Obstetric and Gynecological Nursing Lecture Notes PDF

LECTURE NOTES For Nursing Students Obstetric and Gynecological Nursing Meselech Assegid Alemaya University In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center,...

LECTURE NOTES For Nursing Students Obstetric and Gynecological Nursing Meselech Assegid Alemaya University In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education 2003  Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00. Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Important Guidelines for Printing and Photocopying Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty. All copies must retain all author credits and copyright notices included in the original document. Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication. ©2003 by Meselech Assegid All rights reserved. Except as expressly provided above, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission of the author or authors. This material is intended for educational use only by practicing health care workers or students and faculty in a health care field. Preface This lecture note offers nurses comprehensive knowledge necessary for the modern health care of women with up-to- date clinically relevant information in women’s health care. It addresses and contains selected chapters and topics which are incorporated in the obstetrics and gynecology course for nurses. However, a major focus is provided on the role of the nurse in providing quality maternal and newborn care. The obstetric nurse does a three or four month course of obstetrics part as part of an integrated training. The nurse is part of the health team expected to be able to deal with midwifery. The nurses work among the community and they bear the great responsibility of having to deal with mothers in remote areas and far away from hospitals. The nurses must do their best to educate mothers in prevention of complications. This lecture note is prepared to relieve the shortage of reference materials in the country even though it does not represent the text books. It is organized in a logical manner so that students can learn from the basics to the complex. It is divided in to chapters and subtopics. Each chapter contains learning objectives, descriptions and exercises in the form of discussion, case studies. Important abbreviations and i glossaries have been included in order to facilitate the teaching learning process. The learning objectives are clearly stated to indicate the required outcomes. ii Acknowledgement My deepest appreciation and heart felt gratitude goes to The Carter Center, EPHTI, Addis Abeba for the financial support, initiation of the lecture note preparation, and provision of necessary materials. I also extend my thanks to my colleagues from Alemaya University, Faculty of Health Sciences for their invaluable comments during the revision of the lecture note. Finally, my special thanks and gratitude goes to Ato Aklilu Mulugetta for his devoted support and facilitating the preparation of this lecture note. Last but not least, I thank my university authorities; Acadamic Vice President, Faculty dean and Department for their permission to work on this lecture note besides my other responsibilities. I would also like to thank my faculty secretaries for their cooperation in writing this lecture note. iii  TABLE OF CONTENTs Preface i Acknowledgement iii Table of Containts iv List of figures xi List of Tables xii Abbreviations xiii CHAPTER ONE: INTRODUCTION 1 1.1 Historical development of obstetrics 1 1.2 Magnitude of Maternal Health problem in 2 Ethiopia 1.3 Importance of Obstetrics and Gynecology 3 nursing CHAPTER TWO: ANATOMY OF FEMALE 5 PELVIS AND THE FETAL SKULL 2.1 Femele Pelvic Bones 5 2.2 Anatomy of the female external genitalia 18 2.2.1 The vulva 18 2.3 Contents of the pelvis cavity 20 2.3.1 The bladder 20 2.3.2 The Ureters 21 2.3.3 Urethra 21 2.3.4 The uterus 22 iv  2.3.5 Fallopian tube or uterne tube 24 2.3.5 The ovaries 25 2.4 Physiology of the Femel Reproductive Organs 26 2.4.1 Puberty – the age of sexual maturation 26 2.4.2 The menstrual cycle 27 2.4.3 Phases of menstrual cycle 29 2.5 The Breast Anatomy 31 Review Questions 35 CHAPTER THREE: NORMAL PREGNANCY 36 3.1 Conception 36 3.2 Development of the Fertilized Ovum 37 3.3 Functions of Placenta 40 3.4 The Fetal Circulation 41 3.5 Anatomical Varations of the Placenta and the 46 Cord 3.6 Physiological Changes Of Pregnancy 50 3.6.1 Gastro Intestinal Tract (GIT) 50 3.6.2 Galbladder 51 3.6.3 Liver 52 3.6.4 Urinary systems 52 3.6.5 Bladder 53 3.6.6 Hematological system 53 3.6.7 Cardiovascular System 54 3.6.8 Plumunary system 55 3.6.9 Changes in the Breast 56 v  3.6.10 Change in Skin 56 3.6.11 Change in Vagina and Uterus 56 3.7 Minor Disorders of Pregnancy 57 3.8 Diagnosis of Pregnancy 60 3.9 Antenatal Care 62 3.9.1. History Taking 64 3.9.2 Examination of the Pregnant Woman At 65 First Visit 3.9.3 Laboratory test 74 Review Questions 76 CHAPTER FOUR: NORMAL LABOUR 77 4.1 Mechanism and Stages of Labour 79 4.1.1 Management of 1st Stage of Labour 79 4.1.2 The Second Stage of Labour 94 4.1.3 The Third Stage of Labour 98 4.2 Immediate Care of Mother and Baby 111 4.3 Discharge Planning (Instructions) 113 4.4. Episiotomy 115 Review Questions 120 CHAPTER FIVE: THE NORMAL PUERPERIUM 121 5.1 Physiology of Puerperium 122 5.2 Management of the Puerperium 125 5.3 Postnatal care (Daily care) 127 Review Questions 129 vi CHAPTER SIX : ABNORMAL PREGNANCY 129 6.1 Multiple pregnancy 129 6.1.1 Monozygotic (Uniovular) 129 6.1.2 Dizygotic (Binovular) Twins 130 6.2. Hyper Emesis Gravidarum 138 6.3. Pregnancy Induced Hypertention 140 6.3.1 Preeclampsia 140 6.3.2 Eclampsia 146 6.4. Antepartum Haemorrhage 149 6.4.1 Placenta praevia 150 6.4.2 Placental Abruption 155 6.5 Polyhydramnios 158 6.6. Rhesus Incompatibility 162 6.7 Disease Associated With Pregnancy 166 6.7.1 Infection 166 6.7.2 Pulmonary tuberculosis 167 6.7.3 Cardiac Disease 169 6.7.4 Diabletes Mellitus 171 Review Question 175 CHAPTER SEVEN : ABNORMAL LABOUR 176 7.1. Malpresentation and Malpostion 176 7.1.1 Breech Presentation 177 7.1.2 Brow Presentation 184 7.1.3 Shoulder Presentation 185 7.1.4 Face Presentation 187 vii  7.1.5 Unstable lie 189 7.1.6. Compound or Complex Presentation 190 7.1.7 Occupitio- Posteririor Position 191 7.2. Post partum Hemorrhage 193 7.2.1 Atonic Postpartum Hemorrhage 195 7.2.2 Traumatic Post Partum Hemorrhage 196 7.2.3 Hypo Fibrinogenaemia 197 7.3. Prolonged Labour 200 7.4 Prolapse of Cord 203 7.5 Cephalopelvic Disproportion 205 7.6 Contracted Pelvis 206 7.7 Retained Placenta 207 7.8 Adherent Placenta 208 7.9 Rupture of the Uterus 209 7.10 Lacerations 213 7.11 Premature Rupture of the Membrane 215 (PROM) Review Questions 226 CHAPTER EIGHT : ABNORMAL PUERPERIUM 218 8.1 Urinary Complications 218 8.2 Breast Infections 219 8.2.1 Acute Puerperal Mastitis 219 8.2.2 Breast Abscess 220 8.3 Puerperal Sepsis 221 8.4. Puerperal Psychosis 223 viii 8.5 Subinvolution 225 Review Questions 226 CHAPTER NINE : INDUCTION OF LABOUR 227 9.2 Augmentation (Stimulation) Of Labour 232 9.3 Trial of Labour 233 Review Questions 236 CHAPTER TEN : OBSTETRIC OPERATIONS 237 10.1 Forceps Delivery 237 10.2 Caesarean Section 243 10.3 Destructive Operations /Embryotomy/ 246 10.4 Version 248 10.4.1 Internal Version 248 10.4.2 External Cephalic Version 249 10.5 Vacuum Extraction / Ventouse delivery/ 250 Review Questions 252 CHAPTER ELEVEN : CONGENITAL ANOMALIES 253 OF THE FEMALE GENITAL ORGANS 11.1 Uterine Abnormalities 254 11.2 Cervix Abnormalities 155 11.3 Vaginal Abnormalities 257 Review Questions 258 ix CHAPTER TWELVE : INFECTION OF THE 259 FEMALE REPRODUCTIVE ORGANS 12.1 Pelvic Inflammatory Disease 260 12.2 Vulval Infection 263 12.3 Candidiasis 266 12.4 Trichomoniasis 268 12.5 Trauma of the female genital tract fistulae 270 12.6 Prolaps Of The Uterus 273 12.7 Inversion of the Uterus 275 12.8 Abortion 279 12.8.1 Types Of Abortion 281 12.9 Abnormalities Of The Menstrual Cycle 290 (Menstrual Disorder) 12.9.1 Menstral Disordenrs 290 12.10 Ectopic Pregnancy 293 12.11 Infertility 300 12.12 Disorder Of The Breast 302 12.13. Menopause 306 Self examination of the breast 307 12.14. New growths 310 Review Questions 316 GLOSSARY 317 BIBILIOGRAPHY 320 x  LIST OF FIGURES Figuer 1. Normal Female Pelvis 6 Figuer 2. Pelvic ligaments(Posterior view) 8 Figure 3. Types of female pelvis 11 Figuer 4. Fetal skull 16 Figuer 5.Diameters of fetal skull 17 Figure 6 Female external genitalia 19 Figure 7. Anterior view of female internal reproductive 26 organ Figure 8. Menstrual cycle 30 Figure 9. Anatomy of female breast 34 Figure 10. The fetal circulation 43 Figure 11. Anatomical variation of placenta and cord 48 insertion Figure 12. Fundal palpation 69 Figure 13. Lateral palpation 70 Figure 14. Deep pelvic palpation 71 Figure 15. Pwelick’s grip 72 Figure 16. Types of placenta praevia in relation with 152 cervical os Figure 17. The ventouse or vacuum extractor 252 Figure 18. Abnormal uterine types 255 Figure 19. Possible outcomes of tubal pregnancy 294 Figure 20. Self breast examination 309 xi  LIST OF TABLES Table 1. Measurments of the pelvic canal in 10 centimeter Table 2. Features of different types of female pelvis Table 3. Difference between the true and false 78 labour contraction Table 4.Postnatal discharge instruction 114 Table 5. Difference between monozygotic and 130 dizygotic twins Table 6. Bishopes score system 229 Table 7. Proceduers of induction for multipara and 230 primigravida xii ABBRIVATIONS ACTH Adreno cortico trophic hormone ADH Anti diuretic hormones APH Anti Partum Heamorrage AROM Artificial Rupture Of Memberane BCG Bacillus Calmette Guerine BP Blood pressure Cm Centimeter BUN Blood Urea Nitrogen CO Cardiac Output CPD Cephalo Pelvic Disproportion C/S Ceaserian Section DBP Diastolic blood pressure D&C Dlatation and cruttage DIC Disseminated intravascular coagulation EDD Expected date of delivery FHB Fetal heart beat FSH Follicle stimulating hormone HCG Human Chorionic Gonadotrophin GIT Gastro intestinal tract HPLH Human Placental Lactogenic Hormone Hr/s Hour/hours IgG Immuno globuline G IU International unit IUCD Intra uterine contraceptive device xiii IV Intra venous Kg Kilogram PF2 Prostaglandin Factor 2 P.I.H Pregnancy induced hypertension PO Per os/through mouth PPH Post partum hemorrhage PROM Premature Rupture Of Membrane PUD Peptic ulcer disease RBC Red blood cell Rh Rhesus SBP Systolic blood pressure V.D.R.L Veneral disease research laboratory V.E Vaginal Examination WBC White blood cell xiv  CHAPTER ONE INTRODUCTION Care of childbearing and childrearing families has become a major focus of nursing practice today. To have healthy children, it is important to promote the health of the childbearing women and her family from the time before children are born until they reach adulthood. Prenatal care and guidance is essential to the health of women and fetus and to the emotional preparation of a family for chilbrearing. 