PAKISTAN NURSING COUNCIL DANIYAL COLLEGE OF HEALTH SCIENCES

OBSTETRICAL NURSING WRITTEN BY: DR SADAF JAVERIA (PHD)

Acronym Abbreviation

1 ♀ Female
2 ♂ Male
3 △ Diagnosis
4 - ve Negative
5 + ve Positive
6 <&> Less Than & Greater Than
7 A/P Anterior Posterior
8 A/V Anteverted
9 Ac anti-Cebum Before Meal
10 AGE Acute Gastro Enteritis
11 AMTSL Active management of third stage of labor
12 APH Antepartum Hemorrhage
13 ASP Arterial Septal Defect
14 B/F Before
15 BCG Bacilli Calmette Guerin
16 BD Twice a Day
17 BF Breast Feed
18 Bld Blood
19 BMR Basal Metabolic Rate
20 BOH Bad Obstetrical History
21 BP Blood Pressure
22 BPCR Birth preparedness & complication readiness plan
23 BPD Biparietal Diameter
24 C With
25 C.O Carry over
26 C/F Culture & Sensitivity
27 Cap Capsule
28 Cardia Heart
29 CBC Complete Blood Count
30 CBR Complete Bed Rest
31 CCT Control cord traction
32 CHD Congenital Heart Disease
33 CP Complete Picture
34 CPD Cephalo Pelvic Disproportion

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35 CPR Cardio Pulmonary Resuscitation

36 Crani Brain
37 CSF Cerebrospinal Fluid
38 CTG Cardiotocograph
39 Cx Cervix
40 D&E /D&C Dilatation & evacuation/Dilatation & Curettage
41 D/C Discharge / Discontinue
42 D/R Detail Report
43 D/S Dextrose Saline
44 D/W Dextrose Water
45 DC Discontinue
46 Delivery Labor, Birth, to deliver
47 Dept Department
48 Derm Skin
49 DHO District Health officer
50 DIC Disseminated Intra Venous Coagulation
51 DVT Deep vein thrombosis
52 EBM Expressed Breast Milk
53 EDD Expected Date of Delivery
54 Entro Intestine
55 ER Emergency Room
56 ESR Erythrocyte Sedimentation Rate
57 FHS Fatal Heart Sound.
58 FSH Follicle Stimulating Hormones
59 G/E General Examination
60 GA or GIA Gestational Age/General Anesthesia
61 Gastro Stomach
62 GDM Gestational diabetic mellitus
63 GIT Gastro intestinal tract
64 Gloss/Lingual Tongue
65 GP General Practitioners
66 GW General Ward
67 H20 Water
68 HB Hemoglobin
69 HCG Human Chorionic Gonado Tropic
70 HDN Hemorrhagic Disease of New Born
71 HOF Height of fundus

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72 Hr Hour
73 HS hour of sleep
74 HTN Hypertension
75 Hx History
76 Hystro Uterus
77 i.u. International unit
78 I/D Intra Dermal
79 I/M Intra Muscular
80 I/O intake Output
81 IV Intra Venous
82 IDDM Insulin Dependent Diabetic Mellitus
83 Inj Injection
84 IUCD Intra Uterine Contraceptive Device
85 IUD Intra Uterine Death
86 IUGR Intra Uterine Growth Retardation
87 Laper Abdomen
88 LBW Low Birth Weight
89 LFT Liver Function Test
90 LH Luteinizing Hormones
91 Liq Liquor/ Liquid
92 LMP Last Menstrual Period
93 LOA Left Occipito Anterior
94 LR Labor Room
95 Mater Mother
96 MCH Mother and child health
97 Mist Mixture
98 MMR Maternal Mortality Ratio
99 NA Nursing Assistant
100 NAD No Abnormality Detected
101 Natal Birth
102 Neo New
103 Nepher Kidney
104 NND Neo Natal Death
105 NPO Nothing per oral
106 NUR Nursery/Nursing
107 OE On Examination
108 O2 Oxygen

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109 OD Once a day

110 Oligo Less
111 OPD Out Patient Department
112 OPHER Ovary
113 OT Operation Theater
114 Ot Ear
115 P/A Per Abdomen
116 P/R Per Rectal
117 P/V,V/E Per Vaginal Examination
118 Partum Delivery.
119 Pc Post- cebun After Meal
120 PDA Patent Ductus Arteriosus
121 PG Primi gravida Post graduate
122 Phleb Veins
123 PNC Pakistan Nursing Council
124 PO Per Oral
125 POC Product of conception
126 POD Post operative day
127 Poly Excessive / Many Much
128 Post op After Operation
129 PPH Postpartum Hemorrhage
130 PPIUCD Pos-partum or post placental iucd
131 Pre op Before Operation
132 PT Pregnancy Test/Prothrombin Time
133 PTS Preliminary Training Session
134 Pulmon Lungs
135 Q Every
136 Qhr Every hour
137 QID Four Times
138 R/D Ringer lactate/Ringolact
139 R/V Retroverted
140 RDS Respiratory Distress Syndrome
141 Resp Respiration
142 RH Rhesus Factor
143 RHC Rural health center/Reproductive
144 Rhin Nose
145 RM Registered Midwife

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146 RMO Residence Medical Officer

147 RN Registered Nurse
148 RR Respiratory Rate
149 RTI Respiratory Tract Infection
150 Rx Treatment
151 Salphange Fallopian Tube.
152 SB Still Birth
153 SID Sudden Infant Death Syndrome
154 SNEB Sindh Nurses Examination Board
155 SOS / PRN Whenever necessary / required (as per need ),
156 Stat Immediately
157 SVD Spontaneous Vaginal Delivery
158 Syp Syrup
159 Tab Tablet
160 TDS Three times a day
161 Temp Temperature
162 Thorax Chest
163 TPR Temperature Pulse Respiration
164 URTI Upper Respiratory Tract Infection
165 US Ultrasound Laboratory)
166 UTI Urinary tract Infection
167 V/S Vital Signs
168 VD Venereal Disease
169 VDRL Venereal Disease Research Laboratory
170 Vital sign TPR + BP
171 VSD Ventricular Septal Defect
Prefix - Are added to the beginning of a word to form another word
172 Sub Below
173 Supra Above
174 Post After
175 Pre/Ante Before
Suffix - Are added to the end of word to form another word
176 Ectomy Surgical Removal
177 Otomy Surgical Incision
178 Plasty Repair
179 It is Inflammation
180 Ostomy Surgical Opening

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181 Scopy Visual Examination

182 Logy Study
183 Graphy Record
Abbreviation Measurement
184 Ht Height
185 Wt Weight
186 Kg Kilogram
187 Gm gram
188 Mm Millimeter
189 Cm centi meter
190 Mg milli gram
191 L Liter
192 MI Milli liter
193 Lbs Pounds
194 mcg Microgram
195 Dl Deciliter
196 0z Ounce
197 Tbsp. Tablespoon
198 Tsp Teaspoon
199 Ft Foot
200 Gal. Gallon
201 Gtt Drops

TERMINOLOGY
ANTENATAL CARE:

Ante=before, natal=birth

Care before birth called antenatal care. It is preventive branch of obstetrics and constituent

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OBSTETRICAL NURSING WRITTEN BY: DR SADAF JAVERIA (PHD)

supervision of a woman throughout pregnancy to ensure healthy mother and baby both.

ABORTION:

It is an expulsion or extraction of all (complete) or any part of placenta and membrane without iden-
tifiable or with a fetus alive or dead before 24 weeks of gestation.

APH:
It is stand for Antepartum hemorrhage. It is defined as bleeding through vagina after 24 weeks of
gestation and before birth of baby.

ADHERENT PLACENTA:

A placenta is firmly attached to. the wall of uterus and fails to separate during the 3 stage of

labour.

ATTITUDE:

The degree of flexion or extension of head & libs itS trunk is called attitude.

The relationship of different parts of fetus with each other is called attitude.

ARM:

Artificial rupture of membrane OR amniotomy. It is surgical method of induction of labour

AMNIOTIC FLUID EMBOLISM:

This is rare condition. It occurs when amniotic fluid enters into maternal circulation from uterus or
placental site forming an embolus, which obstructs pulmonary arterioles. or capillaries.

AMNIOCENTESIS:

Is the procedure of puncturing amniotic sac usually through abdominal wall and uterus to obtain a
sample of amniotic fluid for some investigations and in Poly hydramnios cases.

ANENCEPHALY:

The vault of skull and cerebral hemispheres are missing or reduced to small mass. The brain fails to
develop and for head joints the neck

APGAR SCORE:

Apgar score is a method of assessment of status of oxygenation and well being of newborn baby at
birth. In which we see:

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A: AppearanceColour of body.

P :PulseHeart rate.

G :Grimes Rèsponse to Stimuli.

A :ActivityMuscles tone.

R :Respiration

Respiratory efforts.

AUGMENTATION OF LABOUR:

To assist .or acceleration (speed up) labour that had begun normally. The two commonest

procedure used are amniotomy and oxytocin infusion.

AUSCULTATION:

A method of examining the internal organs by listening to Sounds which they give out.

Auscultation of FHS is an important part of abdominal examination in pregnancy and labour,

ANEMIA:

The patient is considered anemic when the level of HB% is 10g or less during the 2 trimester.

BISHOP'S SCORE:

Is a method to assess the favorability of cervix prior to induction of labour. In which the dilation,
length, consistency and position of cervix and station of head.

BREECH:

lt is mal presentation in which fetus lie is longitudinally with buttock in lower pole of uterus. The
presenting diameter is bitrochantric 10cms. In this denominator is sacrum

BIRTH INJURIES:

Birth injuries that occur during the birth process are likely to occur then the baby is large. The

presentation is, breech and forceful extraction is used.

CONCEPTION:

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After fertilization a new life created, this process ,palled' conception.

CERVICAL DYSTOCIA:

In spite of good uterine contractions there is no cervical effacement and dilatation called cervical
dystocia.

CEPHALIC VERSION:

Is a procedure of turning the fetus to make head to. present.

CONTRACTED PELVIS:

A contracted pelvis is one which any of its essential diameter is so reduced that to interferes or alter
the mechanism of normal labour.

CORD PROLAPSE

Prolapse of cord occurs after the rupture of membrane when the presenting part is ill fitting or

abnormal.

CAESAREAN SECTION:

IR n operation to remove fetus. placenta and membrane through abdominal route after 24 weeks of
pregnancy.

CONSTRICTION RING:

A localized annualar spasm of uterine muscle of any level but often near the junction of upper and
lower uterine segments. In the 1 and 2 stage of labour, it may form around the neck of fetus and in 3"
stage causing the retained Placenta.

COLOSTRUMS:

Yellowish secretion comes from breast till 2 - 3 days after delivery called colostrum’s. It contains
lots of immunity protein and vitamins.

CONGENITAL ABNORMALITIES:

Any abnormality presents in baby before the time of birth called congenital abnormality example tal-
ipes and congenital absence of a kidney.

CHLOASMA:

Skin pigmentation on face in butterfly structure during pregnancy due to called chloasma.

CAPUT SUCCEDANEUM:

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CHILD:

This is the swelling on the skull due to oedema within the subcutaneous layer of the scalp caused by
pressure of the dilating cervix on the head at rapidly disappear within few days after delivery.

From birth till five years of age

DYSTOCIA:

Abnormal labor called Dystocia.

ECTOPIC PREGNANCY:

The word Ectopic means out of place An Ectopic pregnancy is one in which fertilized ovum

implants outside of uterine cavity. At leạst 90% of extra uterine pregnancies occur in uterine

tubes but may occur in abdomen

EMBRYO:

After conception till first weeks of life in uterus baby called embryo.

EPISIOTOMY:

It is deliberate incision made into perineum to wider the introits with a view of preventing irregular
tear in Perineum during delivery.

ECLAMPSIA:

It means to flush out with all signs of pre-eclampsia. It is condition characterized by convulsion or
fits and coma. It may occur in Antepartum. intra partum and post partum period

[Link]:

It stands for Expanded Program of Immunization.

EXOMPHALUS:

A herniation of umbilicus of abdominal contents covered with peritoneum.

E.D.D:

It stands for expected date of delivery, which is estimated from first day of last menstrual period.

FETUS:

After 8 week of embryo life till the term in uterus it called fetus

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FONTANELS:

The fontanels are membranous space formed where two or more sutures meet.

FERTILIZATION:

The union of sperms and ovum called fertilization.

FAMILY PLANNNG:

The meaning of Family Panning is:

 To plan a family.
 To decide the number of children a couple wänts to have.
 To decide on the interval between two pregnancies.
 To use a suitable method to postpone unwanted pregnancy.

GRAVIDA:

Number of pregnancy from conception till term. It includes abortion, still birth iUDs, premature and
term deliveries.

HIPER EMESS GRAVIDARUM:

Excessive vomiting in pregnancy, which persists throughout the day and impairs the health of a
mother.

HYDATIDIFORM MOLE:

It is abnormal development of chorionic villi, which lead to development of abnormal placenta. It is

chromosomal defect.

HYDRAMNIOS:

Excessive amount of liquor amni in uterus is called hydramnios /Polyhydramnios. It is more than
1500ml.

HYDROCEPHALY:

An excess of CSF collects in brain cavity and enlarges the fetal head. The fontanels are larger

than normal sutures are separated and skull bones are soft.

HYDROP FOETALIS:

Severe edema of fetus due to blood incompatibility, results in either still birth or neonates deaths.

HYPERBILIRUBNMIẢ:

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An excess of bilirubin iň circulating blood called Hyper-bilirubnemia.

HYPOGLICEMA:

An abnormal low blood sugar in newborn and diabetic patients called hypoglycemia.

HERVAPHRODITE:

A Condition in which the genitive organs of both sexes are present true hermaphrodite rare in

human pseudo hermaphrodite is usually male type with internal female organs. Some have

female type with male internal organs.

INDUCTION OF LABOUR:

It is termination of pregnancy by artificial means after 40 weeks of gestation to secure vaginal

delivery.

It is the stimulation of uterine contractions before the onset of spontaneous labor.

INFANT:

A young child from birth to one year of age called infant.

INVERSION OF UTERUS:

It is turning inside of uterus partially or completely before or after delivery of placenta. It is compli-
cation of 3rd stage.

I.U.D:

It is intra uterine death. The fetus dies in uterus after 24 weeks of gestation. and before birth called
Intra Uterine Death.

I.U.C.D:

It is Intra uterine contraceptive device used for family planning.

INFERTILITY:

It is defined as inability to conceive after one year of unprotected intercourse

KERNICTERUS:

It is also called nuclear jaundice. Yellow staining of basal ganglia of brain: occur in infants with se-
vere jaundice. It is characterized by fits. It may fetal or may Survival but be left with some mental or

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neurological defect. It occurs due to unconjugated bilirubin life The relationship between the long
axis of fetus and long axis of uterus called Life.

LOCHIA:

The discharge from uterus through vagina after the delivery of placenta till 40 days of

puerperium called Lochia. It contains leucocytes, mucus and debris.

LIBIDO:

The termed as desire to sex

MECONIUM:

The greenish black material present in fetal large intestine that is passed per rectum during first three
days of life mastitis. It is the inflammation of the breast. Puerperal mastitis is an infection resulting
usually from the presence of staphylococci and occasionally streptococci, which usually enter
through cracked nipples

MEÑSTURAL CYCLE:

Series of events through hormones, which takes place under the uterine walls and ovaries is said to
be menstrual cycle. It begins from first day of menstruation until the first day of next menstrual. The
cycle has twenty eight (28) days

METORRHAGIA:

If a patient is bleeding beyond seven (7) days into inter menstrual phase of cycle is defined as

metrorrhagia.

MENOPAUSE: (CLIMACTERIC)

End of woman's reproductive life when ovulation and menstruation cease and the woman is no long-
er able to bear children. It can occur at any age between the middle thirties (30) end and the late Fif-
ties (50).

MENORRHAGIA: (Heavy menstrual. bleeding)

Menorrhagia is an abnormally heavy and prolonged menstrual period at regular intervals. It may be
associated, with high blood pressure,. hormonal disturbance and many other conditions including
vitamin K deficiencies. aspirin usage and bleeding disorders.

MENARCHE:

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It is first Sign of menstruation or onset of' menstruation called' menarche. It is sign of puberty.

MICRO CEPHALIC;

The vault of skull is small and there is an associated reduction in amount of brain tissue. The child
wilI mentally retard.

MENINGOCELE:

These are humors of fetal skull they are covered with meninges they usually. protrude through skull
and cystic filled with CSE.

MYELOMEMINGOCELE;:

Hernia. protrusion of spinal cord and its meninges and nerves through column called Myelomenin-
gocele.

MALPRESENTATION:

Any presentation of fetus other than the vertex called Mal presentation.

MULTIPLE PREGNANCIES:

A pregnancy of more than one fetus called twin pregnancy

MOULDINGS:

It is the overlapping of the bones of the vault or top of the skull at the sutures and fontanelle allowing
size of the skull to decrease on shape to alter during its passage through maternal pelvis.

NORMAL LABOUR:

It is spontaneous expulsion at term of single alive fetus through vagina in longitudinal lie Cephalic
presentation, and. Occipito-anterior position followed by after birth of placenta, cord and membrane
in a reasonable time (12 - 18) hours period without any complication.

NEONATE:

A baby from birth till28 days of age is term as neonate.

NEO NATALASPYXIA:

It is the failure of an infant to cry and establish adequate respiration. In this situation O2 decreases
and cO2, increases in blood circulation, it may be mild, moderate and severe.

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OVUEATTON:

Every month ovarian graphic follicles mature under the influence of follicle stimulating hormone
(fSH) and release ovum this process called ovulation

OPHTHALMIA NEONATRUM:

Ophthalmia neonatorum is a purulent discharge from eyes occurring within 21 days of its birth.

OMPHALITIS:

Inflammation of cord called Omphalitis.

OBSTRUCTED LABOUR:

Labour is said be obstructed when there is no advance of presenting part despite of good uterine con-
struction and there is also failure in cervical dilation

POSITION:

The relation of particular part of fetus to particular part of mother's pelvis called position.

PRESENTATION:

The part of fetus which first enters the pelvis occupying the lower pole of uterus called presentation.

PROLONG LABOUR:

Labour is termed as prolong when it exceeds 24 hours or if delivery is not imminent after 12hours of
established labour.

PUBERTY:

Puberty is the period of time when children begin to mature biologically psychologically socially and
cognitively. Girls start to grow into women and boy into men. This is the period of increased general
body growth and development of secondary sexual characters.

PLACENTA:

Placenta is an organ which is the characteristic of true mammals, during pregnancy joining mother
and off spring, providing endocrine secretion and selective exchange of soluble blood born substanc-
es through opposition of uterine and trophoblastic vascularized parts.

PREGNANCY:

The period after the conception of the labor is termed pregnancy its duration is (two Hundred Eighty)
280 days, (forty) 40 wee 9 (nine) months.

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Parity

The numbers of variable Birth after 24 weeks of gestation whether still birth, IUDs or alive prema-
ture and mature.

P.P.H:

Post-partum hemorrhage. It is defined as excessive bleeding more than 500 ml from genital tract af-
ter delivery up to 40 days of puerperium.

PRE- ECLAMPSIA:

It is disease associated to pregnancy occurs after 20 weeks of pregnancy, which is characterized by

high BP (blood pressure), Edema and albumin in urine.

PODALIC VERSION:

Turning the fetus to make breech present.

PUERPERIUM:

It is the period of 6 weeks or 40 days after delivery starts from expulsion of placenta.

PUERPERAL PSYCHOSİS:

This is a severe mental illness affects 1-2 mother in every thousand. The onset is rapid usually occurs
within first few days after delivery.

PREMATURE:

Baby born before 37 completed weeks of pregnancy and now usually called preterm baby: It is usu-
ally a baby of low birth weight.

PALPATION:

lt is examination by touch application of fingers with light pressure to Surface of body for the pur-
pose of determining the condition of parts beneath in physical diagnosis.

PARTOGRÀM:

It is a graphical record of progress labor. It starts from active. phase of labor that is 4 cm through this
we take the decision that either labor is obstructed or prolonged. In this we check cervical effacement
dilatation. membrane intact: ruptured, absent or bulging station of head and P/P & uterine contrac-
tions.

PLACENTA PREVIA:

A placenta which is lies wholly or partially in the lower uterine segment.

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PERINATAL DEATH:

Perinatal death is Death of a fetus occurring between the uterine a fetus weigh át least 500 g (or alter
22 completed weeks of gestation) and the seventh day after birth of a live born infant.

QUICKENING:

It is the first fetal movement noted by a pregnant woman between two weeks earlier by multipara.

RETRACTION RING:A constriction of the junction between the thinned lower uterine segment
and the thick retracted upper uterine segment caused by obstructed labor sign of impending rupture
of the uterus also called Bandl's ring.

PHYSIOLOGICAL RETRACTIONRING:

It is a line of demarcation between the upper and lower uterine segment present during normal labour
and cannot usually be felt abdominally.

RETAINED PLACENTAS

When placenta remains inside, of uterus and not delivered called retained placenta.

RVF

Recto Vaginal Fistula is an artificial opening between rectum and vagina.

STD:

It stands for sexually transmitted disease.

SHOCK:

Emergency situation and is defined as a state in which capillaries perfusion is inadequate which leads
to lack of oxygen in tissue. This can be due to pump failure, deficient circulating blood volume,
trauma, heamorrhage, fluid loss and anesthesia.

STILL BIRTHS:

When baby dies during the process of birth and shows no signs of life called stillbirth. A baby that is
delivered [Link] medical terms it is defined as the death of fetus weighing at least 500 g (or after 24
completed weeks of gestation) before the complete expulsion or extraction from its mother.

SUTURE:

These are cranial joints and formed where two bones join.

SUB- INVOLUTION OF UTERUS:

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Incomplete or delayed return of uterus to its pre-gravid size during the puerperium usually to RPCs
and infection.

SEPTICEMLA:

It is the presence of micro-organism in blood.

SPINA BIFIDA:

It is a condition in which the arches at back of spine are [Link] times there is only

bony gap but sometimes spinal cord is exposed.

SHOW:

A term used to denote the blood stained mucoid discharge onset of labor which comes from

cervical canal plug. It is also called operculum.

SKILLED BIRTH ATTENDANT:

A midwife, nurse, nurse-midwife or doctor has undergone a prescribed course and is registered or
legally licensed to practice This excludes Traditional Birth Attendants (TABs) event if trained.

TRADITIONAL BIRTH ATTENDANT (ALSO CALLED TBA OR DAI):

One who assists the mother during childbirth, $he may have acquired skills by delivering babies her-
self. or through apprenticeship of other TBAS.

THROMBOSIS:

The formation of thrombus (clot) called thrombosis.

