Lecture Notes On Normal Pregnancy PDF

LECTURE NOTES ON NORMAL PREGNANCY COURSE TITLE: PHYSIOLOGY AND MANAGEMENT OF NORMAL PREGNANCY CREDIT HOURS: 3 COURSE TUTOR: Cassandra Osei Nkrumah COURSE DESCRIPTION: this course is designed to equip the student midwife with the knowledge, skills and attitudes to provide high quality anten...

LECTURE NOTES ON NORMAL PREGNANCY COURSE TITLE: PHYSIOLOGY AND MANAGEMENT OF NORMAL PREGNANCY CREDIT HOURS: 3 COURSE TUTOR: Cassandra Osei Nkrumah COURSE DESCRIPTION: this course is designed to equip the student midwife with the knowledge, skills and attitudes to provide high quality antenatal care to maximize health during pregnancy, that includes early detection of potential treats to the health of the woman or her developing foetus and to treat patients with complications. 1 Course Objectives By the end of the course the student will be able to: a. Discuss respectful maternity care b. Describe the steps in clinical decision making c. Utilize key elements of the anatomy and physiology of the female reproductive system in normal pregnancy d. Describe and explain components of pre-conception care e. Explain and describe the physiological changes in pregnancy f. Diagnose pregnancy using signs and symptoms and pregnancy test kits g. Discuss other causes of abnormal enlargement h. Conduct a complete antenatal visit using the midwifery process i. Perform focused physical examination for each antenatal visit j. Identify the component of health history k. Perform a thorough examination of the woman in a systematic manner using the correct techniques (assessment) l. Perform basic laboratory and radiological screening, interpret findings and take appropriate action m. Provide prophylactic management according to current policies and guidelines n. Explain the basic principles of pharmacokinetics of medicines used in midwifery o. Conduct an effective childbirth education classes with a group of pregnant women p. Recognize and manage minor disorders of pregnancy q. Educate pregnant women on birth preparedness and complication readiness plans r. Describe the normal progression of pregnancy s. Identify and manage pregnant women with special needs Course Content 1. Respectful maternity care: importance and strategies 2. Clinical Decision Making Steps: application of clinical decision making in the care of the pregnant woman 3. Preconception care 4. Physiological and psychological changes in pregnancy 5. Diagnosis of pregnancy a. Signs and symptoms i. Presumptive ii. Probable iii. Positive b. Signs of previous pregnancy 2  c. Pregnancy test kits 6. Other causes of enlarged abdomen a. Pseudocyesis b. Abdominal and ovarian tumours c. Uterine fibroids d. Cirrhosis of the liver 7. Midwifery care process a. Assessment b. Diagnosis c. Planning d. Implementation e. Evaluation 8. Focused antenatal care, objectives and benefits 9. Health history 10. Assessment at the antenatal clinic a. Clinical observation b. Physical examination c. Abdominal examination 11. Laboratory investigation 12. Abdominal and pelvic scan 13. Prophylaxis a. IPTp – SP Intermittent Preventive Treatment of Malaria in Pregnancy b. ART – PMTCT recommendations for HIV Positive women 14. Routine administration of haematinics 15. Parent – craft classes 16. Minor disorders of pregnancy 17. Birth preparedness and complication readiness plan 18. Foetal wellbeing and development 19. Special patients a. Teenage pregnancy b. Elderly primigravida c. Grande multipara d. HIV positive pregnant women e. Sickle cell pregnant woman f. Diabetic pregnant woman g. Hypertensive pregnant woman 3 STUDENTS EVALUATION Periodic assignments in relation to topics discussed, students will present one assignment and one presentation in class. 15%. Mid-semester exam 15% End of semester examination 70% TOTAL 100% REFERENCES 1. Baker, P. N. & Holmes, D. (2006). Midwifery by Ten teachers. New York: United State of America, Oxford University Press Inc 2. Ghana Health Service. (2009). National Safe Motherhood Protocol. Ghana. Yamens Press Limited. 3. Fraser,D. M. & Cooper, M. A. (2008). Myles Textbook for Midwives. (15th. ed.) Toronto, London: Elsevier. 4. Verrals, S. (2010). Anatomy and Physiology Applied to Obstetrics, (3rded.) London: Churchill Livingstone TABLE OF CONTENTS Preconception care……………………………………………………6-10 Psychological changes in pregnancy…………………………………10-11 Physiological changes in pregnancy………………………………….11-31 Effect of pregnancy on the client and family…………………………31 Diagnosis of pregnancy……………………………………………….32-34 Signs of previous pregnancy………………………………………… 34-35 Differential diagnosis of pregnancy………………………………… 35-37 4 Midwifery process…………………………………………………….37-41 Management of pregnancy……………………………………………42-71 Health education ……………………………………………………..71-87 Parent craft classes…………………………………………………...87-88 Minor disorders of pregnancy………………………………………..88-104 Special clients………………………………………………………...104-113 Sample questions……………………………………………………..113-115 PRECONCEPTION CARE INTRODUCTION Reduction of maternal and infant mortality and morbidity requires the provision of a continuum of care that spans from pregnancy, childbirth, infancy, childhood, adolescence and adulthood. Interventions before pregnancy can improve the health and wellbeing of women (adolescent), men and the family as a whole as well as and improve subsequent pregnancy and child health outcomes. Definition Preconception care is defined as individualized care for men and women that focused on reducing maternal and fetal morbidity and mortality, increasing the chances of conception when pregnancy is desired and providing contraceptive counseling to help prevent unwanted pregnancy. 5 Aims of Preconception Care. 1. The ultimate aim is to improve maternal and child health, in both long term and the short term. 2. To ensure that the woman and her partner are in optimal state of physical and emotional health at the onset of pregnancy 3. To treat and prevent all conditions that can adversely affect the outcome of the Pregnancy Preconception Period: this is a period of time from three months to one year before conception. Ideally it should include a period of 100 days before conception that is when the ovum and the sperm mature. Preconception care programme takes time to complete therefore adequate time is needed to allow for initial consultation and subsequent follow ups where results, counseling and treatments may be given Ideally everybody needs preconception care but those who really seek out for the care are usually the well-motivated educational couples COMPONENTS OF PRECONCEPTION CARE I. General Health Factors: this comprises 1. Weight: A body mass index of 18.5-24.9 is the desirable or healthy range. Low maternal weight before conception is associated with low birth weight babies. Obese or overweight women are at risk of developing gestational diabetes, or hypertensive disorders in pregnancy. Obesity also increases the risk of caesarean delivery 2. Healthy Diet: A well balanced diet low in fats is recommended. 3. Folate and Folic Acid: These are important in the prevention of neural tube defects. A daily intake of 400micrograms of folic acid and an increase in the intake of folates 4. Iron supplementation to improve haemoglobin level. 6 NB. Folates are folic acid derivatives that re naturally found in foods and folic acid is the synthetic form used in vitamin supplements and fortification of foods 5. Vitamin A; vitamin A is essential for embryogenesis and growth but high levels of the retinol form of vitamin A can be teratogenic. 6. SEXUALLY TRANSMITTED INFECTIONS (STIs)  Provide appropriate comprehensive sexuality education and services  Promote safer sex practices.  Promote condom use for dual protection  Screening for STIs  Increasing access to treatment and other relevant services 7. HIV.  Promote safer sex practices, dual method for birth control and STIs control  Provider- initiating voluntary counseling and testing including partner testing.  Providing antiretroviral therapy for prevention and exposure prophylaxis  Provision of male circumcision  Providing antiretroviral therapy for HIV+ women not on treatment to prevent mother to child transmission 8. MENTAL HEALTH Assess women for psychosocial problems and provision of appropriate counseling before and during pregnancy. 9. VACCINE PREVENTABLE DISEASE Vaccination against rubella, tetanus, diphtheria and hepatitis B to prevent transmission to the fetus II. PRE-EXISTING MEDICAL CONDITIONS 1. Diabetes: babies born to insulin dependent diabetes mothers are at a higher risk of congenital malformations and a higher still birth rate. Diabetic complications such as retinopathy and neuropathy may worsen during pregnancy. 