1.1 Historical development of obstetrics Usually women have cared for other child bearing women through out much of human history. Birth practices in ancient cultures of the world that did not develop written language and relied only on oral transmission of knowledge have been lost or can be reconstructed only by examining current “Primitive” practices. The routes of maternity care in the Western world are also ancient; the first recorded obstetric practices are found in Egyptian records dating back to 1500 B.C Practices such as vaginal examination and the use of birth aids are referred to in writings from the Greek and Roman empires, but 1 much of their information was lost in the dark ages. Advance in medicine made during the renaissance in Europe led to the modern “Scientific” age of obstetric care. Significant discoveries and invitations by Physicians in the 16 and 17th th centuries let the stage for scientific progress. 1.2 Magnitude of Maternal Health problem in Ethiopia Maternal mortality is one of the health indicator which shows the burden of disease and death; the greatest differential between developing and developed countries. More than 150 million women become pregnant in developing countries each year and an estimated 500, 000 of them die from pregnancy related causes. Other than their health problems most women in the developing countries lack access to modern health care services and increase the magnitude of death from preventable problems. Lack of access to modern health care services has great impact on increasing maternal death. Most pregnant women do not receive antenatal care; deliver with out the assistance of trained health workers etc. The life time risk of death as a result of pregnancy or child birth is estimated at one in twenty – three for women in Africa, compared to about one in 10,000 for women in Northern Europe 75% of Maternal morbidity and mortality related to pregnancy and child birth are due to five obstetric causes. 2 Hemorrhage, sepsis (infection), toxemia obstructed labor and complications from unsafe abortion. As Ethiopia is one of the developing countries with inadequate facilities and resources having highest maternal morbidity and mortality and poor coverage of maternal is estimated to be 1000/100,000 live birth. In Ethiopia women get antenatal care are around 905, 283 and overall the national antenatal care coverage in 34.7%. Among this pregnant woman only 259,083 are attended institutional delivery making the national coverage of 10%. Unwanted and unplanned pregnancies are important determinants of maternal in health. So from 1,769,171 of women child bearing age expected to use family planning 635,105 of them use family planning and the national coverage is only 18.7%.Abortion, HIV/AIDS and STIs are also another conditions that increase maternal morbidity and mortality. These all indicated that the maternal health care is too less in Ethiopia. 1.3 Importance of Obstetrics and Gynecology nursing Ensuring healthy antenatal period followed by a safe normal delivery with a healthy child and an uneventful post partum period. Prompt and efficient cares during obstetrical 3 emergencies also prevent so many of complications. The importance of the obstetric and gynecology nursing are: - Equip the nurse with the knowledge and understanding of the Anatomy and physiology of reproductive organ be able to apply it in practice - With a good knowledge of obstetric drugs including, the effect of diseases their Complications and know how to deal with them. - Develop skills in carrying out antenatal care and be able to detect any abnormality, recognize and prevent complications. - Select high risk cases for hospital delivery and provide health education. - Develop skills in supporting the women in labour, maintain proper records, and deliver her safely and resuscitate her new born when necessary. - Be able to care for the mother and baby during the post partum period and be able to identify abnormalities and help them to get-over it. - Be able to educate them on care of the baby, immunization, family guidance and family spacing. - Be ready to offer advice to support the mother and understand her problems as a mature, kind and helpful nurse. 4  CHAPTER TWO ANATOMY OF FEMALE PELVIS AND THE FETAL SKULL Learning Objectives At the end of this chapter the students will be able to: - Describe anatomy of the Female pelvis and Female external genitalia - Mention parts of fetal skull with its features. - Differntiat organs contained in the pelivic cavity. - Describe characteristic of menustral cycle and its disorder - List anatomy of female breast - Define puberity and its featuers. 2.1 Female Pelvic Bones The female pelvis is structurally adapted for child beaing and delivery. There are four pelvic bones - innominate or hip bones - Sacrum - Coccyx 5 Figure 1. Structure of the pelvis (Adele Pilliter, 1995) A. Innominate bones Each innominate bone is composed of three parts. 1. The ilium the large flared out part 2. The ischium the thick lower part. It has a large prominance known as the ischial tuberosity on which the body rests when sitting. Behind and a little above the tuberosity is an inward projection, the ischial spine. In labour the station of the fetal head is estimated in relation to ischial spines. 3. The pubis - The pubic bone forms the anterior part. The space enclosed by the body of the pubic bone the rami and the ischium is called the obturator foramen. B. The sacrum - awedge shaped bone consisting of five fused vertebrae. The upper border of the first sacral vertebra is known as the sacral promontary. The anterior surface of the 6 sacrum is concave and is referred to as the hallow of the sacrum. C. The coccyx: - is avestigial tail. It consists of four fused vertebrae forming a small triangular bone. Pelvic Joints There are four pelvic joints - One Symphysis pubis - Two Sacro illiac joint - One Sacro coccygeal joint - The symphysis pubis is a cartilgeous joint formed by junction of the two pubic bones along the midline. ƒ The sacro iliac joints are the strongest joints in the body. - The sacro coccygeal joint is formed where the base of the coccyx articulates with the tip of the sacrum. In non pregnant state there is very little movement in these joints but during pregnancy endocrine activity causes the ligaments to soften which allows the joints to give & provide more room for the fetal head as it passes through the pelvis. Pelvic ligaments Each of the pelvic joints is held together by ligaments - Interpubic ligaments at the symphysis pubis (1) 7 - Sacro iliac ligaments (2) - Sacro coccygeal ligaments (1) - Sacro tuberous ligament (2) - Sacro spinous ligament (2) Figure 2: Pelvic Ligaments on posterior view (Derexllewllyn, 1990) The True Pelvis The true pelvis is the bony canal through which the fetus must pass during birth. It has a brim, mid cavity and an out let. The pelvic brim is rounded except where the sacral promontory projects into it. The pelvic cavity is extends from the brim above to the out let below. The pelvic out let are two and described as the anatomical and the obstetrical. The anatomical out let is formed by the lower borders of each of the bones together with the sacrotuberous ligament. It is 8 diamond in shape. The obstretrical out let is of the space between the narrow pelvic strait and the anatomical outlet. Important land marks of female pelvis A. Pelvic brim - Sacral promentary posteriorly - Superior ramus of the pubic bone antro lateral - Upper inner boarder of the body of the pubic bone - Upper inner boarder of the symphysis pubis anteriorly B. Mid pelvis - Ischial spine C. Out let - Inferior pubic rami antero laterally - Sacrotuberous ligament postro laterally - Ischial tuberosity laterally - Inferior border of symphsis pubis anteriorly. - Tip of coccyx Important diameters of the pelvis Inlet Diagonal conjugate - a line from the sacral promontory toward the lower boarder of the symphysis pubis and measures 12.5 centimeter. It is measured by pelvic examination. 9 Mid cavity Interspinous diameter-a line between the two ischial spines and measures 11 centimeter. The pelvic out let - Pubic arch - Intertuberous diameter Table 1. Measurements of the pelvic canal in centimeters Anteropostrior Oblique Transverse Brim 11 12 13 Cavity 12 12 12 Out let 13 12 11 The four types of female pelvis 1. The gynacoid pelvis (female type) 2. The android pelvis (male type) 3. The anthropoid pelvis 4 The platypelloid pelvis 10 Table 2.Features of the four types of female pelvis Features Gaynacoid Android Antropaid Platypelloid Brim Round Heart shaped Long oval Kidney shaped Fore- pelvis Genrous Narrow narrowed Wide Side walls Straight convergent divergent Divergent isctial spines Blunt Prominent blunt Blunt sciatic notch Rounded Narrow wide Wide o o o o sub- pubic angle 90 < 90 >90 >90 Incidence 50% 20% 25% 5% Figure 3 Types of female pelvis (Alan H. Decherney l. pemoll, 1994) 11 Pelvic floor Or Pelvic diaphragm The pelvic floor or diaphragm is amuscular floor that demarcates the pelvic cavity and perineum. Its strength is inforced by its associated condesed pelvic fascia, therefore, it is important for pelvic organs protection. Functions: - It supports the weight of the abdominal and pelvic organs The muscles are responssible for the voluntary control of micturation, defication and play an important part in sexual intercourse. It infulences the passive movement of the fetus through the birth canal and relaxes to allow its exit from the pelvis. The main important muscels of pelivic floor are: Levater ani muscles are arising from the lateral pelveic wall and decussate in the midline between the urethra, the Vagina and rectum. It contains pubococcygeous muscle, ileo coccygeus and pubo rectalis. Pubococygeous muscle is constructed in such away that it can expand enough for child bith and contract the pelvis supported 12 The Fetal Skull The fetal head is the most difficult part to deliver whether it comes first or last. It is large in comparison with the ture pelvis and some adptation between skull and pelvis must take place during labour.An understanding of the landmarks and measurements of the fetal skull enables to recognize normal presentation and positions and to facilitate delivery with the least possible trauma to mother and child. The skull is divided into the vault, the base and the face. The vault is the large dome shaped part above the imaginary line drowns 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. A. The occipital bone lies at the back of the head and forms the region of the occiput. B. The two parietal bones lie on either side of the skull. C. The two frontal bones from the forehead or sinciput. 