THROMBOPÍLÈBİTIS:

It is the Inflammation of a vein with clot formation. The clot tends to be adherent to wall of vein and
rarely separate so that the danger of embolism is small.

TALIPES:

It is also called clubfoot. A congenital abnormality in which. the foot has developed at an abnormal
angle to leg. It may equines, calcaneus, varus, valgus and cabus.

TRAIL OF LABOUR:

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It is test of labour conducted on primipara in hospital to decide if NVD is possible or not. It is con-
tinued only when maternal and fetal conditions are satisfactory.

VVE:

It is stand for vesico vaginal fistula. This is an artificial opening between the bladder or urethra and
vagina.

UMBILICAL HERNIA:

A protrusion of intestine though the umbilicus usually slight but occasionally severe.

U.T.I:

UTI is Urinary Tract Infection. The causative organisms are E-coli and B-coli. It enters through rec-
tum and genital tract.

VERSION:

Turning the fetus internally or externally to altera lie or presentation tö one, which is more favorable.

VERTEX:

The area between anterior fontanelle and posterior fontanelle and bounded by two parital

eminence called vertex.

VERNIX CASEOSA:

A greasy substance that covers the fetus in uterus

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OBSTETRICAL NURSING WRITTEN BY: DR SADAF JAVERIA (PHD)

UNIT NO 1
 WHAT IS MIDWIFERY?
Modern midwifery is defined as “The art and science of providing professional services to the Preg-
nant women throughout the maternity cycle, to ensure uneventful pregnancy, safe delivery and nor-
mal puerperium”

 WHO IS A MIDWIFE?
A midwife is a person who has successfully completed a midwifery education program that Is based
on the ICM Essential Competencies for Basic Midwifery Practice and the framework of the ICM
Global Standards for Midwifery Education and is recognized in the country Where it is located; who
has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery
and use the title midwife'; and who demonstrates competency in the practice of midwifery.(ICM)

She must be able to give the necessary supervision, care and advice to Women during pregnancy,
labor and the postpartum period to conduct deliveries on her own responsibility and to care for the
newborn and the infants.

This care includes preventive measures, the detection abnormal conditions in mother and child, the
procurement of medical assistance and the execution of emergency measures in the absence of medi-
cal help. She has an important task in health counseling and education. not only for the woman, but

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also within the family and community. The work should involve antenatal education and preparation
for parenthood and extends to certain areas of gynecology, family planning and childcare. She may
practice in hospitals, clinics health units, domiciliary conditions or in any other service.

 ROLE OF A MIDWIFE:
A midwife is

1. A specialist in normal obstetrics

2. A care provider for the women and their newborns

3. An important member of the maternity care team in a health facility

4. An independent practitioner of normal obstetrics in the community

5. A health educator for the woman, the family and the community

6. A liaison between the community and health services

7. A trainer a supervisor a researcher.

8. A participant in framing of MNCH policies.

9. An agent of change for women's status

10. A savior of lives if well trained authorized and support

11. A counselor.

10. A savior of lives if well trained authorized and support

12. A co-coordinator

13. An advocate

14. A Manager

15. A planner

 FUNCTIONS OF A MIDWIFE:
1. Diagnosis and management of pregnancy, labor and puerperium, in the hospital and the health
centers and in home, in urban and rural settings.

2. Early detection of abnormalities throughout the maternity cycle taking decision for require educa-
tion in each individual case and implementing the decision.

3. Care of normal and premature infants.

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4. Advice/guidance in the form of the health education for healthy habits and prevention of disease.

5. Nursing care of pregnant women with general and gynecological diseases and pre-postoperative
care in obs/gyn cases.

6. Management of Operation Theater, assistance to surgeon in obs/gyn surgeries.

7. Providing general and obstetrical first aid.

8. Making timely referral to next level of EmOC.

9. Advice guidance and services to the mothers to space their pregnancies.

10. Participates in continue medical education to enhance her learning and also in training, supervi-
sion of students and other health workers.

 CORE CƠMPETENCIES OFA MIDWIFE

To provide optimum maternal and newborn care, midwife/SEA needs to have the following compe-
tencies:

1. Familiarity with the social norms and cultural practices of the geographical area in which she
works in an institution or is self-employed.

2. Taking history: Asking relevant questions to ascertain pregnancy, calculating EDD and to assess
the needs of the pregnant woman, providing guidance and advice as needed.

3. Educating communities in general and women and their families in particular about the care of the
women during pregnancy.

4. Enabling women to look after their own health by providing information and assistance.

5. Assisting families in birth preparedness including the choice of the place of birth, money transport
and blood donors.

6 .Recognizing in pregnant woman conditions requiring care beyond her competency, and make re-
ferral to the appropriate source of health care.

7 .Recognizing the signs and symptoms of true labor

8 .Monitoring progress, of about an recording maternal and fetal condition on pantograph

[Link] safe vaginal examination to assess the level of dilatation of the os and descent of the
presenting part.

[Link] delay progress of labor and taking appropriate action including timely referral when
needed

[Link] normal vaginal delivery in the safest possible manner.

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[Link] managing the third stage of labor using oxytocic drugs as authorized.

13. Recognizing Ingpost-partum hemorrhage, providing first aid, and making timely referral if indi-
cated

[Link] eclamptic fits during ante intra or postpartum period and making referral after stabiliza-
tion of the women's condition.

15. Providing immediate care to the neonate and ensuring safe transition to extra uterine life.

[Link] women in the initiation and continuation of breast feeding.

I7. Providing essential care to the mother and the baby during the postnatal period according to the
established routine of the system.

18. Counseling every post-natal mother about spacing pregnancies.

19. Providing, on demand. all contraceptive services excepting those requiring surgical procedures.

20. Using authorized drugs accurately according to the needs of the patients.

21. Practicing infection control measures to ensure safety of the environment and for all health pro-
fessional and procedures to protect the mother and the newborn

22. Function as a health promoter in the community educating the families in disease. Prevention
through healthy habits use of available health services including vaccinations against preventable
diseases.

 SCOPE OF PRACTICE OF MIDWIFE

 The midwife is recognized as a responsible and accountable professional who works in part-
nership with women to give the necessary support, care and advice during pregnancy labor
and the postpartum period. to conduct births on the midwife's own responsibility and to pro-
vide care for the newborn and the infant, This care includes preventative measures, the pro-
motion of normal birth, the detection of complications in mother and child, the accessing of
medical care or other appropriate assistance and the carrying out of emergences measures.
 The midwife has an important task in health counseling and education, not only for the wom-
an but also within the family and the community. This work should involve antenatal educa-
tion: and preparation for parenthood and may extend to women health, sexual or reproductive
health and child care.
 A midwife may practice in any setting including the home, community, hospitals, clinics or
health units.

 MIDWIVES DO MORE THAN THAT THEY:

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I. Respect a woman's informed right of choice and promote' the woman's acceptance of responsibility
for the outcomes of her choices.

2. Work with women, supporting their right to participate actively in decisions about their care, and
empowering women to speak for themselves on issues affecting the health of women and their fami-
lies in their culture ‘society.

3. Together with women, work with policy and funding agencies to define women's needs for health
services and to ensure that resources are fairly allocated considering priorities and availability.

4. Support and sustain each other in their professional roles, and actively nurture their own and oth-
ers' sense of self-worth.

5. Work with other health professionals, consulting and referring as necessary when the woman's
need to care exceeds the competencies of the midwife.

6. Recognize the human interdependence within their field of practice and actively seek to resolve
inherent conflicts.

In their practice the midwives also:

 Provide care for women and childbearing families with respect for cultural diversity while al-
so working to eliminate harmful practices with in those same cultures.
 Encourage realistic expectations of childbirth by women within their own society with the
minimum expectation that no women should be harmed by conception or childbearing.
 Use their professional knowledge to ensure safe birthing practices in all environments and
cultures.
 Respond to the psychological, physical, emotional and spiritual needs of women seeking
healthcare, whatever their circumstances.
 Act as effective role models in health promotion for women throughout their life cycle, for
families and for other health professionals.
 Actively seek personal, intellectual and professional growth throughout their midwife career
integrating this growth into their practice.

 ETHICAL RESPONSIBILITIES:

Midwives:
 Hold in confidence client information in order to protect the right to Privacy, and use judg-
ment in sharing this information.
 Are responsible for their decisions and actions, and are their care of women.

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 May refuse to participate in activities for which they hold deep moral opposition: however,
the emphasis on individual conscience should not deprive women of essential health services.
 Participate in the development and implementation of programs that protect the life and pro-
mote the health of all women and families irrespective of cast, color or creed.
 Advancement of Professional Knowledge Practice Midwives:
 Ensure that the advancement of midwifery knowledge is based on activities that protect the
rights of women as persons.
 Develop and share midwifery knowledge through a variety of ways, such as peer review pub-
lications, and research
 Ensure updating of their own knowledge and skills
 Participate in the formal education of midwifery students and 'midwives.

SAFE MOTHERHÖOD:
How to ensure safe motherhood?

 This is term that covers a broad range of efforts to ensure live and healthy baby and mother at
the end of each pregnancy midwives contribute to making motherhood safe
 How to ensure safe motherhood?
 No one can ensure Safe Motherhood alone. It depends on combined efforts of a maternit y
care team and of the community. A properly trained and competent midwife if properly uti-
lized and supported can be the lead person in these efforts to provide affective obstetrical ser-
vices in the community.

OBSTETRICS
In the medical dictionary is another name for midwifery.

It is a branch of medicine that deals with care of women during pregnancy labor and puerperium.

 Normal Obstetrics covers:

 Preconception Counseling
 Diagnosis of Pregnancy
 Birth preparedness
 Ante-partum Care (Respectful Maternity care)
 Labor and vaginal delivery
 Active management of third stage of labour
 Immediate care of the newborn
 Obstetrical Analgesia
 Care during puerperium
 Postpartum Care of the mother and the newborn
 Establishment of Lactation

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 Diagnosis of actual or expected abnormal conditions during the entire maternity cycle
 Referral to the source of those services of those services which the mid wife cannot provide.
 Obstetrical first aid and stabilization of the mother/neonate before referral and immunization.
 Providing guidance and services for family planning.
 Abnormal Obstetrics covers all deviations from the normal including obstetrical emergencies

Obstetrical Emergency:
A severe life threatening condition that is related to pregnancy or delivery which requires urgent
medical intervention in order to prevent death of the woman and or the fetus.

An obstetric emergency:

 May occur any time during pregnancy, delivery or up to six weeks after childbirth
 May occur suddenly without any [Link] life threatening Requires urgent action
 Requires institutional skilled care of a level higher than the level of the midwife
 Obstetrical Emergency Care (Emergency obstetrical care or EmOC)
 It is the specialized medical care required and given during life threatening obstetrical com-
plications to prevent death and disability of the mother and or of the fetus or newborn.

Obstetrical emergencies are handled at three levels:

 Obstetrical First aid:

Interventions, which could be carried out in the community i.e in the homes or in the basic health
units (BHU), mother and child (MCH) health centers and rural health centers (RHC).These interven-
tions include:

 Administration of: Parenteral oxytocic drugs ( ergometrin/cyntocynon)

 Parenteral antibiotics
 Parenteral sedatives/anti -convulsant
 Intravenous infusions
 Basic Em0C (BEm0C)
 Should be available at all Tehsil hospitals and Rural Health Centers (RHCs). This includes:
 All elements of obstetrical first aid
 Manual removal of placenta
 Removal of retained products of conception
 Assisted vaginal delivery (forceps and vacuum)
 Basic investigations
 comprehensive Em0C (CEmOC)

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 District or Tehsil Hospitals that have skilled health care providers, including anesthetist and
are properly equipped can provide comprehensive EmOC).This includes:
 All the elements of obstetrical first aid and basic EmOC.

PLUS:

Surgery (Caesarean section)

Blood transfusion:

NOTE: You might hear the ward Essential Obstetric Care. This is a word used in WHOs documents.
It includes both Basic and Comprehensive Care. It is not a commonly used term in Pakistan

AVAILABILITY OF AND ACCESSIBILITY TO COMPREHENSIVE EMOC:

It is the main factor in reducing maternal death and disability.

MATERNAL DEATH:

Death of women during pregnancy or within 42 days of termination of pregnancy from any causes
related or aggravated by the pregnancy but not due to accidental and incidental causes.

Maternal Mortality Ratio (MMR):

IN PAKISTAN EVERY 20 MINUTES A WOMAN DIES WHILE GIVING

BIRTH i.e. 25000 DEATHS EVERY YEAR

MATERNAL Mortality Ratio (Ratio) :

MMR is number of maternal deaths per 100, 000 live [Link] is among the countries with
high mmr the exact figure is not known the currently used figure based on estimates is 276 per
1000,000 live births. 178 deaths/100,000 live births (2015 est.) PDHS 201218

Maternal Morbidity:

 Short- or long-term illnesses caused by obstetrical complications.

 Some 830 women still die every day from causes related to pregnancy or childbirth. This is
about one woman every two minutes. And for every woman who dies, 20 or 30 encounter in-
juries, infections or disabilities. UNFPA Factors influencing Maternal Mortality and morbidi-
ty in Pakistan main factors (Same in most developing Countries) Repeated and closely spaced
pregnancies Limited access to or availability of health care.
 Lack of awareness in the people about the importance of care during pregnancy
 Available health facilities not adequately equipped.
 Inadequate preparation of the mother and the family for child birth and for possible
 complications requiring' emergency obstetrical care.
 Care provider at the facility, by and large not skilled enough to provide the required care.

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Three delays:
The Three delays which contribute to maternal deaths are:

1stdelay:

In taking decision to seek professional/medical help.

2nd delay:

Reaching an appropriate medical facility

3rd delay:

Receiving prompt adequate and appropriate treatment at the facility

Some of us believe in FOUR delays

4th*delay is the delay which occurs between the decision making and starting the journey to the
health facility. It is due to making preparations i.e getting permission from whoever holds this power
arranging money transport a couple of blood donors etc and then starting the journey to the health
facility.

How much time do we have to save the mother when a complication is recognized?

Condition Time available to save life

PPH :2 hours

Aph:12 hrs

Obstructed labor:2 days

Infection :6 days

Abortion is covered within the above conditions. The woman will either be bleeding or will have in-
fection or both. Bleeding requires immediate action.

Contributing factors:

 Poverty
 Illiteracy
 Malnutrition
 Early Marriage and other Socio-cultural factors
 Too early, too late, Too many and Too frequent pregnancies,
 Status of women in the society

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Causes of Maternal Deaths:

 Hemorrhages (APH & PPH) 25%
 Eclampsia 12%
 Puerperalsepsis 15%
 Obstructed labour 8%
 Ünsafe abortions 13%
 Other direct causes 8%
 Indirect causes 20%

Direct causes which account for about 73% of maternal deaths globally.

Note: Hospital: figures, collected over the years from hospitals in Pakistan give almost same as the
global percentages for causes of MMR.

(Source: WHO report 2005)

In-direct causes which account 27% death

Pre-existing conditions including Chronic conditions e.g.

 T.B
 Diabetes
 Heart disease
 Kidney Diseases.
 Anemia
 Hepatitis
 Rheumatic heart disease

Averting Maternal Death and Disability

 How can we reduce maternal deaths?

 Awareness in the community about care of women during the entire maternity cycle
 Provision of Primary Health Care
 Accessibility to Basic Maternity Care facilities
 Presence of skilled birth attendant at each child birth.

Clean and safe delivery observing THE THREE CLEANS (clean surface, clean hands. Clean
blade.)

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THE FIVE CLEANS:

Some of us believe in 5 cleans

1. Clean environment (clean place, clean surface where delivery will take place)

2. Clean equipment/ supplies ( anything used while giving care to thể mother and the baby)

3. Clean hands (of birth attendant)

4. Clean cord care (tying and cutting)

5. Clean clothes for the mother and the baby after delivery.

6. Availability of Emergency Obstetrical Care (EmOC) at all times.(24/7)

7. Utilization of family planning services.

All the above combined with improving women's status &empowerment over her own fertility will
ensure Safe Motherhood to a large extent

BPCR (BIRTH PREPAREDNESS AND COMPLCATION READINESS): -

Birth [Link] planning and preparation for delivery-can do much to improve ma-
ternal health [Link] preparedness helps ensure that women can reach professional delivery
care when labor begins addition, birth preparedness can help reduce the delays that occur when
women experience obstetric, complications. such as recognizing the complication and deciding to
seek care reaching a facility where skilled care is available and receiving care from qualified provid-
ers at the facility.

Key elements of birth preparedness include:

 Attending antenatal care at least four times during pregnancy.

 Identifying a skilled provide and making a plan for reaching the facility during labour;
 Setting aside personal funds to cover the costs of travelling to and delivering with a skilled
provider and age required supplies:
 Recognizing signs of complications:
 Knowing what community resources emergency transport funds, communications. etc. are
available in case of emergencies;
 Having a plan for emergencies i.e. knowing what transport can be used to get to the hospital
setting' aside funds; identifying person(s) to accompany to the hospital and' or to stay at home
with family; and identifying a blood donor.
 Because life-threatening complications can occur during the early postpartum period. Birth
preparedness also includes preparing/planning for accessing postpartum care during the first
week after delivery and at six weeks after delivery. Birth preparedness involves hot only the
pregnant woman, but also her family, community and available health staff. The support and

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involvement of these persons can be critical in ensuring that a woman can adequately prepare
for delivery and carry out a birth plan.

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 UNIT 2:
ANATOMY AND PHYSIOLOGY OF REPRODUCTIVE OR-
GANS
FEMALE PELVIS:
Female pelvis a bony canal through which the fetus passes during the process of birth.

Importance in midwifery practice:

 Knowledge of pelvis is important for estimating during pregnancy, the adequacy of the pas-
sage for the fetus to pass through and for assessing the progress of labor by movement of the
fetus in relation to certain pelvic and landmark functions of female.
 The primary function of the pelvic girdle is to allow movement of the body, especially walk-
ing and running it permits the person to sit and kneel.
 The pelvis afford protection to the pelvis organs and to a lesser extent to the abdominal con-
tents.
 The female pelvis is adapted for child bearing.

PELVIC BONES:
The pelvic is composed of four bones

Two Innominate:

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One Sacrum, and

One Coccyx

A. INNOMINATE BONES:

They are also known as hipbones; they form the lateral and anterior wall of pelvic and consist of
three fused bones; the ileum, ischium, and pubis.

1. Ileum:

It is the large flared out part and is fan shaped.

2. Ischium:

It is the thick lowest and heaviest part of innominate bone. It has a large prominence known as the
ischial tuberosity, on which the body rests when sitting

 Important Landmarks of Ischium

Ischial Tuberosity:

It is a large prominence.

Ischial Spines:

Posterior and superior to Ischial tuberosity a projection called ischial spine, it is an important land-
mark during labor. The level of fetal head is assessed in terms of ischial spine.

Pubis:

The smallest front part innominate bone is known as Pubis.

Important Landmarks:

Symphysis Pubis: The point where the two pubic bones articulate with each other.

Pubic Arche: it is formed by two inferior ramie of pubis and Ischium bone.

A. THE'SACRUM:

The Sacrum is wedge-shaped bone consisting of five fused vertebrae. The upper border of thefirst
sacral vertebrae put forward and is known as the sacral promontory.

Important Landmarks:

Promontory of Sacrum: The upper border of first sacral vertebrae is known as Sacral

Promontory.

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[Link] COCCYX:

The coccyx is a vestigial tail. It consists of four fused vertebrae, forming a small triangular bone.

PELVIC JOINTS, LIGAMENTS AND THEIR FUNCTIONS:

PELVIC JOINTS:

There are four pelvic joints

 One symphysis pubis:

This joint is formed at the junction of the two pubic bones, which are united by a pad of carti-
[Link] may separate slightly in later pregnancy and if it widens appreciably the degree of move-
ment may give rise to pain on walking.

 Two Sacro iliac joints:

Are the strongest joints in the body, They join the sacrum to the ileum and thus connect the spine to
the pelvis.

 One sacro-coccygeal joint:

It is formed where the base of the coccyx articulates with the tip of the sacrum. In non-pregnant state
there is very little movement in these joints, but during pregnancy endocrine activity causes the lig-
aments soften, which allows the joints to move in order to accommodate the fetus and help in the
process of birth.

 PELVIC LIGAMENTS:
The function of Ligaments is to bind the pelvic joint together and they are strongest in whole body,
and they are;

 Inter-Pubic Ligament:

At symphysis pubis it strengthens the symphysis pubis.

 Sacro-Iliac Ligament:

This binds sacrum with ileum

 Sacro-Coccygeal Ligament

This binds sacrum with coccyx.

 Sacro-Tuberous ligament:

It is between sacrum and the tuberosity of the ischium.

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 Sacro-Spinous Ligament:

It is between sacrum and ischial spines

 DIVISION OF PELVIS:
The bony pelvis is divided into two parts.

 False pelvis
 True Pelvis.

False pelvis:

It has no obstetric value expect that it directs the baby into True pelvis.

True pelvis:

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The true pelvis is the bony canal through which the fetus passes during birth. It consists of brim cav-
ity and outlet

 THE PELVIC BRIM:

The female has round pelvic brim and is bounded posteriorly by the promontory of sacrum and in
front by the pubic bone

Diameter of Pelvic Brim:

The three diameters are measured as:

Anteroposterior Diameter:

AP diameter is termed as diagonal conjugate measured from the lower border of the symphysis pubis
to sacral promontory. It is 11 to12cm. As the coccyx may be deflected backward during labour, this
diameter indicates the space available during delivery.

Transverse Diameter:

This is the widest part of brim and is measured from side to side immediately behind the ilio-
pectineal eminence. It measures 13 cm. The fetal head commonly enters the Transverse diameter of
pelvic brim.

Oblique Diameter:

It is a line from one sacroiliac joint to the iliopectineal eminence on the opposite sides. These
measures are called the right and left oblique diameters and they measures 12 cm.

PELVICCAVITY:

It is a curved canal between pelvic brim and outlet, which is circular in shape and extends from the
brim above to the outlet below.

Internal Measures of pelvic Cavity:

The internal measures of the pelvic cavity are considered to be the same throughout because cavity is
circular. It is 12 cm approximately.

PELVIC OUTLET:

The outlet is diamond shaped with its apex joining two tuberosities and they are

 Anatomical outlet, Obstetrical outlet

 Anatomical outlet:

It is formed by lower borders of each bone together with the Sacro tuberousligament.

OBSTETRICAL OUTLET:

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It is the space between the narrow pelvic strait and has greater practical significance because it in-
cludes narrow pelvic strait through which fetus must pass. It has three diameters which are as fol-
lows:

Antero Posterior Diameter:

It is a line from the lower border of symphysis pubis to Sacrococcygeal joint and measures 13-
[Link]'s diameter indicates the space available during delivery.

