the skin, for 4-5 cm following the
same line.
 The piston of the syringe should be withdrawn prior to the injection to
check whether the needle is in a blood vessel.
 Using the dominant hand, the midwife places the tip of the opened
scissors and makes an incision at the height of a contraction.
Important to note:
 The incision is best made during a contraction
when the tissues are stretched so that there is a
clear view of the area and bleeding is less
likely to be severe
 Delivery of the head should follow immediately
and it should be controlled to avoid extension of the
episiotomy.
 If there is delay before the head emerges, apply

pressure at the episiotomy site between


contractions to minimize bleeding. Use aseptic
techniques all through. PPH can occur froman
episiotomy site unless bleeding points are
compressed.
Procedure cntd…
 Direct your needle 4-5cm beneath the skin of the
proposed site of injection
 Ensure the needle is not in the blood vessel by drawing
back the piston
 If you withdraw blood, redirect the needle
 Inject the lignocaine as you withdraw the needle
 Distribute the anaesthesia by changing the direction of
the needle to two or more areas on the proposed
injection site
Toxic signs of local anaesthesia that you should be
aware of:
 Drowsiness
 Twitching of the face/lips

 Tingling in the area of the mouth

 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

haemorrhage (PPH). You should never leave the mother


alone even for a short while during this stage.
 The third stage of labour can be managed either passively

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

expelled and bleeding is controlled.


ACTIVE MANAGEMENT
- Giving uterotonic Drugs.
• Oxytocin, ergometrine or syntocinon stimulate uterine
contraction during the third stage of labour.
• Ergometrine 0.5mg given IM causes a uterine contraction to
occur five to seven minutes after the injection. Given
intravenously, it acts within 45 seconds.
• Syntometrine is a mixture of oxytocin and ergometrine 0.5ml
given IM acts within two to three minutes.
• Usually syntocinon (oxytocin) is the preferred uterotonic drug
& is given immediately after delivery of the baby, at a dosage
of 10 I.U intramuscularly.
DELIVERY OF THE PLACENTA AND THE MEMBRANES
- Methods of Delivery of the placenta and membranes
a) Controlled Cord Traction(CCT) method.

• Controlled cord traction involves traction on the umbilical cord


downward and forward, combined with counterpressure
upwards on the uterine body by a hand placed immediately
above the symphysis pubis.
• CCT is used in conjunction with drugs that speed up the
separation process i.e.. syntocinon.
PRE-REQUISITES PRIOR TO APPLICATION OF
CCT METHOD TO DELIVER THE PLACENTA

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

• The uterus is pulled ‘inside out’ as the baby or the


placenta is delivered, and partly emerges through the
vagina.

End
FOURTH STAGE OF NORMAL LABOUR
DESCRIPTRION:

 This is the period of maternal physiological adjustment that occurs after


delivery of the placenta and membranes to the end of the first 1-2 hours
postpartum, until the uterus remains firm on its own.
 During the 4th stage of labour, mother remains in labour ward where her
condition is assessed after delivery.
 In this stabilization phase, the uterus makes its initial readjustment to the non-
pregnancy state.
 The primary goal of the above is to prevent haemorrhage from uterine atony
& the cervical or vaginal lacerations
NOTE: Atony is the lack of normal muscle tone thus uterine atony is failure of
the uterus to contract, leading to postpartum haemorrhage.
 The uterus is firm at level of two fingers breadth below the
umbilicus.
 Restoration of physiological stability is established.
 During this period myometrial contractions and
retraction, accompanied by vessel thrombosis, operate
effectively to control bleeding from the placenta site.
Failure of this mechanism could result in excessive
blood loss (postpartum haemorrhage (PPH)) that could
be life threatening.
 The mother should be closely observed for
haemorrhage, urine retention or hypotension.
 The mother and child relationship should be initiated
and encouraged, as it has an effect to the subsequent
quality of their relationship and bonding
SPECIFIC NURSING/ MIDWIFERY CARE
DURING THE FOURTH STAGE OF LABOR

 Transfer the patient from the delivery table.


Remove the drapes and soiled linen. Remove both legs from the
stirrups at the same time and then lower both legs down at the same
time to prevent cramping. Assist the patient to move from the table to
the bed.
 Provide care of the perineum.
An ice pack may be applied to the perineum to reduce swelling
from episiotomy especially if a fourth degree tear has occurred
and to reduce swelling from manual manipulation of the
perineum during labor from all the exams
 Transfer the patient to the recovery room.
This will be done after you place a clean gown on the patient,
obtained a complete set of vital signs, evaluated the fundal height
and firmness, and evaluated the lochia.
 Ensure emergency equipment is available in the recovery
room for possible complications. E.g.
– Suctioning machine and oxygen
– Syntocinon in the fridge
– IV remains patent for possible use if complications develop
 Check the fundus.
(1) Ensure the fundus remains firm.
(2) Massage the fundus in a smooth circular motion until it is firm
if the uterus should relax
(3) Massage the fundus every 15 minutes during the first
hour, every 30 minutes during the next hour, and then,
every hour until the patient is ready for transfer.
(4) Chart fundal height. The fundus should remain in the
midline. If it deviates from the middle, identify this and
evaluate for distended bladder.
(5) Inform the Charge Nurse or physician if the fundus
remains boggy after being massaged.
NOTE: A boggy uterus many indicate uterine atony or
retained placental fragments.
Boggy refers to being inadequately contracted and
having a spongy rather than firm feeling. This is
descriptive of the post delivery of the uterus.
 Monitor lochia flow.
Lochia is the maternal discharge of blood, mucus, and tissue from the
uterus. This may last for several weeks after birth.
1) Keep a pad count. Record the number of pads soaked with lochia
during recovery
2) Identify presence of bright red bleeding or clots
3) Document thick, foul smelling lochia
4) Observe for constant trickle of bright red lochia as this may
indicate lacerations
 Observe the mother for chills.
The cause of the mother being chilled following birth is
unknown. However, it refers primarily to the result of circulatory
changes after delivery. The best means of relief is to cover the
mother with a warm gown.
 Monitor the patient's vital signs and general condition

1) Take BP, P and R every 15 minutes for an hour, then every 30


minutes for an hr and then every hr as long as the patient is
stable. Take temperature every hrly.
2) Observe for uterine atony or haemorrhage
3) Allow patient time to rest
4) Offer a free hot drink
 Observe patient's urinary bladder for distention.
Be able to recognize the difference between a full bladder and a
fundus.
 Characteristics of a full bladder.

1. Bulging of the lower abdomen


2. Spongy feeling mass between the fundus and the pubis.
3. Displaced uterus from the midline, usually to the right.
4. Increased lochia flow.
 Observe for signs of hemorrhage. These include:-
1. Uterine atony
2. Vaginal or cervical lacerations.
3. Retained placental fragments.
4. Bladder distention
5. Severe haematoma in vagina or surrounding perineum
 Assess for ambulatory stability.
Patient is at risk of fainting on initial ambulation after delivery due to
hypovolaemia from blood loss at delivery & hypoglycaemia from
prolonged nil by mouth (NPO) status thus should be accompanied on
initial ambulation
 Instruct the patient in the proper perineal care.

Should wipe from front to back to avoid contamination after voiding,


and apply the perineal pad from front to back.
 Discontinue IV infusion on a normal patient once she is stable
and the physician has ordered removal
 Complete notes and transfer the stable patient to the postnatal
ward
Post natal discharge instructions
AREA INSTRUCTIONS
Work • All women should avoid heavy work (lifting or straining) for at least
the first three- four weeks following delivery

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)

Contraception  The women should begin contraception measures with the


initiation of coitus (if she desires contraception).
 If she wishes an IUCD, this may be fitted immediately following
delivery or at the first postnatal check up (after 2 weeks)
 Oral contraception are begun about 2-3 weeks after delivery
 All women should be counseled on Lactation amenorrhoea method
by emphasizing on exclusive breastfeeding.