7  Aim is to achieve a normal glycaemia both preconception and when pregnant Women on oral hypoglycemic should be switch on to insulin therapy both in preconception period and in pregnancy 2. Epilepsy: This increases with pregnancy. Anticonvulsants are also known to have teratogenic effect. Aim of care is to help the woman with epilepsy to plan her pregnancy and keep her seizure free on the lowest possible dose of anticonvulsant. The need for folic acid is increased because some of the anticonvulsant are folates antagonist 3. Phenylketonuria: This is a metabolic disorder in which the body lacks the enzyme that metabolizes phenylalanine. Phenylalanine has a toxic effect on the foetus such as microcephaly, mental retardation and heart defect. Women with this condition need specialist care through out. III. DRUGS i. Contraception: This should be stopped 3-6months prior to conception to allow for resumption of natural hormone regulation and ovulation. ii. Drug Abuse: The use of drug such as amphetamines, cannabis etc known to cause miscarriages, preterm delivery, low birth weight stillbirth and abnormalities. IV. ENVIRONMENTAL FACTORS 1. Smoking:  This is known to induce early menopause and menstrual problems. During pregnancy there is an increased risk of low birth weight babies, abortions, preterm labour and perinatal mortalities due placental abruption.  Women who smoke pass on carcinogen to their babies.  Smoking also causes abnormal sperms and decreased motility.  It also compromises nutritional status. Screening of all non-smokers and smokers and counseling on the harmful effects of second hand smoke on pregnancy. Providing cessation advice and intensive behavioural counseling services. 8  i. Alcohol High alcohol intake is associated with menstrual disorders and decreased fertility. It is a teratogen; causes foetal alcohol syndrome (FAS). Alcohol intake while pregnant also causes miscarriages, stillbirth, premature birth and low birth weight babies. In view of these, clients are therefore encouraged to abstain from drinking alcohol while trying to conceive and during pregnancy. ii. Exercises: regular exercise in the preconception period is beneficial and clients are encouraged to do so for healthy pregnancy iii. Workplace Hazards And Noxious Substances Some occupational exposure to hazards can reduce male and female fertility. Exposure to these hazards can also result in miscarriages and birth defects. Avoid unnecessary pesticide use and exposure to lead and mercury V. GENETIC COUNSELLING Couples should be given genetic counseling especially clients of advanced age and those with history of any chromosomal abnormality. A family history should be taken to identify risk factors. VI. INFERTILITY AND SUB-FERTILITY Creating awareness and understanding of fertility and infertility and their preventable and unpreventable causes. Screening and diagnosing of couples following 6-12months of attempting pregnancy and management of underlying causes of infertility and sub-fertility including treatments of STIs. INVESTIGATIONS CARRIED OUT IN A PRECONCEPTION PROGRAM History Family history, medical history, menstrual history, method of contraception, any medication, occupation, diet, smoking and alcohol. Investigations: 9 Height and weight, blood pressure, urine analysis, stool exam, Haemoglobin, folic acid and vitamin level, rubella immunity, Veneral Diseases Research Laboratory, Haemoglobinopathies, semen analysis, cervical smear and high vaginal swab. PSYCOLOGICAL CHANGES IN PREGNANCY Pregnancy is the condition of having a developing embryo or foetus in the body after union of the ovum and the spermatozoon. A period a fertilized ovum embeds in the maternal uterus or tissue to develop until the time when it is born. Transition to motherhood is described as life crises, and emotional watershed and a period of heightened sensitivity which the woman will be extremely venerable as such deserves respect. Many women find it difficult coping with the physiological adaptation to pregnancy Attending antenatal clinic, going through screening tests is emotionally draining and very stressful. This brings anxiety and emotional conflicts. During this stage, the woman should be reassured so that she will be relieved from anxiety or fear. She should be encouraged to express their fears. They should also be supported to build self-confidence which will be needed successfully to assume roles and responsibilities of motherhood.  Psychological changes in the first trimester. Changes in the first trimester may not be easily recognized but they are significant. During this time, some mothers might be filled with a feeling of anxiety about losing their baby. These fears and anxiety though unfolded are perfectly normal 10   Changes in the Second trimester Feelings within this time are usually less intense but they can be troubling. Many mothers begin to feel self-conscious about the weight they are putting on to support the growing foetus and these feelings can lead to low self-esteem.  Changes in the third trimester: In the third trimester, women are anticipating childbirth and coping with significant physical changes. While fear of losing the baby disappears at this time the fear of the baby’s arrival also sets in. worries about labour and birth are also common during this period of the pregnancy PHYSIOLOGICAL CHANGES IN PREGNANCY The growth and development of the fetus is affected by many aspects of the mother’s health; nutritional status, use of drugs, alcohol and cigarettes, use of un prescribed or prescribed medications herbal preparations dietary supplements, medical conditions, age of mother and prenatal care. A study of the physiological changes that takes place in the woman’s body during pregnancy will: 1. Help her explain many of the problems that occur during pregnancy. (signs and symptoms) 2. Help give an effective antenatal care (ANC) to all pregnant women. 11  3. Pregnancy affects the reproductive organs and other organs of the body. HORMONAL CHANGES As soon as fertilization occurs, the corpus luteum continues to grow to produce hormone oestrogen and progesterone until about 12 to 14 weeks when the full developed placenta takes over. The follicle stimulating hormone and the luteinizing hormone are suppressed by progesterone and oestrogen produced by the placenta. 1. Human Chorionic Gonadotrophin (HCG) It is produced by the fertilized ovum and the chorionic villi which maintain the corpus luteum production (oestrogen and progesterone) for the first 10 to 12 weeks of pregnancy until the placenta takes over their production. That is, the corpus luteum continues to function up to 12 weeks and then declines gradually. Chorionic gonadotrophin is excreted through the kidneys and appears in the urine, especially in the early weeks of pregnancy. Its forms the basis for the biological and immunological pregnancy tests. Cessation of Menstruation  Most women experience cessation of menstruation even though about 20% of women have painless spotted bleeding during the early stages of the gestation, this is referred to as gestational or implantational or decidual bleeding.Also bleeding following sexual intercourse may be due to cervical friability 12 Nevertheless, most of these women who have these bleeding episodes continue to full term and have normal infants. NB: All cases of bleeding however slight should be reported to the hospital.It should be borne in mind that pregnancy is a physiological state not a disease. PHYSIOLOGICAL CHANGES IN THE REPRODUCTIVE SYSTEM UTERUS The uterus plays an important role in pregnancy by protecting and supporting the foetus, placenta and amniotic fluid. It expands to accommodate the growing foetus and remains relatively quiescent till time of labour when it contracts regularly and forcefully to expel the foetus due to its unique properties of contractility and elasticity Uterine enlargement results from: 1. Increased vascularity and dilatation of blood vessels 2. Hyperplasia (production of new muscles fibres) and hypertrophy (enlargement or pre-existing muscle fibres and fibro elastic tissue. 3. Development of the decidua Decidua  The hormones progesterone and oestrogen produced by the corpus luteum initially cause the decidua to richer, thicker and more vascularised at the fundus that is the upper body of the uterus.  The Decidua in the lower uterine segment becomes thinner and less vascular in the upper uterine segment (LUS).The upper uterine segment (UUS) is the usual site for implantation. 13   The Decidua provides an environment which is rich in glycogen for the blastocyst until the placenta takes over. The decidua produces relaxin which play a part in uterine quiescence and prostaglandins which either enhances uterine quiescence or initiate labour depending on the specific receptor to which it coupled. Myometrium  This constitutes the main mass of the uterus and the body is made up of plain muscle cell which run in bundles separated by connective tissue.  During pregnancy, the muscle fibres increase up to 15 to 20 times.The increase in the first 12weeks of pregnancy is partly due to;  Hypertrophy (increase in size of myometrial cells) and hyperplasia (increase in number) is due to the action of oestrogen (oestradiol)andprogesterone.  The lymphatics, immune cells and myometrial cells all increase in size and there is increase in elastin in the outer layer which increases its elasticity and allows the uterus to accommodate the growing foetus.  The uterine growth is predominantly due to the foetal growth causing mechanical tension on the myometrium throughout the remaining part of pregnancy.  