Transverse Diameter:

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Is line between the ischial spines. It is the narrowest diameter of pelvis and measures 11 cm.

Oblique Diameter:

It is said to be between the obturator foramen and the sacrospinous ligament. It measures 12 cm

Diameters ANTERIOPOSTERIOR Oblique Transverse

BRIM 11cm 12 cm 13 cm
CAVITY 12 cm 12 cm 12 cm
OUTLET 13 cm 12 cm 11 cm

 TYPES OF PELVIS:
According to the shape of brim, female pelvis has been classified into four types

 Gynecoid Pelvis (female pelvis)

 Android Pelvis& (male pelvis)
 Anthropoid Pelvis (oval monkey shaped)
 Platy pelloid, Pelvis (plate like Kidney shaped)

 CHARACTERISTIC OF FOUR TYPES OF PÉLVIS:

GYNAECOID PELVIS:

It is the true female pelvis. Its main features are the rounded brim, straight side walls, a shallow cavi-
ty with a broad well curved sacrum, blunt ischial spines, a wide sciatic notch, and a pubic arch of 90
degree. It is found in women of average built and height (with a shoe size of four or larger), it is well
suited to child bearing.

Relation to fetus during labour:

The fetal head often engages in the transverse diameter of brim in an occipito-anterior position .The
course and mechanism of labour is normal

Effects on Labour:

The head may engage transversely or in an occipito-posterior position. It is difficult for head to de-
scend through the pelvis Deep Transverse are at occurs because of prominent ischial spine

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ANDROID PELVIS:

This is a type of pelvis found in males. The ischial spines more prominent and the iliac crest pubic
arch and sciatic notches are [Link] brim is heart shape, which makes anteroposterior diameter of
brim short.

Effects on Labour:

The head may engage with the occipito-posterior. The baby is born face to pubis.

PLATYPELLOID PELVIS:

This is a simple flat pelvis and it has a kidney shaped brim, The anteroposterior diameter is short and
transverse diameter is large.

Effects on Labour:

The head will engage in the transverse diameter of the brim. Rotation of head may be restricted and
deep transverse arrest of head may occur.

ANTHROPOID:

This has a long. oval brim in which anteroposterior diameter is longer than transverse. The ischial
spines are not prominent.

DIFFERENCES BETWEEN MALE AND FEMALE PELVIS

Female Male
Pelvic Inlet ᴑ

Pelvic Outlet

Pelvic Cavity

Pubic Arch

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Features Gynecoid Android Anthropoid Platypelloid

Brim Round Heart shape Long oval Kidney shape
Fore pelvis Generous Narrow Narrowed Wide
Side wall Straight Convergent Divergent Divergent
Ischial spines Blunt Prominent Blunt Blunt
Sciatic notch Round Narrow Wide Wide
Subpubic angle 90° <90° >90° >90°
Incidence 50% 20% 25% 5%

 KEY POINTS:
 The Gynecoid pelvis is the most favorable for labor and the most common other shapes of the
following clinical scenarios
 pelvis predispose to the following clinical scenarios
 Android: Deep transverse arrest
 Platypelloid pelvis: Obstructed labor
 Anthropoid pelvis: persistent occiputo, posteriorposition. (POP)

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 PELVIC FLOOR: -
The pelvic floor is made of soft muscular tissue, fat, fascia. skin, and connective tissue. The im-
portance of this structure is to provide support to pelvic organs and prevent them from Prolapse.

There are three openings at pelvic floor.

1. Urethral opening (orifice)

2. Vaginal opening
3. Rectum

FUNCTIONS OF PELVIC FLOOR:

 It supports the contents of abdominal and pelvic organ.

 It causes flexion of the head. This is due to the contraction of the uterine muscles forcing the
head down on the resistant muscles of pelvic floor. The pressure of the floor and contraction
of the uterine muscles causes head to flex.
 It assists in internal rotation. This is due to the slopped floor and shape of the muscles comes
into the contact of pelvic floor, which rotate it forward.

PELVIC FLOOR MUSCLES:

The pelvic floor is composed of superficial and deep layers. The superficial muscles layers forms
half of perianal body and anal and vaginal orifice of pelvic floor and consist of five layers.

1. Two bulbocavernosus muscles:

They extend from the center of perineal body around the vagina to the clitoris. inserted deep in to
labia.

2. Two Ishio-Cavernosus Muscles:

These muscles pass from ischial tuberosities to clitoris support the neck of the urinary bladder and
assist' in the control of micturition.

3. Transverse Perineal muscles:

These start from the ischial tuberosities and go transversely one each to the opposite side to meet
other perineal muscles.

4. The external anal sphincter

Surrounding the anus and attached behind by a few fibers to the coccyx.

[Link] sphincter of the urethra:

Is composed of muscle fibers passing above and below the urethra and attached to the pubic bones. It
is not a true sphincter.

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THE DEEP LAYER:

This layer is composed of three pairs of muscles which together are known as Levator Animuscles.
They are also called because they lift or elevate the anus.

1. Pubococcygeus muscle:

Passes from the pubis to the coccyx with a few fibers crossing over in the perineal body to form its
deeper part.

[Link]:

It is also known as coccygeus, the coccygeus is triangular muscle, partly replaced by the sacrospi-
nous ligaments it arises from the ischial spine and fans out into insertion on the sides of the sacrum
and coccyx.

3. Iliococcygeous:

Passes from the ileum to coccyx.

PERINEAL BODY:
Is a triangular mass of the connective tissue muscle and fat measuring 4 cm. Perineal body fills the
wedge shaped area between the lower end of rectum and vagina, During second stage of labor peri-
neum becomes so thin that it can tear

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FEMALE REPRODUCTIVE SYSTEM: -

REPRODUCTIVE ORGANS:

The female reproductive organ or genitalia are divided in to external and internal organs.

External Genital Organs:

They are collectively known as vulva and consist of following structures:

 Mons Veneris/ Mons Pubis

 Labia Majora
 Labia Minora
 Clitoris
 Vestibule
 Vaginal Orifice
 Urethral Orifice
 Bartholin Glands
 Perineum

Mons Veneris /Mons pubis (mount of venous):

It is a pad of large fat lying over the symphysis pubis. It is covered with pubic hair from the time of
puberty.

Labia majora (larger lips):

These are two large folds of fat and soft tissue. It is covered with skin and pubic hair on outer sur-
face. It forms boundary of vulva. It contains large number of sebaceous glands. They arise in the,
mons veneris and merges into perineum behind

Labia minora (smaller lips)

These are two thin folds of skin, lying between labia majora and contain numerous sebaceous glands.
Anteriorly they divide they enclose the clitoris and posteriorly they fuse to form four chette.

The urethral orifice:

These are two small blind ended tubules 0.5cm long running with in the urethral wall.

The Vaginal orifice:

It is also known as the in troitus of the vagina and occupies the posterior two thirds of the vestibules.
The orifice is partially closed by the hymen.

Clitoris

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It is small erectile rudimentary organ corresponding to male penis and contains erectile tissue .It is
extremely vascular and sensitive and plays a part in the organism of sexual intercourse.

Vestibule:

It is the area enclosed by the labia minora The vagina, urethra, and ducts of greater [Link]
vaginal, orifice is partially closed by hymen.

Hymen:

It is thin layer of mucous membrane. which tears during sexual intercourse or during the birth of first
child.

Bartholin's Glands:

These are two small glands Lying on the posterior part of the labia majora. It's ducts open on either
side of vaginal orifice and secrets mucous, which lubricates vaginal orifice.

Perineum:

It is the area extending from the four chette to the anus. It is a triangular mass of connective tissue,
muscles and fat. It fills the area between vagina and rectum. Perineal body measures 4 cm in each
direction.

INTERNAL GENITAL ORGANS:

The internal organs of the female reproductive system lie in the pelvic cavity and they consist of:

 vagina
 uterus
 fallopian tubes

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 ovaries

Position:

The Vagina is fibro-muscular tube connecting the external and internal organs of reproduction. It
runs obliquely upwards and backwards at angle of about 45 degree between the bladder in front rec-
tum and anus behind.

Relation:

Anterior: In front lies the bladder and the urethra.

Posterior: The pouch of duglus, the perineal body and the rectum.

Lateral: Beside upper two third are the pelvic fascia and the ureters while beside lower third are
muscles of the pelvic floor:

Structure:

In adult, the anterior wall is about 7.5 cm (3įnches) long and the posterior wall about10 cm long. The
difference is due to protrusion of cervix through the anterior wall.

The upper end of vagina is known as Vault, which divides vagina into four arches of fornixes.

Posterior Fornix:

It is the largest arch behind cervix

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Anterior Fornix:

It lies in front of cervix.

Lateral Fornix:

It lies in either side of vagina.

Functions:

 The vagina is a passage, which allows the escape of menstrual flow.

 It receives penis and the ejected sperms (semen) during sexual intercourse.
 It provides an exit for fetus during delivery.

UTERUS
Positions:
It lies in pelvic cavity between the urinary bladder and rectum in an anteversion and anteflexion posi-
tion.

Ante version: It means that the uterus leans forward.

Ante flexion: It means that uterus bend forward almost at right angle to the vagina with its anterior
surface resting on urinary bladder.

Relations:
Anterior: In front of the uterus lie the utero vesical pouch and the bladder.

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Posterior: Behind the uterus are the recto uterine pouch of duglus and the rectum.

Lateral: On either side of uterus are broad ligaments, the uterine tubes and the ovaries

Inferior: Below the uterus is vagina.

Superior: Above the uterus lie the intestines.

Structure:
The non-pregnant uterus is a hollow muscular pear shaped organ flattened antero posterior.

Size:

It is 7.5 cm long, 5 cm wide and 2.5 cm in depth. Each wall-is 1.25 cm thick. Its weight is 60 to90
gms.

Parts of Uterus:

Fundus:

It is a domed shaped part of the uterus above the opening of the uterine tubes.

Body:

This is the main part of the uterus, which is narrowest inferiorly at internal Os where it is continuous
with cervix.

Cornua:

These are the upper outer angles of the uterus where the fallopian tubes joins.

Cavity:

lt is the potential space between the anterior and posterior wall it is triangle in shape.

Isthmus:

It is narrow area between the cavity and the cervix which is 7 cm long and enlarge during pregnancy
to form the lower uterine segment

Cervix :( Neck)

It is the lowest part of uterus, which projects into the vault of vagina.

Internal Os:

It is the narrow opening between isthmus and cervix.

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External Os:

It is the small round opening at the lower end of cervix.

LAYERS:

The wall of uterus is Composed of 3 layers, namely

 Perimetrium,
 Myometrium.
 Endometrium.

Perimetrium

It is the outer layer of uterus consist of double serous membrane, an extension of the peritoneum
which is draped over the uterus, covering all but a narrow strip on either side and the anterior wall
the supra vaginal cervix from where it reflects up over the bladder.

Myometrium:

it is the thickest layer in the uterine wall. It consists of mass of smooth muscles fibers interlaced with
areolar tissue, blood vessels and nerves.

Endometrium:

It consists of ciliated columnar epithelium. It contains large number of mucous secreting tubular
gland. It secrets mucous and alkaline secretion

SUPPORTING LIGAMENTS:

The uterus is supported by the pelvic floor and maintain in position by several ligaments of which at
the level of cervix are the most important.

The transverse cervical Ligaments:

They are also known as Makenrodt's ligaments/Cardinals ligament. Fan out from the

The cervix to the side walls of the pelvis.

Two broad Ligaments:

They are formed by double fold of peritoneum, on each side of uterus.

Round Ligaments:

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These are bends of fibrous tissue between the two layers of broad ligaments, one on each side of
Uterus helps to keep uterus AV.

Two-utero-sacral Ligaments:

These ligaments originate from the posterior part of the cervix and vagina and extended Backwards
one on each side of rectum to sacrum.

Pube-Cervical ligaments:

They pass from the cervix under bladder. to the pubic bone.

BLOOD SUPPLY, LYMPH DRAINAGE AND NERVE SUPPLY:

The Arterial Supply:

Blood supply is by the uterine arteries which are branches of the internal iliac arteries. They pass up
the lateral aspects of the uterus between the two layers of the board ligaments. They supply blood to
uterus and uterine tubes and join with the ovarian arteries to supply ovaries. Branches pass down-
wards to anatomize with the vaginal arteries to supply the vagina.

Venous Drainage:

The thick endometrium is shed during menstruation and flows from vagina.

Lymph Drainage:

Lymph’s drained from the uterine body to the internal iliac glands and also from cervical area to
many other pelvic lymph glands

Function OF Uterus:

Menstruation:

Every month uterus prepares itself for receiving fertilized ovum but if it does not happens it expel
out all the uterine contents in the form of menstruation.

Pregnancy:

The uterus receives fertilized ovum and helps to nourish that ovum. It provides he environment for
growing fetus, during the 40 week gestation period.

Labour:

The muscles of uterus contract during the process of labour and help the foetus and expulsion of fe-
tus Placenta, and membrane

Involution:

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The uterus returns to its normal size following delivery

 FALLOPLAN TUBES:
POSITION:
These are two hollow muscular tubes extending from the sides of uterus and opening into the perito-
neal cavity near the ovaries.

RELATION:
Anterior, Posterior and Superior:The peritoneal cavity and the intestine.

Lateral: The side wall of the pelvis.

Inferior: The broad ligaments and ovaries lie below the tubes.

Medial: Uterus lies between the two uterine tubes.

STRUCTURE:

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Size: Each tube is 11 cm long.

Parts: Each uterine tube has four portions;

Interstitial: It is I.25 cm long, lies within walls of uterus and its lumen 1 mm wide.

Isthmus: It is narrow part which extends for 2.5 cm from the uterus.

Ampulla: It is wider portion, 5 cm long in which fertilization usually occur.

Infundibulum: It is terminal margin, which is composed of many processes known as fimbriae

(One long fimbriae with ovary known as ovarian fimbriae)

FUNCTIONS:
 They propel the ovum towards the uterus.
 Receive the ova
 And provide site for fertilization.

 OVARIES:

POSITION:
The ovaries are female gonads or sex glands. They lie in a shallow fossa on the lateral wall of pelvis
each is attached to the upper part of uterus by ligament.

RELATION:

Anterior: The broad ligaments

Posterior: The intestine.

Lateral: Pelvic ligaments and the sides of pelvic.

Superior: The uterine tubes.

Medial: The uterus and the ovarian ligaments.

SIZE:

It is 2.5 to 3.5 cm long, 2 cm wide and 1 cm thick.

The ovaries have two layers of tissue.

The Medulla:

It lies in the center and consist of fibrous tissue, blood vessels and nerves.

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The Cortex:

It surrounds the medulla. It has a framework of connective tissue or stroma covered by germinal epi-
thelium. It contains ovarian follicles, each of which contains an ovum.

Before puberty the ovaries are inactive but the stroma already contains immature Follicles during
childbearing year one ovarian follicle matures rupture and release its ovum into peritoneal cavity
7during each menstruation cycle.

Functions:

Ovaries produce ova, and hormones.

OVARIAN HARMONES:
 Estrogen
 Progesterone

ESTROGEN:

It is produced under the influence of the FSH follicle-stimulating hormone, Ovulation causes, an in-
creased amount of estrogen secretion into blood stream.

FUNCTIONS OF ESTROGENS:

Estrogens have the following effects on various organs and tissues:

Female reproductive organs- increase in size

 External genital-deposition of fat in the mons pubic, enlargement of labia

 Vagina-change of the epithelial lining after puberty
 Uterus thickening of the endometrium (inner lining of uterus) and development of endometri-
al glands
 Fallopian tubes-increase in ciliated epithelial cells in the fallopian tube to help push the ovum
out
 Breasts- growth of the duct network of the breasts, increase in fat and stroma
 Bone - stimulate bone growth by reducing bone break down and increasing bone deposition
 Metabolism - increases the metabolic rate
 Fat deposition - increases deposition of fat in the subcutaneous tissues. particularly on the
breast, thighs and buttocks
 Skin - increases vascularity, contributes to softer smoother skin
 Kidneys- electrolyte and water retention which is only prominent with high quantities of es-
trogen like during pregnancy

PROGESTERONE:

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The most abundant progestrogen is progesterone, with small quantities of another type of progesto-
gen known as [Link] being secreted by the ovaries.

FUNCTIONS OF PROGESTERONE:

 Uterus - increases secretory actions of the endometrial lining in preparation for pregnancy
 Fallopian tubes- increases secretions to nourish the rapidly developing fertilized ovum
 Breasts- promotes development of breast alveoli and lobules

BLOOD AND NERVE SUPPLY:

The blood vessels and nerves pass to cavity in mesovarium

MAMMARY GLANDS OR THE FEMALE BREAST

SITUATION:

The breasts are accessory glands of female reproductive system. They are situated on the anterior
chest wall over the pectoralis major muscle between second and sixth ribs and each extends from the
sternum to the axilla.

In the female the breasts are quite small until puberty. There after they grow and develop to their ma-
ture size under the influence estrogen and progesterone.

CROSS SECTION:

The glandular tissue of the breasts is arranged in lobes (10 to 20 in number). The The lobes are made
up of lobules. The lobules are made up of alveoli.

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MICROSCOPIC STRUCTURE:

 The alveoli are lined with cells known as acini, which secrete milk after delivery.
 Small lactiferous ducts lead from the alveoli and join up until there is one large lactiferous
duct leaving each lobe raveling towards the nipple.
 The areola is the loose. Pigmented skin surrounding the nipple, it is usually darker in color
than the skin of the breasts.
 The, nipple is composed of erectile tissue situated at the center of the each breasts covered
with epithelium. It contains muscle fibers which have a sphincter-like action.
 Raised sebaceous glands on the areola are about 22 in number and known ‘as Montgomery's
tubercles

Blood Vessels:

Internal and external mammary arteries and veins

Lymphatic Glands:

Axillary and anterior mediastinal lymphatic glands.

Nerve Supply: 4h, 5h, and 6 autonomous nerves, branches of thoracic nerves.

 FUNCTIONS OF BREAST:
The primary function of the female breast is to nourish a baby.

• They are a symbol of beauty: eroticism and femininity.

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THE MALE REPRODUCTIVE SYSTEM: -

The Male Reproductive Organ and their Associated Structure

The male reproductive system consists of the following structure

 2 testis(In the Scrotum)

 2 Epididymis
 2 Deferent ducts (vas deferens)
 2 spermatic vesicle
 2 seminal vessels
 2 Ejaculatory ducts
 1 Prostate gland
 1 penis

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TESTIS:
The testis is the reproductive glands of male and are equivalent of ovaries in the female. They are
suspended in the scrotum by spermatic cord. Each testis is 4.5 cm long, 2.5 cm wide and 3cm thick,
and surrounded by three layers of tissue, called

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 Tunica Vaginalis
 Tunica Albuginea
 Tunica Vasculosa

Function:

They produce spermatozoa and testosterone (testosterone is responsible for the secondary male char-
acteristic

EPIDIDYMUS:

It is a comma shaped coiled tube. It lies on the superior surface and travels down the posterior aspect
of lower pole of testis. Where it leads into the vas deferens

SPERMATIC CORD:

There are two spermatic cords, one leading from each testis. The cord passes through the inguinal
canal at deep inguinal ring. It consists of ducts deferens the testicular blood vessels, Lymph vessels,
and nerves.

Function:

Its transmits the ducts deferens up into body, along with other structures. Its function is to carry the
sperm to the ejaculatory duct.

SEMINAL VESICLE:

They are two fibrous muscular pouches lying on posterior aspect of bladder. They are 5 cm long and
pyramid in shape. Each seminal vesicle opens into a short duct which joins with the corresponding
ductus from an ejaculatory duct.

Function:

Its function is the production of a viscous secretion to keep the sperm alive and motile.

EJACULATORY DUCT:

The two tubes are about 2 cm long, each formed by union of the duet from a seminal vesicle and duct
us deferens. They pass through prostate gland and join the prosthetic urethra.

Function:

Their function is to carry spermatozoa and seminal fluid to the urethra

PROSTATE GLAND:

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It is long 3cm wide and 2 cm deep. Compose of columnar epithelial tissue and muscles, and lies in
the pelvic cavity in front of rectum and behind the symphysis pubis, surrounds the first part of ure-
thra.

Function:

It produces a thin Lubricating fluid which enters the urethra through ducts.

PENIS:

It is formed by three columns of erectile tissue and involuntary muscles. The two lateral columns are
called corpora cavemous and the columns between them are corpora spongiosum. The penishas a
root and body root lies in the perineum and body surrounds the urethra.

Function:

It carries urethra, which provide common pathway for the flow of urine and semen.

During sexual excitement it stiffens and is able to penetrate the vagina to deposit semen.

SCROTUM:

It is the pouch of deeply pigmented skin, divided into two components, each of which contains one
testes, one epididymis and testicular end of spermatic cord. It lies below the symphysis pubis in front
of the upper part of thighs, behind the penis function scrotum from a pouch in which the testes are
suspended outside the body:

URETHERA:

It is about 19-20 cm long (it starts from urethra orifice in bladder and passes through perineum into
the penis)

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PUBERTY AND SECONDARY SEXUAL CHARACTERISTICS

PUBERTY:
A girl is born with almost a complete set of reproductive organs, but she is not fully capable or re-
production until the reproductive organs are functionally active .Puberty is the period of time when
children begin to mature biologically. Psychologically Social and cognitively. Girls' start to grow
into women and boys into men. This is the period of increased general body growth and development
of secondary sexual characters the age of puberty varies between 10 and 14 years

SECONDARY SEXUAL, CHARACTERISTICS:

The secondary sex characteristics in a girl bring about certain external physical changes. These in-
clude growth of hair under the armpits and over the mons [Link] of breasts and col-
lection of adipose tissue over the hipbones.

Similarly, in a boy hair grow on the chest and pubic region, growth of beard, [Link] hoarse-
ness of voice. These characteristics usually appear between these of 13-15 years. Depending upon
the General health. Climate and hereditary influence.

MENSTRUATION:
Menstruation is the physiological bleeding which occurs on the endometrium of uterus, every month.
The bleeding take place through vagina and it is under hormonal control. Which normally occurs at

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regular interval of 28 days. It starts between 12 14 years of age and stop at the menopause around 48
years.

MECHANISM OF MENSTRUATION:
 The hypothalamus in the brain secretes luteinizing hormone releasing factors (LH-RF), which
stimulates the anterior pituitary to secret follicle stimulating hormone and luteinizing hor-
mone.
 Follicle stimulating hormone. (FSH) hormones maturation of ovarian follicles which secret
estrogen.
 Luteinizing hormone (LH) stimulates the development of corpus luteum and secrets proges-
terone.