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,

increased intracranial pressure, maternal


(illicit) drugs withdrawal.
Weak cry – prematurity

Hoarse cry – laryngeal stridor


Immediate care cntd’
ii) Place the infant in a position that would promote drainage of
secretions:
Trendelenburg position – head lower than the body
Side lying position – If trendelenburg position is contraindicated,
place infant in side lying position to permit drainage of mucus from
the mouth. Place a small pillow or rolled towel at the back to
prevent newborn from rolling back to supine position
iii) Keep the nares patent. Remove mucus and other particles that may
be cause obstruction. Newborns are obligatory nose breathers until they
are about 3 weeks old.
iv) Care of the eyes.
It is part of the routine care of the newborn to give prophylactic eye
treatment against gonorrhea conjunctivitis or ophthalmia neonatorum.
Administer tetracycline ophthalmic eye ointment (T.E.O).
Apply over lower lids of both eyes, starting from the inner canthus to
the outer canthus then, manipulate eyelids to spread medication over
the eyes.
v) Vitamin K administration.
The newborn has a sterile intestine at birth, hence, the newborn does not
possess the intestinal bacteria that manufactures vitamin K which is
necessary for the formation of clotting factors. This makes the newborn
prone to bleeding.
So, as a preventive measure, 5mg (preterm) and 1 mg (full term) Vitamin K or
aquamephyton is injected IM in the newborn’s vastus lateralis (lateral
anterior thigh) muscle.
Vi) Care of the cord
Ligate the cord and make sure the ligature is very tight before
you cut the cord.
Clamp and cut the cord (DO NOT MILK THE CORD). It’s
important to apply a sterile gauze swab over it while cutting
in order to prevent blood spraying the delivery field.
Artificial cord clamp is applied a least 3-4cm from the
abdomen
The manner of cord care depends on hospital protocol.
Cord should be cleansed three times daily with an antiseptic
solution.
INSTRUCTIONS TO THE MOTHER ON CORD
CARE:
No tub bathing until cord falls off. Do not sponge
bath to clean the baby. See to it that cord does not
get wet by water or urine.
Do not apply anything on the cord such as baby
powder or antibiotic, except the prescribed
antiseptic solution
Avoid wetting the cord. Fold diaper below so that it
does not cover the cord and does not get wet when
the diaper soaks with urine.
Leave cord exposed to air. Do not apply dressing or
abdominal binder over it.
Cord care cntd’
Report any unusual clinical features which
indicates infection on the cord:
Foul odor in the cord
Presence of discharge
Redness around the cord
The cord remains wet and does not fall off
within 7 to 10 days
Newborn fever
vii) Wipe the baby’s head and the body and wrap to keep
warm.
viii) Record the following information about the baby:
Label the baby with the mother’s name and I.P.
number
Write the date and time of delivery
Sex of the baby
Birth weight
Immediate care of the newborn cntd’

ix) Encourage breastfeeding and routine newborn


care
x) Anticipate the need for neonatal resuscitation
and prepare in advance for it
IDENTIFICATION
Name bands should be applied legibly
on the infant’s wrist or ankle
Should include:-family name, sex of the
infant, date and time of birth.
They should be fastened securely and
should not be too tight or too loose
Care for the baby
Check frequently for bleeding.
daily Change napkin whenever wet or soiled & have mother
do it.
Take temperature twice daily or & hourly if necessary
If the baby’s condition is good mother should be allowed to
feed, as often as she wishes to do so.
Test breast feeding and body activity of the child.
Check cord for bleeding and signs of infection,
xi) INFANT-PARENT BONDING
The baby should remain with his mother
during the first few hours of life
whenever possible, provided the mother
and baby are in good condition. This
facilitates the attachment process.
PHYSIOLOGY OF THE NORMAL
NEONATE
1. THE SKIN
The skin of a newborn is covered with vernix caseosa in utero to
protect and help retain heat and also act as a lubricant during
delivery.
Has an important role in temperature regulation, acts as a barrier to
infections, balances electrolytes, stores fat & insulates against the
cold
The sebaceous glands cease to produce vernix after birth, which may
lead to dryness of the skin. The vernix caseosa peels off within three
days of delivery if left alone.
There is also plenty of fine hair (lanugo) on the skin which falls off in
the first month of life.
The skin of the newborn baby is thin, delicate & easily
traumatized by friction, pressure or substances with a
different PH thus rendering it prone to blistering, excoriation
& infection.
Sterile at birth but colonized with micro-organisms within 24
hours
PH reduces from 6.4 at birth to about 4.9 over 3-4 days
A mature baby has many creases on the palms of the hands
& soles of the feet
Nails are fully formed & adherent to the tips of the fingers
Sensitivity to touch & pressure, heat and cold and pain are
mediated through the skin.
2. THERMO (HEAT) REGULATION