Although the walls of the corpus becomes thicker in the first few months as gestation increases they gradually thin so that by term they are only about 1.5cm thick or less and the uterus is changed to 14  a muscular sac with thin soft, readily indentable walls through which the foetus can be palpated. PERIMETRIUM This is a thin layer of peritoneum that protects the uterus. It usually does not cover the uterus totally to allow for growth and unrestricted growth of the uterus in pregnancy. CHANGES IN THE SHAPE OF THE UTERUS At the beginning of pregnancy to the 8th week, the shape maintains its pear shape. By the 10thweek the uterus is globular about the size of an orange. By the 12th week the uterus is about the size of a grape fruit and risen out of the pelvic cavity and become upright. As the pregnancy advances, it changes to globular until about 20thweek when it becomes ovoid and maintains this shape until term. These changes in shape are due to foetal growth and accommodation of the increasing amount of liquor and placental tissue THE GROWTH OF THE PREGNANT UTERUS Growth of the pregnant uterus in weeks of gestation. 15 The uterus grows at regular rate which makes it possible to estimate the period of gestation by its size. The normal size of the non-gravid uterus; 7.5x5x2.5cm and grows to 30x22.5x20cm at term. Weight: 50-60g prior to pregnancy to 1000g at term. 8thWEEK: The uterus cannot be palpated abdominally. On bimanual examination, it is found to be above the size of the tennis ball. TH 10 WEEK: The uterus is about the size of an orange. TH 12 WEEK: The uterus fills the pelvic cavity and the fundus reaches just above the summit of symphysis pubis. It is globular in shape and about the size of a grape fruit. It is no longer anteverted and anteflexed and has risen out of the pelvis and become upright.The fundus of the uterus is palpable after 12 weeks of gestation. It then becomes an abdominal organ. SIXTEEN WEEKS (16THWEEKS) The uterus is palpable at just less than half way between the symphysis pubis and the umbilicus.Here the isthmus and the cervix develop to form the lower uterine segment which contains less blood vessels and is the site for incision for the majority of caesarean sections The shape is more ovoid than globular. At this stage, the uterus is in contact with the abdominal wall hence quickening is felt and uterine soufflé can be heard on auscultation. Intermittent contractions are present in the uterus. These contractions are painless and felt by the mother called Braxton Hick’s contractions. This encourages blood supply to the uterus and at the latter part of pregnancy it helps pull up the cervix from the vagina (effacement of the cervix). 20THWEEKS the fundus has reached the level of the umbilicus or measures 15cm above the symphysis pubis. By the end of 20th weeks, the walls of the uterus become thinner allowing palpation of foetal parts.Foetal movement is also seen. AT 24WEEKS The fundus is a finger breath or at the upper margin of the umbilicus about 20cm from the symphysis. The uterus tends to be in the right lateral obliquity. 16 AT 30WEEKS At this stage, the fundus could be palpated halfway between the umbilicus and xiphisternum. It contacts the abdominal wall, displacing intestines laterally and superiorly and continues to rise, ultimately reaching the liver. THIRTY SIX WEEKS (36 WEEKS) By the 36weeks, the fundus reaches the xiphisternum especially in the primigravida. It measures 30.5cm.The softening of the tissues of the pelvic floor together with good uterine tone and the formation of the lower uterine segment helps the foetus to sink into the lower pole of the uterus. This is known as lightening. In the primigravida, this brings about the gradual descent into the pelvis and the fetal engages after the 36th week. In the multiparous woman, descent often occurs when labour is established. NB: It is expected that the growth of the fundal height will be 1cm per week between the 20th and 36thweeks. 38 – 40WEEKS The fundal height is now 2-3 finger breaths below the xiphisternum due to engagement of the presenting part into the cervix especially in the primigravida. However the head may not enter the pelvic brim until the onset of labour and this particularly common in the multiparous woman with lightening taking place. The woman is relieved and breaths more comfortable, but the descent of the head may cause pressure on the bladder resulting in frequency of micturition. FACTORS AFFECTING THE SIZE OF THE UTERUS 1. Large fetus 2. Polyhydraminous 3. oligohydraminous 4. Intra uterine death (undiagnosed) 5. A very small single fetus 6. Malposition (transverse line) 7. Wrong date; wrong LMP 8. Laxed abdominal muscle 9. Multiple gestation 10. Fetal abnormalities BLOOD SUPPLY: 17 Uterine blood flow progressively increases to almost seventeen folds from approximately 50mls per minute at 10 weeks to a maximum of 450 to 750mls per minute at term.The uterus receives about 10%-20% total maternal cardiac output New blood vessels develop under the influence of estrogen to correspond with the growth of the uterus and also meet the need of the functioning placenta. CHANGES IN THE CERVIX The Cervix maintains its 2.5cm length but slightly increases in width due to the effect of estrogen.There is softening of the cervix giving it a characteristic feel of lip known as Goodell’ssign. It becomes more vascular giving it a purple colour due to increased blood supply.Hypertrophy and hyperplasia occurs and becomes edematous. The glands in cervix (endocervical cells) secrete thick and viscous mucus under the influence of progesterone to form a plug known as operculum. This prevents ascending infection hence protect the uterine contents (fetus, placenta and membranes). During the latter part of pregnancy, the cervix is withdrawn into the lower segment known as effacement or taking up of the cervix. This normally occurs in primigravida during the last 2 weeks of pregnancy and in the multiparous women this does not take place until labour sets in.During labour,the operculum is shed and mixed with slight blood known as show. This show dislodges as the cervix starts to dilate. CHANGES IN THE ISTHMUS By the 12th.week of gestation, the developing embryo fillthe uterine cavity. The isthmus softens, lengthens and expands to accommodate it. The length of the isthmus increases from 7mm to 25mm. As the fetus grows to fill the body of the uterus, the isthmus unfolds and receives the lower pole of the developing fetus in its cavity.The expanded isthmus is now referred to as the Lower uterine segment.At the end of pregnancy and early labour, the cervix is taken up and also becomes part of the lower uterine segment. CHANGES IN THE OVARIES During pregnancy ovulation ceases, maturation of new follicles is suspended. Corpus luteum functions during early pregnancy (first 10-12weks) producing more progesterone.However, small levels of oestrogen and relaxin are produced by the corpus luteum.After 8 weeks gestation, the corpus luteum remains the source for the hormone relaxin. When fertilization takes place, corpus luteum does not die but continues to develop until about 12 weeks (3rdmonths) of pregnancy when it starts to degenerate. 18 CHANGES IN THE VAGINA  The muscle layer and the epithelium of the vagina are affected by the presence of the estrogen. The muscle layer hypertrophies and increases the capacity of the vagina. There is fat deposition, at the labia majora and this closes and covers the vagina intriotus.  The surrounding connective tissue also changed allowing the vagina to become more nd elastic.These changes enable the vagina to dilate during the 2 stage of labour to accommodate the passage of the fetus. Mucosa increases in thickness, and the connective tissue loosens and the cells become hypertrophied.  The epithelium become thicker and there is desquamation of the superficial cells, these cells release more glycogen which is acted upon by Doderlein`s bacilli a normal commensal of the vagina producing lactic acid and hydrogen peroxide. This leads to increase and more acidic (ph 4.5 - 5)  There is increase in secretion of cervical mucus that is whitish vagina discharge known as leucorrhoea. This provides an extra protection to infections but candida albicans easily establish themselves resulting in frequent occurrence of vaginitis in pregnancy.  The vagina becomes more vascular due to increase blood supply. This gives it bluish discoloration called Chadwick’s sign or Jacquemier’s sign.  