Introduction to Obstetric and Gynaecology Nursing Notes PDF

OBSTERIC AND GYNAECOLOGY NURSING NOTES INTRODUCTION Obstetric and Gynaecological Nursing – Is a specialty that help to assist and support women with their reproductive life from puberty, menopause and beyond. Nursing care is given to women preparing...

OBSTERIC AND GYNAECOLOGY NURSING NOTES INTRODUCTION Obstetric and Gynaecological Nursing – Is a specialty that help to assist and support women with their reproductive life from puberty, menopause and beyond. Nursing care is given to women preparing to give birth, during pregnancy, or going through labour and delivery. Finally, caring for women with diseases or health issues related to the reproductive organs, fertility or menopause and others DEFINITION OF CONCEPTS Obstetrical Nursing- Care given to the client before, during and after delivery. Gynaecological Nursing- Care given to clients to maintain and sustain healthy reproductive life. The care pertains to the structural and physiological health of both primary and secondary reproductive organs such as the ovaries, uterus, oviducts and the breast and reproduction. HISTORICAL PERSPECTIVES The first recorded obstetric practices are found in Egyptian records dating back to 1500 B.C. Attending to women during their birthing experience has been with us since creation when women started bringing forth babies. The traditional methods of assisting the woman before, during pregnancy and after childbirth differ from societies or ethnic groups. Ancient practices of childbearing has been developed with time, presently there more formal “scientific” methods and practices that are being employed in the care of the mother namely obstetric nursing. MATERNAL AND CHILD HEALTH PROBLEMS IN GHANA The magnitude of maternal and child health problems in the country in terms of mortality and morbidity has been a public health menace. Unfortunately, Ghana was not able to meet the Millennium Development Goal 5 (MDG 5) target of 185/100,000 live births for maternal mortality by 2015 (MOH, 2016). Maternal mortality rates determine a country’s health status, human rights and poverty level. One out of 18 women in Ghana is estimated to face the risk of maternal death. Complications of pregnancy and child birth are the major causes of death for women in Ghana (Reduce Maternal and Newborn Deaths in Ghana Guide). To ensure quality care, Safe Motherhood Programme was introduced in the nineties, free maternal health care in 2008 and other programmes. The aim is to reduce maternal mortality and morbidity by improving quality of care delivery and coverage of maternal health services. 1 WHY STUDY OBSTETRIC AND GYNAECOLOGICAL NURSING? To equip the nurse with the knowledge and understanding of Anatomy and Physiology of the reproductive organs and apply in practice. Develop the skills to manage a woman before, (antenatal), during (intra-partum) and after delivery (Postnatal) To gain the ability to detect any abnormality and prevent complications during pregnancy and labour To have good knowledge of obstetric drugs and their effect on diseases of the reproductive system and how to deal with their Complications. Why study Obstetric and Gynaecological Nursing? Monitor and record appropriately maternal care and be able to identify The bony pelvis is shaped like a basin and contains essential organs It articulates above with the fifth lumber vertebrae, the head of the femur and into the right and left acetabulum It carries the weight of the trunk and transmit it to the legs The girdle of the pelvis is the largest formation of bone in the body complications and gaps in nursing care and provide quality care. Develop the necessary skills in supporting women in labour, deliver them safely and resuscitate the new born when necessary. Educate, empower and support the mother to care for herself and baby during the post partum period and identify and report any abnormalities. Why Study Obstetric and Gynaecological Nursing? To gain the knowledge and ability to educate mothers on the care of their babies, need for immunization and family planning. To offer family guidance and psychological support on motherhood Be always helpful and ready to offer advice, assistance and support for the mother, family and significant others for healthy motherhood OVERVIEW OF THE FEMALE REPRODUCTIVE ORGANS Purpose of female reproductive system – Reproduction – Provides the structural and physiological reproductive or sexual basis for the individual – Secretes hormones that support secondary sex characteristic changes – Secretes hormones that sustain pregnancy should fertilization occur THE BONY PELVIS Types of Female Pelvis 2 Four main types of female pelvis classified by Caldwell and Molloy are as follows: 1. The Gynaecoid pelvis (female type) 2. The Android pelvis (male type) 3. The Anthropoid pelvis 4 The Platypelloid pelvis The Types of Pelvis Other types described are – Roberts, Naegele, Justo minor and Contracted Pelvis.  Robert Pelvis – sacrum has no wings and contracted in all diameters  Naegele Pelvis – Sacrum has one wing, making it tilted or oblique  Justo –minor – Miniature gynaecoid pelvis, found in very short women.  Contracted Pelvis – One or more of the essential diameters (antero-posterior, oblique or transverse of the brim, cavity, outlet) is reduced. THE FEMALE PELVIS The female pelvis is structurally adapted for child bearing and delivery. There are four pelvic bones - innominate or hip bones (Two) - Sacrum (One) 3  - Coccyx (One) THE BONES OF THE PELVIS There are two innominate bones, each is composed of three parts. 1. The Ilium the large flared out part 2. The ischium the thick lower part. It has a large prominence known as the ischial tuberosity on which the body rests when sitting and the ischial spine. During delivery or labour the station of the fetal head is estimated in relation to ischial spines. 3. The pubis - forms the anterior part, the space enclosed by the body of the pubic bone, the rami and the ischium is called the obturator foramen The Sacrum The sacrum – It is a wedge shaped bone and consist of five fused vertebrae. The upper border of the first sacral vertebra is known as the sacral promontory, on each side is a widened portion appearing as wings and called the alae of the sacrum. The anterior surface of the sacrum is smooth and concave and is referred to as the hollow of the sacrum. The coccyx: - is four fused coccygeal vertebrae forming a tiny triangular bone that articulate with the sacrum above PELVIC JOINTS When the woman is not pregnant, there is slight movement in the pelvic joints. During pregnancy endocrine activity causes the ligaments to soften and allows the joints to give. This provides more room for the fetal head as it passes through the pelvis. The Four Pelvis Joints The two sacro-iliac joints – they are slightly movable and the strongest joints in the body. Location - on the first two sacral vertebrae. The symphysis pubis is a cartilagenous joint formed by the junction of the body of the two pubic bones along the midline. The sacro-coccygeal joint is formed where the base of the coccyx articulates with the tip of the sacrum. It can tilt backwards 4 PELVIC LIGAMENTS Each of the pelvic joint is held together by ligaments, they are as follows; Inguinal or Pouparts ligament –From anterior superior iliac spine to the body of the pubis Inter-pubic ligaments - at symphysis pubis (1) Sacro iliac ligaments (2) they are the strongest Sacro coccygeal ligaments (1) Sacro tuberous ligament (2)- from lower border of the sacrum to ischial tuberosity. Sacro spinous ligament (2) –Sacrum to ischial spines DIVISIONS OF THE PELVIS The Pelvis brim divides into two parts 1) The False pelvis – This is above the brim and of little importance to midwifery 2) The True Pelvis - Includes the pelvis brim and all the bones that lie below it. It is divided into the Brim, Cavity and Outlet. Pelvic brim or Inlet – The Structures are as follows; Promontory of the Sacrum Alae of the sacrum The sacro Iliac joint Iliopectineal line Iliopectineal eminence Inner border of the Superior pubic ramus Upper inner border - body of the pubic bone Upper inner border of the symphysis pubis Important Landmarks of the Female Pelvis – The Cavity Pelvic Cavity Extends from the brim above to the outlet below and consist of the following; Greater sciatic notch The back of the acetabulum The obturator foramen 5  The back of the body of the pubic bone Important Landmarks of the Female Pelvis – The Outlet Pelvic Out let – This is of two types The Anatomical Outlet The Obstetric Outlet The Anatomical Outlet –Structures The lower border of the symphysis pubis The inferior pubic rami The ischial tuberosities The sacro-tuberous ligament The tip of the coccyx Obstetrical Outlet- Structures The lower border of the symphysis pubis The ischial spines The sacro-spinous ligament The lower border of the sacrum Important Diameters of the Pelvis DIAMETERS Inlet -Diagonal conjugate - a line from the sacral promontory toward the lower border of the symphysis pubis and measures 12.5 centimeters. It is measured by pelvic examination And an important diameters of the Pelvis Mid cavity Inter-spinous diameter- a line between the two ischial spines, measures 11 centimeters. The pelvic outlet - Pubic arch - Inter-tuberous diameter -Measurements of the Pelvic Canal PELVIC FLOOR OR PELVIC DIAPHRAGM The pelvic floor or diaphragm is a muscular floor that demarcates the pelvic cavity and perineum. Its strength is enforced by its associated condensed pelvic fascia and important for the protection of pelvic organs. It is gutter shaped, higher anteriorly than posteriorly. Three canals run through its tissues – Urethra, vagina and rectum, Layers of Pelvic Tissues - An outer covering of skin; Subcutaneous fat; Superficial muscles enclosed in fascia; Deep muscles enclosed in fascia; Pelvic fascia thickened to form pelvic ligaments and; Peritoneum 6 Superficial Pelvic Floor Muscles Transverse Perinei – arise from each ischial tuberosity and meet at the center of the perineal body Bulbo – cavernous – Two muscles arise in the center of the perinuem, they pass one on each side of the urethra and vagina round the orifices into the pubic bone Ischio cavernous – runs from each ischial tuberosity to the pubic bone Membranous sphincter of the urethra The rectal sphincter Pelvic Floor Muscles Deep Floor Muscles; Levater ani muscles - Arise from the lateral pelvic wall and decussate in the midline between the urethra, the Vagina and rectum. It contains, Ischio-coccygeous muscle, ilio coccygeus and pubococcygeous. Pubococygeous muscle is constructed in such a way that it can expand enough for child birth and contract the pelvis Functions of the Pelvic Floor It supports the weight of the abdominal and pelvic organs The muscles are responsible for the voluntary control of micturation, defecation and play an important part in sexual intercourse. It influences the passive movement of the fetus through the birth canal and relaxes to allow its exit from the pelvis THE PERINEAL BODY It is found between the vagina and rectal canals and triangular in shape measuring 3.8 cm in length on each side of the triangle. Structure – the Outer covering is composed of skin, then the superficial pelvic muscles which are the Bulbo cavernous and transverse perinei. Blood supply are from the pudendal arteries which are branches of the internal iliac artery, venous drainage is to its corresponding veins. Nerve supply are the pudendal nerves Functions of the Perineal Body Assist in the process of childbirth and defecation It stretches and helps the fetal head and body to be delivered. Note: It can overstretch or get torn during delivery of the baby, the midwife must try to avoid or minimise injuries to this structure when delivering the baby THE FEMALE REPRODUCTIVE ORGANS The female reproductive system is composed of both external and internal reproductive organs. The organs which are divided into two are also referred to as; 1. The External Genitalia 2. The Internal genitalia The External Genitalia (The Vulva) This term applies to the external female genital organs and consists of the following structures. 7 The Mons Pubis or Mons Veneris is a pad of fat lying over the Symphysis pubis and covered with pubic hair from the time of puberty. The labia majora (greater lips) are two large folds of fatty tissue covered by skin. Inner aspect is smooth and contains numerous sweat and sebaceous glands The labia minora (lesser lips) are pink skin lying longitudinally within the labia majora, anteriorly it encloses the clitoris and posteriorly forms the fourchette. The clitoris is a small rounded extremely sensitive organ of erectile tissue situated within the prepuce and frenulum of the vulva. The vestibule is the flattened, smooth surface that can be seen inside of the labia The vaginal orifice or Introitus is found below the urethral meatus. Bartholin's glands (vulvovaginal glands) are located lateral to the vaginal opening on the sides. The fourchette is a ridge of tissue formed by the joining of the two labia minora and the labia majora. Blood supply comes to the vulva is mainly from the pudendal arteries and a portion of the inferior rectus artery. The blood drains through the pundendal veins. Lymphatic drainage is into the inguinal glands Nerve supply is a branch of the pudendal nerve THE INTERNAL GENITAL ORGANS The Vagina The Uterus The Oviduct or Fallopian tubes The Ovaries 8  STRUCTURES OF THE INTERNAL GENITALIA THE VAGINA OR INTROITUS This is a canal running from the vestibule to the cervix, the walls are pink in appearance and thrown into small folds known as ruggae. These allow the vaginal wall to stretch during intercourse and child birth. It has a PH of 4.5. It is found in front of the rectum and behind the bladder and urethra. The posterior wall is longer than the anterior wall. It is composed of the following layers; squamous epithelium, vascular connective tissue, weak inner coat of circular fibers and stronger outer coat of longitudinal fibers. Pelvic fascia surrounds the vagina forming a layer of connective tissue. Blood supply come from the branches of the internal iliac artery and drains through corresponding Veins. The lymphatic drainage is through the inguinal, the internal iliac and the sacral glands. They drains the lymphatic fluid. THE UTERUS The uterus is a hollow, muscular pear shaped organ situated in the true pelvis. The non pregnant uterus is 7.5 cm long, 5cm wide and 2.5cm in depth, each wall is 1.25 cm thick. The cervix forms the lower third of the uterus and the body the upper two thirds. It leans forward, this is known as ante-version and bends forwards on itself also known as ante-flexion. It is related anteriorly with the bladder and posteriorly the rectum. Superiorly lie the