Obstetrics Handout PDF

OBSTETRICS LECTURE NOTES COMPILED BY MRS. JANET ANSAH- DANSO Table of content 1. Terms used in Midwifery...............................................................\...4 2. Review parts and function of the male and female reproductive organs..........13 3. Bony pelvis.................................................................................30 4. Fetal skull.................................................................................\...47 5. Menstrual cycle.............................................................................53 6. Fertilization and development of embryo...............................................55 7. Placenta.......................................................................................59 8. Fetal circulation and changes after birth..................................................64 9. The female breast............................................................................68 10. Normal pregnancy..................................................................\..........74 11. Antenatal care...........................................................................\......87 12. Normal labour...............................................................................102 13. Post natal care..............................................................................120 14. Neonatal care................................................................................135 15. Specific obstetric emergencies............................................................147 16. Drugs used in obstetric: review the following drugs.................................\...186 TERMS USED IN MIDWIFERY - Midwifery - Midwife - Domiciliary --It pertains to the home or dwelling place. Domiciliary midwifery therefore means caring for the pregnant woman in her own home by the midwife. - Obstetric -- The branch of medicine dealing with pregnancy labour and puerperium - Puerperium The period of 6 to 8 weeks following child birth during which the uterus and other reproductive organs return to their pre-gravid -state. - Maternity Maternity means Childbearing - Gynaecology - Pregnancy (Cyesis) - Gravida - Primi-gravida - Multi-gravida - Grand- multigravida - Para - Primi-para - Multi-Para - Grande-multipara - Nully-para - Gestation - Pseudo Cyesis - Fertilization - Ovum - Embryo - Fetus - Viable - Term - Preterm baby - Trimester - Antenatal (Ante partum) Before birth of or delivery. - Partum --delivery - Post- natal (Postpartum) - Abortion - Miscarriage - Operculum - Show - Placenta - Membrane - Funis - Liquor Amnii ( Amniotic fluid) - Quickening - Lightening - Engagement - Menarche Initial or onset of menstruation - Amenorrhea Absence of menstruation. - Miltelschinerz This is ovulation pain. - Menopause The normal cessation of menstruation. - Climacteric -- menopause. - After Pain Lower abdominal and waist pain as a result of contraction of the uterus occurring in the early days of puerperium. - Lying in -- Period - Neonate - Neonatal - Congenital Pertaining to something present at birth either due to heredity or intrauterine origin. - Labour - Dystocia - Eutocia -- Normal labour - Episiotomy Any incision made into the perineum during delivery of the baby to increase the outlet. - BBA - Still born or birth - Maceration - Involution - Lochia - Colostrum - Meconium - Ante partum Hemorrhage (APH) - Post-Partum Hemorrhage (PPH) - PIH / ( pre-eclampsia) -- A condition very peculiar in pregnancy which is characterized by two or more of hypertension, proteinuria, edema - 65\. Eclampsia - Attitude - LIE - Presentation - Vertex - Denominator - Position The relationship of the denominator to the 6 landmark or area of the pelvis.These are Right occipito anterior (ROA) Left occipito anterio (LOA) Right sacro anterior (RSA) Left sacro anterior (LSA) Right Occipitor posterior (ROP) left occipito posterior (LOP) - Podalic /Breech is the buttock. - LMP Last menstrual period (1^st^ day start counting). - EDD/EDD Expected date of confinement or delivery. - ANC Antenatal clinic or care - PNC Post natal clinic or care - Small for date Baby who weighs less than expected at the period of gestation. REVIEW OF MALE AND FEMALE REPRODUCTIVE SYSTEM The Female Reproductive Organs It include all the structures that are involved in female reproduction. The female reproductive system consist of the external genitalia (Vulva) and the internal genitalia THE VULVA The term vulva applies to the external female genital organs. It consist of the following structures - Mons Veneris, Mons Pubis or Mount of Venus Is a pad of fatty tissue and covered with skin lying over the symphysis pubis; it is covered with pubic hair after puberty - Labia Major a: They are two large folds of fatty and areola tissue covered with skin. It arises from the Mons Veneris anteriorly and merges into the perineum behind. The inner surface is smooth and the outer surface is covered with hair - The Labia Minora: - The clitoris: - The vestibule: - The urethra orifice: - The vagina orifice: (introitus) - Bartholins glands: - Blood Supply: From external and internal pudendal arteries. - Venous return into the corresponding veins - Lymphatic: Into the inguinal glands - Nerve supply is by pudendal nerves and perineal nerves It consist of the vagina, cervix, uterus, ovaries and fallopian tube ![](media/image2.jpeg) THE VAGINA - The vagina is a fibro-muscular tube or canal which extends from the vestibule of vulva to the cervix of the uterus. - It runs upwards and backwards parallel to the plane of pelvic brim. - It is surrounded and supported by the pelvic floor muscles - The posterior wall measures 10-11cm long while the anterior wall measures 7.5cm. This is because the cervix projects at right angle into its upper part Macroscopic structure - The upper part of the vagina is called the vault. It forms porches or recess at where the cervix projects into it called fornices. - The posterior fornix is the largest because it is attached to the uterus at a high level. The anterior fornix lies in front of the cervix and the two lateral fornices lies on each side. - The vagina orifice opens into the vestibule of the vulva and is covered by hymen in virgins. Relations - Anteriorly, base of the bladder and the urethra - Posteriorly, pouch of Douglas, rectum and the perineal body, each occupying almost one-third of the vagina wall - Superiorly, the cervix and the uterus - Inferiorly, the external genitalia - Laterally, pubococcygeus muscle below and pelvic fascia above Microscopic structure - The inner lining of the vagina of stratified Squamous epithelium thrown into transverse folds called rugae. Beneath is vascular connective tissue which gives the vagina that pink colour. - Then the involuntary muscle layer composes of smooth, weak inner circular muscle fibres and strong outer longitudinal muscle fibres. The inner circular has blood vessels, nerves and lymphatic. - Pelvic fascia of connective tissue surrounds the vagina. - The vagina has acidic medium of PH 3.8 -- 4.5 by the action of Doderlin's bacilli, a normal commensal of vagina which convert glycogen to lactic acid and prevent pathogenic growth - Blood supply to the vagina is by vaginal artery and descending uterine artery from internal iliac artery - Venous return is by vaginal and uterine vein - Lymphatic -- drains into the inguinal glands, internal iliac glands and sacral glands - Nerve supply is by sacral plexus at the upper part and the lower part by pudendal nerves Functions of Vagina - It allows for entry of spermatozoa - It opens up for menstrual flow - It opens up for exit of product of conception - It support the uterus - It receives the penis and plays an active role during coitus - It helps prevent infection and ascending infections by its acidic medium The Non Pregnant Uterus - The uterus is a pear shaped hollow muscular organ - It is situated within the true pelvis and adopts an anti-flexed and ante-verted position. - It weighs 60 g and measures 7.5 cm long \*5 cm wide \* 2.5 thick with each wall measuring 1.25 cm. Relations - Anteriorly, bladder and the uteroversical pouch - Posteriorly, rectum and pouch of Douglas - Superiorly, intestine and peritoneum - Inferiorly, vagina - Laterally the broad ligaments, ovaries and uterine tubes Gross structure The uterus has two main parts, the body (corpus) and the cervix. The body - The part above the isthmus. - It forms the bulk of the uterus occupying the upper 2/3^rd^ of the uterus and measures 5cm long. - Fundus- The dome upper part between the insertion of the uterine tubes at the cornua - Cornua- The area of uterus where the uterine tubes are inserted - Cavity- Is a potential space between the anterior and posterior wall of the uterus. It is triangular in shape with its base uppermost - Isthmus- The area between the cervix and the body of the uterus. It measures 7mm long The cervix - Is the area below the Isthmus. - It forms the lower 1/3^rd^ of the uterus and measures 2.5cm long. - The internal os which opens into the uterine cavity - The external os which opens into the vagina - The cervical canal is the area between the internal os and the external os - Supra-vaginal cervix lies above the vagina - Infra-vaginal cervix is the part that project into the vagina Microscopic structure The cervix has three structures namely; Endometrium, myometrium and perimetrium The Endometrium Endometrium is the inner layer of the Uterus. - It is lined with mucous membrane of ciliated epithelium on a base of connective tissue called stroma. - The epithelium is cubical or cuboidal in shapes that dip down to form glands that secret alkaline mucus. - The cervical endometrium is of ciliated columnar epithelium arranged into patterns or folds called arbor vitae and contains racemose glands that secret mucus. - The Infra vaginal cervix is lined with Squamous epithelium and the portion where the epithelium changes is called squamous columnar junction Myometrium - It composed of involuntary muscle fiber that are intermingled with areola tissues, blood vessels, nerves and lymphatic's forming a spiral shape. - It thickens at the upper part and become sparsely towards the isthmus and cervix. - The muscle fibres at the cervix are embedded in collagen fibres. Three muscle fibres are distinct. - The inner circular is arranged concentrically and found more at the cornua and the cervix. - The middle oblique (Living ligatures) compose of interlocked spiral fibres perforated in all direction by blood vessels and do not extend to the cervix. - The outer longitudinal extends longitudinally from the isthmus anterior and runs over the fundus to be inserted into the vault of the vagina posteriorly. Perimetrium - The outer covering of the uterus. - It composes of double layer of serous membrane from peritoneum. - It covers the entire uterus except the lateral uterine wall and the anterior wall of the Supravaginal cervix. - The peritoneum reflects over the bladder to form the uteroversical pouch and over the rectum to form the pouch of Douglas. - Blood supply to the fundus is by ovarian artery from abdominal aorta, the body and the cervix is by uterine artery from internal iliac artery. - Venous return is by ovarian veins from the fundus into the inferior vena cava on the right and hepatic vein on the left and the lower part is drained by uterine veins into internal iliac veins - Nerve supply is by the sacral plexus (Lee Frankehauser) - Lymphatics -- internal iliac glands and the sacral glands Functions of the uterus - It prepares a bed for fertilized ovum - It nourishes fertilized ovum for gestational period - It expel product of conception at full term - The muscles help in haemostasis during 3^rd^ stage of labour - It involutes after child birth - It shares it lining at menstruation Support of uterus - Round ligaments From the cornua of uterus in front and passes between the folds of broad ligament to be inserted into each labia majors - Broad ligament Folds of peritoneum which drape over the fallopian tube and hangs down like a curtain. It spreads from the uterus to the side walls of pelvis - Transverse cervical/ Cardinal ligament (strongest ligament in the body). It extend from the vault of vagina and Supravaginal cervix and runs transversely to the side walls of pelvis - Utero-sacral ligament It extends from the cervix to the sacrum - Pubo-cervical ligament It originates from vault of vagina, Supravaginal cervix and neck of bladder to the pubic bone - Ovarian ligaments Extends from the cornua of uterus between folds of broad ligaments to the ovaries The cervix The cervix is the neck of the uterus and forms the lower 1/3 of the uterus. It has a funnel like shape and measures 2.3 cm long. Relations - Anterior -- Bladder, uteroversical porch and ureters - Posterior -- pouch of Douglas and rectum - Superior -- body of uterus - Inferior -- vagina - Lateral -- broad ligament Structure - The part of the cervix above the vagina is called supra vaginal cervix and the part that project into the vagina is called infra vaginal cervix - It has the internal os which is the narrow opening between the isthmus and the cervical canal - The external os is the small opening at the lower end of cervical canal and opens into the vagina - Cervical canal is the area between the internal and external os Microscopic structure - The cervical endometrium is of mucous membrane of ciliated epithelium which is columnar in shape. The epithelium is arranged infolded pattern called arbor vitae (tree of life) as it assists in passage of sperms. Within the lining is are racemose glands which secrets mucus - The Infravaginal portion is lined with Squamous epithelium like vagina. The cervical portion where the epithelium change occurs is known as squamo-columnar junction. - Muscle layer -- The cervical myometrium consist of smooth muscle of more inner circular fibres and outer longitudinal fibres which are embedded in dense collagen fibres (enable stretching in labour) - The peritoneum/perimetrium covers the anterior portion of the Supravaginal cervix and reflects loosely over the bladder - Blood supply is by uterine arteries and venous return is by the uterine veins - Nerve supply is by Lee Frankehauser (sacral plexus) Uterine Tubes/Fallopian Tubes/ Oviduct - It is a hollow muscular tube which extends from the cornua of the uterus laterally towards the side walls of the pelvis and arch down within the peritoneal cavity near the ovaries. - It lies within the folds of the broad ligaments and measures 10-12.5cm long and 3mm wide. Relations - Anterior - Peritoneum and intestine - Posterior - Peritoneum and intestine - Superior - Peritoneum and intestine - Lateral- Side walls of pelvis - Inferior -- Broad ligament - Medial - Uterus ![](media/image4.png) Macroscopic structure It has four portions which includes: - The Interstitial portion is the narrowest part that lies within the wall of the uterus. It measures 1-2cm long and 1mm wide. - The Isthmus is another narrow portion which extend 2.5cm long from the cornua of the uterus (A reservoir for sperms as it has a lowered temperature) - The Ampulla is the widest portion of the tube and extends from the isthmus to the infundibulum (Site for fertilization). It measures 5cm long - Infundibulum is the terminal and distal portion of the tube with a fimbriated. It has a funnel shaped end which opens into the peritoneal cavity. It has many processes or finger-like projections called fimbriae. One fimbria elongate and attach to the ovary called fimbria ovarica (Receives ovum and propels it upwards) Microscopic structure - It has an inner mucous membrane of ciliated epithelium cubical in shape and thrown into folds called plicae. Within the epithelia cells are goblet cells which produces a secretion containing glycogen (It nourishes the fertilized ovum). Beneath is a vascular connective tissue - The muscle layer is of smooth involuntary muscle composed of inner circular muscle fibres and outer longitudinal muscle fibres - The outer covering is of peritoneum but absent on the inferior - Blood supply is from ovarian and uterine artery - Venous return by the ovarian and uterine veins - Nerve is supplied by ovarian plexus - Lymphatic's by the lumbar glands Functions of the uterine tubes - It receives sperms as they travel up - It provides site for fertilization - It propels fertilized ovum towards the uterus - It nourishes the fertilized ovum as it travels down to the uterus Abnormalities of fallopian tubes - Blocked tube - Strictures - Stenosis - Tumours The Ovaries The ovaries are two small grayish almond shaped organ located on either side of the uterus below the fimbriated end of the fallopian tube at the level of the pelvic brim. It is attached to the posterior wall of the broad ligament in a small depression called ovarian fossa by the mesovarian within the peritoneal cavity. It has a dull white colour with corrugated surface (roughen and irregular). It measures 3-5cm long, 1.5-3cm wide, 1-1.5cm thick and weighs 5-8 grams Gross structure - Birth-Puberty is dull, smooth and solid in consistency. - Menstrual -- Is larger, irregular on the surface and more like a walnut - Post-Menopausal -- Small, shrinks and scarring on the surface (Due to rupture of Graafian follicles month after month) Relations - Anterior- Broad ligament - Superior -- Uterine tubes - Laterally - Infundibulum of fallopian tubes and Walls of pelvic - Medially -- Uterus Microscopic structure The ovary is divided into 2 parts. - The medulla -- Is the central and the supporting frame work of the ovary. It composes of fibrous tissue, elastic smooth muscles and a few connective tissues. It contains ovarian blood vessels, lymphatics and nerves. - The cortex: Is the functioning part of the ovary. It is made up of vascular connective tissues surrounded by Stroma in which numerous minute follicles are embedded. Each follicle contains oocytes (germ cell) or ovum in different stages of development. The ripening follicles become Graafian follicle which ruptures and release the ovum at ovulation - Corpus luteum: Is the yellow body that form from Graafian follicle after ovulation - Corpus albicans: Is the white scar that develops after degeneration of the corpus luteum ![](media/image6.jpeg) - The outer layer of the ovary is covered by a tough fibrous coat called Tunica albuginea - Germinal epithelium (Modification of the peritoneum) encloses the ovary - The ovary is the only organ in the peritoneal cavity that is not covered by peritoneum - Blood supply -- Ovarian artery - Venous Return -- Ovarian veins - Lymphatics -- lumber glands, Aortic lymph nodes - Nerves -- Ovarian plexus Functions - They produce the ova - They produce ovarian hormones (Oestrogen and progesterone) The male reproductive organs The male reproductive organs consist of the external and the internal structures The external structures are made up of the penis and scrotum Internal Organs - Testes - Vas deference - Seminal ducts - Seminal vesicle - Ejaculatory ducts - Prostate gland - Balbo urethra glands - Urethra THE PENIS - It is an elongated male organ. It suspends between the thighs and hangs flaccidly most of the time and downwards in front of the scrotal sac below the symphysis pubis - It consists of a shaft and a gland. The skin on the gland doubled backwards on itself to form prepuce. The penis is made up of 3 cylindrical columns of erectile tissues namely - Corpus spongiosum - Corpus Cavernsum - Part of the urethra The corpus spongiosum surrounds the penile urethra. The distil end expand to form a corn shape gland called the glans penis. The enlarged portion of the urethra within the gland is called Navicular Fossa. Corpus cavernosum It is the outer longitudinal layer and inner circular layer of dense fibrous tissue called tunica albuginea (it Controls the distention of erectile tissue beyond a certain point) The scrotum - Is a porch-like sac which contains the testes. - It lies below the symphysis pubis in between the upper thighs and behind the penis. - It is formed by a loose pigment skin and separated by medium ridge called raphen into two compartments, one for each testis TESTES Each testis measures 4.5cm long, 2.5cm wide and 3cm thick. It has 3 layers. - Tunica vasculosa is the inner layer of connective tissue containing network of capillaries. - Tunica albuginea a fibrous covering in growth of which divides the testes into 200-300 lobules - Tunica vaginalis -- outer layer of peritoneum ( brought down the descending testis from the lumber region of fatal life ) Microscopically The glandular tissue consist of about 200-300 lobules. - Each lobe contains convoluted semnifenuos tubules. - Between the tubules are interstitial cells which secrete testosterone. - The tubules join to form a system of channels that leads to epididymis. - The epididymis then leads into the vas deference within the spermatic cord to the level of the inguinal at region. - The deferent duct continues upwards and arches backwards behind the bladder to emerge with seminal duct from the seminal vesicle to form the ejaculatory duct. It produces viscous fluid to keep sperm alive and motile - The ejaculatory duct passes through the prostate gland to join the urethra carrying spermatozoa and seminal fluid - The prostate gland produces a thin lubricating fluid which adds the seminal fluid in which sperms suspend - The bulbo-urethral gland is situated just below the prostate gland. It secret another lubricating fluid which adds to the seminal fluid. A small amount of the fluid releases prior to ejaculation to lubricate the penislogged. Functions of Testes The testes produce sperms and the male hormone. The hypothalamus produces gonadotropin releasing factors which stimulate the APG to produce FSH and LH. FSH act on seminiferous tubules to bring about production of sperms. LH act on the interstitial cells to produce testosterone. This is responsible for male secondary sex characteristics like deepening of voice, growth of genitalia and hair on chest, pubis and axilla THE PELVIS (THE GYNAECOID PELVIS) The pelvis is a basin-like structure that connects the spine to the lower limbs. It contains and protects the female reproductive organs which include uterus, fallopian tube, ovaries, urinary bladder, rectum and the descending colon. Functions 1. It protects the pelvic organs and some abdominal organs. 2. It is a support for the body and muscle attachment 3. It forms part of passage during delivery 4. Bears the weight of the body when sitting 5. Act as a bridge between the femurs, forms part of the hip joint 6. Allows movement of the body for walking and running 7. Transmit the weight of the trunk to the lower limbs. 8. The sacrum transmits caudal equina and distributes nerves to the various parts of the pelvic. ![](media/image8.png) Bones that forms the pelvis 1. Two innominate bones formed by the Ilium, Ischium and Pubis. 