There is pulsation in the lateral fornices due to increased vascularity. This is termed as Osiander’s sign. CHANGES IN THE ABDOMINAL WALL As pregnancy advances, the abdominal wall stretches and straie gravidarium (stretch marks) develops in the skin and become glistering silvery lines after pregnancy. Linea nigra which is a dark pigmentation develops extending from the umbilicus down the middle line to the symphysis pubis. CHANGES IN THE FALLOPIAN TUBES These also rise out of the pelvis with the uterus and lie almost longitudinally at the sides of the uterus in late pregnancy. CHANGES IN THE BREAST 19 The breast undergoes changes due to hormonal activity. Estrogen develops the duct system and progesterone the glandular tissue. The nipples are prepared for breast feeding and so the nipples become larger, more deeply pigmented and more erectile by progesterone. Increase enlargement of the breast is due to increased tissue growth, blood supply and fat disposition. Most of the changes occur quite early. Tenderness and tingling sensation occur. Secretion of colostrum, a yellowish secretion rich in antibodies is produced by the stimulation of prolactin. CHRONOLOGICAL CHANGES IN THE BREAST 3-4 weeks Prickling, tingling sensation due to increased blood supply. Particularly around the nipple 6 weeks Enlargement, tension and tenderness increase especially in women normally experiencing premenstrual changes 8 weeks Superficial veins are increased due to increase blood supply 9-12 Weeks Montgomery’s tubercles become more prominent on the areola. They secrete sebum to keep the nipples soft. 16 Weeks Secondary areola appears at scattered pigmented area around the primary areola of each breast known as Montgomery’s tubercles. Colostrum can be expressed Late pregnancy Colostrum may leak from the breast. Progesterone causes the nipple to become more prominent. All the above changes are more marked in primigravida than in the multigravida. The depth of pigmentation varies with the person’s complexion. 20 CHANGES IN THE URINARY SYSTEM  There is frequency of micturition at early part of pregnancy. This may be due to pressure of the growing foetus on the bladder. Frequency often occurs in later part of pregnancy when lightening takes place. Ureters  The ureters become dilated and lengthen and are thrown into curves (kinking) this slows down urine outflow making infection a greater possibility.  The enlarged uterus displaces the ureters laterally so that, as they pass through the muscle wall into the bladder, they become shorter and perpendicular (instead of oblique) and therefore less efficient at the junction.  Peristalsis is slowed down in the ureters and stasis of urine may occur. This may prevent efficient drainage of urine to the bladder thus predisposing the pregnant woman to urinary tract infections (UTI). This explains why pregnant women are prone to pyelonephritis Kidneys  The kidneys work harder to excrete both maternal and foetal waste, because of this kidney disease turns to get worse during pregnancy.  There is an increase amount of urine during pregnancy with low specific gravity.  Pregnant women show the tendency to excrete glucose in urine due to lowered urinary threshold for sugar. Although a reduction in urinary threshold for sugar is often associated with pregnancy, the presence of any sugar or glucose in urine should always be reported and further investigations done. Bladder  There is decreased bladder tone leading to incompetence of the vesico-ureteral valve and reflux of urine is seen in up to 3.5% of pregnant women especially in the third trimester  Bladder pressure increases due to the enlarging uterus displacing it superiorly and anteriorly thereby flattening it resulting in reduced bladder capacity  To compensate for this, the urethra lengthens and intra urethral pressure increases. 21  The muscles of the internal urethral sphincter relaxed and along with pressure from the pregnant uterus on the bladder, causes a significant number of women to experience some degree of stress incontinence. Note: Pelvic floor exercise helps to resolve it. The relation of the urinary blabber and the uterus GASTROINTESTINAL CHANGES  There is increased vascularity to the gums and they also become oedematous.  It feels soft and spongy and easily traumatized due to the influence of oestrogen. This could lead to gingivitis which bleeds easily and may interfere with chewing, this regresses after birth.  During pregnancy, the pregnant women’s appetite and food intake fluctuate.  Early in pregnancy, in response to increasing levels of Human Chorionic gonadotrophic hormone (HCG) some pregnant women experience morning sickness which is nausea with or without vomiting.  It occurs about 4-16 weeks and subsides by the end of the 3rdmonth of pregnancy or first trimester 22 MORNING SICKNESS Morning sickness may not have any harmful effect on the growing foetus or the woman but if vomiting is severe or exceeds beyond the first trimester or if it is accompanied by fever, pain or weight loss then medical intervention must be sort. MOUTH  Ptyalism: Begins early in pregnancy and ceases after birth. This is associated with stimulation of the salivary glands by ingestion of starch.  This perceived increased in salivation is thought to be caused by the decrease in unconscious swallowing by the woman when she feels nauseated. In spite of this there is increased appetite due to the effect of progesterone which act as an appetite stimulant and the movement of glucose and other nutrient to the fetus and also due to taste changes even before the person missed her period. Food consumption increases from early trimester peaks at mid trimester and decreasing near term. TEETH Pregnancy does not cause tooth decay but due to gingival alterations however the pregnant woman will be aware of pre-existing or newly developing dental caries which may deteriorate as a result of the acidic saliva. The pregnant woman requires about 1.2g of calcium and phosphorus every day during pregnancy. In a well-balanced diet these requirement are satisfied Other prominent changes include;  There is a taste change even before the person missed her period.  There is increased appetite due the effect of progesterone which act as an appetite stimulant and the movement of glucose and other nutrient to the fetus.  There is cravings and aversion for certain foods. Common aversions include tea, coffee, fried fish and eggs and later in pregnancy sweet foods. There is Pica; that is persistent cravings and compulsion of non-food substances  Gastrointestinal tone is decreased due to progesterone and estrogen and decreased activity motilin resulting in slow emptying of the gastrointestinal content. Abdominal distension causes the woman to feel bloated.  There is constipation and haemorrhoids caused by the action of progesterone reducing peristalsis in the colon and pressure on veins below the level of the enlarging uterus respectively coupled with relaxation effect of progesterone on the veins.  Heartburns due to the altered position of the stomach, increased intragastric pressure and reduced pressure of lower gastroesophageal sphincter. 23   Gall bladder volume is increased but emptying is reduced during the 2nd and 3rd trimester due to relaxed muscle tone and reduced motility.Bile is dilute and ability to make cholesterol soluble is reduced leading to formation of stones (GALL STONES). Reduced gall bladder tone leads to retention of bile stones resulting in pruritus.  There is reduced hepatic blood flow by 35% due to diversion to uteroplacental circulation CHANGES IN METABOLISM Numerous and intensive changes occur in response to rapidly growing foetus and placenta. Generally, the metabolic rate during the latter half of the pregnancy increases to about 20-25% this is in respond to the demand of the growing foetus and maternal tissues. Normal fasting blood sugar is 80-100mg per mlof blood and the kidneys do not excrete glucose in the urine in the normal individual until blood glucose rises about 160mg. WATER METABOLISM  The average woman retain about 6 -8 liters of extra water during pregnancy secondary to hormonal influence.  Approximately 4 -6 liters cross into the extra cellular spaces.  This creates a physiologic increase in blood volume (hypervolaemia). Women experience normal accumulation of fluid in their legs and ankles at the end of the day and disappears with rest and is rarely seen in the mornings.  The return flow of blood from the lower limbs is slowed down and coupled with slow returns from the uterine veins which results in congestion of the fluid in the lower limbs.  Retention of fluid is one of the main reasons why the pregnant woman is weighed on each visit or regularly PROTEIN METABOLISM Foetus, uterus, and maternal blood are rich in protein rather than fat or carbohydrate. In–normal non –pregnant woman, the total protein per liter of plasma is 65 – 85g.  Due to the increased plasma volume in pregnancy the protein count is reduced from 35 to 25g during the first 20 weeks.At term, foetus and placenta contain 500g of protein or approximately half of the total protein increase of pregnancy. LIPID METABOLISM During pregnancy there is an accumulation of fats stores mostly cholesterol, phospholipids and triglycerides in the early and mid-pregnancy. 24   Later in the pregnancy as foetal nutritional demand increases maternal fat stores decreases.  Fats are used by the woman as an alternate energy in order to conserve glucose for the foetus during the second half of the pregnancy th  Fats storage occurs before the 30 week’s gestation. CARBOHYDRATES METABOLISM  There is increased glucose secretion by 15-30%.  Maternal glucose are however 10-20% less than in non-pregnant woman. th  From the 20 week the secretion of insulin increases by 3folds and insulin increased resistance decreases glucose uptake by the muscles and adipose tissues.  