peritoneum and intestines, inferiorly is the vagina. On both sides of its lateral walls are the broad ligament, oviduct and ovary. Structure The uterus is divided into the following parts; The body or corpus, the largest part that form the upper 2/3 of the uterus The fundus; this is the dome shaped upper wall between the areas where the fallopian tubes are inserted. The cornua; are the upper outer angle of the uterus where the fallopian tubes join. 9  The cavity - is the space between the anterior and posterior walls. The isthmus - is the narrow area between the cavity and the cervix, it is 7mm in length and enlarges during pregnancy to form the lower uterine segment. The cervix or neck - protrudes into the vagina -The narrow opening of the cervix is referred to as internal os (mouth). It is between the isthmus and the cervix. The lower end of the cervix is referred to as external os. It is a small round opening. Muscles of the Uterus The uterus has three muscle layers; The endometrium: - forms a lining of ciliated epithelium (mucous membrane) and embedded on a connective tissue or stroma. It constantly changes in thickness during the menstrual cycle. The myometrium or muscle coat: - It is thick in the upper part of the uterus and sparse in the isthmus and cervix. It has three parts: Outer longitudinal, middle oblique and inner circular. The perimetrium is a double serous membrane and extends from the peritoneum and cover the uterus. Ligaments or supports of the Uterus The Uterus is supported by the pelvic floor and maintained in position by several ligaments. These Ligaments are; Peritoneal ligament Broad ligament Genito-inguinal ligament Round ligament Transverse cervical ligament Utero- sacral ligament Functions- it houses the fetus during pregnancy and responsible for menstrual flow and pregnancy. During delivery it contracts to expel its contents. Blood supply – The uterine artery arrives at the level of the cervix and is a branch of the internal iliac artery. The blood drains through its corresponding veins. Nerve supply is from the autonomic nervous system that is sympathetic and para-sympathetic via pelvic plexus. THE FALLOPIAN TUBES OR OVIDUCT They lie within the broad ligament and extend from the cornu of the uterus, each tube is approximately 10cm (4in) and 3mm (0.12) in diameter. The lumen of each tube extends to the cavity of the uterus superiorly and the peritoneal cavity inferiorly. The anterior, posterior and superior parts are related to the peritoneal cavity and intestines. The inferior aspect is related to the broad ligament and ovaries, the lateral is to the infundibulo-pelvic ligament and medial to the uterus Parts or Structure of the Oviducts The interstitial portion is 1.25cm long found within the wall of the uterus. Its lumen is 1 mm wide. The isthmus, -its narrow part and extends from the uterus. It is 2.5 cm long The ampullar -its wider portion where fertilization usually occurs. It is 5 cm long. 10  The infundibulum -its funnel - shaped fingered end composed of fimbriae. One fimbria is elongated and attached to the ovary. Functions – The ovum and sperm can pass, unite and start their early development. Blood Supply is by the uterine and ovarian arteries and their corresponding veins. Nerve Supply is the ovarian plexus. Lymphatic drainage is into the lumber glands OBSTETRIC CONDITIONS ASSOCIATED TO THE FALLOPIAN TUBES Infertility – Partial or complete obstruction of one or both tubes. Ectopic gestation- Pregnancy occurring in the fallopian tube Ruptured ectopic gestation – when the tube ruptures when it unable to contain the developing fetus. Sterilization – The clamping and cutting of the Fallopian tube to prevent pregnancy. THE OVARIES They are found attached to the back of the broad ligament at a location called the mesovarian and near the fimbriated end of the fallopian tube. The size is 3cm long, 2cm wide. They are small, almond shaped, dull white with corrugated surface and solid in consistency. Before and at the onset of Puberty they are smooth. During the menstrual phase that is from Puberty to menopause they are walnut rather than almond shaped and is larger and irregular on the surface. After menopause of post menopausal period they are small, shrunken with scar tissues Structure of the Ovaries Germinal epithelium – made of peritoneum covers or encloses the ovary Tunica albuginea is its tough, fibrous outer coat Cortex is the largest outer part composed of stroma where graafian follicles in their various stages of development in the menstrual or fertile age are embedded. Follicles contain an ovum and when they burst out the scar tissue that is formed is called corpus luteum. Medulla this is the central portion where the blood vessels, lymphatic's and nerves enter and leave Function – To produce ova for fertilisation and hormones, that is oestrogen and progesterone. Blood supply: - ovarian arteries and drains by the ovarian veins. The right ovarian vein joins the inferior venecava, but the left returns its blood to the left renal vein. Nerve supply is from the ovarian plexus and lymphatic drainage into the lumbar glands THE MENSTRUAL CYCLE A menstrual cycle is the periodic uterine bleeding in response to cyclic hormonal changes that occur in the ovary and uterus. The first menstrual period is called menarche and occurs at the average age of 12 years. It may occur as early as age 9 or late as age 17. The accepted average length is 28 days. The length of the average menstrual flow is 1-9 days and the average length is 5 days. Amount of flow is from spotting to 80 ml on average. 11 Organs involved in the Menstrual Cycle They are as follows; The hypothalamus The pituitary gland The ovaries and The uterus. Cervix Phases of the Menstrual Cycle Regenerative or proliferative Phase; this follows immediately after menstruation. The ovary starts releasing oestrogen by the influence of the follicle stimulating hormone from the pituitary gland making the endometrium of the uterus to start growing rapidly. The length is variable. It is also called estrogenic, follicular, or postmenstrual phase. Ovulation phase; a Graafian follicle become fully grown and rupture to release ovum Secretory phase; where the Graafian follicle ruptured the area begins to increase in size by the influence of the luteinising hormone from the pituitary gland and become the corpus luteum. The menstrual phase or uterine tears is the bleeding from the uterine lining Secretory Changes of the Uterine Lining The uterine lining or endometrium becomes thicker and spongier. There is increased activity of the secretory glands with deposition of Mineral salts and glucose and other nutrients for nourishment. The lining is then prepared for the fertilised ovum. DIAGRAM OF THE MENSTRUAL CYCLE 12 MENSTRUATION When fertilisation does not occur after 8-10 days the corpus luteum in the ovary ceases to grow. The production of progesterone and oestrogen decreases. With the withdrawal of progesterone stimulation, the endometrium lining of the uterus begins to degenerate (at approximately day 24 or day 25 of the cycle). The capillaries rupture, with haemorrhage, and menstruation begins. Signs and Symptoms of Menstruation and Ovulation Menstruation Some women have symptoms such as anxiety, fatigue, abdominal bloating, headaches, loss of appetite, irritability and depression in the pre-menstrual period. Some women may also experience abdominal pain