ANORMAL OBST NOTES OK Final-1

NORMAL OBSTETRICS COURSE SYLLABUS
1. General information
Institute: Kibogora Polytechnic
Program A1
Course title: Normal obstetrics
Credit hours: 15 credits
Period of the course: November, 2015
Prerequisites: Anatomy and physiology
Fundamental of nursing and midwifery 1 and2
2. Facilitators information
Name: Marie Jeanne UWIMANA
Title: Bachelors Degree in General nursing and Diploma in Midwifery
Office and location: Nyamata Hospital/Maternity department
Phone number: 0788484883
Contact hours: from 7.00 to 5.00pm (working days)
E-mail address: uwimanajeanne2007@yahoo.com
3. INFORMATIONS RELATED TO THE COURSE
3.1 COURSE DESCRIPTION.

Throughout this course different variation of structure and functions of female
reproductive system will be discussed, it is important for a midwife/nurse to be familiar
with various terminologies used in obstetrics. To take charge of women from pregnancy
stage throughout the delivery, and provide care to the newborn, include post-partum care.
3.2 BACKGROUND AND PURPOSE OF COURSE

The course aim is to enable the learner to understand different variation of structure
and functions of female reproductive system and takes charge of woman from
conception stage throughout the delivery, to provide care to the newborn, include post
partum care.
3.3 COURSE OBJECTIVES

At the end of this course, the students will be able to:
Described the Genital apparatus and pelvic structure of the woman.
Describe Obstetrical pelvis
Explain the Egg development
Explain the objectives and the process of an Antenatal consultation
Explain the role ( objectives, content ) of midwife/nurse in the different stage of labor,
childbirth /delivery and post partum
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Normal obstetrics notes
Describe the stages succession of Normal child birth
3.4 COURSE POLICIES/ REQUIREMENTS
Every student is requested to complete required readings and prepare for class before
attending.
They are also required to attend regularly class as indicated in the academic regulations
Full active individual and group participation is recommended
Student should refer to the academic regulations for the course attendance and lateness
policies
Language used; English is accepted in the audience.
3.5 GRADING CRITERIA
Assignments 20%
Tests 20%
Final exam 60%
Total 100%
3.6 TEACHING /LEARNING ACTIVITIES
Lecturing
Group discussions
Presentations
Demonstrations
3.7 RECOMMENDED READING
Coad,(2008), anatomy and physiology for midwives , 2nd edition, Churchill

Livingstone, london, UK.
FRASER &COOPER 2009(Myles textbook for Midwives)15 Edition,churchull

Livingstone,London ,UK.
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4. TABLE OF CONTENTS
Chapter I: Genital apparatus and pelvic structure of the woman.
Chapter II: Obstetrical pelvis
Chapter III: Egg development
Chapter IV: The pregnancy diagnosis
Chapter V: Antenatal consultation
Chapter VI: The labor
Chapter VII: Eut ocic/ Normal child birth
Chapter VIII: The postpartum monitoring
INTRODUCTION
Obstetrics
The branch of medicine that deals with the care of women during pregnancy, childbirth, and the
recuperative period following delivery. It also includes the study of the physiologic and
pathologic function of the female reproductive tract
Terms used in obstetrics
Trimester; which refers to a three month calendar period;

Gravidity; which is the number of times a woman has been pregnant regardless of the
outcome of the pregnancies;
Parity; refers to the delivery of a child that grew beyond 28 weeks (the age of
viability) irrespective of whether the baby was born alive or dead;
Primigravida; refers to a woman who is pregnant for the first time;
Primipara; is a woman who has only had one delivery;
Multigravida; refers to a woman who has had two or more pregnancies;
Multipara; is a woman who has had two or more deliveries;
Nullipara; refers to a woman who has never delivered;
Grand multipara: is a woman who has had 6 or more deliveries.
Ante-natal care: is the care you give to a pregnant woman to ensure that she reaches
the end of her pregnancy, both physically and psychologically healthy, and that she
delivers a healthy baby.
Lie: This refers to the relationship between the long axis of the foetus and that of the
mother and can either be longitudinal, transverse or oblique
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Attitude: This refers to the relationship of the foetal head and limbs to its trunk. It is
most commonly flexion.
Presentation: which means the foetal part that is lying at the pelvic brim or in the
lower pole of the uterus and can either be vertex, breach, face, shoulder or brow. The
most common is the vertex. Note that vertex/brow/face all refer to head presentation;
Denominator is the name given to the presenting part for example, occiput for vertex,
sacrum for breech and mentum for face;
Position: which refers to the relationship between the denominator of the presentation
and the landmarks of the pelvic brim?
CHAPTER I: Genital apparatus and pelvic structure of the woman
After this lesson student will be able to:
Discuss Female Sexual & Reproductive System
Describe internal and extenal ginital organs
Describe Female Maturation Cycle
Discuss Female Reproductive and Sexual Health
A) Internal and external genital organs
B) Functioning of each organ and of support system
C) The menstrual cycle of a woman
D) external female genital organ (vulva
FIG I
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Structures
The vulva refers to those parts that are outwardly visible
The vulva includes:
Mons pubis
Labia majora
Labia minora
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Clitoris
Urethral opening
Vaginal opening
Individual differences in:
Size
Coloration
Shape
Of external genitalia are common
Other structures:
the perineum
the Sebaceous glands on labia majora
the vaginal glands:
o Bartholin's glands
o Paraurethral glands called Skene's glands
THEIR FUNCTIONS
Mons Pubis
The triangular mound of fatty tissue that covers the pubic bone
It protects the pubic symphysis
During adolescence sex hormones trigger the growth of pubic hair on the mons pubis
Hair varies in coarseness curliness, amount, color and thickness
The clitoris is an erectile organ, similar to the male penis that responds to sexual stimulation.
The vaginal opening serves as a passageway for menstrual flow, receives the erect penis during
intercourse, and is the birth canal during childbirth
Monsveneris a pad of fat over the pubic covered by skin and, after puberty hair.
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Labia majora one of two thick folds of fatty tissue covered with skin, extending from the Mons
to the perineum. The inner surface contains sebaceous glands.
Labia minora one of two small, smooth folds of skin between the labia majora, containing
sweat and sebaceous glands. Anteriorly it encircles the clitoris forming prepuce and a smaller,
lower fold called the frenulum.
Urethral meatus situated between the clitoris anteriorly and the vaginal orifice posteriorly it
connecting superiorly to the bladder.
Perineum
Extends from the fourchette to the anal margin, covering the pelvic floor muscles
The muscle and tissue located between the vaginal opening and anal canal
It supports and surrounds the lower parts of the urinary and digestive tracts
The perinium contains an abundance of nerve endings that make it sensitive to touch
An episiotomy is an incision of the perinium used during childbirth for widening the
vaginal opening
B. INTERNAL FEMALE GENITAL ORGANS
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From outside to inside, the path to the uterus is as follows:
Vagina
Cervix "neck of uterus"
o External orifice of the uterus
o Canal of the cervix
o Internal orifice of the uterus
corpus uteri - "Body of uterus"
o Cavity of the body of the uterus
o Fundus (uterus)
Vagina
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The vagina is a fibromuscular tube, about 10 cm long, it extends from the cervix of the uterus
to the outside.
Functions
The vagina is able to distend to facilitate the passage of the penis during intercourse and the
baby during child birth.
Cervix
The cervix (or neck of the uterus) is the lower, narrow portion of the uterus where it joins with
the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper
anterior vaginal wall.
Functions & mode of action of the cervix
During menstruation the cervix stretches open slightly to allow the endometrium to be shed. This
stretching is believed to be part of the cramping pain that many women experience. Evidence for
this is given by the fact that some women's cramps subside or disappear after their first vaginal
birth because the cervical opening has widened.
After a menstrual period ends, the external os is blocked by mucus that is thick and acidic. This
"infertile" mucus blocks spermatozoa from entering the uterus
During pregnancy the cervix is blocked by a special antibacterial mucosal plug which prevents
infection
During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in diameter to
allow the child to pass through.
UTERUS
The uterus is a muscular organ that receives the fertilized oocyte and provides an appropriate
environment for the developing fetus.
It is situated with the bladder anteriorly and the rectum posteriorly and normally sits in
apposition of anteversion( learning forward towards the bladder) and anteflexion ( curved
forward on itself).The uterus is divided into the body and the cervix.
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Body or corpus this includes the upper two-thirds of the uterus. The cavity of the body is
triangular in shape. The structure is made up of the fundus, cornua and the isthmus
Cervix is the lower third of the uterus
The junction between the body of the uterus and the cervix is called the Isthmus
The junction of the uterine body and the fallopian tube is known as cornua
Before the first pregnancy, the uterus is about the size and shape of a pear, with the narrow
portion directed inferiorly. After childbirth, the uterus is usually larger, and then regresses after
menopause.
Layers
The layers, from innermost to outermost, are as follows:
Endometrium
The lining of the uterine cavity is called the "endometrium". It consists of the functional
endometrium and the basal endometrium from which the former arises. In most
mammals, including humans, the endometrium builds a lining periodically which is shed
or reabsorbed if no pregnancy occurs. Shedding of the functional endometrial lining in
humans is responsible for menstrual bleeding
Myometrium
The uterus mostly consists of smooth muscle, known as "myometrium."
Perimetrium
The loose surrounding tissue is called the "perimetrium."
Peritoneum
The uterus is surrounded by "peritoneum
Functions of the uterus
The reproductive function of the uterus is to accept a fertilized ovum which passes through the
utero-tubal junction from the fallopian tube. It then becomes implanted into the endometrium,
and derives nourishment from blood vessels which develop exclusively for this purpose.
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The uterus provides structural integrity and support to the bladder, bowel, pelvic bones and
organs.
The uterus helps separate and keep the bladder in its natural position above the pubic bone and
the bowel in its natural configuration behind the uterus.
Fallopian Tubes
There are two uterine tubes, also called Fallopian tubes or oviducts. There is one tube
associated with each ovary. The end of the tube near the ovary expands to form a funnel-shaped
infundibulum, which is surrounded by fingerlike extensions called fimbriae. Fertilization
usually occurs in the Fallopian tube.
Ovaries
The primary female reproductive organs, or gonads, are the two ovaries. Each ovary is a solid,
ovoid structure about the size and shape of an almond, about 3.5 cm in length, 2 cm wide, and 1
cm thick. The ovaries are located in shallow depressions, called ovarian fossae, one on each side
of the uterus, in the lateral walls of the pelvic cavity. They are held loosely in place by peritoneal
ligaments.
THE FEMALE MATURATION CYCLE
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Female Puberty;
Begins anywhere from 8 to 15 years of age
Earlier onset of menstruation may be due to being overweight; can vary with race
Puberty lasts about 3 to 5 years
Begins when pituitary gland initiates release of FSH and LH, which increases the ovaries
production of estrogen
Increased size of Fallopian tubes, uterus, vagina, breasts, buttocks, thighs, Pelvis widens
Pubic hair grows
During puberty (usually 11 or 12 years), ovulation commences
Menarche occurs during this time as well, although it may be a few months before or
after ovulation begins
MENSTRUAL CYCLE
The menstrual cycle is a cycle of physiological changes that occurs in fertile females.
The menstrual cycle, under the control of the endocrine system, is necessary for reproduction.
In the menstrual cycle, changes occur in the female reproductive system as well as other systems
(which lead to breast tenderness or mood changes, for example). A woman's first menstruation is
termed menarche, and occurs typically around age 12. The end of a woman's reproductive phase
is called the menopause, which commonly occurs somewhere between the ages of 45 and 55.
The periodic (about 28 days) discharge of blood and fluid from the uterus cause by low levels of
estrogen and progesterone at the end of the monthly cycle (hormone withdrawal).
The menstrual cycle is not the same for every woman. On average, menstrual flow occurs every
28 days (with most women having cycles between 24 and 34 days), and lasts about 4-7 days.
However, there is a wide variation in timing and duration that is still considered normal,
especially if the periods began within the last few years.
A small percentage of women have periods more often than every 21 days or less often than
every 35 days. These variations may be normal.
The menstrual cycle is a repetitive sequence of events including:
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1) The discharge of the uterine lining (the endometrium).
2) Ovulation which is the development and release of the ovum.
3) The replacement of the discard of the uterine lining.
The Three Stages of Menstruation:
Stage 1: Preovulatory
Stage 2: Ovulation
Stage 3: Secretion
STAGE 1: PREOVULATORY (DAY 1-13)
With both estrogen and progesterone levels in the blood low, the uterus begins to shed its
endometrium.
During the first 3 5 days, blood and tissues of the recently produced endometrium are shed in
what is referred to as menstruation.
The portion of the body that ultimately controls the female menstrual cycle is the hypothalamus
At the same time the pituitary gland begins to secrete follicle stimulating hormone (FSH).
Under the influence of FSH, cell clusters around the immature ovum will begin to grow forming
a follicle which will continue to grow steadily throughout the first 14 days.
In the ovary, during this phase, the follicles where the eggs are produced are growing. Follicles
are structures formed by the aggregation of the germinal epithelial cells of the ovary.
In this phase, the follicles grow further. The FSH stimulates one of the follicles. The stimulated
follicle grows in size.
One of the cells of this follicle becomes bigger and separated from the rest by a follicular cavity.
This cell becomes the egg.
The outer layer of cells of this follicle is called the internal. This layer secretes a hormone called
estrogen. This follicle is called the Graafian follicle. This phase lasts from the 6th to the 10th day.
In the uterus, this phase sees the inner wall of the uterus being built up again in order to receive
the product of fertilization, if there is one. It is again supplied with blood vessels.
The follicle secretes estrogen which targets:
1) The uterine lining undergoes rapid cell division to build up the endometrium.
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2) The cervix which secretes alkaline mucus, changing the normally acidic vaginal
environment to one that is more hospitable to sperm cells.
STAGE 2: OVULATION (14 DAY)
When the follicle is mature, the pituitary gland secretes another hormone called luteinizing
hormone (LH). LH stimulates the follicle to rupture and release the egg.
The release of egg is called ovulation and occurs between the 10th and the 16th day. The egg
moves along the oviduct during this time and may be fertilized by the sperm. If not, it starts
disintegrating.
Luteinizing Hormone (LH)
As the 14th day approaches, hormone production changes and rising estrogen levels in the blood:
1) Stop FSH from being produced (negative hormonal feedback)
2) Causes a rapid increase in the amount of luteinizing hormone (LH), bringing on what is called
the LH surge (positive hormonal feedback)
STAGE 3: SECRETION (DAYS 15-28)
This phase lasts between the 16th and the 28th day. Once the egg is released, the Graafian follicle
re-aggregates to form corpus luteum.
The corpus luteum secretes two pregnancy hormones - progesterone and relaxin. The
degenerating corpus luteum is called corpus albicans.
The vacated ovarian follicle forms a new structure called the corpus luteum. This structure
continues to secret estrogen as well as second hormone progesterone.
Both of these hormones target the endometrium where progesterone causes:
1) The continued thickening of the endometrium
2) The accumulation of glycogen which will provide the nourishment for the zygote
(fertilized egg)
3) The growth of milk ducts in the breasts.
If an embryo is not implanted:
1) Into the uterine lining it will start to disintegrate;
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2) The production of estrogen and progesterone will decrease;
3) The endometrium will start to lose its receptive state.
Each menstrual cycle typically lasts for 28 days. Thus it occurs every month. Each cycle has the
following phases:
Menstrual phase
Follicular phase
Ovulatory phase
Luteal phase
Menstrual Phase
It lasts for the first 3-4 days. During this phase the inner lining of the uterus is shed which causes
the blood vessels to rupture. This causes bleeding and is called menstruation. The first
occurrence of mensuration is termed menarche. It stops by the age of 45-50 years and is called
menopause.
In the ovary, during this phase, the follicles where the eggs are produced are growing. Follicles
are structures formed by the aggregation of the germinal epithelial cells of the ovary.
Follicular Phase
In this phase, the follicles grow further. The FSH stimulates one of the follicles. The stimulated
follicle grows in size. One of the cells of this follicle becomes bigger and separated from the rest
by a follicular cavity. This cell becomes the egg. The outer layer of cells of this follicle is called
theca interna. This layer secretes a hormone called oestrogen. This follicle is called the Graafian
follicle. This phase lasts from the 6th to the 10th day.
In the uterus, this phase sees the inner wall of the uterus being built up again in order to receive
the product of fertilisation, if there is one. It is again supplied with blood vessels.
Ovulatory Phase
When the follicle is mature, the pituitary gland secretes another hormone called luteinizing
hormone (LH). LH stimulates the follicle to rupture and release the egg. The release of egg is
called ovulation and occurs between the 10th and the 16th day. The egg moves along the oviduct
during this time and may be fertilized by the sperm. If not, it starts disintegrating.
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Luteal Phase
This phase lasts between the 16th and the 28th day. Once the egg is released, the Graafian follicle
re-aggregates to form corpus luteum. The corpus luteum secretes two pregnancy hormones -
progesterone and relaxin. The degenerating corpus luteum is called corpus albicans.
In the uterus, its lining is thickened further.
At the end of 28 days, if fertilisation has not taken place, the lining is shed along with the egg.
This starts a new cycle all over again.
SEX HORMONES; Follicle stimulating hormone FHS-

Luteinizing hormone LH-signals ovulation
Estrogen- produced throughout the menstrual cycle
Progesterone-produced during second half of cycle
Contributes to thickening of the endometrium which is shed during menstrual phase if

fertilization does not take place , Both FHS and LH are produced in the pituitary gland
Both estrogen and progesterone are produced by the follicles in the ovaries
CHAPTER II: OBSTETRICAL PELVIS
A) Subdivisions and limits
B) Dimensions
C) Obstetric role of each subdivision in the progression of fetal motion
INTRODUCTION;
In your role as a nurse/midwife, you will need to have a sound knowledge and understanding of
the anatomy of the female pelvis in order to be able to competently assess a womans progress in
labour. This involves you being able to identify the relationship between the position and descent
of the woman's fetus and the relevant landmarks of her pelvis. Where you are able to do this
competently, you should then be able to recognize any deviations from what is recognized as
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normal physiology and acceptable labour progress and, where there is an indication, facilitate
appropriate referral to a medical practitioner (obstetrician), or emergency procedure.
The pelvic girdle is a basin-shaped ring of bones connecting the vertebral column to the femurs
or the pelvic girdle or bony pelvis, the irregular ring-shaped bony structure connecting the spine
and the femurs
The bony pelvis
The pelvis consists of four pelvic bones:
Two innominate
One sacrum
One coccyx
The innominate bones are each divided into three regions:
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Ilium
Ischium
Pubis
Fig; showing the innominate bone
The true pelvis: The part of the pelvis significant in child birth is known as the true
pelvis through which the baby negotiates passage during labour and birth.
This is divided into three regions known as the brim, cavity and outlet
The pelvic brim; The land marks of the pelvic brim are used to describe the relationship
between the fetus and the pelvis as the presenting part descends. This is the 1st test that
the fetus has to pass as it descends through the pelvis. The midwife assesses the
engagement of the presenting part during abdominal and vaginal examination. The brim
is the inlet to the true pelvis and is almost circular except posterior where the sacral
promontory juts into the brim
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The pelvic cavity: The cavity extends downwards from the brim to the outlet of the
pelvis. In the anteroposterior view the cavity is wedge shaped, that is shallow at the front
and deep at the back. Viewed above the cavity is circular in shape in gynaecoid pelvis and
designed to facilitate the descent and rotation of the presenting part. Cavity boundaries;
curve of the sacrum, sacroiliac joints, sacrospinous ligaments, ischium, superior pubic
ramus, inferior pubic ramus, bodies of the pubis, symphsis pubis.
The pelvic outlet: the outlet is diamond shaped, the pelvic outlet can be described in two
ways: anatomical and obstetric dimension. The anatomical outlet boundaries are made up
of; tip of coccyx, sacrotuberous ligaments, ischial tuberosities and pubic arch. Obstetric
outlet is bounded by: The inner border of the base of the sacrum, sacrospinous ligaments,
ischial spines, and the lower inner border of the symphsis pubis
JOINTS AND LIGAMENTS OF THE PELVIS
These innominate bones, sacrum, and pubis are all connected by the joints. These joints are
cartilaginous in type, and the pelvis also provides attachment points for ligaments, which are
brands of tissue connecting two structures. In normal circumstances, ligaments do not posses the
ability to stretch, and they prevent excessive movements within the joints to enhance stability.
In pregnancy, joints and ligaments undergo temporary changes due to the hormones relaxin,
progesterone and oestrogen, enabling some movement of the joints to facilitate birth. Pelvic pain
can occur during pregnancy, birth or postpartum and is thought to be linked to overstretching of
ligaments in the pelvis and lower spine.
PELVIC WALLS
The inner aspect of the bony pelvis is covered with muscles;
Above the brim --- iliacus & psoas

Sidewalls ---- obturator internus & its fascia
Post wall ---- pyriformis
Pelvic floor ---- lavator ani & coccygeus
PELVIC LIGAMENTS
Ligaments
Sacrospinous ligament lateralaspect of the sacrum to ischial spines
Sacrotuberous ligament lateral aspect of the sacrum to inner aspect of ischial
tuberosity
Sacroiliac ligament medial surface of the ilium to sacrum
lliolumbar ligament iliac crest to transv lumbar vertebra
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Diagram showing major pelvic joints
1. Its primary functions are to bear the weight of the upper body when sitting and standing
2. Its secondary functions are to contain and protect the pelvic and abdominopelvic viscera
(inferior parts of the urinary tracts, internal reproductive organs); provide attachment for external
reproductive organs and associated muscles and membranes
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TYPES OF PELVIS
Gynaecoid (gyne, woman), anthropoid (anthropos, human being), platypelloid (platys, flat), and
android (aner, man). [38]
The gynaecoid pelvis is the so-called normal female pelvis. Its inlet is either slightly
oval, with a greater transverse diameter, or round. The interior walls are straight, the sub
pubic arch wide, the sacrum shows an average to backward inclination, and the greater
sciatic notch is well rounded. Because this type is spacious and well proportioned there is
little or no difficulty in the birth process. gynaecoid pelvis is found in about 50 per cent
of women
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The platypelloid pelvis has a transversally wide, flattened shape, is wide anteriorly,
greater sciatic notches of male type, and has a short sacrum that curves inwards reducing
the diameters of the lower pelvis. Less than 3 per cent of women have this pelvis type.
The android pelvis is a female pelvis with masculine features, including a heart shaped
inlet caused by a prominent sacrum and a triangular anterior segment. The reduced pelvis
outlet often causes problems during child birth. This type is found in one third of white
women and in one sixth of non-white women
The anthropoid pelvis is characterized by an oval shape with a greater anteroposterior

diameter. It has straight walls, a small sub pubic arch, and large sacrosciatic notches. The
sciatic spines are placed widely apart and the sacrum is usually straight resulting in deep
non-obstructed pelvis. this type is found in one quarter of white women and almost half
of non-white women
PELVIC ASSESSMENT: The function of a pelvic assessment is to estimate whether the

fetus will successfully pass though the pelvis during labour and delivery. Pelvic
assessment is not a determinant of outcome but acts as a component of an overall
assessment of pelvic adequacy.
The assessment includes:
Abdominal examination to assess engagement and descent of the presenting part.