MENSTRUAL CYCLE:
A series of change that take place concurrently in the ovaries and uterine walls, which finally result
in bleeding, stimulated by changes in the blood concentration of hormones. Menstrual cycle begins
from first day of menstruation, until the next menstruation. The cycle is of 28 days.

Hypothalamus

Luteinizing hormones releasing hormones

Anterior pituitary

Follicle stimulating hormones luteinizing hormones

Ovarian follicle corpus luteum

Estrogen progestogen

 PHASES OF MENSTRUAL CYCLE:

The phases of the menstrual cycle that denote changes in the uterine wall are

Proliferative Phase 10 days

Secretory phase 14 days

Menstrual phase 04 days

PROLIFERATIVE PHASE:

At this stage an ovarian follicle, stimulates by FSH, is growing towards maturity and is producing
Estrogen. Estrogen stimulates endometrium, which becomes thicker by rapid cell multiplication, ac-
companied by an increase in mucus secreting glands and blood capillaries. This phase ends when ov-
ulation occurs and Estrogen production stops.

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SECRETORY PHASE:

Immediately after ovulation. The lining cells of ovarian follicle are stimulated by LH to develop cor-
pus luteum,which produces progesterone. Under the influence of progesterone, the endometrium be-
comes edematous and the secretory glands produce increased amounts of water mucus. There is a
similar increase in the secretion of water mucus by the glands of the uterine tubes, vagina and cervix.

MENSTRUAL PHASE:

If the ovum is not fertilized. the high level of progesterone in the blood inhibits the activity of the
pituitary gland and the production of luteinizing hormone is considerably reduced .The with drawal
of this hormone causes degeneration of the corpus luteum and thus progesterone production is de-
creased. About 14 days, after ovulation the lining of the uterus degenerates and breaks down and
menstruation begins. The menstrual flow consists of the extra secretions endometrial cells and blood
from the broken-down capillaries and the unfertilized ovum.

If the ovum is fertilized there isn't any breakdown of the endometrium and thus no menstrual flow.
The fertilized ovum (Zygote) travels through the uterine tube to the uterus where it comes embedded
in the wall and produces the hormone chorion gonadotrophin which is similar to anterior pituitary
luteinizing hormone. This hormone keeps the corpus luteum intact continue to secrete progesterone
for the first 3 to 4 months of pregnancy inhibiting maturation of ovarian follicles. During this period
placenta develops and produces Estrogenprogesterone and gonadotrophin.

 MENOPAUSE: (Climacteric)
Menopause is time in a woman's life when her periods. (menstruation) eventually stop and the body
goes through changes that no longer allow her to get pregnant. lt is a natural event that normally oc-
curs in women age 45 – 55.

CAUSES, INCIDENCE, AND RISK FACTORS:

 During menopause, a woman' ovaries stop making eggs and they produce less estrogen and
progesterone changes in these hormones cause menopause symptoms. Periods occur less of-
ten and eventually stops. Sometimes this happens suddenly but most of the time period slow-
ly stops over time.
 Menopause complete when you have not had a period for one year. This is called post meno-
pause. Women who are postmenopausal can no longer get pregnant.
 Surgical menopause is when medical treatments cause a drop in estrogen. This can happen if
ovaries are removed or if one receives chemotherapy or hormone therapy for breast cancer.

SYMPTOMS:

Symptoms vary from woman to woman. They may last 5 or more years. Some women may have
worse symptoms than others. Symptoms of surgical menopause can be more severe and start more
suddenly.

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The first thing may notice is that periods start to change. They might occur more often or less often.
Some women might get their period every 3 week. This might last for 1- 3 Years before the periods
completely stop.

Common symptoms of menopause include:

 Menstrual periods that occur less often and eventually stop

 Heart pounding or racing
 Hot flashes, usually worst during the first l -2 years
 Night sweats
 Skin flushing
 Sleeping problems (insomnia)
 •Other symptoms of menopause may include:
 Forgetfulness (in some women)
 Headaches

Decreased interest in sex, possibly decreased response to sexual stimulate

 Mood swings including irritability, depression and anxiety.

 Urine-leakage
 Vaginal dryness and painful sexual intercourse
 Vaginal infections
 Joint aches and pains
 Irregular heartbeat (palpitation)

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UNIT 3:
DEVELOPMENT OF FETUS
OVUM AND OVULATION:
The ovum is a female reproductive cell (egg), which is required for producing an offspring. Each
Ovary contains large number of Ova. Each month, out of large number of Ova, only one ovum or
egg cell becomes mature under the influence of Follicles Stimulating Hormone (FSH). The mature
ovum is discharged from the ovary into the abdominal cavity where it collected by finger-like fim-
briated end of fallopian tube. This process is called ovulation.

SPERMTOZOA:
This is the male reproductive cell The individual spermatozoa has a head, a body and a long mobile
tail which lashes to propel the sperm along the tip of the head is covered by an acrosome, which con-
tains enzymes to dissolve the covering of the ovum in order to penetrate it.

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FERTILIZATION / CONCEPTION:
Union between ovum and sperm, which results in beginning of new life is known as fertiliza-
tion(conception). Most commonly it takes place at the ampulla of tube. The fertile period is 12-
14hours after ovulation. The sperm penetrates the outer covering of mature ovum: the muscles of two
cells fuse together and form "Zygote".chromosome

Every human cell contains 46 chromosomes arranged in pairs. The chromosomes contain the basic
hereditary substance, which determine the individual's characteristic and traits.

In female, two chromosomes are same and size and shape, which is called XX. Where as in
male, they are slightly different, one is an X and another slightly smaller is Y chromosome.

ln conception, when an X bearing spermatozo on fertilizes an ovum the offspring is female and when
Y bearing spermatozoa fertilizes an ovum, the offspring is male

OFFSPRING

X X XX (Female

X Y XY (Male)

The midwife needs to have an understanding of fetal development in order to estimate the approxi-
mate age of baby.

DEVELOPMENT OF FERTILIZED OVUMIZYGOT:

 Following ovulation the ovum passes into fallopian tube and moved towards uterus, by the
peristaltic muscular contraction of the tube. After reaching at uterus (in 3 -4 days’ time) cell
division take place and the fertilized ovum divides into two cells then 4 then 8. 16, and so on
until a cluster of cell is formed, known as morula (mulberry).Next, a fluid filled cavity or
blastocele appears in the morula, which now become known a blastocyst.
 On the outer side of blastocyst, there is single layer of cells known as the trophoblast, which
form the placenta and chorion. While the remaining cell forming the inner cell mass, and
will become the fetus and amnion.
 After the six or seven days of fertilization. The blastocyst embeds itself in the endometrium,
Embedding, sometimes known as nidation (nesting), is normally completed by the eleventh
day after ovulation.

DEVELOPMENT OF AN EMBRYO
On 13th day:

Three primitive layers can be differentiated in the ovum. Each layer will develop a particular part of
fetus

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 The Ectoderm: forms nervous system. Skin and certain lining of mucosa.
 The Mesoderm: Forms bones, circulatory system and certain internal organs.
 The Endoderm: Forms the mucosa of elementary canal, epithelium of liver, pancreas, and
Lungs and bladder.

On 18th Day two cavities appear on inner cell mass.

The Amniotic Sac: Enlarges and filled with Amniotic Fluid.

The Yolk Sac; Provides nourishment for embryo until trophoblast

DEVELOPMENT OF A FETUS MONTH TO MONTH:-

FIRST MONTH:

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 Fertilization occurs Zygote implants itself in the lining of the uterus

 Rapid cell division occurs embryonic stage lasts from 2 weeks to 8 [Link] differentiate
into three distinct layers: the ectoderm, the mesoderm, and the endoderm Nervous system be-
gins to develop Embryo is l-2 inch long.

SECOND MONTH:

 Heart and blood vessels form

 Head ‘area develops rapidly Eyes begin to form detail Internal organs grow. especially the
digestive system Sex organs develop rapidly and sex is distinguished
 Arms and legs form and grow
 Heart begins to beat faintly
 Embryo is I inch long and weighs 1/10 ounce

THIRD MONTH:

 Head growth occurs rapidly

 Bone formation begins to form rapidly
 The digestive organs begin to function
 Arms, legs, and fingers make spontaneous movements
 Fetus is 3 inches long and weighs 1 ounce

FOURTH MONTH :

 Lower parts of the body show rapid growth

 Bones are distinct in X rays
 Reflex movement become more active
 Heartbeat detected-by physician
 Sex organs are fully formed
 Fetus is 7 inches long and weighs 5 ounces

FIFTH MONTH :

 Mother begin feel reflex movements

 A fine, downy fuzz covers the entire body
 Vernix (a waxy coating) collects over the body
 Ears and nose begin to develop cartilage

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 Finger nails and toenails begin to appear

 Fetus shows hiccups, thumb sucking, and kicking
 Fetus is 12 inches long and weight 14 ounces

SIXTH MÔŅTH:

 Eyes and eyelids fully formed. Fat is developing under the skin
 Fetus is 14 inches long and weighs 2 pounds

SEVENTH MONTH:

 Cerebral cortex of brain develops rapidly

 Fetus is I7 inches long and weighs 3 pounds

EIGHTH MỘNTH:

 Subcutaneous fat is deposited. for later use

 Fingernails reach beyond the fingertips
 Fetus is 17 inches long and weighs 5-pounds

NINTH MONTH:

 Hair covering the entire body is she

 Organ systems function actively
 Verrnix is present over the entire body
 Fetus settles into position for birth
 Neonate is.21 inches long and weighs 7 pounds

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THE DEVELOPMENT, STRUCTURE, FUNCTIONS AND

ABNORMALITIES OF PLACENTA:
The placenta is a remarkable organ originating from the trophoblastic layer or fertilized ovum. It is
completely formed and starts from 10 week after fertilization. The survival of the fetus depends upon
is integrity and efficiency. It is a link between mothers with fetus during intrauterine life

DEVELOPMENT OF PLACENTA:

Initially the ovum appears to be covered with a fine, downy hair, which consists of the projections
from the trophoblastic layer. These proliferate and branch from about 3 weeks after, fertilization
forming the chorionic villi. The villi become most profuse in the area where the blood supply is rich-
est, that is, in the basal decidua. This part of the trophoblast is known as the chorion frondosum and
it will eventually develop into the placenta. The placenta is completely formed and starts from 10th
week after fertilization. In its early stages, it is a relatively loose structure: but becomes more com-
pact as it matures. Between I2 to 20 weeks of gestation the placenta weighs more than the fetus be-
cause the fetus organs are insufficiently developed to cope with the metabolic processes of nutrition
later in pregnancy some of the fetal organs. Such as the liver, begin to function, so the cyto tropho-
blast and the syncy totrophoblast.

APPEARANCE OF PLACENTA:

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The placenta is a round, flat mass about 20-cm in diameter and it weighs approximately one sixth of
baby's weight at term. It has surfaces. they are as follows.

SURFACE OF PLACENTA:

The Maternal Surface:

Maternal blood gives this surface a dark red color. The chorionic villi are arranged in 20 lobules
known as cotyledons.

The Fetal Surface:

Fetal surface is white shiny and smooth in appearance. This surface is covered by Amnion and cho-
rion membranes.

The Amnion Membrane:

It is a smooth tough transparent membrane derived from the inner mass lining. It is thought to have
role in the formation of amniotic fluid.

The Chorion Membrane:

This is a thick opaque friable membrane derived from the trophoblast. It is continuous with the cho-
rionic plate, which forms the base of placenta.

FUNCTIONS OF PLACEŅTA:

 Although a single organ, the placenta fulfils a number of roles for the baby before birth in-
cluding those related to digestion, gas exchange, nitrogenous waste removal, liver function,
fluid balance and hormonal activities - it is a multi-organ.
 We should remember that while supporting and maintaining the baby the placenta also has a
profound controlling influence on the mother and her metabolism.
 It could be said that the placenta puts a little PEP into the baby's life by being involved Pro-
duction, Exchanges. and Protection. The placenta produces hormones, enables the exchange
of nutrients/gases/waste products between mother and baby, and protects the baby against
some infections and toxins.

PRODUCTION:

 The placenta is an important source of hormones throughout its existence, and can therefore
be classified as an endocrine organ. The syncy totrophoblast is the most active producer of
[Link] first hormone produced by the trophoblast is the protein hormone human cho-
rionic gonadotrophin (HCG).

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 This hormone appears before implantation and it primary function is to maintain the activity
of. the corpus luteum. Production of HCG by the trophoblast peaks by about8 weeks after fi-
nalization and then diminishes.
 The presence of HCG in the mother's urine forms the basis of a pregnancy test. As the pla-
centa is formed it begins to release progesterone and estrogen to help maintain the pregnancy.
 The placenta produces a protein hormones that is similar to growth hormone - it is called
human Placental lactogen. (HPLH)
 This hormone has a variety of effects Influencing the preparations of the breasts for lactation
and lipid and carbohydrate metabolism.

EXCHANGE:

The placenta is involved in both active and passive transfers of selected materials between mother
and baby and baby and mother for example, oxygen, nutrients, and water pass from mother to baby,
while carbon dioxide and other metabolic wastes and water pass from baby to mother.

Unfortunately, possibly harmful gases such as carbon monoxide and inhalation anesthetics canals to
cross from mother to baby. Other harmful materials can cross the placenta barrier too. For example
drugs such as alcohol and thalidomide, some viral infections such as HIV, rubella, and cytomegalo-
virus the spirochetes of syphilis, and the parasite toxoplasmosis. These materials and organisms have
the potential to harm the developing baby - they are teratogens.

PROTECTION:

Some proteins maternal immunoglobulin’s against certain infectious diseases such as diphtheria and
measles are transported actively from mother to baby will provide the baby with passive immunity
against these diseases for a time after birth while the baby's own immune system matures.

SUMMARY OF THE FUNCTIONS OF PLACENTA:

 Normally functions after 12 weeks of pregnancy

 Provide nutrition to the fetus.
 Stores some glucose in the form of glycogen and converts it to glucose as required.
 Excrete some substances e.g. carbon dioxide and bilirubin.
 Provides barrier to infection
 Perform respiratory function for fetus.
 "Placenta is an important endocrine organ. It secrets HCG,HPLH, Estrogen and Progesterone

ANATOMICAL VARIATION OF PLACENTA:

Abnormalities according to:

 Size (Large placenta may be attach to lower pole)

 Weigh(increase in weight is found in Rhesus incompatibility, diabetes.(RDS)
 Morphology (bipartite, &tripartite. Succenturiate. Circumvallate, Placenta membranacia

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 Degenerative anomalies (Hydatidiform mole)

 Attachment
 Umbilical cord (battle dore. Velamentous insertion.)
 Site (placenta previa)
 Depth (accreta, increta . percreta)
 Succenturiate lobe of placenta:

A small extra lobe, separate from main placenta, is present and joined to it by blood vessels. Which
run through membrane? OR accessory cotyledons with vascular connections to the main body of the
placenta may not always deliver with main placenta leading to PPH. Delivered placenta should be
carefully examined for torn vessels and uterus explored for accessory lobe if found.

BIPARTITE PLACENTA:

Two complete and separate lobes present with separate cord with joins at short distance from two
parts of placenta.

TRIPARTITE PLACENTA:

Is similar lo bipartite placenta but it has three distinct lobe.

CIRCUMVALLATE:

Approx. 1%of cases, small central chorionic area inside a paler colored circle of tissue,

This is associated with an increased rate of antepartum bleeding early delivery and perinatal death.

PLACENTA MEMBRANACIA

Failure of the chorion leave to atrophy means that complete fetal envelope acts as the placenta.

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ADHERENT PLACENTA:
Adherent Placenta occurs when the placenta is implanted too deeply into the uterine wall, and will
not detach during the late stages of childbirth, resulting in uncontrolled bleeding.

There are three types of adherent placenta

PLACENTA ACCRETA:

Occurs when the placenta attaches too deep in the uterine wall bit it does not

penetrates the uterine muscles. Placenta accreta is the most common accounting for approximately
75% of all cases

PLACENTA INCRETA:

It occurs when the placenta attaches even deeper into the uterine wall but it does not

Penetrate into the uterine muscle. Placenta increta accounts for approximately

15% of all cases.

PLACENTA PERCRETA:

It occurs when the placenta penetrates through the entire uterine wall and attaches To another organ
such as the bladder. Placenta percreta is the least common of the three conditions accounting for ap-
proximately 5 percent of cases.

RETAINED PLACENTA:

This occurs when placenta remains in uterus for more than 1 hour, May be associated. With hemor-
rhage and should be' removed Retained placenta may be caused by:

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 Encarceration of separated or partially separated placenta being trapped by closing cervix-

following injection [Link] oxytocic
 Uterine atony accompanied by bleeding
 Abnormally adherent placenta

PLACENTA PREVIA:

A placenta which lies wholly or partially in the lower uterine segment

HYDATIDIFORM MOLE:

it is abnormal development of chorionic villi, which leads into development of abnormal

placenta. It is chromosomal defect.

CHORIOCARCINOMA:

This malignant cancer is caused in the mother by highly invasive tissues derived from the Tropho-
blast

AMNIOTIC FLUID:

Amniotic fluid also termed Liquor Amni is a clear pale straw colored. Fluid, consisting of
99%[Link] amniotic fluid that surrounds a developing baby plays a crucial role in normal devel-
opment this clear-colored liquid cushions. And protects the baby and provides it with fluids. By the
second trimester, the baby is able to breathe the fluid into his lungs and to swallow it, promoting
normal growth and development of the lungs and gastrointestinal system. Amniotic fluid also allows
the baby to move around, which aids in normal development of muscle and bone.

ORIGIN:

The amniotic sac that contains the embryo forms about 12 days after conception. Amniotic fluid im-
mediately begins to fill the sac. In the early weeks of pregnancy. amniotic fluid. consists mainly of
water supplied by the mother. After about 12 weeks, fetal urine makes up most of the fluid.

VOLUME:

 One liter (at 38 weeks of pregnancy)

 800 ml (at term) to 1000ml
 The amount of amniotic fluid increases until about 28 to 32 weeks of pregnancy.
 When it measures a little less than 1 quart. After that time the level of fluid generally stays
about the same until the baby is full term (about 37 to 40 weeks), when the level begins to
decline.

FUNCTIONS OF AMNIOTIC FLUID:

 Maintains an even temperature.

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 Protects fetus and cord from injury.

 Prevents sides of the fetal sac from sticking together.
 Helps to dilate the cervix in labor.
 Washes and cleans cervix and birth canal
 Prevents uterine infection.
 Allows the fetus to move freely in the uterus.

UMBILICAL CORD:
The umbilical cord extends from fetus to the placenta and transmits the umbilical blood vessel .two
arteries an done vein. These are enclosed and protected by wharton's jelly. The whole cord is covered
in a layer of amnion, which is continuous with the amniotic covering of placenta,

MAINCHARACTERISTICS OF CORD:
Length:

The average length of cord is 50 cm and this is sufficient to allow for delivery of baby without apply-
ing any traction to placenta.

Short Cord:

A cord is considered to be short when it measures less than 40 cm which may complicate labor by
preventing the decent of fetal head.

Long Cord:

A long cord may have true knots which if tight during labor will cause still birth.

INSERTION SITES FOR CÓRD:

Central Insertion: At the center of placenta

Lateral Insertion: Distance from the center but not at the edge

Battledore Insertion: Attached to the edge of the placenta

Velamentous insertion of umbilical cord:

An abnormal condition in which the umbilical cord does not insert into the placenta Mass but in-
stead, traverses the fetal membranes before it inserts into the umbilical cord main danger is vasa pre-
via, a condition in which the blood vessels may be lodged between fetus and the entrance to the birth
canal. The unprotected vessels may rupture at any time during pregnancy, causing fetal hemorrhage
and death.

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KNOTS OF CORD:

False Knots:

They are lumps of Wharton's jelly on the side of the cord.

True Knots:

A very long cord become warred round the neck or body of the fetus or become knotted either event
result in occlusion of blood vessels especially during lab

FETAL SKULL:-

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The fetal skull contains delicate brain it is large in relation to fetal body. The head is the most diffi-
cult part to deliver whether it come first or last.

An understanding of the landmarks and measurement of fetal skull enable a midwife to recognize a
normal presentation and position to facilitate delivery with the least possible trauma to fetus and
mother. When male presentation and position exists she will be able to identify it and alert the medi-
cal staff.

BONES OF THE VAULT:

 There are five main bones of vault of the skull.
 The occipital bone lies at the back of the head and form the region of' the occiput.
 The two parietal bones lie on the either side of the skull.
 The two frontal bones form the forehead or sinciput. The frontal bones fuse into a single
 Bone by 8 years of age.
 In addition to these five, the upper part of the temporal bone is also flat and forms a small
part of the vault.

SUTURES AND FONTANELLS:

 Sutures are cranial joints and are formed where two skull bones join to gather. Where two or
 More sutures meet, a fontanelle informed.

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 There are two fontanelles and four sutures of obstetrical importance.

 The lambdoidal suture is formed where two parietal bones join with an occipital bone.
 The sagittal suture lies, between the two parietal bones.
 The coronal suture separates the two frontal bones from the parietal bones.
 The frontal suture runs between the two halves of the frontal bones,
 The posterior fontanelle or [Link] is at the junction of lambdoidal and sagittal sutures.
 T is small triangular in shape and be recognize vaginally. It normally closes by 6 weeks of
age.
 The anterior fontanelle or bregma
 It is found at the junction of sagittal, frontal and the coronal sutures it is broad kite shaped
and recognizable vaginally. It normally closes at the age of 18 months.
 The sutures and fontanelles, because they consist of membranous spaces allow for a degree of
over lapping of the skull bones during labor and delivery. (Moulding)

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DIAMETERS OF FETAL SKULL

The measurements of the skull are important because midwife need to practical understanding of the
relationship between fetal head and mother pelvis

There are two transverse, diameters

 Biparietal diameter 9.5cm-betweon the two parietal eminences.

 Bitemporal diameters 8.2, between the furthest points of the coronal sutures

The remaining diameters are anteroposterior or longitudinal.

 suboccipitobregmatic 9.5cm from the below the occipital protuberance to the center of ante-
rior fontanelle or bregma.
 Suboccipitofrontal 10 cm -from below the occipital protuberance to the center of frontal su-
ture.
 Occipitofrontal 11.5 cm-from the occipital protuberance to the glabella.

•Mentovertical 13.5cm – From the point of chin to the highest point on the vertex.

•Submentovertical 11.5cm – From the point where the chin joints the neck to the highest point on
the vertex.

•Submentobregmatic 9.5cm – From the point where the chin joint the neck to the center of the ver-
tex.