13 Sutures and fontanelles Sutures are cranial joints and are formed where two bones adjoin. Where two or more sutures meet, a fontanell is formed. Types of sutures A. The lambdoidal suture is shped like the Greek letter lambda and separates the occipital bone from the two parital bones. B. The sagital suture lies between the parital bones C. The coronal sutrue separetes the frontal bones from the parital bones, passing from one temple to the other. D. The frontal suture runs between the two haves of the frontal bone Types of fontanelle A. The posterior fontanelle or lambda is situated at the junction of the lambdiodal and sagital sutures. It is small triangular in shape and can be recogonized vaginally. B. The anterior fontanelle or bregma is found at the junction of the sagital, coronal and frontal sutures and recognized vaginally. The sutures and fontanelles, because they consist of memberanous spaces, allow for a degree of overlapping of the skull bones during labour and delivery. 14 Regions of the Skull A. The occiput lies between the foramen magnum and the posterior fontanelle. The part below the occipital protuberance is known as the suboccipital region. B. 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. C. The sinciput or brow extends from the anterior fontanelle and the coronal suture to the orbital ridges. D. 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 knowns as the glabella. The chin termed the mentum and is an important land mark. Land Marks of the Fetal Skull - Sinciput - Occiput - Glabella - Anterior fontanelle - The vertex - Posterior fontanelle - Occuputal protuberunse - The mentum 15 Figure 4. Fetal skull (V.RUTH BENNETT. LINDA K. BROWN, 1993) Diameters of the Fetal Skull The measurement of the skulls are transverse, anteropositerior or longitudinal. - Transverse diametes. Biparietal diameter 9.5 cm between the parietal eminence. Bitemporal diameter 8.2cm between the furtherse points of the coronal suture at the temples. - Anteroposterior or longitudinal diameters. Suboccipitobregmatic 9.5 cm from below the occipital protuberance to the center of the anterior fontanelle or bregma 16. Suboccipitofrontal 10cm from below occipital protuberance to the center of the frontal suture.. Occipitofrontal 11.5 cm from the occipital protuberance to the glabella.. Mentovertical 13.5cm from the point of the chin to the highest point on the vertex sightly nearer to the posterior than to the anterior fontanelle.. Submentovertical 11.5 cm from the point where the chin joins the neck to the highest point on the vertex.. Submentobregmatic 9.5cm from the point where the chin joins the neck to the center of the bregma. Figure 5. Anteroposterior or longitudinal Diameters of Fetal Skull (V. RUTH BENNETT. LINDA K. BROWN, 1993) 17 2.2. Anatomy of the female external genitalia 2.2.1 The vulva This term applies to the external female genital organs. It consists of the following structures. The mons pubis or mons veneris - is a pad of fat lying over the Symphysis pubis. It is covered with pubic hair from the time of puberty. The labia majora (greater lips) The labia minora (lesser lips) anteriorly encloses clitoris and posteriorlny forms furchette. The clitoris is a small rounded organ of erectile tissue at the forwarded junction of the labia minora. The vestibule is the flattend, smooth surface in side the labia The vaginal orifice Bartholin's glands (volvovaginal glands) are located just lateral to the vaginal opening on the sides. The furchette is ridge of tissue formed by the posterior joining of the two labia minora and the labia majora. The vulval blood supply comes mainly from the pudendal arteries and apportion of the inferior rectus aretery. The blood drains through the pundendal veins. Lymphatic drainage - inpuinal glands Nerve supply - branch of pudendal nerve 18  Figure 6. Female external genitalia (Adele pillitteri,1995) The vagina Position – is a canal running from the vestibule to the cervix. Relations:- A knowledge of the relation of the vagina is essential for the accurate examination of the pregnant woman and her safe delivery.It is found infront of the rectum and behind the bladder and urthrea. Structure - the posterior wall is longer than the antrerior 19 - the vaginal walls are pink in appearance and thrown into small folds known as rugae. These allow the vaginal wall to stretch during intercourse and child birth. Layers - squamins 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. Contents - the vaginal fluid is strongly acidic (PH 4.5) Blood supply - from braches of the internal iliac artery and drains through corresponding Veins. Lymphatic drainage - via the inguinal, the internal iliac and the sacral glands drains the lymphatic fluid. 2.3. Contents of the pelvis cavity 2.3.1 The bladder The bladder is the urinary reservoir which stores the urine until it is convenient for it to be voided. 20 Position:- In the non-pregnant female, the bladder lies immediately behind the symphysis pubis and infront of the uterus and vagina. The bladder when empty is of simillar size to the uterus but when full of urine it becomes, much larger. Its capacity is around 600ml but it is capable of holding more, particularly under the influence of pregnancy hormones. 2.3.2 The Ureters The tubes which convey the urine from the kidneys to the bladder are the ureters. Function – They assist the passage of the urine by the muscular peristaltic action of their wall. The upper end is funnel shaped and merges in to the pelvis of the kidney where the urine is received from the renal tubules. 2.3.3 Urethra The female urethra is about 4cm long and courses downward and anterior to the bladder neck. It terminates in the vestibule of the vagina between the labia minora and about 2.5cm posterior to the glans of the clitoris. 21 2.3.4 The uterus The uterus is a hallow, muscular, pear shaped organ situated in the true pelvis. Function:- exists to shelter the fetus during pregnancy. If prepares for this possibility each month and following pregnancy it expels the uterine contents. Position - It leans forward, which is known as anteversion, it bends forwards on itself, which is known as anteflexion Relation- anteriorly the bladder and posteriorly rectum Inferior - Below the uterus is the vagina Superior - above the uterus lie the intestine Lateral-on both sides of the walls are the broad ligaments, the fallopian tubes and the ovaries. Supports - supported by the pelvic floor and maintained in position by several ligaments. Ligaments are; - Pertonial ligament ƒ Broad ligament - Genito inguinal ligament 22  ƒ Round ligament - Ligaments formed by pelvic fascia ƒ Transverse cervical ligament ƒ Utero sacral ligament Structures - the non pregnant uterus 7.5 cm long, 5cm wide and 2.5cm in depth, each wall being 1.25 cm thick. The Cervix forms the lower third of the uterus. Parts of the uterus - The body or corpus - the upper 2/3 of the uterus and is the greater part. - The fundus - the domed upper wall between the insertions of the fallopian tubes. - The cornua - are the upper outer angle of the uterus where the fallopian tubes join. - The cavity - is a potential space between the anterior and posterior walls. - The isthmus - is a narrow area between the cavity and the cervix, which is 7mmlong. It enlarges during pregnancy to form the lower uterine segment. - The cervix or neck - protrudes in to the vagina. - The internal os (mouth) is the narrow opening between the isthmus and the cervix - The external os is a small round opening at the lower end of the cervix. 23 Layers:- The uterus has three layers, of which the middle muscle layer is by far the thickest. The endometrium: - forms a lining of ciliated epithelium (mucous memberane) on a base of connective tissue or stroma. It is constantly changing in thickness through out the menustral cycle. The myomatrium or muscle coat: - is thick in the upper part of the uterus and is sparser in the isthmus and cervix. It has three parts: Outer longitudinal, middle oblique and inner circular. The perimetrium is a double serous memberane, an extension of the peritoneum, which is dragged over the uterus. 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 corresponding veins. Nerve supply – from the autonomic nervous system, sympathetic and para smpathetic via pelvic plexus. 2.3.5 Fallopian tube or uterine tube Function-Propels the ovum towards the uterus ƒ Receives the spermatozoa as they travel up wards 24 ƒ provides a site for fertilization ƒ It supplies the fertilized ovum with nutrition during its continued journey to the uterus Position - extend laterally from the cornea of the uterus towards the side walls of the pelvis Supports - are held in place by their attachment to the uterus. Structure - Each tube is 10cm long. It has four portions - The interstitial portion is 1.25cm long and lies with in the wall of the uterus. Its lumen is 1 mm wide. - The isthmus is another narrow part which extends for 2.5cm from the uterus - The ampoule is the wider portion where fertilization usually occurs. It is 5 cm long. - The infundibulum is the funnel - shaped fingered end which is composed of many process known as fimbriae. One fimbria is elongated to form the ovarian fimbria which is attached to the ovary. 2.3.6 The ovaries Function: - produce ova and the hormones estrogen and progesterone Position: - they are attached to the back of the broad ligamentnear the fimbriated end of the fallopian tube. 25 Blood supply: - Supplied by the ovarian arteries and drains by the ovarian veins.The right ovarian vein join the inferior venecava, but the left returns its blood to the left renal vein. Lymphatic drainage is to the lumbar glands Nerve supply is from the ovarian plexus. Figure 7. Anterior view of female reproductive organs (Adele Pillitteri, 1995) 2.4 Physiology of the Femel Reproductive Organs 2.4.1 Puberty - the age of sexual maturation ThIs is the stage of life at which secondary sexual characterstics appear. Girls begin dramatic development and 26 maturation of reproductive organs at approximately age 12 to 13 years, Although the mechanism that initiates this dramatic change is not well understood, the hypothalamus under the direction of the centeral nerveous system may initiate or regulate mechanism set to “turn on” gonadal functioning at this age. There is a wide variation in the times that adolescents move through developmental stages; however the sequential order is fairly constant. In girls pubertal changes typically occur in the order of: - Marked physical growth - Increase in the transvers diameter of the pelvis - Breast development - Growth of pubic and axillary hair - Vaginal secretion /Menarche 2.4.2 The menstrual cycle A menstrual cycle (also termed a female reproductive cycle) can be defined as periodic uterine bleeding in response to cyclic hormonal changes or a serioes of changes that occur on the ovary, uterus, and cervix in response to hormonal change. The average age at which menarche (the first menustral period) occurs at the average age of 12.8 years. This may occur as early as age 9 or as late as age 17 years. 