Vaginal examination to determine the size and shape of the pelvis by assessing
the following;
- The prominence of the sacral promontary, which usually cannot

be palpated on vaginal examination
- The prominence of the ischial spines
- The pubic arch, which usually accommodates two fingers
- The prominence of the ischial tuberosities, which usually

accommodates four knuckles when measured at the level of the
perineum.
It may also include x-ray examination, ultrasound scans, magnetic resonance

imaging.
Other factors that may enable a complete assessment of the true pelvis:
- Normality of the womans gait
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- Height of the woman
- Shoe size less than a 4
- Previous successful vaginal delivery
- Non engagement of the fetal head at 38weeks in primigravid

women
- History of rickets or previous pelvic injury
- Previous trial of labour or prolonged labour
- Malpresentation such as breech
- The extent of caput or moulding of the fetal skull present

during labour.
The Bony Pelvis

Introduction
Knowledge of the shape and dimensions of the normal female pelvis is essential for a proper
understanding of labor and its abnormalities. The female pelvis shows adaptations that are of
obstetric advantage; these are chiefly developed in childhood until puberty. It is an important
component which determines the birth canal structure.
The shape and size of the bony pelvis are important factors determining the outcome of labor.
The Latin word pelvis means basin. The pelvis is that part of the trunk which is surrounded by
the bony pelvis.
General anatomy
The bony pelvis
This is made up of 4 bones joined together by ligaments. At the sides are the paired hip bones.
The bony pelvis is made up of the ilium, pubis, ischium, sacrum, and coccyx.
These are joined in front at the symphysis pubis and, behind, they articulate with the ala of the
sacrum forming the sacroiliac joints. The fourth bone the coccyx, is loosely articulated with the
lower border of the sacrum.
pelvic brim divides the abdominal (false) portion from the true portion of the pelvis. The
abdominal (false) pelvis is the part above the arcuate line. The true pelvis is the part below this
line. It forms the passageway through which the infant passes during parturition.
The hip bone is composed of 3 separate elements- pubis, ischium and ilium.
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The sacrum is composed of 5 fused vertebrae, and is directed backwards and downwards, and
this throws its superior border into prominence as the sacral promontory, an important bony
landmark for assessing the size of the pelvis, especially the antero-posterior diameter, its pelvic
aspect, providing in part the characteristic curve of the birth canal.
Pelvic bone is made up of various sections:

Four planes
The pelvic inlet: the greatest
The midplane:the least
The pelvic outlet(two planes)
The pelvic inlet

Posteriorly by promontory of sacrum
Bilaterally by linea of iliac-pubis
Anteriorly by superior surface of pubis
The midplane:the least
Anteriorly by the lower border of pubis
Bilaterally by ischial spines is very important clinically
because arrest of fetal descent occurs most frequently
The pelvic outlet
Irregular
Consisting of two triangles
It is bounded by
Posteriorly: the tip of sacrum
Laterally : ischial tuberosities sacrotuberous ligaments
Anteriorly:the lower border of pubis symphysis.Composed of ilium, ischium, pubis,

Supports and protects internal organs in posterior body cavity.
For obstetrical purposes, the pelvis is divided by thePelvic brim into two parts:
The False Pelvis

The True Pelvis
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The pelvis is divided into a true and false pelvis, delineated by the iliopectineal line.
the pelvis is divided by the pelvic brim into two parts: the False and the True
The False Pelvis is that portion above the brim. It does not take part in the mechanism of
labour and is of no obstetric interest.
False pelvis - lies above this line (Fig 8.9b)
Contains no pelvic organs except urinary bladder (when full) and uterus during
pregnancy
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lies above the linea terminalis (pelvic brim)
has no obstetrical significance
The True Pelvis is that portion below the pelvic brim. It determines the size and shape of the
birth canal.
True pelvis - the bony pelvis inferior to the pelvic brim, has an inlet, an outlet and a
cavity
Lies below linea terminalis (pelvic brim)
has important role in child birth
It has inlet, cavity & outlet
Pelvic brim - a line from the sacral promontory to the upper part of the pubic symphysis
Formed by the upper magrins of pubic bones, the ilio-pectineal lines and the anterior
upper margin of the sacrum.
Cavity: formed by the pubic bones, ischium, ilium, and sacrum
Outlet: diamond-shaped made up of pubic bones, ischium, ischial tuberosities,
sacrotuberous ligament, and 5th segment of sacrum
General anatomy
There are four parent-types of pelvises but frequently there are mixed types:
1. Gynaecoid [True female type]

2. Anthrapoid [resembling anthrapoid apes]
3. Android [True male type]
4. Platypelloid
Gynaecoid: Ideal pelvis favouring a normal delivery; 50.6% of women. Brim slightly
oval transversely but almost rounded; sacrum curved; sub-public arch rounded angle at
least 90 o
1. It is the commonest type (50%)
2. Inlet is slightly oval or round (TD~APD)
3. Sacrum is wide with average concavity and inclination.
4. ischial spines not prominent (transverse diameter is = >10cm)
5. Sacro-sciatic notch is wide.
6. wide pubic arch
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Android: male-type pelvis favouring OP positions and apt to cause deep transverse arrest
of head; 22.4% of women. Heart-shaped brim; funnel-shaped pelvis.
1. It is~ 30% of white & ~15% 0f nonwhite women.
2. Inlet is triangular or heart-shaped with anterior narrow apex.
3. Side walls are converging (funnel pelvis) with projecting ischial spines.
4. Sacro-sciatic notch is narrow.
5. Subpubic angle is narrow <90o.
6. The extreme android pelvis have poor prognosis for vaginal delivery.
Anthrapoid: ape-like pelvis favouring OP positions often requiring operative vaginal

deliveries, 22.7% of women. Oval brim AP; side walls straight, sacrum slightly curved;
sub-pubic angle narrow.
1. It makes 25% of white & ~ 50% of nonwhite women.
2. All anteroposterior diameters are more than transverse diameters (Oval

anteroposteriorly)
3. Ischial spines mostly prominent.
4. Sacrum is long and narrow.
5. Sacro-sciatic notch is wide.
6. Subpubic angle is narrow.
Platypelloid: often leads to cephalo-pelvic disproportion, 4.4% of women. Flat brim AP;
wide walls straight, sub-pubic arch wide.
1. It is a flat female type, it is rarest ~3% of women only.
2. All anteroposterior diameters are short.
3. All transverse diameters are long (oval transverse)
4. Sacro-sciatic notch is narrow.
5. Subpubic angle is wide.
6. The sacrum usually is well curved and rotated backward.
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The gender differences
The female pelvis differs from the male pelvis, being overall broader with a rounded brim that is
conducive to its specific role in childbearing. The female pelvis also acts as a protective structure
for the reproductive organs the uterus and ovaries - as well as the bladder and rectum and, to a
much lesser extent, the organs in the lower abdomen.
The physiological changes that take place during the course of pregnancy cause alterations in the
composition of the pelvis, its shape, and the plane of inclination and internal dimensions of the
true pelvis. All of these changes serve to support the pregnant uterus throughout the term of
pregnancy and assist with the normal mechanisms of childbirth.
Comparing Male and Female Pelvis
Males - bone are larger and heavier
Pelvic inlet is smaller and heart shaped
Pubic arch is less the 90
Female - wider and shallower
Pubic arch is greater than 90
The female pelvis
It differs from the male pelvis in that;
(1 )-the female pelvis is wider
(2)-the female pelvic brim is transversely oval (less prominent sacral promontory) while
the male pelvic brim is heart shaped.
(3 )-the outlet is wider and the subpubic arch is round while the male subpubic angle is
acute.
The major obstetric interest in the bony pelvis is that it is not distensible and minor
degrees of movement are possible at the symphysis pubis and sacroiliac joints.
Its dimensions are critical at childbirth

More space in the true pelvis
29
30
In obstetrics the inlet to the true pelvis, bounded by the sacral promontory, the horizontal rami of
the pubic bones, and the top of the symphysis pubis. Because the infant must pass through the
inlet to enter the true pelvis and to be born vaginally, the anteroposterior, transverse, and oblique
dimensions of the inlet are important measurements to be made in assessing the pelvis in
pregnancy.
There are three anteroposterior diameters: the true conjugate, the obstetric conjugate, and the
diagonal conjugate. The true conjugate can be measured only on radiographic films because it
extends from the sacral promontory to the top of the symphysis pubis. Its normal measurement
is 11 cm or more. The obstetric conjugate is the shortest of the three. It extends from the sacral
promontory to the thickest part of the pubic bone and measures 10 cm or more. The diagonal
conjugate is the most easily and commonly assessed because it extends from the lower border of
the symphysis pubis to the sacral promontory. It normally measures 11.5 cm or more. The inlet
is said to be contracted when any of these diameters is smaller than normal.
True pelvis
Pelvic inlet (superior strait)
Boundaries: a. rami of Pubic bone, symphysis pubis
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p. sacral promontory
1. linea terminalis
DIAMETERS OF THE PELVIS
The major obstetric interest in the female bony pelvis is that it is not
distensible, with only minor degrees of movement being possible at the
symphysis pubis and sacroiliac joints.
The various dimensions of the pelvis are therefore particularly significant in
the context of childbirth and the successful passage of the fetus through the
bony pelvic structure.
The most common type of female pelvis (gynaecoid) is considered to be the

optimal shape and size for childbirth; this is providing the fetus isnt above
average size and the pelvis isnt smaller than average, or where there is a
combination of both factors.
1. Anteroposterior diameter
Obstetrical conjugate:
Shortest distance between the promontory and symphysis pubis
Normally measures 10cm or more.
(others: true conjugate & diagonal conjugate)
2. The transverse diameter
greatest distance between linea terminalis on either side
3. Rt & Lt oblique diameter
Extend from one of the sacroiliac synchondroses to the iliopectineal eminence on the other side
Mid pelvis
- at the level of ischial spines
- interspinous diameter usually ~10cm
- Smallest diameter of the pelvis
Pelvic outlet
- boundaries a. the area under the pubic arch
p. the tip of the sacrum
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l. ischial tuberosities, sacrosciatic ligments
- diameters
1. Anteroposterior diameter(9.5-11.5) from the lower margins of the symphesis pubis to the tip of
the sacrum
2. The transverse diameter (11cm) the distance between the inner edges of the ischial tuberositis.
3.The posterior sagittal diameter (>7.5) from the tip of the sacrum to the line between ischial
tuberositis
Diameters
Antero -posterior diameters:

o Anatomical antero-posterior diameter (true conjugate) = 11cm
from the tip of the sacral promontory to the upper border of the symphysis
pubis.
o Obstetric conjugate = 10.5 cm
from the tip of the sacral promontory to the most bulging point on the back
of symphysis pubis which is about 1 cm below its upper border. It is the
shortest antero-posterior diameter.
o Diagonal conjugate = 12.5 cm
i.e. 1.5 cm longer than the true conjugate. From the tip of sacral
promontory to the lower border of symphysis pubis.
o External conjugate = 20 cm
from the depression below the last lumbar spine to the upper anterior
margin of the symphysis pubis measured from outside by the pelvimeter .
It has not a true obstetric importance.
Transverse diameters:
o Anatomical transverse diameter =13cm
between the farthest two points on the iliopectineal lines.
It lies 4 cm anterior to the promontory and 7 cm behind the symphysis.
It is the largest diameter in the pelvis.
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o Obstetric transverse diameter:
It bisects the true conjugate and is slightly shorter than the anatomical
transverse diameter.
(C) Oblique diameters:
o Right oblique diameter =12 cm
from the right sacroiliac joint to the left iliopectineal eminence.
o Left oblique diameter = 12 cm
from the left sacroiliac joint to the right iliopectineal eminence.
o Sacro-cotyloid diameters = 9-9.5 cm
from the promontory of the sacrum to the right and left iliopectineal
eminence, so the right diameter ends at the right eminence and vice versa.
34
ADEQUACY OF THE PELVIS TO ACHIEVE VAGINAL DELIVERY
WHAT IS MEANT BY CLINICALLY FAVORABLE PELVIS?
Sacral promontory can not be felt
Ischial spines are not prominent
Subpubic arch accept 2 fingers
Intertuberous diameter accept 4 knuckles on pelvic exam
35
WHAT IS THE TRUE CONJUGATE?
APD between promontory of the sacrum & superior margin of the symphysis pubis
WHAT IS THE DIAGONAL CONJUGATE?
Distance between sacral promontory & inferior margin of the symphysis pubis
Measured clinically
Pelvic inadequacy: -big baby
-small pelvis
-abnormal position
FETAL SKULL
The skull is formed of the face, the vault & the base
The bones that form the skull are: two frontal bones, two parietal bones, two temporal bones
wings of the sphenoid & occipital bone
The bones of the face & base are heavy & fused
The bones of the vault are 2 frontal, 2 parietal & occipital
The bones of the vault are not joined thus changes in the shape of the fetal head during labor can
occur due to molding
FETAL SKULL DEFINITIONS
Bregma Ant fontanelle
Brow lies between bregma &root of the nose
Face lies between root of the nose & suborbital ridges
Occiput boney prominence behind post fontanelle
Vertex diamond shaped area between ant & post fontanelles & parietal eminences
FETAL SKULL SUTURES
Frontal suture between 2 frontal bones
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Sagittal suture between 2 parietal bones
Coronal suture between parietal & frontal
Lambdoid suture between parietal & occipital
Temporal suture between inferior margin of the parietal & temporal
FETAL SKULL FONTANELLES
Anterior fontanelle
diamond shaped space between
coronal & sagittal suture 3 * 3 cm ,
ossifies at 18 m
Post font (lambda)
triangle shaped space between sagittal &
lambdoid suture
FETAL SKULL DIAMETERS
Biparietal diameter 9.5 cm.
between parietal eminences The greatest transverse diameter
Suboccipitobregmatic 9.5 cm.
middle of the bregma to undersurface of the occipital bone at the neck
The presenting diameter of the well flexed head in labour
Suboccipitofrontal 10.5 cm
root of the nose to undersurface of the occipital bone at the neck
The presenting diameter of the partially flexed head
MOULDING OF THE HEAD
Occurs with descent of the fetal head into the pelvis to reduce the head circumference
Frontal bones slip under parietal bones
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Parietal bones override each other
Parietal bones slip under the occipital bone
DEGREE OF MOULDING
Assessed vaginally
0 suture lines are separate
+1 suture lines meet
+2 suture lines overlap but can be reduced by gentle digital pressure
+3 overlap irreducible
CHAPTER III: EGG DEVELOPMENT
INTRODUCTION
As freshly ejaculated sperm is unable or poorly able to fertilize, the sperm undergoes the
phenomenon called capacitation.
It is estimated that during the ejaculation 300,000,000 sperm are released, from which only 200
reach the oviduct.
Capacitation is the process through which the spermatozoon is prepared for the merging with the
egg
Definition of Fertilization
Fertilization is the fusion of a female's egg cell (oocyte) and a male's sperm cell (spermatozoa) to
form the first cell of a new and unique being.
Implantation; The blastocyst remain free within the cavity of the uterus from 2 to 4 days before
it actually attaches to the uterine wall. During this time, nourishment is provided by secretion of
the endometrium, sometimes called uterine milk. The attachment of blastocyst to the
endometrium takes 7 to 8 days and it is called implantation.
During implantation, the cells of the trophectoderm secrete enzymes that enable the
blastocyst to penetrate the uterine lining. The release of enzymes by the trophectoderm
digests and liquefies the endometrial cells. The fluid and nutrients further nourish
blastocyst for about one week after implantation. The blastocyst becomes oriented so that
38
the inner cells mass is toward the endometrium. Eventually, nutrients are delivered
through the placenta for the subsequent growth and development of the embryo and fetus.
Summary of Fertilization, Egg dynamic and segmentation and Implantation
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During the process of conception: One very lucky spermatozoon out of hundreds of millions
ejaculated by the man may penetrate the outside layer of the ovum and fertilize it. This happens
typically in the upper third of one of the woman's Fallopian tubes. The surface of the ovum
changes its electrical characteristics and normally prevents additional sperm from entering.
A genetically unique entity is formed shortly thereafter, called a zygote. This is commonly
referred to as a "fertilized ovum."
Half of the zygote's 46 chromosomes come from the egg's 23 chromosomes and the other half
from the spermatozoon's 23. The result is a unique DNA structure, different from both that of the
ovum and the spermatozoon. Thus, the resulting newborn will contain a different DNA from its
birth mother, and birth father, and from its siblings. These differences may give the child a
reproductive advantage or disadvantage over other children in society. It is this factor that
Charles Darwin made the driving force of his theory of evolution
The zygote "is biologically alive. It fulfills the four criteria needed to establish biological life:
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1. Metabolism,
2. Growth,
3. Reaction to stimuli, and
4. Reproduction." 1
It can reproduce itself through twinning at any time up to about 14 days after
It can reproduce itself through twinning at any time up to about 14 days after conception; this is
how identical twins are caused.
The zygote will contain an X sex chromosome donated from the egg and either an X or Y sex
chromosome coming from the spermatozoon. If it ends up with XX chromosomes, the zygote is
female; if XY, it is male. In this way, the sex of a zygote, embryo, fetus and child is determined
by the birth father's spermatozoa. Unfortunately, in the past, women were often blamed for
producing new or no male children. In some cultures, particularly those where women are
devalued, they are still unjustly blamed.
Conception is the point when the vast majority of pro-life groups and conservative Christians
define as the beginning of pregnancy. Most of these groups also define the start of a human
person as occurring at conception.
The zygote first divides into two identical cells, called blastomeres. They continue to subdivide
once every 12 to 20 hours as the zygote slowly passes down the fallopian tubes. It develops into
a morulla and blastocyst.
The medical definition of the start of pregnancy is about 10 days after conception, when the
blastocyst implantats itself in the inner wall of the uterus.
About 3 days after conception: The zygote now consists of 16 cells and is called a 16 cell
morula. It has normally reached the junction of the fallopian tube and the uterus.
5 days or so after conception: A cavity appears in the center of the morula. The grouping of
cells is now called a blastocyst. It has an inner group of cells which will become the fetus and
later the newborn; it has an outer shell of cells which will "become the membranes that nourish
and protect the inner group of cells." 3 It has traveled down the fallopian tubes and has started to
attach itself to the endometrium, the inside wall of the uterus (a.k.a. womb). The cells in the
inside of the blastocyst, called the embryoblast, start forming the embryo. The outer cells, called
the trophoblast, start to form the placenta. It continues to be referred to as a pre-embryo.
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9 or 10 days after conception: The blastocyst has fully attached itself to endometrium.
Primitive placental blood circulation has begun. This blastocyst has become one of the lucky
ones. The vast majority of ova is never fertilized and make it this far in the process.
If the woman has taken a "morning after" pill, and it has not prevented ovulation, and it has not
prevented conception, then it will generally prevent the blastocyst from attaching to the wall of
the womb.
Notes: 12 days or so after conception: The blastocyst has started to produce hormones which
can be detected in the woman's urine. This is the event that all (or almost) all pro-choice groups
and almost all physicians define to be the start of pregnancy. If instructions are followed exactly,
a home-pregnancy test may reliably detect pregnancy at this point, or shortly thereafter.
The Stages of Human Embryonic Development
Fetal appendices and their roles
Human prenatal development is divided into an embryonic period and a fetal period. The
embryonic period begins with fertilization and ends eight weeks later. The term embryo is used
to describe the developing offspring during the first 8 weeks following conception, and the term
fetus is used from about 2 months of development until birth
Development divided into two phases
Cellular multiplication
Cellular differentiation
CELLULAR DIFFERENTIATION
Embryonic Membranes
During the embryonic membranes form. These membranes lie out side the embryo and
protect and nourish embryo and ,later, the fetus. The membranes are -Yolk sac, amnion,
chorion, and allantois.
1. The yolk sac is an endoderm-membrane that in many species provides the primary or
exclusive nutrient for the embryo. However the human embryo receives its nourishment from the
endometrium and yolk sac remains small. During an early stage of development it becomes a
nonfunctional part of the umbilical cord
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2. Chorion; Is derived from the trophectoderm of the blastocyst and its associated mesoderm. It
surround the embryo and, later, the fetus.The chorion becomes the principal embryonic part of
placenta, the structure through which materials are exchanged between mother and fetus.
3. The amnion also surround the fetus and eventually fuses to the inner layer of the chorion. Is a
thin protective membrane that initially overlies the embryonic disk and is formed by the eight
days following fertilization. As the embryo grows, the amnion entirely surrounds the embryo
and becomes field with amniotic fluid.
4. Amniotic fluid serves as a shock absorber for the fetus.The amnion usually ruptures just
before birth and with its fluid constitutes the bag of waters.
5. Allantois; Is a small vascularized membrane. Later its blood vessels serve as connections in
the placenta between mother and fetus. This connection is the umbilical cord.
The 5th week marks the start of the embryonic period. This is when the baby's brain, spinal,
heart and other organs begin to form. At this point the embryo is made up of three layers, of
which the top one(called ectoderm) will give rise to the baby's outermost layer of skin, central
and peripheral nervous systems, eyes, inner ear, and many connective tissues. The heart and the
beginning of then circulatory system as well as the bones, muscles and kidneys are made up from
the mesoderm (the middle layer). The inner layer of the embryo will serve as the starting point
for the development of the baby's lungs, intestine and bladder. This layer is referred to as the
endoderm. A baby at 5 weeks is normally between 1.6 and 3.2 mm in length. In the 6th week,
the baby will be developing basic facial features and its arms and legs start to grow. At this point,
the embryo is usually no longer than 4.2 to 6.3 mm. In the following week, the brain, face and
arms and legs quickly develop.In the 8th week, the baby starts moving and in the next 3 weeks,
the baby's toes, neck and genitals develop as well.
EMBRYO DEVELOPMENT
3 stages of development
Pre embryonic: 1st 14 days
Embryonic: day 15 through 8th week: tissues differentiate into essential organs.
Main external features develop and most susceptible to teratogens
Fetal stage: end of 8th week until birth (9-40 weeks
As the embryo grows and develops important structures form outside of it;
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Amniotic Sac: A thin, fluid filled membrane that surrounds and protects the developing embryo.
Insulates the embryo from temperature changes
Umbilical Cord: Ropelike structure that connects the embryo and the mothers placenta. The
umbilical cord consists of an outer layer amnion containing the umbilical arteries and umbilical
vein, supported internally by mucous connective tissue from the allantois.
The maternal and fetal blood not normally mix. Oxygen and nutrients from the mothers blood
diffuse into the capillaries of the villi. From the capillaries the nutrients circulate into the
umbilical vein. Wastes leave the fetus through the umbilical arteries, pass into the capillaries of
the villi and diffuse into the maternal blood.
Placenta: Thick, blood-rich tissue that lines the walls of the uterus during
pregnancy and nourishes the embryo. The placenta has the shape of a flat
cake when fully developed and is formed by the chorion of the embryo and a
portion of the endometrium of the mother.It provides an exchanges of
nutrients and wastes between fetus and mother and secretes hormones
necessary to maintain pregnancy. If implantation occurs, a portion of
endometrium becomes modified and is know as decidua. The types of
decidua: The decidua parietal is a portion of modified endometrium that
lines the entire pregnant uterus, except for the area where the placenta is
forming. The decidua capsularis is the portion of the endometrium between
the embryo and the uterine cavity.The decidua basalis is the portion of the
endometium between the chorion and the stratum basalis of the uterus.The
decidua basalis becomes the maternal part of the placenta.
Time from conception to birth is usually around 9 full months. 9 months divided into trimesters,
each 3 months long
0-2 weeks Zygote may float freely for 48hrs before implanting
Spinal cord grows faster than the rest of the body
Brain, ears and arms begin to form
Heart forms and begins to beat
3-8 weeks Embryo is about 1 inch long at 8 weeks
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Mouth, nostrils, eyelids, hands, fingers, feet and toes begin to form
Nervous system can respond to stimuli
Cardiovascular system is full functional
9-14 weeks Fetus develops a human profile
Sex organs, eyelids, fingernails and toenails develop
By week 12 the fetus makes crying motions, but no sounds
May suck its thumb
15-20 weeks Fetus can blink(succer)

Body begins to grow
Growth of head slows
Limbs reach full proportion
Eyebrows and eyelashes develop
Fetus can grasp and kick and becomes more active
21-28 weeks Fetus can hear conversations

Regular cycle of waking and sleeping
Rapid increase in weight
Fetus is about 12 inches long and weighs a little more than a pound
May survive if born after 24 weeks, but will require special medical care
29-40 weeks Fetus uses all five senses