2. One sacrum 3. One Coccyx Ilium - It's the flat upper flare part of the innominate bone. - It forms the upper ^2/5^ of the Acetabulum. - It has a rough posterior surface for muscles attachment (Gluteal muscle). - The inner anterior surface is smooth and concave forming iliac fossa where Iliacus muscles originate. - Below the iliac fossa is a distinct ridge called Iliopectineal line. The line ends in a bony projection where the ilium fusses with the superior ramus of pubis to form Iliopectineal eminence. - The outer surface is rough and makes attachment for the gluteus muscles of the buttocks. - The upper boarder has a ridge called iliac crest which is rough for attachment of abdominal muscle. - Anteriorly the ridge end at the anterior superior iliac spine and posteriorly at the posterior superior iliac spine. It has inferior iliac spines which are below the superior iliac spines. - The posterior spine is marked by dimples called Rhomboid of Michelles is formed by the superior tip the tip of spinous process of the 5^th^ lumbar vertebrae and the lower tip is formed by the Gluteal clef. - Below the posterior inferior iliac spine, the ilium turns sharply inwards to form greater sciatic notch through which the sciatic nerve passes. - Posteriorly the Ilium fuses with the sacrum to form the Sacroiliac joint. [ ] Ischium - The Ischium is the thickened lowest part of the innominate bone. - It has got the Ischia spine, a projection which separates the greater from the lesser Sciatic notches. - Ischia Tuberosity is the thickened area of bone which forms the body of Ischium. - The body joins the ilium to form lower 2/5^th^ of acetabulum. Pubis - It is the smallest of the three bones. - It has one body and two arms called Rami. - The body is squared shape at it medial aspect. - It articulates with each other to form the Symphysis Pubis. - The uppermost arm projecting from the body is called the ascending/superior ramus and fuses with the ilium at the Iliopectineal eminence. - The lower ramus fuses with the Ischium. The left and the right inferior ramus form the pubic arch. The foramen surrounded by the Ischium and pubis is the Obturator foramen The Sacrum - The sacrum is form by the fusion of five (5) sacral vertebrae. - It is triangular in shape with the apex pointing downwards. - It forms the posterior wall of pelvic cavity. - The posterior surface of the sacrum is rough for muscles attachment. - The anterior surface is smooth and concave but curve slightly side by side called hollow of sacrum. - The center of the upper boarder of the 1^st^ sacral vertebral is the promontory of sacrum. - On each side of the promontory is wings called alae which articulate with the Ilium to form the sacroiliac joint. - The apex of the sacrum articulates with the coccyx to form the sacrococcygeal joint. - The sacral canal runs longitudinally via center of sacrum for passage of spinal nerves. Four pairs of foramina forms when sacrum fuses together for passage of nerves and blood vessels. The Coccyx Form by four (4) fused coccygeal bones. It is triangular in shape with base pointing uppermost. It articulates with the sacrum at sacrococcygeal joint. ![](media/image10.png) Pelvic Joint There are four (4) pelvic joints: 1. Two Sacroiliac joints- It is formed by the 1^st^ and the 2^nd^ sacral vertebrae and the articular surfaces of the ilium. 2. The Sacrococcygeal- The base of the coccyx articulate with the tip of the sacrum 3. The Symphysis pubis- the body of the pubic bone unit by a pad of cartilage Pelvic Ligaments 1. Sacrotuberous ligament - From the lower boarder of Sacrum to the Ischial Tuberosity. 2. Sacro spinous ligament - From the side of sacrum and coccyx across the greater Sciatic notch to the Ischial spine. 3. Lacunar/Crimbernats -- Small ligament occupying the angle between the inner end of the inguinal ligament to the upper part of the pubic bone. 4. Obturator Membrane - Is a ligament closing the Obturator foramen excluding a small area to permit passage of nerves and small blood vessel 5. Sacroiliac Ligament - Binds the Sacroiliac joint. 6. Inguinal/Pouparts ligament - Is from the anterior superior iliac spine to the upper part of the body of the pubic bone. 7. Sacrococcygeal ligament -- It binds the sacrococcygeal joint. 8. Interpubic ligament- it surrounds the Symphysis pubis ![](media/image12.png) Divisions and measurements The pelvis is divided into two main parts namely; 1. The false pelvis-The upper extended part of pelvis above the brim 2. True pelvis- the part of pelvis below the pelvic brim. It is of great obstetric importance as the fetus passes through to be born. The true pelvis is further divided into three; The Brim/Inlet, Cavity and Outlet. Inlet or Brim In the normal female pelvis (gynaecoid), the brim is roughly oval in shape. It has an imaginary flat surface known as plane of the brim. Boundaries of the Inlet - Promontory of Sacrum - Alae - Upper part of Sacroiliac joint - Iliopectineal line - Iliopectineal eminence - Inner upper boarder of superior Rami - Inner upper boarder of body of pubic bone - Inner upper boarder of Symphysis pubis. Cavity It extends from the inlet to the outlet and is circular in shape. Its walls are composed of the following structures; - Anteriorly, it has anterior surface of pubic bone and Symphysis pubis. - Posteriorly it has the hollow of sacrum - Laterally it has greater Sciatic notch, internal surface of small portion of Ilium and the body of Ischium, the posterior of Acetabulum, the Obturator foramen occupied by the Obturator internus muscle. - The cavity is curved in shape and the posterior wall is 3 times as long as the anterior wall. Outlet There are two outlets: Anatomical outlet and Obstetrical outlet Anatomical outlet Is a diamond shaped structure at the lower boarder of Pelvis. - Symphysis pubis - The pubic arch - Inner boarder of Ischial Tuberosity - Sacro tuberous ligament - Tip of the coccyx Obstetrical outlet - Lower boarder of Symphysis pubis - The Ischia spines - Sacrospinous ligament - Lower boarder of sacrum - Imaginary line passing obliquely from pubic arch to the Ischia spine. Dimensions The brim - Anterior posterior diameter is taken from the sacral promontory to the inner part of Symphysis pubis known as the true conjugate. It measure 11cm. - Oblique diameter is taken from sacroiliac joint to the opposite Iliopectineal eminence which measures 12cm. - Transverse diameter is the widest diameter measured from side to side immediately behind Iliopectineal eminence. It measures 13cm. - Sacro -- Cotyliod diameter is taken from sacral promontory to Iliopectineal eminence on the same side. It measures 9cm. ![](media/image14.png) Cavity Is round so all measurement are the same. It measures 12cm which ever direction is taken. Anterior posterior, oblique diameter and transverse diameter Outlet - Anterior posterior diameter is taken from lower boarder of Symphysis pubis to lower boarder of sacrum which measures 13cm. - Transverse -- We have two diameters namely, Bi-spinous diameter- Taken from the Ischial between the two Ischial spines. It is the obstetrical transverse diameter Bi-tuberous is the anatomical diameter measured between the inner boarders of the two Ischial Tuberosity, roughly it is 11cm. Oblique diameter is taken between Obturator foramen and Sacrospinous ligament. It measures 12cm. Division Anterior posterior Oblique Transverse ---------- -------------------- --------- ------------ Brim 11 12 13 Cavity 12 12 12 Outlet 13 12 11 [PLANES OF PELVIS] These are imaginary flat surface passing across the bone pelvis at cliff levels. Plane of Brim Is a flat surface that can be occupied by a piece of paper cut to the appropriate shape of the brim. Plane of Cavity Is an imaginary surface extending from the midpoint the successive planes through the pelvis making the route through which the fetus passes during delivery. The curve is called curve of carus. Planes of Outlet It passes through the lower boarder of the sacrum and the lower boarder of Symphysis pubis. Angles /Inclination - Brim -- The brim makes an angle 60^0^. - Cavity - 30^0^ to the plane - outlet-15^0^ to the plane Axis of the Pelvis The curve of carus is an imaginary line drawn at right angles to each of the planes of pelvis. The curve of carus is the path which the fetus takes as it travels through the birth canal. Clinical Measurement of Pelvis (Pelvimitory) The pelvis should be assessed at antenatal clinic for: - Pelvic deformity - Size of pelvis (considered in relation to the fetal head as the fetal head is the best pelvimeter). External measurements includes - Interspinuos -- Taking between the anterior superior iliac spines. - Intercrystal -- From point of farthest from iliac crest. - External conjugate -- From the upper anterior boarder of the Symphysis pubis to the depression beneath the tip of the spine of the 5^th^ lumbar vertebrae. Internal Pelvic Measurement The pelvis is assessed internally at the certain stage in pregnancy to find out if it is adequate for vaginal delivery - Diagonal or internal conjugate - Measured from lower boarder of Symphysis pubis to center of sacra promontory. - X-Ray Pelvimitory. It is most adequate method in assessing the size and shape of the pelvis. Because of its effects, it is not often used unless it is necessary. Types of Pelvis There are four main types; - Gynaecoid - Android(male type) - Anthropoid - Platypelliod ![](media/image16.png) ----------------------- -------------------------------- ------------------------------------- -------------------------------- ------------------------------------------- Object Gynaecoid Android Anthropoid Platypelliod Bone/Brim Light thin and smooth, rounded Heavy thick and rough, heart shaped Oval shaped, long A-P diameter Kidney/ bean shaped, short A-P,long trans Sacrum Broad and well curved Narrow and straight Long and deeply, concave Flat and broad Cavity Shallow Deep Deep shallow Side wall Parallel Converge Parallel Diverge Ischia spine Blunt Sharp Blunt Blunt Sciatic notch Rounded Narrow Shallow and wide Shallow Sub pubic angle 90^0^ 85^0^- 90^0^ Less than 90^0^ 90^0^ and above 90^0^ ----------------------- -------------------------------- ------------------------------------- -------------------------------- ------------------------------------------- Other types of pelvis include, - long pelvis which is more like anthropoid - Justominor- Miniature gynaecoid with reduced diameters, seen in petit women less than 1.5m tall - Contracted pelvis- one or more of diameters of brim, cavity or outlet is reduced - Robert pelvis- it has no wings (alae of sacrum). It occurs from congenital abnormality - Naegele pelvis has only one wings, may be due to injury or congenital abnormality. It causes obliquity or can occur in women who limp for a long time Clinical Application Antenatal D - Diagnosis of contracted and deformed pelvis. - Determine the cephalo-pelvic disproportion During labour - Making accurate pelvis examination (VE) - Ascertaining the progress of labour - Determining the position of the fetal head. - Determining the most suitable position for delivery. - Facilitate the birth of the baby (curve of carus). E.g. the Ischial spines/the level of the cavity or whether head is in cavity or at brim. THE PELVIC FLOOR MUSCLES - It is also known as the pelvic diaphragm. Is a support for the pelvic organ and comprises of two layer muscles namely, - The deep floor muscles - Superficial muscle - There are also peritoneum as soft tissues, fats, connective tissue, fascia and skin covering the outside. Functions - Support the weight of abdominal and pelvic organs. - Its gutter shape place a role in the mechanism of labour. - It closes the pelvic outlet. - It relaxes to allow the baby to be born. - Its muscles are partly responsible for the voluntary control of micturition and defecation ![](media/image18.png) Structure Coronal section - Pelvic peritoneum (innermost). - Connective tissue of fascia. - Deep muscles levator ani. - Superficial muscle - Connective tissue of loose fat. - Skin Muscles of Superficial Layer They are: - Transverse perinea or transverse perineal originate from the inner surface of Ischia Tuberosity and passes transversely to meet in the middle. - Bulbo cavernoses -- It arise from the perineum and run longitudinal on each side