27 The purpose of a menstrual cycle is to bring an ovum to maturity and renew a uterine tissue bed that will be responsive to its growth should it be fertilized. The average age of onset of menstrual cycles is 21 to 35 days.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. Four body structures that are involved in the normal physiology of the menstrual cycle are: - The hypothalamus - The pituitary gland - The ovaries and - The uterus. - Cervix For a menstrual cycle to be complete, all four structures must contribute their part, in activity from any part will result in an incomplete or ineffective cycle. Some women have symptoms of anxiety, fatigue, abdominal bloating, headache, appetite disturbance, irritability and depression in pre-manustural period. Some women may experience abdominal pain during ovulation and the release of accompanying prostaglandins. Some even notice irritation when a drop or two of follicular fiuid or blood spills in to the abdominal cavity. 28 Thispain, called mitlelschmerz may range from a few sharp cramps to several hours of discomfort. It is typically felt on either side of the abdomen (near an ovary) and may be accompanied by scant vaginal spotting.It is known as Mittelschmerz. 2.4.3 Phases of menstrual cycle Proliterative phase: - Immediately following a menstrual flow (occurring the first 4 or 5 days of a cycle), the endometrium, or lining of the uterus is very thin, only approximately one cell layer in depth. As the ovary begins to form estrogen (in the funicular fluid, under the direction of the pituitary FSH), the endometrium begins to proliferate, or grow very rapidly, increasing in thickness approximately eight fold. This increase continues for the first half of the menstrual cycle (from approximately day 5 to day 14). This half of a menstrual cycle is termed interchangeably as the proliferative, estrogenic, follicular, or postmenstrual phase. Secratory phase- What occurs in the next half of in a menstrual cycle depends on whether the released ovum meets and is fertilized by spermatozoa. If fertilization does not occur, the corpus luteum in the ovary begins to regress after 8 to 10 days. As it regresses, the production of progesterone and oestrogen decreases. With the withdrawal of progesterone stimulation, the endometrium 29 of the uterus begins to degenerate (at approximately day 24 or day 25 of the cycle). The capillaries rupture, with minute hemorrhage, the endometrium sloughs off, and menustration starts. Figure 8.The menustral cycle (Derexllewllyn, Jones,Vol.1. 1990) 30 2.5. The Breast Anatomy The female breasts The female breasts, also known as the mammary glands, are accessory orgns of reproduction. Situation One breast is situated on each side of the sternum and extends between the levels of the second and sixth rib. The breasts lie in the superficial fascia of the chest wall over the pectoralis major muscle, and are stabilized by suspensory ligaments. Shape Each breast is a hemispherical swelling and has a tail of tissue extending towards the axilla (the axillary tail of spence). Size The size varies with each individual and with the stage of development as well as with age. It is not uncommon for one breast to be little or larger than the other. Gross structure The axillary tail is the breast tissue extending towards the axilla. The areoa is a circular area of loose, pigmented skin about 2.5 cm in diameter the centre of each breast. It is a pale pink colour in a fair- skinned woman, darker in a brunett, the colour deepening with pregnancy. Within the area of the areola lie 31 approximately 20 sebaceous glands. In pregnancy these enlarge and are known as montgeomery’s tubercles. The nipple lies in the centre of the areola at the level of the fourth rib. Aprotuberance about 6mm in length, composed of pigmented erectile tissue.The surface of the nipple is perforarted by small orifices which are the openings of the lactiferous ducts. It is covered with epithelium. Microscopic structure The breast is composed largely of glandular tissue, but also of some fatty tissue, and is covered with skin. This glandular tissue is divided into about 18 lobes which are completely separated by bands of fibrous tissue. The internal structure is said to be resemble as the segments of a halved grape fruit or orgnge. Each lobe is a self-contained working unit and is composed of the following structures Alveoli: Containing the milk- secreting cells. Each alveolus is lined by millk-secreting cells, the acini, which extract from the mammary blood supply the factors essential for milk formation. Around each alveolus lie myoepithelial cells, sometimes called ‘basket’ or ‘spider’s cells. When these cells are stimulated by oxytocin they contract releasing milk into the lactifierous duct. Lactifierous tubules: small ducts which connect the alveoli. Lactifierous duct: a central duct into which the tubules run. 32 Amplulla: the widened-out portion of the duct where milk is stored. The ampullae lie under the areola. Blood supply Blood is supplied to the breast by the internal mammary, the external mammary and the upper intercostals arteries.Venous drainage is through corresponding vessles into the internal mammary and axillary veins. Lymphatic drainage This is largely into the axillary glands, with some dranage in to the portal fissure of the liver and mediastinal glands. The lymphatic vessels of each breast communicate with one another. Nerve supply The function of the breast is largely controlled by hormone activity but the skin is supplied by breanches of the thoracic nerves. There is also some sympathetic nerve supply, especially around the areola and nipple. 33 Figure 9. Anatomy of Female breast (Sylvia Verrals,1993) 34 Review Questions 1. List different menastrial disorder and responsablitiies of the nurse in their management: 2. List the main femal gentail orgns that are important in the process of reproduction. 3. Mention the main pelvic land mark that are important in obstatrics during proegnancy and labour process. 4. What are the obstratrical importancy of fontanalles and sutures in the process of labour mangment. 35  CHAPTER THREE NORMAL PREGNANCY At the end of this chapter the students will be able to - Describe the physiology of pregnancy - list the methods of diagnosis of pregnancy - Describe stage of embryological development - Describe placental abnormalities and its consequencies - Enumerate the functions of placenta - Describe placental abnormalities and its consequencies - Identify major care given for pregnant women during pregnancy 3.1 Conception Other terms used to describe this phenomenon are fertilization, impregnation or fecundation. Definition -Fertilization is the union of the ovum and a sepermatozoa. Fertilization must occur fairly quickly after release of the ovum because it usually occurs in the outer third of a fallopian tube, 36 the ampullar portion. The functional life span of aspermatozoa is about 48 hours / may be as long as 72 hours or longer. Therefore, sexual coitus during this time may result in fertilization /pregnancy. 3.2 Development of the Fertilized Ovum After fertilization the ova passes through the fallopian tube and reaches the uterus 3 or 4 days later. Division takes place and the fertilized ovum divides into two cells, and then into four, then eight, and sixteen and soon until a cluster of cells is formed known as the morula. These divisions occur quite slowly about once every 12 hours. Next, fluid filled the cavity or blastocele appears in the morula which now becomes known as the blastocyst. Around the out side of the blastocyst there is a single layer of cell known as the trophoblast while the remaining cells are clumped together at one end forming the inner cell mass. The trophoblast will form the placenta and chorion, while the inner cell becomes the fetus, umbilical cord and the amnion. Embedding of the blastocyst is normally completed by the 11th day after ovulation and the endometrium closes over it completely. 37 The Decidua This is the name given to the endometrium during pregnancy. Three layers are found in decidua. - The basal layer lies immediately above the myometrium. - The functional layer consists of tortus glands which are rich in secretions. - The compact layer forms the surface of the decidua and is composed of closely packed stroma cells and the neck of the glands The Trophoblast Those trophoblastic cells differentiate into layers, the outer syncitiotrophoblast (syncitium), and inner cytotrophoblast and below this, a layer of mesoderm or primitive mesenchyme. The syncitiotrophoblast is composed of nucleated protoplasm which is capable of breaking down tissue as in the process of embedding. The cytotrophoblast is a well defined single layer of cells which produces a hormone known as human chorinic gonadotrophin (HCG). 