Begins to pass water from the bladder
Some fetuses dream during periods of sleep in the eighth and ninth month of
development
Approximately 266 days after conception, the baby weight 6-9 pounds and
is ready to be born
Fetal circulation Key points

In the fetus, gas exchange occurs in the placenta.
The fetal circulation is shunt-dependent.
Cardiac output in the fetus is defined in terms of combined ventricular output (CVO).
The presence of fetal haemoglobin and a high CVO help maintain oxygen delivery in the fetus despite
low oxygen partial pressures.
The transition from fetal to neonatal life involves closure of circulatory shunts and acute changes in
pulmonary and systemic vascular resistance.
45
Flow Chart of Fetal Circulation
46
47
Fetal circulation (prenatal):
Fetal circulation (prenatal) ,in the adult, the lungs provide oxygen and CO2 exchange In the
fetus, the lungs are basically collapsed & fluid-filled so there is high resistance to blood flow The
placenta provides oxygen for the fetus; delivers nutrients & removes wastes
Placenta and umbilical vessels:
Placenta and umbilical vessels Placenta functions as fetal lungs and the oxygenated blood passes
into left umbilical vein which enters the liver. The umbilical arteries (right and left) carry
deoxygenated blood from the fetus to the placenta
Umbilical Circulation:
Umbilical Circulation Pair of umbilical arteries carry deoxygenated blood & wastes to placenta.
Umbilical vein carries oxygenated blood and nutrients from the placenta.
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The left umbilical vein:
The left umbilical vein Highly oxygenated,nutrient rich blood comes from the left umbilical
vein. Much of this blood is diverted into ductus venosus, which connects the left umbilical vein
to IVC in the liver left umbilical vein
The Placenta:
The Placenta Facilitates gas and nutrient exchange between maternal and fetal blood. The blood
itself does not mix.
Umbilical arteries:
Umbilical arteries About 65%of blood in the descending aorta Passes into umbilical arteries(right
and left) Which are direct branches of fetal internal iliac arteries(hypo gastric arteries)
Remaining 35% of blood supplies the lower half of the body and viscera
Sphincter mechanism in the liver:

Sphincter mechanism in the liver This regulates the flow of remaining blood from umbilical vein
into IVC through hepatic veins. It is generally agreed that a physiological sphincter exists and
prevents overloading of heart when the venous flow in the left.umb.vein is high (eg.during
uterine contractions)
Problems of fetal circulation:

Problems of fetal circulation The lungs do not function in fetal life. Hence the left heart and the
systemic circulation are maintained by number of by-pass mechanisms namely; Foramen
ovale ,Ductus arteriosus, Ductus venosus.
Foramen ovale: Foramen ovale Blood is shunted from right atrium to left atrium, skipping the
lungs. More than one-third of blood takes this route. Is a valve with two flaps that prevent back-
flow.
Ductus arteriosus: Ductus arteriosus Low oxygenated blood from SVC and some amount of
blood from IVC pass into right ventricle and thence into pulmonary artery (trunk). 90% of this
blood is by-passed into the aorta by a channel ductus arteriosus
Ductus arteriosus: Ductus arteriosus Connects the left branch of the pulmonary trunk to arch of
aorta (beyond the origin of left subclavian artery) It protects the lungs from circulatory
overloading.
Pulmonary vascular resistance: Pulmonary vascular resistance is high in fetal life and
pulmonary blood flow is low as the lungs do not need much blood for their survival but
developing brain does.
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Postnatal changes:
Postnatal changes Once the child takes the first respiration, pulmonary circulation begins and the
right and left hearts become completely independent of each other. All the by-pass channels
having served their purpose, obliterate. Foramen ovale is closed and becomes fossa ovalis in the
right atrium
Ligamentum arteriosum:
Ligamentum arteriosum The ductus arteriosus becomes a fibrous band called ligamentum
arteriosum(which has left recurrent laryngeal nerve hooking around) (By 96 hours after birth
100% closure occurs) Many factors contribute to this process of obliteration called
involution(mainly oxygen, and transforming growth factor)
Ligamentum venosum:
Ligamentum venosum Ductus venosus becomes a fibrous band called ligamentum venosum
which is seen in continuation with ligamentum teres(obliterated left umbilical vein)
Other changes and clinical aspects:
Other changes and clinical aspects The umbilical arteries become umbilical ligaments attached to
the internal iliac arteries upto superior vesical arteries. Any failure of all these closures lead to
Patent foramen ovale,ASD,VSD,PDA and coarctation of aorta. The left umbilical vein remains
patent for considerable time and can be used for exchanging transfusions.
Fetal Post-natal:
Fetal Post-natal Right-sided pressure higher Higher pulmonary resistance 3 shunts exist Placenta
provides oxygenated blood IVC blood is O2 rich SVC,CS is O2 poor Lungs inflate; lowers pulm
resistance/ Rt-heart pressures Lt-heart press. rises; closes foramen ovale Ductus arteriosus closes
w/in 48-72 hrs; becomes ligamentum Ductus venosus closes as flow ceases; becomes
ligamentum
Changes at birth:
Changes at birth When newborn begins to breathe, the babys body gets higher levels of O2
Pulmonary vascular resistance decreases, blood flow into the lungs increases LAP rises; closes
foramen ovale Increases O2 levels, lower vascular resistance closes ductus arteriosus
Clamping umbilical cord ends placental function; closes umbilical vein & ductus arteriosus In
premature infants, PFO & PDA are common
Foramen ovale Closes shortly after birth, fuses completely in first year. Ductus arteriousus
Closes soon after birth, becomes ligamentum arteriousum in about 3 months. Ductus venosus
Ligamentum venosum Umbilical arteries Medial umbilical ligaments Umbilical vein
Ligamentum teres
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Problem with persistence of fetal circulation:
Problem with persistence of fetal circulation Patent (open) ductus arteriosus and patent foramen
ovale each characterize about 8% of congenital heart defects. Both cause a mixing of oxygen-
rich and oxygen-poor blood; blood reaching tissues not fully oxygenated. Can cause cyanosis.
Surgical correction now available, ideally completed around age two. Many of these defects go
undetected until child is at least school age.
CHAPTER IV: THE PREGNANCY DIAGNOSIS
Many changes occur in a woman's body during pregnancy. These changes, although most
apparent in the reproductive organs, involve other body systems as well. Weeks may pass before
the female realizes she has become pregnant or she may learn upon a visit to a doctor for other
reasons. Confirmation of her pregnancy is most important for both the mother and the fetus. It is
then when she can begin receiving medical care for the health and welfare of herself and the
baby. In this lesson, we will cover key definitions and present presumptive, probable, and
positive signs of pregnancy along with tests used to determine pregnancy.
VI.1 ANAMNESIA
Definition
The totality of information gathered by the physician from the mother or the persons
accompanying him, or from medical papers, claiming to establish the diagnosis, prognostic or
treatment.
As soon as she believes she is pregnant seek prenatal care
Always need good medical care, whether it is her first, second, or a later
pregnancy
Most of the time, a woman does not know she is pregnant until several weeks after conception.
Many signs can indicate pregnancy BUT No single sign is, by itself, a sure sign of pregnancy
Pregnancy divided into Three Stages
The first trimester (early pregnancy): 1-12w
The second trimester (middle pregnancy): 13-27 w
The third trimester (late pregnancy): 28-40w
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DETAILED EXAMINATION OF SYSTEMS
a. PERSONAL AND PRELIMINARY DATA
1. name
2. age
3. gender
4. place of birth
5. place of living
6. ethic or racial apartenence
7. profession and employment history
General OB/GYN Assessment
Collect Subjective data
Prenatal history
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Past pregnancies
Gynecologic history
Current medical history
History
Medical history should include:
Entire medical history
Obstetric history
Medical history concerns
Pregnancy
Can exacerbate or complicate history
Diabetes
Heart disease
Hypertension
Neuromuscular disorders
Medications and allergies to medications
Should be identified and recorded
Obstetric History Concerns
Gravida/para (G/P) status
Number of living children?
Complications with previous pregnancies or deliveries?
History of preterm delivery?
Gestational age?
History of lective or spontaneous abortion?
Have all previous births been vaginal or was cesarean section performed?
Has patient delivered vaginally after a cesarean section?
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When was, and what was length of, last labor?
With regard to current pregnancy, what is estimated date of confinement (EDC)?
Has patient received adequate, limited (three or fewer visits), or no prenatal care?
Any problem with pregnancy identified?
If so, what?
Diagnostic tests like ultrasound done?
If so, what were results?
Is patient taking any medications for obstetric or nonobstetric reasons?
If so, which medication(s), what dose(s), and compliant schedule(s)?
Drug or alcohol abuse suspected?
If so, which substance(s), frequency of use, date of last use?
Patient smoking?
Pregnancy weight gain normal, or patient malnourished or obese?
Is patient having contractions?
If so, when did they begin, and what are their frequency and duration?
Objective signs
Physical exam
Head to toe assessment including wt; vital signs
Pelvic Exam: pap, STD screening; evaluate size of uterus; pelvic adequacy (pelvic
inlet and outlet)
Abdominal exam for pregnant mother is basically same as that for nonpregnant patients
Displacement and compression of abdominal organs by the gravid uterus makes

identifying abdominal landmarks challenging
Measure fundal height (FH) of uterus, in centimeters, from the symphysis pubis to the
most superior portion of the fundus
Each centimeter of FH corresponds roughly to gestational age in weeks
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Fetus position can be determined by palpating the uterus for the head and buttocks
Fetal spine can often be palpated, as well
Objective signs
Objective data:
Vital signs
Weight gain
Edema
Uterine size
Fetal heart tones
Pregnancy divided into Three Stages
The first trimester (early pregnancy): 1-12w
The second trimester (middle pregnancy): 13-27 w
The third trimester (late pregnancy): 28-40w
VI. 2: PRESUMPTIVE SIGNS AND SYMPTOMS OF PREGNANCYOR PREGNANCY

SUBJECTIVE SIGNS
Presumptive signs and symptoms of pregnancy are those signs and symptoms that are usually
noted by the mother, which impel her to make an appointment with a physician. These signs and
symptoms are not proof of pregnancy but they will make the physician, nurse. Midwife, and
woman suspicious of pregnancy
Collect Subjective data
Prenatal history
Past pregnancies
Gynecologic history
Current medical history
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Objective data:
Vital signs
Weight gain
Edema
Uterine size
Fetal heart tones
Laboratory tests and screening
Objective Data
Laboratory and diagnostic tests and screenings: CBC, Blood type and RH factor;
Hepatitis B, rubella, RPR, blood glucose; HIV;
Physical exam
Head to toe assessment including wt; vital signs
Pelvic Exam: pap, STD screening; evaluate size of uterus; pelvic adequacy (pelvic
inlet and outlet)
The Diagnosis of the First Trimester
1. Amenorrhea (Cessation of Menstruation): The first and the most important

symptom(Delay of 10 or more days)
Cessation of menstruation: This is the first frequent symptom of pregnancy; Amenorrhea is one
of the earliest clues of pregnancy. The majority of mother has no periodic bleeding after the onset
of pregnancy. However, at least 20 percent of women have some slight, painless spotting during
early gestation for no apparent reason and a large majority of these continue although a few
women may have slight bleeding after conception. But amenorrhea is not only due to pregnancy
but also other reasons. Women of breast feeding may be pregnant before the recovery of menses.
other reasons or Other causes for amenorrhea must be ruled out, such as:
Menopause.
Stress (severe emotional shock, tension, fear, or a strong desire for a pregnancy).
Chronic illness (tuberculosis, endocrine disorders, or central nervous system
abnormality).
Anemia.
Excessive exercise.
Changes in climate
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Diet
Rapid change in body weigh
1. Nausea and vomiting
Also called morning sickness because they occur upon arising.
o Usually occurs in early morning during the first weeks of pregnancy but May
occur at any time of the day
o About 1/2-1/3 experience
o Occurring at the same time daily through 4th month 12th week good sign.
o Usually spontaneous and subsides in 6 to 8 weeks or by the twelfth to sixteenth
week of pregnancy.
o Usually occurs in 1st trimester as body adjusts.
o Fatigue, swirling, nausea and vomiting (the 6th week the 12th week).
Its severity varies from mild nausea to persistent vomiting (e.g. Hyperemesis gravid arum).
o Hyperemesis gravidarum: This is referred to as nausea and vomiting that is

severe and lasts beyond the fourth month of pregnancy. It causes weight loss and
upsets fluid and electrolyte balance of the patient.
o Hyperemesis gravidarum: vomiting necessitating hospitalization.
Nausea and vomiting are unreliable signs of pregnancy since they may result from other
conditions such as:
(a) Gastrointestinal disorders (hiatal hernias, ulcers, and appendicitis).
(b) Infection (influenza and encephalitis).
(c) Emotional stress, upset (anxiety and anorexia nervosa).
(d) Indigestion.
2. Urinary symptoms
o Increased frequency of urination is due to increased circulation in pelvis
associated with the effect of estrogen and progesterone on the bladder, combined
with pressure by the gradually enlarged uterus on the bladder.
o It subsides as pregnancy progresses and the uterus rises out of the pelvic cavity.
o The uterus returns during the last weeks of pregnancy as the head of the fetus
presses against the bladder.
o Bladder irritability, frequency and nocturia
Note: Frequent urination is not a definite sign since other factors can be apparent (such as
tension, diabetes, urinary tract infection must be ruled out
3. Breast Changes
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o In early pregnancy, changes start with a slight, temporary enlargement of the
breasts, causing a sensation of weight, fullness, sensation to frank pain and mild
tingling.
o Breast enlargement and vascular engorgement. Nipple and areola become blacker.
Enlargement of the accumulated sebaceous glands of the areolas (Montgomerys
tubercles) may be noted.
o As pregnancy continues the patient may notice:
(a) Darkening of the areola--the brown part around the nipple.
(b) Enlargement of Montgomery glands--the tiny nodules or sebaceous glands
within the areola.
(c) Increased firmness or tenderness of the breasts.
(d) More prominent and visible veins due to the increased blood supply.
(e) Presence of colostrums (thin yellowish fluid that is the precursor of breast
milk). This can be expressed during the second trimester and may even leak out in
the latter part of the pregnancy.
o (3) These breast changes can be more positive if the mother has not recently
delivered and is not presently breastfeeding
By the 16th week (2nd trimester) the breasts begin to produce colostrum. This is the
precursor of breast milk. It is a thin, watery, yellowish secretion that thickens as
pregnancy progresses. It is extremely high in protein.
Nursing implication: Inform the pregnant patient to wear a good, supporting bra.
5. Constipation
Smooth muscle relaxant (P)
The diagnosis of the second and the third trimester pregnancy
Quickening (Feeling of Life).
This is the first perception of fetal movement within the uterus. It usually occurs toward the end
of the fifth month because of spasmodic flutter.
A multigravida can feel quickening as early as 16 weeks.

A primigravida usually cannot feel quickening until after 18 weeks.
Once quickening has been established, the patient should be instructed to report any instance in
which fetal movement is absent for a 24-hour period.
Skin Changes.
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(1) Striae gravidarum (stretch marks). These are marks noted on the abdomen and/or buttocks.
o These marks are caused by increased production or sensitivity to adrenocortical

hormones during pregnancy, not just weight gain.
o These marks may be seen on a patient with Cushing's disease or a patient with
sudden weight gain.
(2)Linea nigra.
o This is a black line in the midline of the abdomen that may run from the sternum
or umbilicus to the symphysis pubis.
This patient has both striae gravidarum (stretch marks) and the midline linea nigra
o This appears on the primigravida by the third month and keeps pace with the
rising height of the fundus.
o The entire line may appear on the multigravida before the third month.
o This may be a probable sign if the patient has never been pregnant.
3. Chloasma: This is called the "Mask of Pregnancy." It is a bronze type of facial coloration
seen more on dark-haired women. It is seen after the sixteenth week of pregnancy.
4. Fingernails. Some patients note marked thinning and softening by the sixth week.
o Fatigue. This is a common complaint by most patients during the first trimester.
Fatigue may also be a result of anemia
PROBABLE SIGNS OF PREGNANCY
Probable signs of pregnancy are those signs commonly noted by the physician upon examination
of the patient. These signs include uterine changes, abdominal changes, cervical changes, basal
body temperature, positive pregnancy test by physician, and fetal palpation.
Uterine Changes.
o The uterus continues to enlarge
EDC: +9 or 3 (month), +7 (day)
Enlargement of uterus
1) 12th week: 2 finger above the symphysis
2) 16th week: midway between the symphysis and the umbilicus.
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3) 20th 22nd week: at the umbilicus
(1) Position. By the twelfth week, the uterus rises above the symphysis pubis and it should
reach the xiphoid process by the 36th week of pregnancy. These guidelines are fairly
accurate only as long as pregnancy is normal and there are no twins, tumors, or excessive
amniotic fluid.
(2) Size. The uterine increases in width and length approximately five times its normal size. Its
weight increases from 50 grams to 1,000 grams.
Abdominal enlargement and fetal movement generally occurs after the 18th to 20th week of
gestation.
o The fetal body can usually be palpated by the 18 th to 20th week of gestation unless the
patient is too fat, the abdomen is tender or there is an excessive amount of amniotic fluid.
(3) Hegar's sign. This is softening of the lower

uterine segment just above the cervix. When
the uterine is compressed between examining fingers, the wall feels tissue paper thin. The
physician will use bimanual maneuver simultaneously (abdominal and vaginal) and will cause
the uterus to tilt forward (see figure 3-1). The Hegar's sign is noted by the sixth to eighth week of
pregnancy.
(4) Ballottement. This is demonstrated during the bimanual exam at the 16th to 20th week.
Ballottement is when the lower uterine segment or the cervix is tapped by the examiner's finger
and left there, the fetus floats upward, then sinks back and a gentle tap is felt on the finger (see
figure 3-2). This is not considered diagnostic because it can be elicited in the presence of ascites
or ovarian cysts.
o Fetal movement (FM): Fetal movement (quickening) can usually be seen or heard after
18th week of gestation
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b. Abdominal Changes. This corresponds to changes that occur in the uterus, as the uterus grows
the abdomen gets larger. Abdominal enlargement alone is not a sign of pregnancy. Enlargement
may be due to uterine or ovarian tumors, or edema. Striae gravidarum may also be classified as a
probable sign of pregnancy by the physician.
c. Cervical Changes.
(1) Goodell's sign. The cervix is normally firm like the cartilage at the end of the nose. The
Goodell's sign is when there is marked softening of the cervix. This is present at 6 weeks of
pregnancy.
(2) Formation of a mucous plug. This is due to hyperplasia of the cervical glands as a result of
increased hormones. It serves to seal the cervix of the pregnant uterus and to protect it from
contamination by bacteria in the vagina (see figure 3-3). The mucous is expelled at the end of
pregnancy near or at the onset of labor.
(3) Braxton-Hick's contractions. This involves painless uterine contractions occurring throughout
pregnancy. It usually begins about the 12th week of pregnancy and becomes progressively
stronger. These contractions will, generally, cease with walking or other forms of exercise. The
Braxton-Hick's contractions are distinct from contractions of true labor by the fact that they do
not cause the cervix to dilate and can usually be stopped by walking.
d. Basal Body Temperature. This is a good indication if the patient has been recording for several
cycles previously. A persistent temperature elevation spanning over 3 weeks since ovulation is
noted. Basal body temperature (BBT) is 97 percent accurate.
e. Positive Pregnancy Test by the Physician. This may be misread by doing it too early or too
late. Even if the test is positive, it could be the result of ectopic pregnancy or a hydatidiform
mole (an abnormal growth of a fertilized ovum) (see figure 3-4).
f. Fetal Palpation. This is a probable sign in early pregnancy. The physician can palpate the
abdomen and identify fetal par
o POSITIVE SIGNS OF PREGNANCY

o Positive signs of pregnancy are those signs that are definitely confirmed as a pregnancy.
They include fetal heart sounds, ultrasound scanning of the fetus, palpation of the entire
fetus, palpation of fetal movements, x-ray, and actual delivery of an infant.
Fetal heart tones
o Fetal heart sound can be heard at rate varies from 120 to 160 beats per minute.
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Figure 1
o a. Fetal Heart Sounds. The fetal heart begins beating by the 24th day following
conception. It is audible with a doppler by 10 weeks of pregnancy and with a fetoscope
after the 16th week (see figure 3-5). It is not to be confused with uterine souffle or
swishlike tone from pulsating uterine arteries. The normal fetal heart rate is 120 to 160
beats.
Warning Signals
Bleeding from vagina
Sever or continuing nausea or vomiting.
Continuing or sever headache
Swelling or puffiness of the face or hands, or marked swelling of the feet and ankles.
Sudden gush of fluid from vagina
Vaginal bleeding
Abdominal pain
Temperature above 101F and chills
Dizziness, blurring of vision, double vision
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Persistent vomiting
Severe headache
Edema of hands, face, legs and feet
Muscular irritability, convulsions
Epigastric pain
Oliguria
Dysuria
Absence of fetal movement
Physical Changes during Pregnancy
Body undergoes dramatic changes during pregnancy
Most obvious changes during pregnancy are the increased size of breasts and abdomen
As skin stretches, the tissues just below the skin surface may tear
Can cause pink or red marks called stretch marks
Usually fade into faint, silvery lines
Slow even weight gain within the doctors recommendations is the best way to
prevent stretch marks.
Internal pressure also affects the bladder.
Early in pregnancy, growing uterus pushes against the bladder and causes the woman to
urinate more often.
In middle months, fetus moves out of the pelvic region and into the abdomen, which
lessens pressure on the bladder.
Late in pregnancy, baby again puts pressure on the bladder, causing a need to urinate
more frequently
Emotional Changes during Pregnancy
Not as obvious as physical ones- just as real.
Important influence on emotions is how she feels about being pregnant.
Hormones cause many of a womans emotional changes during pregnancy.
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Positive thoughts and feelings are impossible for a woman to have a health baby.
Feelings stimulate the nervous system and the flow of adrenaline (hormone that prepares
the body to cope with stress; makes person feel more energetic.)
When happy adrenaline level is low, heartbeat and breathing are slow, and muscles are
relaxed.
When stressed, adrenaline crosses placenta to baby, carrying stress signals.
Mothers stress increases her heartbeat and muscle tension as well as the babys.
If stress is long lasting, severe, or frequent, the baby may be smaller, fussy, or quite active
May also affect a womans digestive system
During 1st trimester may experience nausea
Toward end of pregnancy, as growing fetus exerts more pressure on her stomach and
intestines, may feel heartburn and indigestion.
Often changing what she eats can help
6. Weight gain
Changes of the reproductive organs
Vagina: The vaginal wall become discoloration as the pelvic blood vessel becomes congested.
Cervix: Cyanosis and a gradual softening due to congestion
Uterus: enlargement and softening. The isthmus of the uterus is also soft and can be compressed
between the fingers palpating vagina and abdomen (Hegars sign). After the 12 th week, the
fundus of the uterus is usually palpable above the symphysis pubis.
Para clinics examinations
First trimester screening is a combination of fetal ultrasound and maternal blood testing
performed during the first trimester of pregnancy. This screening process can help to determine
the risk of the fetus having certain birth defects.
LABORATORY TESTS FOR PREGNANCY
The laboratory test for pregnancy are based on the identification of human chorionic
gonadotropin (hCG), which can be detected as early as 7-9 days after fertilization by high
sensitive technique. The samples may be blood or urine. Tests are based on the presence of
human chorionic gonadotropin (HCG) in the urine or blood
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Human chorionic gonadotropin
The hormone human chorionic gonadotropin (better known as hCG) is produced during
pregnancy. It is made by cells that form the placenta, which nourishes the egg after it has been
fertilized and becomes attached to the uterine wall. Abnormal levels are associated with an
increased risk for chromosome abnormality.
Pregnancy test
Urine HCG test (one step): + or
-HCG: >25mIU/L
Urine
This test can be performed accurately 42 days after the last menstrual period or 2 weeks
after the first missed period.
The first urine specimen of the morning is the best one to use.
Blood
Radioimmunoassays (RIA) can detect HCG in the blood 2 days after implantation or 5
days before the first menstrual period is missed.
Ultrasonography/ultrasound
An ultrasound scan is a diagnostic technique which uses high-frequency sound waves to

create an image of the internal organs.
A screening ultrasound is sometimes done during the course of a pregnancy to check

normal fetal growth and verify the due date.
TYPE OF EXAMINATIONS
standard
limited
specialized
(During the second & third trimesters)
First trimester obstetric ultrasonography is distinct from this
Ultrasounds functions/roles
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In the first trimester
to establish the dates of a pregnancy
to determine the number of fetuses and identify placental structures
to diagnose an ectopic pregnancy or miscarriage
to examine the uterus and other pelvic anatomy
in some cases to detect fetal abnormalities
Mid-trimester: (sometimes called the 18 to 20 week scan)
to confirm pregnancy dates
to determine the number of fetuses and examine the placental structures
to assist in prenatal tests such as an amniocentesis
to examine the fetal anatomy for presence of abnormalities
to check the amount of amniotic fluid
to measure the length of the cervix
Third trimester:
to monitor fetal growth
to check the amount of amniotic fluid
to determine the position of a fetus
to assess the placenta
Standard Examination
fetal presentation, amniotic fluid volumecardiac activity, placental position, fetal

biometryanatomic survey, and uterus & adnexa
after 16~20 weeks of gestation can be difficult to visualize because of fetal size, position,
movement, abdominal scar, increased maternal wall thickness
Limited Examination
When a specific question requires investigations
Ex: fetal heart activity in a bleeding patientfetal presentation in a laboring patient
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Specialized Examination
Anomaly is suspected on the basis of history, biochemical abnormalities or clinical evaluation, or

suspicious results from standard, limited exam
Fetal Doppler, biophysical profile, fetal echocardio-graphy, additional biometric studies. By an

operator with experience and expertise
First-Trimester Ultrasonography
Indications
suspected ectopic pregnancy and H-mole
the cause of vaginal bleeding
pelvic pain, estimate gestational age
evaluate multiple gestations
cardiac activity , pelvic mass, uterine abnormality
Imaging Parameters
1. presence of a G-sac in uterus or adnexa