Thermal control in the neonate is initially


poor for some time
The neonate leaves a thermo constant
environment of 37.1 degrees Celsius, where
they have survived for nine months and enters
a much cooler atmosphere at delivery. This
affects the neonate in various ways.
Firstly, heat regulation in the neonate is poor because of
their inefficient heat regulating centre/immaturity of the
hypothalamus.
The subcutaneous fat layer of the neonate is thin and
provides poor insulation, allowing the transfer of core
heat to the environment and also cooling of the baby’s
blood.
A baby’s normal core temperature is 36.5- 37.3˚C thus a
normal baby is able to sustain these temperatures so long as
the environmental temperature is sustained between 18˚C &
21˚C
Reasons as to why neonatal physiology
predisposes to poor thermoregulation.
Wet skin at birth and high surface area to body ratio thus
lost heat via skin surface.
Immature hypothalamus
Lack of enough subcutaneous fat (term) and/or adipose
tissue or brown fat (preterm)
Poor energy stores and limited brown fat which leads to
limited thermogenesis (heat production)
METHODS OF HEAT LOSS IN
NEONATES
EVAPORATION – heat loss through wet skin
CONVECTION – heat loss from cooler air circulating
around warmer skin particularly when exposed
CONDUCTION – heat loss through direct contact with a
cold surface (e.g. scales, unwarmed mattress)
RADIATION – heat loss from heat radiating towards a
cooler surface (e.g. a cold window, wall or incubator wall)
3. RESPIRATORY SYSTEM
At birth, the respiratory system is developmentally
incomplete, growth of new alveoli continuing for several years
The lumen of the peripheral airways is narrow, which
predisposes to atelectasis (a complete or partial collapse of a
lung or a lobe of a lung)
Respiratory secretions are more than in an adult. Their
mucous membranes are delicate and sensitive to trauma
Normal respirations in a neonate is 20- 60 (average 44 b/min)
Their breathing is diaphragmatic, chest and abdomen rising
and falling synchronously
Their respirations are shallow and irregular, interspersed
with brief 10-15 seconds of periods of apnoea (a period of
cessation of external breathing) hence periodic
breathing.
Babies are obligatory nose breathers and do not convert
automatically to mouth breathing when nasal obstruction
occurs
4. CARDIOVASCULAR SYSTEM
Foetal type of circulation ceases as the respiration
commences
Normal circulation starts when the temporary structures
stop functioning. These temporary structures are:-
Foramen ovale
Ductus arteriosus
Ductus venosus
Umbilical vein and hypogastric arteries
At birth, the baby takes a breath and blood is
drawn to the lungs and then to the left atrium.
The placental circulation ceases and less
blood returns to the right side of the heart.
The pressure in the left side is greater while
that in the right side is less
Functional closure of the foramen ovale occurs
Anatomical closure of the ductus arteriosus
and formation of ligamentum arteriosum.
As the placental circulation ceases soon after birth when the
umbilical cord is ligated, the blood flow to the right side of
the heart decreases and the blood on the left side increases
causing the foreman ovale to close.
With the establishment of pulmonary respiration, the ductus
arteries close. Complete closure happens within eight to ten
hours of birth.The cessation of placental circulation will result
in the collapse and subsequently drying of the umbilical veins,
the ductus venosus and the hypogastric arteries
Initially, the heart rate is rapid; 120- 160 beats per minute.
Peripheral circulation is sluggish thus resulting in mild
cyanosis of the hands, feet and circumoral areas
The total circulating blood volume at birth is 80 ml/kg body
weight. This volume is usually raised where there’s delay in
clamping of the cord at birth
The h.b is high (13-20 g/dl) of which >50% is fetal
haemoglobin. Conversion from fetal to adult h.b is completed
within the first 1-2 years of life
Breakdown of the excess r.b.cs in the liver & the spleen
predisposes to jaundice in the 1st week
5. THE RENAL SYSTEM
Though the kidneys are functional in foetal life, their workload
is minimal until after birth
The glomerular filtration rate is low & tubular reabsorption
capabilities are limited.
The baby is not able to concentrate or dilute urine very well in
response to variations in fluid intake, nor compensate for high or
low levels of solutes in the blood. This results in a narrow margin
btwn homeastasis & fluid imbalance
The ability to excrete drugs is also limited & the baby’s renal
system is vulnerable to physiological stress
The first urine is passed at birth or within
the 1st 24hrs & thereafter with increasing
frequency as fluid intake rises
The urine is dilute, straw coloured &
odourless
6. GASTROINTESTINAL SYSTEM
The G.I.T of the neonate is structurally complete, although
functionally immature in comparison with that of the adult. The
mucous membrane of the mouth is pink & moist &The teeth are
buried in the gums
The stomach has a small capacity(15-30ml), which increases
rapidly in the 1st wks of life. The cardiac sphincter is weak,
predisposing to regurgitation
The gut is sterile at birth but is colonized within a few hrs. bowel
sounds are present within one hr of birth
Bowel sounds are present within 1 hour of birth
LIVER FUNCTION
Physiological jaundice is usually seen in 50%
of normal neonates from the third to the sixth
day of life. This is due to excessive break
down of red blood cells resulting from a high
haemoglobin level (Hb of 14 - 18mgs/100mls).
The process of breaking down red blood cells
leads to formation of bilirubin. The liver is not
able to conjugate the excess bilirubin to
enable its secretion through the kidneys.
This leads to physiological jaundice.
STOOLS
The neonate is capable of passing the first stool, known
as meconium, within the first two to three days of life.
This is because the foetus swallows liquor amnii in utero.
Thus, their sucking and swallowing reflexes are usually
present at birth.
The colour of the meconium is dark greenish for the 1st
48-72 hours and later changes to a mustard (yellowish)
colour from the 3rd-5th day. The bowels may be opened
three to five times daily.
Note:
The consistency and frequency of stools reflect the type of
feeding
Breastmilk results in loose, bright yellow and inoffensive acid
stools
The stools of a bottle fed baby are paler in colour, semiformed,
less acidic and have slightly sharp smell
7. IMMUNOLOGICAL ADAPTATION
Neonates demonstrate a marked susceptibility to
infections, especially those gaining entry thru the
mucosa of the respiratory & gastrointestinal
systems
The baby has some immunoglobulins at birth but
the sheltered intrauterine existence limits the need
for learned immune responses to specific antigens.
There are 3 main immunoglobulins, igG, igA and
igM and of these, only igG is small enough to cross
the placental barrier
At birth, the baby’s levels of igG are equal to
or slightly higher than those of the mother.
This provides passive immunity during the
last few months of life.
8. REPRODUCTIVE SYSTEM
In boys, the testes are descended into the
scrotum, which has plentiful rugae, the
urethral meatus opens at the tip of the penis
& the prepuce is adherent to the glans
In girls both at term, the labia majora
normally cover the labia minora, the hymen
and the clitoris may appear
disproportionately large
In both sexes, withdrawal of maternal oestrogens
results in breast engorgement with a nodule of
breast tissue around the nipple
9. MUSCULOSKELETAL SYSTEM
The muscles are complete, subsequent growth
occurring by hypertrophy rather than by
hyperplasia
Long bones are incompletely ossified to facilitate
growth at the epiphyses
10. PSYCHOLOGY AND PERCEPTION
Newborn babies at birth are alert and aware of
their surroundings and they have long
periods( 60%) of ‘quiet alert state’ & react to
stimuli
i) Special senses
a) VISION
Though immature, the structures necessary 4
vision are present & functional at birth. Babies
are sensitive to bright light which cause them to
frown or blink. They demonstrate a preference for
bold black & white patterns and the shape of the
human face
b) HEARING
Newborn babies’ eyes turn towards sound. On
hearing a high pitched sound, they 1st blink or
startle then become agitated and are comforted
by low pitched sounds
c) SMELL & TASTE
Babies prefer a smell of milk to that of other
substances & show a preference for human milk
d) TOUCH
Is the most highly developed sense in a
neonate at birth. Neonates respond well to
touch. The senses of taste, smell, and hearing
are functional in the newborn; however, not
to the extent of touch.
ii) SLEEP AND AWAKENING
Following initiation of respirations at birth,
the baby remains alert & reactive for a
period of at least 1 hr, then relaxes & sleeps
The baby goes into 2 sleep states, namely;
deep sleep and light sleep
11. GROWTH & DEVELOPMENT