with some irritation during ovulation when follicular fluid or blood spills in to the abdominal cavity With the onset of menses some women exhibit abnormal symptoms such as dysmenorrhea, that is painful menstruation, this may be accompanied with nausea, vomiting and loss of appetite. Ovulation A sharp pain, called Mittlelschmerz is typically felt on either side of the abdomen near an ovary usually accompanied by scant vaginal spotting during ovulation. A thick stretchy mucous membranes like the white of an egg is released and seen coming from the vagina during this period. It is used as a sign of ovulation in Family Planning and it is called the Billings method. FERTILISATION AND DEVELOPMENT OF THE OVUM Fertilization is the union of the ovum and a spermatozoa usually occurring in the outer third of a fallopian tube, the ampullar portion. The functional life span of spermatozoa is about 48 hours / may be as long as 72 hours or longer. After fertilization the ova passes through the fallopian tube and reaches the uterus 3 or 4 days later. The name of the fertilised ovum is called zygote. EARLY DEVELOPMENT OF THE PLACENTA The zygote divides and subdivides by mitoses into a round mass of cells called the morula. The next stage of development or change is the blastocyst about 2mm in diameter, some cells in the center disintegrate leaving a small space. It has the inner cell mass that develop to form the fetus, umbilical cord and amniotic sac and the outer layer of cells called trophoblast. The trophoblast has root-like structures, called the primitive chorionic villi, it develops to form the placenta and the chorionic membrane of the amniotic sac. THE DECIDUA This is the name given to the endometrium during pregnancy. Three layers are found; Decidua Basalis -The basal layer lies below the ovum and above the myometrium. Decidua Capsularis –The area that encloses the embedding ovum functional layer Decidua Vera - The remainder of the decidua forming the entire uterine lining. 13 Chorionic Villi These are spike-like structures that burrow into the decidua and cause erosion of maternal tissues and blood vessels and bath in pools of maternal blood. It takes nourishment through its permeable membrane from the mother to the developing fetus. Gradually spikes covering the decidua vera becomes deficient of blood supply and atrophy leaving a smooth membrane the chorion. Those of the decidua basalis maintains a rich blood supply and develops to become the placenta. By the fourteenth week the placenta is fully developed and occupies one third of the uterus. Structures of the Chorionic Villi Syncitium; It lines the spaces between the villi, it is a protective layer surrounding the root-like structure Layer of Langerhans ; A layer of single cells, the trophoblastic layer Mesoderm; this is found in the villus out of which the fetal circulation develops Note: All three form a permeable membrane for exchange of vital substances from mother and baby. Inner Cell Mass While the trophoblast is developing into the placenta which will nourish the fetus, the inner cell mass is forming the fetus. The cells differentiate into three layers: The ectoderm mainly forms the skin and nervous system; The mesoderm forms bones and muscles and also the heart and blood vessels, including those which are in placenta; The endoderm forms mucous membranes and glands. The three layers together are known as the embryonic plate. Early Development of the Fetus The site for fetal development is known as Embryonic Plate. The first stage of fetal development is the formation of two enclosed cavities lying adjacent to each other. They are: The amniotic sac and the yolk sac. The amniotic sac is lined with ectoderm from the embryonic plate and responsible for growth of the fetal skin, hair, nails, teeth, nerve tissues, sense organs, salivary glands, nasal cavity and lower part of the anal canal. The yolk sac also has the lining of endoderm from the embryonic plate and develops to form the digestive tract, liver, pancreas, lungs, bladder and the urethra. Mesoderm is the remainder of the embryonic plate of the inner cell mass and produces; the circulatory system; lymphatic system; the skeleton; muscles; and kidneys, ureters and sex organs The Fetal Membranes The chorionic villi that atrophy and lines the decidua vera of the uterus is the Chorion membrane. Within the chorionic membrane is the amnion, it forms the fetal sac and covers the umbilical cord or body stalk which connects the fetus to the developing placenta. Umbilical Cord This is a duct that develops from the amniotic sac and the yolk sac. It has two arteries and one vein protected by a jelly substance the Wharton’s jelly and covered with amnion which is continuous to the 14 skin. It is thick as the thumb of an adult and at term measures 40-50 cm long. It is important to check the cord and blood vessels at birth for abnormalities. Amniotic Fluid This is a fluid secreted by the amniotic membrane. It is clear, straw coloured about 800mls and alkaline in reaction. It protects the fetus in utero from injury and allows it to move freely and help maintain a consistent intrauterine pressure and temperature. It douches the birth canal when it ruptures during labour If it is excessive over 1500mls, it is called polyhydraminous, if it is scanty 300 mls or less it is known as oligohydraminous. Amniocentesis is the method used to obtain amniotic fluid for investigations of diseases such as sex linked diseases, chromosomal abnormalities and sex of baby. PLACENTA AT TERM The placenta is usually situated at the upper segment of the uterus. It is flat and roughly circular in shape. It is thick (2cm) in the center and thinner towards the circumference and approximately 22cm in diameter. It weighs one sixth of the weight of the baby and has two surfaces in structure called the maternal surface and the fetal surfaces. The maternal surface is deeply embedded in the decidua and arranged into sixteen or twenty lobes or cotyledons, grooves separating the lobes are called sulci. The surface is dark red in colour. It reaches its full development at 28 weeks after which it begins to degenerate. Fetal Surface is the portion that is adjacent to or faces the baby. It is bluish grey in colour, and smooth with a shiny surface. The umbilical cord is inserted into the center of this surface. Blood vessels can be seen radiating through from the cord. It is covered with amniotic membrane that can be stripped from the chorion to the insertion of the umbilical cord an ABNORMALITIES OF PLACENTAL DEVELOPMENT During the development of the placenta certain abnormalities may occur, these are of various types and includes the following; Placenta Succenturiata, Placenta Bipartita, Placenta Circumvallata, Placenta Velamentosa, Vasa Praevia and Placenta Battledore Battledore insertion of the cord - in this case the cord is attached at the very edge of the placenta in the manner of the table tennis bat. Danger -it is likely to be detached on applying traction during active management of the third stage of labour Placenta Succenturiata A small extra lobe or accessory cotyledon is found separate from the main placenta and joined to it by blood vessels that ran through the membrane to reach it. The danger or complication – The extra small lobe may be retained in utero after delivery, and cause post partum haemorrhage and infection. Secondly, if the presenting part of the fetus presses on the 15 vessels there will be fetal anoxia. On the other hand during rupture of the membranes the vessels may rupture and cause bleeding, Vasa Praevia This describes blood vessels that lie below the presenting part. With the rupture of the membranes these vessels may rupture as the fetus pushes on to the vessels Placenta Bipartita The Bipartita Placenta has two complete and separate lobes, each has a cord leaving it. The two cords join at a short distance from the two parts of the placenta to become one and connect to the fetus. Danger- Usually no complication arise but it is likely the extra lobe may be retained during delivery. Placenta Circumvallata This appears as an opaque ring on the fetal surface of the placenta. It is formed by a doubling back of the chorion and amnion around the circumference of the placenta. 16 Danger may result in the membranes leaving the placenta nearer the center instead of at the edge as usually the case and cause ante partum haemorrhage Placenta Velamentous The cord is inserted into the membranes some distance from the edge of the placenta. The umbilical vessels run through the membranes from the cord to the placenta. Danger -The vessels may tear with cervical dilatation and would result in sudden blood loss, fetal anoxia and vasa praevia. Functions of the Placenta Respiration - Pulmonary exchange of gases between mother and fetus who must obtain oxygen and excrete carbon dioxide because the lungs are inactive. Nutrition – Derives food from the mother’s diet already been broken down into forms into substances required by the fetus, even depleting the mother’s own supply in some instances. Storage - Metabolises glucose also store it in the form of glycogen and reconverts it to glucose as required. Store iron and fat soluble vitamins. 17  Stabilisation – The chorionic villi anchor the placenta deeply stabilising it. Excretion -The main substance excreted from the fetus is carbon dioxide; urea and bilirubin Protection - It acts as a barrier to infection with the exception of some bacteria and viruses such as treponema of syphilis and rubella virus. There can be a leakage giving rise to the haemolytic disease of the newborn. Functions of the Placenta Endocrine - Human chorionic gonadotrophin (HCG) is produced by the cytotrophoblastic layer of the chorionic villi. Oestrogens as the activity of the corpus luteum declines, the placenta takes over the production of oestrogen, which are secreted in large amounts through out pregnancy. Human placental lactogen (HpL) has a role in glucose metabolism in pregnancy. Progestrone is also being produced. PATHOLOGICAL CONDITIONS OF THE PLACENTA These include the following; Hydatidiform Mole; Premature Degeneration; Infarcts; Oedema; Excessive size Hydatidiform Mole This is the rapid proliferative growth of the chorionic villi that absorbs the inner cell mass preventing the growth of the baby causing the development of moles. The proliferating moles secrete larger amounts of chorionic gonadotrophin, a pregnancy test give highly positive results. Diagnosis – Highly positive pregnancy test with vaginal bleeding and excessive morning sickness Complications – Chorioepithelioma a malignancy occurs in about 10% of cases Treatment – If spontaneous abortion does not occur, dilatation and curettage is done to evacuate the uterus. Chemotherapy is administered and hysterectomy is performed if cancerous. Urine test is carried out for two years and beyond till the chorionic gonatrophin in the urine becomes very low. The patient is advised not to get pregnant at this period. Premature Degeneration Maternal diseases for example essential hypertension and kidney diseases can cause constriction of the blood vessels restricting blood to the placenta. The placenta is unable to develop and degenerate leading to fetal death. Pregnancy may be terminated before the age of twenty eight weeks Placental Infarction Placenta begins to degenerate at normally the 28th week of pregnancy. Degeneration becomes extensive in conditions associated with pre-eclampsia because of arteriole spasms causing infarcts. Placental infarction occurs when the blood supply to an area of the placenta is blocked and tissue necrosis results (placental insufficiency). Fetal circulation is reduced. It appears most commonly on the maternal surfaces and most often associated with vascular disease. When the pregnancy becomes overdue that is post maturity (40 weeks and above) there is extensive calcareous degeneration accompanied with fetal hypoxia. If the circulation throughout the rest of the organ is sufficient, the fetus may survive. 18 Oedema, Excessive Size Oedema – A large pale water-logged placenta that can weigh half of fetus, it can be associated with severe haemolytic disease of the newborn. Hydrops Fetalis is a term used to describe oedematous fetus Excessive size – May be pale and greasy if due to Syphillis. When in association with a large fetus, diabetes mellitus is suspected. The influence of the growth hormone of the pituitary gland may also be a cause of an excessive size of placenta. Nursing Responsibilities In view of the pathological and anatomical abnormalities of the placenta, it should be: Examined carefully together with the Chorion and amnion membranes during the third stage of labour to see if they are normal and complete. Incomplete placenta and membranes may be due to a part that has been retained. Immediate removal can prevent post partum haemorrhage. ASSESSORY ORGAN OF THE REPRODUCTIVE SYSTEM THE FEMALE BREAST The female breast also called the mammary gland is a secondary female reproductive organ and found overlying the chest muscles (pectoralis major) on each side of the sternum. It extends from the level of the second to the sixth rib anteriorly and stabilised by suspensory ligaments. They are hemispherical in shape with a tail that extends to the axilla. The size is variable to individuals, age and the stage of development. They are made of specialized tissue (glandular tissue) that produces milk as well as fatty tissue. The amount of fat determines the size of the breast. Structure of the Breast Macroscopically the breast is seen to have; Areola, this is a pigmented skin or dark area of skin surrounding the nipple, it is about 2.5cm in diameter encircling the center of each breast, within it are about twenty sebaceous glands that secrete sebum to keep it and the nipple supple. The nipple, it is also found in the middle of the areolar. It is about 6mm long and composed of erectile tissue, it is perforated by small orifices which are openings of the lactiferous ducts. Microscopic Structure of the Breast The internal structure resembles halved grapefruit or orange and composed of a glandular tissue divided into lobes. Each lobe is a working unit and includes: Alveoli or acini, these are secreting cells Lactiferous tubules, they are small ducts connecting to the alveoli. Lactiferous duct is the central duct that divides into the tubules. 19  Ampulla is a widened portion where milk is stored. Continuation of lactiferous duct, extends from the ampulla and open into the nipple. Function of the breast –To supply milk for infant and for sexual excitation Blood supply – by internal mammary, external mammary and upper inter-coastal arteries. Venous drainage is into the internal mammary and axillary veins. Lymph drainage is into the axillary glands and the portal fissure of the liver. Nerve supply is branches of thoracic nerves and sympathetic nerves around areola and nipple. Hormonal control is by prolactin from anterior pituitary and oxytocin from posterior pituitary as well as oestrogen and progesterone from the ovaries STAGES OF BREAST DEVELOPMENT At birth – The breast tissue is confined to the nipple area, only the nipple is prominent. Circulating maternal hormones in the baby sometimes makes the breast swell with fluid oozing out. This condition wears off gradually and requires no treatment. At Puberty – The breast tissue begins to bud, the amount of fatty and fibrous tissues are increased. Childbearing years – Breast changes are similar to what takes place during pregnancy and occur at the latter half of the menstrual cycle e.g. fullness etc. BREAST IN PREGNANCY Early pregnancy – Oestrogen develops the nipple, areola and the growth of lactiferous tubules and ducts. Progesterone proliferates the alveoli in preparation of the production of milk 6-8 weeks – The breast become full, nodular, tender and tingling. Subcutaneous veins become clearly visible 12th week – Nipple and areola become deeply pigmented, sebaceous glands in the areola enlarge and are called Montgomery tubercles. They secrete oily substances to lubricate the nipple in preparation for breast feeding After 12 weeks – A clear watery fluid called colostrum can be expressed, it functions to clear the duct for free flow of breast milk After 16 weeks – Secondary areola which is a mottled area appear above the areola. It disappears after child birth. THE BREAST AFTER DELIVERY The breast reaches its full development at this stage and starts’ lactating approximately three days after the baby is born. The first milk is yellowish in colour and called colostrum. It consists of protein, fat, lactose, leucocytes, dead epithelial tissues, mineral salts and colostrum corpuscles Functions of Colostrum To keep the lactiferous ducts and tubules clear It acts as aperients for the infant and help to empty meconium which is the first stool from the bowels. 20  It’s high nutritive content provides the best food for the baby’s early days of life. Its small amount is appropriate for the immature digestive system. It consists of low fat for easy digestion. Colostrum contains antibodies from the mother this functions to boost the infants’ immune system PHYSIOLOGY OF LACTATION With the separation and expulsion of the placenta, oestrogen and progesterone balance is altered, this activates the anterior pituitary gland to release a hormone called prolactin which is responsible for lactation. There is increased blood supply to the breast making possible for essential substances for milk formation to be extracted. Secretory cells that lines the alveoli of the glandular tissue start to release breast milk by the 3rd day after delivery The milk-producing part of the breast is organized into 15 to 20 sections called lobes. Within each lobe are smaller structures where milk is produced. The milk travels through a network of tiny tubes called ducts. The ducts connect and come together into larger ducts, which eventually exit the skin in the nipple. Nerves provide sensation to the breast. The breast also contains blood vessels, lymph vessels, and lymph nodes. HORMONAL INFLUENCES – Estrogen stimulates the ductile systems to grow, then estrogen levels drop after birth – Progesterone increase the size of alveoli and lobes – Prolactin contributes to increasing the breast tissue during pregnancy – Alveoli secrete milk and contract when stimulated – Oxytocin stimulates milk secretion and is released during the ‘let down’ or milk ejection reflex. Milk travels after “let down” into the ductules, then to the larger – lactiferous or mammary ducts RELEASE OF BREAST-MILK These depends on two factors – Back Pressure – new milk pushes the old milk into the lactiferous tubules and then into the lactiferous ducts. Neuro-hormonal Reflex – When baby sucks the breast the rhythmical movement empties the ampulla and large lactiferous ducts enabling milk to be forced down the nipple. Nervous reflex action causes the secretion of oxytocin to cause contraction of lactiferous vessels for the flow of milk. MAINTENANCE OF EFFECTIVE BREAST FEEDING The more often the baby is put to the breast the better the milk supply. 21 Essential factors that enhance the production of breast milk are; Stimulus – The infants gums on the breast suctioning the areola results in neuro- hormonal reflex. Emptying by the hands can be a stimulating factor. Complete emptying of the breast – Regular emptying of the breast ensures free flow of new or better milk supply. BREAST MILK This is alkaline and bluish white in colour. The specific gravity is 1031 and contains 20 calories per fluid once. It contains less Protein and but more fatty acids for its rapidly growing brain, 46% saturated fat and 54% unsaturated fat. Lactose provides 40% of its caloric requirements. Fat soluble vitamins – Vitamins A – retinol gives colostrum its yellow colour. Vitamin D –calciferol, it is essential for the metabolism of calcium and phosphorous to prevent rickets. Vitamin E – prevents the oxidation of polyunsaturated fatty acids and prevent types of anaemia. Vitamin K – tocopherol, essential for the synthesis of blood clotting factors. It also has adequate water soluble vitamins. e.g. Vit B, etc. It also contains minerals for example Iron, zinc, calcium phosphorus, sodium and others. Water content is about 88%. Anti- Infective factors that are found in it are Leucocytes, most commonly found are macrophages and neutrophils, they destroy harmful bacteria. It is also composed of immunoglobulins IgA, IgG,IgE,IgM and IgD. IgA is significant and paints the mucosal linings against the entry of bacteria and enteroviruses. Lysosomes – kills bacteria by destroying their cell wall. Lactoferrin –prevents E.coli from taking up iron. Bifidus factor – promotes growth of gram positive bacilli in gut. Hormones and growth factors - Epidermal growth factor and insulin-like growth factors are common , they help with the growth and maturation of the gastrointestinal tract and strengthen its barrier properties. BREAST FEEDING The mother must be educated and given the necessary assistance and support. The positioning of the mother can be either sitting up or lying down. When sitting up the mothers back should be upright and at right angle with the lap. Positioning of the baby – the head should be turned towards the mother’s body and the mouth in correct relationship with the mother’s nipple and areolar. Attaching the baby to the breast – The baby will open her mouth if the head is moved towards the nipple. As he gapes the breast is moved quickly for his grasp, the nipple and areolar must be in his mouth to form a teat. The baby’s jaw moves up and down following the action of the tongue. The baby will release the breast when he had sufficient milk from it. The baby is then made to bring up wind and put on the second breast. He should not be deliberately removed from the breast and should be fed frequently to allow for successful breast feeding Exclusive Breastfeeding In May 2001 at the 54th Assembly of the World Health Assembly in Geneva the importance of breastfeeding for the first 6 months of life was affirmed. Babies are fed with only breast milk without 22 water. Given frequently and adequately it satisfy the infant’s nutritional needs and fluid requirements even in hot climates. The baby is introduced to weaning foods after 6 months CONTRAINDICATIONS TO BREAST FEEDING Drugs – certain drugs are contraindicated. Generally drugs should not taken indiscriminately. Cancer – may aggravate the condition Breast Surgery. Breast injury. HIV infection –to prevent HIV transmission to the baby. PROBLEMS WITH BREAST FEEDING -MOTHER Engorgement – this should be distinguished from full breast Deep breast pain – may be due to intra-ductal pressure from inefficient milk removal. Mastitis –Inflammation of the breast Breast abscess – swelling developing from a previously inflammed area, pus may be discharged from the nipples Blocked ducts – lumpy areas that feel tender and firm may be the distention of a glandular tissue due to a blocked duct. Flat nipples and some abnormalities or pain from cracks of the nipples PROBLEMS WITH BREAST FEEDING -INFANT Cleft palate – sucking becomes a problem Tongue tie Blocked nose Prematurity Illness or surgery ADVANTAGES OF BREAST FEEDING Easily available with the right amount of essential nutrition Not contaminated, has the right temperature Gives protection against diseases Release of oxytocin help with the contraction of the uterus Prevents constipation in the child No cost, already made Used for Family planning DISADVANTAGES Emotional problems after weaning Lactational amenorrhea method of family planning may fail It takes a lot of time and attention of working mothers 23  Anxiety and frustration when the mother is not lactating well and the baby is not feeding well CARE OF THE BREAST Daily washing is important to keep the breast neat and hygienic. Brassieres must be roomy with broad bands and washed frequently Breast pads to absorb leaks during lactation should be changed often. THE FETUS IN UTERO FETAL CIRCULATION The fetus has its own circulation during intra uterine life, at birth there is a dramatic alteration with an instantaneous change because the lungs were not active while in utero and should be made active for interchange of oxygen and carbon dioxide to take place. The placenta was performing this function. There are several temporary structures that enabled the fetal circulation to take place, these allow for changes that had to occur at birth. They are: The umbilical vein leads from the umbilical cord to the underside of the liver and carries blood rich in oxygen and nutrients. It has a branch which joins the portal vein and supplies the liver The ductus venosus (from a vein to a vein) connects the umbilical vein to the inferior vena cava. And transmits greater amount of oxygenated blood into the inferior vena cava. Inferior Vena cava – Carries blood from the lower limbs and trunk of the fetus, joins with the hepatic vein and ductus venosus to the right auricle of the heart. At this point the blood mixes with deoxygenated blood returning from the lower parts of the body. Superior Vena cava – returns blood from the head and upper extremities to the right atrium The foramen ovale (oval opening) is a temporary opening between the atria. It allows the blood from the inferior vena cava to pass across into the left atrium. The reason for this diversion is that the blood does not need to pass through the lungs and already oxygenated The Pulmonary artery – Shunts blood to the lungs to nourish it. The ductus arteriosus (from an artery to an artery) leads shunts greater portion of the blood from the bifuraction of the pulmonary artery to the descending aorta. The hypogastric arteries branch off from the internal iliac arteries and become umbilical arteries when they enter the umbilical cord. They return blood to the placenta. This is the only vessel in the fetus which carries unmixed blood. FETAL CIRCULATION DIAGRAM 24 CHANGES AFTER BIRTH At birth the infant cries, takes a deep breath and expand its lungs causing blood flow from the four pulmonary veins to the left auricle or atrium. The placental circulation ceases soon after birth and so less blood returns to the right side of the heart. In this way the pressure in the left side of the heart is greater while that in the right side of the heart becomes less. This results in the closure of the foramen ovale which separated the two sides of the heart and stops the blood flowing from right to left. The umbilical vein, ductus arteriosus, ductus venosus and hypogastric arteries fibrose and they become ligaments. The cessation of the placenta circulation results in the collapse of the umbilical vein, the ductus venosus and the hypogastric arteries. These vessels after collapse change to the following structures: The umbilical vein → the ligamentaum teres The ductus venosus → the ligamentum venosum The ductus arteriosus → the ligamentum arteriousm The foramen ovale → the Fossa ovalis 25  The hypogastric arteries → the obliterated hypogastic arteries: FETAL SKULL The fetal head is large in comparison with the true pelvis and some adaptation between skull and pelvis must take place during labour. An understanding of the landmarks and measurements of the fetal skull help to recognize normal presentation and positions and to facilitate delivery with the least possible trauma to mother and child. Development of the Fetal Skull The bones of the fetal skull are developed from membranes and not from cartilage as for some bone structures. These membranes have five points of ossification and in utero calcium is laid down in these centers and bones begin to develop. Calcification begins as early as the fifth week of gestation. At full term the edges are still membranous because the ossification is still incomplete, these become known as sutures and fontanelles. However ossification continues if the fetus remains in uterus for more than 40 weeks, the bones then becomes dense and hard and delivery of the head becomes difficult and the baby stands the risk of having intracranial haemorrhage. DIVISIONS OF THE FETAL SKULL The skull is divided into the vault, the base and the face. The vault is the large dome shaped part above the imaginary line drawn between the orbital ridges and the nape of the neck. The base is composed of bones which are firmly united to protect the vital centres in the medulla. The face is composed of 14 small bones which are also firmly united and non- compressible Bones of the Vault There are five main bones in the vault of the fetal skull. The occipital bone lies at the back of the head and forms the region of the occiput. The two parietal bones lie on either side of the skull. The two frontal bones from the forehead or sinciput SUTURES AND FONTANELLES Sutures are cranial joints and are formed where two bones join together. Fontanelles – they form where two or more sutures meet. Sutures and fontanelles are membranous spaces that allow for a degree of overlapping of the skull bones during labour and delivery. SUTURES The lambdoidal suture is shaped like the Greek letter lambda and separates the occipital bone from the two parietal bones. The saggital suture lies between the parietal bones 26  The coronal suture separates the frontal bones from the parietal bones, passing from one temple to the other. The frontal suture runs between the two halves of the frontal bone FONTANELLES There are six fontanelles but two are usually mentioned. They are: The posterior fontanelle or lambda is situated at the junction of the lambdoidal and saggital sutures. It is small triangular