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Diameters Length
SOB Suboccipitobregmatic 9.5cm
SOF Suboccipitofrontal 10cm
OF Occipitofrontal 11.5cm
MV Mentovertical 13.5cm
SMV Submentovertical 11.5cm
SMB Submentobregmatic 9.5cm

FETAL CIRCULATION:-

The fetal circulation works differently from that of born humans, mainly because the lungs are not in
use: the fetus obtains Oxygen and nutrients from the mother through the placenta and the umbilical
cord.

PLACENTAL ROLE:

• The core concept behind fetal circulation is that fetal hemoglobin has a higher attrac-
tion for oxygen than does adult hemoglobin, which allows a diffusion of oxygen from the
mother’s circulatory system to the fetus.
• The circulatory system of the mother is not directly connected to that of the fetus, so
the placenta functions as the respiratory center for the fetus as wellassite of filtration for
plasma nutrients and wastes.
• Water. glucose. amino acids. Vitamins and inorganic salts freely diffuse across the
placenta along with oxygen:
• The uterine arteries carry oxygenated blood to the placenta and permeate the sponge
like material there
• Oxygen then diffuses from the placenta to the chorionic villus, an alveolus like struc-
ture where it is carried to the umbilical vein.

COURSE OF CIRCULATION:

 During pregnancy. the fetal circulatory system works differently than after birth:
 The fetus is connected by the umbilical cord to. The placenta the organ that develops and im-
plants in the mother's uterus during pregnancy.
 Through the blood vessels in the umbilical cord, the fetus receives all the necessary nutrition
Oxygen, and life support from the mother through the placenta
 Waste products and carbon dioxide from the fetus are sent back through the umbilical cord
and placenta to the mother's circulation to be eliminated
 Blood from the mother enters the fetus through the vein in the umbilical cord. It goes to the
liver

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 And splits into three branches. The blood then reaches the inferior vena cava, a major vein
connected to the heart.

INSIDE THE FETAL HEART

 Blood enters the right atrium, the chamber on the upper right side of the heart. Most of the
blood flow to the left side through a special fetal opening between the left and right Atria
called the foramen ovale.
 Blood then passes into the left ventricle (lower chamber of the heart) and then to the aorta.
(The large artery coming from the heart).
 From the aorta, blood is sent to the head and upper extremities. After circulating there, the
blood returns to the right atrium of the heart through the superior vena cava.
 About one-third of the blood entering the right atrium does not flow through the foramen
ovale, but, instead. stays in the right side of the heart, eventually flowing into the pulmonary
artery
 Because the placenta does the work of exchanging oxygen (0 2) and carbon dioxide(C02)
through the mother’s circulation, the fetal lungs are not used for breathing. Instead of blood
flowing to the lungs to pick up oxygen and then flowing to the rest of the body the fetal circu-
lation shunts (bypasses) most of the blood away from the lungs.
 In the fetus, blood is shunted from the pulmonary artery to the aorta through a connecting
blood vessel called the ductus arteriosus.

CHANGES AT BIRTH:

At birth the lungs can. Inflate and perform their true function meaning that the fetal bypass systems
are no longer required.

BLOOD [Link] BIRTH:

 With the first breaths of air the baby takes at birth, the fetal circulating changes. A larger
amount of blood is sent to the [Link] pick up Oxygen.

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 Because the Ductus arteriosus (the normal connection between the aorta and the pulmonary
valve) is no longer needed, it begins to wither and close off.
 The circulation in the lungs increases and more blood flow into the left atrium of the heart.
This increased pressure causes the foramen ovale to close Blood circulates normally.

UNIT 4.
PREGNANCY

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DEFINITION:
The period after the conception till the onset of the labor is termed as Pregnancy OR

The state of being pregnant: the period from conception to birth when a woman carries developing
fetus in her uterus.

DURATION OF PREGNANCY:

The average period of pregnancy is 280 days or 40 weeks and the whole term is divided into three
trimesters, i.e.

1 Trimester 2nd Trimester 3d Trimester

01-14 Weeks 15-28 Weeks 29-40 Weeks

SYMPTOMS AND SIGNS OF PREGNANCV:

 There are both symptoms and signs of pregnancy. These symptoms and signs depend upon
the time in pregnancy.
 In, the first trimester of pregnancy the 1st sign of pregnancy is most often amassed menstrual
period. If sexually active women periods are generally regular, missing period for a week or
more is presumptive evidence of pregnancy.
 Early symptoms of pregnancy also include feelings of breast swelling' and tenderness, and
nausea sometimes with vomiting. Morning sickness not always in the morning. Many women
become fatigued early in pregnancy, and some may feel abdominal enlargement
 Early in pregnancy, the woman may feel she has to urinate frequently, especially at night
time .and she may leak urine with cough and Sneeze or laugh. This is also normal later in
pregnancy and is not a problem.
 Other changes characteristic of pregnancy include the deepening color of the areola (area sur-
rounding the nipple), increased body temperature, the mask of pregnancy (darkening of skin
on the forehead ,bridge of the nose, or cheekbones), and a dark line going down from the
middle of the central abdomen area to the pubic area

SUMMARY OF SIGNS OF PREGNANCY

Sign Time of Occurrence Differential Diagnosis
(Gestational age)

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Possible and presumptive sign

Early breast changes 3 - 4 weeks weeks Contraceptive pill (Unrelia-
ble in the multigravida)
Amenorrhea 4 weeks + Hormonal imbalance/ Emotional
stress/Illness
Morning sickness 4 - 14 weeks Gastrointestinal disorders Pyrexial
illness
Bladder irritability 6 - 12 weeks Urinary tract infection
Quickening 16 - 20 weeks + Intestinal movement wind
Probable Signs
Presence of HCG* in:
Blood 4 -12 weeks Hydatidiform mole
Urine 6 - 12 weeks Choriocarcinoma
Softened isthmus (Hegar's Sign) 6 - 12 weels
Blueing of Vagina (Jacquemier's Sign) 8 weeks + Pelvic Congestion
Pulsation of Vagina (Osiander Sign) 8 weeks +
Uterine growth 8 weeks + Tumors
Braxton Hicks contractions ,16weęks 16 weeks
Ballottement of fetus 16 - 28 weeks
Positive Signs
Visualization of fetus by:
Ultrasound 6 weeks + No alternative diagnosis
X-ray 16 weeks +
Fetal hearts sounds by:
Ultrasound 6 weeks +
Fetal stethoscope 20 - 24 weeks
Fetal movements:
Palpable 22 weeks +
Visible Late pregnancy
Fetal parts palpated 24 weeks + No alternative diagnosis

PHYSIOLOGOCIAL CHANGES OF PREGNANCY:

When a woman becomes pregnant, certain physiological changes occur in her body due to the effects
of hormones (mainly estrogen and progesterone). These changes enable her to nurture the fetus, pre-
pare body for labor and develop her breasts for production of breast milk.

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CHANGES IN REPRODUCTION SYSTEM:

 Uterus:
 After conception, the uterus develops to provide nutritive and protective environment
 In which the fetus will develop and grow.
 Uterine Layers:
 Decidua:
 The decidua is name given to the endometrium during pregnancy The decidua provides gly-
cogen rich environment for blastocyst until the trophoblastic cell begin to form placenta.
 Myometrium
 Inner circular
 Middle oblique
 Outer longitudinal
 During pregnancy the muscle layers become more differentiated and organized for their parts
in expelling the fetus at term

PERIMETRIUM:

This does not totally cover the uterus, being deflected over the bladder anteriorly to form the utero
vesical pouch and over he rectum posteriorly to form pouch of [Link] management allows for
the unrestricted growth of uterus.

WEIGHT:

It Increase from 60 gm to 1100 gm.

The 'average weight gain of around 12 tol4 kg can be physically attributed to:

SIZE

From 7.5 x5x 2.5 cm to 30x 23 x 20 cm

BLOOD SUPPLY:

The blood supply to the uterus must increase to keep pace with its growth and also to meet the needs
of the functioning placenta.

Estrogen cause development of new blood Vessels to keep pace with its growth and also to meet the
need of function placenta

UTERINE SHAPE BY WEEK:

The uterus also changes from pear-shape to globular in shape during the first 12 weeks of pregnancy
and at 20 weeks restored to original pear shape.

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12 weeks of pregnancy:

The uterus rise out of the pelvis and become upright often inclines and rotates to the right and the
fundus of uterus may be palpated abdominally above the symphysis.

20 Weeks of pregnancy:

The uterus has a thicker. more rounded fundus and become progressively more vertical and fundus
appears just below the umbilical level.

30 Weeks of pregnancy:

The lower uterine segment can be identified

36 Weeks of pregnancy;

The uterus now reaches the level of the xiphi-sternum and lower uterine segment is formed

CERVIX:

During pregnancy the cervix becomes more vascular and softer in response to increased level at Es-
trogen: The cervical glands secrete mucus in the cervical canal. This thick mucous helps in prevent-
ing ascending infection.

VAGINA:

The' epithelium of vagina undergoes hyperplasia. hypertrophy and increased vascularization

throughout pregnancy. By the end of pregnancy. the vaginal wall and perineal body have become
relaxed to allow passage of [Link] discharge occurs throughout pregnancy due to increased
activity of epithelial cells

ENDOCRINE SYSTEM:

Placenta:

This is an active gland, which produces the following hormones.

• Human Chorionic Gonadotrophin (HCG)

• The level of thịs hormone rises rapidly in early pregnancy both the maternal plasma
and in the urine). It provides a useful basis for pregnancy test.
• Human Placental Lactogen (HPL):
• This increases in quantity as the pregnancy progresses. It is important in the growth
and development of the breasts.
• Estrogen:

The three main estrogen are oestradiol, oestriol and esteron. Oestradiol is the most important for the
growth of the uterus and breasts

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Progesterone:

This has a general smooth muscle relaxant effect. It inhibits the release of prostaglandin in the my-
ometrium, decidua and reduces the myometrial activity.

PITUTÄRYGLAND:

This enlarges in pregnancy. There is an increase in adrenocorticotrophic hormone, thyro trophic

hormone and melenocyte stimulating hormone. the later accounts for the increase pigmentation
found in pregnancy.

THYROID GLAND:

This normally enlarges in pregnancy. In pregnancy the tested plasma binding proteins cause propor-
tionate rise in the bound form of thyroxin and reduce the free thyroxin

The basal metabolic rate increases by as much as 20--25%.

CIRCULATORY SYSTEM:

Heart:

Due to an increase in work load the heart may increase in size. lt may also be displaced upwards ånd
to the left, rotating anteriorly because of the increasing pressure from the growing uterus.

Plasma volume

From 10 week of pregnancy, a normal increase in circulating plasma is co-related with fetal well be-
ing and good outcome of pregnancy, its maximum Ievel of approximately 50% above Non-pregnant
value by 32-34 week and maintained until term.

Red blood mass

Increases in response to the extra oxygen requirement made by maternal and placental tissue

Blood pressure:

 Blood pressure is dependent on several factors: the increased cardiac output tends to raise the
blood pressure. Whereas decreased peripheral resistance tends to cause lowering of the blood
pressure.
 Decrease in peripheral resistance in pregnancy is due to the reduced viscosity of blood and
vasodilation caused by the relaxing effect bf progesterone. The resultant effect is a reduction
in blood pressure in second trimester of pregnancy: this levels out again in the third trimester.
 The cardiac output increases during pregnancy and labor and stabilizes after delivery.

RESPTRATORY SYSTEM:

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By the end of pregnancy, oxygen requirement have increased by about 20%. In the [Link], the
enlarging uterus pushes the diaphragm upwards and compresses the lower lobe of the lungs. These
changes result in a fall of part pressure of carbon dioxide (PCÓ2). which aids the elimination of fetal
carbon dioxide across the placenta.

RENAL SYSTEM:

 In the first trimester of pregnancy, the enlarged uterus in the pelvis may compress the bladder
and cause frequency of micturition.
 In the last trimester-the head when it becomes engaged may have the same effect, this may
compress the lower end of the uterus and there will be slow emptying of bladder and renal
pelvis may cause urinary tract infection.
 The blood flows to the kidneys and glomerular rate is increased by 50%. The renal threshold
for glucose is lowered (6.6 mmol/1) hence causing glycosuria.

[Link] system is also affected by the progesterone level. Give rise to heart-
burn. constipation and gastric stasis in labor.

SKIN PIGMENTATION:

 Linea nigra: It is a pigmented line in the midline of the abdomen

 Chloasma: Chloasma or mask of pregnancy is seen as an increase in pigmentation on the
face, over the cheeks and forehead it appears after the 16 week of pregnancy, and pigmenta-
tion increases gradually till delivery but, fades after that.
 Striae gravidarum are stretch marks seen as reddish., irregular streaks on the abdomen.
These are due to the separation of underlying connection tissues. These usually fade after de-
livery but never totally disappear.

MUSCULOSKELETAL SYSTEM:

In late pregnancy there is softening of ligaments and joints. This may slightly enlarge the Capacity of
the pelvis. The laxity of the pelvic joints usually causes backache.

GENERAL METABOLISM:

The average increase in weight is 2 -3 kg during the first 20 weeks of pregnancy- and 10 kg in the
second 20 weeks. An average increase of 0.5 kg a week in the latter half of pregnancy is considered
normal.

BREAST CHANGES:

AIl breast changes are the result of increased hormone activity. Estrogen develops System and pro-
gesterone the glandular tissue.

They prepare the nipple for subsequent breast feeding prolactin stimulates the production of colos-
trum. The breasts enlarge due to increased tissue growth. Blood supply and fat deposition

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SUMMARY OF BREAST CHANGES

3-4 Weeks prickling, tingling, sensation due to increased blood supply

Particularly around nipple

6Weeks

eveloping ducts and glands cause the breast to be Enlarged, painful and tense particularly in women
who normally experience pre-menstrual changes.8 Weeks Bluish surface veins are visible.

8-12 Weeks

Montgomery's tubercles become more prominent on theaerolar. These sebaceous glands secrete se-
bum which keeps the nipple soft and supple. The pigmented area around the nipple darkens and may
enlarge slightly. This area is known Primary Areola.

16 weeks

Colostrum can be expressed late pregnancy Colostrum may leak from the breasts; progesterone caus-
es the nipple to become more prominent and Mobil.

RELATIONSHIP OF FETUS TO UTERUSAND PEIVIS:-

PRESENTATION:

The presentation' of the baby refers to the part of het. Or that is sitting in the woman's lower belly,
over her cervix. During labor the 'presenting parts refers to the part of the baby that 'leads the way'
down the birth canal, usually being the crown of the baby's head, medically referred toas the 'vertex'
often written as Vx' or simply "V The refers to the. Crown of the baby’s head, if baby is breech (bot-
tom down) this may be written as 'Br. and if baby is lying across belly it is transverse' or 'Trans': Ba-
bies lying diagonally across are referred to as 'oblique

POSITION:

The 'position' of the baby refers to where the baby’s back is Iying in relation to the mother’s body,
specifically her pelvic bones and back, The position is not usually recorded@ until after about 34 to
36 weeks of the pregnancy and is written as a 3 word acronym, with letters such as:

L=left side and also used for 'lateral' (meaning the woman's side?

R=right side.

A = anterior.

P=posterior.

0= occipito (the occiput is the term used to describe the backof the baby's head).

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S= sacral (the sacrum of the baby is the base of their spine near the top of their bottom. used to De-
scribe breech positions):

The following is a brief explanation of the different letters that can be used and what they

Mean.

LOA = Left occipito anterior which means the baby is lying on their mother's left side, headdown,
with their back (and the back of their head or 'occiput') facing the front of the woman’s belly.

LOL: Left occipito lateral. Which means the baby is lying on their mother's left side. Head

Down, with their back (and the back of their head or 'occiput') facing woman's side.

LOP =Left occipito posterior. Which means (the baby is lying on their mothers left side, head down,
with their back (and the back of their head or occiput) facing woman's backbone.

ROA=Right occipito anterior. Which means the baby is lying or their mother's right side, head
down, with their back (and theback of their head or 'occiput') facing the front of the woman’s belly.

ROL = Right occipito lateral. Which means the baby is lying on their mother's right side, head
down, with their back (and the back of their head or 'occiput) facing woman's side.

ROP = Right occipito posterior. Which means the baby lying on their mother’s right side. Head
down, with their back (and the back of their head or ‘occiput) facing woman's backbone.

RSA = Right sacral anterior. Which means the baby is lying on their mother's right side, bottom
down, with their back (and their sacrum)) facing the front of the woman's belly.

RSL =Right sacral lateral. Which means e baby is lying on their mother's right side, bottom down,
with their back (and their sacrum) facing the woman's side.

RSP = Right sacral posterior. Which means the baby is lying on their mother's right side. Bottom]
down, with their back (and their sacrum) facing the woman's backbone.

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ENGAGEMENT OR 'STATION':-
 Engagement is when the presenting part of the baby moves down into the woman's pelvis in
readiness for labor. Usually about I to 4 weeks before the birth. In most cases it is the baby’s
head that engages, but when a baby is in a breech position their bottom can also engage
 The engagement or 'station' is usually measured in '5ths' and is based on the fact that the
width of an adult hand is about the size of a ‘term baby's head. When recording engagement
on your pregnancy records, usually the amount of the baby's head that is felt by the caregivers
hand is measured and written down providing a guide as to how much of the baby's head is
engaged in the pelvis. As a guide:
 Most babies become 2 to 3 fifths engáged (or 2 to 3 fifths palpable) before labour commenc-
es,

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Station:

This reference the presenting part to the level of the ischial spines measured in plus. or minus, centi-
meters.

Attitude:

This refers to the posturing of the joints and relation of fetal parts to one another. The normal fetal
attitude when labor begins is with all joints in flexion.

Lie:

This refers to the longitudinal axis of the fetus in relation to the mother's longitudinal ax-
is:(.transverse, oblique, or longitudinal (parallel).

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Point of Reference of Direction (Denominațor)

This is an arbitrary point o the presenting part used to orient it to the maternal pelvis [usually occi-
put, mentum (chin) or sacrum].

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 MINOR DISORDERS OF PREGNANCY:

PELVIC PAINS:

Especially if lateral and referring to the upper thighs, are usually due to ligamentous stretch. They
require reassurance only. Pain is reproduced by gentle sideways traction on an otherwise non-tender
and soft womb. Maximal 13 to 16 weeks.

URINARY FREQUENCY:

Is common but should be investigated as 8% of pregnant women will have otherwise asymptomatic
UTIs.

ANKLE OEDEMA:

May relates to compression of inferior vena cava and to vasodilatation due tộ ỉncreased hormones. If
no associated proteinuria or hypertension, it is best treated by rest with leg elevation, or natural diu-
retics such as celery or Vitamin B6.

VARICOSITIES:

Occur for the. same reasons, and relief after confinement can be dramatic. Once recognized, the early
use of support stockings is wise, while the short term use of pelvic elevation and ice pack scan ease
the symptoms of vulval varicosities.

HEARTBURN:

Heart burn is due (o gastro-esophageal reflux, combined with increased abdominal pressure.. Postur-
al and dietary àdvice with the use of antacid settles most, f occasionally H2 antagonists (category B
in pregnancy) are required.

CONSTIPATION:

Can occur early so at least in- part is due to hormones, but is aggravated by enlarging pelvic con-
tents. With the vasodilatation and compression of pelvic veins this may result in hemorrhoids. Wom-
en should be advised to increase their fluid and fiber intake, and if laxative sare needed they should
be used with doctor's order.

LOW BACK PAIN:

I is common due to altered posture; but also to the affects of the .hormone relaxin on ligaments. al-
lowing excessive movement of sacro-iliac joints. A regular exercise program. Preferably Swimming,
with physiotherapy as required, complements postural back care. Some women develop symphyis-
pubis pain, especially. If coexistent scoliosis, and may require a special Corset, obtainable through
physiotherapy departments.

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Dental decay and periodontal disease accelerates in pregnancy and should be reviewed by dentist, as
early as possible.

SKIN CHANGES:

 Include chloasma and spider, naevi, which commonly disappear after the pregnancy.
 The increased. production of melanin in pregnancy may lead to the diagnosis of pre-existent
[Link] occurs in 179% gravid women.
 Interestingly, 50% women with atrophic dermatitis improve during pregnancy.
 If no rash, consider iron deficiency, or the potentially more serious cholestasis of pregnancy.
 Antihistamines may be helpful.
 Stretch marks may occur when growth has been rapid.
 The dryness and irritation may be eased by vegetable oil or Vitamin E cream and soap avoid-
ance.

INCREASED VAGINAL DISCHARGE:.

Normally. the which vagina discharge increases during ,pregnancy. But if. accompanied by afoul
smell, itching or blood stains, doctor should be consulted.

INCREASED EMOTIONAL VULNERABILITY:

Mother will be surprised at her unpredictable moods. But these are partially a result of the elevated
levels of certain hormones. Exhaustion, nausea and worries regarding the well being or ryour unborn
baby could be the other reasons.

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SUMMARY OF COMMON DISCOMFORTS OR MINOR DISOR-

DERS OF PREGNANCY

Summary of Common discomforts OR Minor disorders of Pregnancy

Discomforts Trimester Interventions

Eat dry carbohydrate in early morning. Avoid
Morning sickness First fried, odorous and greasy food Small meal ra-
ther than large.
Fatigue First Rest frequently as needed
st,
1 end of
Urinary retention Kegel exercise, perineal pad for leakage.
3rd
Heart burn 2nd, 3rd Small meals bland foods, antacid

Sufficient fluid, high roughage food, regular

Constipation 2nd, 3rd
bowel habits, no laxative until ordered.

Avoid constipation, increase fluid Intake. pro-

Hemorrhoids 3rd
mote regular bowel habit.

Avoid crossing legs and long standing or Sit-

Varicosity 3rd
ting. Rest with feet and hips elevated.

Use good posture and body mechanics. Low

rd
Backache 3 heeled shoes, exercises to strengthen back
muscles.
Exercises, suprive pillow. warm shower Before
Insomnia 3rd
sleeping.

Flex toes towards knees for relief, Ensure ade-

Leg cramps 3rd
quate calcium in diet.

supine hypotension 3rd Left side lying position syndrome.

Vaginal discharge 2nd Correct personal hygiene, refer to physician

Skin changes, dry-
All Cool baths, lotion, oils needed,
ness, Itching.