Babies are dependent on their mothers 4
continued survival, growth & dvpt. These will
progress satisfactorily if the baby is
physiologically & neurologically normal, is in
a safe envt, nutritional needs are met &
physiological dvpt is promoted by appropriate
stimulation & loving care
WEIGHT
The average normal birth weight ranges from
2.5 - 3.5 kilograms. During the first three
days of life, the baby loses approximately 10 -
20% of their birth weight but regains it again
within one to two weeks.
POSSIBLE REASONS FOR WEIGHT LOSS IN A
NEWBORN
Due to tissue fluid loss during the heat loss when
the baby is born
When the baby opens their bowels, the meconium
which was present in the gut is lost, leading to
weight reduction
Poor sucking on the breast due to tiredness incurred
during the baby’s passage through the birth canal
during labour will affect the baby’s weight since
they are not getting enough fluid intake
FIRST EXAMINATION OF THE NEONATE
This is the first/ initial physical examination that is done to a
newborn baby
Examination whenever possible should be done near the
parents and findings explained to them
OBJECTIVES OF THE FIRST EXAMINATION:-
To rule out external congenital malformations
To determine maturity of the neonate and rule out
prematurity
To rule out birth trauma or injury
A thorough physical examination is done during the 1st 4 hours after
birth
In order to carry out this examination, you need to have with you the
following equipment in a tray:-
Tape measure
Second hand watch
Gloves
Weighing scale
Clinical thermometer
Swabs
Stethoscope
A flat surface or cot
PREPARATION PRIOR TO FIRST EXAMINATION
The midwife should first perform hand hygiene:-This is to
prevent the spread of infections.
The midwife’s hands should be warm:-This is to avoid
chilling of the infant
The neonate should be in a warm, draught (windy) free
environment
There should be enough light to allow the midwife to see
the neonate clearly
The examination is performed in an orderly manner from
head to toes
APPEARANCE
The baby should be pink in colour.
Note any abnormal facies
Lies in an attitude of flexion
Vernix caseosa-a white, sticky substance is present on the
skin. It has a protective function and is absorbed within a
few hours
Residual vernix in the axillae and groin predisposes to
excoriation of the skin
THE SKIN
Sterile at birth and is colonized by micro-
organisms within 24 hours
General colour of the skin depends on the
baby’s ethnic origin
Lanugo,downy hairs cover the skin and
are plentiful over the shoulders, upper
arms and thighs
Mature baby has plentiful skin creases on
the palms of his hands and soles of his feet
Examine
Vital signs the baby
- heart systematically
rate (120-160/min),inrespiration
the following manner:
(20-60 average
44/min), and temperature (36.5-37.3 degrees centigrade).
Head - Check the shape to see if there is excessive moulding, caput
succedaneum or depressed fractures to exclude head injury,
microcephalus or hydrocephalus.
On palpation of the vault of the skull:
The bones should feel hard in a full term infant
It may also be done to determine the degree of moulding
Take the occipital-frontal head circumference (Approximately 34-37
cm).
HEAD CNTD’
Fontanels should be flat, soft, & firm.
They bulge when the baby cries or if
there is increased in ICP( Intracranial
pressure).
Wide anterior fontanelle or splayed
sutures may indicate hydrocephalus or
immaturity
Sunken fontanelles denote dehydration
EYES
No tears are present in the eyes of a baby and
they become easily infected
Each eye should be visualised to confirm that it is
present and the lens is clear
The baby may open his eyes spontaneously if held
in an upright position
Any slight bleeding or oedema is noted
Observe for jaundice,
The normal space between the eyes is upto 3cms
The inner canthal distance averages 2.5-3cms
EARS
Placement and position:-
Draw an imaginary line from the outer canthus
of the eye to the occiput and the top of the
pinna should meet or cross this line.
The upper notch of the pinna should be level
with the canthus of the eye
Abnormal:-low set ears Down’s syndrome,
renal anomalies
THE MOUTH
The mouth can be easily opened by pressing
against the angle of the jaw. This allows visual
inspection of the tongue, gums and palate.
The palate should be high arched, intact and the
uvula central
The midwife uses her little finger to feel the
palate for any submucous cleft.
Inspect for cleft lip and palate
A normal baby responds by sucking the finger
Precocious teeth may protrude through the
central part of the lower gum
Though usually covered by
epithelial tissue, such teeth may
have erupted and be loose,
requiring extraction in the early
neonatal period to prevent their
inhalation.
Inspect for ankyloglossia (tongue
tie)
Nostrils - Check for patency with no polyps or
flaring.
Neck - Check for congenital goitre or enlarged
glands.
Limbs and digits - Check for equality, free
movement, fractures, webbed fingers, extra digits
and any bony tissues. Extra digits can be ligated
with silk and will fall off (with the parents
permission). Check for Erb's palsy.
The digits should be counted and separated to
ensure webbing is not present
Normal flexion and rotation of the ankle and wrist
joints should be confirmed
THE HIPS
Specific exams are done to detect
developmental dysplasia of the hips
NOTE:-care must be taken to avoid
producing an iatrogenically unstable
hip
Exams done are:-Ortolani’s test
- Barlow test
ORTOLANI’S TEST
The baby’s legs are grasped with the flexed knees
in the palms of the examiner’s hands
Femur is splinted between the index and middle
fingers and the thumb
From an adducted position, baby’s thighs are
flexed on to the abdomen, rotated and abducted
through an angle of 70-90 degrees towards the
examining surface, while lifting the trochanter
anteriorly.
NO FORCE SHOULD BE EXERTED
If the hip is dislocated,a clunk sound will be felt
Ortolani’s test
Barlow’s test
Baby’s legs flexed, then, the thigh is
grasped loosely with the examiner’s index
and middle finger along the greater
trochanter and the thumb on the inner thigh.
As hip is gently adducted to 70 degrees,
gentle pressure is exerted in a backwards
and lateral direction
A ‘clunk’ is felt as head of femur dislocates
out of the acetabulum
Chest - Check for continuity of sternum and the
shape of rib-cage, respiratory rate, enlarged
breast or absence of breast tissue .
Abdomen - Should be intact and firm, check for
umbilical hernia and exomphalus (protrusion of
abdominal organs through a defect in the
anterior wall). Abdominal distension is present in
hydrops foetalis. Check for blood oozing from the
cord and clamp again if necessary (cord shrivels
within 24 hours, falls off within 6-10 days).
Exomphalus
External genitalia - Confirm the sex of
the baby to rule out pseudo-
hamaphroditism or intersexes.
In males, check for undescended testes,
Epispadias and hypospadias and phimosis.
In females, check for bleeding from
urethral and vaginal orifice. Vaginal
bleeding may be due to excessive
hormones from the mother
THE SPINE
The baby lies prone and midwife examines
the back
The spinal column should be continuous
Any swellings, dimples or hairy patches
may signify an occult spinal defect
Neurological Assessment
This entails the checking of reflexes, which deal with the
function of the baby’s nervous system as well as physical
and behavioural assessments.
At the beginning of the examination, observe the baby’s
movements. These movements involve all extremities and
should be random and symmetrical but never
stereotyped
a) Moro Reflex
Also known as Startle reflex.
Support the baby’s head and body in supine position about a centimetre
from the cot. Allow the head to drop back. Look at the baby’s response.
The baby throws out his arms extending the elbows and fingers with
embracing movements of the arms.
The Moro reflex is symmetrical in a normal baby at birth and disappears
after four (4) months.
It is incomplete in the pre-term baby and absent in the baby with intra-
cranial injury.
NB// >>> If the Moro reflex is still present after the age of 6 months,
neurological maturity may be delayed or another neurological disorder
may be present thus the need for further evaluation/ assessment of the
child.
b) TONIC NECK REFLEX
Also known as the ‘FENCING REFLEX’
A fencing position is assumed, that is, the baby lies on the
back, head rotated to one side with one arm and leg partially
or completely extended.
The opposite arm and leg are flexed. This is a manifestation
of the immaturity of the newborn’s nervous system.
Disappears at 6 months of age
c) Rooting Reflex
To test for the rooting reflex, gently touch the corner of
the baby’s mouth with clean fingers.
The baby will open his/her mouth turning towards the
stimulus in anticipation of the mother’s nipple.
To check for;
d) Sucking reflex
Place a clean finger in the baby’s mouth noting the sucking
strength.
The sucking reflex is poor in pre-term babies.
e) Stepping Reflex