of the vagina and urethra to be inserted at the corpus of clitoris just below the pubic arch. - Ischio cavernosus - it arises from each of the Ischial Tuberosity and run along the pubic bone to the corpus of clitoris. The fibers interweave with fibres of membranous sphincter of urethra. - External Anal Sphincter -- they encircle the anus and a few fibers attach to the coccyx behind. - Membranous sphincter of urethra -- it passes above and below the urethra and insert into the pubic bone. - Triangular ligament (made of deep fascia) fill the space within the deep and - superficial layersThe deep pelvic floor muscles ![](media/image20.png) - These muscles lie at a deep level in the pelvis and above the superficial layer. - They are about 5mm in depth. Each has insertion around the coccyx and therefore sometimes called the coccygeal muscles. - These muscles although aided by the superficial layer, one vital function is the voluntary control of the bladder and bowels. - The hygiene, comfort and social wellbeing of a woman as well as her childbearing ability are therefore dependent upon the effectiveness of their muscle tone. - There are three pairs of muscles to make up each levator ani muscles. Each of the muscles arises from one of each of the innominate bone and therefore derives its name from the bone. - It arises from the side walls of pelvis known as the white line of fascia on the inner aspect of each iliac bone and from each Ischial spine then covers the Obturator and internus muscles and runs posteriorly to the coccyx - Arises from each Ischia spine passes downwards and backwards to the upper part of the coccyx and lower boarder of the sacrum posterior, the pelvis diaphragm is now almost closed. - This muscles help to stabilize the sacroiliac and sacrococcygeal joint. Pubococcygeus - Each muscle arises from posterior inner boarder of the body of the pubic bone and from the white line of fascia. - They then sweep downwards posteriorly and inwards to unite with others in 3 distinct bands. A central band of fibres surrounds the urethra. - Some make a U-loop around the vagina and insert into the lateral and posterior vaginal wall and into the central part of the perineum. - Some fibres continue posteriorly and form a loop around the anus inserting into the lateral and posterior walls of the anal canal. - They insert finally in the coccyx. It is most important muscle of all the pelvic floor muscles. They surround and support the urethra, vagina and rectum controlled micturition and defecation, as well as normal sexual functions are dependent upon them. Perineal body - There is fibromuscular piramid situated between the lowest 1/3 of the vagina anteriorly and the rectum posteriorly. It is triangular in shaped with the apex directed upwards. Structure - It upper parts is formed by fibers of levator ani specifically the pubococcygeus while the lower half is of superficial pelvic muscle specifically Bulbo cavernoses and transverse perinei the base is covered by fascia and skin known as the perineum. The perineal body stretches and flattens during labour. - Blood supply -- is from the pudendal arteries, branches of the internal iliac artery - Venous drainage -- is into the corresponding veins - Lymphatic drainage -- is into the inguinal and external iliac glands. - Nerves supply -- is form the perinea branch of the pudendal nerve. THE FETAL SKULL It is the skeleton of the fetal head. The fetal head is the most important part of the fetus this is because: - It contains the brain which is vital organ subjected to pressure through the birth canal - It is large as compared to the true pelvis and thereby needs adaptation via the birth canal - About 95% - 96% of baby's present by the head - It is the most difficult part to deliver whether it come first or last. The fetal skull consists of: - The Vault - Base Face The vault - Is the large dome shaped compressible part which covers the brain and ossifies after birth - It extendS from the occipital pl orbital region and naro of to the foramen magnum behind. ![](media/image22.jpeg) The five (5) main bones forming the vault are: - Two frontal bones --Anteriorly lie the right and left frontal bones, whose ossification Centre's are named frontal eminences or frontal bosses. - Two parietal bones --Laterally, on the right and left are the parietal bones with their ossification Centre's at parietal eminences. - One occipital-One bone which lies posteriorly. The ossification Centre can be easily defined and is named the occipital protuberance. These bones are joined to each other and to the bones of the face and the base of the skull. The ossification starts from 8^th^ weeks of pregnancy. After birth the membranous ends can be felt between these flat bones called sutures. Where 2 or more sutures meet is called fontanel. Sutures They are cranial joint and are formed where 2 bones adjoined. Those of most obstetric significance are described as follows - Frontal sutures- It runs between the frontal bones. - Sagittal sutures - Lies between two parietal bones. - Coronal sutures -- Separate the frontal bones from the parietal bones passing from one tempo to the other. - Lambdoidal sutures -- It separates the occipital bones from the two parietal bones posteriorly. Fontanelles It picks it shape from the type of bone and the number of bones forming it. There are two important Fontanelles namely: Anterior Fontanelle (Bregma) - It looks like a diamond and it's the largest. - It is formed where the two coronal sutures, one sagittal suture and one frontal sutures meet. - It measure 3 -- 4cm long 1.5 -- 2cm wide. - Pulsation of cerebral vessels can be felt through it. It closes at 18months of the Childs life. Posterior Fontanelle (lambda) - It is formed by the occipital bone and two parietal bones - It is triangular in shape. I - Its junctions are sagittal suture and two Lambdoidal sutures. - It closes by 6 weeks of age. Area of the fetal skull - Glabella --Bridge of nose or the point the between the eyebrow - Bregma -- the anterior fontanelle - Vertex -- the highest point of the fetal skull. The area bounded by the anterior and posterior fontanelle and the parietal eminences. 96% of babies born with the head first, 95% present by vertex. - The sinciput or brow extends from the anterior fontanelle and the coronal suture to the orbital ridges/bridge of nose. - The face -- Extend from the orbital ridges and the root of the nose to the junction of the chin and the neck. - Mentum- the chin - The occiput -- lies between the foramen magnum and the posterior fontanelle. - The occipital protuberance -- The prominent point seen or felt on the posterior aspect of the skull. - Suboccipital region --below the occipital protuberance. - Lambda- Posterior fontanelle. Diameters of fetal skull There are two diameters- longitudinal diameter and transverse diameter Transverse diameters - Bi-Parietal diameter (9.5cm) diameter between two parietal eminences. - Bi-temporal diameter (8.2cm) diameter between farthest point of the coronal sutures at temples. - Longitudinal diameters - Sub-occipitobregmatic (SOB), 9.5cm - Measured from where the head joins the neck behind to the center of anterior fontanelle. - Sub-occipitofrontal (SOF), 10cm- Measured from sub occipital region to the center of forehead. - Occipitofrontal (OF), 11.5cm measured from center of forehead to occipital protruberance - Mentovertical (MV), 13.5cm --Measured from the chin to the highest point on the vertex. - Submentovertical (SMV), 11.5cm- Measured from the junction of the neck with chin to the highest point on the vertex. It present in face presentation when the head is fully extended. - Submentobregmatic (SMB,) 9.5cm- Measured from the junction of chin with the neck to the center of anterior fontanelle. ![](media/image24.png) Presenting diameters The presenting diameters are those which are at right angles to the curve of carus. The diameters presenting in cephalic or head presenting are: - Vertex presentation -- When the head is well flexed suboccipito-bregmatic and the biparietal diameter presents. Both diameters have the same length of 9.5cm and thus the presenting area is circular which makes it the most favorable shape for dilating the cervix i.e. engaging diameter. The diameter which distend the vaginal orifice is the suboccipito frontal which is 10cm. when the head is not flexed but erect, the presenting diameters occipito frontal (11.5cm) thus the diameter distending vagina orifice is occipito-frontal (11.5cm) which prolongs labour. - Partially flexed Presenting is the sub-occipitofrontal and the biparietal diameter, with good uterine contractions, head will flex and labour is likely to be normal. - Brow presentation - Face presentation Moulding The term applied to the change in the shape of the fetal head that takes place during passage through the birth canal. The change in shape is made possible because the bones of vault (sutures) allows slight degree of bending and overriding The skull bones are able to override at sutures, the overriding allows a considerable reduction in the sizes of the presenting diameters while the diameter at right angles to them is able to lengthen owing to the give of the skull bones. Moulding is a mechanism which protects the fetal brain from being compressed as long as it is not excessive, too rapid or in an unfavorable direction. - Excessive moulding occurs in prolong labour as a results of disproportion between maternal pelvis and the fetal head, the preterm baby as the bones are softer and have wider sutures and the post term baby as the bones are hard and tends to make labour more difficult. - Upward moulding occurs in persistent occipito posterior position and aftercoming head of breech. The falx cerebri tears and blood vessels at this area can rupture leading to intracranial haemorrhage - Rapid moulding occurs in precipitate labour where there is rapid compression and depression leading to tearing and bleeding. - Babies who are subjected to severe moulding will suffer some degree of asphyxia at birth. THE MENSTRUAL CYCLE It is the cycle of event for ovulation and fertilization The menstruation last between 28 -- 30 days. Monthly bleeding occurs between 4-7 days. The amount of blood loss is between 50 --200mls. Phases of the cycle Three main phases: - Proliferative - secretary - Menstrual Proliferative Phase The anterior pituitary gland under the direct control of the hypothalamus secret follicle stimulate hormone (SFH) which causes some primordial follicle of ovaries to grow and mature. The growing follicles produce estrogen which makes the endometrium of the uterus to grow thick by multiplication of the cells. Repining Of Graafian follicle In the normal event, all the follicles degenerate except one which matures. The follicle which survived enlarges, filled with fluid and become congested reaching a diameter of 1-2cm. The matured follicle rises to the surface of the ovary and ruptures ovulation. This occurs by the 14^th^ day of the menstrual cycle. The follicle then becomes corpus leteum and ends the proliferative phase Signs of Ovulation - Rise in body temperature - Breast enlarges, areola darkens and the nipples become erect. - Increase vaginal discharge becoming slightly slimy - The vagina becomes rummy - There is thick vaginal mucus on ovulation day - There may be mood swing, dullness or easily irritated - Thick vaginal mucus on ovulation by frequency of micturition. The secretory phase The luteinizing hormone (LH) from the anterior pituitary gland, act on the corpus leteum (the ruptured graafian follicle) which produce progesterone in increasing amount. This stimulates the endometrium to grow further and prepare its lining to receive the fertilized