2. cardiac activity when embryo > 5 mm
3. fetal number
4. uterus presence, location, size of leiomyoma, adnexal masses
Second-Trimester Ultrasonography
Indications
estimation of gestational age
evaluation of fetal growth
vaginal bleeding
abdominal and pelvic pain
fetal presentation
multiple gestation
uterine size
pelvic mass
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H-mole
cervical cerclage placement
ectopic pregnancy
fetal death
uterine abnormality
polyhydramnios or oligohydramnios
abruptio placentae
fetal weight, presentation in preterm labor
abnormal serum screening value
follow up fetal anomaly
placeta previa
previous congenital anomaly
fetal condition
Imaging Parameters
1. fetal cardiac activity (abnormal rate or rhythm)
3. placenta (location, appearance, relationship to the internal cervical os) umbilical cord
vessel number
4. assess gestational age by BPD, FL
5. Interval measurement shoud be evaluated no less than 2 weeks
6. maternal uterus and both adnexa
(leiomyomata, adnexal masses)
OTHER TESTS
Progesterone test
Progesterone is given to women with amenorrhea.
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If she is pregnant, no bleeding will follow, otherwise, bleeding should occur within 7-10
days of progesterone administration.
This is reliable in the nonpregnant patient only if there is adequate estrogen stimulation of
the endometrium
Basal body temperature (BBT)
A persistent elevation of BBT for longer than 18 days may be presumptive evidence of
pregnancy
Fetal electrocardiogram.
A fetal electrocardiogram can first be recorded at about the 12th week of pregnancy.
X-ray
An x-ray will identify the entire fetal skeleton by the 12th week.
In utero, the fetus receives total body radiation that may lead to genetic or gonadal
alterations.
An x-ray is not a recommended test for identifying pregnancy
DETERMINATION OF DUE DATE
The methods here are based on the average 28-day cycle.
If you are a mathematician, the following formulas can give you an answer:
Date of the first day of your last period + 7 days - 3 months = due date
Many women, especially if it is their first pregnancy, are insufficiently prepared for the important
event: the birth of their child.
Primary health care professionals can have a very important role in preparing women for
childbirth.
During antenatal visits, they can counsel clients, provide them easy-to-understand information
about labor and the delivery process, and respond to their concerns and fears.
Physiological adaptations to pregnancy

A womans body adapts and adjusts to the needs and demands of a growing fetus in remarkable
ways. Knowledge of the physiology of pregnancy provides an insight into the foundations and
rationale of antenatal education. Table 2.1 provides a summary of the physiological changes and
describes the feelings the woman experiences as these changes are taking place.
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TABLE 2.1 Physiological adaptations to pregnancy
Areas of the body Physiological changes Womens experience

Endocrine system. Human chorionic The early rise in this
Important because gonadotrophin hormone is the basis for
hormonal control many pregnancy tests, and
affects the woman it is thought to be the cause
throughout of early pregnancy nausea
pregnancy; the most Estrogen: produced by the Tender breasts
active hormones placenta after 12 Amenorrhoea (no
include: weeks of gestation; menstrual period)
suppresses ovulation, Uterus grows
inhibits lactation,
encourages growth of the Tender breasts
breasts, uterus and vagina Prevents uterine
contractions
Progesterone: produced by May lead to varicose veins,
the placenta after constipation or
12 weeks of gestation; urinary tract infections
responsible for Feeling of warmth
development of breast Darkening of skin pigment
tissue, relaxes smooth Linea nigra, chloasma and
muscle all over the body secondary areola
Thyroid-stimulating of nipples develops
hormone: stimulates the
metabolism through the
action of thyroxin
Melanocyte-stimulating
hormone: as
pregnancy progresses and
the pituitary gland
enlarges more is produced
Metabolism Increases to meet demands Weight gain of about 1012
of mother and kg
fetus
Respiratory system 1520% increase in Dyspnoea (awareness of
demand for oxygen; breathing) in later
easier gas exchange; lower pregnancy
70
ribs flare
Gastrointestinal Whole system relaxes, Heartburn
System mainly due to Constipation
progesterone, although May need smaller meals
internal organs are
squashed by growing
uterus
Renal system Increased blood flow to Glycosuria (sugar in the
kidneys causes 50% urine) can occur
increase in glomerular Urinary tract infection can
filtration occur, frequency of
Action of progesterone micturation due to pressure
causes kinking of the on the bladder
uretters from the growing uterus
and fetal head
Reproductive system Uterus: thickens and grows Changing body image:
from a pelvic at 12 weeks, uterine fundus
organ weighing 70 g to an is felt above the
abdominal organ pubic bone
weighing 1 kg at 24 weeks, uterine fundus
Much greater blood supply is palpated above
the umbilicus
Cervical canal is filled by at 38 weeks, uterus
operculum, mucous presses on xiphysternum
plug or show
Vagina: has increased (lower edge of sternum, in
blood supply and the centre of rib
estrogen acts on mucous- cage)
producing cells Increase in vaginal
discharge
Breasts Both estrogen and Vascular changes visible,
progesterone encourage colostrum may be
growth and blood supply secreted from 16 weeks
increases
Montgomerys tubercules
become more
active and prominent
Skeletal system Progesterone softens the Can cause back pain, or
ligaments, which laudosis (curved
assists in the delivery spine)
UNIT V: ANTENATAL CARE/CONSULTATION
1) ANTENATAL CARE PROCESS
At the end of this module students should:
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understand the purpose of antenatal care
Know what should be covered during antenatal care
Know which tests to conduct during antenatal care
Be aware of the need to educate women about emergency obstetric care(signs of
danger)
The aim of antenatal care is to assist the woman to remain healthy and thus aid the health of the
unborn baby. Antenatal care should also provide support and guidance to the pregnant woman
and her partner or family, to help them in their transition to parenthood.
This implies that both care and education are required from care providers.
During this important time the role of the midwife/ nurse is to:
__ promote health activities;
__ prevent ill health;
__ provide curative services;
__ liase with other services such as specialist care and antenatal education;
__ teach the woman both knowledge and skills regarding her own health care;
__ become a supportive provider who is approachable and willing to listen to the womans needs
and to assist with any concerns she or her family may have about the pregnancy, birth or
postpartum period.
There are a number of important issues around the provision of antenatal care. These include
determining what kind of care should be offered to all women and what is needed by women
with difficulties or complications arising during pregnancy or birth. Other issues include the
frequency of visits, what should actually be offered in terms of care for the woman at each visit
and what screening tests are necessary. Quality of care is important and womens perceptions of
their care should be sought and considered at all stages.
INTRODUCTION:
Antenatal care includes goal-directed interventions
Provided by skilled birth attendant
Screening and prevention of diseases that may complicate pregnancy
Health promotion and Counseling on family planning, breastfeeding, and danger signs
BIRTH PLAN: Birth preparedness and complication readiness
WHAT IS EFFECTIVE ANC?
Care from a skilled attendant and continuity of care delivered to the pregnant women.
Preparation for birth and potential complications
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Promoting health and preventing disease
Tetanus toxoid, nutritional supplementation, tobacco and alcohol use, etc
Detection of existing diseases and treatment
HIV, syphilis, tuberculosis, other co-existing medical diseases (e.g., hypertension,

diabetes)
Early detection and management of complications
Focused antenatal care is based on the premise that every pregnancy is at risk for complications.
All women should receive the same basic care including the identification of complications.
This model of prenatal care involves a minimum of 4 visits in normal or uncomplicated
pregnancies.
It stresses quality rather than number of visits and has essential goal-directed elements including
screening for diseases that complicate pregnancy like pre-eclampsia and anemia. It also reduces
cost, lessens workload and provides more time to interact with patients thereby improving
quality of care.
OBJECTIVES OF PRENATAL CARE
To detect diseases which may complicate pregnancy:
To detect problems that might affect the woman's pregnancy and require additional care -
routinely screen for anaemia, hypertension, HIV, syphilis and diabetes mellitus. Recognize other
problems that may complicate pregnancy: malnutrition and tuberculosis, vaginal bleeding,
vaginal discharge, foetal distress and abnormal foetal position after 36 weeks.
Educate women on danger and emergency signs & symptoms
Danger and emergency signs may be Fever, vaginal bleeding, headache and blurring of vision,
severe abdominal pain, convulsion, severe difficulty of breathing.
Prepare the woman and her family for childbirth
STEPS TO FOLLOW IN PRENATAL CARE
1. Immediate assessment for emergency signs.
Unconscious/Convulsing
Vaginal bleeding
Severe abdominal pain
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Looks very ill
Severe headache with visual disturbance
Severe difficulty in breathing
Dangerous Fever
Severe vomiting
Make an immediate assessment of all pregnant women in the antenatal clinic. Women with
emergency signs should be prioritized.
2. Make the woman comfortable.
Greet her, make sure she is comfortable and ask how she is feeling.
If first visit, register the woman and issue a Mother and Child Book (antenatal
record form).
3. Assess the pregnant woman
FIRST visit:
How old is patient?
Past Medical History
Obstetric History: Gravidity?
Alcohol/Drug/substance abuse?
Ask about or check record for prior pregnancies:
Convulsions
Stillbirth or death in the first day
Heavy bleeding during or after delivery
Prior cesarean section, forceps or abortion
2ND AND THIRD TRIMESTER
1. Leopolds exam, fetal heart beat
2. Give education & counseling on family planning
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Do not perform vaginal exam as a routine prenatal care procedure.
Always record findings.
All pregnancies are at risk. Encourage all pregnant women to deliver in the health
facility.
Refer patients with abnormal findings to higher facility.
Leopolds exam: Abdominal Palpation / Leopolds Maneuver
Standing on the Right side, face the woman and palpate with the palms of the hands.
The bladder must be emptied before measurement; the pregnant women must be lying on
the gynecological bed.
Steps 1 - Start at upper funds and palpate for the head or buttocks
Step 2 - Go down each side and locate back
Step 3 - Gently grasp lower portion of uterus and feel for the head
Step 4 - Turn and face the woman and repeat the steps.
4. Get baseline laboratory information of the woman on the first or following the first visit.
Hemoglobin, blood type and Rh factor
Urinalysis
VDRL or RPR to screen for syphilis
Screening for gonorrhea and Chlamydia
HIV testing
If not available, refer to the nearest health center with PMTCT&VCT or hospital for the tests.
5. Check for pallor or anemia.
Ask about getting tired easily or shortness of breath during routine work.
On 1st visit, check hemoglobin & blood type. The normal hemoglobin cut-off level for a
pregnant woman is 11g/dl.
On subsequent visits:
Look for conjunctival pallor.
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Look for palmar pallor.
Count number of breaths in one minute.
The World Health Organization (WHO) recommends giving ferrous sulfate 320 milligrams (60
mg of elemental iron) twice a day to all pregnant women. If the womans hemoglobin is 8 gm or
less at any visit, increase her iron supplementation to three times a day for the entire pregnancy.
If ferrous sulfate is not available, give an equal amount of elemental iron in another iron
preparation.
6. Check for hypertension/ pre-eclampsia
Measure BP in sitting position.
If diastolic BP is 90 mm Hg or higher repeat measurement after 1 hour rest.
If diastolic BP is still 90 mm Hg or higher ask the woman if she has:
Severe headache
Blurred vision
Epigastric pain
Check urine for protein.
7. Check for gestational diabetes.
ASK ABOUT ;Family history of diabetes & history of obesity.
Past pregnancy for difficult labor, large babies, congenital malformations and
previous unexplained fetal death.
LOOK FOR ;signs of maternal overweight or obesity
o Polyhydramnios ;Signs of large baby or fetal abnormality;Vaginal infection.
8. Check for fever, burning sensation on urination and abnormal vaginal discharge.
Ask about episodes of fever or chills and take temperature.
Ask about pain or burning sensation on urination.
Ask about presence of abnormal vaginal discharge, itching at the vulva or if partner has a
urinary problem.
9. Imminatitation of Tetanus
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10. Give Mebendazole to treat for intestinal parasites.
500 mg single dose once in six months (after the 1st trimester)
11. Give iron and folic acid supplementation to prevent anemia and neural tube defects:
60 mg Fe & 250 mcg Folic acid
If Hemoglobin <80 gm/dl double the dose
12. Refer for preventive intermittent treatment for falcifarum malaria (if area is endemic)
and distribute the mousquito net.
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13. Provide health information, advice
Health information contains:
1. Nutrition: what food to eat and what foods to avoid during pregnancy.
2. Self-care during pregnancy: educate on the importance of hygiene
3. Effect of tobacco, alcohol & drugs
4. Breastfeeding: discuss the benefits of breastfeeding during the prenatal consultation.
5. Birth & Emergency situationsExplain the danger signs and the signs of labor.
6. Schedule of appointment
14. Advise on Danger Signs
1. Vaginal bleeding
2. Convulsions
3. Severe headache
4. Severe abdominal pain
5. Fast or difficult breathing
6. Fever or burning urination
15. Encourage the woman to come back for return visits.
At least 4 routine antenatal visits
1st visit: before 4 months
2nd visit: 6 months
3rd visit: 8 months
4th visit: 9 months return if undelivered within 2 weeks after the last visit or the EDC.
NOTE: Pregnant women who do not come for prenatal care should be visited at home.
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THE BIRTH PLAN: This is a written document prepared during the first prenatal consultation.
This must be discussed with the patient and her family
It may change anytime during pregnancy if a problem is detected.
Contains information on:
the womans condition during pregnancy
preferences for her place of delivery and choice of birth attendant
available resources for her childbirth and newborn baby
Preparations needed should an emergency situation arise during pregnancy, childbirth and
postpartum.
EMERGENCY PLAN
Advise on danger signs
Where to go?
How to go?
Who will go with you to health center?
How much will it cost? Who will pay? How will you pay?
Start saving for these possible costs now.
Who will care for your home and other children when you are away?
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SUMMARY
ANTENATAL CARE: Key Messages
Reduced number of visits
Provided by skilled birth attendant
Screening and prevention of diseases that may complicate pregnancy
Preventive Measures: Tetanus immunization, iron and folic acid supplementation
Counseling on family planning, nutrition, breastfeeding, and danger signs
BIRTH PLAN: Birth preparedness and complication readiness
2) RISK FACTORS AND PREGNANCY (a) AND DRUGS AND PREGNANCY (b)
INTRODUCTION
There are the risk factors that are necessary to be identified during pregnancy period and the
study on the drugs is important due to their side effects to the foetus.
High-Risk Pregnancy: Definition
A high risk pregnancy is one in which some condition puts the mother, the developing fetus, or
both at higher-than-normal risk for complications during or after the pregnancy and birth.
It is the pregnancy associated with increased risk whether for the mother, or the fetus, or the
newborn.
A pregnancy is also considered high-risk when prenatal tests indicate that the baby has a serious
health problem (for example, a heart defect). In such cases, the mother will need special tests,
and possibly medication, to carry the baby safely through to delivery.
Furthermore, certain maternal or fetal problems may prompt a physician to deliver a baby early,
or to choose a surgical delivery (cesarean section) rather than a vaginal delivery.
The risk factors may be divided into categories of socioeconomic, demographic and medical.
SOCIOECONOMIC FACTORS
1. Socioeconomic status: Low standards (poverty)
2. Parental occupation.
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3. Social support: The support and guidance that the family receives during the period prior to
delivery of a baby will influence the familys ability to cope with the stress of changing family
structure.
4. Maladaptation may increase anxiety which can cause physical complications during pregnancy
including preterm labor.
DEMOGRAPHIC FACTORS
1. Maternal age: Optimal maternal age for childbearing is 2035 years. With a steadily increasing
risk of perinatal mortality with increasing age above 30yrs.
2. Maternal education: As the length of the mothers" education increases, perinatal mortality and
morbidity rates drop significantly.
3 Grandmultiparity
MEDICAL FACTORS
1. Hypertension.
2. Diabetes.
3. Rh Incompatibility
4. Cardiac diseases.
5. Pulmonary diseases.
6. Renal diseases.
7. Postterm and preterm labor, etc.
8. Previous 2 or more abortions, or missed abortion or intrauterine foetal death.
ANTENATAL RISK FACTORS
1. Obstetric history, e.g pretem delivery, fetal (congenital) anomaly, still birth (IUFD),
placental abruption (accidental hemorrhage).
2. Mothers belo 2. Mothers age (below 20 years, more than 35 years).
3. Mothers weight (overweight, underweight).
4. Preexisting medical conditions of the mother , e.g. diabetes, hypertension , psychiatric,

sickle cell anemia, heart disease
5. Family history (congenital malformations)
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6. Smokers.
7. Drug abusers
8. Social deprivation.
9. Domestic violence.
10. Previous 2 or more Cesarean section.
DRUGS IN PREGNANCY
The possible bad effects of drugs on the growing foetus are expressed by the term "teratogenic",
who means the making of monsters or abnormal children. Drugs with such properties are
particularly dangerous soon after implantation when the majority of the foetal organs are being
formed (organogenesis).
Foetus is most vulnerable to teratogenic effects at 4-12 weeks gestational (period of

organogenesis)
Gestational age and stage of development, dose, duration of exposure and individual
susceptibility influence the potential effects of drug exposure during pregnancy.
Drugs in Early Pregnancy
Early pregnancy is a time characterized by nausea, vomiting and occasionally depression.

Antiemetic drugs, used to stop vomiting are dangerous to the foetus and should be avoided
whenever possible. In particular, the following should be avoided:
antiparasitic agents
anti-cancer drugs, for example, methotrexate
Strong antibiotic agents.
Anti-viral agents.
Drugs in Late Pregnancy
Drugs given in late pregnancy may not cause gross anatomical defects but they can affect the
foetus in other ways, including the following:
Androgens or progesterone can cause foetal masculinization;
Iodine and anti-thyroid drugs can cause goitre;
Tetracycline can interfere with bone and tooth development.
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Drugs Just Before Labour
Drugs given at this time may accumulate in the foetal circulation. The foetal liver is not mature
enough to be able to excrete them. Anticoagulants will cause severe neonatal haemorrhage.
Sulphonamides can cause jaundice. Chloramphenicol results in a general collapse of the baby.
Drugs During Labour
Any drug which acts to depress the respiratory system, such as those given to the mother to
relieve pain, will make the newborn have difficulty in starting respiration.
Barbiturates and anaesthetic agents may depress the newborn's respiration.
As a general principle drugs should be avoided throughout pregnancy, especially in the first 12
weeks.
Antimicrobial Agents
All enter foetal circulation to some degree.
Information on safety of newer extended-spectrum or late-generation agents limited.
Penicillins and Cephalosporins generally are regarded as safe for use in any trimester.
Analgesic Agents
Acetaminophen is the analgesic agent of choice!
ASA-
1st trimester- congenital defects.
Later- Coagulation abnormalities with hemorrhagic complications in neonate and

mother and premature patent ductus arteriosus closure
ASA and NSAIDs-
May prolonge gestation and labor through inhibition of cylooxygenase. Also

association with oligohydramnios, intestinal perforation and renal failure
(especially Indomethacin).
Gastrointestinal Agents
Nausea and Vomiting-
o Antiemetics safety has not been studied in prospective human trials, but benefit of
improved metabolic conditions and maternal well being should be considered.
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o Promethazine (category C), metoclopramide (B) (5-10mg PO, IV,IM)
Dyspepsia-
o Most antacid preparations like cimetidine, and ranitidine are regarded as safe.
Cold Preparations
Cold preparations are usually combinations with sympathomimetic agents vasoconstrictive

properties vascular-mediated congenital defects.
When absolutely necessary, consider each agent of combined preparation.
1st trimester exposure to dextromethorphan or guaifenesin has not been associated with adverse
foetal effects.
Anesthetics
Lidocaine-
o Not associated with detrimental fetal effects.
Combination Tetracaine, Adrenaline-Epinephrine, & Cocaine (TAC) and Lidocaine,

Adrenaline, & Tetracaine (LAT) should not be used because have risks of absorbed
cocaine and adrenaline-epinephrine
Contraceptives should be discontinued during pregnancy!
However, no demonstrated risk of fetal malformation in early pregnancy.
Uterine Stimulants
These include protaglandins, oxytocin and ergometrine.
Prostaglandins
These are a group of naturally occurring agents, which, depending on the circumstances,
can either contract or relax smooth muscle.
Certain types of prostaglandins cause vigorous uterine contractions at any stage of

pregnancy. They can be used to induce an abortion or to induce labour.
Oxytocin
This is produced by the posterior lobe of the pituitary gland. it produces rhythmic contractions of
the uterus with a relaxation phase in between, thus mimicking normal uterine activity in labour.
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Its uses include:
Induction of labour
Sometimes treatment of uterine inertia
Management of some cases of postpartum haemorrhage
Use in management of inevitable abortions
Use during evacuation in molar pregnancy.
Dangers of Oxytocin include foetal hypoxia and perinatal death as well as rupture of uterus.
Ergometrine
It has the ability to cause strong contractions of soft muscle, including the uterine muscle.
It produces a sustained tonic contraction of the uterus and its effects wear off after two to four
hours. It is, therefore, unsuitable for inducing labour where slow, regular contraction with a
good relaxation phase, like those produced by oxytocin, is needed.
Ergometrine is the most important drug used to treat or prevent post-partum haemorrhage. This
is because of its ability to produce a prolonged contraction, which cuts down the muscle fibres so
as to prevent bleeding from the placental site.
Ergometrine can also cause peripheral vasoconstriction; hence the patient's blood pressure can
increase after an injection of ergometrine, particularly after an intravenous injection
To avoid toxic effects, 1.5mg is the maximum total dose of ergometrine maleate, which can be
given safely in 24 hours.
Immunizations During Pregnancy