Increased insulin resistance promotes flow of glucose to the foetus. Increasing insulin resistance is mediated by increased levels of estrogen, human placental lactogen, cortisol and prolactin. NUTRIENT REQUIREMENT CALORIC REQUIREMENT  Additional calories are usually not required during the first trimester due to the limited metabolic demands.  An additional 300kcal/dl is required during the second and third trimester of the woman and this is based on individual. PROTEIN REQUIREMENT Adequate amino-acids(end product of protein) is needed to accommodate the normal development of the foetus(bloodvolume) IRON REQUIREMENT Total circulating red blood cell (R BC’S) increased to 40% to 50% during pregnancy, therefore iron requirements are increased to 20 to 40mg daily. Supplemental iron is necessary during pregnancy or lactation 25 WEIGHT GAIN Weight gain in pregnancy is attributed to uterus and its contents, the breast, increase in the blood volume and extracellular fluid. A smaller fraction is the result of metabolic changes known as maternal reserves Approximately 62% of the weight gain consists of water which is retained in all the body systems  Ideally, the average woman is expected to gain 1/5 of her normal weight which is about 11.5 - 16kg with average being 11 - 12kg at the end of pregnancy. Optimal weight gain is12.5kg.  During the first 20wks of gestation, she gains approximately 2kg - 3.5kg that is 0.5kg per month.  For the second half (20weeks) a steady weight of about 0.45kg or 0.5kg a week is gained.  This will give a total 12kg - 12.5kg term  An increase of more than 2kg a month in the second half of pregnancy must be investigated. If it is due to over feeding, she must be counselled on diet. At times, it could be due to oedema which may be hidden or may be the first sign of pregnancy induced hypertension (PIH).  Inadequate weight gain during the first half of pregnancy could be due to poor nutrition, smoking and conditions like hyperemesis gravidarium.  Fetal growth retardation could be attributed to inadequate weight gain during the second half of pregnancy. DISTRIBUTION OF WEIGHT GAIN IN PREGNANCY  Foetus3.2 -34kg o Placenta 0.5g –0.7kg o Amniotic fluid 0.8kg o Uterus 1.1kg o Breast 0.7kg -1.4kg o Blood volume 1.2kg -1.6kg o Maternal stores 1.8kg -4.3kg 26  CHANGES IN THE CARDIOVASCULAR SYSTEM  During pregnancy, the heart has a greater output. This is due to the increase blood volume and increased oxygen and growing foetus. To be able to function effectively, the heart muscles slightly hypertrophies. This tends to worsen in clients who already have cardiac condition or diseases. Example is hypertension.The main changes in the cardiovascular system includes the following; a. Increased cardiac output b. Sodium and water retention resulting in blood volume expansion c. Reduction in systemic vascular resistance d. Reduction in systemic blood pressure These changes begin in early pregnancy, reach their peak in mid trimester and remain relatively constant till delivery. CHANGES IN THE HEART For the heart to pump vigorously, its rate increases by about 10 to 15 beats per minute. That is from (pre-pregnancy) to 85 BPM (during pregnancy) to meets its demands. It pumps about 7 liters of blood in a minute instead of the usual 5 liters. BLOOD VOLUME CHANGE The blood volume is increased by about 40% to 50% (1450 to 1750ml) during pregnancy. This increase commences about the 10 weeks of pregnancy to its maximum of 50% at about 32 to 34 week. This is maintained till term. PLASMA VOLUME Plasma volume increases about 50% (1250- 1600), though the red blood cells also increases slightly, it does not correspond to that of the plasma volume. Hence there is general dilution of the blood know as physiological haemodilution. The increase in plasma volume reduces blood viscosity. As a result of these changes, the hemoglobin level, haematocrits (Packed cell volume) and red blood cell count are reduced. This results in physiological anemia. The haemodilution effect is most clearly seen at 32 -34 weeks gestation. BLOOD PRESURE 27 Though there is an increase in the blood volume and cardiac output, there is no physiological increase in the blood pressure during pregnancy. Blood pressure rather falls slightly below normal about 5 to 10 mmHg especially during mid-pregnancy. This is due to the influence of progesterone which relaxes the plain muscles of the arteries causing peripheral vasodilatation. The drop which occurs in both the diastolic and systolic pressure gradually returns to pre-pregnancy level. This can cause faintness. Maternal blood pressure will also rise with uterine contractions and returns to the baseline level after the uterine contractions are over. Maternal positions influences blood pressure, the highest readings is obtained in the left lateral position When the woman lies in the supine position there is compression on the inferior vena cava by the enlarging uterus in late 2nd trimester and 3rd trimester which results in decreased venous return and cardiac output. As the woman suffers a condition known as Supine hypotension syndrome. IRON METABOLISM  A fall in the haemoglobin physiological while a high Haemoglobin (Hb) level is a sign of pathology.  An average requirement of about 1000mg is needed, 500mg to increase the red blood cell mass 300mg to be transported to the foetus mainly in the last 12 weeks and 200mg to compensate for the insensible loss in urine and stool  Iron demand increase from 2-4mg daily with the absorption rate of 5 - 10% in dietary iron in the first trimester and increases to 6-7mg daily with the absorption rate of 66% by the 36th week. Even if mothers have severe iron deficiency anaemia the placenta still provides from the maternal stores for foetal Haemoglobin production  If a woman enters pregnancy with depleted stores in spite of the increase in the gastrointestinal absorption, amount absorbed from diet and that metabolised from stores, it may be insufficient to meet the demand imposed by the pregnancy. 28   Iron supplements are therefore given to maintain stores to prevent true anaemia occurring. CLOTTING FACTORS o The increase in clotting factors and fibrinogins, reduced plasma fibrinolytic activity and increase circulating fibrin degradation products in the plasma leads to a Hypercoagulable state o From the 12 week there is an increase in the synthesis of fibrinogen by 50%. This is critical in the prevention of bleeding at the time of placenta separation o There is a decreased in the endogenous anticoagulants which is intended to reduce the risk of haemorrhage at time of delivery, however, due to the physiological vasodilation in pregnancy they increase the risk of mothers in having thromboembolism PLATELATES There is no significant change in number, appearance, or function of platelets. Average platelet count is 140,000 to 400,000 which increases the risk to the pregnant woman for venous thrombosis. IMMUNITY  Pregnancy poses a challenge for mother’s immune system as mechanisms necessary to protect against infections are greatly reduced. Conversely there is an increase in the white blood cell levels. Lymphocytes functions are depressed There is decreased resistance to viral infections such as herpes, influenza, rubella, as well as malaria  Serum levels of immunoglobulins IgA, IgG and IgM are decreased steadily from the 10th week and reach their lowest level at 30weeks and remains till term. CHANGES IN THE RESPIRATORY 29  There is marked changes in the respiratory system. As the uterus enlarges during pregnancy, the lungs and the diaphragm are displaced upwards resulting in congestion in the chest cavity. This causes acute sensation of shortness of breath in late pregnancy until lightening takes place to relieve the pressure. o There is hyperventilation which causes arterial oxygen tension to increase and arterial CO2 to fall.  The lower ribs flare outwards prior to any mechanical pressure from the growing uterus. The flaring out of the lower ribs causes the diaphragm to rise up by 4cm.These changes are mediated by the effect of progesteron which together with relaxin, increase the elasticity of the ribcage by relaxing the ligaments.  Progesteron also causes bronchial and tracheal smooth muscle relaxation there by reducing airway resistance. This improves air flow along the bronchial tree.This explains why women with respiratory problems in pregnancy do not deteriorate.  Blood volume expansion and vasodilation of pregnancy results in hyperaemia and oedema of the upper respiratory mucosa which predisposes the woman to nasal congestion, epistaxis or even change in voice.  There is a slight increase in respiratory rate (18-20cpm).  Increased vascularity also leads to impaired hearing, earaches or sense of fullness in the ears.  These are the result of swelling of the tympanic membranes and Eustachian tubes due to increased vascularity. CHANGES IN THE MUSCULOSKELETAL SYSTEM  There is a definite change in the pelvic joint due to the hormone relaxin and progesterone. They encourage relaxation of ligament and muscle.This relaxation allows the pelvis to increase its capacity in readiness to accommodate the foetal presenting part at the end of pregnancy and in labour  The symphysis pubis and the sacroiliac joint soften while the sacrococcygeal joint loosen to allow the coccyx to be displaced or tilt back.  