The stepping or dancing reflex is present


at birth but disappears soon after.
Once this reflex diminishes, the infant does
not attempt a stepping motion until he/she
starts to walk.
 Hold the infant up, with the feet touching
a surface. The infant will attempt to make
some steps or pressing movements.
f) Grasp Reflex
At birth, the grasping reflex of both hands and feet is present.
The infant will grasp any object you place in their hand, and then
let it go.
They are able to hold on to a finger so securely, that you can lift
them to a standing position.
Stroking the soles of the feet causes the toes to turn downwards
trying to grasp.
By applying traction to the baby's wrists raise them to a sitting
position.
A full term infant will offer a strong resistance while a pre-term
does not resist the pull.
g) Protective Reflex
Other reflexes include protective reflexes such as:
The blinking reflex, which protects the eyes from
bright light
Sneezing and coughing reflexes used to clear the
infant’s throat
The yawn reflex, which draws additional oxygen
Cry reflex, which helps to withdraw from painful
stimuli
Once this examination is completed, the
baby can be placed on the cot for
transfer to the nursery or given to the
mother.
After completing the delivery of the
baby, you should transfer the mother to
the postnatal ward where she will rest.
DAILY EXAMINATION OF A NEWBORN
Similar to the first exam but concerned with
monitoring daily changes in the baby and detecting any
signs of infection.
The baby should be examined everyday by a midwife in
order to evaluate the progress and identify problems as
they arise
OBJECTIVES OF DAILY EXAMINATION
OF NEWBORN
To detect any neonatal complications the baby
might have developed since birth and take
appropriate action
To detect and rule out any internal congenital
anomalies
Assess growth and development of the baby
Monitor progress of the baby
INDICATION:
All newborn babies
Requirements for daily examination of
the neonate
Top shelf of the trolley:
Accessories:
Gallipot with cotton wool
swabs Weighing scale
A thermometer Receptacle for used
Stethoscope, tape measure
swabs
Bottom shelf of the trolley:
Baby’s chart
Extra linen, Povidine
iodine solution (Betadine),
spirit
A jar of hot water
A bowl
PREPARATION:
1. Baby
Explain the procedure briefly to the mother to
gain her verbal consent.
Make the baby comfortable
Undress the baby and wrap it to keep it warm
2. Equipment
 Clean the trolley and set it with the equipment
stated above
Have a weighing scale in good working order
3. Environment
Close the nearby windows
Screen the bed for privacy
Ensure the room is warm with adequate lighting
Wheel the trolley next to the bed
Place the receptor for used swabs
4. Self (Midwife)
Review guidelines for daily examination of the newborn
Wash and dry hands
Obtain brief history on labour, date and time of birth and birth
order
Ask on immediate condition of the baby after birth and initial
examination findings
PERFORMANCE:-
Ask the mother to undress the baby but wrap up
warmly
Lay the baby flat on the bed
Wash hands and expose the baby briefly for
general inspection and cover it as soon as possible
Note the posture, breathing pattern, general color,
rash and skin changes then examine systematically
as follows:
The head:
 Note any swelling e.g. development of
cephalohaematoma and if caput succedaneum is
subsiding. Examine for resolution of birth injuries,
abnormal size of the head and take head
circumference if applicable
 Examine for presence of cradle cap, signs of
dehydration and increased intracranial pressure
(denoted by bulging of the fontanelles).
Eyes: examine for signs of infection e.g eye discharge,
jaundice and resolution of subconjuctival haemorrhage
Ears: observe for signs of infection e.g. leakage of fluid
and note the hygiene behind the ears
Nose: observe for signs of infection and presence of
dry mucus
Mouth: observe for cyanosis on the lips, sucking
blisters and signs of oral thrush. Dry lips denote
dehydration status.
Neck: assess for hygiene, peeling of the skin at the
folds and presence of a heat rash
Chest: assess for ease of breathing, count the
respiratory rate & the heart rate, presence of breast
engorgement, skin condition e.g. pemphigus
neonatorum (excoriation of the skin because of an
infection)
Abdomen: assess for tenderness, the
state of the cord and listen to the bowel
sounds ( should be present)
Genitalia: assess for hygiene on the skin
folds, for females, check for
pseudomenses and for males, enquire for
any problem
Buttocks: assess for hygiene, nappy rash
and excoriation of the skin
Limbs( upper and lower): assess for
Take vital signs e.g. apex beat, temperature and respirations
Take weight and comment accordingly then dress the baby
Make the baby comfortable & communicate your findings to
the mother and advise her accordingly throughout the
examination
Clear the tray and wash hands
Record the examination on the relevant charts and
communicate any abnormal findings to the staff in charge of the
shift
Enquire from the mother the baby’s feeding habits, elimination
and sleeping pattern and interpret accordingly & thank the
mother and leave them comfortable
Top-tailing a Newborn
OBJECTIVES:
To provide comfort to the baby
To maintain baby hygiene
ORGANIZATION:
Review the set guidelines on the procedure
Greet the mother and introduce self
Explain the procedure to the mother to gain her consent
and cooperation
Ensure you have the following:
(Requirements)
Warm water at a temperature of 37-38
degrees Celsius in a clean jug or container.
Dry cotton wool swabs
A clean bowl
Clean wrappers, baby clothes and a diaper
Covered small mattress on a bench/bed and
Oil-(PRN)
Ensure cleanliness and warmth of the
room at a range of 24-30 degrees Celsius
Close the nearby windows
By ready to perform the procedure
quickly to avoid exposing the baby to
cold
Undress the baby and cover warmly
Performance
Wash and dry hands, put warm water into the bowl and
soak some cotton wool
Squeeze excess water from the swabs to avoid too much
wetness on the skin and on clothings, every time before
use
Start by wiping each eye at a time, starting from the
inner to the outer canthus
Clean the face with another swab
Clean the ears, paying attention to the skin folds
Wipe the neck and axilla, paying attention to the skin
folds
Wipe the elbows, hands and between the fingers
Clean the groin and genitalia, paying attention to
the skin folds
Lift the baby’s legs with the left hand and clean the
buttocks, including other areas on the back
soiled with meconium/stool
Wipe the feet and between the toes
Apply oil on the skin if necessary
Fix the diaper after massaging the area thoroughly
with a thin layer of oil
Dress the baby, wrap warmly and give to the mother
to feed. Thank the mother for her cooperation
N.B. talk to the baby throughout the procedure
Discard dirty swabs in the respective coded
bin
Discard the dirty water appropriately
Wash the bowl with soapy water and sterilize
it ready for next use
Put the dirty linen in the respective bin ready
for laundry
Document, interpret and report to the staff in
charge of the shift any complication(s) noted
during the procedure
MINOR DISORDERS OF A NEWBORN
& THEIR SPECIFIC MANAGEMENT
Vomiting
Rash:-
Heat rash
Nappy rash
Breast engorgement
Pseudo-menstruation
Constipation
Oral thrush
Moulding
VOMITING:
Vomit on first day due to irritation of
stomach by swallowed amniotic fluid.
Vomiting soon after feed is due to faulty
technique of feeding. If vomiting persists
for longer it leads to some other
conditions
Eruption of papules and blisters when baby is kept
HEAT RASH

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

It is commonly met in artificially fed babies.


Management :Correction of the diet and
extra water is usually effective
ORAL THRUSH
1% gentian violet solution or nystatin
suspension, applied to each side of the
mouth with a cotton swab 3-4 times a
day.
MOLDING
The head may appear asymmetric in
the newborn of a vertex birth.
Caused by the overriding of the
cranial bones during labor and birth.
Diminishes within few days after
birth, so just reassure the mother.

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

 Uterus: The uterus in pregnancy


enlarges by about 11x its non pregnant
weight. Its growth is influenced by
progesterone and estrogen, which cause
hyperplasia and hypertrophy
 Uterine involution occurs mainly by
decrease in myometrial size and is
complete by the 6th postpartum week
LOCHIA
Lochia are the discharges from the
uterus, cervix and vagina for the
first fortnight (14 days) during
puerperium.
They are alkaline in reaction and
contain blood, debris of deciduas,
and liquor amnii, lanugo, vernix
caseosa and meconium.
THE SEQUENTIAL CHANGES IN
LOCHIA
 Lochia rubra (red) lasts from the 1st -4th days post-
partumly. Consists of blood, chorion, decidua,
amniotic fluid, lanugo, vernix caseosa and
meconium.
 Lochia serosa – lasts from 5th -9th days post-partumly.
Colour is yellowish or pink or pale browne. contains
less blood, more serum as well as leukocytes &
organisms
 Lochia alba- (pale white) lasts from 10th -15th day
post- partumly.
The character of the lochia gives useful information
CHARACTERISTICS OF LOCHIA
Should not be excessive in amount
Should never have an offensive odor
Should not contain large pieces of tissue/
debris
Should not be absent during the first 3 weeks
Should proceed from rubra -- serosa – alba
sequentially
Cervix,vagina, muscular walls, fallopian
tubes, ovaries
Cervix closes during puerperium to remain as a
slit
Inflammatory changes with no clinical signs of
salpingitis occur
The vagina returns to its antepartum state by
the third week
The torn hymen heals and is known as the
carunclae myrtiformes
The voluntary muscles regain tone during
puerperium
Abdominal muscle involution may take
about 6-7 weeks
The vagina