YES: Inactivated (killed-virus) vaccines including:
o Influenza
o Tetanus toxoid with or without diptheria toxid
o Immunoglobins including tetanus, hepatitis, rabies, & varicella
NO: Live-virus vaccines including:
o Measles
o Mumps
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o Rubella
o Poliomyelitis
o Varicella
Preventive Medicine & Counseling
Nutrition & Nutritional Supplements
Average total weight gain- 12.5 kg (28 lbs.)
Folic Acid before and during pregnancy to prevent neural tube defects (1mg/day-
no history of neural tube defects, 4mg/day- + history on previous pregnancy with
neural tube defects)
Vitamins A, D, C, and B6 in excess may lead to congenital defects.
Fe supplementation recommended
Zinc deficiency neural tube defects15mg/day recommended
Caffeine
Studies show an increased risk of miscarriage in 1 st and 2nd trimesters with

consumption of caffeine >150mg/day.
Aspartame
Metabolized to phenylalanine crosses into fetal circulation high

concentration can lead to mental retard. (Fetal toxicity unlikely unless excessive
maternal intake)
Substance Abuse
Cocaine- increase the risk of abruptio placenta, growth-restricted infants, preterm

labor, developmental delay
Opiates- no known teratogenic effects. Increased danger with disappear.
Amphetamines- congenital abnormalities.
Hallucinogens & Designer Drugs- inconclusive
Nicotine- increases rates of spontaneous Abortion, abruption, preterm labor, low
birth weight (effects reduce if cessation by 16 weeks)Nicotine gum (Category
C), Nicotine patch (D)
Alcohol-
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Fetal Alcohol Syndrome- microcephaly, mental retardation, & behavioral delay.
Greatest risk 1st trimester and no established safe quantity of consumption
Travel
No restraints in normal pregnancy.
Frequent ambulation during long duration.
Protective restraint devices at all times!
Exercise: moderate physical exercises are recommended
Some recommendations:
Non-weight behavior(minimize chance of abdominal trauma)
No scuba diving
No exercise in supine position
Individual based programs
FETAL POSITON AND PRESENTATION
Fetal presentation: Is the part of the fetus that lies closest to or has entered the true pelvis.
There are three types of fetal presentation:
Cephalic or head presentation

Breech or butt presentation
Shoulders presentation
Cephalic presentations are vertex, brow, face, and chin. Breech presentations include
frank breech, complete breech, incomplete breech, and single or double footling breech.
Shoulder presentations are rare and require cesarean section or turning before vaginal
birth.
(a) Cephalic or head presentation.
Obstetrics Any position of the baby in which the head presents, which may be the vertex
(normal)the easiest presentation to deliver;
. Compound presentation involves the entry of more than one part in the true pelvis, most
commonly a hand next to the head.
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Eight position of cephalic presentation
1. Occiput Posterior (OP) - head facing mother's tummy (sunny side up)
2. Occiput Anterior (OA) - head facing mother's back
3. Left Occiput Anterior (LOA) - head facing mother's right butt cheek (best position)
4. Right Occiput Anterior (ROA) - head facing mother's left butt cheek
5. Left Occiput Transverse (LOT) - head facing mother's right side
6. Right Occiput Transverse (ROT) - head facing mother's left side
7. Left Occiput Posterior (LOP) - head facing front of mother's right leg
8. Right Occiput Posterior (ROP) - head facing front of mother's left leg
Fetal position
Definition: This is the relationship between a predetermined (denominator), or direction on the

presenting part of the fetus to the pelvis of the mother.
The maternal pelvis is divided into quadrants.
(a) Right and left side.
(b) Anterior and posterior. This is a line cutting the pelvis in the middle from side to side. The top
half is anterior and the bottom half is posterior.
(c) The quadrants never change, but sometimes it is confusing because the student or physician's
viewpoint changes.
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As we have seen that the normal presentation of fetal is cephalic presentation there are main six
positions described below:
The fetal position is often described using three letters.
This is an example of LOA, meaning:
Left
Occiput
Anterior
1. Left occiput anterior (LOA). Left Occiput Anterior (LOA)
In other words, the fetal occiput is directed towards the mother's left, anterior side.
2. Left occiput posterior (LOP). Occiput posterior positions, including direct OP, LOP (Left
Occiput Posterior) and ROP (Right Occiput Posterior) are positions favored by certain internal
pelvic shapes. This position has some obstetrical significance.
Normally, if the head is at 0 Station, the biparietal diameter is at the pelvic inlet and the
head is fully engaged. In posterior positions, at 0 Station, the biparietal diameter is still a
couple centimeters above the pelvic inlet, meaning that the head is not fully engaged.
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Babies can deliver in the posterior position, but the pelvis needs to be large enough and it
usually takes longer.
Forceps are often used to deliver babies in this position, but there is controversy whether
the fetus should be delivered in the posterior position, or rotated with the forceps to the
anterior position. Much depends on the clinical circumstances and the experience of the
operator.
Right Occiput Posterior (ROP)
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Left Occiput Posterior (LOP)
3. Left occiput transverse (LOT). Transverse Position

This LOT (Left, Occiput, Transverse) position and its' mirror image, ROT, are common in early
labor. As labor progresses and the fetal head descend, the occiput usually rotates anteriorly,
converting this LOT to an LOA or OA as the head delivers. If the head fails to rotate despite
steady descent, this is called a "deep transverse arrest," and is common among:
Babies who are too big to come through, and

Mothers with flat pelvises that favor a transverse delivery
Women with this condition who fail to deliver spontaneously are treated with cesarean section,
forceps, or vacuum extraction, depending on the clinical circumstances, available resources, and
experience of the operator.
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LeftOcciput Transverse (LOT) Right Occiput Transverse (ROT)
4. Right occiput anterior (ROA). This is an example of ROA, meaning:Right, Occiput,Anterior
These anterior presentations (ROA and LOA) are normal and usually are the easiest way for the
fetus to traverse the birth canal.
Right Occiput Anterior (ROA)
Observations about positions :
LOA and ROA positions are the most common and permit relatively easy delivery. LOP and
ROP positions usually indicate labor may be longer and harder, and the mother will experience
backache
UNIT VI: THE LABOR
NORMAL LABOR
Definition
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Is the process by which a single full term living viable fetus is expelled from the natural passage
within reasonable hours. In which the fetus presents by the vertex and which terminates naturally
without artificial aid and without complications.
Normal Labor is the process of expulsion of a mature foetus with the placenta and membranes. It
is divided into three stages.
Labor ;is defined as the onset of rhythmic contractions and the relaxation of the uterine smooth
muscles which results in effacement or progressive thinning of the cervix, and dilation or
widening of the cervix .This process culminates with the expulsion of the fetus and expulsion of
the other products of conception (placenta and membranes) from the uterus.
CAUSES OF LABOR
Decrease in Progesterone
Increase in Estrogen
High levels of Prostaglandins
Over distention of Uterus
Degeneration of Placenta
Premonitory Signs of Labor
o lightening
o false labor pain
o show
o rom
o backache
o diarrhea
o sudden increase in energy
o Most primigravidas and many multigravidas experience the following S & Sx of labor:
The Beginning of Labor
Lightening- occurs when the baby settles deep into the mothers pelvis.
Lightening may occur days or weeks before labor depending on the pregnancy.
Lightening typically occurs closer to delivery with every pregnancy each mother has
o Lightening the fetus settles into pelvic outlet (review: engagement); leg cramps,
pelvic pressure, leg edema, vaginal secretions
Show or Bloody Show refers to as loosing the mucus plug.
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o Throughout the pregnancy the mucus plug seals the Cervix: the lower part of the uterus.
o This mucus helps prevent bacteria from moving up the vagina into the uterus where it
might cause infection.
o As birth gets closer, the mucus begins to liquefy- the woman may notice a few drops of
blood or a slightly vaginal staining.
This show may come as early as a few days before labor begins.
In some women, the onset of labor is signaled by a trickle- or sometimes a gush- of warm
fluid from the vagina.
We commonly refer to this as the water breaking.
Occurs when the membrane holding the amniotic fluid surrounding the baby has broken.
For most, this membrane does not rupture until she is at the hospital in active labor.
Once the water has broken, mother should take notice of:
The time
Amount of fluid
Color & odor of fluid
She should contact her mother immediately & report this information.
The doctor usually will want to deliver the baby within 24 to 48 hours- to protect baby
from infection.
o Braxton Hicks contractions (irregular, intermittent contractions or Practice

throughout pregnancy, like menstrual cramps. Strong woman in false labor
o Cervical changes rigid, firm cervix softens or ripens
o Bloody show mucus plug is expelled exposed cervical capillaries pink-tinged

secretions
o Rupture of membranes ROM (not range of motion). 12% before labor begins. Then
80% go into labor within 24 hrs. Watch carefully: if fetus not engaged, cord can prolapse
with fluid gush. Inc risk for infection
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o Sudden burst of energy 24 48 hrs /a delivery
o Other: weight loss 1-3 lbs, N&V, diarrhea
The onset or signs of the labor:
Is recognized by:
(1) Painful uterine contractions (labor pains).
(2) Blood stained cervical mucus the show'.
(3) Commencing dilatation of the cervical.
(4) Formation of the bag of fore-water.
1. Labor painsor Painful uterine contractions
Regular, frequent, uterine contractions which lead to progressive dilatation of the cervix.
Braxton-Hicks contractions
Uterine contractions occurring prior to the onset of labor. They are normal and can be
demonstrated early in the middle trimester of pregnancy. These innocent contractions can be
painful, regular, and frequent, although they usually are not effective.
Mechanism of contraction
Contractions: the tightening and releasing of the muscle of the uterus.
When the uterus contracts, it gets shorter and harder- like any other muscle.
With each contraction the uterine muscle, shortens and harden- holds the hardness for a
short time, and then relaxes and rest for a few minutes.
This is the clearest sign that labor has begun.
The onset of labor may be sudden or gradual, and is defined as regular uterine activity in the
presence of cervical dilatation.
During a contraction the long muscles of the uterus contract, starting at the top of the uterus and
working their way down to the bottom (Fundal dominence).
At the end of the contraction, the muscles relax to a state shorter than at the beginning of the
contraction.
This draws the cervix up over the baby's head.
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Each contraction dilates the cervix until it becomes completely dilated (10+ cm in diameter).
While the uterine contractions of labor are usually painful, they are sometimes mildly painful, in
the early stages of labor. Occasionally, they are painless.
gradual onset with slow cervical change towards 3 cm (just over 1 inch) dilation is referred to as
the "latent phase".
The labor may begin with a rupture of the amniotic sac, the paired amnion and chorion( rupture
of bag of fore water).
True vs. False Labor
Many women often experience "false labor" before "true labor" actually begins.
False contractions may begin as early as three or four weeks before the
termination pregnancy. Contractions, show, the cervix, and fetal movement all
are vital in distinguishing between true and false labor
FACTOR TRUE LABOR FALSE LABOR
Contractio Produce progressive dilation and Do not produce

ns effacement of the cervix. Occur regularly progressive dilatation and
and increase in frequency, duration, and effacement. Are irregular
intensity. Felt in lower back, radiating to
and do not increase in
lower portion of abdomen
frequency, duration, and
intensity. Often stop with
walking, Contractions felt in
abdomen above umbilicus
(abdominal pains)
Show Is present. There will be pinkish mucus or Not present. May have
a bloody discharge. This mucus or brownish discharge that
discharge may also be from the mucous may be from vaginal
plug from the cervix exam if within the last 48
hours.
Cervix Becomes effaced and dilates progressively. Usually uneffaced and

closed.
Fetal No significant change, even though fetus May intensify for a short
Movement continues to move. period or it may remain
the same.
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The purpose of uterine contraction.
1. Accomplish the effacement and dilation of the cervix.
2. Facilitate the descent & rotation of the fetus through the passages.
3. Facilitate the separation & expulsion of the placenta.
4. Control bleeding after delivery by compressing blood vessels.
Effacement= the thinning or shortening of the cervix.
The process begins between 38 and 40th week. The exact cause of onset is not understood. There
are several hypothesis: Progesterone withdrawal relaxation of the myometrium, whereas
estrogen stimulates myometrial contractions and production of prostaglandins. As you will learn
later, prostaglandin E is used to induce labor. During labor, prostagIandin the connective
tissue in the cervix to soften, thin out, and open during labor. Oxytocin, a hormone produced by
the pituitary, plays a major role in the onset and maintenance of contractions during the labor
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process. Corticotropin-releasing hormone makes the uterus more sensitive to oxytocin and the
prostaglandins. Different theories for one of the most emotional experiences.
Contractions have a rhythmic pattern, with periods of relaxation between, allowing the woman
to rest. This resting period allows for restoration of placental circulation: important to uterine
muscles but also for the babys oxygenation.
Increment: the building up and longest; acme peak; and decrement or letting up.
Characteristics: frequency: time between beginning of one contraction to the beginning of the
next. Duration: beginning to completion of a single contraction. Intensity strength of
contraction. Experienced nurse can estimate by palpating the fundus (top) during the contraction.
Mild: the uterine wall can be indented; strong, it cannot be indented. Intensity can be measured
directly with an intrauterine probe.
Look at Figure17-1, pg, p 317
3. Effacement and dilatation of the cervix
Dilatation = the gradual opening of the cervix and is a continued extension of the
contraction-retraction process already described.
Dilatation and effacement take place concurrently throughout labor.
Dilatation is assessed by vaginal examination, and is recorded in centimeters from 0-10

cm.
Cervical dilatation alone does not confirm labor, since many women will demonstrate some
dilatation (1-3 cm) for weeks or months prior to the onset of labor.
Thus, labor will be determined by observing the patient over time and demonstrating progressive
cervical changes, in the presence of regular, frequent, painful uterine contractions.
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The process of dilatation and effacement occurs for mechanical &biochemical reasons.
The force of the contracting uterus naturally seeks to dilate and thin the cervix. However, the
cervix to be respond to these forces requires it to be "ready.
The process of readying the cervix on a cellular level usually takes place over days to weeks
preceding the onset of labor (ripening).
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4. Formation of the bag of fore-water
Hydrostatic Force = another power that facilitates the process of labor and birth.
Includes the pressure of the fetus within the amniotic sac.
As contraction occur, the membranes and amniotic fluid facilitates dilation and
effacement.
Since the lower uterine segment and cervix are regions of lesser resistance, the additional
pressure of the amniotic sac is of great importance in promoting the birth process.
COMPONENTS OF NORMAL LABOUR/ OR FACTORS THAT MAY EXTEND OR

INFLUENCE THE DURATION OF LABOR--5 PS
There are five essential factors that affect the process of labor and delivery. They are easily
remembered as the five Ps (passenger, passage, powers, placenta, and psychology).
a. Passenger (Fetus).
(1) Presentation of the fetus (breech, transverse).
(2) Position of the fetus (ROP, LOP).
(3) Size of the fetus.
b. Passage (Birth Canal).
(1) Parity of the woman, if she has ever delivered before.
(2) Resistance of the soft tissues as the fetus passes through the birth canal.
(3) Fetopelvic diameters.
c. Powers (Contractions).
(1) Force of the uterine contractions.
(2) Frequency of the uterine contractions.
d. Placenta.
(1) Site of implantation.
(2) Whether it covers part of the cervical os.
e. Psychology (Psychological State of the Woman).
(a) Patient extremely anxious.
(b) Emotional factors related to the patient.
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(c) Amount of sedation required for the patient.
THERE ARE FOUR STAGES OF THE LABOR
a. First Stage of Labor. The first stage of labor is referred to as the "dilating" stage. It is the
period from the first true labor contractions to complete dilatation of the cervix (10cm)
The forces involved are uterine contractions. The first stage of labor is divided into three phases:
(1) Latent (early) or prodromal.
(2) Active or accelerated.
(3) Transient or transitional.
b. Second Stage of Labor. The second stage of labor is referred to as the "delivery or expulsive"
stage. This is the period from complete dilatation of the cervix to birth of the baby. The forces
involved are uterine contractions plus intra-abdominal pressure.
c. Third Stage of Labor. The third stage of labor is referred to as the "placental" stage. This is
the period from birth of the baby until delivery of the placenta. The forces involved are uterine
contractions and intra-abdominal pressure.
d. Fourth Stage of Labor. The fourth stage of labor is referred to as the "recovery or
stabilization" stage. This period begins with the delivery of the placenta and ends when the
uterus no longer tends to relax. The forces involved are uterine contractions
First Stage of Labor 0 - 10 cm.
The first stage can be divided functionally into three phases: the latent phase, the active phase
and Transition phase.
Stage I lasts from the onset of labor to full dilatation of the cervix.
In primigravida: this stage lasts for about 10 to 12 hours.

In multipara: it lasts from 6 to 8 hours.
Phase 1 - Latent - dilate 0 - 3 cm.
Phase 2 - Active - dilate 4 - 7 cm.
Phase 3 - Transition - dilate 8 - 10 cm
Stage 2 - From complete dilation and effacement to delivery of the baby
Stage 3 - From delivery of baby to the delivery of the placenta
Stage 4 - the first hour after delivery
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Phase I: is the longest and least painful phase of labour. It starts from the time when the cervix
first starts to dilate to the time when the cervix is 4 cm dilated. It is also called 'Latent phase' of
labor. It can last for days and can occur with only the mildest discomfort to the pregnant woman.
commences with maternal perception of regular contractions
accompanied by progressive & slow cervical dilatation and ends at between 3 and 5 cm
of dilatation
Latent phase of labor (also known as prodromal labor) precedes the active phase of labor.
Women in latent phase labor
Is less than 4 cm of dilatation.

Have regular, frequent contractions that may be painful.
The contractions wax and wane
Cervix dilate only very slowly
Can usually talk or laugh during their contractions
May find this phase of labor lasting days or longer
Phase II: Active Phase Labor
A woman is said to be in "active labor" when contractions have become regular in frequency (3-4
in 10 minutes) and about 60 seconds in duration. The powerful contractions are accompanied by
cervical effacement and dilation.
Active phase labor lasts until the cervix is completely dilated.
Women in active phase labor:
Are at least 4 cm dilated.

Have regular, frequent contractions that are usually moderately painful.
Demonstrate progressive cervical dilatation of at least 1.2-1.5 cm per hour.
Usually are not comfortable with talking or laughing during their contractions
The contractions are more painful, of longer duration and come more regularly. It is also called
the 'middle phase ' of labor.
Phase III: During this phase, the cervix dilates from 8 cm to 10 cm, the cervix is fully dilated
and the baby's head can come out of the uterus safely and easily. This phase is also called the
'transition phase' of labor since it marks the transition of the First stage to the Second stage.
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In the "transition phase" from 8 cm10 cm of dilation, the contractions often come every two
minutes & lasting 7090 seconds.
Stage II: lasts from the full dilatation of the cervix to the expulsion of the baby. In a first
pregnancy, it lasts for about 1- 2 hour, in subsequent pregnancies, it lasts for about hour.
This stage is a stage when the baby's head is travelling down the vaginal canal to be delivered.
The contractions are very painful, appearing to produce continuous pain.
begin when cervical dilatation is complete and ends with fetal expulsion
median duration: in nulliparas - 50 min, in multiparas - 20 min
average second stage labor was lengthened about 25 minutes
limit of the length of the second stage
Progress of Labor
For a woman experiencing her first baby, labor usually lasts about 12-14 hours. In multigravida,
labor is generally quicker, lasting about 6-8 hours. These averages are only approximate, and
there is considerable variation from one woman to the next, and from one labor to the next.
During labor, the cervix dilates (opens) and effaces (thins). This process has been likened to the
process of pulling a turtleneck sweater over your head. The collar opens (dilates) to allow your
head to pass through, and also thins (effaces) as your head passes through.
Descent assessed by abdominal palpation: At 0/5, the sinciput (S) is at the level of the
symphysis pubis.
It should be assessed by abdominal examination immediately before doing a vaginal

examination, using theCervical diltation rule of fifth to assess engagement
The rule of fifth means the palpable fifth of the fetal head are felt by abdominal
examination to be above the level of symphysis pubis
When 2/5 or less of fetal head is felt above the level of symphysis pubis , this means that
the head is engage , and by vaginal examination , the lowest part of vertex has passed or
is at the level of ischial spines
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B P: Record every 2 hours and mark with arrows.
Temperature: Record every 4 hours.
Protein, acetone and urine volume: Record every time urine is passed
Descent; means that the fetal head descends through the birth canal.
The "station" of the fetal head describes how far it has descended through the birth canal.
This station is determined relative to the maternal ischial spines( bony prominences on each side
of the maternal pelvic sidewalls).
"0 Station" means that the top of the fetal head descended through the birth canal just to the level
of the maternal ischial spines.
-This means that the fetal head is "fully" engaged (or "completely engaged"), because the widest
portion of the fetal head has entered the opening of the birth canal (the pelvic inlet).
- If the fetal head not reached the ischial spines, this is indicated by negative numbers, such as -2
(the top of the fetal head is 2 cm above the ischial spines).
-If the fetal head has descended further than the ischial spines, this is indicated by positive
numbers, such as +2 (the top of the head is 2 cm below the ischial spines).
Negative numbers above -3 indicate the fetal head is unengaged (floating).
Positive numbers beyond +3 (+4 or +5) indicate that the fetal head is crowning and about to
deliver.
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Primigravida demonstrate deep engagement (0 or +1) days to weeks prior to the onset of labor.
Multiparous woman not engage below -2 or -3 until they are in labor, and nearly completely
dilated.
Cervical dilatation
In the second stage of labor, perform vaginal examinations once every hour.
It is the most important information and the surest way to assess progress of labour , even
though other findings discovered on vaginal examination are also important
when progress of labour is normal and satisfactory , plotting of cervical diltation remains
on the alert line or to left of it
if a woman arrives in the active phase of labour , recording of cervical diltation starts on
the alert line
when the active phase of labor begins , all recordings are transferred and start by pltting
cervical diltation on the alert line
Techniques for Assessment /Diagnosis of labour
Regular painful contractions resulting
in progressive change of the cervix
+/- show
+/- rupture of membranes
Assessment of progress of labor
Once diagnosed, progress of labor is assessed by:
-Measuring changes in cervical effacement and dilatation during the latent phase.
-Measuring the rate of cervical dilatation and fetal descent during the active phase.
-Assessing further fetal descent during the second stage.
Plot a simple graph of cervical dilatation (centimetres) on the vertical axis against time (hours)
on the horizontal axis.
Vaginal examinations
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Vaginal examinations should be carried out at least once every 4 hours during the first stage of
labor and after rupture of the membranes. At each vaginal examination, record the following:
-Color of amniotic fluid;
- Cervical dilatation;
-Descent of the presenting part (can also be assessed abdominally).
THE PELVIS
Determine if the pelvic cavity is of adequate size to allow for the passage of the full term infant
Optimum shaped pelvis is Gynecoid
Abdominal Palpation / Leopolds Maneuver
Standing on the Right side, face the woman and palpate with the palms of the hands.
Step 1 - Start at upper funds and palpate for the head or buttocks
Step 2 - Go down each side and locate back
Step 3 - Gently grasp lower portion of uterus and feel for the head
Step 4 - Turn and face the woman and repeat the steps.
Auscultation
Assess for the area of Greatest Intensity of the FHR.
Vaginal Examination
Presentation
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Position
Condition of Membranes --ruptured or intact
Dilation - enlargement and widening of os (cm.)
Effacement- thinning of the cervix (%)
Station: degree that the presenting part has descended into the pelvis. Relationship to ischial
spines
Engagement: largest diameter of presenting part has passed through the pelvic inlet
Assessment of Contraction
Contractions
Frequency
Intensity
Duration
Vaginal exam
Determine if true or false labor:
True: contractions regular, becoming stronger, lower back radiating to abdomen, more intense
with walking cervical changes, fetus moving to lower pelvis.
False: irregular contractions which stop with walking, pain abdominal and stopping with comfort
measures.
1. Subjective symptoms by woman
2. Palpation and timing by the Nurse/Midwife
3. Use of Electronic Fetal Monitor
Observations of the contractions are made every hour in the latent phase and every half-hour in
the active phase
Frequency how often are they felt?
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Assessed by number of contractions in a 10 minutes period
Duration how long do they last?
Measured in seconds from the time the contraction is first felt abdominally, to the time the
contraction phases off
Each square represents one contraction
USING THE PARTOGRAPH
A partograph is a graphical record of the observations made of a women in labour
For progress of labour and salient conditions of the mother and fetus
It was developed and extensively tested by the world health organization WHO
The WHO partograph has been modified to make it simpler and easier to use.
The latent phase has been removed and plotting on the partograph begins in the active phase
when the cervix is 4 cm dilated.
Cervical dilatation assessed at every vaginal examination and marked with a cross (X). Begin
plotting on the partograph at 4 cm.
Alert line: A line starts at 4 cm of cervical dilatation to the point of expected full dilatation at the
rate of 1 cm per hour.
Action line: Parallel and 4 hours to the right of the alert line.
Partograph function
The partograph is designed for use in all maternity settings , but has a different level of
function at different levels of health care
in health center, the partograph critical function is
to give early warning if labor is likely to be prolonged and to indicate that the woman should
be transferred to hospital (ALERT LINE FUNCTION )
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in hospital settings, moving to the right of alert line serves as a warning for extra
vigilance , but the action line is the critical point at which specific management decisions
must be made
other observations on the progress of labour are also recorded on the partograph and are
essential features in management of labour
Components of the partograph
Part 1 : fetal condition ( at top )
Pqrt 11 : progress of labour ( at middle )
Part 111 : maternal condition ( at bottom )
Outcome:
Part 1: fetal condition
this part of the graph is used to monitor and assess fetal condition
1 - Fetal heart rate
2 - membranes and liquor
3 - moulding the fetal skull bones
Caput
Part111: maternal condition
Name / DOB /Gestation
Medical / Obstetrical issues
Assess maternal condition regularly by monitoring:
drugs , IV fluids , and oxytocin , if labour is augmented
pulse , blood pressure
Temperature
Urine volume , analysis for protein and acetone
Palpate number of contraction in ten minutes and duration of each contraction in seconds
MANAGING LABOR USING THE PARTOGRAPH
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OVERVIEW
The partograph can be used by health workers with adequate training in midwifery who are able
to:
o Observe and conduct normal labor and delivery.