The slight increase in movement in these joints surface cause a slight extension in the pelvic cavity which in tend makes labour easy.  This is referred to as the GIVE OF THE PELVIS. 30  CHANGES IN THE ENDOCRINE SYSTEM The changes involve many organs.  The pituitary gland is greatly altered during pregnancy and changes in the cells of the glands are so marked.  The anterior pituitary gland is enlarged.  Follicle Stimulating Hormone and Luteinizing Hormone are inhibited by oestrogen and progesterone.  Prolactin secretion increases but it is held in check by oestrogen.  The posterior pituitary gland is stimulated to produce increasing amount of oxytocin during pregnancy. The concentration does not change in pregnancy but rises in the second stage of labour  The placenta is also important in producing the hormone oestrogen and progesterone to maintain pregnancy CHANGES IN THE NERVOUS SYSTEM There is no much change in the nervous system but there is often minor upset in the pregnant woman. Some women may be irritable. There is increased production of beta endorphines. This increases maternal threshold for pain in the later part of pregnancy. SKIN CHANGES Changes in skin, hair, nails, subcutaneous & sweat glands are influenced by hormonal, immunological & metabolic factors. Genetic predisposition is responsible for such skin changes as straie and pigmentation. Almost all women experience some skin darkening as early sign of pregnancy due to increased melanocyte stimulating hormone, progesterone & oestrogen  Hyperpigmentation is more marked in dark-skinned & more pronounced in areas normally pigmented – areolar, genitalia & umbilicus & in areas prone to friction – axillae, inner thighs & recent scars.  Linea alba changes to linea nigra  About 75% of women have chloasma/melasma /mask of pregnancy, which worsens with sun exposure & clears mostly postpartum. 31   Straie gravidarum from tearing of dermal collagen occurs as maternal size increases & stretching of collagen layer of the skin over the breasts, thighs & abdomen occurs. Appear as red stripes, changing to glistening and silvery white lines about 6mths after birth. Influenced by hormones, adrenocorticoids, relaxin and oestrogens.  There is pruritiswhich can be distressing & may be associated with a rash.  Rise in body temperature as a result of progesterone effect makes the pregnant woman ‘feel the heat’ & sweat profusely in hot humid climate.Peripheral vasodilation & increased sweat gland activity help to dissipate excess heat produced by maternal, placental & foetal metabolism.  Angiomas on the face & palmer erythema occur frequently as a result of high oestrogen levels disappear post partum. These are of no significance. Although do not have clinical significance, may mask some other serious conditions such as malignant tumours, herpes gestations & intra hepatic cholestasis 4. EFFECT OF PREGNANCY ON CLIENT AND FAMILY Client 1. Stigmatization: This comes about when the individual is afraid of what people will say if she is not married 2. Financial problems: In large families of about 5 or more, pregnancy brings financial problems on the family if the couples are not financially stable. 3. It therefore becomes difficult to care for the whole family as well as the expectant mother 4. Anxiety: This is due to past experiences of previous pregnancies. The client is anxious about outcome of the pregnancy 5. Happiness: The pregnancy can bring joy if it is expected. 6. Loss of job: In certain companies, pregnant women sometimes are asked to leave their jobs especially in private companies 32 DIAGNOSIS OF PREGNANCY Pregnancy may be determined by cessation of menses, enlarged uterus, and a positive result on pregnancy test. These and the many other manifestations of pregnancy are classified into three groups: PRESUMPTIVE, PROBABLE AND POSITIVE. PRESUMPTIVE SIGNS Presumptive signs and symptoms of pregnancy are the changes felt by the woman or physiological changes which the woman notice or experience. These physical signs and symptoms suggest but do not prove pregnancy. Since most of these signs and symptoms may be signs and symptoms for other condition or problem. These include; 1. Amenorrhea 4weeks 2. breast changes 3-4weeks 3. morning sickness 4-14weeks 4. bladder irritability 6-12weeks 5. Skin changes 6. Quickening 16-20weeks Amenorrhoea Abrupt cessation of menses (Amenorrhoea): pregnancy is suspected if more than 10 days have passed since the time of expected onset of menses in a healthy woman, who has regular and normal periods. In pregnancy amenorrhea occurs because as soon as there is implantation of the fertilized ovum, production of estrogen and progesterone increase and converts the endometrium to decidua. This ceases menstruation from occurring. Some other conditions may also cause amenorrhea. Examples are;  chronic ill health as in active TB or syphilis  Severe anemia and malnutrition  Ovarian and pituitary imbalance  Ovarian cyst or multiple fibroids 33   Emotional upset  Localized uterine infection  Change of environment PROBABLE SIGNS. These are signs that indicate pregnancy most of the time, however there is still the chance they can be false caused by something other than the pregnancy.  PRESENCE OF HUMAN CHORIONIC GONADOTROPHIN(HCG) in Blood and urine as early as 9-10 gestation  HEGAR’S SIGNS(softened isthmus)  JACQUIMIERS SIGNS(chadwick’s signs/blueing of vagina)  OSIANDERS SIGNS(pulsation of the fornices )  CHANGES IN UTERUS(uterine growth)  UTERINE SOUFFLE  ABDOMINAL ENLARGEMENT  BRAXTIN HICKS’ CONTRACTION  BALLOTMENTS OF FOETUS around the 16th -18th week HAGAR’S SIGN It is seen between 6th- 12th weeks of pregnancy one of the early signs is mainly done to establish gestational age.Two fingers are inserted into the anterior fornix of the vagina and the other hand is place behind the uterus abdominally the fingers of both hands almost meet due to the softening of the isthmus JACQUIMIERS SIGN(chadwick’s signs) This is the purplish discolouration and congestion of the vulva and vaginal mucous membrane. It occurs between the 4th -8thweek gestation and peaks at 16weeks and persists throughout pregnancy. SOFTENING OF THE CERVIX 10thweek onward the consistency of the cervix is comparable with that of the lips, while the cervix of the non-pregnant uterus fees like the tip of the nose. UTERINE SOUFFLE From 16thweek onwards soft blowing sound, this is head on auscultation and synchronous with the mothers pulse N/B: uterine souffle is also head when fibroid /tumors are present and during the puerperium. 34  th ABDOMINAL ENLARGEMENT (16 week onwards) Abdominal enlargement may however be due to  Fat  Gaseous distention of the bowel  A full bladder  Tumor TH TH INTERNAL BALLOTMENT(16 TO 20 week)  Client should be in semi-recumbent position, two fingers are inserted into the vagina and the uterus is given a sharp tap just above the cervix which causes the foetus to float upwards in the amniotic fluid.  The left hand is placed abdominally on the fundus to detect the impact of the foetus  Detect the gentle impact of the foetus. The foetus sinks back again and is felt by the fingers in the vagina.  The rebound is known as ballottement.  None of these signs is positive as there are fallacies mostly gynecological in origin that prevent them from being conclusive  The probable signs are more reliable then presumptive signs POSITIVE SIGNS These are signs that cannot under any circumstance be mistaken for other conditions and are evidence that pregnancy has occurred  Ultrasonic evidence 5weeks th  Hearing the fetal heart 20 week th  Fetal part palpated 24 week th  Fetal movement 20 week th  Radiological demonstration of the fetal skeleton at 16 weeks SIGNS OF PREVIOUS PREGNANCY The midwife should be aware whether the woman has previously given birth to a child. 35   The breast: the breasts are more flabby and the nipple more prominent in women who has breast fed their infant and pigmentation of the areola may still persist in brunettes  The abdomen: the abdominal muscles are more lax and the skin loose so that there may be anterior obliquity of the uterus and bulging of the colon at the sides of the abdomen Striae gravidarum; are silvery – white in appearance, but when due to the present pregnancy they are pink. Some pigmentation of the linea alba and striae may be present from a previous pregnancy  The uterus: The uterine wall is less rigid and the fetus is more easily palpable  The second stage of labour may be very rapid in a multiparous women and if the midwife is under the impression that the woman is a primigravida she may not be scrubbed up for delivery in time  The Vulva 1. The vagina gapes, and more patulous and orifice is larger and a cystocele may be evident 2. The labia minora tend to project below the labia major and are darker in colour and leathery in texture. 3. Carunculae Mytiformes(tags of hymen ) are present. 