Although the vagina may never return to its


prepregnancy state, the supportive tissues of the
pelvic floor gradually regain their former tone.
Women who deliver vaginally should be taught
and encouraged to perform Kegel exercises
(intermittent tightening of the perineal muscles)
to maintain and improve the supportive tissues
of the pelvic floor by tightening the perineal
muscles.
Physiologic changes
Fluid and electrolyte balance
The baby and placenta weigh about 5kg
After their delivery about 4kg is lost in form
of fluid
Electrolyte balance is back to normal by the
end of the first week
Cardiovascular changes
 Immediately following delivery, there is a marked
increase in peripheral vascular resistance due to
the removal of the low-pressure uteroplacental
circulatory shunt.
 The cardiac output and plasma volume gradually
return to normal during the first 2 weeks of the
puerperium. As a result of the loss of plasma
volume and the diuresis of extracellular fluid, a
marked weight loss occurs in the first week.
Cardiovascular changes cntd…
There is an increase in
thromboxane(vasoconstrictor or that of
prostacyclin(vasodilator)
Blood volume decreases from 5-6 l to 4l by
the third week.
Mean loss is 500ml in vaginal birth and
1500ml by cesarean section or delivery of
twins or triplets
Haematopoesis: During pregnancy there is an
increase of haematocrit by 30% about 15 %
of this is lost after delivery
Return of Menstruation and
ovulation
 In women who do not nurse, menstrual flow
usually returns by 6 to 8 weeks, although this is
highly variable.
 Although ovulation may not occur for several
months, particularly in nursing mothers,
contraceptive counseling and use should be
emphasized during the puerperium to avoid an
undesired pregnancy.
The breasts
 Usually the breasts are soft on palpation during
the first 24 hours post delivery; there may or
may not be any colostrum at this time. But by
day 3 they normally becomes swollen, warm
and increased vascularity is demonstrated.
 From Day 2-4, milk secretion is established in
most cases.
 It is important that the mother is shown the
correct technique for proper positioning of the
baby and attachment to avoid cracking of the
nipples.
The Psychology of the
Mother During Puerperium
 During the puerperium the mother is subjected to
emotional turmoil and you must be supportive and
observant. She should be allowed to cuddle her
baby and express her love as she wishes. This
maternal instinct is at times delayed.
 The midwife should be kind, patient, and
compassionate towards the mother and give her the
necessary education concerning her and the baby.
Each mother should be taken as an individual based
on her maternal experience, educational
background, maturity and parity.
 Mothers should be given all the information
necessary to ensure they know how to care for
their babies.
 ‘Rooming in’ is the term given when a hospital
plans for the mother to stay with the baby for
most of the 24 hours in a day. It is highly
recommended because it has been seen to have
great psychological advantages for both mother
and baby.
 Bonding commences immediately and demand
breast-feeding can be successfully practiced
General Involution
 Every system in the body is affected during this
process, including the heart and circulatory system.
With the cessation of the utero-placental
circulation, the work done by the heart decreases.
The quantity of blood required also gradually
returns to normal. The renal and musculo-skeletal
systems also return to normal.
Involution of the Uterus
DEFINITION
 The uterus returns to its normal site, tone &
position of non pregnant state Mechanism
 The size of the pregnant uterus is 30 x 22 x 20cm
and it weighs 1000gms at the end of labour. It is
15 x 11 x 7.5cm by the end of puerperium.
 Involution takes place, by which point it
measures 7.5 x 5 x 2.5cm and weighs 60gms.
 Involution is the return of the uterus to its
normal size, position and tone and is brought
about by autolysis and ischaemia.
Autolysis is a process by which muscle
fibres are digested by the proteolytic
hormone. The muscle fibres have to
dissolve a large amount of their protein in
order to achieve this reduction in size.
This means that a great deal of nitrogen is
excreted by the body in the urine together
with the excess fluid retained during
pregnancy.
This is why a lot of urine containing large
amounts of nitrogen is excreted during the
first few days after delivery. In addition, the
epithelial lining of the uterus, other cellular
debris, and red blood cells are expelled as
lochia from the uterus.
 Ischaemia is localized anaemia of the uterus,
which occurs when the placenta is expelled. Blood
vessels are constricted, which results in the
reduction of the blood supply to the uterus. The
phagocytes dispose of the redundant muscle fibre
and elastic tissue. The vagina, ligaments of the
uterus and muscle of the pelvis also return to their
pre-gravida state. If not, prolapse of the uterus
may occur later.
 Lining of the uterus is cast off and is replaced first
by granular tissue and then by endometrium
PROGRESS OF CHANGE IN THE UTERUS AFTER
DELIVERY