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UNIT:-5.
ANTENATAL CARE
DEFINTTION:
Antenatal care comprises of the systemic, regular and periodic supervision (examination of the pa-
tient and rendering advice) of the pregnant woman from conception until the onset of labor.
AIMS & OBJECTIVES:
1. To maintain the physiology of the pregnancy.
2. To relieve maternal anxiety by reassurance about the satisfactory progress the pregnancy.
3. To detect medical and obstetrical disorders complications and manage them.
4. To render advice regarding diet, hygiene, immunization, medications, travel, investigations.
Breast-feeding and delivery plan.
3. To carry out special investigation like U/S and test for fetal well-being as needed.
6. To ensure a normal pregnancy, that ends in a delivery of a healthy baby to a healthy mother.
7. To reduce Maternal and Perinatal morbidity and mortality.
8. To assess and manage fetal and maternal risks.
TIME FRAME:
1. First visit may be made as soon as woman suspects she is pregnant, frequently after 1st missed
Period. First (booking visit) is usually B/W 8______14 weeks
2. Subsequent visits every month until 8th month, (32wks)
3. Every 2 weeks during the 8th month (32_____ 36wks)
4. Weekly during the 9th month (36____till delivery)
5. More frequent visits are scheduled if problems arise.
Antenatal care ideally consists of:
• Preconception clinic
• Risk factor
• Detail history
• Self-medications
• Diet
• Exercise
• Antenatal visit
• Pathology tests
• Health education
• General physical examination
• Common discomforts of pregnancy

PRECONCEPTION CLINIC:
The Preconception clinic offers genetic services to couples and individuals that are not pregnant.
Common reasons for referral are a family history of a genetic diseases. Recurrent pregnancy losses,
or a previous child with a birth defect or genetic disease.
A preconception checkup typically includes:

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• A detailed family history and review recurrence risk

• Available genetic testing and possible prenatal or preconception genetic testing in a future
pregnancy
• A complete physical examination. Blood tests to check immunity to infections such as chick-
enpox (varicella) and German measles (rubella) that can cause serious birth defects or illness
in baby.
• If mother İs not immune to these infections, doctor may vaccinate her.
RISK FACTORS:
Assessment of risk factors largely occurs at the first visit.
Risk factors arising during pregnancy:-
• Fetal movement pattern change
• Poor weight gain weight loss
• HB lower than 10gm % Protein urea glycosuria, bacilluria,
• Uterus larger or small for age
• BP systolic <140 diastolic <90mmhg
• Excess or decreased liquor
• Mal presentation
• Head not engaged in primi gravid lady by 38wkg
• Any vaginal bleeding premature labor.
• Vaginal infection
The date of onset of LMP should be noted, but also the pattern of menses preceding this, as irregular
cycles or OCP withdrawal bleeds will make dating the pregnancy unreliable. (If doubt exists then an
ultrasound can be performed - the earlier the scan the more the accurate it is for dating the concep-
tion but the less accurate for fetal morphology.)
Also a full history and examination Including breast &thyroid, and a Pap smear if not done recently.
DETAILED HISTORY:
As medical personnel we are ideally suited to obtain details of the woman's medical history and ex-
amination, but also any financial and social aspects that may have a bearing on the pregnancy. For
example, previous history, or her personality and lack of family supports, may put her at Increases
risk of post-natal depression; in which case early involvement of social workers and mother craft
services may avert a crisis.
SELF MEDICATION:
A history of smoking, alcohol, and drug intake should be taken and women advised not to self-
medicate without checking first for safety. It is worth specifically mentioning vitamin and herbal
therapies as some of these are to be limited in pregnancy, e.g. Vitamin A>2500 I.U. daily capsules)
may cause birth defects, It is would also recommend advise to minimize chemical and infection ex-
posure in general - which includes occupational exposure.
DIET:
Dietary advice should focus on a well-balanced and varied diet with an emphasis on
Complex carbohydrate, and protein, and with adequate daily folate (0.5mg. or 5mg if high NTP risk)
Neural tube defect) iron (15mg) calcium (1200mg) and fluids (2-3L).

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Foods likely to be contaminated with listeria should be avoided e.g. raw meat seafood, soft cheeses.
Many first trimester women can minimize nausea by frequent small, meals rich in B group vitamins
and low in spice and fat. Severe caloric restriction can result in reduced fetal growth.
EXERCISE:
Exercise is commonly restricted to non-contact sport after 16 weeks, and exercise intensity should
be reduced by 25%. Always followed by cool down period. Core temperature should not exceed
38*C and HR 140/min. so ideally, strenuous exercise should be limited to I5-20 minutes.
Further, walking more than five hours a day increases preterm labor risk by 14 compared to les than
two hours a day. (References available)

 ANTE-NATAL VISITS:
Visits are usually monthly to 28weeks, fortnightly to 36 weeks. Then weekly to delivery. Each visit
should involved checks on maternal and fetal well-being. As these are usually in a share-care capaci-
ty, à joint record card should be carried by the woman to each visit.

• Weight gain (12-15. kg in, total, with 3kg in first 20 weeks)

• BP (a diastolic pressure>90, or increase of>20 from first visit is significant)

• Urinalysis (watch, for protein, glucose, and UTI)

• Fetal movements

• Uterine size in accordance with dates and ultrasound

• Fetal The. Presentation, and engagement. especially after 36 weeks

CARE AT EVERY VISIT:

Treat the woman and her family with kindness and respect; tell her what is being done and answer
her questions. Take her blood pressure; give iron/folic acid (IFA) to all women; give extra IFA to
enemic women; counsel on insecticide-treatment, using bed net and to eat extra meal/day

CARE AT INITIAL VISIT:

BP; tetnus toxide: hemoglobin; give IFA councel on danger signs. test for HepB HIV and screen

or malaria and TB, if over 16weeks give sulfadoxine-pyrimethamine(Sp)

 Thorough collection of data about client to form basis for comparison with data collected on
Subsequent visit and to screen for any risk factors

 Menstrual history, Menarche Regularities, Frequency, Duration of flow and last period.

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 Obstetrical history all pregnancies, our comes. complications, contraception use and sexual

 Medical history includes past illness, surgeries, current use of medication, ay history of blood
transfusion, smoking. alcohol, and drug intake and any allergy.

 Family history/psychosocial data include history of any illness ,twins etc.

 Present obstetrical history or current concern

 Complete physical Examination includes general appearance, systemic examination ab-

dominal examination and per vaginum examination if indicated )

CARE AT SUBSEQUENT VISITS:

 Collection OF data specially : weight blood pressure HD. urine test for glucose and protein

 Fetal monitoring

 Measure fundal height

 Vaccinations.

 Contraception teaching.

 BPCR

 Deworming as per country guideline

 Health education regarding exercise /nutrition /rest and sleep/clothing' personal hy-
giene/bowel habit and routine habitation,

Vitamin A:

• Can be found in foods such as carrots eggs fish oil liver and broccoli.

• High doses of vitamin A can be unsafe during he first two months of pregnancy, but it is safe
toLive as much as 10,000 IU daily at any time during pregnancy

COMPLETE PHYSICAL EXAMINATION:

• WEIGHT

• Blood Pressure,

• Height ,

• Urinalysis

• Blood test

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• General Appearance (Head ta toe Examination )

• breast examination

• Oedema

• Abdominal examination

THE ESSENTIAL ELEMENTS OFA FOCUSED APPROACH TO ANTENATAL CARE

 Identification and surveillance of the pregnant woman and her expected child recognition
and management of pregnancy-related complications, particularly pre-eclampsia
 Recognition and treatment of underlying or concurrent illness
 Screening for conditions and diseases such as anaemia, STIs (particularly syphilis)HIV
 Infection, mental health problems, and 'or symptoms of stress or domestic violence
 Preventive measures, including tetanus toxoid immunization, de-worming. iron and folic
acid.


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Intermittent preventive treatment of malaria in pregnancy (IPTp), insecticide treated bed nets
Advice and support to the woman and her family for developing healthy home behaviours and a birth
and emergency preparedness plan to:

• Increase awareness of maternal and newborn health needs and self care during pregnancy and
the postnatal period, including the need for social support during and after pregnancy
• Promote healthy behaviors in the home, including healthy lifestyles and diet, safety and inju-
ry prevention, and support and care in the home. such as advice and adherence support for
preventive interventions like iron supplementation condom use, and use of ITN Insecticide-
Treated Net(s)
• Support care seeking behavior, including recognition of danger signs for the woman and the
newborn as well as transport and funding plans in case of emergencies
• Help the pregnant woman and her partner prepare emotionally and physically for birth and
care of their baby. particularly preparing for early and exclusive breast feeding and essential
newborn care and considering the role of a supportive companion at birth
• Promote postnatal family planning/birth spacing

 WEIGHING:

 In the past, weighing a woman at each pregnancy visit was regarded as an essential
part of a caregiver's routine pregnancy care. It was thought that by detecting a sudden in-
crease in weight (or not enough. weight gain) it may be possible to identify potential health
concerns for the pregnancy or the baby. For example, a sudden increase in weight gain indi-
cating fluid retention (or 'oedema} and possibly high blood pressure, or perhaps having a
larger or smaller than average baby.
 Many information sources and. pregnancy books will try to provide guides about the
 Recommended weight gain' during pregnancy. These are usually along the lines of
'putting on2 -3 kg in the first 20 weeks, then 1/2 kilo per week until the baby is due, averag-
ing 12-14 kg in total. While this may be true or some in women, in practice this is rarely the
case.
 Many women will put on most of their pregnancy weight gain during the first 20
weeks, or only gain a few kilograms up until 12 to 16 weeks of the pregnancy, then experi-
ence a large 'growth spurt' during the middle of their pregnancy up until about 32 weeks,
slowing down their weight gain over the next 4 to 6 weeks and then losing I to 2 kg just prior
to going into labour. A woman's overall weight gain when carrying a single baby may be as
little as 8 kg, or as much as 20 kg.
NOTE:
For conversion, 1 kg= approx. 2.2 lbs. To convert pounds into kilograms you divide the
number of pounds by 2.2 (for example. 22 lbs divided by 2.2 = 10 kg).
The 'average' weight gain of around 12 to14 kg can be physically attributed to:

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• Fetus = 3 to 4 kg
• amniotic fluid = 0.6 to 1 kg
• placenta =0.5 kg
• blood volume = 1.5 kg
• uterus = 1 kg
• breasts =0.4 kg
• Fat stores for breast feeding =3.5 kg
• Fluid retention =1.5 kg

Diagram ……

BLOOD PRESSURE:
Mother's blood pressure will be taken at first appointment and at every check-up from then on
In the case of an abnormally high or low blood pressure, she will need to be closely monitored
ULTRASOUND:
Ultrasound not only allows to see baby on screen but also enables midwife or doctor to pick up a
problem with the pregnancy. eg if baby is not growing at a normal rate. or if the placenta is in an ab-
normal position.

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• In such cases she may be asked to return for a follow-up scan ultrasounds are also used to
major detect foetal age. position, expected date of delivery, as well as some abnormalities.
• Some women may be offered an ultrasound scan at their first appointment, but most have
One at 14 to 16 weeks to confirm the baby is developing normally and again at 28 weeks.
There are no known side effects of ultrasound scans.

FETAL HEARTBEAT:
Baby's heartbeat will be monitored at each visit to check it is alive and that the heartbeat is normal.
This is done using an instrument called Doppler which is placed against abdomen. or as part of ul-
trasound scan.
URINE TESTS :
The urine of a pregnant woman can be tested for a variety of things. Urine tests can be done after
providing a urine sample (for a pregnancy test or to send to pathology to look for an infection) or by
passing urine directly onto a reagent strip of coloured litmus paper (called a 'dipstick"). How when
and why urine may be tested will vary between care givers and hospitals. It may be a standard rou-
tine procedure done at every pregnancy visit or something that is only done for some women to in-
vestigate possible concern about their health.
The following is a general guide as to why urine may be tested and what caregiver is looking for.
•
• Pregnancy test
• Urine infection
• Protein
• Glucose
• ketone

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ANTENATAL CARE :
Diagram ………

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ABDOMINAL EXAMINATION:-

Aims of abdominal examination:

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• To observe sign of pregnancy

• To assess fetal size and growth
• To diagnose the location of fetal parts
• To assess fetal health
• To assess any deviation from normal.
Preparation:

• The woman should be lying in comfortable position with her arms by her side.
• Bladder should be emptied
• Privacy should be maintained
METHOD:
Inspection:
• The size of the uterus is assessed with eyes.
• The shape of the uterus
• Fetal movement
• Contour of the abdominal wall
• Skin changes;-any stretch mark, linea nigra any scar of previous operation

Palpation:
• The hand should be clean and warm
• Three types of palpation is fundal, lateral and pelvic is carried out to assess lie, presentation,
position and attitude, station and engagement of fetal parts.
• The size of the uterus is traditionally described via comparison with its size at different stages
of pregnancy
• The size of uterus can be ascertained via bimanual palpation. A non-pregnant uterus is de-
scribed as plum sized; 6 week pregnant uterus as egg-sized; 8 week uterus as the size of a
small orange a 10 week uterus is the size of a large orange.
FROM CONCEPTION TO 12 WEEKS:

 Before 12 weeks of the pregnancy the uterus is contained within the bones of the
woman's pelvis and cannot be felt through her belly.

 After 12 weeks of pregnancy the fundus of the uterus is palpable above the symphy-
sis pubis. It reaches the umbilicus by the 20-22 weeks, and finally ceases to ascend at 36-38th
week (uterine fundus at about the level of the xiphisternum).

 Some women with subsequent pregnancies will have a uterus that is a little more
bulky' from previous pregnancies, making it move up out of he pelvis earlier (possibly after
about 10 or 11weeks). This may also be the case if woman is having twins or more, if mother
feels she is 12 weeks pregnant or more and her uterus cannot be felt by caregiver. it may be

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that she is not as far pregnant as she first calculated, or perhaps it is one physical sign of a
missed miscarriage.
From 12 to 20 weeks:

 From 12 to 20 weeks of the pregnancy caregiver will feel belly as part of every rou-
tine-
 Pregnancy visit. During this phase the baby is not large enough for caregiver to detect
their position, so the main aim of palpating before 20 weeks is just to ensure that the uterus is
actually growing ,hopefully at a progressive rate.
 By about 16 weeks of pregnancy the top of the uterus (or fundus) will usually have
grown to about halfway between the pubic hair line and the belly button or navel ( when ly-
ing down)
 By about 20 weeks of the pregnancy the fundus should be closer to the level of the
belly button. Caregiver may start using a measuring tape during this time to measuring fundal
height, but its not essential at this stage.

From 20 to 34 weeks:
 From 20 to 34 weeks baby is growing much larger and is now big enough for caregiver to
feel where their head is lying. Babies change position frequently during this phase of preg-
nancy and are quite often in a breech position (bottom down )or lying across belly in a trans-
verse position
• The size of uterus should continue to grow at a progressive rate , being approximately
relevant to gestational age. Guesses on the baby's birth weight cannot be, estimated until the
last 2 to 3weeks of the pregnancy. Many caregivers will use fundal height measurements as
part of monitoring the baby's growth during this phase of the pregnancy
From 34 to 37 weeks:
 After about 34 weeks baby will more likely move, into a head down position (howev-
er a few babies will still remain in a breech position. women having twins will often
find that one baby is head down. while their sibling Is breech baby will not usually
move their head from being down now (because their head is more larger and heavi-
er).but their back arm move frequently from one side of belly to the other .At this
stage. it does not really matter if baby's back is 'anterior (toward mothers front or pos-
terior towards mothers back)
 The size of uterus should continue to grow, reaching the base of breast bone (or 'ster-
num') by about 36 to 37 weeks. Again the baby should be growing at a progressive
rate but after 35 to 36 weeks they tend to become irrelevant, because the baby cannot
move much further up than the level of breastbone.

From 37 to birth

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
Baby should definitely be head down now. Although not common, a few babies will con-
tinue to change position frequently even at this late stage of the pregnancy ,being referred
to as an unstable lie.
 Baby's head can engage any time from 1 to 4 weeks or so before birth. Although it can be
normal for some women’s babies not to engage until they start labouring ,especially
women having a second or subsequent baby ,but also in some first pregnancies
DOING THE MEASUREMENT:

 Essentially, measuring the fundal height involves the woman lying down (it is not
meant to be done with the woman in a standing or sitting position) and her caregiver placing
at end of the measuring tape on her symphysis pubis bone.
 The symphysis pubis bone is situated just. below the pubic hair line in the middle.
The length of tape is then positioned up the middle of the woman's belly with the measure-
ment taken from where the tape reaches the top of her uterus (oF 'fundus'), giving a fundal
height in centimeters (cms).
 Fundal heights tend to be used from about 16 to 37 weeks of the pregnancy, with their
greatest benefit believed to be between 22 to 34 weeks. A text book fundal height is sup-
posed the equal the same amount of weeks as the pregnancy. For example, 20 weeks pregnant
= 20cms and so forth (up until about 36 to 37 weeks). However. fundal height measurements
can fluctuate 2 to 4 cms, higher or lower than the 'norm' for various reasons, with the baby
still being Very normal and healthy. The reasons for not having a 'text book' fundal height
can include

THE POSITION OF BABY:

Fundal height measurements are designed to measure babies who are lying in a head down position,
A baby in a breech position may measure higher and a Baby in a transverse position (lying across
ways) or oblique position (lying diagonally),will increase significantly lower.

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Diagram …………..

Physical differences in each women's height and weight

The fundal height can vary between very tall and very short women. Also women who are very slim
on measure less and women who are over their ideal weight can measure more.

If this is first or subsequent baby

Women having their first baby tend to have tighter abdominal muscles and ligaments that hold their
uterus in place more at the 'expected level. Women having their second or subsequent baby tend to

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Carry lower and may measure less, although during earlier pregnancy the uterus can be more bulky
and measure higher.

AUSCULTATION OR LISTENING TO THE BABY:

 As the pregnancy progresses caregiver will start to try hear unborn baby's heartbeat This is
mainly aimed at confirming that baby is indicated alive with some women not really being
concerned about whether their caregiver listens or t, because their baby is vigorously regular-
ly.
 An unborn baby’s heart rate changes as they grow.
 By around 8 to 10 week of the pregnancy when the heart beat may first measured on an ultra-
sound image) the rate is significantly higher at around 170 to 200 beats per minute (bpm).
 However, by about 20 weeks, the rate drops to be more around 120 to 160 beats per minute,
but may fluctuate between 110 and 170 bpm usually in relation for the baby moving, being a
higher rate when they are more active and lower when they are asleep During labour and after
birth the heart rate is normally between 120 and 160 bpm (ranging from 110 to 170 bpm)
 Midwife may listen to the heartbeat for only a few seconds, of up to a minute or more. They
may even time the "beats per minute" or look at the Doppler readout letting you know what
the rate is (for example 124min or 156/min). However, irregularities in' a baby's heart rate
are not usually able be detected simply through these brief listen If caregiver is concerned.
this is done by using a continuous monitoring machine or CTG machine 20 minutes or more.

WRITING ON PREGNANCY RECORDS

The information a midwife gain from feeling pregnant belly and listening to baby will be
recorded on pregnancy records recent years many countries have provided women will be their copy
e pregnancy records to carry around with them.
What is written women’s card?
Gestation age and fundal height, Presentation, Position and Engagement or 'station Movements and
heartbeat.

Gestational age and fundal height:

The gestational age refers to how far pregnant mother is as calculated from the first day of your last
menstrual period (LNMP) or perhaps from an early pregnancy ultrasound therefore, if mother is 32
weeks pregnancy , her baby's gestational age is 32 weeks and is written as "32". If pregnancy visit is
scheduled halfway between her calculated weeks (for example between 32 and Week then midwife
may record this as 32+' weeks.

DIAGRAM:

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HEALTH EDUCATION DURING ANTENATAL PERIOD:-

NUTRITIONAL SUPPORT:
Based on the woman's dietary history, the resources available to the woman and her family. and any
other relevant findings or discussion, individualize the following key nutrition messages.
ALL WOMEN SHOULD:

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• Eat a balanced diet consisting of beans and nuts, starchy foods (e.g.. potatoes maize. Cereals
rice), animal products (meat, milk, eggs, fish. yogurt, cheese), and fruits and vegetables.
• Eat a variety o foods each day including foods rich in: iron: red meat, liver. eggs. peanuts len-
tils. dark green leafy vegetables, and shellfish. Substances that inhabit iron absorption. such
as coffee or tea and calcium supplements, should be avoided or taken 2 hours alter meals.
• Vitamin A: liver milk products, eggs. sweet potatoes. pumpkin. carrots. and papaya,
• Calcium: milk. dark green leafy vegetables. dried fish. beans, lentils, whole-grain millet and
oil seeds.
• Magnesium: cereal. dark green leafy vegetables, seafood, nuts, legumes, and groundnuts.
• Vitamin C: oranges or other citrus fruits, tomatoes, and potatoes.

PREGNANT WOMEN SHOULD ALSO:

• Eat at least one additional serving of staple food per day

• Eat smaller, more frequent meal if unable to consume large amount in fewer meals.
• Take micronutrient supplements as directed.

IRON/FOLATE SUPPLEMENTATION:

• To prevent anemia, prescribe iron 60 mg + folate [Link] to be taken by mouth once daily
• Throughout the pregnancy.
• Dispense sufficient supply to last until the next visit.
• Provide health messages and counseling as follows:
• Eat foods rich in vitamins C. as these help the body absorb iron. Sources of vitamin C include
citrus fruits (oranges. grapefruit, lemons, limes), tomatoes. Peppers and potatoes
• Avoid tea coffee, and colas. as these inhibit iron absorption.
• Possible side effect of the iron/folate tablets include black stools, constipation, and nausea.
• Lessen side effects by doing the following:
• Drinking more fluids (an additional 2-4 cups per day)
• Eating more fruits and vegetables
• Getting adequate exercise (such as walking)
• Taking tablets with meals or at night

 PREVENTION OF INFECTION/ PERSONAL HYGIENE:

General hygiene:
Hands should be washed before the following activities:
• Eating or drinking
• Preparing food
• Feeding a baby
• Hands should he washed after the following activities:
• Using the toilet
• Changing a baby's diaper/napkin

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• Safe water should be used for drinking to avoid infections and diarrhea, which may compro-
mise nutritional status.
To prepare safe drinking water, do the following:
• Boil water for 10 minutes before use if it is not
• Store clean water in a container with a lid.
• Food should be handled and stored safely by doing the following;
• Clean surfaces on which food is prepared or served.
• Cover food to avoid flies and contamination.
• Store food for no more than 12 house without refrigeration.
• The woman’s body, clothing bedding, and environment should be kept clean; this means:
• Bathing regularly
• Changing bedding and clothing
• Cleaning regularly

Hygiene during pregnancy:

In addition to practicing good general hygiene (above), the pregnant woman should be advised of the
following:
• During pregnancy. The pregnant woman should be especially careful about hygiene to pre-
vent disease and infection-pregnant women sweat more and have more vaginal discharge than
non-pregnant women (due to hormonal changes), and may be more vulnerable to germs.
• Dental hygiene is especially important during pregnancy because increased estrogen levels
can cause swelling and increased sensitivity in gum tissues. Whether she cleans her teeth with
a dental stick or n toothbrush and toothpaste, the pregnant woman should do so regularly.

REST AND ACTIVTTY:

Based on the woman's history and any other relevant findings and discussion, individualize the fol-
lowing key messages:
• A pregnant woman should try to decrease the amount of heavy work and increase rest time.
• A pregnant woman needs additional rest. In early pregnancy, the woman will feel tired as her
body becomes accustomed to being pregnant. In later pregnancy. the growing fetus uses more
of the woman’s energy and causes greater strains on her body. As the pregnancy progresses,
show will need more and more rest.
• A pregnant woman should have predicts periods during the day in addition to whatever
amount of sleep she normally needs.
Note: In most cultures, women do not get permission to rest during pregnancy may
be your role to play advocate for the woman, and help her find creative ways to
reduce her workload and find more time for rest.

• A pregnant woman should avoid lying on her back. The best resting position for a pregnant Women
is lying on her left side with her feet elevated.
• Pregnant women should avoid sitting or standing for long periods during the day.

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Why Side-Lying is Important for the Pregnant Woman

When a pregnant woman lies fiat on her back (such as when she is resting or sleeping),the en-
larged uterus puts pressure on the major vessels of her circulatory system, which
• Decreases blood flow from the lower half the body, which in turn:
• Reduces the anxiety of blood filling the heart;
• Lowest cardiac output:
• Restricts blood flow to the fetus: and
• May result in low blood pressure. which may cause the woman to faint when she gets up.
The woman can alleviate this: syndrome by sitting up or lying on her side.
• During pregnancy, hormonal changes cause softening of cartilage in some joints and relaxa-
tion in other joints. This means that the pregnant woman is much, more susceptible to inju-
ries. She should therefore!
• Avoid overexertion
• Avoid carrying loads; and
• Use proper mechanics especially when lifting anything as a small child.
The, pregnant has increased caloric needs. She should consider decreasing her workload
and o avoiding heavy physical labor, especially if she:
Appears to be getting thinner,
Has unsatisfied hunger or work-related fatigue; ors
Cannot increase her dietary intake enough to meet the caloric requirements of pregnancy or the phys-
ical demands of her daily life.

PROPER BODY MECHANICS:

 Use proper body mechanic for lifting
• Squat (keeping the spine erect), rather than bend, to lift anything so that the legs (thighs), ra-
ther the the back bear the weight and strain.
• When squatting or rising from a squatting position. spread the feet apart and place one lightly
in front of the other, so that there is a broad base for balance.
• Practice good posture when standing or sitting.
• Do not cross the legs when sitting.

SEXUAL RELATIONS AND SAFER SEX

Practicing safer sex can reduce the risk of HIV and other sexually transmitted infections (STIs):
• Abstinence or mutually monogamous sex with a partner who is free from HIV or STIs is the
only sure protection.
• Consistent use of condoms is important even during pregnancy
• A decrease or increase in the woman's desire for sex is normal during pregnancy. Intercourse
during a pregnancy that is progressing normally will not harm the woman or the fetus.
• Intercourse should be avoided, however. if she experiences the following:
 leaking watery fluid
 Vaginal bleeding

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 Signs of premature labour

• As the pregnancy progresses changes in sexual position may be needed to accommodate the
women enlarged abdomen or satisfy both partners sexual needs.
• Having or contracting, an STI such as HIV, syphilis, gonorrhea, or Chlamydia-while pregnant
is dangerous to the women her partner. And the unborn baby.

Sexual intercourse is avoided in pregnancies where the women has a history

of miscarriages or repeated abortions’
TRAVELING
Any jerky form of travel should be avoided. Smooth traveling over a reasonable distance will not
harm pregnancy. In conditions like a threatened abortion, bed rest is advised.
SMOKING
Smoking affects the unborn child. The heavier the smoking is, the more damaging its effect on the
fetus Passive smoking, that is the inhalation of cigarette smoke being smoked by someone else is as
harmful as active smoking.
ALCOHOL:
Now and then with a meal. is not harmful, but large drinking is to be avoided.
JERKY MOVENENTS:
Are to be avoided. especially modes of transport which make it unavoidable.
LONG JOURNEYS:
Also to be avoided if possible.
X-RAYS:
especially in the 1st and 2nd trimesters are harmful.

MEDICINES AND DRUGS

Must be carefully considered. The first three months of pregnancy are the most crucial various or-
gans systems of the baby are taking shapes Any influence at this stage is likely to cause damage.
CHECK OUT THESE AVOIDABLES
• Antibiotics-tetracyclince, doxycyclines. long acting sulphate
• Certain dugs that prevent the clotting of blood.
• Anti thyroid diabetic drugs dosages may have tơ be altered.
• Anti-epileptics - a safer drug may be substituted.
• Sleeping pills
• Anti-cancer drugs
• Anti-hypertensives might have to be changed or he dose adjusted.
• Sex hormones – except when advised by your doctor under special circumstances
• Steroids except when used in suitable dosages as when required for certain diseases.
• Narcotics (LSD, Cocaine, Heroin) car do incalculable damage to the unborn child.
• Artificial hair dyes -natural ones like Mehndi/Henna may be used instead
FOLIC ACID

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• Folic acid is he only vitamin supplement that is recommended for women who are otherwise
eating balanced diet
• Folic acid is needed for development of healthy red blood cells, and taking enough of it de-
creases the chance of a baby being born with neural tube defects.
• A baby's brain and spinal cord are formed from the neural tube very early in pregnancy. Ex-
ample ,of' neural tube defects spina bifida, where an area of spinal cord is not properly en-
closed. This can cause problems such as paralysis of the legs and incontinence. Best to start
taking folic acid before pregnancy (ideally about three months before trying to achieve), or as
soon as the woman realizes she is pregnant: should be continued for at least the first 12
weeks. 400 micrograms is the recommended daily dose, which is over the usual recommend-
ed dietary intake of 200 micrograms.
• Folic acid is found naturally in fresh dark green vegetables such as broccoli, peas, green
beans and spinach. Many breakfast cereals and some breads are fortified with folic acid.
HERE ARE SOME OF THE MOST COMMON NUTRIENTS AND THEIR SOURCES
Nutrient Needed for Best sources
Protein Cell growth and blood produc- Lean meat, fish,poultry, egg
tion whites beans, peanut butter,
coffee
Carbohydrates Dairy energy production Breads,rice, potatoes, pasta,
fruits, vegetables
Calcium Strong bones and teeth, mus- Milk, cheese, yogurt, sardines
cle contraction, nerve function or salmon with bones, spinach
Iron Red blood cell production Lean red meat, spinach, iron
(needed to prevent anemia) fortified, whole grain breads
and cereals
Vitamin A Healthy skin, good eyesight, Carrots, dark leafy greens,
growing bones sweet potatoes
Vitamin C Healthy gums, teeth and Fruit, broccoli, tomatoes, forti-
bones, assistance with iron fied fruit juices
absorption
Vitamin B6 Red blood cell formation ef- Pork, ham, whole grain cere-
fective use of protein fat and als, bananas
carbohydrates
Vitamin B12 Formation of red blood cells, Meat, fish poultry, milk (Note:
maintaining nervous system vegetarians who don,t eat
health dairy products need supple-
mental B12)
Vitamin D Healthy bones and teeth, aids Fortified milk, dairy products,
absorption of calcium cereals, and breads
Folic Acid Blood and protein production, Green leafy vegetables, beans,
effective enzyme function peas, nuts

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Fat Body energy stores Meat, whole milk dairy prod-

ucts, nuts, peanut butter mar-
garine, vegetable

HIGH RISK PREGNANCY:-

For many women, pregnancy is a time of unparalleled joy and expectation. But for others. especially
those with chronic medical conditions or who are expecting multiples, pregnancy can be a time of
intense fear and uncertainty. In those instances. Both mother and child need specialized care to en-
sure good health.
Some five to ten percent of pregnancies are termed high risk." A pregnancy is "high
risk" or "complicated" when the life or health of the mother or baby nay be at risk.

Families can cope more successfully with a high-risk pregnancy with appropriate medical interven-
tion. education, and a strong support system. In fact, many risk factors can be identified even before
conception occurs.
Health problems can also develop during a pregnancy that can make it high-risk. S)
problems may occur even in a woman who was previously healthy.

 Maternal age is one factor that contributes to pregnancy risks.

 The chances of pregnancy-induced high blood pressure or diabetes in the mother and ab-
normal development of the baby increase with the mother's age.
 The mother's height and weight are factors, also. Women who weigh less than 100
pounds are likely to deliver underweight babies.
 Those who are overweight put themselves at risk for gestational diabetes and hyperten-
sion
 Short height less than 5 ft: contracted pelvis
 Woman with chronic medical conditions. such as lūpus, cancer, diabetes, or arthritis. are
all at risk for Complicated pregnancies.
 A family history of mental retardation or birth defects can indicate a high-risk pregnancy.
 Likewise, women who have experienced miscarriages, pre-term deliveries, stillbirths. or
neonatal
• deaths need specialized care to ensure a healthy pregnancy and birth.
• H/O difficult or prolong labor.
• Male presentations, Premature, rupture of membranes. multiple pregnancy, and Grand
multiparity
• Polyhydramnios.
• Rh and ABO incompatibility.
• smoking commonly leads to low birth weight. include spontaneous
abortions, congenital heart defects, and premature births.
• Drug abuse is not dangerous for a mother s health. but also can cause premature birth.

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• Sunted growth mental retardation and/or drug addiction in her baby.

With proper care. 90 to 95 percent of high-risk pregnancies produce healthy, viable babies.
The earlier a problem is detected, the better the chances that both mother and baby will stay
healthy. It is important to remember, however, that not all condition can be diagnosed, and
some pregnancies begin normally, but develop problems later.

FAMILY PLANNING:-
There is a burst in the population growth over the last few years in Pakistan. There is a dire need for
the development of effective family planning services in Pakistan. This strong need stems from five
main background problems.
1 Rapid population growth
2. Environmental pollution
3. Worsening poverty
4. Unplanned pregnancies
5. deteriorating maternal and child health
Quick successive pregnancies result in increase in maternal and perinatal morbidity and
mortality, marital disharmony and financial crisis culminating in child abuse
Family planning provides a means of spacing pregnancies at a desired level
size.
Family planning clinic there fore provides consultation and guidance in the choice of most appropri-
ate contraceptive methods which should be most suitability that particular couple
Advantages of family' planning:
• Family planning reduces maternal and prenatal morbidity and mortality.
• Improves women's health by preventing unwanted and high risk pregnancies
• Family planning reduces the need for unsafe abortions
• Contraception’s by the consistent condom use prevent transmission of sexually transmitted
diseases (STD) including HIV.
METHODS OF CONTRACEPTION
There are different methods of contraception
• Natural Family planning
• long-acting reversible contraception LLRC has the implant or intra uterine device (IUD)
• hormonal contraception such the pill or the Depo Provera injection
• barrier methods Such as condoms
• emergency contraception
• fertility awareness
• permanent contraception such as tubal ligation and vasectomy

NATURAL FAMILY PLANNING: (NFP)

The natural family planning is refer to the several methods for spacing, avoiding or increasing th
possibilities of pregnancy without using any chemical or other methods of conversation or
without any physiological alteration of the reproductive system either in the male or female, NEP
use no birth control drugs or devices. the best time or conceiving is exactly halfway between two )

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periods. Sperm can only survive for 2 to days at most. Contraception is unnecessary until the 7th day
of the cycle. Ovulation always occurs in the 14th day of the cycle.

COMPARING TYPICALY EFFECTIVNESS OF CONTRACEPTIVE

METHODS
Diagram.

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THERE ARE A NUMBER OF METHODS EMPLOYED IN NFP METHODS.

• Lactational amennorrhea method. (LAM)
• Cervical mucus method
• Symptothermał method. (Basal body temperature method)
• Withdrawal method
Advantages of NFP Methods:
NFP is sate, healthy. inexpensive, lifelong, completely reversible and easy to learn.

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Lactational Amenorrhea Method:

This method is commonly used and called as Contraception by Breast Feeding
This Contraceptive method is effective only
• if the mother is exclusively breast feeding (Breastfeeding on demand at least every four hours
during the day. and every six hours at night)
• is not having menses since the birth of the child (amenorrhea ,the baby is less than 6 months
old.
• Under these conditions. it is about 98% effective.
BARRIER MIETHODS OF CONTRACERTION
Commonly used method in Males is Condom and in females is Diaphragm.
MECHANISM OF ACTION:
Condoms are made of rubber or latex heath which traps the ejaculate in the tip and thereby prevent-
ing sperms from entering the vagina thus preventing fertilization.
Advantages:
Condoms help to reduce risk of STDs and also help to reduce the risk of transmission of HIV.
Disadvantages?
• Condoms are commonly used incorrectly and so they are much less effective. About 98% ef-
fective when used correctly.
• IT is vital that condoms be worn property and should not tear or slip and should be with-
drawn immediately after ejaculation with worn condom.
Precautions:
• Condoms must be stored in a cool, dry place in order to prevent its deterioration of rubber.
• use of Lubricants and/or spermicides can cause condom failure by accelerating deterioration
of condoms rubber.

ORAL CONTRACEPTIVE PILLS:

Pills that contain low doses of 2 hormones progestin and an estrogen Like the natural
hormones progesterone and estrogen in a woman's body.
Combined oral contraceptives (COCs) are also called "the Pill," low-dose combined pills, OCPs and
OCs.
In Pakistan all available pills are of combined variety called Combined Oral Contraceptive
Pills. COCs

MECHANISM OF ACTION:
 Work primarily by preventing the release of eggs from the ovaries (ovulation)
 They Prevent Ovulation by negative feedback effect.
 Thickens Cervical Mucous thus making it impermeable to entry of sperms
ADVANTAGES:
 Very Effective form of contraception when used properly. 97% to 99.9% effective.
 Decreases risk of PID, Uterine and Ovarian Cancers.

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 Regulates Menstrual Cycle.

 Reduces Dysmenorrhea.(pain associated with periods )
 Reduces menstrual blood loss
 Reduces incidence of Benign ovarian cysts,
 Quickly reversible.
DISADVANTAGES:
 Minor Side Effects
 Compliance of patients is poor as they have to be taken daily.
 Reduces Breast milk so not suitable during first 3 to 6 months of lactation.
SIDE EFFECT’S:
• Nausea.
• Breast Tenderness.
• Headache and worsening of migraine.
• Weight gain
• Mood Changes
• Irregular vaginal bleeding and spotting
• Serious Side effects like effect of Lipid metabolism, CVS side effects.
• MEDICAL Sciences
• Increased chances of stroke and venous problems.
CONTRAINDICATIONS:
Absolute
 Pregnancy.
 Unexplained vaginal bleeding.
 Breast Lump/cancer.
 Severe Diabetes.
 Severe Hypertension/Heart disease.
 Smoker aged over 35.
 Breast Feeding (less then 6 months}.
 Active Liver Disease,
Relative:
 History of Heart disease.
 History of Liver/gall bladder disease.
 Chronic Headaches.
 History of Stroke.
 Medications usage like Anti epileptics. anti-TB.
 History of Thrombosis.
 METHOD OF USE:

 The Combined Pills are started on 1 St. day of menstrual bleeding i.e. when bleeding starts.
 They have taken at same time of day daily and taken in order as shown on package.

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 Start next pack straight away. If I pill is missed , that missed pill is taken assoon as it is re-
membered while taking that day pill as usual and continue taking pills on each day as before.
 When 2 pills are missed take 2 pills each day for as many days as the number of pills and
then continue taking I pill each day if 3 or more pilIs are forgotten, also use another method
of contraception besides, taking pills like Condoms or abstinence.
 DANGER SIGNS:
When any one of these signs is present, the client must report to doctor as early as possible.
 Severe lower abdominal pain.
 Severe Headache.
 Loss or Blurring of Visions
 Slurred Speech.
 Severe leg/calf pain

 KEY POINTS FOR PROVIDERS AND CLIENTS

 Take one pill every day. For greatest effectiveness a woman must take pills daily and start
each new pack of pills on time.
 Bleeding changes are common but not harmful. Typically, irregular bleeding for the first
few months and then lighter and more regular bleeding
 Take any missed pill as soon as possible. Missing pills risks pregnancy and may make some
side effects worse
 Can be given to women at any time to start later. If pregnancy cannot be ruled our, a pro-
vider can give her pills o take later; when her monthly bleeding begins.

 WHO CAN AND CANNOT USE COMBINE ORAL CONTRACEPTIVES:

 Safe and Suitable for Nearly All Women
 Nearly all women can use COCs safely and effectively, including women who:
 Have or have not had children
 Are not married
 Are of any age, including adolescents and women over 4 years old
 Have just had an abortion or miscarriage
 Smoke cigarettes-if under 35 years old
 Have anaemia now or had in the past
 Have varicose veins
 Are infected with HIV, whether or not on antiretroviral therapy

WOMEN CAN BEGIN USING COCS:

• Without a pelvic examination
• Without any blood tests or other routine laboratory tests
• Without cervical cancer screening

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• Without a breast examination

• Even when a woman is not having monthly bleeding at the time

MAKING UP MISSED PILLS WITH 30-35 UG ESTROGENT

Number of
Pills Missed when pills miss what to do 7 day backup
First 1-2 beginning of pack Take as soon as you remember
Take the next pill at the usual time yes
(This means you may take two pills in one day)
I-2 pills Day 3-day 21 take a pill as soon as you remember
Take the next pill at the usual time No
(this means you may take two pills in one day)
3 or more pills First two weeks Take pill as soon as you remember yes
Take the next pill at the usual time
(this means you may take two pills in one day)
3 or more pills third week Do not finish pack. throw away remaining pills
Start next pack yes
1-7 reminder pills Fourth week Throw away the missed reminder pills No
Take next reminder pill at the usual-time

LONG ACTING REVERSABLE CONTRACEPTIVES:-(LARC)

There are two types of LARC
the intra uterine device (IUD) that lasts for five to ten years the implant that lasts for one-three years.
They are sometimes called "Fit and forget” contraception because you don't need to remember it eve-
ry day or every month.
LARCs are the most effective types of contraception. They are more than 99% effective at prevent-
ing pregnancy.

 IMPLANT /NORPLANT:
These are match stick sized implants which release progesterone which suppresses
Ovulation. Each Implant lasts for 5 years and are placed in upper arm in form of fan
Efficacy: 99.9% effective in first 2 years and then reducing to 96% in year 5.

These are available only in specialized centers.

INTRAUTERINE CONTRACEPTIVE DEVICES: (TUCD)
• These are mainly of 2 types.
• Medicated _containing long acting progesterone like Progestasert
• Non-medicated like Copper T or Multi load.
MECHANISM OF ACTION:
The Non-medicated IUCDs like Copper T act as foreign body inside endometrial cavity. They in-
crease Fluids which hinder uterine and tubal transport so fertilization dose not occur.

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EFFICACY:
They are about 98% effective.
SIDE EFFECTS:
• Irregular Vaginal Bleeding _May be Heavy.
• Pelvic pain.
• High chances of ectopic Pregnancy.
• High chances of PID.
DISADVANTAGES
IUCDS are not the first choice for women with no children or those who are at risk of STDs.
LONG ACTING HORMONAL [INJECTABLE] CONTRACEITIVES
There are 3 types of injectable Contraceptives.
• One injected every month.
• One injected every 2 months.
• One injected every 3 months
MECHANISM OF ACTION:
• These act by Suppressing Ovulation through negative feed back effect.
• They also thicken cervical mucous thus making it impermeable to sperms.
ADVANTAGES:
• Very Eftective.99.6% to 99.7% effective.
• Lasts for 3 months so compliance is much better.
• There is no effect on Breast feeding after 6 weeks.
• Protection against Endometrial Cancer.
• Reversible.
• Reduces Anemia due to amenorrhea.
DISADVANTAGES:
• Irregular Bleeding.
• Delay in return to fertility.
CONTRAINDICATIONS:
• Pregnancy.
• Breast feeding {less than 6 weeks).
• Diabetes.
• Hypertension.
• History of Stroke.
• Breast Lump/cancer.
• Unexplained Vaginal Bleeding.
• Jaundice/ Liver problems.
• Heart/vascular Disease.
SIDE EFFECTS:
• Irregular Vaginal Bleeding.
• Weight gain.
• Amenorhea causing worries about pregnancy.
• May result into heavy bleeding

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METHOD OF USE:
The first injection is given during the first 7 days of menstrual cycle. Effect last for3 months in case
of Depo Provera (long acting Progesterone}. When client wants to conceive no more injections are
given and fertility is restored within 6 to 12 months of last injection. The first injection given during
the first 7 days of menstrual cycle. Effect last for 3 months in case of Depo Provera {long acting
Progesterone}.When client wants to conceive no. more injection are given and fertility is restored
within 6 to 12 months of last injection
PERMANENT CONTRACEPTION
Permanent contraception, sometimes called sterilization, prevents all future pregnancies . It is very
difficult or impossible to reverse. Permanent contraception is either a Vasectomy or a tubal ligation
MALE AND FEMALE STERILIZATION:
Vasectomy is performed in men and Tubal Ligation in women. 99.6% to 99,9% effective.
COMPLICATIONS:
These are rare and include Infection, Bleeding can occur.
This is permanent method of contraception and should be employed only in those clients who are
certain that they never want more children

WHAT IS EMERGENCY CONTRACEPTION

 There are two options for emergency contraception the emergency contraceptive pill (ECP)
or a copper IUD.
 The ECP is approved to be taken up three, days after unprotected sex. If you are an average
weight, the ECP is 98% effective
 If you weight more than 70kg, the ECP is less effective and a copper IUD is recommended. If
you weight more then 70kg and you choose to take ECP, you should ask if taking a double

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dose is the right option for you. The copper IUD can be inserted up to five days after unpro-
tected sex, and is more than 99% effective preventing pregnancy.
EMERGENCY CONTRACEPTION CAN BE USED TO PREVENT PREGNANCY IF :
• Have not used protection
• normal contraception fails e.g. condom splits
• have missed more than one contraceptive pill
• have been vomiting or had diarrhea while on the pill
• have missed injection
• have been forced to have sex without contraception.
• should not be used the ECP as regular method of contraception.
UNIT NORMAL LABOUR:
Labor is progressive dilatation of the uterine cervix in association with repetitive
Contractions spontaneous or induced term or preterm leads to expulsion of fetus, placenta and mem-
branes through the birth canal.
NORMAL LABOR:
Normal labor is the spontaneous expulsion at term of a single fetus in longitudinal lie: cephalic
presentation. occiputoanterior position followed - by the after birth (placenta, cord and membranes)
within 18 hours of the spontaneous. onset of labor without any complication.(Episiotomy is not
counted as an intervention).
STAGES OF LABOR:
Three stages of labor have traditionally been described:
I. First stage of labor lasts from the on set of labor up to the full dilatation of the cervix.
( Shortening and dilatation of the cervix).
Phases:
Latent phase: 0-3cm
Active phase: 4-10cm
Average length:
Primipara: 12-13hrs
Multipara: 1-8hrs
2. Second stage spans the interval-from full cervical dilatation up tl the expulsion of the baby.
(delivery of fetus )
Average length
primipara 1hr
Multipara 20min
3. Third stage begins with the birth of the baby and ends with complete expulsion of the pla-
centa and the membranes.(delivery of the placenta with the umbilical cord
Membranes)
Average length
primipara 15-30min
Multipara 5-15min
4. Fourth stage is a time period of two hours after completion of the third stage of labor.
( about two hours after delivery (inspection and surgical help)

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THEORIES OF ONSET OF LABOR:-

 Prostaglandins are compounds, which can be synthesized by the body. They can cause the
uterus to contract and cause the cervix to become ripe. The decidua and the fetal membranes
are rich sources of precursors of prostaglandins.
 Prostaglandin administration at any stage in pregnancy leads to termination of the pregnancy
The levels of prostaglandin increase progressively during labor. Prostaglandin causes stimu-
lation of smooth muscles of many tissues in the body.