4. A lax or deficient perineum and the scars from previous laceration or episiotomy may be seen DIFFERENTIAL DIGNOSIS OF PREGNANCY Some conditions exhibit symptoms of pregnancy. These are I. Amenorrhoea which could be due to;  Change of environment  Emotional disturbances or general illness such as tuberculosis can cause amenorrhea  Hyperprolactinemia (high level of Prolactin) also cause amenorrhea  Pathological conditions such as anaemia and severe malnutrition, diseases of the ovary and also condition of the thyroid glands known as thyrotoxicosis also cause amenorrhea 36   Others are discontinuity of contraceptive pills. All these conditions cause amenorrhoea which could be mistaken for pregnancy. In all of the above, there is no abdominal enlargement and pregnancy test is negative. II. Vomiting Varieties of conditions also cause vomiting; some are gastro-enteritis, urinary tract infection, worm infestation or any febrile condition like malaria III. Abdominal Enlargement  Condition like ovarian cyst, fibroids, distended bladder, ascites and increased abdominal fats cause abdominal enlargement.  To differentiate between these conditions abdominal enlargement should be uniform and fundal height should correspond with the period of gestation in pregnancy.Other causes of abdominal enlargement include; i. Ovarian Tumor  Ovarian tumors are usually benign but have a greater chance of becoming malignant. Often arise from functional changes in the ovary- from grafian follicle or corpus luteum. Even though the abdomen enlarges in this case, pregnancy test is negative and amenorrhea will occur should the two ovaries be affected. In their early stages they are asymptomatic and painless. They may grow to a large size and tend to undergo mechanical complications such as torsion and perforation Other signs and symptoms include;  Tender palpable mass  Rupture causes acute pain and tenderness  May mimic appendicitis or ectopic  Frequency of micturition ii. Uterine fibroid 37   In uterine fibroid, the abdomen enlarges, it is not uniformed and amenorrhea hardly occurs. Rather there may be severe bleeding at each monthly period.  Pregnancy test is always negative.  Sometimes multiple fibroids can be mistaken for fetal parts but mostly fibroids are fixed while fetal parts are freely movable. iii. Distended bladder Retention of urine may distend the bladder causing abdominal enlargement which could be mistaken to be pregnancy. 5. Pseudocyesis Phantom or false pregnancy are term applied to the condition in which a woman shows several of the signs and symptoms of pregnancy such as, breast changes and Large abdomen, firmly believe she is pregnant and yet no pregnancy exists. Such women are infertile married women who have overwhelming desire to give birth to a baby. The obstetric examination reveals the absence of any pregnancy 6. VOMITING Varieties of conditions also cause vomiting; some are gastro-enteritis, urinary tract infection, worm infestation or any febrile condition like malaria MIDWIFERY CARE PROCESS This care process is dynamic, continuous, and circular when needed, following an orderly succession of steps and requiring critical thinking and various types and levels of decision-making throughout. At times data collected or decisions made or unanticipated outcomes will require re-visiting an earlier step and re-planning with the woman. The midwifery process like the nursing process Modified scientific method; Goal-oriented approach of care Provides framework to nursing care Uses critical thinking & clinical judgment to categorise clients’ issue and course of action Phases of Midwifery Process. 5 major overlapping phases/ steps: (ADPIE) A – assess (what data is collected?) D – diagnose (what is the problem?) P – plan (how to manage the problem) 38  I - implement (putting plan into action) E – Evaluate (did the plan work?) ASSESSMENT: The first and most crucial step in the nursing process is assessment. Assessment is the organized and systematic process of collecting information from a variety of sources in order to evaluate the health status of the client. Assessment provides the basis for the delivery of quality, individualized care. This Include; History and current needs expressed by woman, Physical examination, and laboratory findings.[cognitive, psychomotor, affective functions] Types and Sources of data: 1. Subjective data : Woman, in most instances, the primary source of information is the client. The client who is oriented and responds appropriately can provide the most information about her past and present illnesses, life-style, and health care needs. 2. Objective data; family, available records, observation. Criteria for success: Systematic and accurate data collection done in culturally appropriate, respectful manner. 2. DIAGNOSIS Includes: Organizing data collected to clarify actual or potential midwifery diagnoses based on woman’s needs/problems and determining if emergency action required. [Cognitive & affective functions] Criteria for success: Correct interpretation of data that results in accurate midwifery diagnoses. Midwifery diagnosis = problems + its etiology or cause (if known) The Problem. The first element of the nursing or midwifery diagnosis is the identified problem that the client is experiencing or may experience. The problem could be actual, potential or risk or high risk. 1. Actual: a problem that is experienced or perceived by the client, one that is occurring in the “here and now.” This type of problem is validated by the presence of defining characteristics or signs and symptoms. Example: Alteration in nutrition, less than body requirement. 2.Potential/ Risk/High Risk: a problem which may develop in the future due to the presence of certain risk factors; and altered state which may occur unless specific nursing actions are ordered and implemented. This type of problem is validated by risk factors. Examples: Risk for fluid volume deficit related to prolong vomiting. 39 Cause or Etiological Factors The second element of the nursing diagnosis statement consists of the cause or etiology, contributing factors, or risk factors. In order to prevent, minimize, or resolve a problem, you must have some idea about why it is occurring or may occur in the future. The etiology is that which will be affected by nursing intervention. It is preceded in the nursing diagnosis statement by the phrase “related to.” You must remember that the medical diagnosis is not the etiology of a nursing diagnosis statement. 3. PLANNING: Includes: Prioritizing need for action in partnership with the woman, determining which needs/problems will be resolved by midwifery actions; need for consultation or referral. After the data has been collected and organized and nursing diagnoses have been formulated, it is time for the planning phase of the nursing process. Planning is determining the approach to be used in the assisting the client toward optimal wellness. This is deciding which actions will be used to help solve, lessen, or minimize the effects of the identified problems, or to prevent potential problems. There are four essential steps in the planning process: 1. Prioritizing the identified nursing diagnoses. 2. Developing measurable goals/outcome statements. 3. Planning nursing actionsthat will help achieve each goal/outcome 4. Documentation-the Nursing Care Plan. 4. IMPLEMENTATION: Includes: Timely, appropriate, safe midwifery care provided with compassion and cultural sensitivity, promoting self-care when possible Criteria for success: Timely intervention with safe, evidence-based, efficient, ethical, compassionate care-giving along with appropriate recording of data and plan of care. After deciding upon a plan of action, the next step in the nursing process is to execute that plan. During implementation, all the previous phases of the nursing process are integrated. While giving the actual care, you must continue to assess, validate concerns, modify the plan and identify priorities. Nursing interventions may include any of the following: 1. Directly performing an activity for a client. 2. Assisting the client as he/she performs an activity. 3. Observing or supervising the client as he/she independently performs an activity. 4. Teaching the client and/or family. 40 5. Counseling the client (or family). 6. Monitoring or assessing the client for potential complications of illness. 5. EVALUATION: Midwife checks & assess for progress towards goals/outcomes, if progress, slow or regression occurred then midwife Changes/amends plan of care accordingly. If goal achieved, care can cease NB: new problems may be identified here, i.e. Evaluation stage ; Start nursing process all over! Includes: Feedback from woman/family on needs met, satisfaction; midwife self-assessment and reflection on outcomes & whether new approach needed; confirmation/validation from colleagues, teachers. Sources of data: Self, woman, family, peers, supervisors. Criteria for success: Extent to which care given met needs of woman and midwifery goals. An outcome of midwifery care includes improved health/well-being of women and newborns. 