WEIGHT OF DIAMETER OF CERVIX


UTERUS PLACENTAL SITE

END OF 900GMS 12.5CMS SOFT,


LABOUR
END OF 1 450GMS 7.5CMS 2CMS
WK
END OF 2 200GMS 5CMS 1CM
WKS
END OF 6 60GMS 2.5CM
WKS
Onset of Lactation
 Lowered oestrogen levels trigger the production of
prolactin from the anterior pituitary gland, which
initiates lactation.
 The maintenance of lactation depends on putting
the baby on the breast, but secretion of milk
commences on the third to fourth day.
 The baby should be put on the breast immediately,
which leads to oxytocin release and assists in
keeping the uterus well-contracted & also triggers
the milk let down reflex
Specific Management of
Normal Puerperium
The aim of managing the puerperium is to:
Maintain the mother’s good health
Aid involution of the pelvic area
Promote exclusive breast-feeding
Prevent infection and other puerperium
complications
Educate the mother on the proper care
of her own health and the baby
General condition
 Ensure that the patient is feeling well
and relaxed, has no signs of anaemia or
jaundice, The vital signs of temperature,
pulse, BP and respiration are within
normal range, and the uterus is well
contracted.
 While the mother should be encouraged
to rest adequately, early ambulation and
exercise should be encouraged.
Care of the mother
After the birth of the baby & expulsion of the
placenta:
Clean perineum & apply sterile pad
Make her comfortable
Give her a cup of tea and something light to
eat (immediate)
Allow her to rest
Record vital signs:
4 hourly for the 1st & 2nd day
then twice daily
if elevated as doctor ordered
Check for any bleeding & intervene
appropriately
The mother and the baby should be
examined daily and if any abnormality is
noted, the doctor should be informed.
Perform a daily post natal examination of
the mother as described below:
PERFORMING DAILY POST
NATAL EXAMINATION OF THE
MOTHER.
 Briefly explain the procedure to the mother and ask
her to empty the bladder.
 Have the environment prepared i.e. close the
nearest window and screen the bed
 Assemble the necessary equipment i.e. vital signs
tray, tape measure& clean gloves
 Wash hands and wear gloves
 Instruct the mother to lie on the bed with only one
pillow under her head
 Examine the head for hygiene and general neatness
of the hair
 Examine the eyes for anaemia, jaundice and sight
problems
 Examine nose and ears for signs of infection,
hygiene and hearing problems
 Examine the mouth for signs of dehydration and
general oral hygiene
 Neck, check for hygiene, enlargement of the thyroid
and lymph glands
 Check the chest for breathing, breasts for signs of
infection and success of lactation
 Examine the abdomen for size, shape and
organomegally. Examine for involution of the
uterus i.e. size, consistency and take the fundal
height. The fundal height should reduce by 0.5 - 1
centimeter daily.
 Examine the upper limbs for hygiene, pallor,
oedema, muscle wastage and tremors
 Examine the lower limbs for hygiene, oedema,
muscle wastage, signs of varicosity and D.V.T.- by
checking on the calf muscles
 Instructthe mother to remove pad. Inspect lochia
for colour, consistency, amount, smell and
compare the findings with expectation. Check
perineum for hygiene, oedema, healing of
laceration, episiotomy or tear.
Ifthere is persistent lochia rubra, this points to
the need for further investigation. Offensive
lochia odour denotes infection.
Advise the mother to wash the episiotomy at
least four times a day with salt water and
change the pad as soon as it is soiled and after
she goes to the toilet.
 Take the vital signs and enquire on the feeding
habits, elimination and the sleeping pattern of
the neonate
 Advice the mother accordingly during the
examination and congratulate her appropriately
 Leave the mother comfortable; communicate
your findings in simple terms. Allow the mother
to ask questions
 Clear the trolley or tray & un-screen the bed
 Record the findings on the relevant charts and
report any abnormalities for further
intervention(s).
Specific management of puerperium ctd’
Ambulation is important to prevent deep
venous thrombosis. Encourage the mother
to walk around and keep the bladder
empty.
Take her temperature, pulse, respiration
and blood pressure twice daily.
Check the breasts and if she is not lactating,
express colostrum.
 Increase expressing on the second day and milk should
be sufficiently established by the fourth day.
 Advise the mother on how to feed the neonate.
 When fixing the baby on the breast she should put
the whole areola in the baby’s mouth.
 She should initially breast feed the baby for three
minutes to prevent cracked nipples and empty the
breast in cases where the baby does not feed a lot.
This is especially important in the first days to
prevent engorgement.
Counselling the client on
postpartum care and hygiene
 It is important that after delivery, the woman is counselled
comprehensively on the following topics:
 Explain the importance of having someone nearby for the first 24
hours/subsequent few days to monitor any change in her condition
 Nutrition counselling should include: the importance of eating more
and healthier foods and drinking plenty of fluids. Explore and dispel
any myths on particular food taboos.
 Counsel the woman on the importance of maintaining personal
hygiene. This includes discussing with women the type of pads they
will use, the frequency of changing the sanitary wear (4 to 6 hourly)
and their disposal
 Counsel the woman on how to care for the perineum (or
episiotomy) when she goes home, taking into consideration
her home environment. She needs to know the importance
of not inserting anything into the vagina
 Hand washing is particularly important to prevent infection.
This is also imperative when handling the baby.
 Adviseher to avoid sexual intercourse until the perineal
wound has healed
 Discuss return to fertility – (as soon as 4 weeks after
delivery if not exclusive breast feeding)
 Discuss breast care (and infant feeding) and the importance
of exclusive breast-feeding).
 Advise her on Pelvic floor exercise to strengthen the
perineal muscles
THE 6 WEEKS POST NATAL EXAMINATION
 This is carried out during the sixth post-partum week
PURPOSE
 Toassess the general physical & emotional health of
the mother
 Toassess whether the reproductive organs have
gone back to their pre-gravid state
 To evaluate family planning needs
REQUIREMENTS
A trolley containing:
Top shelf: a vaginal examination pack containing
speculum
Bottom shelf:
A bowl with cotton wool swabs
Antiseptic lotion in a bucket of warm water
Transport media container
Lubricant
Sanitary pads
Bed linen
A clean gown
Vital signs tray
Sterile gloves
Clean gloves
Clock
 Accessories:
Mother’s notes
Coded bin
Potarble light
Weighing scale
Baby cot
FP devices
Urine jug
 Collect information on:
Mother’s health status & menses
Baby’s feeding, sleeping, growth & immunization status
Explain the procedure to the mother
Ensure that the bladder is empty
Assist the woman in supine position on the
couch
Screen the bed
Take vital signs
Assess the state of health & note whether calm,
happy or depressed
 Exclude pallor of the conjuctiva, tongue, palm &
fingers
 On the chest note;
 Respirations, size & shape of the breasts
 State of nipples, whether cracked, sore, flat,
inverted or prominent
 Examine breasts for lumps
 Educate her on breast examination
 Abdomen: inspect firmness of the muscles & palpate
for uterine involution
 Genitalia: inspect for cleanliness, discharge, oedema,
sores, warts and note state of episiotomy & tears
 Perform a digital vaginal or speculum examination.
A pap smear should also be done for detection of
cancerous cells on the cervix
 Dry the vulva and leave her comfortable
 Examine the legs for varicose veins, oedema and
tenderness
 Highlight important findings and inform the
mother
 Counsel the mother on FP & Future pregnancies
 Share health talks with the mother on exclusive
breastfeeding, hygiene e.t.c.
TARGETED
POSTNATAL CARE
Definition of targeted post natal
care
 Targeted postnatal care is an
approach, which defines a set of
postnatal care services delivered to
both the mother and baby in a
minimum of four visits spread
throughout the first six months
following delivery.
Elements of targeted postnatal
care
These include the following:
a) Maternal care:
 Health promotion using health messages and counselling (e.g.
on nutrition and resumption of sexual activity)
 Assist the mother and her family to develop a personalized PNC
(post-natal care) plan
 Provision of Essential postpartum care by a skilled attendant
 Early detection of post-partum danger signs and treatment of
problems
 Elimination of mother to child transmission of HIV (EMTCT)
 Emergency Preparedness and Complication
readiness post-partumly
 Counselling and service provision for
Postpartum FP / healthy timing and spacing
of pregnancy
 Screening for other conditions e. g cervical
cancer, breast cancer, STI/RTI’s
Ct… Elements of targeted postnatal
care
b)Newborn care
 Provision of Essential Care of the
Newborn.
 Counselling on infant and young child
feeding
 Early detection of major neonatal danger
signs and treatment of problems
 Immunization in order to prevent and
reduce childhood morbidity and mortality
related to immunisable diseases.
Schedule of targeted postnatal
care visits
The recommended schedule for Kenya is as
follows:
1. Within 24-48 hours = visit 1
2. 1 to 2 weeks = visit 2
3. 4 to 6 weeks = visit 3
4. 4 to 6 months = visit 4
1st VISIT i.e. within 1ST 24-48
 NOTE: hours
The initial assessment should be carried out as
soon as possible after delivery.
In case of a facility birth, the mother and baby
should be checked again before discharge.
Where delivery has occurred at home, both
mother and baby should be reviewed by a skilled
provider as soon as possible within 24/48 hours
1st visit. Check /perform:
Mother Baby
• Physical assessment: Pallor, • Apgar scoring
Temperature, Blood Pressure, • Take temperature
uterine involution, • Take and record birth weight
• Inspection of the C/S wound- if • Head to toe examination
present- for bleeding
• Assess for danger signs for baby
• Assess lochia and blood loss
• Observe a breast feed &
• Breast examination for
interpret appropriately
establishment of lactation,
• Calf tenderness to rule out DVT
Danger signs in newborns
There are 8 major danger signs in newborns:
1.Poor feeding
2. Lethargy
3. Convulsions
4. Hypothermia
5. Hyperthermia
6. Chest indrawing
7. Fast breathing (>60 breaths/min)
8. Neonatal Jaundice
2nd visit. Check /perform:
Mother Baby

• Mental status • Growth monitoring; chart


• Pallor, BP, temperature, pulse weight
rate • Head to toe examination
• Lochia loss- (Colour, amount, • Assess for danger signs for baby
smell) • Check eyes for discharge
• Assess for calf tenderness • Immunization status
• Infection /pus from C/S site or • Observe a breast feed
perineal wound
• Breast condition
• Uterine involution
• Observe a breast feed
3rd visit. Check /perform:
Mother Baby