o Perform vaginal examination in labor and assess cervical dilatation accurately
o plot cervical dilatation accurately on a graph against time
There is no place for partograph in deliveries at home conducted by attendants other than those
trained in midwifery.
Whether used in health centers or in hospitals, the partograph must be accompanied by a

program of training in its use and by appropriate supervision and follow up.
Objectives
early detection of abnormal progress of a labor
prevention of prolonged labor
recognize cephalopelvic disproportion long before obstructed labor
assist in early decision on transfer , augmentation , or terminjation of labor
increase the quality and regularity of all observations of mother and fetus
early recognition of maternal or fetal problems
The partograph can be highly effective in reducing complications from prolonged labor
for the mother (postpartum hemorrhage, sepsis, uterine rupture and its sequelae) and for
the newborn (death, anoxia, infections, etc.).
PARTOGRAPH FUNCTION
The partograph is designed for use in all maternity settings, but has a different level of function
at different levels of health care in health center, the partograph is critical function is to give
early warning if labor is likely to be prolonged and to indicate that the woman should be
transferred to hospital (ALERT LINE FUNCTION )
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In hospital settings, moving to the right of alert line serves as a warning for extra vigilance, but
the action line is the critical point at which specific management decisions must be made
Other observations on the progress of labor are also recorded on the partograph and are essential
features in management of labor.
COMPONENTS OF THE PARTOGRAPH
Assessment of fetal well being
Assessment of maternal well being
Assessment of progress of labor
Measuring Fetal Well Being during Labor
Fetal heart rates and pattern
Degree of molding, caput
Color of amniotic fluid
Measuring Maternal Well Being during Labor
Pulse, temperature, blood pressure
Urine output, ketones, protein
Measuring Progress of Labor
Cervical dilatation
Descent of presenting part
Contractions
Duration
Frequency
Alert and action lines
Using the Partograph
Patient information: Name, gravida, para, hospital number, date and time of admission, and time
of ruptured membranes
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Fetal heart rate: Record every half hour
Amniotic fluid: Record the color at every vaginal examination:
I: membranes intact
C: membranes ruptured, clear fluid
M: meconium-stained fluid
B: blood-stained fluid
Molding:
1: sutures apposed
2: sutures overlapped but reducible
3: sutures overlapped and not reducible
Cervical dilatation: Assess at every vaginal examination, mark with cross (X)
Alert line: Line starts at 4 cm of cervical dilatation to the point of expected full dilatation
at the rate of 1 cm per hour
Action line: Parallel and 4 hours to the right of the alert line
Alert line (health facility line)
The alert line drawn from 4 cm dilatation represents the rate of dilatation of 1 cm / hour.
Moving to the right or the alert line means referral to hospital for extra vigilance.
Action line (hospital line)
The action line is drawn 4 hour to the right of the alert line and parallel to it.
This is the critical line at which specific management decisions must be made at the hospital.
Descent assessed by abdominal palpation: Part of head (divided into 5 parts) palpable above the
symphysis pubis; recorded as a circle (O) at every vaginal examination. At 0/5, the sinciput (S) is
at the level of the symphysis pubis.
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Hours: Time elapsed since onset of active phase of labor (observed or extrapolated)
Time: Record actual time
Contractions: Chart every half hour; palpate the number of contractions in 10 minutes
and their duration in seconds
Less than 20 seconds:
Between 20 and 40 seconds:
More than 40 seconds:
Oxytocin: Record amount per volume IV fluids in drops/min. every 30 min. when used
Drugs given: Record any additional drugs given
Temperature: Record every 2 hours
Pulse: Record every 30 minutes and mark with a dot ()
Blood pressure: Record every 4 hours and mark with arrows
Protein, acetone and volume: Record every time urine is passed
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The Modified WHO Partograph (Figure C-10)
CHAPTER VII: NORMAL CHILDBIRTH/ DELIVERY
INTRODUCTION
Physical preparation for childbirth has been recommend for many years
Each woman does exercises according physiological status; and those exercises are very
important during pregnancy and at the end, facilitate labor process and delivery. Before delivery
also psychological preparation is very important
DEFINITION OF NORMAL CHILDBIRTH/ DELIVERY
Is the process by which a single full term living viable fetus is expelled from the natural passage
within reasonable hours.
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In which the fetus presents by the vertex and which terminates naturally without artificial aid and
without complications.
Normal Labor is the process of expulsion of a mature fetus with the placenta and membranes. It
is divided into four stages
PREPARING NORMAL CHILDBIRTH/ DELIVERY
In normal childbirth/ delivery, usually a midwives or a nurse have to prepare the woman
Psychologically
Physically
1. PSYCHOLOGICAL PREPARATION
Psychological preparation is based on:

Motivation for pregnancy
Support
Preparation
Trust in staff
Maintaining control
Culture
Nurse or Midwives should formulate some questions:
Are your ready to be parents?
If it is the first time for you to become parents, psychological preparation is one of the most
important things.
You muse have a lot of new expectation on your new baby. For example, whom the baby looks
like, what kind of talent the baby may have, and so on. However, some times, you might be
worry about that some unexpected happens.
Therefore, new parents must be brave facing the new life which will be fulfilled with un-
expectations
CLARIFY THE PURPOSE TO HAVE A BABY
Have you been ever thinking why you are going to have a baby?
Answering this question is helpful to clarify what is the most important in your life.
Parents value will affect the next generations value.
Therefore, please think about the goal of the life. Whether everything you are going to do during
fostering your children will represent your value and the dream for the future.
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TAKE THE RESPONSIBILITY AS A FATHER/MOTHER
No matter mother works out or stays as housewife, in modern society, father takes more and
more responsibility in fostering their children.
These two decades, according to psychologist and professionals in children development, father
takes an important role in educating children.
And there are some activities can not be replaced by mothers.
LEARN TO ACCEPT THE CHILD IN REALITY
Each child has his / her own unique personality. When he / her personality is not as same as your
expectation, you may be a little bit disappoint. You need to learn to accept the child in reality; to
develop his / her personality and potential. You will be able to get progress together during love
atmosphere
It is different form mother, fathers encourage and push can develop childrens potential.
Separating the roles in fostering children let father and mother know each other more deeply.
It is helpful to make a happy family
GIVE BABY A SUITABLE NAME
How to give your baby a suitable name, you can make a reference as follows:
The name reflects your wish to your baby.
Let your with go with your child for his / her whole life.
Be natural and smooth to read.
The name needs to give others a good and deep impression.
Give brothers or sisters a similar name
PREPARATION FOR LABOR AND DELIVERY
a. Relaxation and Psychological Control of Pain. Several methods of relaxation and

psychological control of pain during labor are listed below:
(1) Lamaze method (Psychoprophylactic method-PPM).
This method is the most widely taught. It deals with combating the fears associated with
pregnancy by teaching relaxation and breathing techniques.
(a) The patient is taught to replace responses of restlessness and loss of control with more useful
activity.
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(b) The patient is taught to respond to pain with respiratory activity and relaxation of uninvolved
muscles.
(c) The patient is taught controlled breathing and mind-focusing techniques.
(d) The partner is taught to help the patient stay in control.
2) Bradley method (husband-coached childbirth). This is similar to the Lamaze method.
Emphasis is placed on slow, deep breathing along with complete relaxation.
Women using this practice often appear to be asleep during labor.
However, they are not asleep, but are simply in a state of deep mental relaxation
Signs of Approaching Labor
b. signs of approaching labor are taught to all patients. When the patient notices them, she is
aware that labor will be forthcoming. The signs are
(1) Lightening. This is the descent of the fetus into the brim of the pelvis (dropping).
(2) False labor (Braxton-Hicks Contractions). This is intermittent uterine contractions occurring
at irregular intervals, which serve to tone the uterus.
(3) "Show." This is when the blood-tinged mucoid vaginal discharge becomes more pronounced
and red as cervical dilatation increases during labor.
(4) "Burst of energy." This is an increase in energy level. It occurs approximately 24 hours before
onset of labor. The patient should be advised to relax during this time since labor will be starting
soon
.;(5) Rupture of membranes. This occasionally may be the first sign. Due to the risk of the
prolapse cord, the patient needs to be aware that she should come to the hospital immediately
even if she is not having contractions. If the membranes rupture prematurely, it then becomes a
complication
(6) Frequent urination. His, again, becomes a problem in the last stages of pregnancy. Pressure
on the bladder is due to the enlarging uterus and the head settling back into the pelvis.
Emotional Supports
Knowledge and childbirth education prepare coupled with reassurance
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Compliments and encouragement are critical during all phases of childbirth
The presence of loved ones ,a labor coach and a responsive medical team will help to see that
you are supported as you wish and you childs birth is a safe
2. Physical preparation
The first of all, a midwives or nurses have to prepare the admission room
This room must have
A good environment: E.g good air, light ventilation , no noise
Without intoxication products
Comfortable and appropriate bed & chair
Put some drinks like fantasy, tea juice
Bed pan, under sheet, cotton, gauze, latex exam gloves, disinfectant
Materials of vital signs and labor monitoring
Plastic protection .
Woman preparation:
Nurse and client they have to be agreed about preparation process.
Midwives or nurse give a good position
Takes vital signs
Physical examination
Genital organs disinfected
Obstetric examination
Advise the woman to go to bath, if it is necessary
Advise about the importanceof some physical exercises
Advise about the importance of drinking during labor
Encourage mother to rest
Eat lightly and conserve energy
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Assist with relaxing activities such as reading walking, breathing exercises during contraction as
needed
Encourage position changes
Relaxing and slow breathing or vocalizing during contractions
Drinking fluids and/ or eating light foods desired or allowed
Reassure mother that to the end and that all of the intense sensations are indeed normal
Nursing responsibility
A Resting Phase
Encourage rest,
Review pushing positions,
Remind mother to empty bladder if unmediated
Drink fluids and wait for the urge to bear down.
May need to request that mother be able to labor down if urge is not strong enough
Descent Phase
Encourage position changes as mother
Prefers or if no noticeable progress
Rest between contractions
Drinking fluids
Water and other fluids are important to re-hydrate a mother body before, during and after
delivery. The full benefit of hydration to help our bodies work the best they can.
For example, sugary drinks may taste nice and give her energy, when needed.
Being dehydrated can make you more tired and so you perform better when your body is
hydrated well.
Water and other fluids are important to re-hydrate a mother body before, during and after
delivery. The full benefit of hydration to help our bodies work the best they can.
For example, sugary drinks may taste nice and give her energy, when needed.
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Being dehydrated can make you more tired and so you perform better when your body is
hydrated well.
Respect these messages and signs, and listen out for them.
The more in tune you are with your body, the better and more prepared you will be for when you
go into labor
Sitting cross legged on the floor will help the inside thigh (adductor) muscles become more
flexible, as will sitting on the floor with your legs apart and knees straight. This will also stretch
your hamstrings.
Flexibility of muscles is very important during labor. As conclusion to prepare a woman pregnant
about delivery, is very important for family, woman herself and for the future new born. Those
reassure a woman about delivery process.
Normal delivery
Process of normal delivery
The normal delivery is a process of giving birth a single living fetus delivered spontaneously,
through the birth canal within a reasonable time, without surgical intervention (except
episiotomy) without fetal or maternal complications
PREPARATION OF MATERIAL
On the cleaned trolley; Delivery set includes;
Surgeon gown,2 forceps, 2 scissors, amniotome, Gauze swabs, clamp cord, A tray for the
placenta, Sterileundersheets, Foetoscope/dopler ,Urinary catheter, Syringes+needles,
sterile gloves, stitch catgut, Patient identity bracelets, Dustbin, security box
For midwife; boots, masks, eye glasses, head cup, plastic protection
Material of the baby; Babyscale, Tape measure, thermometer, Emergency trolley
Process of delivery
As known there are 5 components which work together, they are interrelated in their influence
on the process of labor and birth these are; Passenger (fetus),Powers (uterine
contractions),Passage (the pelvis & maternal soft parts),Position (maternal),Psyche (maternal
psychological status).
Power
the Forces of Labor
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Primary forces: is the uterine contraction complete effacement and dilation of the cervix.
Secondary forces: use of abdominal muscles to push during the 2nd stage of labor.
Phases of Contractions
Increment
Acme
Decrement
Characteristics of contractions
Frequency
Duration
Intensity
The Birth Passage
Implications of Pelvic types for Labor and Delivery
Pelvic Divisions and Measurements
The Passenger
Mechanical influences
Fetal head
Fetopelvic relationships
Landmarks: Head is divided into designated areas (1) the sinciput or brow portion; (2) the vertex,
or top of the head between the 2 fontanelles; (3) the occiput or back of the head over the occipital
bone.
Position
Position of the placenta,time, mode of expulsion
Cardinal Movements
Also called the mechanisms of labor. A series of adaptations the fetus makes as it moves
through the maternal bony pelvis during the process of labor & birth. Influenced by the size and
position of the fetus, the powers of labor, the size and shape of the maternal pelvis, and the
mothers position.
8 Cardinal Movements
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In an anterior occiput positionEngagement, Descent, Flexion, Internal rotation, Extension,
Restitution, External rotation of the shoulders, Expulsion.
Engagement
The mechanism by which the fetus nestles into the pelvis. A fetus is engaged when the biparietal
diameter of the fetal head reached the level of the maternal ischial spines; known as zero station.
Leopolds maneuvers: the head is more difficult to move and less of the head is able to be
palpated abdominally after engagement.
Descent
Describes the process that the fetal head undergoes as it begins its journey through the pelvis.
Pressure from uterine contraction, hydrostatic forces, abdominal muscles, and gravity promote
descent of the fetus through the pelvic inlet and midplane. Descent is continuous from the time
of engagement until birth. Assessed by measurements called stations.How far the baby is "down"
in the pelvis, measured by the relationship of the fetal head to the ischial spine. The ischial spine
is in (0) Station
If the presenting part is higher than the ischial spine, the station has a (-) neg. Positive =
presenting part has passed the ischial spine. Positive (+) is at the outlet.
Flexion
The process of the fetal heads nodding forward toward the fetal chest and occurs as a result of
descent, the thickening of the uterine fundus, & increased resistance of the soft tissues.
Engagement, descent and flexion tend to occur simultaneously.
Internal Rotation
Most commonly the fetus rotates internally from the occiput transverse position assumed at
engagement into the pelvis to an occiput anterior position while continuously descending.
Extension
Enables the head to be born when the fetus is in a cephalic position. Results from the downward
forces of the uterine contractions and the resistance of the pelvic floor muscles. Begins after the
head has crowned and is complete when the head passes under the symphysis pubis and the
occiput, anterior fontanelle, brow, face, and chin pass over the sacrum & coccyx and are born
over the perineum.
Restitution
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Results in a realignment of the fetal head with the body, after the head is born. It is common that
as the head internally rotates to an anterior position before its birth, the shoulders may enter the
pelvis in the oblique diameter. This allows the head to turn, but as a result, the neck twists.
Restitution occurs when the head is free of pelvic resistance, allowing the head to turn back until
it is again at right angles to the shoulders.Delivery of head - CONTROL head to prevent
subsequent tearing check for presence of cord around neck
External Rotation
After the head is born & restitution occurs, the shoulders externally rotate so that they are in the
anteroposterior diameter of the pelvis.This is the largest diameter of the outlet, it easily allows
the birth of the broad shoulders. Aspirate oral and nasal cavities with gauze swabsShoulders are
born by first delivering the anterior shoulder from under the symphysis pubis and then the
posterior shoulder from over the perineum.
Expulsion
The last cardinal movement; consists of the birth of the entire body, the body usually follows
easily after the birth of the head and shoulders. The time of birth is often documented at the
moment of expulsion complete delivery and put the baby on the abdomen of the mother, Section
of cord Give oxytocin IM
In general, the activity of the normal birthing process is given below:

a. Crowning, the appearance of the infant's head on the perineum.
b. Delivery of the head. This includes suctioning of the infants nose and mouth with a bulb
syringe. A DeLee suction trap is used if meconium is present.
c. Delivery of the anterior shoulder and the posterior shoulder.
d. Delivery of the trunk and lower body.
e. Clamping and cutting of the umbilical cord.
THIRD STAGE OF LABOR (PLACENTAL STAGE)

As previously mentioned, the third stage of labor is the period from birth of the baby through
delivery of the placenta. This is considered a dangerous time because of the possibility of
hemorrhaging. Begins after delivery of baby and ends with delivery of the placenta Average
duration: 8 minutes
Signs of the placental separation are as follows:

a. The uterus becomes globular in shape and firmer.
b. The uterus rises in the abdomen.
c. The umbilical cord descends three (3) inches or more further out of the vagina.
d. Sudden gush of blood.
Procedure
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Apply gentle traction one hand, pull cord another hand press on the supra pubic
Receive the placenta with two hands when it reach into the vagina and do twisting movement Put
on tray the placenta Check Placenta for completeness Recover missing pieces of placenta as
necessary Massage uterus to aid in hemostasis.
NURSING CARE DURING THE THIRD STAGE
a. Continue observation. Following delivery of the placenta, continue in your observation of the
fundus. Ensure that the fundus remains contracted. Retention of the tissues in the uterus can lead
to uterine atony and cause hemorrhage. Massaging the fundus gently will ensure that it remains
contracted.
b. Allow the mother to bond with the infant. Show the infant to the mother and allow her to hold
the infant.
INFORMATION TO RECORD
Record the following information;

a. Time the placenta is delivered.
b. How delivered (spontaneously or manually removed by the physician).
c. Type, amount, time and route of administration of oxytocin. Oxytocin is never administered
prior to delivery of the placenta because the strong uterine contractions could harm the fetus.
d. If the placenta is delivered complete and intact or in fragments.
INFORMATION TO BE RECORDED ABOUT THE DELIVERY

Record the following information.
a. Exact date and time of delivery.
b. Sex of the infant.
c. Condition of the infant (APGAR) after birth. APGAR is the most widely used method of
evaluating the condition of a newborn baby. A value of 0 to 2 is given for each observation (i.e.,
heart rate, respiratory effort, muscle tone, reflex irritability, and color). The values are added
giving a total APGAR score).
excellent condition would score 9 to 10 and a dead baby would score 0. Most babies score 7 or
better. The condition of the infant will be taken at one (1) minute, at five (5) minutes, and at
thirty (30) minutes.
d. Position of the infant at delivery.
e. Type of episiotomy, lacerations.
f. Spontaneous or forceps delivery.
g. Use of oxygen and suction on the infant.
h. Number of vessels in the cord.
i. Mother's name.
j. Any other pertinent facts about the delivery.
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Episiotomy
An episiotomy is an incision that is made on the perineum, the area between the vagina and the
anus, during a vaginal delivery to enlarge the outlet. It is no longer considered a routine
procedure during childbirth although it is performed in most first deliveries and in many
multigravida women (women who have been pregnant more than one time). Much controversy
exists regarding the advantages and disadvantages of this procedure as well as the type of
episiotomy to be performed.
Indications
An episiotomy is done so as to :
hasten the birth of a distressed baby

prevent perineal tears
allow for the use of instrumentation, such as the application forceps, during delivery
protect the head of a premature baby during delivery
minimize or avoid complications associated with abnormal presentation such as breech,

face, or shoulder
deliver a big baby or when the babys head is too large
An episiotomy is not done as routine procedure but considered in the circumstances mentioned
above. The tissues that are incised are the vaginal epithelium (inner lining of the vagina), the
perineal muscles and skin. The wound is sutured (stitched) together after delivery of the baby
and placenta, and usually heals well by 4 to 6 weeks.
Types of Episiotomies
The two most common types of episiotomy are the midline episiotomy and the medio-lateral
episiotomy. There has been significant debate about the advantages and disadvantages of these
two types of episiotomy.
Midline Episiotomy
A midline episiotomy refers to an episiotomy where the incision of the vaginal opening is
directly in the midline, straight down toward the anus.
The advantages are :
less blood loss with this procedure.

less pain.
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an easier to perform procedure.
wound repair is done easily.
better cosmetic results due to less scarring.
However, the disadvantages are is that it :
Is ineffective in protecting the perineum and sphincters and may result in anal
incontinence (inability to hold feces in the rectum) due to third degree perineal tear. A
third degree perineal tear involves tear of the perineum as well as partial or complete
disruption of the anal sphincters.
May cause fourth degree perineal tear, where there is complete tear of the perineum and
damage to the anal sphincters as well as rectal mucosa.
Medio-Lateral Episiotomy
Mediolateral Episiotomy
The perineal tissue is cut diagonally from the center of the vaginal opening (6 oclock position)
outwards towards the ischial tuberosity (the rounded protuberance on the hip bone on which the
body rests while in a sitting position).
The advantages are that :
there is less chance of perineal damage.

third degree and fourth degree perineal tears are less likely.
The disadvantages are :
more difficult to repair.