ovum. The average growth of the endometrium is about 4-6 thick There is increased production of watery mucus making the lining more tortuous. The ovum stays in the fallopian tube for 24 hours and dies if no fertilization occurs. The secretory phase last for about 10 days. The menstrual phase If no fertilization occurs the level of progesterone reduces 14^th^ day after ovulation. The anterior pituitary gland withdraws luteinizing hormone by 12-15 days preparation for pregnancy ceases and the endometrium is shed as the menstrual flow. Blood vessel become constricted becomes necrosed and then shedding of the endometrium. Menstruation Is the discharge of blood from the uterus at approximately 4 weeks interval commencing at puberty and lasting until menopause. Menstrual disorders - Amenorrhoea- Absence of menstruation. - Menorrhagia- An excessive menstrual discharge. - Metrorrhagia- Haemorrhage from the uterus other than or independent of menstruation - Oligomenorrhia- Scanty menstruation. FERTILIZATION, EMBEDMENT AND DEVELOPMENT OF THE OVUM - Fertilization is the fusion of the sperm and ovum which takes place in the fallopian tube (The Ampulla). - Following ovulation, the fimbrae of fallopian tube draw the ovum into the lumen and is wafted along the uterus by the cilia and peristaltic muscular contraction of the tube. - At ejaculation, about 300millions of cells are deposited at the posterior fornix of vagina. - The cervix, under the influence of estrogen secrets alkaline mucus to attract the sperms. - Some degenerate within the acidic medium of PH (4.5) of vagina and through the uterus until only thousands reach the uterine tube where they meet the ovum, usually the ampulla. - The sperm finally matures and releases hyaluronidase, an enzyme which breaks the cell membrane surrounding the ovum and penetrate the zona pellucid. - The membrane is sealed to prevent further entry of sperm. The two nucleus fuse and each contribute half chromosome to make total of 46 or 23 pair. - The sperm and the ovum are then male and female gamete. T - The fertilized ovum is called zygote ![](media/image26.jpeg) Embedment - The fertilized ovum continues its journey through the tube and reaches the uterus by 3^rd^ -- 4^th^. - It is nourished by goblet cell of uterine tube and secretory glands of uterus. - Segmentation or cell division occurs every 12 hours until a cluster of cell resembling mulberry is formed called morula. - The zygote then moves to one side of the cell forming a cavity called blastocyst (a fluid filled cavity or blastocelle appears in the morula which becomes blastocyst). - Around the blastocyst is a single layer of cell called Trophoblast which will form the placenta and chorion. The remaining cell clump together at one end of the cavity to form the inner cell mass which will later form the fetus, amnion and umbilical cord. - The blastocyst lies freely within the uterus for 2 or 3 more days. - The trophoblast secretes some substances which erode the endometrium into the tissue for embedment (nidation/nesting). - Embedment completes by 10^th^ -11^th^ day after ovulation. - After embedment of the zygote the uterine lining then becomes decidua. Layers of Decidua - Decidua is the name given to endometrium in pregnancy. It grows 4 times its non-pregnant thickness by the action of progesterone and oestrogen. - The basal layers -- is the layer that lies immediately above the myometrium. It remains unchanged and it is the part that endometrium grows during puerperium. - Functional layer -- it consist of tortuous glands rich in secretions. It has the spongy layer where separation occurs. This prevent excessive invasion of syncytium. - Compact layer -- this forms the surface of the decidua and is composed of closely packed stroma cell and neck of glands. - Areas of decidua - Decidua basalis -- The decidua underneath blastocyst - Decidua capsularis (capsular decidua) -- The decidua that covers the blastocyst - Parietal or true decidua -- (decidua Vera) it forms the remaining areas of the decidua eventually the capsular and parietal decidua meet as the fetus grows. The Trophoblast Finger like projection appears or develop from the Trophoblast and become more prolific at the area of contact (primitive chorionic villi). It differentiates into layers namely: 1. The syncytiotrophoblast or syncytium -- It is capable of eroding decidua and maternal blood vessel and makes it accessible to cytotrophoblast. 2. Cytotrophoblast (langhans layer) -it selects nutrient from maternal blood to the developing fetus.It produces HCG to inform corpus leteum that pregnancy has occurred. 3. Mesodem or primitive mesenchyme -- primitive blood vessels for the embryo are carried with the mesoderm. Systems of blood vessels develop within it together with the chorionic villi of other branches. It unit to form a large vessel and joins the embryonic blood vessels or body stalk at the base which develop to form the umbilical vein and two artery. 4. Some chorionic villi -- bury deep into the decidua called anchory villi ( lacks blood vessels) it stabilize the developing placenta. 5. Other villi -- branches from there and the spaces between them and the spaces between them is called the intervilous spaces. The villa in the region of decidua basalis proliferates to become chorion fondosum which develops to form the placenta. 6. The villi lying under the decidua capsularis -- become smaller as the blastocyst enlarges, they degenerate to form a membrane called chorion leave. It lines the uterine cavity and becomes the chorion. The Inner Cell Mass The inner cell mass develop to form the fetus. Three differentiation are formed, each forms particular parts of the fetus Ectoderm-Lines the amniotic sac and it develops into nervous system, skin, hair, nails, teeth, salivary glands lower anal canal, nasal cavity and mammary gland Endoderm from the yolk sac develops the internal organs like digestive tract, liver, pancreas, larynx, trachea, lungs, bladder and urethra. Mesoderm The cells between the yolk sac and amniotic sac form circulatory and lymphatic, skeletons, muscles, kidney, ureter, sex organs subcutaneous tissue of the skin. The three (3) layers are called embryonic plate. Two cavities form from the inner cell mass namely: The amniotic cavity lie on the side of ectoderm, it is filled with fluid and gradually folds around the fetus to enclose it. The amnion forms its lining and swells out into the chorionic cavity Yolk sac The yolk sac lies on the side of the endoderm and provides nourishment for the embryo until trophoblast takes over. Embryo is a name given to a developing zygote from implantation until 8weeks THE PLACENTA AT TERM ![](media/image28.jpeg) - The placenta is a temporal organ that links the fetus and the mother and is expelled after delivery. - It is flat and roughly circular in shape. - It measures 20cm in width, 2.5cm thick at its center and 62.5 in circumference. - It weighs 0.5kg at term (450-500g) and has a normal colour of dark red. It has two surfaces namely maternal surface and fetal surface. Maternal Surface - This is the dark red and freshly surface. - It is attached normally to the upper uterine segment of the decidua basalis. - It consists of about 16-20 lobes or cotyledons. Separating each lobes are groves called sulci (Furrows). - The lobes are made up of lobules and each contains chorionic villi with branches and blood vessels from both maternal and fetal systems. Fetal Surface - It is the smooth, shining, silvery or white surface. It lies adjacent to the amniotic sac. - Blood vessels are seen radiating from the cord to the deep substance of the placenta before reaching its circumference. - The membrane amnion cover the fetal part. - The umbilical cord is inserted into its center. - It consist of double layer. The outer membrane is the chorion which lies under the capsular decidua and become adherent to the uterine wall - The inner membrane is amnion which contains the amniotic fluid Development of Placenta - The fertilize ovum initially is covered with a fine hair called blastocyst and is also covered with a layer of cell called trophoblast. - The trophoblasts become sticky and adhere to the endometrium. - Small projections begin to appear over the blastocyst which become more prolific at the area of contact called primitive chorionic villi. - The villi proliferate more and form branches. - The villi become more prolific at the area where blood supply is richest i.e. basal decidua. This part of the trophoblast is known as chorion fondosum and it will eventually develop into the placenta. - The villi under the capsular decidua degenerate and form chorion laevae which become the membrane chorion. The villi erode and open maternal blood vessels as they penetrate the decidua to form lake of maternal blood in which they float. - The opened blood vessels are called sinus and the areas surrounding the villi as blood space. This enables the villi to select food, nutrient, oxygen and excrete waste called nutritive villi. - A few villi penetrate deep into the decidua called anchoring villi which stabilize the placenta. Each villus differentiates into three cells - The inner mesoderm which forms the fetal blood vessels, the middle cytotrophoblast and the outer layer of syncytiotrophoblast FUNCTIONS OF PLACENTA 1. Respiration The fetus obtains oxygen and excretes carbon dioxide through the placenta. Within the capillaries Oxygen or hemoglobin from mothers blood is passed into the fetal blood by simple diffusion carbon dioxide is also given off into the maternal blood similarly. 2. Nutrition The fetus need nutrient to mature and develop into a require size and weight. The same nutrient as needed by anyone. Amino acid required for body building, glucose for energy, calcium and phosphorus for bones and teeth. Mineral and iron for blood formation, Food for the fetus is derive through the placenta from the mother's diet. The placenta is able to select nutrient needed by the fetus. At the time it reaches the placenta it has broken down into simpler form. 3. Endocrine - Human chorionic gonadotrophic hormone is produced by the chorionic villi and its present in the large quantities at the early stage of pregnancy. It reaches its peak between the 7^th^ and 10^th^ week and gradually reduces as pregnancy advances. It functions to stimulate the growth and activity of the corpus leteum. - Oestrogen The placenta takes over the production of oestrogen from corpus leteum. It is secreted in large amount throughout pregnancy - Progesterone is secreted in the syncitial layer of the placenta in increasing amount until immediately before the onset of labour - Human Placenta Lactogen (HPL) Plays the role of glucose metabolism in pregnancy and used in the assessment of fetal growth - Relaxin-enhances stretching of the pelvic ligaments 4. Storage The placenta is able to store glucose in a form of glycogen and reconvert it to glucose when required. It can also stores iron and fat soluble vitamins. 5. Excretion The placenta excrete carbon dioxide, bilirubin, urea and uric acids. They are excreted in small amounts into the maternal blood. 6. Protection - The placenta provides a limited barrier to infection. - Few bacterial can also penetrate e.g. treponema of syphilis - Some drugs can also cross the placenta, some may cause damage, some may be harmless and others are beneficial like antibiotics given to pregnant women. - Immunoglobins are also transferred to the fetus towards the end of the pregnancy. - Iron, phosphorus, calcium and vitamins are also given. - Barrier between maternal and fetal blood tissue also protect fetus against mother's rejection. 