38  Blastocyst Trophoblast Inner cell mass Placenta + Chorion Fetus + Amnion +Umblical cord The inner cell mass While the trophroblast is developing into the placenta, which will nourish the fetus, the inner cell mass is forming the fetus itself. The cells differentiate into three layers, each of which will form particular parts of the fetus. - The ectoderm mainly forms the skin and nervous system - The mesoderm forms bones and muscles and also the heart and blood vessles, including those which are in placenta. - The endoderm forms mucous memberanes and glands. The three layers together are known as the embryonic plate. The amniotic cavity- lies on the side of the ectoderm; the yolk sac lies on the side of the endoderm and provides 39 nourishment for the embryo until the trophoblast is defficiaently developed to take over. 3.3. Functions of Placenta Respiration - As pulmonary exchange of gases does not take place in the uterus the fetus must obtain oxygen and excrete carbon dioxide through the placenta Nutrition - Food for the fetus derives from the mother’s diet and has already been broken down into forms by the time reachs the placenta site. The placenta is able to select those substances required by the fetus, even depleting the mother’s own supply in some instances. Storage - The placent metabolises glucose and can also stores it in the form of glycogen and reconverts it to glucose as required. The placenta store iron and the fat soluble vitamins. Excretion -The main substance excerted from the fetus is carbondioxide; bilrubin will also be excreted as red blood cells are released relatively frequently. Protection - It provides a limited barrier to infection with the exception of the treponeona of syphilis and, few bacteria can 40 penetrate. Viruses, however, can cross freely and may cause congenital abnormalities as in the case the rubella virus and HIV virus. Endocrine - Human chorinnic gondotroghin (HCG) is produced by the cytotrophoblastic layer of the chorinonic villi. ƒ 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. ƒ Human placental lactogen (HpL) has a role in glucose metabolism in pregnancy. ƒ Progestrone 3.4. The Fetal Circulation At the birth there is a dramatic alteration in this situation and almost instaneous change must occur. Besides this all, the postnatal structures must be in place and ready to take over. There are several temporary structures inaddition to the placenta itself and the umblical cord and these enable the fetal circulation to take place while allowing for the changes at birth. The Umbilical vein Leads from the umblical cord to the underside of the liver and carries blood rich in oxygen and 41 nutrients. It has a branch which joins the portal vein and supplies the liver. The ductus vensous (from a vein to a vein) connects the umblica vein to the inferior venacava. At this point the blood mixes with deoxygenated blood returning from the lower parts of the body. Thus the blood throughout the body is at best partially oxygenated. The foramen ovale (oval opening) is a temporary opening between the atria which allows the majority of blood entering from the inferior vencava to pass across into the left atrium. The reason for this diversion is that the blood does not need to pass through the lungs since it is already oxygenated. The ductus arteriosus (from an artery to an artery) leads from the bifuraction of the pulmonary artery to the descending aorta, entering it just beyond the point where the subclavian and carotid arteries leave. The hypogastric arteries branch off from the internal iliac arteries and become umbilical arteries when they enter the umblical cord. They return blood to the placenta. This is the only vessel inthe fetus which carries unmixed blood. 42 Figure 10. The fetal circulation (V.Ruth Bennett. Linda k. Brown,1993) Adaptation to extra Uterine life At birth the baby takes a breath and blood is drawn to the lungs through the pulmonary arteries. It is then collected and returned to the left atrium via the pulmonary veins resulting in 43 a sudden inflow of blood. 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 a flop over the formaen ovale which separated the two sides of the heart and stops the blood flowing from right to left. The cessation of the placenta circulation results in the collapse of the umbilical vein, the ductus venosus and the hypogastric arteries. These vesels after collapse change to the following structure. The umbilical vein → the ligamentaum teres The ductus venosus → the ligamentum venosum The ductus arteriosus → the ligamentum arteriousm The foramen ovale → the Fossa ovalis The hypogastric arteries → the obliterated hypogastic arteries The Placental Circulation The placenta is completley formed and functioning from 10weeks after fertilization. Between 12 and 20 weeks gestation the placenta weighs more than the fetus.Fetal blood, low in oxygen, is pumped by the fetal heart towards the placenta along the umblical arteries. Having absorbed oxygen the blood is returned to the fetus via the umblical vein. 44 Appearance of the Placenta at Term The placenta measures about 20 cm in diameter and 2.5cm thick from its center. It weighs approximately one sixth of the baby’s weight at term. It has two surfaces. 1. The maternal surface maternal blood gives this surface a dark red colour and part of the basal decidua will have beenseparated with it. The surface is arranged in about 20 lobes which are separated by sulci 2. The fetal surface. The amnion covering the fetal surface of the placenta gives it a whitish, shiny appearance. Branches of the umbilical veins and arteries are visible and spreading out from the insertion of the umbilical cord which is normally in the center. The aminotic sac consists of a double memberane. Chorion – Outer layer adher to the uterine wall. Amnion.-The inner layer of the aminotic sac containing an aminotic fluid and cover the fetal surface of the placenta and are what give the placenta its typical shiny appearance. Protects the fetus from any infection and the amniontic fluid is a clear, pale straw in colour.It secreted by the amnion and fetal urine also contributes to the volume from the 10th weeks of the gestation on wards.The total amount of amniotic fluid is 45 about 1 litter and diminished to 800ml at 38 weeks of gestation (term). If the total amount exceeds 1500 ml, the condition is known as polyhdramnous and if less than 300ml it is known as oligohydraminous. It constitutes 99% water and the remaining 1% is dissolved organic maters including substances and waste products. Function - Allows for free movement of the fetus - Protects the fetus from injury - Maintains aconstant temperature for the fetus - During labour it protects the placenta and umblical cord from the pressure of uterine contraction - Aids effeciement of the cervix and dilation of the uterineos 3.5. Anatomical Varations of the Placenta and the Cord Succenturiate lobe of placneta: A small extra lobe is present, separate from the main placenta and joined to it by blood vessles which ran through the memebrane to reach it. The danger is that this small lobe may be retained in utro after delivery, and if it is not removed it may lead to haemorrhage and infection. 46 Identification On inspection, the placenta will appear torn at the edge, or torn blood vessles may extend beyond the edge of the placenta. Circumvallate placenta In this situation an opaque ring is seen on the fetal surface. It is formed by a doubling back of the chorion and amnion. Danger may result in the memberanes leaving the placenta nearer the center instead of at the adge as usually. Battledore inseration of the cord The cord in this case is attached at the very edge of the placenta in the manner of the table tennis bat. Danger Likely it is detached up on applying traction during active management of the third stage of labour. Velamentous insertion of the cord It is inserted into the memberans some distance from the edge of the placenta. The umblical vessles run through the memberanous frorm the cord to the placneta. Danger The vessles may tear with cervical dilatation and would result in sudden blood loss. Bipartite Placenta Two complete and separate lobes are present, each with a cord leaving it. The bipartite cord joins a short distance from the two parts of the placenta. Danger-The extra lobe may retained during delivery. 47 A tripartite Placenta is similar but with three distinct lobes. Succenturiate lobe of placneta Battledore inseration of the cord Circumvallate placenta Velamentous insertion of the cord Bipartite Placenta Figure 11.Anatomical variations of placenta and cord insertion (Adele pillitteri,1995) 48 Placenta infarction Placental infarction occurs when the blood supply to an area of the placenta is blocked and tissue necrosis results. It appears most commonly on the maternal surfaces and most often associated with vascular disease of the utero- placental unit secondary to maternal hypertension. As the infarct at area becomes necrotic, fetal circulation is reduced because blood flow through the placenta will decrease. However, if the circulation through the rest of the organ is sufficient, a fetus may survive when as much as 20% to 30% of the placenta is infracted. Placental infractions can be treated. Placental tumors (Haemongiomata of the Placenta) These tumors are relatively common, being found in approximately 1 percent of all placentas. Most tumors are small and without clinical significance but a few are large and associated with hydraminious, antepartum hemorrhage and premature labour. The Umblical Cord The umblical cord or funis extends from the fetus to the placenta and transmits the umblical blood vessles, two arteries and one vein. These are enclosed and protected by Wharton’s jelly, (a gelatious substance formed from 49 mesoderm). The whole cord is covered in a layer of amnion continuous with that covering the placenta. The length of the average cord is about 50cm. A cord is considered to be short when it measures less than 40cm. 3.6 Physiological Changes of Pregnancy There are physiological biochemical and anatomical changes that occur during pregnancy. These changes may be systemic or local. Most of the systemic changes return to pre pregnancy status 6 weeks after delivery. These changes occur during pregnancy to maintain a healthy environment for the fetus with out compromising the mother’s health. And prepare for the process of delivery and care of the newborn. Understanding of the normal changes helps to understand coincidental disease processes. 3.6.1 Gastro Intestinal Tract (GIT) Nubribonal requirements including for vitamina and minerals are increased so usually mothr’s appetite increase Pregnant women tend to rest more often conservig energy and there by enhancing fetal nutrition 50 Oarl cavity feels salivation Gums- hypertkophic and hyperemic easily bleed (20 to increased systemic estrogen) Gastrointestinal mobility May be reduced due to increased progesterone (w/c decreased the hormone motline stimulate smooth msceles in GIt) hence gastric emptying is slowed and similarly in other part of GIT constipation (due to increased water absorption) Stomach Production of gastrin increase increased arstric volume and decreases PH, mucous production increased PUD usually improve or disappear becuase of these changes during pregnancy,However during the pregnancy because of the enlarging uterus heart burn is common due to gastric refulex Enlarging uterus slower emptying time, increase intragstric pressure increase acidty and increased gasric refulex The anatomical postion of small and large intestine as well as appendix will shift because of the enlarging uterus 3.6.2 Galbladder Progestrone decresed motility → decreased emptiy time of bile →stasis →stone formation and infection. 51 3.6.3 Liver No morphological changes but functional changes Decreased plasma protein (albumen) an globline (synthesized by liver) increases serum alkaline phosphatese activity. 3.6.4 Urinary systems - Each kidney increase in length and weight - The renal pelvis and ureter dilate and lengthen Thus there is an increase urinary stasis increase risk of infection and stone formation Renal function ƒ Chage occur due to increased maternal and placental hormones ƒ (ACTH, ADH, cortisole, etc.) and increase in plamsma volume ƒ Glomerular Filtration Rate increase by 50% (begins early and last up to term) ƒ Renal blood flow rate increase by 20-25% (early to midtrimester) after the end of 2nd trimester remain constant. ƒ Urine volume dose not increase although glomerular filitration rate increase because of reabsorption. 52 ƒ Creatinine and BUN decrease because of increased clearance ƒ rate ƒ Glycosuria is not necessarily as normal ƒ Protein uria changes little during pregnancy 3.6.5 Bladder Is displaced upward and anteriorly by enlarged uterus as a result it increases pressure leading to and urinary urgency and frequency 3.6.6 Hematological system: - Increase in blood volume – most striking change - The change occurs until term and the average increase in volume is 45-50% - The mechanism for increase the volume of blood is not well understood (aldestrone related factor during pregnancy may contribute to this effect) increase water and salt retention. - RBC increased by 33% - Iron need increases because of increase in red blood cell mass.This is why Iron suplimentation is necessary during pregnancy. - WBC total count usually increase - Platlates increase in production 53 - Clotting factors - Several factors increase- F- I, F-VIII mainly - To lesses extent, F-VII, IX, X and XII - Decrease- F- XI, F-XIII 3.6.7 Cardiovascular System Heart slightly shift in postion Enlarging Uterus → diaphrym→ displace up ward → shift of apex beat Caradiac capcity increase by 70-80ml Cardiac out put - increase a 49% during pregnancy reach may at 20-24 weeks of gestation the constant until term - During early pregnancy SV increase by 25-30 % with length enig sesthtion HR increase (bttern increase by 15 b/min than non prgnancy) co= Blood Presure Systemic blood pressure declines slightly during pregnancy There is little change in SBP but DBP decrease by 5-10 mmHg from 12-26 weeks, then incrase to non pregnant level by term. Venous pressure - No change in the upper body 54 - Increase in the lower extermities enlarged - Decrease venous return to the heart increases pressure and results in edema. 3.6.8 Plumunary system - Capillary dilatation occurs in the respiratory route (Nasopharynx, larynx, trachea, bronchi) → make breathing difficult through nose, elarged Uterus pushs the diaphragm and the lungs as well. Summary of Pulmonary changes Changes to volume Tidal volume increase by 35-50% Residual volume decreased by 20% Expiratory reserve volume decrease by 20% So increase Tidal volume and decrease Residual vloume → incrased alveolar ventilation by 65%. Functional respiratory changes include A slight incrase in respiratory rate 50% increase in minute ventilation 40% increase in minute tidal volume Progressive increase in oxygen consumption (15-20% above non pregnant level by term) 55 3.6.9 Changes in the Breast Breast increases in size with enlargement of the nipple and increased vascularity and pigmentation of areola. 3.6.10 Change in Skin Hyperpigmentaion over some part of the body Face (forehead, cheek) - cholasma Abdomen –subumbilical midline dark purplish pigmentation of linea alba- linea nigra Streach mainly - Striea gravidarum Enlarging abdomen → streach on collagen fibers of the skin and effect of ACTH 3.6.11 Change in Vagina and Uterus Vagina – increase in capacity and length secondary to the hyperthrophy of the lining epithelium and muscle layer. Incresed glycogen content in the wall secondary to the effect of estrogen Increases vascularity and change the colour to purpleFold increases by term Uterus – Upper part fundus and body change in to upper uterine segment 56 - Lower part cervix and isthmus change in to lower uterine segment - Weight increases from 60gm to l kg at term, volume 10ml to 5 litres. 3.7 Minor Disorders of Pregnancy Minor disorders are only disorders that occur during pregnancy and are not life threatening. 1. Nausea and vomiting- This presents between 4 and 12 weeks gestation. Hormonal influences are listed as the most likely causes. It is usually occurs in the morning but can occur any time during the day, aggravated by smelling of food. Management: - Reassure the mother - Small frequent meals (dry meals) - Reduce fatty and fried containing foods. - Rest 2. Heart burn: - is a burning sensation in the mid chest region. Progesterone relaxes the cardiac sphincter of the stomach and allows reflex of gastric contents into esophagus. Heart burn is most troublesome at 30-40 weeks gestation because at this stage is under pressure from the growing uterus. 57 Management: - Small and frequent meal, sleeping with more pillows than usual. - For persistence/sever case/ prescribe antacids. 3. Pica: - This is the term used when mother craves certain foods of unnatural substances such as coal, soil...etc. The cause is unknown but hormones and changes in metabolism are blamed. Management: - Seek medical advice if the substance craved is potentially harmful to the unborn baby. 4. Constipation: - Progestrone causes relaxation and decreased peristaltic activity of the gut, which is also displaced by the growing uterus. Management: - Increase the intake of water, fresh fruit, vegetables and ruphages in the diet. - Exercise is helpful especially walking 5. Backache - The hormones sometime soften the segments to such a degree that some support is needed. Management: - Advice the mother to sleep on firm bed. - Advice support mechanisms of the back. 58 6. Fainting: - In early pregnancy fainting may be due to the vasodilation occuring under the influence of progesterone before there has been a compensatory increase in blood volume. The weight of the uterine contents presses on the inferior venacava and slows the return of blood to the heart. Manageemnt: Avoid long period of standing - Sit or lie down when she feels slight dizziness - She would be wise not to lie on her back except during abdominal examination 7. Varicositis- Progesterone relaxes the smooth muscles of the veins and result in sluggish circulation. The valves of the dilated veins become insufficent and varicositis result. It occurs in legs, anus (hemorrhoids) and vulva. Management: - Exerciseing the calf muscles by rising on the toes - Elevate the leg and rest on the table - Support tighs and legs - Avoid constipation and advise adequate fluid intake. - Sanitary pad give support for vulva varicositis Most minor disorders can be advanced into a more serious complication of pregnancy. The disorders require immediate actions are as follows (Danger signals of pregnancy) 59 - Vaginal bleeding - Reduced fetal movements - Frontal or recurring headaches - Sudden swelling - Rupture of the membrane - Premature onset of contractions - Maternal anxiety for whatever reason 3.8 Diagnosis of Pregnancy Pregnancy is mainly diagnosed on the symptoms reported by the woman and signs elicited by a health care provider. Signs and symptoms of pregnancy These signs and symptoms are divided in to three classifications; presumptive, probable, and positive. Possible (presumptive) signs ƒ Early breast changes-increase in size, darkening of areola, Montgomery’s tubercles ƒ Amenorrhea-a women having regular cycle with out the use of hormonal contraceptives ƒ Morning sickness ƒ Bladder irritability like frequency of micturation ƒ Quickening -the date of the first fetal movement felt by the mother provides an indicator of pregnancy. A primigravid 60  women feels it at 18-20 weeks the multi gravida at 14-16 weeks Probable signs Presence of HCG in - blood - urine Uterine growth Braxtonhicks contractions Ballottement Positive signs Visualization of fetus by Ultrasound 6 weeksof gestation X-ray after 12 weeks of gestation Fetal heart sounds by - Ultrasound - Fetal stethoscope or fetoscope (20th to 24th weeks of gestation) Fetal movements by - Palpation - Visible 61 3.9 Antenatal Care Definition: - Antenatal care is the care given to a woman during her pregnancy. Objectives: 1. To promote and maintain good health of the mother and fetus during pregnancy 2. To ensure that the pregnancy result in healthy infant and healthy mother. 3. To detect early and treat appropriately 'high risk' conditions (Medical or Obstetrical). 4. To prepare the woman for Labour, Lactation and the subsequent care of the baby. Early antenatal care is important as soon as possible after pregnancy hasbeen confirmed (after one or two missed periods) Defintions Gravidity: Pregnancy Primigravida = a woman pregnant for the first time Multigravida = a woman who has had two or more pregnancice Parity- refers to delivery, Nullipara = a woman who has not given birth to a child birth) 62 Multipara a woman who has given birth to more than one child Grandmultipara woman who has given birth to or more children Lie: is the relationship of the long axis (spine) of the fetus to the long axis of the mother’s uterus, and the normal lie is longitudinal Abnormal are transverse, oblique and variable. Attitude: is the relationship of the fetal parts to one another, and the normal attitude is flexion, abnormals are extension and deflection Presenting part: is the part of the fetus felt at the lower pole of the uterus and felt on abdominal examination and on vaginal examintion. Presentation: is the part of the fetus in the lower pole of the uterus and the normal presentation is vertex, abnormal are breech, face, brow and shoulder. Position: is the relationship of the denominator to the six areas of the mother’s pelvis, normal position is anterior or lateral abnormal is Malposition is Occipital posterior position. Crowned: When the Bi-parietals pass the ischial spines and the head no longer recedes between contractions. 63 Denominator: The part of the fetus which determines the position. (Vertex- occipute, breach -sacrum. Face- mentum). Engaged: when the Bi-parietal diameters of the fetal head passes thruogh the pelvic brim. 3.9.1. History Taking History taking:- Is a means of assessing the health of the woman to find out any condition which may affect child bearing. 1. Social Histiory Name, age, address, occupation; Age less than 18 years or greater than 35 years are considerd as high risk mothers. 2. Family History To know the genetic predisposition to certain diseases 3. Medical History Former illnesses may have damage certain structures or organs which could give rise to complications during pregnancy and labour. 4. Surgical History:- - Operations on the genital tract. - Any abdominal operations 64 The Obstetric History 1. Past Obstetrical History. Record of previous pregnancies and labour Was labour premature or postmature, spontaneous or induced, history of instrumental deliveries, previous obstetric complications and previous babies? 2. History of the Present Pregnancy Ask the last normal menstrual period and then calculate the gestational age of the pregnancy and expected date of delivery. 3.9.2 Examination of the Pregnant Woman at First Visit Objective: To diagnose pregnancy To identify high risk pregnancy To give advice for pregnant mother General Appearance As she walks in, observe any deformity, stunted growth, limp etc. does she look well or pale and tired? 65 Clinical Observation Height; - 150 cm or less needs special care. Weight:- The average weight gain during pregnancy is about 12-14 kg in the first trimester a woman should gain o.4 kg per month and in the second and third trimester she should gain 0.4 kg per week. It is Concedred as excessive if it is more than 3 kg a month during the second and third trimester; it is lessthan normal if it is less than 1 kg per month during the second and third trimester. Women who are under weigth coming in to pregnancy should gain more weigth than the average (0.5 kg per month or week rather than 0.4 kg). And may gains lessthan average (0.3 kg). Sudden increase in weight that suggests fliud retention or a loss of weight tht suggests illness should be carefully evaluated at prenatal visits. Blood pressure: - Checked and recorded at each visit, Physical Examination:- Appearance: - The hair of a healthy woman is shining and glossy, her eyes bright and clear, Face: - Oedema, sign of anaemia Neck - Swollen glands 66 Breast Examination Asses the size, any Lumps in the breast Nipples are they inverted or flat? Teach the mother self - examination of the Breast Heart and lungs are examined as usual to exclude diseases. Abdominal Examination AIMS - To observe signs of pregnancy - To assess fetal size and growth - To assess fetal health - To diagnose the location of fetal parts. - To detect any deviation from normal. Steps for Abdominal Examination 1. Inspection 2. Palpation 3. Auscultation Inspection (5s) a) Shape:- - Note contour -is it round, oval, irregular or pendulous? - Longtudinal, ovoid in primigravida - Rround in multipara. - Broad in transuerse lie. 67 b) Size:- Should correspond with the supposed period of gestation c) Skin: - The dark line of pigmentation which is lineanigra is seen any rash? d) Strae gravidarum e) Scar - Any operation scar(c/s) On Palpation: 1. Fundal height and fundal palpation (1st Leopoled Maneuver) 1.1 Fundal Height At about 12 to 14 weeks of pregnancy, the uterus is palpated above the symphysis pubis as a firm globular sphere; it reaches the umbilicus at 20 to 22 weeks, the xyphoid process at 36 weeks, and then often returns to about 4 cm below the xyphiod due to “lightening” at 40 weeks. Method: Measure distance of fundus with points on abdomen and assessing the fundal height in finger breadth below the xiphisternum or measure by centimeter. 68  1.2 Fundal Palpation Purpose- To know lie and presentation. Method: - Use 2 hands using palms of hands palpate on either side of the fundus. Fingers held close together, palpate the upper pole of then uterus and feel that as it is hard or soft or irregular. Figure:12 Fundal palpation (Derex llewllyn- Jones,vol.1,1990) 69 2. Lateral Palpation: (2nd Leopled maneuver) Purpose-To know lie and position Method: - always facing the mother, fix the hand on the center of the abdomen, fix the right hand and palpate with left hand and vise versa. Note the regularity; the regular side is the back. Figure ; 13 Lateral palpation (Derex llewllyn Jone, vol.1, 1990) 70 3. Deep pelvic Palpation: (3rd Leopoled Maneuver) Purpose -To Know Presentation & Attitude Method: - Feel presenting part, is it hard or soft while palpatingfor the presenting part feel for eminences on back side. Figure 14: Deep pelvic palpation (Derexllewllyn-Jone, Vol.1,1990) 71 4. Pawlick's Grip: (4th Leopard Maneuver) The lower pole of the uterus is grasped with the right hand the midwife facing the women's head, feel the occiput and sinciput, note which is lower. Figure 15. Pwlick’s grip (Derexllewllyn-Jone,Vol.1,1990) 72 Auscultation: Check Fetal heart, rate and rhythm, count for one minute if regular. Method: Use Pinards stethoscope - hand should not touch it while listening, - ear must be in close from contact with stethoscope, Pelivic assessement - By x-ray of the pelvis - Clinical (assessing sign of contracted pelvis) - Head fitting Head fitting The head is the best pelvimeter METHOD 1: Head fitting, sitting patient, Method Let her lie on a couch, place hand on the Symphysis pubes and get the woman to sit up by her own effort. The effort should force the head in to the pelvis. METHOD 2 : Left hand grip method Grasp the fetal head with left hand and push it down wards and backwards if a sense of give is felt the head has entered and there is no over and no cephalo pelvic disproportion. Genito-Urinary System - Frequency of micturation - Check for abnormal discharge 73 Circulatory System Varicosities: - Varicose veins may occur in the legs, anus (hemorrhoids) and vulva. Vulval varicosities are rare and very painful. The Vulva - Vulval warts - Purulent irritating discharge The Lower Limbs Examine for bones alignment and deformities. Check pitting oedema in the lower limbs by applying fingertip pressure for 10 seconds over the tibial bone. 3.9.3 Laboratory test Urine:- For Protein and glucose Blood Tests:-V.D.R.L. - Rhesus and blood grouping. - Hemoglobin 3.9.4 Points to Be Advised On ƒ The advantages of antenatal check up ƒ The use of tetanus toxoid vaccine. ƒ The danger of lifting heavy loads (exercise). 74 ƒ Rest at least 10 hrs at night and 2 in the afternoon, clothing shuold be confortable ƒ Breast care ƒ Diet - Rich in Iron and protein Report the following Vaginal bleeding Reduced fetal movements Frontal or reccuring headaches Sudden swelling Rupture of the membranes Premature onset of contractions etc. Booking for Confinement Women should attend: - Monthly upto 28 weeks - Every 2 weeks up to 36 weeks - Weekly 36 weeks there after. N.B. High risk mothers eg. multiple pregnancy, suspected disproportion etc. should attend weekly. At subsequent Visits:- ƒ Blood pressure, weight (edema) ƒ Abdominal examination (all steps of abdominal examination) ƒ Hematocrit test should be repeated at 28 and 36 weeks of ƒ gestation Health Education ƒ Listening and managing any complaint 75 Review Questions 1. Mention the high risk factors that should be ruled out during ANC. 2. State at least two physiological changes in the following body system; Gastro intestinal and urinary system. 3. List the techniques for pregnancy diagnosis. Case Study W/o Marta, a 28 years old lady who is amenorrhic for the last five months came to health center for antenatal health services for the 1st time. 1. What are the basic assessments and investigations will be done for W/o Marta? 2. What are the important advices that you give for W/o Marta? 76  CHAPTER FOUR NORMAL LABOUR At the end of this chapter students will be able to: - Define labour - Describe – mechanism of labour - List the stages of labour with their features - Identify the false sign of labour - Mention managment of second stage of labour - Mention care of mother during labour - Identify types of episiotomy with its indications. Defintion- Labour is described as the process by which the fetus, placenta and memberane are expelled through the birth canal. Normal labour occurs at term and is spontaneous in onset with the fetus presenting by the vertex. The process should be completed with acceptable time with in 24 hours vaginally. With no complications arise. Cause of the Onset Of Labor Hormonal, Biochemical and mechanical charges that occur around term may trigger labour. 77 Hormonal - release of oxytocin - Altered Oestrogen progestron ratio Biochemcial - Prostaglandin Mechanical - Prssure from the presenting part - Over streched uterus Table 3 Differentiation between the true and false labour contractions False contractions True contractions Begin and remain irregular Begin irregularly but become regular and predictable Felt first abdominally and Felt first in lower back and remain confined to the sweep around to the abdomen abdomen in a wave Often disappear with Continue no matter what the ambulation women’s level of activity Do not increase in duration, Increase in duration, frequency, frequency or intensity and intensity. Do not achieve cervical Achieve cervical dilatation dilatation 78 - Labour is said to be established with regular painful uterine contraction occurs and effacement of cervix with 2 cm dilated. 4.1 Mechanism and Stages of Labour It has three stages.These stages are described as: The first stage of labour it begins with regular rhythmic contraction and is complete when the cervix is fully dilated. The second stage is begins when the cervix is fully dilated and is completed when the baby is completely born. The third stage begins with the delivery of the baby and ends with delivery of placenta. It also involves the control of bleeding. 4.1.1 Management of 1st Stage of Labour Is the care given through out the 1st stage of labour A. Adimission procedure Well coming the mother and her partner On Arrival - Greet the mother - Introduce your self - Inform relative to wait 79 B. Admission criteria - Check- show - rupture of membrane - regular uterine contraction with progressive cervical dilatation History - Information from the mother - Ask the mother on set of contraction - Rupture of membranes / passage of liquor - Show or any other bright red bleeding Physical examination - The general condition Exhausted, anemic, pain, dehydrated general edema Vital sign: Blood Pressure, Temperature, pulse, respiration Abdominal examination 1. Inspection 2. Palpation lie, presentation, attitude engagement 3. Fundal height 4. Auscultation fetal heart rate & rhythm Vaginal examination To cheek if the mother is in labour. cervical dilatation. Membrane intact or not 80 To assess progress of labour - Station, Position - presenting part; moulding, caput and station Investigations. Hematology. Hematocrit. Hemoglobine. Blood Group, Rh, cross- match. Urine analysis. Protein (Albumin). Sugare. Ketone Write on patient chart and inform relatives. Use partograph and record on it. Emotional support 1. A good nurse will give confort, relieve pain, make strength, prevent exaustion.Maintain cleanliness, asepsis & antisepsis during labour. Prevent complications, recognize early & promptly act when complication occurse unitl the arrival of the docter. 81 These principles are not confined to labour only, for the management of labour begins during the AnteNatal period, by building woman's heath gaining her confidence, promoting encourage & supervise. Detect abnormalities which may adversely affect labour. The nurse must handle child birth with sensitivity and compassion because the emotions of the woman in labour deeply influence her reaction to discomfort & pain with are a contrn butany factor in determining the amount of physical and mental exhaustion she will experience. Fear of labour Child birth and bring occasion - the husband is encouraged to stay with his wife this gives comfort with happiness to both, she needs the companionship, love with sympathy of those who are dean to her. Influence of the mid wife. The qualities of a good mid wife are sympathetic understanding, patient & kind because women in labour are sometimes irritable not only must the midwife desire to give emotional support, she must demonstrate for her compassion by words & actions. Companionship is melded - the companionship of the woman in labour needs the professional presence of the nurse. ExampleCommunication style eg. No loud talking & noise 82 Relief of pain & promotion of comfort Pain exhausts the woman physically & emotionally so it must be reviled by every obstetrically safe means. The midwife by her kindly confident bearing & professional proficiency has an assuring beneficent influence. Back rub and explanation of the labuor process is very much important in pain relieving. Fewer drugs are now being prescribed during labour. Eg. pethedine, analgesia. Drug choice - if apprehensive a tranqulezer, if tired ahyponotic, for discomfort & pain an analgesic & sedative. Diet during labour During early labour tea & digestive biscuit can scrued. Avoid dehydration. Prolonged labour can present serious problem. If dehydration present give I.V infusion 5 or 10 % Dextrose in water and also Glucose 40%. Attention to the bladder A full bladder will prevent the head from engaging, empty bladde revery 2 hours. Recordings:- 1. Half hourly- maternal pulse, contractions for length, strength and frequency, FHB 83 2. Every 1 1/2 - 2 hours check bladder 3. Every 4 hours – B/P. Temperature, abdominal examination for descent,V.E, urine test acetone, albumin Psychological methods of pain relief The personality of the mid wife is of paramount impurtancy in handing women in labour. Many midwives have by their sympathetic understanding manner unknowingly used psychological mortheds of pain relief. Cleanliness Antisepsis, Asepsis The woman must be protected by every available means from infection which may cause ill-health with loss of life. The woman is venerable to infection at this time. The Partograph PARTOGRAPH – Managerial tool for the prevention of prolonged labour:- Measuring progress of labour in relation to time. Observations charted on partograph a) The progress of labour with time - Cervical dilatation - Descent of fetal head Descent: abdominal palpation of fifths of head felt above the pelvic brim. 84 Uterine contraction - Frequency per 10 min - Duration /shown by different shading/ b) The fetal condition - Fetal heart rate - Memberanes & liquor - Moullding of the fetal skull Grading: 1) normal- space felt between the edged of parital bone in the sagital suture. 2) mild - the egde of parital bone comes very closer at the sagital suture. 3) moderate- the edge of the parital bone over lap at sagital suture but can be easly separated. 4) severe- over lap of the bones and not separable. c) The maternal condition - Pulse, B/P temperature - Drug and IV fluids - Urine /volume, protein, acetone/ - Oxytocin regime The progress of labour The 1st stage is divided in to the latent and active phases 85 Latent phase- slow period of cervical dilatation from 0-.2cms and also it is the period of gradual shortening of the cervix. Active phase-faster period of cervical dilatation from 3-10cms or full cervical diltation. Starting the partograph A partograph chart must only be started when a woman is in labour you must be sure that she is contracting enough to start a partograph. In the latent phasec truction must be 2 or more in 10 minute each lasting 20 second or more. In the active phase contractions must be 2 or more /10minutes each lasting 20 second ormore. There difference is in dilatation of cervix. In the center of the partograph there is a graph. Along the left side are numbers 0-10 against squares. Each square represents 1cm dilatation. Along the bottom of the graph are numbers 0-24: each square represents 1 hour. Dilatation of the cervix is measured in centmeter. The dilatation of the cenvix is plotted with an "x". The 1st V.E on admission includes a pelvic assessment & the findings are recorded. The V.E are made ever 4 hrs unless contraindicated. However in 86 advanced labour women may be assessed more quickly, particularly the multipara. Plotting cevical diatation when admission is in the active phase.When a woman is admitted in the active phase the dilatation of the cervix is plotted on the alert line and the time written directly under the X in the space for time. If progress is setisfeutory, the plotting of cervical dilatation will remain or to the left of the alert line. The latent phase normally should not take longer than 8hrs. When admission is in the latent phase, diltation of the cervix is plotted at O time. Transfer from latent to Active phase Plotting cervical dilatation when admission is in the latent phase & goes in to active phase.When labour goes in to the active phase plotting must be transferred by a broken line to the alert line. The recordings of cervical dilatition and time are plotted 4 hrs after admission then transferred immediately to the alert line using the letters "TR" leaving the area between the transferred recording blank. The broken transfer line is not part of the process of labour. 87 Points to remember 1. The latent phase is from 0-2cm dilatation & is accompanied by gradual shortening of cencix. It should normally not last longer than 8 hrs. 2. The active phase is from 3-10cms & dilatation should be at the rate of at least 1cm/hr. 3. When labour progresses well, the dilatation should not move to the rt of the alert line. 4. When admission to hospital takes place in the active phase the cervical dilatation is immediately plotted in the alert line 5. When labour goes from latent to active phase plotting of the dilatation is immediately transferred from the latent phase to the alert line. Descent of the Fetal Head For labor to progress well, dilatation of the cervics should be accompanied by descent of the head. However, descent may not take place until the cervics has reached about 7cms dilatation. Descent of the head is measured by abdominal palpation and expressed interms of fifths above the pelvic brim. 88 Method – by abdominal palpation identify the anterior shoulaer of the fetus. Ther distance between this point and the pelvic brim is measured in fingers and expressed interms of fifth. E.g 3 figer between the two point indecates Recording contractions on the partograph Key points on plotting the partograph Memberane: I - Intact R-Ruptured A.R.M - Artificial Rupture of memberane Colour of liquer: M- Meconium stained C-clear A - Absent Moullding - degree of overlap Normal separation /can feel sutures/ - Bones meeting + Over lapping can be pushed back ++ Over lapping can't be separated +++ 89 Abnormal fetal heart rates A heart rate greater than 160/minute is tachylardia and a heart rate less than 120/minute is bradycardia and thse conditions may indicate fetal distress. If abnormal FHB is heard, listen it every 15 minutes for at least 1 minute immediately after contraction. If the fetal heart remains abnormal over 3 observations action should be taken urless delivery is very close. A heart beat of 100 or lower indicates very sever distress & action should be taken at once. - Moving to the right of the alert line means warning. Transfer woman from health center to hospital. - Reaching the action line means possible danger. Decision needed on further management. /usually by obstetrician/. 90 Eg. Partograph Name _____________________________ gravida ___________ para _______Reg No__________ Date of admission ___________Time of admission ________ ruptured memberane __________HRS Frequency Contraction Duration Intensity 10 Latent phase Active phase 9 8 7 Alert Action 6 5 4 3 2 1 0 Hrs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Time Pulse B.P TempoC Drugs Given and I.V Fluids FHB 91 Vaginal Examination in Labour When Doing Vaginal Examination Always Remember:- 1. The vaginal is not a sterile cavity, - the Uterus is. Every vaginal examination increases the danger of intrauterine infection, if carelessly performed. 2. A vaginal examination is uncomfortable and embarrassing for the patient. 3. Careful abdominal examination gives a lot of information. Do it always before vaginal examination. 4. When doing a vaginal examination, find out all the information you can, this may save it having to be repeated. Indications 1. When in doubt about the presentation, dilatation, or position and to assess progress. 2. To assess the shape and size of the pelvis. 3. To know the cause in fetal or maternal distress. 4. When the memberanes rupture and the head is high or there is Malpresentation, to make sure there is not prolapsed cord. Information: To be got on Vaginal Examination 1. Presenting Part - Presentation - Level of presenting Part 92 - Caput - Sutures and Fontanelles. - Overlapping or moulding 2. Membrens Intact - Bulging or flat? Rruptured - Colour of liquar 3. Cervix: RIPE - firm or soft EFFACEMENT - long or short - taken up. OEDEMATOUS- thick or thin APPLIED to the presenting part- Loose or well applied. DILATION- Measure in cm. 4. Vagina: Lax or tight, Warm or hot, Moist or Dray 5. Pelvis: Cavity, sacral promontory Curve of the sacrum, iscaheal spine Lateral pelvic side walls- parallel or convergent Now Co-relate your findings, after recording them and determine the stage of labour. 93 4.1.2 The Second Stage of Labour Definition: It is the stage from full dilatation of the cervix (i.e no cervix felt on V.E) until the Baby is born:- Duration: Primigravida 45 min – 1 hour, as long as 2 hrs Multigravida 1/2 hour can be as little as 5 minutes. N.B. there should always be advance or descent in this stage Signs of Second Stage: 1. No cervix felt on Vaginal examination 2. Contractions are much stronger, and last 30-50 seconds 3. The patient wants to push (Urge to push) 4. Sometimes head can be seen at the vulva Mechanism of the second stage: Before we deliver a baby we must understand the mechanics or mechanisms of how the baby passes down through the pelvis. We also must know the pelvis, and certain definitions. Mechanism: Is the series of movements of the fetus in its passage through the birth canal. 94 Echanism of Labour in a Normal Vertex Presentation Position- Left OcciputoTransverse Lie -Longitudinal Attitude- Flexion Presentation-Vertex Position- Left occiputo transverse Th