increased bleeding as compared to median episiotomy.
more difficult to heal.
greater chances of scarring.
more pain during healing.
Technique of episiotomy
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Episiotomy should be performed at the time of maximum uterine contraction and only when the
presenting part distends the vaginal opening to about 3 to 4 cm. If forceps are to be applied,
episiotomy should be done just prior to its application.
By inserting two fingers in the vagina, the perineal skin is held away from the presenting
part of the fetus (head, buttocks, face, or shoulder).
The area to be cut is infiltrated with local anesthesia if epidural anesthesia is not given.
Still keeping the fingers within the vaginal opening, the tissue is cut by a pair of rounded
episiotomy scissors.
The incision given is approximately 3 to 5 cm in length, either in the midline or
mediolaterally.
The cut enlarges the vaginal opening and helps in easy delivery of the baby.
If a forceps or vacuum delivery is contemplated, a larger incision may be necessary.
After delivery of the baby and placenta, the episiotomy incision is repaired in layers by
means of absorbable suture materials which will not need to be removed later.
After delivery of the baby and the placenta, the vagina and perineum are cleaned and carefully
examined. The physician must be sure that there has been no tearing of the vaginal walls or
cervix. The doctor or midwife may use a special instrument (a metal retractor) to adequately
visualize the vagina and cervix. Once the provider is certain there has been no further tearing, the
episiotomy itself will be visualized. The physician may wash the area with sterile water or an
antibacterial soap solution. If the incision has involved the lining of the rectum or the anal
sphincter (a doughnut shaped muscle that controls the anus and prevents the leakage of stool),
sterile fluids may be used to wash out the wound
Perineal repair
The Royal College of Obstetricians and Gynaecologists (RCOG) produced guidelines for the
repair of the perineum following either episiotomy, tear or both.
It estimates that 85% of women who have a vaginal delivery will have some degree of
perineal trauma and that 60 to 70% will require suturing.
Many years ago perineal tears or cuts were not routinely repaired but left to heal
spontaneously.
A Scottish study looked at 1st-degree or 2nd-degree perineal tears that were randomised
to suturing or not.
There was no difference in pain or depression at 6 weeks but there was poorer wound
closure and approximation in the unsutured group.
In practice it is sometimes necessary to repair the wound to achieve haemostasis.
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A recent study showed there may be an increased need for analgesia at the time of
hospital discharge but, otherwise, outcomes were not different
The following is recommended as a routine for perineal repair:
Ensure adequate analgesia. This may be achieved by topping up an epidural or by

infiltration with local anaesthetic.
It is often useful to place a pad high in the vagina to prevent blood from the uterus from
obscuring the view. Check the extent of cuts and lacerations. Sometimes the anatomy is
not clear and it becomes more apparent as the wound is repaired. If it is complex, a more
experienced operator may be required.
First repair the vaginal mucosa:
o The RCOG recommends polyglactin as the suture material of choice as it is

resorbed faster than polyglycolic acid (Dexon).
o Use of the longer-acting material results in greater risk of needing to remove
suture material some months later, but this is still present with polyglactin.
o A newer material called Vicryl Rapide is now available. This is absorbed much
faster and is far more satisfactory.
Use a large, round body needle and start above the apex of the cut or tear as severed
vessels retract slightly.
o Use a continuous stitch to close the vaginal mucosa.
o It may be necessary to place extra sutures to close lacerations.
o Use a continuous running stitch and not a locking stitch.
Interrupted sutures are then placed to close the muscle layer. Usually 3 are required.
Closure of the skin follows:
o Interrupted black silk sutures used to be standard practice but the area swells
considerably and examination a few days later will show that they are very tight
with bulging tissue between each suture.
o A Cochrane review found that a continuous subcuticular stitch produced more
comfortable results.
o A curved cutting needle is required.
o Work from the apex to the fourchette getting good apposition.
Some authors recommend closing the perineum in 2 rather than 3 layers.
Check that the repair is neat and satisfactory:
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o Perform a gentle vaginal examination to check for any missed tears or
inappropriate apposition of anatomy.
o Remove the pad that was placed at the top of the vagina and check that no other
swabs have been left in the vagina.
Finally put a finger in the rectum to check that no sutures have passed through into the
rectal mucosa and that the sphincter is intact.
o If sutures are felt in the rectum they must be removed and replaced.
o The anal sphincter will feel lax with an epidural anaesthetic.
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Severity of Episiotomies
The severity or extent of a vaginal laceration or episiotomy is often referred to in degrees as

discussed below.
Degrees of vaginal tears:
First Degree -The smallest or most simple episiotomy, extending only through the vaginal
mucosa. It does not involve the underlying tissues.
Second Degree -This is the most common type of episiotomy. It extends through the vaginal
mucosa and into the submucosal tissues, but does not involve the rectal sphincter or mucosa.
Third Degree -A third degree episiotomy involves the vaginal mucosa, submucosal tissues, and
a partial or complete transection of the anal sphincter muscle.
Fourth Degree -The most severe type of episiotomy includes incision of the vaginal mucosa,
submucosal tissues, and anal sphincter, and it also involves of the lining of the rectum.
The severity of the episiotomy is directly associated with the amount and seriousness of
postpartum and long-term complications. As the degree of the episiotomy increases, there is
more potential for infection, postpartum pain, and other complications, such as leakage of stool
and development of recto-vaginal fistula.
Care and Healing of episiotomy
The episiotomy wound normally heals by 4 to 6 weeks. The length of the incision as well as the
suture material used will determine the healing time. Proper care of the episiotomy wound is
necessary for quick healing and early recovery.
Pain relief during the first 24 hours can be obtained by using ice packs.
Pain relievers should be taken only on doctors advice.
Keeping the incision area clean with warm water and soap.
Sitting in a Sitz bath (a tub full of warm water) for 20 minutes several times a day can
help to relieve pain.
Application of local anesthetic ointments for pain relief.
Avoiding constipation, which can put pressure on the stitches
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Advantages of an Episiotomy
The delivery process becomes much easier.
Less effort is required by the mother to push the baby out during delivery.
Delivery can be hastened, especially when the baby is distressed.
Less chance of injury to the tissues.
A surgical incision is easier to repair than a jagged tear.
Fewer complications during delivery.
Complications of Episiotomy
Chances of perineal tear.
With third or fourth degree perineal tears, there are likely to be problems with gas and
feces control.
Longer duration of painful intercourse following childbirth.
Scarring at the incision site.
Bleeding.
Wound infection.
Pain and swelling locally.
Delay in wound healing.
Opening of the stitches.
Improper closing of the wound.
Scar endometriosis.
FOURTH STAGE OF LABOR (RECOVERY STAGE)
The fourth stage of labor, as previously mentioned, is the period from the delivery of the placenta
until the uterus remains firm on its own. In this stabilization phase, the uterus makes its initial
readjustment to the non pregnant state. The primary goal is to prevent hemorrhage from the
uterine atony and the cervical or vaginal lacerations.
NOTE: Atony is the lack of normal muscle tone. Uterine atony is failure of the uterus to
contract.
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NEWBORN CARE AND ASSESSMENT
INTRODUCTION
The practical nurse has a unique opportunity of closely observing and providing care for the
newborn infant after delivery .Because of the newborn infant's helplessness; his needs must be
met initially by nursing personnel. Many nursing assessments and evaluations are conducted for
the well-being of the infant. Nursing care does not stop with the newborn infant. Interaction with
the parents is also important in the development of a family unit.
After delivery of the baby and in the absence of any immediate problems, essential newborn care
begins with a thorough general clinical assessment.
This should be done on all infants soon after birth to detect signs of illness and congenital
abnormalities
Definition of newborn
The term newborn is the baby born in the 37 to 42 completed weeks of gestation.
The newborn period is defined as beginning at birth and lasting through the 28th day
following birth. Newborn is a baby from birth to four weeks.
CARE OF THE NEWBORN IN THE DELIVERY ROOM
There are several needs of a newborn infant that require close attention. Establishing and
maintaining respirations are the two needs that must be met immediately.
a. Establishing and Maintaining the Newborn's Airway
The midwife nurse suctions the infant before it is completely born with a bulb syringe or a
DeLee trap. A DeLee trap is used if meconium was present in the amniotic fluid. The bulb
syringe is used to remove mucus from his mouth and nose. The infant's mouth is suctioned first
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and then his nose. Once the infant is delivered, his head is held slightly downward to promote
drainage of mucus and fluid. The infant's face is wiped thoroughly clean. If the infant doesn't
breathe spontaneously, he should be stimulated to cry by slapping his heels, lightly tapping the
buttocks, and/or rubbing his back gently. The infant is then positioned with his head slightly
down when placed in the radiant warmer.
(1) Common characteristics of newborn respirations.
(a) Nose breathers. Sleeps with mouth closed, does not have to interrupt feedings to breathe.
(b) Irregular rate.
(c) Usually abdominal or diaphragmatic in character.
(d) Ranges from 30 to 60 breathers per minute.
(e) Breathing is quiet and shallow.
(f) Easily altered by external stimuli.
) Acrocyanosis may occur during periods of crying. Acrocyanosis refers to cyanotic look of the
baby's hands and feet when he is crying. When the baby stops crying, his hands and feet get pink
again.
(2) Signs and symptoms of newborn respiratory distress.
(a) Increased rate or difficulty breathing-growing and seesaw breathing. In normal respirations,
the infant's chest and abdomen rise. With seesaw respirations, the infant's chest wall retracts and
his abdomen rises with inspirations
(b) Sternal or subcostal retractions.
(c) Nasal flaring.
(d) Excessive mucus, drooling.
(e) Cyanosis.
b. Maintaining Body Temperature.
(1) Dry the infant thoroughly immediately after delivery. The infant is extremely vulnerable to
heat loss because his body surface area is great in relation to his weight and he has relatively
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little subcutaneous weight. Heat loss after delivery is increased by the cool delivery room and the
infant's wet skin.
(2) Place the infant in a radiant heat warmer.
(3) Place a stockinette cap on the infant's head to prevent heat loss through the head.
(4) Wrap /cover the infant snugly in a warm blanket.
(5) Place the infant closely to the mother's skin. Skin-to-skin contact with the mother will help
prevent heat loss.
c. APGAR SCORING OF THE NEWBORN
The APGAR scoring is a method of evaluating the condition of the newborn at one minute and at
five minutes after delivery.
a. Purpose: The APGAR scoring chart is used to evaluate the conditions of the baby at birth,
determine the need for resuscitation, evaluate the effectiveness of resuscitative efforts, and to
identify neonates at risk for morbidity and mortality.
b. Objective Signs Used for Evaluation:
(1) Heart rate.
(2) Respiratory effort.
(3) Muscle tone.
(4) Reflex irritability.
(5) Color.
c. Scoring.
(1) Evaluations at each of the five categories are initially done at one minute after birth.
(2) Each item has a maximum score of two and a minimum score of zero.
(3) The final APGAR score is the sum total of the five items, with a maximum score of ten. The
higher the final APGAR score, the better condition of the infant.
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(4) Evaluations at one minute quickly indicate the neonate's initial adaptation to extrauterine life
and whether or not resuscitation is necessary.
(5) The five-minute score gives a more accurate picture of the neonate's overall status, including
obvious neurologic impairment or impending death.
THE APGAR SCORE
SIGN SCORE
0 1 2
Activity/muscle tone Limp/flaccid SOME FLEXION OF ACTIVE

EXTREMITIES
Pulse Rate ABSENT <100 bts/min >100 bts/min
Grimace/ REFLEX NO RESPONSE GRIMANCE CRY, COUGH

IRRITABILITY
APPERANCE/ PALE BLUE BODY PINK, COMPLETELY PIN
COLOUR EXTREMITIES BLUE
RESPIRATORY EFFORT ABSENT SLOW IRREGULAR GOOD CRYING
Totals:
0-2 = severe distress
3-6 = moderate distress
7-10 = minimal distress
d. CORD CARE FOR THE NEWBORN INFANT
a. Inspect the cord frequently for signs of bleeding immediately after it has been cut.
b. Apply triple dye (refer to local policy) to the cord after the infant has had his bath and has
been determined to be stable. The dye prevents infection and helps the cord to dry.
Cord care
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The umbilical stump needs particular attention as there are risks of bleeding and
infection.
Good cord care includes:
Cutting cord with sterile equipment

Ligation with a sterile plastic clamp
Keeping cord stump exposed, clean (with 70% alcohol, 4% chlorhexidine or simple soap
and water) and dry
Observe for cord detachment. The cord detaches in ten to fourteen days. The cord dries
faster when left uncovered. Have the parents roll the infant's diaper down some in front
initially so the cord is not covered.
Observe for signs of infection and report findings immediately. The signs of infection are
purulent drainage, redness, and possible swelling (more than usual).
e. Medication
Eye prophylaxis
With single-use doses of sterile ophthalmic ointment containing 1% tetracycline or 0.5%

erythromycin is usually done within the first hour after birth, but may be delayed until after the
first breastfeeding.
This medication is given to all neonates to prevent gonococcus ophthalmic neonatorum.
As you administer the ointment, take care to ensure that the agent reaches al parts of the
conjunctiva sac.
Excess solution can be wiped away after at least one minute
Vitamin K
Is given to prevent Vitamin K-dependant hemorrhagic disease of thenewborn.
A single dose of natural vitamin K1 oxide should be administered parenterally within the
first hour after birth
f. Identify the Infant after Delivery
(1) The infant must be properly identified before leaving the delivery room. An
identification (ID) band is placed on the infant's wrist and leg.
(2) labels record date of birth name of mothers baby and sex
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(3) An indelible pen should be used and writing should be clear and legible
(4) These should be shown to the mother or partner and applied to the babys ankles or
wrists whilst in the mothers presence
(5) The labels should not removed until the baby is in his own home
g. Establish Parent-Infant Bonding Process
(1) Parent-infant bonding is the initial step in the process of attraction and response between the
newborn and the parents. This paves the way for development of love and affiliation that forms a
strong family unit.
(2) This process should begin as soon after delivery as possible. In the delivery room as soon as
the infant is dry and identified, he should be given to the parents. The infant is more alert during
the first hours (approximately four) after birth than in the immediate subsequent hours.
EXAMINATION OF A NEWBORN BABY
Examination of a baby allows us to assess and monitor the babys condition and promptly
treat and give appropriate care as early as possible.
It is an important part of overall care contributing to the babys well being and survival.
Clinical assessment and Routine measurements
(a) Length (from top of head to the heel with the leg fully extended). +-3(52)
(b) Head circumference - repeat after molding and caput succedaneum are resolved. +-3(33)
Weight
normal 2.5 3.99kg
Length
normal 48 52cm
Occipital frontal circumference (OFC)
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normal 33 37cm
chest circumference
(c) Chest circumference (at the nipple line).
(d) Abdominal circumference.
(2) Record measurements in inches and centimeters.
(3) Document the information in the appropriate areas on nursing notes the delivery room record,
and the instant data card.
(4) Take infant's vital signs and document on nursing notes and the delivery room record.
(a) Temperature-only the first one is done rectally, the remainder is axillary.
(b) Heart rate and respirations-count a full minute because of the irregularities in rhythm.
Do a complete head-to-toe assessment, looking for any gross abnormalities on his hands, feet,
palate, spine, and so forth.
Clinical assessment of Head
After these general observations, examine the infant starting with the head and moving down the
body.
Observe the size and shape of the head (micro- or macrocephaly; cephalhaematoma)
Check the anterior and posterior fontanelles and that the skull sutures feel normal
Form and position of ears (low set ears occur in chromosomal abnormalities)
Assess for anomalies
Observe the general contour of the infant's head. Gently palpate the sutures and
fontanelles. The anterior fontanelle is approximately two inches long and is gem/diamond
shaped. The posterior fontanelle is smaller than the anterior fontanelle. Normally, the
fontanelle feels soft and is either flat or slightly indented. The anterior fontanelle usually
bulges when the infant cries, coughs, or vomits.
Observe the general appearance of the infant's neck. The infant's neck is usually short,
thick, and covered with folds of tissue. The infant should be able to move his neck from
side to side, from flexion to extension, and can hold his head in the midline position.
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Observe the infant's eyes for symmetry of size and shape. Note the infant's eye
movements. Strabismus caused by poor neuromuscular control is normal. An infant older
than ten days should look in the direction in which you turn. Note the color of the infant's
eyes.
Inspect the infant's ears for structure, shape, and position. The ears should be firm with
wee-formed cartilage. Tops of the auricles should be parallel to the outer canthus of the
eye.
Inspect the infant's nose for patency.
Inspect the infant's mouth for cleft palate by gently depressing his tongue when he cries.
Check the mucous membranes. Observe the soft and hard palate. Make sure they are in
tact.
Skin Clinical assessment
Inspect the infant's skin and nails. Observe for jaundice, birthmarks, milia, petechiae, and lanugo.
Observe the infant's hands and feet for normal creases. Observe the color of the infant's nail
beds; they should be pink. Acrocyanosis may be present up to 24 degrees, especially when the
infant is crying.
Vernix caseosa: a cream/white cheesy material on the skin at birth which cleans off
easily with oil.
Lanugo; fine downy hairs seen on the back and shoulders especially in preterm infants.
Milia: pinpoint whitish papules on nose and cheeks due to blocked sebaceous glands.
Inspect the size, shape, and symmetry of the infant's chest. Normally, an infant's chest is circular
or barrel-shaped. The breast tissue of both male and female infants may be slightly engorged
during the first few days of life.
Palpate the infant's peripheral pulses (femoral, brachial, and radial).
Assessment of Gastrointestinal System
Inspect the size and shape of the infant's abdomen. The abdomen should be cylindrical in shape.
Sunken or distended abdomen should be reported. Check the umbilical cord for the number of
vessels.
Auscultate the infant's abdomen for bowel sounds. Bowel sounds should be present within one to
two hours after birth.
Observe for excessive drooling, coughing, gagging, or cyanosis during feeding.
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Place the infant on his abdomen and observe his spine for curves, masses, or abnormal openings.
Inspect the male infant's genitalia. The penis should be checked for location of the urinary
meatus. The scrotum may appear edematous and proportionately large.
Inspect the female infant's genitalia. The labia majora may appear edematous and cover the
clitoris and the labia minora.
Assessment of Neuro System
Reflexes are involuntary movements or actions. Some movements are spontaneous, occurring as
part of the baby's usual activity. Others are responses to certain actions. Reflexes help identify
normal brain and nerve activity. Some reflexes occur only in specific periods of development.
The following are some of the normal reflexes seen in newborn babies
SUCK REFLEX
Rooting helps the baby become ready to suck. When the roof of the baby's mouth is
touched, the baby will begin to suck.
This reflex does not begin until about the 32nd week of pregnancy and is not fully
developed until about 36 weeks.
Premature babies may have a weak or immature sucking ability because of this.
Babies also have a hand-to-mouth reflex that goes with rooting and sucking and may suck
on fingers or hands.
ROOTING/ ROOT REFLEX

This reflex begins when the corner of the baby's mouth is stroked or touched.
The baby will turn his/her head and open his/her mouth to follow and "root" in the
direction of the stroking.
This helps the baby find the breast or bottle to begin feeding.
GRASP REFLEX
stroking the palm of a baby's hand causes the baby to close his/her fingers in a grasp.
The grasp reflex lasts only a couple of months and is stronger in premature babies
MORO REFLEX OR THE "STARTLE" REFLEX
This reflex is a response to a surprisingly loud noise or when an infant feels like it is
falling. This newborn reflex disappears when babies reach their second month of life.
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The presence of this reflex lets the baby's doctor know that the baby's brain is
appropriately communicating with the bodies.
BABINSKI REFLEX
When the sole of the foot is firmly stroked, the big toe bends back toward the top of the
foot and the other toes fan out. This is a normal reflex up to about 2 years of age.
STEP REFLEX
This reflex is also called the walking or dance reflex because a baby appears to take steps
or dance when held upright with his/her feet touching a solid surface.
Examination of a baby allows us to assess and monitor the babys condition and promptly treat
and give appropriate care as early as possible.
It is an important part of overall care contributing to the babys well being and survival.
CHAPTER VIII: THE POSTPARTUM MONITORING
INTRODUCTION
Care during the postpartum period provides the opportunity to ensure the mother and infant are
progressing well, to support the breastfeeding mother and to detect and manage any problem.
Postpartum care does present a special challenge, because there are two patients with very
distinct needs: a newly delivered woman and her infant
Skilled care and early identification of problems during this time could reduce the incidence.
DEFINITION
Postpartum is a time when problems may develop quickly, which if not diagnosed promptly and
treated effectively, can lead to illness and death of the mother or infant.
It is an area of maternal care that deserves more attention and consideration
It is the period of time when the anatomic and physiologic changes of pregnancy are reversed
and the body returns to the normal non-pregnant state
The postpartum period, or puerperium, starts after the delivery of the placenta and continues for
42 days or 6 weeks
Postpartum monitoring deals with the necessary maternal and child health care that should be
provided both
THE GOALS OF POSTPARTUM CARE
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Support of the mother and her family in the transition to a new family constellation, and response
to their needs.
2. Prevention, early diagnosis and treatment for complications of mother and infant.
3. Referral of mother and/or infant for specialist care when necessary.
4. Counseling on infant care.
5. Support of breastfeeding
6. Counseling on maternal nutrition, and supplementation, if necessary.
7. Counseling and provision of contraception and advice regarding resumption of sexual activity
(Family planning).
8. Immunization of the infant.
Timing and Services of Postpartum Care
TYPES OF POSTPARTUM MONITORING
1. Immediate postpartum
2. Late postpartum
1 .IMMEDIATE POSTPARTUM MONITORING
Immediately postpartum,
A full assessment of maternal and fetal wellbeing must be made following delivery. Mothers
should be given their babies to hold for an unlimited period with skin-to-skin contact within
thirty minutes of delivery (or within thirty minutes of the mother being able to respond in the
case of Caesarean deliveries) in a relaxed unhurried environment. They should be encouraged to
initiate the first breastfeed as soon as the baby is receptive .
Rest, refreshment and analgesia should be offered prior to warding.
POSTPARTUM ASSESSMENT AND PATIENT EDUCATION
Primary responsibilities of nurses in postpartum settings are to assess postpartum clients, provide
care and teaching, and, if necessary, report any significant findings. Postpartum nurses are
essentially detectives searching for findings that might lead to negative outcomes for clients if
left unattended. Thus, it is imperative for nurses to distinguish between normal and abnormal
findings and to have a clear understanding of the nursing care necessary to promote clients
health and well-being.
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Many nurses find it useful to use the acronym BUBBLE-LE to remember the necessary
components of the postpartum assessment and teaching topics. These include: breasts, uterus,
bowel function, bladder, lochia, episiotomy/perineum, lower extremities, and emotions.
Breasts
Assess the breasts for:
Signs of engorgement, including fullness, around postpartum days 3 and 4

Hot, red, painful, and edematous areas, which could indicate mastitis
Nipple condition and latch-on technique of clients who are breastfeeding.
Breastfeeding clients should wear a comfortable, well-fitted support bra. Instruct them to gently
rub colostrum or breast milk into their nipples and allow the nipples to air dry after each feeding
to condition the nipples. Clients can prevent drying by avoiding soap when washing the
nipples.
It is also extremely important to teach clients proper breastfeeding techniques to ensure a

positive experience for clients and their infants. Teaching proper latch-on techniques and how to
break the infants suction after feeding can have a positive and lasting effect upon clients
breastfeeding experiences. Otherwise, clients may develop sore, cracked, and sometimes
bleeding nipples, which can discourage the continuation of breastfeeding.
According to the Joanna Briggs Institute (2009), Among the options of applying warm-water
compresses, breast milk or teabags, the placement of a warm-water compress was found to be the
most effective intervention in controlling nipple pain and trauma.
Instruct bottle-feeding clients to wear a well-fitting support bra and to avoid any type of nipple
stimulation until lactation is discontinued.
Uterus
Assess the fundus:
By approximately one hour post delivery, the fundus is firm and at the level of the
umbilicus.
The fundus continues to descend into the pelvis at the rate of approximately 1 cm or
finger-breadth per day and should be nonpalpable by 10 days postpartum.
In addition, assess clients for uterine cramping and treat for pain as needed.
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Clients or a family member can be taught to assess the firmness of the fundus and to provide
massage in the event of a boggy uterus or excessive bleeding. Encourage clients to void before
palpation of the uterine fundus because a full bladder displaces the uterus and can lead to
excessive bleeding.
Bowel Function
Assessment of the bowel is important in all postpartum clients. It is especially vital for clients
following C-sections. Assess for the following:
Bowel sounds
Return of bowel function
Flatus
Color and consistency of stool
Administer prescribed stool softeners or laxatives as needed to treat constipation and ease
perineal discomfort during defecation.
Encourage clients to ambulate soon after delivery. Teach the need to eat fruits, vegetables, and
other high-fiber foods daily. Postpartum clients should consume at least 2,000 mL/day of fluid.
While clients may consider 2,000 mL a lot to drink in one day, consumption can be spread out
throughout the day.
Bladder
Assess urination and bladder function for the following:
Return of urination, which should occur within 6 to 8 hours of delivery.

For approximately 8 hours after delivery, amount of urine at each void. Clients should
void a minimum of 150 mL per void; less than 150 mL per void could indicate urinary
retention due to decreased bladder tone post delivery (in the absence of preeclampsia or
other significant health problems).
Signs and symptoms of a urinary tract infection (UTI).
The bladder should be nonpalpable above the symphysis pubis.
Encourage clients to drink adequate fluid each day and to report signs and symptoms of a urinary
tract infection, including frequency, urgency, painful urination, and hematuria.
Lochia
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Assess lochia during the postpartum period:
Saturating one pad in less than an hour, a constant trickle of lochia, or the presence of
large blood clots is indicative of more serious complications (e.g., retained placenta
fragments, hemorrhage) and should be investigated immediately. A significant amount of
lochia despite a firm fundus may indicate a laceration in the birth canal, which should be
addressed immediately.
Foul-smelling lochia typically indicates an infection and needs to be addressed as soon as
possible.
Lochia should progress from rubra to serosa to alba. Any changes in this progression
could be considered abnormal and should be reported.
It is important to note that clients who had a C-section will typically have less lochia than clients
who delivered vaginally; however, some lochia should be present.
After discharge, clients should report any abnormal progressions of lochia, excessive bleeding,
foul-smelling lochia, or large blood clots to their physician immediately. Instruct clients to avoid
sexual activity until lochial flow has ceased.
Episiotomy/Perineum
The acronym REEDA is often used to assess an episiotomy or laceration of the perineum.
REEDA stands for redness, edema, ecchymosis, discharge, and approximation. Redness is
considered normal with episiotomies and lacerationshowever, if there is significant pain
present, further assessment is necessary. Furthermore, excessive edema can delay wound healing.
The use of ice packs during the immediate postpartum period is generally indicated.
There should be an absence of discharge from the episiotomy or laceration, and the wound edges
should be well approximated. Perineal pain must be assessed and treated. Nurses are encouraged
to assess the rectal area for hemorrhoids and, if present, should instruct clients to discuss
hemorrhoidal treatments (e.g., witch hazel pads or other over-the-counter hemorrhoid
medications) with their certified nurse-midwife or physician.
Various actions can aid in perineal healing, To avoid infection, teach clients to pat from front to
back and to use a peri-bottle for gentle cleansing of the perineum after a bowel movement or
urination. Many certified nurse-midwives and physicians prescribe topical ointments and sprays
to ease the discomfort of a sore perineum. Instruct clients to use a sitz bath and then apply the
suggested topical agent for best results.
149
Analgesics are often prescribed for pain. Clients are generally instructed to apply ice packs to the
perineum immediately after delivery. Inform clients with lacerations and episiotomies that, as
sutures dissolve, the perineum may itch and that this is normal in the absence of any other
perineal abnormalities. Instruct clients to avoid tampons and sexual activity until the perineum
has healed.
Performing Kegel exercises are an important component of strengthening the perineal muscles
after delivery and may be begun as soon as its comfortably do so.
Lower Extremities
To assess for deep vein thrombosis (DVT), the lower extremities should be examined for the
presence of hot, red, painful, and/or edematous areas. In the past, postpartum nurses assessed for
DVTs by eliciting a Homans sign (dorsiflexion of the foot). The presence of pain when eliciting
the Homans sign indicated the probable presence of a DVT. However, it is now contraindicated
to use the Homans sign to assess for DVTs as this action may dislodge a clot. Massage of the
legs should also be avoided.
Assess the legs for adequate circulation by checking the pedal pulses and noting temperature and
color. In addition, the lower extremities should be assessed for edema. Pedal edema is normally
present for several days after delivery as fluids in the body shift. However, lasting edema should
be reported for further assessment.
To improve circulation and prevent the development of thrombi, encourage clients to ambulate
shortly after delivery. Also teach them to avoid crossing the legs for long periods of time and to
keep the legs elevated while sitting. Many certified nurse-midwives and physicians seek to
combat the development of thrombi by encouraging clients to wear TED hose and/or sequential
compression devices (SCDs) after delivery.
Emotions
Emotions are an essential element of the postpartum assessment. Postpartum clients typically
exhibit symptoms of the baby blues or postpartum blues, demonstrated by tearfulness,
irritability, and sometimes insomnia. The postpartum blues are caused by a multitude of factors,
including hormonal fluctuations, physical exhaustion, and maternal role adjustment. This is a
normal part of the postpartum experience. However, if these symptoms last longer than a few
weeks or if the postpartum client becomes nonfunctional or expresses a desire to harm herself or
her infant, she should be instructed to report this to her certified nurse-midwife or physician
immediately. Appropriate interventions should be implemented to protect the client and her
infant; this behavior is indicative of postpartum depression (discussed below under Postpartum
Complications).
150
Postpartum clients and their families should be taught to understand that the baby blues are a
normal part of the postpartum experience. Encourage clients to rest regularly and to allow family
members to care for them as needed. Instruct clients to get plenty of fresh air and gentle exercise.
Acquaint clients with groups for new mothers that provide the support of others experiencing
postpartum blues. Finally, teach postpartum clients and their families about the signs and
symptoms of postpartum depression.
CARE OF MOTHER
A. Monitor the vital signs
After complete delivery nurse or Midwives puts the mother in comfortable position.
For 15 minutes during the first hour, every 30 minutes during the next hours: nurse or midwives
takes vital signs and recorded
Temperature
Blood pressure
Breaths
Haemoglobin
Repeat temperature measurement after 2 hours
If temperature is still >38C
Chills
Look for abnormal vaginal discharge.
Feel lower abdomen for tenderness
Temperature still >38 oC and any of:
Foul-smelling vaginal discharge
Low abdomen tenderness
Temperature still >38 oc
If diastolic blood pressure is 90 mmHg, repeat after 1 hour rest.
If diastolic blood pressure is still 90 mmHg, ask the woman if she has:
severe headache
151
blurred vision
epigastric pain
Check protein in urine, if positive
Those can be worning signs of pre-eclampsia or eclampsia
Diastolic blood pressure 50 or 40mmHg on readings
Tachycardia
Look for conjunctiva pallor.
Look for palmer pallor. If pallor:
Is It severe pallor?
Some pallor?
Count number of breaths in 1 minute
Hemoglobin<7 g/dl.
Severe palmar and conjunctiva pallor or
Any pallor with >30 breaths per minute.
Any bleeding.
7-11 g/dl.
Palmar or conjunctival pallor.
Hemoglobin>11g/dl
No pallor.
B. CONTROL UTERUS CONTRACTION
Make sure that uterus is well contracted
The postpartum period is a critical transitional time for the woman on physiological, emotional
and social levels.
It is an important and integral phase of a woman's reproductive life cycle.
The principle change is uterine contracted after delivery.
152
It is important to monitor the fundal height because lack of uterine contraction may indicate
infection or retained products of placenta.
If pad is soaked in less than 5 minutes, manage as on.
If uterus not firm, massage the fundus to make it contract and expel any clots.
If bleeding is from perinea tear, repair or refer to hospital.
If the mother cannot pass urine or the bladder is full (swelling over lower abdomen) and she is
uncomfortable, help her by gently pouring water on vulva
CAUSES OF NO UTERINE CONTRACTION
Grand multiparty
Infection that can be caused by: prolonged labor, premature rupture of membrane with prolonged
labor posses greatest risk with an open passage to the uterus for pathogens to enter
Incompleteness of placenta and membranes
Hormone deficiency (estrogen).
C. VAGINAL BLEEDING
Look for abnormal vaginal discharge.
Assess the amount of vaginal bleeding.
Encourage the woman to eat and drink.
Ask the companion to stay with the mother.
Advise on Postpartum care and hygiene.
Ensure the mother has sanitary napkins or clean material to collect vaginal blood
If heavy vaginal bleeding, palpate the uterus and do
Uterine expulsion of clots
According WHO 2000, postpartum hemorrhage is the major cause of maternal death in the
world.
Reported that 26% of maternal deaths occurred during the postpartum period (11% in week one,
7% in week two and 8% in weeks three to six postpartum).
153
Causes included postpartum hemorrhage, genital sepsis and hypertensive disease.
The majority of these deaths 88% occur within four hours of delivery.
The primary causes of hemorrhage are uterine atony and retained placenta.
Vaginal or cervical lacerations
D.STATE OF PERINEUM
Is there bleeding from the tear or episiotomy
Does it extend to anus or rectum?
Other abnormal: Perinea Hematoma
NURSING INTERVENTION
Prevention of Complications
Reduce Discomfort
Nutrition
Rest & Sleep
Initiation to breasts feeding
Breasts Colostrums is the yellowish alkaline secretion from the breasts that may be present in the
last months of pregnancy and or the first three days after delivery.
It has high protein, vitamin A and immunoglobulin contents.
Colostrum has a laxative effect on the infant and is an idea, natural initial food.
The normal flow of milk secretion begins during the third postpartum day.
NEW BORN DURING SIX HOURS
Continue observation of the following:
1. Color
2. Respiration
3. Umbilical cord bleeding
4. Suckling response
154
5. Baby activity
6. Elimination
7. Temperature taking
Skilled nurse or midwives, good care and early identification of problems during this time could
reduce the incidence, and maintain health condition of the mother and baby
POST PARTUM COMPLICATIONS
POSTPARTUM HEMORRHAGE
The leading cause of mortality nowadays in women of childbearing age.
A blood loss that exceeds 500 ml after a vaginal birth or 1,000ml. After a cesarean birth.
Predisposing Factors in Postpartum Hemorrhage
Over distention of the uterus ( Multiple Gestation, , Hydramnios )
Multiparity ( > 5 )
Use of tocolytic drugs in precipitate labor or delivery
Prolonged labor
Use of forceps or vacuum extractor
Ceasarean birth
Manual removal of the placenta
Previous postpartum hemorrhage
General anesthesia
Low implantation of placenta
Clotting disorders
Previous uterine surgery
EARLY POSTPARTUM HEMORRHAGE
Causes:
Uterine Atony 80% - 90%
155
Trauma / lacerations to the birth canal during labor and delivery
Hematoma formation
EARLY SIGNS OF POSTPARTUM HEMORRHAGE
An uncontracted uterus
Large flow or stable drop of blood from the vagina
Saturation of more than 1 peripad per hour
Severe unrelieved perineal or rectal pain
Tachycardia
1. UTERINE ATONY
The lack of muscle tones that result in the failure of the uterine muscle fibers to contract firmly
around blood vessels when the placenta separates.
24 hrs. After birth uterus should be a firmly contracted ball resembling a grapefruit located at the
level of the umbilicus.
Lochia is dark red, moderate in amount; saturation of 1 pad/hr. is excessive.
SIGNS
Uterine fundus that is difficult to locate
Soft feel when fundus is located
Uterus that becomes firm when massaged but loses its tone when massage is stopped.
Uterine fundus that is located above expected level
Excessive lochia
MANAGEMENT
Uterine massage and expression of clots
Pharmacologic measures
20 u oxytocin in 1 L D5LRS per doctors order
156
Methylergonovine 0.2mg.IM per doctors order
If postpartum hemorrhage is uncontrollable, do a Hysterectomy.
2. TRAUMA
Can include vaginal, cervical, perineal lacerations and hematoma
If with lacerations of the birth canal, theres excessive uterine bleeding when fundus is
contracted firmly and on the right location. Bleeding is bright red, oozing, slow trickle or frank
hemorrhage.
FACTORS THAT CAUSES THE INCIDENCE OF OBSTETRIC LACERATIONS
Operative birth
Precipitate delivery
Congenital abnormalities of the maternal soft parts
Contracted pelvis
Size, abnormal presentation and position of the fetus
Relative size of the presenting part and birth canal
Previous scarring from infection, injury, operation
Vulvar, perineal and vaginal varicosities
3. HEMATOMAS
Occur when bleeding into a loose connective tissue occurs while overlying tissue remains intact.
Blood collects 25-500 ml. in the soft tissue
Related to vascular injury during spontaneous or assisted delivery involving the vulva or vagina.
Vulvar hematoma a discolored bulging mass producing deep, severe, unrelieved pain with
feelings of pressure.
SYMPTOMS
Severe vulva pain.
Unilateral purplish discoloration of the perineum or buttocks which are firm and tender.
Feeling fullness in the vagina.
MANAGEMENT
157
Application of small ice packs
Surgical evacuation\
RETAINED PLACENTA
Non-adherent Retained Placenta.
Result from partial separation of a normal placenta, entrapment of the partially or completely
separated placenta by an hourglass constriction ring of the uterus, mismanagement of the third
stage of labor or abnormal adherence of the entire placenta or a portion of the placenta to the
uterine wall.
MANAGEMENT
Manual separation and removal by a primary health care provider under light anesthesia to
facilitate exploration and removal.
Adherent Retained Placenta
Thought to be a result from zygotic implantation in an area of defective myometrium so that

there is no zone of separation between the placenta and the decidua.
Attempts to remove the placenta in the usual manner are unsuccessful, laceration or perforation
of the uterine wall may result putting woman in a greater risk of PPH and infection.
Degrees of attachment
Placenta Accreta slight penetration of myometrium by placental trophoblast.
Placenta Increta deep penetration of myometrium by placenta
Placenta Percreta perforation of the uterus by the placenta
MANAGEMENT
Blood component replacement therapy
Hysterectomy
LATE POSTPARTUM HEMORRHAGE
Blood loss of more than 500 ml. later than 24 hrs after delivery.
Sometimes not occurring until 5-15 days after delivery
158
CAUSES
Sub-involution delayed return of uterus to its pre-pregnant size and consistency.
Retained placental fragments.
PREDISPOSING FACTORS
Attempts to deliver placenta before separation
Manual removal of the placenta
Placenta accreta
MANAGEMENT
Oxytocin, Methylergometrine or Prostaglandins
Curettage
Broadspectrum antibiotics
If there is infection (fever, uterine tenderness, foul smelling lochia)
UTERINE INVERSION
Occurs when the uterus completely or partly turns inside out, usually during the 3rd stage of
labor.
PREDISPOSING FACTORS
Pulling on the umbilical cord before the placenta detaches from the uterine wall
Fundal pressure during birth
Fundal pressure on an incompletely contracted uterus after birth
Increased intra-abdominal pressure
An abnormally adherent placenta
Congenital weakness of the uterine wall
159
Fundal placental implantation
Signs
Uterus is either absent from the abdomen or a depression in the fundal area is present
Management
Doctor tries to replace the uterus through the vagina into a normal position
Laparotomy - if the above is not possible
Hysterectomy
After replacement, oxytocin is given to contract the uterus
POSTPARTUM INFECTIONS
Puerperal Infection
Term used to describe bacterial infections after childbirth
A fever of 38 C (100.4 F) or higher after the first 24 hrs. After childbirth occurring on at least 3
of the first 10 days after the first 24 hrs.
During the first 24 hrs. A slight elevation may occur because of dehydration or the exertion of
labor.
Organisms can move from the vagina, cervix, and uterus and out of the fallopian tube to infect
the ovaries and the peritoneal cavity. Blood vessels or lymphatic can carry infection to the rest of
the body.- Septicemia
Causative organisms can be Staphylococcus aurous,
gonococci, coli form bacteria, and rarely by Clostridia
Risk or Predisposing Factors
Cesarean birth increases the risk 5x because of trauma to tissues
Prolonged labor
Colonization of the vagina with pathogenic organisms
History of previous infections (UTI, mastitis thrombophlebitis)
Trauma
160
Prolonged rupture of membranes
Catheterization
Excessive number of vaginal examinations
Retained placental fragments
Hemorrhage
Poor general health (fatigue, anemia, frequent minor illness)
Poor nutrition (< PRO, Vitamin C)
Poor hygiene
Medical conditions such as diabetic
Low socioeconomic status
Signs and Symptoms of Postpartum Infection
Fever and chills
Pain and redness of wounds
Purulent wound drainage or wound edges not approximating
Tachycardia
Uterine Sub involution
Abnormal duration of lochia or foul odor
Elevated white blood cell count
Frequency or urgency of urination, dysuria or hematuria
Suprapubic pain
Localized area of warmth, redness or tenderness in the breast
Body aches, general malaise
ENDOMETRITIS
Infection of the uterus with pelvic cellulitis involving the decidua, myometrium, and
parametrical tissues
161
Caused by organisms those are normal inhabitants of the vagina and cervix (E. coli, bacteroids,
staphylococcus, and anaerobic non-hemolytic streptococcus
Signs and Symptoms
Occurs during the first 2-7 days
Fever, chills, malaise, anorexia, abdominal pain and cramping, uterine tenderness, purulent foul
smelling lochia, tachycardia, sub involution.
Management
Broad spectrum antibiotics IV Ampicillin, Cephalosporin's, Gentamycin, Clindamycin
Antipyretics and Oxytocics which increases drainage of lochia and involution.
Thrombus is a collection of blood factors, platelet, and fibrin on a vessel wall. Its formation is
associated with inflammatory process in the vessel wall (Thrombophlebitis).
3 MAJOR CAUSES OF THROMBOSIS
Venous stasis occurs from compression of the large vessels of the pelvis and legs by the
enlarging uterus
Woman stands for prolonged periods of time
Prolonged time in stirrups for delivery and repair of episiotomy.
Hyper coagulation
Levels of most coagulation factors are increased and fibrinolytic symptoms is suppressed which
hinders clot disintegration
Blood Vessel Injury - specifically to the intima of the blood vessel
FACTORS THAT INCREASES THE RISK OF THROMBOSIS
Inactivity (immobility)
Obesity
Cesarean birth
Smoking
History of previous thrombosis.
162
Varicose veins
Diabetes Mellitus
Prolonged time in stirrups
Maternal age older than 35 years
Parity greater than 3
Clinical Manifestations
Pain and tenderness in the lower extremity
Physical examination may revealwarmth, redness and an enlarged hardened vein over the site of
the thrombosis.
Deep vein thrombosis is more common in pregnancy and is characterized by unilateral leg pain,
tenderness, and swelling.
MANAGEMENT
Analgesia
- Rest with elevation of the affected leg
- Use of elastic stockings
- Local application of heat
- For Deep Vein Thrombosis Anticoagulant, Bed rest, Analgesia, use of elastic stockings.
PERITONITIS
Inflammation of the membrane lining the walls of the abdominal and pelvic cavities and may
lead to pelvic abscess.
Sub involution of the Uterus refers to a slower than expected return of the uterus to its pre-
pregnancy size after childbirth.
Uterus descends at the rate of 1 cm. or 1 fingerbreadth per day. By 2 weeks it should not be
palpable above the symphysis pubis.
CAUSES OF SUBINVOLUTION OF THE UTERUS
Retained placental fragments
Pelvic infection
163
Signs
Prolonged lochial discharge
Irregular or excessive uterine bleeding
Pelvic pain or feelings of heaviness
Backache, fatigue and persistent malaise
On bimanual exam, uterus feels larger and softer than normal during puerperium.
Treatment
Methylergonovine Maleate 0.2 mg every 3-4 hrs for 24-48 hrs.
Antimicrobial therapy.
Mastitis
An infection of the lactating breast occurring during the 2nd or 3rd wk. after birth although it may
develop at anytime during breastfeeding.
Common in mothers nursing for the first time and affects only one breast.
Causes
Staphylococcus aurous or E. coli- enters thru cracks or fissures in the nipple
Engorgement and stasis of milk
Fatigued and stressed out mothers.
Symptoms
Flu like with fatigue and aching muscles
Fever of 38.4C or higher
Chills, malaise and headache
Localized area of redness and inflammation
Purulent discharge rare.
Management
Antibiotic therapy
164
- Decompression of the breast by breastfeeding or pump
- Application of heat or ice packs, breast support
- Analgesics
References;
Principal of anatomy and physiology, 5thEdition,Gerard J. Tortora and Nicholas P.

Anagnostakos.
British Association of Perinatal Medicine. Fetuses and Newborn

567583
Infants at the Threshold of Viability: A Framework for Practice.
London: BAPM; 2000 [www.bapm.org/media/documents/
publications/threshold.pdf].
Blum LD. (2007). Psychodynamics of postpartum depression.
Psychoanalytic Psychology, 24(1), 4562. Retrieved January 31, 2008,
from PsycARTICLES.
Brockington IF, Oates J, George S, Turner D, Vostanis P, Sullivan M, Loh
C & Murdoch C. (2001). A screening questionnaire for mother-infant
bonding disorders. Archives of Womens Mental Health, 3, 13340.
Centers for Disease Control and Prevention (CDC). (2008). Summary of

recommendations for adult immunization. Retrieved February 14,
2008, from http://www.immunize.org/catg.d/p2011.pdf.
165

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NORMAL OBSTETRICS COURSE SYLLABUS

3. INFORMATIONS RELATED TO THE COURSE

3.1 COURSE DESCRIPTION.

3.2 BACKGROUND AND PURPOSE OF COURSE

3.3 COURSE OBJECTIVES

Described the Genital apparatus and pelvic structure of the woman.

Describe Obstetrical pelvis

Explain the Egg development

Explain the objectives and the process of an Antenatal consultation

3.4 COURSE POLICIES/ REQUIREMENTS

Full active individual and group participation is recommended

Language used; English is accepted in the audience.

3.5 GRADING CRITERIA

Final exam 60%

3.6 TEACHING /LEARNING ACTIVITIES

3.7 RECOMMENDED READING

Coad,(2008), anatomy and physiology for midwives , 2nd edition, Churchill

FRASER &COOPER 2009(Myles textbook for Midwives)15 Edition,churchull

Chapter I: Genital apparatus and pelvic structure of the woman.

Chapter II: Obstetrical pelvis

Chapter III: Egg development

Chapter IV: The pregnancy diagnosis

Chapter V: Antenatal consultation

Chapter VI: The labor

Chapter VII: Eut ocic/ Normal child birth

Chapter VIII: The postpartum monitoring

Terms used in obstetrics

Trimester; which refers to a three month calendar period;

CHAPTER I: Genital apparatus and pelvic structure of the woman

After this lesson student will be able to:

Discuss Female Sexual & Reproductive System

Describe internal and extenal ginital organs

Describe Female Maturation Cycle

Discuss Female Reproductive and Sexual Health

A) Internal and external genital organs

B) Functioning of each organ and of support system

C) The menstrual cycle of a woman

D) external female genital organ (vulva

The vulva refers to those parts that are outwardly visible

The vulva includes:

Individual differences in:

Of external genitalia are common

the vaginal glands:

o Paraurethral glands called Skene's glands

It protects the pubic symphysis

Hair varies in coarseness curliness, amount, color and thickness

B. INTERNAL FEMALE GENITAL ORGANS

o External orifice of the uterus

o Canal of the cervix

o Internal orifice of the uterus

corpus uteri - "Body of uterus"

o Cavity of the body of the uterus

Functions & mode of action of the cervix

Cervix is the lower third of the uterus

The layers, from innermost to outermost, are as follows:

The uterus mostly consists of smooth muscle, known as "myometrium."

The loose surrounding tissue is called the "perimetrium."

The uterus is surrounded by "peritoneum

Functions of the uterus

THE FEMALE MATURATION CYCLE

Begins anywhere from 8 to 15 years of age

Puberty lasts about 3 to 5 years

Pubic hair grows