in shape and can be recognized and felt vaginally. It indicates the relationship of skull to the four quadrants’ of the mother’s pelvis. Closes normally by the sixth week. The anterior fontanelle or bregma is found at the junction of the saggital, coronal and frontal sutures and recognized or felt vaginally if the head is well flexed. It is diamond shaped 2.5 cm in length and 1.3cm wide. It is ossified by the eighteenth month. REGIONS OF THE VAULT The occiput lies between the foramen magnum and the posterior fontanelle. The part below the occipital protuberance is known as the suboccipital region. The vertex is bounded by the posterior fontanelle, the parital eminences and the anterior fontanelle. Of the 96% of the babies born head first, 95% present by the vertex. Regions of the Vault (Cont.) The sinciput or brow extends from the anterior fontanelle and the coronal suture to the orbital ridges. The face is small in new born baby. It extends from the orbital ridges and the root of the nose to the junctions of the chin and the neck. The point between the eye brows is known as the glabella. The chin termed the mentum and is an important land mark. IMPORTANT LANDMARKS OF THE VAULT Bregma – the anterior fontanelle Sinciput - the forehead Occiput – the area occupied by the occipital bone Glabella – the bridge of the nose The vertex –the highest point on the fetal skull Lambda - Posterior fontanelle or Sub occipital area- lies below the Occipital protuberance The mentum – the chin DIAMETERS OF THE SKULL The measurement of the skull are transverse, antero-posterior or longitudinal. Transverse diameters Bi-parietal diameter 9.5 cm taken between the parietal eminences, it is the widest. 27  Bi-temporal diameter 8.2cm between the two extreme points of the coronal suture. Antero-posterior or longitudinal diameters Sub-occipito-bregmatic 9.5 cm from below the occipital protuberance to the center of the anterior fontanelle or bregma. Presents in a well flexed head. Sub-occipitofrontal 10cm - from below occipital protuberance or sub-occipital region to the center of the frontal suture or sinciput. The head is less well flexed. Occipito-frontal 11.5 cm - from the occipital protuberance to the glabella. The head is erect Mento-vertical 13.5cm - from the point of the chin to the highest point on the vertex slightly nearer to the posterior than to the anterior fontanelle. The head is extended and the brow presents Submento-vertical 11.5 cm - from the point where the chin joins the neck to the highest point on the vertex. Submento-bregmatic 9.5-cm from the point where the chin joins the neck to the center of the bregma. The head is fully extended and thrown back so that the face presents NOTE – When larger diameters are likely to present, if possible episiotomy should be given early enough to prevent severe trauma CIRCUMFERENCE OF THE FETAL SKULL A well flexed head – the circumference to engage the pelvis is the suboccipito bregmatic circumference. It is 30.5-33cm and taken around the occipital protruberance, parietal eminences and bregma. It is circular and conform to the shape of the pelvis making delivery easy An erect head – The circumference engaging the pelvis is the occipito-frontal circumference 33- 36cm and taken around the posterior fontanelle, parietal eminences and the orbital ridge. It is ovoid and larger making the delivery of the fetal head difficult. A partly extended head – The circumference that engage the pelvis is the mento-vertical. It measures 38cm and too large to pass through the pelvis it is taken around the chin up to the vertex. It is associated with brow presentation CEREBRAL MEMBRANES These are tough fibrous membranes which consist of a outer membrane called the dura mater which is one of the three meninges covering the brain and the spinal cord. They are ; Falx cerebri – double fold of dura mater that is found deep between the cerebrum. Tentorium Cerebelli – it is shaped like horse shoes and divides the cerebrum from the cerebellum. It is a fold of dura mater. The superior longitudinal sinus – found at the convex border of the falx cerebri, it recieves veinous drainage from the superior cerebral veins and the pericranium. The inferior longitudinal sinus – a vessel found at the free border of the falx cerebri. It receives veins from the falx cerebri and drains into the medial aspect of the brain 28  The straight sinus – it is a continuation of the inferior longitudinal sinus and found at the junction of falx cerebri and tentorium cerebelli. It drains into the inferior longitudinal sinus and the great vein of Galen The vein of Galen – This is made up of many vessels from the brain and seen joining the straight sinus at its junction with the inferior longitudinal sinus. NOTE – During labour when the fetal head is adapting to the pelvis and the shape of the head changes, some degree of pressure is put on these structures, but they are able to withstand if not intra cranial haemorrhage is likely to occur MOULDING This describes the change that occurs when the fetal head is passes through the birth canal. The dangerous types of moulding are; Excessive moulding – Occurs in prolonged labour due to disproportion of the head to the maternal pelvis or when the bones are not almost completely ossified as in prematurity. Upward moulding – Moulding occurs in the submento-bregmatic direction pulling on the falx cerebri and likely to tear with the tentorium. It occurs when the baby is delivered face to pubes Rapid moulding – There is rapid compression and decompression of the head also likely to tear. It usually occurs in precipitate labour NOTE : Babies who were born with any of these types of moulding should be observed intensively for 24-48 hour. If possible cot nursed CAPUT FORMATION These are conditions that occur and involve the tissues and cause swelling on the infants head. They are known as; Caput succedaneum – this is an oedematous swelling of the subcutaneous tissues of the skull when there is early rupture of the membranes with no bag of forewaters to take the pressure of the dilating cervix Characteristics: Present at birth It is an oedematous swelling Found on the part of the head lying over the internal os It disappears within 24 to 48 hours No treatment is required. CEPHAL HAEMATOMA This is formed due to bleeding between the periosteum and the skull bones and occurs owing to friction when the skull bones override during moulding. It can occur during normal delivery or more difficult labour Characteristics 29  It is not present at birth appears two to three days The swelling is limited to the periosteum and occur only on a bone The head is more red and bruised Takes at least six weeks to disappear Treatment if necessary vitamin K is given to raise the prothrombin level and assist with clotting SCALP TISSUES These are of five layers – from without are The skin – the outer covering Subcutaneous tissue Muscle layer – containing tendon of Galea Connective tissue – loose layer Periosteum – covers the skull. REFERENCES AND READING MATERIALS 1. V. RUTH BENNETT. LINDA K. BROWN, 1993 2. Meselech Assegid Alemaya University (2003) Obstetric and Gynaecological Notes, Ethiopia Public Health Training Initiative, The Carter Center, Ethiopia 3. Verralls S, ( ) Anatomy and Physiology Applied to Obstetrics Churchhill Livingstone 4. Fraser E., Cooper M., Nolte A (2009) Myles textbook for Midwives, African Edition, London. 30