41  Graphical representation of midwifery process Foundational Midwifery Knowledge, Skills & Professional Behaviors (KSBs) Critical Thinking Assessment History Physical Examination Ask Laboratory Look listen Findings feel Evaluation Diagnosis Woman’s Needs met? need Organize data collected Problems resolved? problems Clarify needs/potential Woman satisfied? Problems Midwife self-assessment Emergency action needed? Reflection Appropriate Implementation intervention planning Timely, appropriate care Prioritize needs Promote self-care Create plan with woman Compassionate, culturally appropriate care Need for consultation or referral? 42 Self care Safe care  MANAGEMENT OF PREGNANCY DEFINITION OF TERMS 1. Gravidity: is defined as the number of times that a woman has been pregnant 2. Parity is the number of times that she has given birth to a foetus with a gestational age of 24 weeks or more, regardless of the outcome. Example, a woman who is described as "gravida 2, para 2" (sometimes abbreviated to G2 P2) has had two pregnancies and two deliveries after 24 weeks, and a woman who is described as "gravida 2, para 0 " (G2 P0) has had two pregnancies, neither of which survived to a gestational age of 24 weeks If they are both currently pregnant again, these women would have the obstetric profile of G3 P2 and G3 P0 respectively. Sometimes a suffix is added to indicate the number of miscarriages or terminations a woman has had. So if the second woman had had two miscarriages, it could be annotated G3 P0+2. 3. A Nulliparous Woman (Nullip) has not given birth to a viable child. She may however have been pregnant previously and aborted a viable child. She may however have been pregnant previously and aborted and can be called para 0. 4. A Primigravida: a woman in her first pregnancy. 5. Nulligravida: a woman who has never been pregnant. 6. A Primiparous Woman who has given birth once. The term 'primip' is often used interchangeably with primagravida, although technically incorrect as a woman does not become primiparous until she has delivered her baby 7. A Multigravida has been pregnant more than once. 8. A MultiparousWoman (Multip) has given birth more than once. 9. A Grand Multipara is a woman who has already delivered five or more infants who have achieved a gestational age of 24 weeks or more, and such women are traditionally considered to be at higher risk than the average in subsequent pregnancies. 10. A Grand Multigravida has been pregnant five times or more. 11. A Great Grand Multipara has delivered seven or more 43  ANTENATAL CARE This is the health care and education given during pregnancy. A safe delivery and postpartum health depends on good antenatal care and as such antenatal care services are important part of preventive and promotive services in the care delivery system To ensure quality care, antenatal care services must be organized in such a manner as to provide comprehensive and individualized care. As much as possible all care activities example history taken, physical examination and treatment should be provided by the same care provider to the pregnant woman (Focus Antenatal Care) FOCUS ANTENATAL CARE  Focus antenatal care is an individualized, client centered and comprehensive services given to pregnant women and their families for health promotion, disease detection and prevention, and management of complications. Focus antenatal care means that providers focus on assessment and actions needed to make decisions and provide care for a woman’s individual situation.  This is a comprehensive individualized care which ensures privacy and confidentiality. Continuous care is provided by the same provider or by the same midwife as much as possible throughout the pregnancy. Focus antenatal care is based on ;  Quality of care rather than the quantity.  Four comprehensive visits for normal women with pregnancy  Individualized, client centered care  Diseases detection and not risk categorization  Evidenced based practices during care provision.  Birth and emergency preparedness AIMS OF FOCUS ANTENATAL CARE  To achieve a favorable outcome for the mother and baby as well as prevent any complications that may occur in pregnancy, labour, delivery and postpartum. 44   To reduce maternal and newborn morbidity and mortality to the barest minimum using existing available resources. OBJECTIVES OF FOCUSED ANTENATAL CARE  Ensuring maximum benefit of antenatal care for mother and fetus.  Early detection and treatment of health related problems.  Prevention of complications using safe, simple and cost-effective interventions.  Birth preparedness and complication readiness.  Health promotion using health message and counseling.  Provision of care by a skilled attendant.  Venue for frank and confidential discussions.  Gain the trust and confidence of the client.  Discuss traditional/cultural practices that may have adverse effect on pregnancy outcome and offer appropriate counseling.  Provision of proven interventions that promote maternal and child survival  Micro nutrient supplementation. UNDERLYING PRINCIPLES OFFOCUSED ANTENATAL CARE There are general principles that are integral to the provision of high quality focused antenatal care for pregnant women. The care should be:  Woman friendly: The woman’s health and survival, basic human rights and comfort are given clear priority. The woman’s desires and preferences are also respected.  Integrated:FANC includes STI and HIV counseling/testing, malaria detection and prevention, micronutrient provision, birth planning, emergency planning and family planning counseling.  Inclusion of woman’s partner or other family members: Respect for household decision-making process ensures fuller and safer reproductive health experiences for the woman, her newborn and family. 45   Culturally appropriate: It is essential that the health provider knows about beliefs, taboos, and practices surrounding pregnancy and child birth.  Individualized: Consider uniqueness of every pregnant woman, taking into consideration all the information known about the woman’s current health status, medical history, daily habits and lifestyle, household situation, cultural beliefs and custom.  Continuity of care:focus antenatal ensures continuity of care since care is continually provided by the same midwife IMPORTANT/BENEFITS OF FANC 1. Increased ANC attendance. 2. Early utilization of ANC services by pregnant women. 3. Individualized care, education and counseling more tuned to client’s needs. 4. All care component given by the same provider. 5. Improved client-provider interaction. 6. Increased used of delivery facility. 7. Decreased stillbirth rate. 8. Enhanced use of postnatal care services. 9. Comprehensive history taking. 10. Detection of existing diseases. 11. Prevention of disease and promotion of health. 12. Birth preparedness and complication readiness. 13. Improved Postpartum care. 14. Encouraging continuity of care. CHALLENGES  Staff attrition 46   Pre-service training-Pre-service training institutions and professional bodies were not involved in the initial design and it planning and subsequent introduction.  Thus the curricula for pre-service training remained unchanged.  Limited use of FANC –Most women still make their first visit after 20 weeks gestation.  Insufficient funding - Inadequate funding to support the delivery of an increased range of services.  Limited implementation- Implementation of FANC in Ghana remained a responsibility of individual facility. SUSTAINABILITY OF FANC  There should be continued availability of funding targeted at strengthening FANC services.  Increased equipment and supplies needed to offer these services at clinic providing FANC.  Training providers to make them fully competent in all the component services and to offer them in an integrated fashion.  Ensuring that supervisors are able to support and enable providers to deliver integrated and comprehensive care. PACKAGE OF SERVICES  Health History taking: 1. Personal medical and surgical history. 2. Social history. 3. Family medical history. 4. Past and present obstetrical history.  Clinical observations: 1. Temperature 2. Pulse 47  3. Blood pressure 4. Weight and gait 5. General physical examination; head to toe examination  Laboratory investigation: 1. Haemoglobin level 2. Full blood count 3. Sickling 4. Veneral Disease Research Laboratory- syphilis 5. Human Immunodeficiency Virus for PMTCT-prevention of mother to child transmission 6. Grouping and cross matching 7. Stool for worms 8. Urine ; sugar, protein  Malaria prevention through chemoprophylaxis or Intermittent Preventive Treatment (IPT) and use of insecticide treated nets and case management.  Nutrition education  Iron- folate supplementation  Tetanus immunization  Screening and treatment of infections  Birth preparedness plan  Family planning education  Education on breastfeeding  Education on other relevant health issues  Care of the newborn  Danger signs in pregnancy administration of steroids for preterm labour  Calcium supplementation in areas of low intake ANTENATAL SCHEDULE The World Health Organization (WHO) recommends that: Women can benefit from just few antenatal visits, as long as those visits are thorough. Ideally women should have atleast4 48 thorough, comprehensive, and personalized antenatal visits and these could be spread out as follows: 1. 1st visit: