MICHAEL.

F.E.DIEJOMAOH
Clinical Case
A 35 year old female, obese, gravida 3, para 0, a known
case of NIDDM and grandmal epilepsy on epanutin
(phenyl hydantoin) therapy has presented in the
antenatal clinic with 8 weeks amenorrhoea. Outline the
principles of the antenatal/intrapartum management of
this case.

Problems in the case

Age : 35 years
Gravida:` 3 Para 0
Medical problems: 1. NIDDM? Treatment
2. Grandmal epilepsy on
epanutin
Amenorrhoea: 8 weeks
OBJECTIVES OF LECTURE:
AT THE END OF THE LECTURE
You should be able to:
a. Define antenatal care and discuss the benefits of
such care
b. Understand the principles of antenatal care
c. Participate in the conduct of antenatal care as your
posting progresses
d. Define the process of labour and the various stages
of labour
e. Diagnose the onset of labour
f. Understand the management of labour and
participate in the intrapartum care of patients
g. Define the puerperium and appreciate the steps
involved in providing care in the puerperium.
ANTENATAL CARE
Medical outpatient supervision all through
pregnancy until labour commences
Care is provided by:
- Midwives
- General Medical Practitioners
- Obstetricians and Gynaecologists
- Other specialists as required
- Physicians (Sub-speciality interests)
most often required
A collaborative service

Role played by above professionals at various

stages of pregnancy vary world wide

Scope of antenatal care also varies world wide

Better antenatal care services in the developed

countries of the world
AIMS AND OBJECTIVES OF ANTENATAL
Main aim of antenatal care is to ensure a
healthy mother and baby at the end of the
pregnancy

Principle involved is a preventive health

measure utilizing investigations and
prophylactic and definitive treatment where
indicated
The aims and objectives of antenatal care are:
1. Reduce maternal morbidity and mortality and reduce fetal
loss
2. Reduce preterm birth and other fetal complications such
as FGR (fetal growth restriction) fetal anomalies etc.
3. Assess the general health and well being of the mother
and her fetus and plan appropriately for adequate care in
pregnancy, labour and in the puerperium
4. Predict and where possible prevent any fetal or maternal
complications developing during pregnancy
(prenatal diagnosis and management of fetal abnormality –
sickle cell anaemia etc)
5. Detect early and manage effectively any maternal or fetal
complications developing during pregnancy
6. Prepare the couple (mother and father) to cope with
pregnancy, labour and the care of the newborn baby
7. Provide appropriate health screening and health education
Some benefits of Antenatal Care
A. Lack of antenatal care associated with five times
increase in perinatal loss in some studies
B. Antenatal care is one of the main factors involved in
the very low perinatal and maternal morbidity and
mortality in developed compared to developing
countries
C. Women who receive no antenatal care and who have
pregnancy complications perform more poorly
compared to those who have received antenatal care
- Preterm labour
- Intrapartum complications In the
absence of
- Anaemia
antenatal care
- Infections
PRINCIPLES OF ANTENATAL CARE

PRE- PREGNANCY CARE

- Diabetes mellitus
- Epilepsy
- Cardiac disease
- Haematological disorders
- Drugs

Booking Status
“Booked” - Had antenatal care
“Unbooked - No antenatal care
FIRST VISIT TO THE CLINIC (booking visit)
The visit should be as early as possible in pregnancy,
preferably before the 12th week of pregnancy
Objectives:
- Establish gestational age
- Early detection of abnormalities (fetal / maternal)
- Appropriate intervention measure
- diagnosis
- treatment
- Advice on medical disorders antedating pregnancy
- Advice on drugs and other habits (e.g. smoking,
drinking) considered inimical or harmful to the
pregnancy
AT THE FIRST VISIT
DetailedHistory
(Obstetric/Gynaecological/Medical/Surgical/Social)
Complete Clinical examination: Height and weight
Investigations

CALCULATION OF EDD
1. Add 7 days to LMP ( date of delivery)
2. Subtract 3 months from the month of the menses
(month of delivery)
INVESTIGATIONS
1. Complete Blood count (CBC)
2. ABO and Rhesus Grouping
3. Rhesus Antibody Titre if RH Negative
Other atypical bodies
4. Fasting Blood sugar/Post prandial Blood sugar
(FBS / PPBS ) ?? GTT
5. VDRL Test
6. Sickling / Hb Electrophoresis (where indicated)
7. Rubella / Hepatitis / HIV (?)
8. Urine – Protein/Sugar/Acetone
9. Midstream urine – Microscopy, Culture and
sensitivity (where indicated)
10. Ultrasonography - Dating of pregnancy
- Fetal anomaly
- Status of cervix
11. Other Tests (As indicated)
α . → GBS

(Group B Streptococcus culture)

β . → STD screening

χ . → Triple screen for women ≥35 years (≤ 35 years)

- Amniocentesis etc
END OF BOOKING VISIT CONSULTATION
SUMMARY OF FINDINGS/DIAGNOSIS Low Risk
High Risk
pregnancy
• Medications-Folic Acid/ Vitamins
• Supplementary Iron( Fefol from 16-18 weeks)
• Specialised drugs (diabetes/hypertension/ thyroid
disease etc)
• Detailed discussion / Follow up programme
Schedule of future/follow-up visits
Appointments made for
Every 4 weeks until 28 weeks (32 wks with some practitioners)
Thence after: Appointments made for :
Every two weeks until 36 weeks
Every week from 36th week until delivery
Appointments adjusted to more frequent intervals, if
pregnancy is “precious” or some abnormalities detected
Appointment schedules for nullipara and multipara may
be different
SCHEDULE OF VISITS NEED TO BE MODIFIED
ACCORDING TO INDIVIDUAL NEEDS
SCHEDULE OF VISITS ALSO VARY IN OTHER
LOCATIONS
Plan for action in subsequent visits
First follow – up visit
General health of patient investigated through general
questions and specific questions relating to the
pregnancy/other systems
- Nausea, vomiting, heart burn, vaginal bleeding, fetal
movements
- Her weight and blood pressure are taken and
compared with previous results. Check for oedema:
pre-tibial, fingers etc
- The urine is tested for protein and sugar
- Obstetricexamination performed( multiple/singleton)
SUMMARY
Detailed Discussion
- History / Examination
- Results of investigations. Iron therapy after 16 wks
- High Risk / Low Risk Category
- Follow - up plan
- Mode of delivery
- Appropriate therapy
(Plan for anti- D Inj. for RH Negative mothers who
have no antibodies at 28, 32 weeks)
OTHER FOLLOW-UP VISITS
At each Subsequent visit, steps outlined for first
follow - up visits are repeated
Obstetric Examination(SFH, Lie, Pres, FHS,
Multiple/singleton)
A gradual weight gain is expected
A gradual increase in the fundal height is also
expected
MANAGEMENT GUIDELINES AT FOLLOW-UP VISITS
1. 20-24-28 WEEKS: Screen for gestational diabetes if
indicated
2. 20-24; 32-36 weeks: CBC check
3. Follow – up U/S examination is usually carried out
- Fetal anomaly scan (18-20 wks)
- Biophysical profile / fetal weight (34 weeks)
4. Rhesus negative mothers should usually have their
blood tested for antibodies again at about 32-34 wks
5. Other tests (as indicated: –atypical antibody titre,
maternal serum alpha-feto protein screening)
At each visit: Apart from routine medications, patient
should be reassured, anxieties alleviated and minor
discomfort occurring during pregnancy discussed
After 36th week of pregnancy, Delivery plans again
discussed. Engagement of presenting part checked;
pelvic assessment may be performed
Some events of note in pregnancy

1. Average weight gain in pregnancy from 15th -

38th week of pregnancy is about 0.5 kg per
week
2. Blood Pressure
- Systolic increase >30mm (over booking BP)
- Diastolic increase >15 mm (over booking BP)
≥ BP – 140/90
(P.I.H etc)
ABNORMALITIES DURING ANTENATAL CARE

Any abnormality detected should be fully investigated

as indicated and as soon as such abnormality is detected.
In line with the objectives of antenatal care, early
detection of abnormalities, appropriate investigations
and treatment should be emphasized.
Admission for specialized treatment may be indicated in
some cases
Look out for
Abnormal weight gain / No weight gain /Rise in blood
pressure
Rapid increase in fundal height
Fundal height greater than gestational age :
Multple pregnancy
Fetal macrosomia
Gestational diabetes
Polyhydramnios/ fetal anomaly
Lack of/Sluggish increase in fundal height
- static fundal height
Fundal height less than gestational age:
Fetal growth restriction FGR
Intra-uterine growth
Restriction (IUGR)
Oligohydramnios/PROM
Fetal anomaly
 MINOR DISORDERS/QUESTIONS IN
PREGNANCY

Diet - Normal Diet

Cramps - Reassurance / Calcium
Heartburn - Antacids
Constipation - Reassurance
Dietary Advice
Fluids / Fruits
Rarely aperients needed
Syncope/Fainting - Reassurance
Vaginal discharge - Vaginitis
Treat as appropriate
Frequency of - Investigate
Micturition
Stress incontinence - Treat as indicated/ Reassurance
Varicose Vein - Reassurance
Haemorrhoids - Treat if troublesome. Crepe-
Bandage for varicose veins
Exercise - OK: Advisable
Not strenuous
Not allowed in “premium
pregnancy”
Work/Employment - Ok
- Disallowed in
“premium pregnancies”
Travel -Car Okay if roads are
-Train good and journey
-Air not long.

Air travel (especially long journeys ) not

advisable after 35th week of pregnancy.

Travel of course disallowed if any abnormality of

pregnancy e.g. bleeding is present.
Immunisations:
Immunisation against rubella not allowed
during pregnancy .
Vaccination against Tetanus toxoid/Poliomyelitis
allowed.

Vaccination against Cholera /meningitis allowed.

Sexual Intercourse:
No restrictions except in cases of abortions or
vaginal bleeding In early / late pregnancy.
Dental care:
Consult the dentist
Dental problems more common in
pregnancy.
Smoking /Alcohol/ Drugs-
Caution.
Reduction in quantity /stop.
OTHERS- Vomitting ,Carpal Tunnel syndrome
etc
DEFINITION OF LABOUR
Labour is defined as:
Progressive dilatation of the cervix in
association with repititive uterine contractions
Cervical dilatation without uterine contractions
* Cervical Incompetence
Repititive uterine contractions without
progressive dilatation of the cervix
* False labour
* Disorders of labour
INITIATION OF LABOUR
LABOUR: TERM / PRE-TERM
* Spontaneous False labour
Braxton Hicks
contractions
* Induced
* Augumented
Symptoms and signs of labour
* Onset of painful regular contractions
* "Show"
* Rupture of membranes
* Effacement / dilatation of cervix
STAGES OF LABOUR

THREE Stages well recognised

"FOURTH" Stage also described

FIRST STAGE
From onset of true labour until full cervical
dilatation.
Latent / Active phases

* Active phase: Cervix 3-4 cm dilatation

with contractions 3 in 10 minutes
* Progressive cervical dilatation

* Usually descent of the presenting part.

Complications of first stage
* Fetal distress
* Prolonged labour
* Obstructed labour / ruptured uterus
* Bleeding per vaginam
* Trauma
* IUFD etc
SECOND STAGE
Commences at full cervical dilatation and ends
with delivery of baby
Main features
* Painful frequent contractions
* Bearing down feeling / Expulsive
efforts
* Delivery of baby
Complications of second stage
* Fetal distress
* Delay in second stage
* Deep Transverse Arrest
* Persistent occipito-posterior position
* High head
* Bleeding / trauma
* Shoulder dystocia
THIRD STAGE
Commences after birth of baby until
placenta and membranes delivered.

Main features
* Weaker contractions
* Delivery of placenta & membranes
DURATION OF LABOUR (stages 1-3)
Varies with parity
Influenced by various factors
* Age
* The Forces - Failure in the
forces
* The Passage - Problems with
the passage
* The Passenger- Difficulties with
the passenger
THE MECHANISM OF LABOUR
The aim of labour is the delivery of the baby
followed by the delivery of the placenta and
membranes.
Events involved in the ultimate delivery of the
baby include:
* Descent
* Flexion
* Internal Rotation
* Extension
* Restitution
* External Rotation
* Delivery
MANAGEMENT OF LABOUR
Initial Assessment
1.History A. Detailed review of prenatal data:
Previous obstetric history
(Mother / baby)
Previous gynaecological history
PMH / FSH
History of current pregnancy
B. Labour Details
Contractions /Show /Bleeding
/ Liquor etc.
Physical Examination
* General state of patient
vital signs T P BP
* Systemic examination
* Obstetric examination
Abdomen - Fundal height
- Lie / Presentation
- Engagement
- FHS. singleton / multiple
- Contractions
Vaginal Exam
- Inspection
- LGT
-Cervix effacement/position/dilatation
- Presenting part
- Level of P.P
- Pelvic assessment
Investigations
CBC
Blood Grouping /Cross matching
Blood sugar
Others
SUMMARY OF FINDINGS
Diagnosis
* Low Risk - Labour room II
Low parity
* High Risk - Labour room I
* PIH / Multiple pregnancy /
Prem. labour /APH / IOL/
IVF etc.
Routine Care In Labour Room
* Enema
* Bath
* IV Fluids
* CTG
* Nil Per oral
* Nursing Care
* Psychological support
* Careful Monitoring (TWO
PATIENTS!)
* Consent
FIRST STAGE
1. CTG
2. Partogram/ Active management of
labour
3. Regular VE / Assessment
3 - 4 - 6 hourly
(May be more frequent in special
cases)
4. I.V.Fluids
5. Analgesia
* Pethidine/ Anti-emetic
* Epidural
6. Antacid - (especially if surgery planned)
Ranitidine Inj. 50mg. i.m. as required
Oral antacid
7. Intervene as required
8. Special cases - Specialist care required
* P.I.H.
* Eclampsia
* Cardiac
* APH
* Diabetes Mellitus
9. Preparation for delivery
SECOND STAGE
Delivery of the baby: Maternal position
Maternal / fetal monitoring
* Normal vaginal delivery
* Ventouse
* Forceps
* Breech
* Anticipate difficulties - shoulder dystocia
* Gas Inhalation: ENTONOX.
Analgesic Injections!!! (Primip / OP)
Episiotomy
* usually R medio-lateral
* local anaesthesia
* pudendal block
* perineal infiltration
Care of Perineum
Care of Baby - Suction
- Airways
- Paediatrician
THIRD STAGE:
A. Mechanism of Placental Separation
Shultze Mechanism of Placental Separation
* Retroplacental clot
* Placenta / membranes dragged downwards
* Membranes peel from periphery
* Placenta delivered by inversion
Duncan Mechanism of Placental Separation
* Separation at periphery of placenta
* Placenta descends to vagina sideways
* Maternal surface of placenta appears first
at vulva
THIRD STAGE
B. Delivery of the placenta
Signs of placental separation
* Descent / Lengthening of umbilical cord
* Uterus rises up
* Gush of blood (small quantity)
* Placenta in vagina
Active management: Brant - Andrews Method
* Ergometrine - 0.5 mg (a)
I:V / I:M / after delivery of baby at MOH

* Methergin - 0.20 mg (b)

* Syntometrine / Syntocinon (c)
Avoid (a) , (b), (c) if BP ↑ in labour
Caution
* Side effects
* Hypertension
* Hypertensive cases
* Cardiac cases
Are the placenta and membranes complete?
Careful examination of placenta / membranes
Problems
* Primary PPH
* Secondary PPH
Repair of Episiotomy / perineal lacerations
Care of Perineum
SPECIAL PROBLEMS / COMPLICATIONS
DETECTED IN THIRD STAGE - {ANTICIPATE}

* Vaginal lacerations
* Cervical lacerations
* Extension of episiotomy
* Retained placenta / Parts / Membranes
* Primary postpartum haemorrhage
(Look out for)
Ruptured uterus
Shock
Vulval haematoma
FOURTH STAGE: { usually about 1-2 hrs after
delivery}
Vital signs
* BP , Pulse
* Full Bladder
* Trauma
* Uterine Relaxation / Atony
* Sudden Collapse / Shock
* Could be very serious
VULVAL HAEMATOMA.RUPTURED UTERUS
After pains
* Analgesia
TRANSFER TO LYING - IN WARD IF ALL IS WELL
OPERATIVE DELIVERIES
Vaginal
* Ventouse
* Forceps
* Breech
Abdominal
* Caesarean Section
* Indications
* Types / Procedures

Preparation for Operative Deliveries

* Counselling / Consent - if not already
obtained.
* Pre-anaesthetic assessment
* Analgesia / Anaesthesia 1. Regional
2. General
DEFINITION
The puerperium is that period after delivery
during which the pelvic organs return to their
non-pregnant state.