7. Anchorage: The chorionic villi anchors the placenta firmly in the decidua Membranes Chorion Is thick, opaque, friable membrane derived from the trophoblast and continue with the chorionic plate which forms the base of placenta Amnion Is the smooth, tough and transparent membrane derived from the inner mass (ectoderm) it secretes amniotic fluid and covers the placenta and the amniotic cavity. Amniotic Fluid - Clear, pale and straw coloured fluid - Originate from the amnion, exudates from maternal and fetal vessels and fetal urine from 10^th^ week of gestation. - The fluid is changed every three hours. - The normal amount is between 500-1500mls. - The amount is 1000mls around 38 weeks and 800mls at term. - Above 1500mls is Polyhydramnous while below 300mls is oligohydramnous. Constituents of amniotic fluid - Water -- 99% - Dissolve solid -1% including food substances and waste products, fetal sheds skin cells, Vernix caseosa and lanugo. Abnormal constituents - Meconium/ green colour in fetal distress - Yellow colour in icterus gravis neonatorium. Umbilical Cord or Funis - It extends from the fetus to the fetal surface of the placenta. - At full term the cord measures an average length of 50cm long and a diameter of 1-- 2cm. - The cord transmits the umbilical blood vessels which are two umbilical arteries and one umbilical vein. - They are enclosed and protected by the Wharton's jelly a gelatinous substance formed from mesoderm. - The whole cord is covered in a layer of amnion which continuous with that covering the placenta. - At the fetal end it continues with the skin of the abdomen. - Amount of jelly makes the cord thick or thin. - It has no nerves or lymphatic. Factors Affecting Functioning Of Placenta - Age of placenta -- It start to generate after 40 weeks and form infarction - Maternal disease e.g. diabetes mellitus, syphilis, PIH, essential hypertension - Development errors- tumors, infarction and cord insertion. Abnormalities of the Umbilical Cord - Length of insertion of cord: Very short cord prevents descent of the fetus during labour and there may be pulling of placenta causing partial separation. - Very long cord may be long as 100cm wide round the fetal neck and cause intrauterine strangulation causing asphyxia, false and true knot if down tight during labour. Abnormality of Placenta Formation and Cord - Normal: The normal placenta is flat round with the cord at the centre. - Battledore: The cord is inserted at the edge of the placenta - Velamentosa: The cord is inserted in the membranes with blood vessels through the membranes placenta. There is a danger if blood vessel lie in front of presenting part. (vasa praevia) and the membranes ruptures there is a likely-hood of blood vessels to rupture and lead to fetal haemorrhage. - Circumvalata: A double layer of membranes amnion and sometimes chorion which has undergone infarction and is seen as opaque ring about 2.5cm from the edge. - Sucenturiata[:] An extra small lobe of placenta in the membranes with blood vessels running to it. It develops somewhere in the uterus. The extra lobe may be left behind after placental expulsion resulting in postpartum haemorrhage - Bipartita; Two or three placenta or lobes are formed and the umbilical cord divides at a point into two - Placenta Accreta: Abnormality of placenta embedment in the uterine muscle due to mal-development of the decidua where there is no spongy layer FETAL CIRCULATION This is a type of blood circulation special to the fetus where blood and nutrient are transmitted from the placenta to the fetus. In fetal circulation, oxygen is derived from the mother through the placenta and carbon dioxide is taken back to maternal uterine veins through the umbilical arteries to the placenta by simple diffusion, osmosis and selective reabsorption. There are four temporal structures in addition to the placenta and the umbilical cord while making ready postnatal structures to take over after birth. These are 1. Ductus venosus 2. Foramen ovale 3. Ductus arteriosus 4. Hypogastric arteries Course of Blood Flow From the placenta, the umbilical vein leads through the umbilical cord carrying oxygenated blood through the abdominal wall to the under surface of the liver. - It has a branch which joins the portal vein to supply the liver the only vessel in fetus which carries unmixed blood. - Ductus venosus (connect a vein to vein) connect the umbilical vein to the inferior vena cava carrying deoxygenated blood returning from the lower part of the body. The blood mixes and thus the blood throughout the body is partially oxygenated. - The blood passes into right atrium and most of it is directed across through the foramen ovale (an opening between the atria) to the left atrium. This is because blood need not to be pump into the lungs for oxygenation - Blood then enters the left ventricles and pumps into the aorta. - The coronary artery branches immediately to supply the heart, carotid artery to supply the brain, subclavian arteries supply the arms. Each receives relatively well oxygenated blood and this explains why the arms develop more than the legs at birth - Blood from the upper part of the body returns to the right atrium through superior vena cava. Through the tricuspid valve the blood passes into the right ventricles. The streams of blood remain separated but there is about 25% mixing of blood to allow little oxygen and nutrient to be taken to the lungs via pulmonary artery. Little amount of blood is required by the lungs. The remainder of the blood passes via the bifurcation of the pulmonary artery into the descending aorta through Ductus arteriosus( connect artery to artery) - The descending aorta supply the abdomen, pelvis and lower extremities although low in oxygen it is sufficient to supply the lower organs. The internal iliac arteries leads into the Hypogastric arteries which return deoxygenated blood to the umbilical arteries - The remaining blood supplies the lower limbs and returns blood to the inferior vena cava. ![](media/image30.jpeg) Changes at Birth At birth when the baby cries the lungs expands or inflate for the first time - The blood in Ductus arteriosus flows to the lungs for oxygenation. - Within five minutes after birth it constrict and then closes later and becomes cardiac ligament - Blood returning from the lungs through pulmonary veins increases pressure in a left atrium and pressure in right atrium decreases which closes the flap over the foramen ovale and prevent blood flow between the atria. - The removal of placental circulation further decreases pressure in right atrium blood then moves from right atrium to right ventricles to the lungs soon after clamping of cord. - The umbilical vessels cease to pulsate and collapse. - The umbilical vein fibrose and becomes ligamentum teres of liver. - Foramen ovale becomes fossa ovalis - Ductus venosus become ligamentum venosum which support the attachment of portal vein to inferior vena cava - The Hypogastric artery become obliterator Hypogastric artery - If these adaptations do not take place after birth they become evident as congenital abnormalities. THE BREAST - They are two mammalian accessory reproductive gland of female reproduction. - It is situated on each side of the sternum and lies on the superficial fascial of the pectoralis major and serratus anterior muscles and supported by suspensory ligament - Size-it varies according to the number of adipose tissue. - It is hemispherical in nullypara and pendulous in multiparous - It extend vertically from the \[2^nd^ rib to the6th rib\] and horizontally from the axilla\[3^rd^ rib \] to lateral margin of sternum Microscopic Structure The Nipple is the central/conical eminence or the protuberance at the level of the 4^th^ rib. It's about 6mm in length. It composes of erectile tissues containing smooth contracting muscle fibers. It is covered by pigmented epithelium content. The lactiferous ducts open into the nipple by small orifices Areola-is circular loose pigment area surrounding the nipple in the center of the breast. Width - about 25cm in diameter Content -- it has about 20 sebaceous glands at the edges. It enlarges during pregnancy (montgomery's tubercles) it secret sebum to keep the nipple supple. It has a tail to extend into the axilla known as axillary tail of Spence (it contains fatty tissues). Microscopic Structure ![](media/image32.jpeg) - The breast is a compound secretory gland composes mainly of glandular tissues and some adipose tissue. T - The glandular tissues are divided into about 18-20 lobes. - Each lobe is a complete unit which is separated from each other by fibrous bands of connective tissues. - Each lobe is divided into several lobules that consist of cluster of alveoli. - Each alveolus is lined with acini cells. - Surrounding each alveolus is myoepithelia cells which contract to propel milk into lactiferous tubules. - The tubules empty it content into the central duct called the lactiferous ducts. - The duct extends and widens towards the nipple to form lactiferous sinus or ampulla. - The duct then extend from the ampulla and opens at the nipple. - Blood supply --internal and external mammary artery and intercostal artery from the subclavian, axillary and the aorta respectively. - Venous -- corresponding veins - Lymphatic- Lymph drains into the axillary glands, portal fissure of liver and the mediasternal glands. The lymph flows freely between the two breasts. - Nerve- Is controlled by the hormonal activity, the skin is by the cutaneous branch of the thoracic nerves and the nipple and areola by the sympathetic nerves. Physiology of Lactation Two factors are involved in the secretion of milk by the breast These are Production of milk and Passage of milk Production of Milk - Milk is produced under the influence of the hormone prolactin from anterior pituitary gland. Prolactin levels in blood during pregnancy rises but its action is inhibited by the placental hormones (oestrogen and progesterone). - With separation and expulsion of placenta at the end of labour, the level of progesterone and oestrogen falls and prolactin is activated. - There is blood supply to the breast and essential substances are extracted by the acini cells within the alveoli to produce the milk. - The base of the secretory cells distends the acini cells and milk is pushed into the lactiferous tubules. - Once lactation has established, prolactin level is maintained by frequency of passage of milk i.e. every 2-3 hours. - Prolactin level is highest at night. Passage of Milk Two factors are involved in passage of milk from breast cells to the nipple Back pressure The force of new milk produced in the cells exerts a pressure to pushes the foremost milk into the lactiferous tubules. ( - A negative feedback control of milk production) when the child sucks, the milk flow to the nipple and another production commences. Neuro-hormonal reflex (let down reflex) - When the baby is put to breast, tactile stimulation or sucking movement of the breast causes nervous stimulation to causes an unconditional reflex in the posterior pituitary gland to releases oxytocin. - Oxytocin causes myoepithelia cells (spider cells or basket) around the alveoli to contract and push milk into the lactiferous tubules. - Milk flows to the ampulla and another production of milk commence. Maintenance of Lactation - Supply of milk is maintained by demand. Stimulus from breast fed babies such as suckling causes more prolactin to be release to cause production of milk. - Feed baby on demand and as long as he/she wants. - Ensure the baby is well fixed to the breast (The areola) - Empty one breast completely before offering the other breast - Emotional stability of the mother enhances milk production and flow - Breastfeeding mothers should have pain free especially during feeding times - Improved the nutrition and Hemoglobin level. Components of Breast Milk - Fats and fatty acids are more in the hind-milk and high in the afternoon. It consist of about 98% In a form of triglycerides, 56% Unsaturated and 46% Saturated. It provides more than 50% of the caloric requirement by the newborn. - Proteins- Human milk contains less amount of protein than any other mammals. Is easily digestible because it is predominantly whey alpha lactalbumin, caseinogens which is difficult to digest is in lower quantity. - Carbohydrates- The chief component of carbohydrate in human milk is lactose which is converted to galactose and glucose by an enzyme bifidus factor. It enhances the absorption of calcium and promotes the growth of lactobacilli in the intestinal and helps reduce the growth of pathogenic organisms. - Vitamins- Fat soluble vitamins A, B, C, D and E are in higher quantities. K is less and an injection of vitamin K given at birth - Anti- Infective Factors/ protective factors - Leucocytes-surrounds and destroy harmful bacteria by their phagocytic activities. - Antibodies- The breast milk contains antibodies especially T&A to protect the child intestinal mucosa from pathogenic organs until the child is able to make her own antibodies. - Antitrypsin Factors-Ensures that Immunoglobins are not destroyed. - Anti-allergic Factors - Lysosomes- it inhibits the growth of bacteria's by disrupting their cell walls. - LACTEFERRIN-It binds the enteric iron and prevents E-coli from obtaining the iron for their survival. - Bifidus Factors - It promote the growth of gram positive bacilli in the gut flora called lactobacillus bifidus which prevent other bacteria's from growing and Prevent diarrhea Advantages *o*f Breastfeed to the Mother 1. It saves time, money and unnecessary worry to mother 2. It aid in the involution of uterus 3. It decreases the chances of PPH 4. It delays ovulation 5. It enhances bonding between mother and baby 6. It gives protection against breast and ovarian caner 7. Mother derives emotional and physical satisfaction 8. Breastfeeding time is resting time. Advantages to the Baby - Breast milk is a natural food which offers complete nutrition to the baby - It contain immune factors which protect against pathogenic organisms and allergies - It promote infant brain growth - Is free from organisms and thus is sterile - Breastfed babies are healthier and re-enforces child survival. - It is always of correct temperature - It never go sour or spoil - It is easily digestible and thus diarrhea diseases are prevented, if it occurs it is less. - It is always available and always ready - It is easy to provide feeds during night and day. PREGNANCY (NORMAL) All the system are effected by pregnancy when ovum fertilize, the fertilize ovum get embedded in the mothers uterus. After embedding certain changes takes place in the mothers body. These changes are physiological, physical and emotional. Physical changes occur to enable various part of the body to adapt themselves to play their roles fully to support the fetus and to expel it at the end of pregnancy. Physiological Changes in Pregnancy Hormones Progesterone When pregnancy occurs, the corpus luteum persists to continuing to produce progesterone to maintain the decidua. By the 12^th^ week of pregnancy the placenta is well matured and takes over the hormone production from corpus luteum. It maintains the decidua throughout pregnancy relaxes smooth muscles and promotes the growth of glandular tissues of the breast. Oestrogen Produce by the corpus luteum and later by the placenta. It enhances the growth of the uterus and the duct system of the breast. It also initiate onset of labour. Relaxin Produced by the placenta. It causes pelvic joints and ligament relaxation during late pregnancy. Human chorionic gonadotrophic hormone (HCG) In the process of the placenta developing, it produces a hormone called (HCG) human chorionic gonadotrophic hormone which has a very identical action to that of progesterone. HCG is excreted by the kidneys and can be observed in the urine of pregnant women from the early weeks of pregnancy. HCG forms the basis of all the pregnancy test. Prolactin Produced by the anterior pituitary gland but it is suppressed by high oestrogen level in pregnancy. It is responsible for milk production Oxytocin Produced by posterior pituitary gland and the action is suppressed by progesterone and oestrogen levels until their levels falls just before onset of labour. - It is responsible for causing onset of labour There is increased activity in other endocrine gland like thyroid gland and adrenal cortex. - The basal metabolic rate is therefore increased, pulse at neck is very fast and the hollow gets fill up. Changes in the uterus Increase in the size to 30cm long by 25cm wide by 20cm at term and measures 900g. This increase is brought about by hypertrophy and hyperplasia. The uterus rises out of the pelvis to become an abdominal organ by 12^th^ week. Towards the later part of the pregnancy, the uterus develops into 2 distinctive parts. The Upper uterine segment by upper 2/3 of the body of the uterus and the lower upper segment formed by isthmus between the cervix and body of the uterus. Blood supply to the uterus become greatly increased which causes softening of the cervix. The cervical mucus thickens to form a plug known as operculum. The uterine muscle layers become more distinct and organized. During pregnancy the endometrium is known as decidua. Changes in Fallopian Tubes As the uterus grows, the fallopian tubes get developed. As the uterus rises up out of the pelvis, the fallopian tubes drop by the sides of the uterus by 10^th^ weeks. Changes in Ovaries The corpus luteum does not degenerate but become large until 12^th^ week when placenta takes over hormone production. The ovaries are also displaced as the uterus rises. Their normal function ceases. Changes in Vagina Vagina grows slightly, the cells become thicker and bluish due to congestion. Blood supply is increases, and causes vaginal fornices to pulsate. Secretion increases in volume and the PH become more acidic. Changes in Vulva There are increase blood supply and the skin around the vulva becomes pigmented. The veins may become varicose Changes in the Skin The skin around the abdomen, breast and buttock is greatly stretched. Some silvery lines may be seen at these areas called striae gravidarum. There is pigmentation of the breast around the nipples, presence of linea nigra on the abdomen and pigmentation of vulva and face (Cloasma) i.e. the mask of pregnancy. Changes in Breast The breast become nodular and lumpy due to enlargement of milk secreting cells and duct. They respond to the action of oestrogen and progesterone. Tenderness and tingling sensation, increased blood supply causing the breast to become more prominent and pigmented. Sebaceous gland in the areola become enlarged known as montgomery's tubercles. Colostrum can be expressed from the breast from the 16^th^ weeks. Changes in Cardiovascular System There is increase blood volume for about 25% in the plasma parts from about the 10^th^ week onwards to cater for the enlarging uterus, breast and placenta. There is a smaller increased in blood cells and hemoglobin leading to haemodilution. Plasma proteins are decreased and this partly explains the edema commonly observed in pregnancy. Blood pressure is lowered partly because of relaxation of smooth muscles. Changes in Urinary Tract system The workload on the kidneys increases as total blood volume increases. The renal threshold for sugar is lowered and sugar may be found in the urine without the woman suffering from diabetes. The ureters are relaxed, become dilated and kinked. Slow emptying of the ureter and renal pelvis may follow which cause urinary tract infection. The pregnant uterus tend to press on the urinary bladder predisposing her to frequent micturition (early pregnant by the) enlarge uterus and late pregnancy by engaging head. Changes in weight The mother's weight increases during pregnancy due to increase in body tissue. By term the woman gains about 12kg. The weight accounted for by the following. - Foetus 3.4kg - Placenta -- 0.6kg - Amniotic fluid 0.6 - Uterus 0.9kg - Breast 0.5kg - Blood 1.5kg - Extra cerlular 1kg - Fat 3.5 The mother gains 2.5kg during the 1^st^ 20weeks and 9.5kg during the 2^nd^ half of pregnancy. Skeletal Change Change in the joint of the mother, Shoulders are thrown backwards, there is relaxation of pelvic joint and difficult in walking in the advanced stage sometime the change in gait is known as the pride of pregnancy. Emotional and Nervous Changes The pregnant woman may develop a special liking for certain things especially things that goes into the mouth (Pica). She becomes irritable and mental relapse may show in women with mental history or psychological problem. Diagnosis of pregnancy We have 3 different type of the signs and symptoms - Presumptive signs - Probable signs - Positive signs Presumptive sign presumes that one is pregnant. Amenorrhea,(1^st^ -- 4^th^ week) early breast changes (6^th^ week), morning sickness (4 -- 16^th^ weeks), bladder irritability or frequency of micturition (4 -- 16^th^), Quickening (16^th^-20^th^ week), some skin changes Positive signs these signs confirms pregnancy Fetal part felt on palpation (24^th^ week), fetal movement palpated and visible, fetal heart sound by ultrasound and fetal stethoscope, visualization of fetus by ultrasound or x -- ray (14 -- 16^th^ week) Diagnosis of pregnancy History -- e.g. last menstrual period signs and symptoms, physical examination e.g. palpation, observing breast and other parts and various investigations conducted Differential diagnosis of pregnant 1. Amenorrhoea -- In general illness e.g. tuberculosis, throtoxicosis, change of environment, during lactation and at menopause. 2. Morning sickness -- In gastritis, in urinary tract infection. 3. Enlargement abdomen -- From increase of fat, tumours, e.g. ovarian cyst and fibroids or ascites. 4. Pseudo cyesis -- Amenorrhoea may be present, associate symptoms suggesting pregnancy. Abdomen may be enlarged but not pregnant. It is sometimes seen in a woman who is anxious to have babies. 5. Act -- Is a psychological disorder in which a woman has a false but fixed believe that she is pregnant. Minor Disorders of Pregnancy They are common disorders experienced by pregnant women. They are not life threatening but causes some discomfort for the pregnancy woman. Causes of Minor Disorder Hormones -- The presence of certain hormones, metabolic changes,posture and accommodation changes are common causes of minor disorders Digestive system Nausea and Vomiting (Morning Sickness) Nausea is a sensation of sickness with inclination to vomiting. Vomiting is the expulsion of the stomach content via the esophagus and the mouth. It starts around the 4^th^ -- 16th week of gestation and about 50% of women experience this. Cause -- the actual cause is not known but it is believe to be cause by hormones present in pregnancy, hypoglycemia and smell of certain foods, certain strong scented soap and positioning in lying. It is usually aggravated by anxiety and emotional disturbance. Management - Reassure and explain the reasons to her that it is common in pregnancy and will resolve as the pregnancy advances. - Encourage her to take light diet. [ ] - Encourage her to take carbohydrate foods when going to sleep such as light sweet milk and early in the morning such as a cup of tea with dry biscuit to prevent hypoglycemia. - Encourage her to take small meal at frequent intervals, small amount of fluids between meals to improve loss from vomiting. - Avoid eating highly spicy foods or pungent odours which can trigger nausea and vomiting. - Encourage to eat easily digestible foods rich in vitamin and mineral salt. - Investigate and rule out any other disease. - Remove any stimulus that aggravates her discomfort. Complication Excessive vomiting with dehydration can lead to hyperemesis gravidarum. Refer for further management when that occurs b. Heart Burns Burning sensation felt in the media-sternal region. It occurs in most pregnanty women from the 2^nd^ half of pregnancy around 30^th^ -40^th^ week of gestation Causes It is thought to be due to the action of progesterone which relaxes the cardiac sphincter of the stomach causing regurgitation of acid or stomach content, Pressure from the large uterus on the stomach and reduced gastric motility, the action of food in the stomach is reduced. Management - Advice to avoid bending in her activities as there is reflux in bending. - Advice to take small food in frequent time as there is small room for food from the pressing uterus. - Advice to sleep on more pillows than usual. - Advice to sit up a while before lying down after eating. - Lie on side instead of recumbent position. - If it persists refer, alkaline medicines such as antacids such as aluminum hydroxide (Aludrox) or magnesium hydroxide (Maalox) is prescribed. c. Ptylism Excessive Salivation experienced by the pregnant woman. This occurs from the 8^th^ week of pregnancy and the cause is taught to be due to pregnancy hormones Management - Frequent mouth washes is advise - Presence of food or something in the mouth to keep the saliva d. Pica Is a term used when the mother craves certain foods or unnatural substance. Cause -- the cause is unknown but it is known to be associated with iron deficiency. Management - Reassure and explain that it will go gradually as is common in pregnancy. - If the substance can be harmful to the fetus then, refer to for appropriate treatment. e. Constipation In frequent or incomplete action of the bowel causing hard retained stools in the bowel Causes- The hormone Progesterone relaxes the intestine and that there is decrease peristalsis - The uterus displace the intestine reducing peristaltic movement of bowels - Habit forming - Taking in of some drugs e.g. iron drugs - Certain foods. Management - Reassure and encourage taking extra fluids and increase water intake - Intake of roughage, vegetable diet and fresh fruits. - Exercise may be helpful to stimulate the bowels but not vigorous e.g. walking, sweeping. - Warm glass of water in the morning before tea or breakfast activates the gut. - Encourage to make an effort to empty the bowels frequently. (same time, every day) - Advice against continues straining to prevent hemorrhoids. - If the condition is not relieved by diet, milk of magnesia or lactulose (a stool softener) is given to loosen stool for easy passage. Musculoskeletal System Backache- There is abnormal change of spine as the pregnancy continues, this posture needed to adapt the change by tilting causes back ache. The hormone causes softening of the ligament. It is more common in multipara woman with poor muscle tone. Management - Educate her to understand the change and reassure. - Advise her to wear low heel shoes to adapt to the curvature. - Adapt good posture during sitting, sleeping or walking by tilting the pelvis forward - Educate her to sleep on a firm bed - Investigate to rule out urinary tract disease - In advance stage examine whether it is not onset of labour. b. Muscle Cramp A cramp is painful spasmodic muscular contraction. It may be due to muscle fatigue usually muscles of the legs Cause -- unknown but may be due to lack of blood supply to certain part (ischemia), may result from the changes in electrolytes causing electrolyte imbalance, decrease Calcium level, increase serum potassium or change in PH. Management - Advise to raise the foot of her bed about 25cm - Advise to do leg exercise by bending the toe upwards (dorsiflexion) - Advise to put the legs in warm water and make gentle movement to promote circulation - In severe cases refer for further management - Aluminum hydroxide gel may be given to lower phosphorus level in the path - Calcium and B-complex may also be given. 3\. Genitourinary System a\. Frequency of Micturition This occurs in early weeks of pregnancy when the uterus presses on bladder. It may last for 3 months and disappear. It re-occurs in later stages in pregnancy when the fetal head presses on the bladder. Management - Investigate to rule out urinary tract disease - Ask whether there is no burning sensation - Reassure if these are ruled out that it will resolve after 12^th^ weeks when uterus rises into the abdomen and if late stage, reassure her. b. Leucorrhoea Is an increase in the normal vaginal secretion, there is excessive secretion but not offensive. Management - Reassure that is normal in pregnancy but if the discharge cause irritation then it must be investigated. - Educate on personal hygiene. - Use of ordinary water to wash the vulva if she feel it becomes too much - Advice to wear cotton panties c. Pruritus Vulvae Severe irritation of the vulva it could be lack of cleaning, thrash or trichomonas Management Advise on personal hygiene and investigate as it could be diabetes mellitus 4\. Circulatory System a\. Fainting-Brief loss of consciousness due to lack of oxygen to the brain. It may be due to vasodilation caused by progesterone. - Late pregnancy when the woman is lying at her back due to pressing of the uterus on the inferior vena cava reducing blood supply. - Standing in crowded area for long time due to hypotension. - Sudden change in position. - Sometimes after waking up. Management - Explain to her the phenomenon and reassure her not to be anxious - Advise to sit down and press the head in between the thighs - Loosen all tight clothes when she faint, move to airy place and later refer to the specialist - Explain she should not lie on her back but lie on her side - Quickly sit or lie down if she feel slightly faint - Avoid long standing, crowded or stuffy areas Varicose Veins A condition in which the veins are dilated, painful, inflamed and engorged. It usually occurs in women with family history of varicosities. It occurs around the legs, vulva, and anus leading to heamorrhoids. It occurs with very large uterus or multiple pregnancy. Causes - Progesterone causing relaxing of the smooth muscle of veins resulting in sluggish circulation - The weight of the uterus put pressure on the vessel returning from the lower extremities resulting in accumulation of blood in the vessels. Management - A good history to know family history of varicosity - Tell her to elevate the legs on a stool for about 15 minute twice daily - Exercise by standing on the toe - Advise on elastic stocking or bandage above the area of distention before rising up - Encourage to wear vulva pads if at vulva - In hemorrhoids avoid constipation by fiber diet and adequate fluid Haemorroids Varicose vein in the anus associated with constipation Management - Advise on diet to have loose stool - The use of hemorriodal suppository - Advise on mild laxative 5. The Skin Itching of the skin Cause - Resulting from the respond of the liver to the hormones present in pregnancy as a result there is rise in bilirubin causing the itching. - It may be due to stretching of the skin of abdomen and breast - Generalized itching, it is believed to be endocrine disorder therefore rule out diabetes mellitus Management - Reassure and explain to patient - Application of soothing ointment e.g. cold creams - If severe refer for proper management 6. Nervous System Insomnia- Inability to sleep Cause - Anxiety such as previous histories - Uncomfortable bed, heat or growing fetus. - Frequency of micturition - Fetus may be kicking a lot Management 1. Reassure to allay anxiety 2. Find out if there is any fear about the pregnancy and prepare her 3. Advise to sleep in the afternoon or go to bed early 4. Encourage to do anything that will induce sleep 5. Advice to take a diet containing protein as protein helps one to sleep well. 6. In pendulous abdomen support it with pillows Carpal Syndrome This is a feeling of numbness and tingling sensation (pins and needle sensation). Causes - Fluid retention which create oedema causing pressure on nerves and its usually occurs in the morning Management 1. Reassure and explain it is a disorder pregnancy 2. Can put the hand on pillows or splint to rest the hand. MANAGEMENT OF THE PREGNANT WOMAN ANTENATAL CARE It is the combination of physical and psychological care given to pregnant women before birth. It is an organized care rendered to pregnant women to attain and maintain a state of good health throughout pregnancy and to ensure the safe delivery of a live infant at term. It can be given in hospital, clinic, health centers, health post and private clinic. They are advice to attend at a clinic near them and the clinic should have facilities to make client comfortable e.g. comfortable, chairs, large waiting room, and privacy like examination room. There should be toilet, water supply, adequate light a place for testing urine and a place for dispensing drugs. Aims of Ante-Natal Care - To promote and maintain good physical, mental and social health of mother throughout pregnancy, labour and puerperium - To monitor progress of pregnancy to ensure good maternal health and the normal development of the fetus - To ensure the delivery of a mature live healthy infant - To promote exclusive breastfeeding and prepare the woman for lactation and subsequent care of the baby - To detect early and treat appropriately medical, surgical and obstetrical conditions that can endanger the mother or baby. - To prevent mother to child transmission of HIV/ AIDS - To give her the appropriate support to enhance her psychological and social wellbeing - To ensure trusting relationship between the pregnant woman, her family and the health care provider - To offer family planning counseling on individual basis Benefits of Antenatal - It help reduce the number of maternal and fetal deaths - It help to reduce the number of neonatal deaths - It helps to reduce the number of complications of pregnancy e.g. Anaemia, pre-eclampsia - It help to reduce the number of complications of labour e.g. ruptured uterus, PPH - To help improve the general health of mother. Focus Antenatal care (Quality rather than quantity) It is a new system of ANC to enhance quality of service to the pregnant woman thereby reducing both maternal and neonatal morbidity and mortality. It emphasizes on quality of visits with a minimum of four visit for healthy client. - It is a holistic approach by providing individualized and client centered care to the expectant mother. - It takes into consideration the physical, psychological, social and spiritual wellbeing of the client, her family and the community as a whole. - It emphasizes on early detection of diseases rather than grouping women into risk category - It gives the client the opportunity to be cared for by the same skilled provider throughout her pregnancy. - She is assured of confidentiality, birth preparedness and complication readiness. - It enhances quality of care to pregnant women thereby reducing maternal, fetal and neonatal morbidity and mortality The aim - To provide individualized care - Provision of efficient care by skilled attendant - Early detection of any disease or complication that may arise during pregnancy - Promote health - Identify early pre-existing medical condition and prepare for birth and plan to get ready for complications. - It ensures privacy, - confidentiality - Implementation of recommended reproductive health protocols Standard Schedul

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