• General condition of mother, • Growth monitoring; chart


head to toe physical exam weight
• Mental status • Head to toe examination
• BP, Weight, temperature • Assess for danger signs for baby
• Uterine involution • Immunization status
• Lochia (amount /Colour)
• Observe a breast feed
4th visit. Check /perform:
Mother Baby
Check:
• Check the general health of mother • Growth monitoring; chart weight
Provide:
• Head to toe physical
• FP method of choice
examination
• Screening for RTI /STI
• Assess for danger signs for baby
• Screening for cervical cancer –if not
done • Immunization status
• Screening for TB
• Clinical Breast examination
• Treat or refer any complications that
are detected
Minor ailments/ disorders of
puerperium & Their specific
management
 Postpartum blues
 After pains
 Sub-involution
 Pain on the perineum
 Breast related disorders- breast
engorgement, sore & cracked nipples
 Postnatal diuresis
 Constipation
Postpartum Tears or Fourth Day Blues
A minor disorder during puerperium
This condition is characterized by mild
depression and mood swings due to a
temporary endocrine hormonal imbalance
following childbirth.
It occurs in fifty 50% of post-natal mothers on
around the fourth day.
CLINICAL FEATURES OF POST PARTUM BLUES
INCLUDE:-
 Inappropriate guilt or negative feeling towards self
 Decreased interest or pleasure in normal activities
 Mother feels tired and /or agitated all the time
 Disturbed sleep (too much or too little, waking early)
 Diminished ability to think or concentrate
 Marked loss of appetite, loss of libido
 Rejection of the baby and
 Mother cries easily
SPECIFIC MGT OF POST
PARTUM BLUES
A midwife should try to prevent the 'blues' by educating
the mother during the pre-natal period on how to take
care of herself and the baby to build up her confidence
 The woman needs to be assured that the experience is
quite common and that many women experience the same
thing.
 The provider should listen to her concerns and give her
emotional encouragement and support.
 The partner and family need to be counselled to provide
assistance to the woman.
Management of post-partum
blues cntd’
 Teach the mother how to check for minor
discomfort and the relevant remedies to
reduce the feeling of anxiety that the baby is
ill whenever they cry.
 She should be followed up in two weeks and
referred if no improvement is noted to
prevent occurrence of major depression.
Note:
Any prolonged episodes of depression
during or after pregnancy should receive
urgent psychiatric attention.
AFTERPAINS
 It is the spasmodic, intermittent pain felt in the
back and lower abdomen after delivery for a
variable period of 2-4 days.
 It is often felt more frequently while breast-
feeding. Presence of blood clots or bits of the
after the birth leads to spasmodic hypertonic
contractions of the uterus in an attempt to expel
them out.
MANAGEMENT

 Massage the uterus with expulsion of


the clot.
 Administer analgesics (ibuprofen) and
antispasmodics
SUBINVOLUTION

Term used to describe a uterus that remains


large and fails to reduce in size and in mass
following child birth.
It may result from retained placental
fragments, infection and myoma.
 Sub-involution is suspected if the following
occurs:
The lochia fails to progress from rubra to
serosa
The woman gives a hx of excessive bleeding
Uterus is tender on palpation (suggests
endometritis)
Leucorrhoea and backpain
Enlarged uterus is palpable
MGT OF SUB-INVOLUTION

Evaluate for the cause and manage


appropriately e.g. completely remove all
products of conception
oral antibiotics : usually effective in metritis
PAIN IN THE PERINEUM

 Some degree of pain is felt in the


stitches.
 Abnormal pain should be
investigated to diagnose vulvo-
vaginal hematoma or infection is
developing.
RELIEVING MEASURES
 After using the bathroom, spray or pour warm
water over the entire vaginal area.
 Encourage mother to pat the area dry, making
sure to start at the front and end at the back to
avoid spreading germs from the rectum to the
vagina.
To reduce the swelling;
Apply Ice packs
 Wrap the ice pack in a washcloth or
other soft or absorbent material. Do
not directly apply the ice
Sitz bath

Encourage the mother to sit in a tub with


2-3 inches of warm salty water for about
15 minutes, three times in a day
Care of perineal stitches
Clean and dress the perineal area daily
and cover with sterile pad.
Swabbing should be done from above
downwards
Breast related disorders
BREAST ENGORGEMENT
 May occur about the third day postpartum and is
often regarded by mothers as the result of the milk
coming in.
 It is due to exaggerated normal venous and
lymphatic engorgement of the breasts which
precedes lactation.
 The mother approaches with pain and tense
feeling of the breasts, generalized malaise and
painful breastfeeding
SPECIFIC mgt
 Encourage the mother to consume lots of fluids.
 Support the breasts with a binder or brassiere.
 Apply warm bags on breast before nursing and ice
bags after.
 Express the milk manually.
 The baby should be put to breast regularly after
the expression of milk.
 Analgesics may also be prescribed to relieve pain
Sore, cracked and damaged nipples

Caused by trauma from the baby’s mouth and


tongue which results from incorrect
attachment of the baby to the breast.
Nipples should be kept dry and exposed to air
Other causes of soreness is infection with
candida albicans and both baby and mother
should receive concurrent fungicidal
treatment.
Recommended Methods of
Treatment for Cracked Nipples
Rest the breast for 24 hours or until the
crack is healed
Meanwhile express the milk manually
Expose the breast to the air for 20 minutes
six hourly or to an electric lamp 30cm
distance to promote healing
Prevention of Breast Complications
 Encourage breastfeeding by providing information on
the advantage of breastfeeding.
 Educate the mother during prenatal care on the
prevention of breast complications. Help her to fix
the baby properly on the breast.
 Stress the importance of emptying the breast by
manual expression in case of excess milk, to avoid
engorgement.
Emphasise the importance of
infection prevention, including
prompt treatment of any members of
the family with boils, burns or any
skin lesions.
Postnatal diuresis
 Within 12hrs of the birth the
women begins to lose excess tissue
fluid accumulated during
pregnancy.
 The profuse diaphoresis occurs
especially at night for the first 2-3
days after childbirth
Causes of post natal
diuresis
 Decreased estrogen levels
 Removal of increased venous pressure
in the lower extremities
By the above mechanisms the body rids
itself of excess fluid in the body
SPECIFIC mgt
Keep the mother clean and dry
Change her dress frequently
Change the bed sheets frequently
Care must be taken to ensure that the
mother is well hydrated.
CONSTIPATION
The problem is much less because of
early ambulation and liberalisation
of dietary intake.
Encourage the mother to take a diet
containing sufficient amount
of roughage and fluids is enough to
move the bowel.
Post-partum danger
signs to be reported
immediately
 Increased vaginal bleeding (more than 2 or 3 pads
soaked in 20-30 minutes after delivery OR bleeding
increases rather than decreases after delivery)
 Fits (convulsions)
 Fast or difficult breathing
 Fever and Excessive body weakness (e.g. too weak to
get out of bed)
 Severe abdominal pain
 Severe headaches with blurred vision
 Swollen, red or tender breasts or nipples
 Problems urinating, or leaking of urine and/or
faeces
 Increased pain in the perineum
 Infection in the area of the wound (redness,
swelling, pain, or pus in wound site)
 Foul smelling vaginal discharge.
Major Complications of
puerperium
 Postpartum haemorrhage
 Deep Venous thrombosis
 Pulmonary embolism
 Retention of urine or retention with overflow
 Urinary tract infection
 Puerperal sepsis and pyrexia
 Puerperal psychosis

END

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