The period of the puerperium is usually stated as

SIX WEEKS (6 weeks) although some of the
organs may not have returned completely to their
normal non pregnant state.
In most women who are not breast feeding (and
even in some women who are breast feeding)
ovulation is reestablished during the period of
the puerperium.
PHYSIOLOGICAL CHANGES IN THE
PUERPERIUM
1. General
2. Cardiovascular system
3. Haematological change
4. Urological changes
5. Genital Tract
-Breasts
-Uterus
-Lochia
6. Lactation
Routine Care In The Puerperium
1. Recording of Vital Signs/Palpation of Abdomen
Temperature - Slight rise under 38ºC noted
in first 24 hours after
delivery
Pulse
Blood Pressure State of uterus
Respiratory Rate
2. Breast feeding / Care of breasts
3. Analgesia -Indications/drugs
-Episiotomies/Lacerations
-Operative deliveries
-Caesarean sections etc.
4. Mobilisation
5. Involution of the uterus/Perineal care
Lochia rubra
Lochia serosa
Lochia alba
6. Disorders of Micturition
Emptying of the bladder
Retention of urine
In-continence of urine
7. Bowel function
8. Diet – Normal diet
9. Sleep disturbances/Depression
-Ensure adequate rest during the day and
good sheep at night
Insomnia inspite of adequate measures-
Sinister sign
Watch out for depression and early
puerperal psychosis and treat early.
10. Immunisations
Anti-D 300mg should be given to the Rhesus D
Negative who is not isoimmunised and who has an
Rhd Positive baby soon after delivery. Other
immunizations depend on local variations.
11. Physiotherapy/postnatal exercise should be
encouraged where facilities are available and where
possible.
Contribute to good tone of abdominal wall
muscles and to good vaginal function.
12. Contraceptive advice
-Counselling and appropriate contraception before
discharge where possible.
13. Discharge from Hospital
Varies from place to place. After vaginal delivery,
discharge home, if all is well, should be between 48
hours and 4 days after delivery.
Time of discharge after operative deliveries usually
varies also.
Discharge home after caesarean section should be
between 6-10 days post-operative.

14. Postpartum Follow-up

Check up after delivery should be about 6 weeks
after delivery -the end of the puerperal period
Extent of check-up varies, but there is an ideal
postpartum check up.
Cervical Smear (Other Tests)
 ABNORMALITIES OF THE PUERPERIUM
Puerperal Pyrexia
Puerperal pyrexia is defined as a temperature of 38˚C
(100.4˚F) or higher or any 2 of the first 10 days
postpartum with the exclusion of the first 24 hours after
delivery.
Most of the causes of puerperal pyrexia originate from
infections in the genital tract.
Causes of Puerperal Pyrexia
1. Genital Tract Infection
2. Urinary Tract Infection
3. Breast Disorders
4. Wound Infections
5. Thrombophlebitis
6. Respiratory Tract Infection
7. Intercurrent Infections
1. Gentital Tract Infection
Sites of Infection

- Placental bed
- Lacerations of genital tract
- Operative wounds
Sources of Infection
Endogenous
Exogenous
Predisposing Factors
Spontaneous/Induced Labour
Duration of labour
Premature rupture of membranes
Multiple vaginal examinations
Internal fetal monitoring
Anaemia-Severe
Mode of Delivery -Vaginal
-Operative
-Caesarean Sections
Caesarean Sections -Elective
-Emergency
-Indications etc
Pathology/Bacteriology
The organisms causing genital tract infection are
quite varied.
- Aerobes - Streptococci/Staphylococci
- Gram Neg Org- Pseudomonas/Kliebsiella et
- Anaerobes - Bacteriodes
Clostridium
Others: Chlamydia Trachomatis
The infection may be localized to the affected area
e.g. perineal, or eventually spread to other pelvic
organs.
The infection may be mild, moderate or severe with
ENDOGENOUS
Coliform organisms
Enterococci (Streptococcus Faecalis)
Anaerobic Streptococci
Gonococci
Chlamydia
Streptococci
Groups B,C,D and G
Anaerobic Bacteria (Bacteroides SPP)
Clostridium perfringens
EXOGENOUS
Haemolytic streptococcus, Group A
Staphylococcus Aureus
Spread of Infection may follow a variety of pathways
Vagina/Cervix ------> Pelvic cellular tissue
Pelvic Cellulitis
Uterus ------> Parametrium (parametritis)
------> Fallopian tubes/Ovaries
------> Pelvic Peritonitis
-------> Acute Salpingo-Oophoritis with pelvic peritonitis
-------> Haematogenous Spread
-------> Septicaemia
 QUESTIONS?????
• QUESTIONS

Short Questions

Write short notes to answer the questions below.

1. The benefits of antenatal care.
2. What routine blood investigations are performed for antenatal
patients?
3. What drugs are used in the management of the third stage of
labour? List the major side effect.
4. What are the most frequently encountered abnormalities of
the puerperium? Outline the management of one of them.
5. MCQ QUESTIONS TO FOLLOW.