THE OXYTOCIN THEORY:

Oxytocin is a potent stimulant of uterine contractions. There is a progressive increase in the number
of oxytocin receptors in the myometrium near term. Oxytocin acts on the decidua to promote the re-
lease of prostaglandin.

ESTROGEN-PROGESTERONE RATIO THEORY:

An agent called 'uterotropin'. which acts as antiprogesterone in humans has been suggested to be re-
sponsible for the balance in favor of estrogen dominance there by initiating the labor process.

MYOMETRIAL STRETCH THEORY: -

It is well known that conditions such as mutiple pregnancies. hydramnios, which cause excessive
stretching of the uterus, can load,to preterm delivery. However the role of myometrial stretch toward
labor initiation is not established. -The cause of labor appears to be multifactorial in origin, being a
combination of endo-crinological and mechanical factors.

DIAGNOSIS OF LABOR:

DIAGNOSIS OF LABOUR INCLUDES:

• diagnosis and confirmation, of labour:
• diagnosis of stage and phase of labour,
• assessment of engagenent and descent of the fetus:
• identification of presentation and position of the fetus.

DIAGNOSIS AND CONFIRMATION OF LABOUR

• Suspect or anticipate labour if the woman has:
• intermittent abdominal pain after 22 weeks gestation:
• pain often associated with blood-stained mucus discharge (show):
• watery vaginal discharge or a sudden gush of water.
• Confirm the onset of labour if there is:

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• cervical effacement--the progressive shortening and thinning of the cervix during labour: and
cervical dilatation--the increase in diameter of the cervical opening measured in centimetres.

EFFACEMENT AND DILATATION OF THE CERVIX

DIAGNOSIS OF STAGE AND PHASE OF LABOUR

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Symptoms and Signs stage Phase

Cervix not dilated false labour/not in labour
Cervix dilated less than 4 cm first latent

.Cervix dilated 4-9 cms

Rate of dilatation typically 1cm first active
per hour or more
Fetal descent begins

Cervix full dilated (10 cm)

Fetal descent continues second Early(non-expulsive)
No urge to push

ASSESSSMENT OF ENGAGEMENT AND DESCENT OF THE FETUS:

ABDOMINAL PALPATION
 By abdominal palpation, assess descent in. terms of fifths of fetal head palpable above the
symphysis pubis
 -A head that is entirely above the symphysis pubis is five-fifths (5/5) palpable
(Fig C-4 A)
 A, head that is entirely below the symphysis pubis is zero-fifths (0/5) palpable.

FIG C-4 A ABDOMINAL PALPATION FOR DESCENT OF THE FETAL

HEAD
DIAGRAM

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DIAGRAM
FETAL DESCENT STATIONS (BIRTH PRESENTATION)

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Vaginal examination:
If necessary, a vaginal examination may be used to assess descent by relating the level of the fetal
presenting part to the ischial spines of the maternal pelvis (Fig C-5).
Note: When there is a significant degree of caput or moulding, assessment by abdominal palpation
using fifth of head palpable is more useful than assessment by vaginal exam.

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Assessing descent of the fetal head by vaginal examination; 0 station is at the level
of the ischial
spine (Sp).
Fig C-6

 IDENTIFICATION OF PRESENTATION AND POSITION:

 DETERMIE THE PRESENTING PART

 The most common preventing part is the vertex of the fetal head. If the vertex is not the pre-
senting part manages as a malpresentation.
 If the vertex is the presenting part, use landmarks on the fetal skull to determine the position
of the fetal head is relation to the maternal pelvis (Fig C-6).

LANDMARKS OF THE FETAL SKULL

(FIG C-7)
DIAGRAM

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DETERMINE THE POSITION OF THE FETAL HEAD

THE fetal normally engages in the maternal pelvis in an occiput transverse position ,with the fetal
occiput transverse in the maternal pelvis
….diagram

OCCIPUT TRANSVERSE POSITION (FIG -C-8)

With descent the fetal head rotates so that the fetal occiput is anterior in the maternal pelvis

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(occiput anterior position ,Fig C-8) Failure of an occiput transverse position to rotate to an occiput
anterior position should be managed as an occipito posterior position
OCCIPITO ANTERIOR POSITION (FIG C-9)
DIAGRAM

An additional feature of a normal presentation is a well -flexed vertex (Fig C-9),with the occiput
LOWER IN THE VAGINA THAN THE SINCIPUT
FIGURE C-10
WELL-FLEXED VERTEX
DIAGRAM

FIRST STAGE OF LABOR:-

DEFINITION:

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Part of the labor process. During this stage, cervical dilation is the predominant [Link] patient is
admitted to the labor room/ward and is under continuous monitoring for the maternal wellbeing, fetal
wellbeing and progress of labor.

PHYSIOLOGY OF FIRST STAGE OF LABOR:

Pain in labor is transmitted along the smaller nerve fibers that are designed to sense the sharp burn-
ing or aching pain. These nerves sense the contractions of the uterus. The dilation of the cervix and
the pressure and stretching of the [Link] floor and perineum.

Duration:
The length of labor varies widely and is influenced by partially birth intervals, physiological
state and character of uterine [Link] is Common to expect the active phase to be completed
within 12 hours.

Polarity:
It is a term Used to describe the neuromuscular harmony that prevails between the two poles (upper
and lower) or segments of uterus throughout labor. The upper pole contracts strongly retracts to ex-
pelthe fetus. The lower pole contracts slightly and dilates to allow expulsion to take place.

UTERINE CONTRACTION/ UTERINE ACTION:

FUNDAL DOMINANCE: contraction starts in the fundus near one of the corner and spreads across
downwards. This pallet permits the cervix to dilate and the contracting fundus to expel the fetus.

THE MUSCULATURE OF THE PREGNANT UTERUS IS ARRANGED IN THREE STAG-

ES:

• An external hood like layer which arches over the fundus and extends into the var-
ious ligaments.
• An internal layer consist of sphincter-like fibers around the orifices of the tubes and the in-
ternalos.
• Lying between the two , a dense network of muscle fibers perforated in all directions by
blood vessels.
• The main portion of the uterine wall is formed by middle layer which consists of an inter-
lacing network of muscle fibers between which extend the blood vessels.
• As the result of such an arrangement, when the cells contract after delivery, they constrict
the vessels and thus act as a "living ligatures."
• Uterine contractions are involuntary and for the most part, independent of extra uter-
ine control.
• It has been demonstrated that the uterus has pacemakers to produce the rhythmic coordinat-
ed contractions of labor.
• The interval between contractions diminishes gradually from approximately ten minutes in
early labor to as little as two minutes near the end of labor.

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• In the normal process there is a progressive increment in the strength of contractions

from approximately 20 mm of mercury at the onset of labor to 50 to 80 mm late in
labor.
• The effect of uterine contractions of this frequency and intensity is two fold on the
uterine cervix.
• First effacement consists of thinning of the cervix with a shortening of the endocervical
canal is produced.
• Secondly, cervical dilation concurs, initially slowly as it accompanies of process of efface-
ment ofthe cervix, and then more rapidly as cervical effacement has been accomplished.
• Most of these contractions are imperceptible to the pregnant individual but toward the end
of pregnancy they may achieve on a sporadic basis strength equivalent to those of early la-
bor False labor , Braxton-hicks contractions, and pre-labor contractions are terms that
have been applied to this uterine activity.
• The latter term is probably the most appropriate and it is this uterine activity which accom-
plishes a significant degree of effacement and even some dilations in days or weeks prior to
the onset of recognizable labor.
• Descent of the presenting part of the fetus into the birth canal. Particularly in a first preg-
nancy is another result of pre-labor.
CERVICAL EFFACEMENT AND DILATATION:
Effacement refers to the taken of the cervix. It may occur late in pregnancy or may not take place
until labor begins. In primi gravida the cervix will not dilate until effacement is complete, whereas
in multigravida effacement and dilation may occur simultaneously.
FORMATION OF UPPER AND LOWER UTERINS SEGMENT:
By the end of pregnancy the body of the uterus has divided into two segments the upper segment is
mainly concerns with the contractions and is thick and muscular while the lower segment is pre-
pared for distention and dilation and is thinner.

FORMATION OF FORE WATER BAG:

As the lower segment stretches the chorion become detached from it and increased intrauterine pres-
sure cause this loosen part of sac of fluid to bulge downwards into the dilating internal os.

RUPTURE OF MEMBRANE:
Membrane ruptures at the end of the second stage of labor when the cervix is fully dilated and no
longer support the bag of fore waters.
 MANAGEMENT OF FIRST STAGE OF LABOR:-

Welcome the mother and her parents.

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TAKING HISTORY OF PRESENT LABOR:

• Name, case number if booked case.

• Onset of labor
• Membrane (ruptured or intacked)
• Frequency and strength of contractions.

PAST HISTORY:

• If booked collect information from antenatal record. If unbooked ask

• Parity
• Character of previous pregnancy and labor.
• Type of delivery
• Outcome of previous labor.
• Condition of previous baby
• Any complication arrised in previous labor. Evidence of CPD
• Maternal disease
• Rhesus iso-immunisation.
• History for parity. exact gestational age, Presentation and risk factors.

AVAILABLE INVESTIGATION:

Hb, blood group, Rh factor, blood sugar ,urine for albumin and sugar.

Clinical examination or pelvic assessment, stages of labor, fetal wellbeing and any risk factor:
General and abdominal examination, refer to page No 94-96)
VAGINAL EXANIMATIONS:

Vaginal examinations should be carried out at east once every 4 hours during the active first stage of
labor and after rupture of the membranes. Plot the findings on a partograph,

At each vaginal examination, record the following:

• Color of amniotic fluid: -

• Cervical dilatation;
• Descent of head

 CARE OF MOTHER:

VITAL SIGNS:
The vital signs of the laboring woman need to be monitored periodically during the labor process.
Pulse rate, temperature, respiration and blood pressure should be kept. Under observation.
POSITIONING:

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 She should be allowed to be in a comfortable position. There is no need to confine her to the
labor cot in lying own position.
 On the other hand allowing her to be up and about improves the pains as well as reduces the
analgesic requirements.
 If the patient is a high-risk case or where an intravenous line is running, ambulation is not
possible. Support the woman's choice of position for birth
 Positions that a woman adopt during labour

NUTRITION:
Labor process needs energy and woman should be given ample nourishment during labor. Food,
which is easy to digest and ample intake of water should be maintained to avoid dehydration and star-
vation(ketoacidosis).

ELIMINATION:

The patient should be encouraged to empty her bladder every two to three hours.

Note: Do not routinely give an enema to women in labor.

PERSONAL HYGIENE:
Personal hygiene should be maintained she should have a warm shower to make her feel fresh and
prevent from infections.

Medication:

 Maintain l/v line, draw blood sample for advised investigation (Hb ,blood group etc if re-
ports are not available)
 IV Fluids (normal saline, Ringer lactate/ Dextrose water as indicated)
 Antibiotics cover ( if premature df membrane, any sign of infection present or traditional
birth attended case.
 Syntocinon infusion as per protocol.

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SUPPORTIVE CARE:

 Encourage support from the chosen birth companion.

 Arrange seating far the companion next to the woman
 Encourage the companion to give adequate support to the woman during labor and child-
birth (rub her back, wipe her brow with wet clothes, assist her to move about).
 Ensure good communication and support by staff:
 Explain all procedures, seek permission and discuss, findings with the woman
 Provide a supportive. encouraging atmosphere for birth, respectful of the woman's
wishes.
 Ensure privacy and confidentiality. Teach breathing techniques for labor and delivery.
 Encourage the woman to breathe out more slowly than usual and relax with each expira-
tion.

HELP THE WOMAN IN LABOR WHO IS ANXIOUS, FEARFUL OR IN PAIN:

• Give her praise, encouragement and reassurance.

• Give her information on the Process and progress of her labor.
• Listen to the woman and be sensitive to her feelings.

PAIN MANAGEMENT

• If the woman is distressed by pain: Suggest changes of position.

• Encourage mobility.
• Encourage her companion to massage her back or hold her hand and sponge her face be-
tween contractions:
• Encourage breathing techniques.
• Encourage warm bath or shower.
• If necessary, give pethidine 1 mg/kg body weight (but not more than 100 mg) IM or Iv
slowly or give morphine 0.1 mg/kg body weight IM.

EVALUATE THE WOMAN FOR SIGNS OF DISTRESS:

 If the woman's pulse is increasing, she may be dehydrated or in pain. Ensure adequate hydra-
tion via oral or IV routes and provide adequate analgesia.
 If Blood pressure of the woman decrease, suspect hemorrhage.
 If acetone is Present in the woman's urine. suspect poor nutrition and give dextrose IV.
FETAL WELLBEING:

Listen to the fetal heart rate immediately after a contraction:

• Count the fetal heart rate tor a full minute at least once every 30 minutes during the active
phase and every 5 minutes during the second stage.
• Decelerations are most frequently encountered at this time if they are present.

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• If there are fetal heart rate abnormalities (less than l00 or more than 180 beats per minute) sus-
pect fetal distress.
• Presence of meconium, Especially thick and with vertex presentation particularly indicate a high
chance of pre-existing fetal distress.
• If the membranes have ruptured, note the color of the draining amniotic fluid.

PROGRESS OF LABOR (RECORDS)

ASSESSMENT OF PROGRESS OF LABOR

 Once diagnosed, progress of labor is assessed by:

 measuring changes in cervical effacement and dilatation daring the latent phase.
 measuring the rate of cervical dilatation and fetal descent during the active phase;
 Labor process must be completed within a reasonable time period. As the labor duration goes
on Increasing beyond normal, there is a gradual worsening of Perinatal outcome and a pro-
gressive increase in the maternal morbidity.
 Progress of the first stage of labor should be plotted on a partograph once the woman enters
the active Phase of labor. A sample partograph is shown in Fig C-10. Alternatively, plot a
simple graph of cervical dilatation (centimeters) on the vertical axis against time (hours) on
the horizontal axi.

PARTOGRAPH:
It is a graphical record of progress in labor. It stars from active phase of labor that is 4 cm through this
we take the decision that either labor is obstructed or prolonged. In this we check Cervical effacement
dilatation, membrane is intact, ruptured, absent or bulging, station of head and P/P contraction are mild
moderate or strong.

PARTS OF PARTOGRAPH:

Patient information:
Fill out name, gravida, Para, hospital number, date and time of admission and time of ruptured mem-
branes.

Fetal heart rate:

Record every half hourly.

Amniotic fluid:
Record the color of amniotic fluid at every vaginal examination:

I: membranes intact;

C: membranes ruptured, clear fluid;

M: meconium-stained fluid,

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B: blood-stained fluid.

Moulding:

1: sutures apposed;

2: sutures overlapped but reducible:

3: sutures overlapped and not reducible

Assessed at every vaginal examination and marked with a cross (X).Begin plotting on the partograph at
4cm.

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:
Action line is Parallel and 4 hours to the right of the alert line.

DESCENT ASSESSED BY ABDOMINAL PALPATION:

It refers. to the part of the head (divided into 5 parts) palpable above the symphysis
recorded as a circle (0) at every vaginal examination.
HOURS: Refers to the time clasped 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 l0 minutes and their duration in seconds.
 Less than 20 seconds:
 Between 20 and 40 seconds:
 Mere than 40 seconds:
 Oxytocin:
Record the amount of oxytocin per volume IV fluids in drops per minute every 30 minutes when
used.
Drugs given:
Record any additional drugs given.

Vital signs:

• Pulse: Record every 30 minutes and mark with a dot(.)

• Blood pressure: Record every 4 hours and mar with arrows.
• Temperature: Record every 2 hours
• Protein, acetone and volume: Record. every time urine is passed

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DIAGRAM:

SECOND STAGE OF LABOR:-

DEFINITION:

Second stage of labor begins with full dilatation of the cervix and ends with the delivery of the ba-
by. The predominant movement in his stage is one of descent. The maximum time period of normal
second stage is Considered as 2 hours in a primi gravida and 1/2 hour in a multipara. The rate of
descent is normally more than one cm per hour.

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PHYSIOLOGICAL CHANGES:

• The uterine contractions become more intense, the frequency may increase further and
the duration becomes longer and more sustained.
• As the baby descends downward, there is pressure on the pelvic diaphragm.
• There is a feeling of pelvic fullness and the sensation of bearing down.
• There is a compulsive urge to push because of the pressure (on the rectum),
• The mucosa becomes thinned out and is liable to be injured due to the softening in-
duced by pregnancy.
• There is an irresistible urge to pass stools and any residual fecal matter in the rectum
may get expelled.
• As a part of the reflex, the anal opening gapes.

RECOGNITION OF SECOND STAGE

• There is no dramatic change occurring at full cervical dilatation and it may be recognized
by change if an examination is carried out at this line,[How ever when the presenting part
come at the level of the pelvic floor, several signs appear
• As already mentioned, involuntary expulsive effort called bearing down pains begin on
the part of the mother.
• With each contraction at its summit the anus gapes.
• The presenting part becomes visible at the introits without separating the labia.
• The mother gets an irresistible urge to pass the stool.
• The membranes, if not already ruptured, loose their support and may rupture at this stage.
• And there is a sudden gush of liquor.
• There may be a small amount of blood stained discharge or actual bleeding at this time.
• The only confirmatory sign is a vaginal or rectal examination revealing that no part of the
cervix is felt and the cervix is indeed fully dilated.

MACHANISM OF LABOR:
Mechanism of labor is defined as the series of movements that the fetus undergoes during its pas-
sage through the birth canal during childbirth. This sequence of movements is more or less similar
and occurs in most labors. The sizes and shapes of the fetus and pelvis are such that delivery would
be impossible without the fetus undergoing the specific movements.

DESCENT:
Descent means progression of the fetus toward the pelvic outlet. Descent is the cardinal movement of
labor. It is continuous and all other movements occur simultaneously with descent.
FLEXION:
There is flexion of the head at the neck and the spine. Flexion and descent make the smaller sub-
occipi tobregmatic diameter to engage in the right oblique diameter of the pelvic inlet. The denomina-
tor is the occiput, which lies against the ischiopubic ramus.
INTERNAL ROTATION:

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Internal rotation with progressive descent and flexion, the head reaches the pelvic floor. Because of
the gutter-like forward inclination of the pelvic floor the occiput under goes an internal rotation
through 1/8th of a circle and lies under the symphysis pubis. This is achieved with a twist at the
neck.
EXTENSION OF HEAD:
Extension of the head with further descent the head is born by a process of extension. Restitution af-
ter he birth of the head he twist at the heck is undone by a process of restitution in which there is a
correction of the rotation of the head by 1/8th of a circle.
EXTERNAL ROTATION:
With continued descent, the shoulder engage in the left oblique diameter of the inlet. There is inward
rotation the anterior shoulder So that it comes to lie under the pubic symphysis. The head externally
rotates through I/8th of a circle along with the shoulders. This is called as 'external rotation' OR Res-
titution.
MANAGEMENT OF SECOND STAGE OF LABOR:
FETAL WELLBEING:

•In second stage, fetus is exposed to maximum stress and therefore is liable to undergo dis-
tress.
• Fetal heart sound should be osculated every five minutes during this stage. Premature
bearing down cause pull on the uterus and it supports with resultant occurrence of pro-
lapsed.
• Once the expulsive phase. Of second stage has begun, preparations must be made for
the delivery of the baby.
• All he necessary instrument are checked at this stage.
• The mother should be informed that the end of labor is close and what she should do.
• Equipment needed for the baby is also checked.
• If the baby is expected to require specialized care like resuscitation at birth (preterm de-
livery instrument application, fetal distress etc) the neonatologist should be available in
time.
CARE OF MOTHER:

• The external genitals should again be cleaned thoroughly with antiseptic solution. The uri-
nary bladder must be emptied. A full urinary bladder is likely to get damaged in the deliv-
ery.
• A full bladder also inhibits uterine contractility, and emptying it often improves the pains.
• The mother should be encouraged to empty her bladder at this time. Often, because of the
pressure on the presenting part, this becomes impossible. In that case, the bladder needs to be
emptied using urinary catheter.
• As catheterization can introduce infection, strict aseptic care should be maintained. It should
be avoided if possible.
• At his time, requirements for pain relief is possibly maximum.

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• The mother is encouraged to push along with the contractions.

• Constant encouragement and support is often needed at this time.
• Some Women do not know what is needed to them. Guidance should be given to follow her
own reflexes.
• Criticisms should be avoided at all times.
• Continuous and sustained pushing is not useful in shortening the second stage.
• On the contrary, it may be harmful because it can lead to maternal and consequently
fetal hypoxia.

CONDUCTING THE DELIVERY:

Positions that a woman may adopt during childbirth

• Vaginal examination should be done to confirm full dilation of cervix. The presentation,
position, station and descent of the head with the uterine contraction and bearing down ef-
fort should also be noted.
• When the presenting part becomes visible, the midwife should prepare herself for the deliv-
ery.
• She should scrub up with soap and plenty of water and then wear sterile gloves.
• The perineum should be cleaned with plenty of cotton swabs soaked in antiseptic solution.
• Implementation of antiseptic and aseptic techniques
• The need for an episiotomy is assessed at this time.
• The mother is encouraged to push with contractions.

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• One hand should remain near the occiput, thereby controlling he birth of the head, The
other hand with a pad covers the perineum, thereby preventing premature extension of
the head.
• When the widest diameter of the presenting part is encircled by the introitus, crowning
takes place, the mother is asked not to bear. This prevents sudden stretching of the perine-
um and its tearing.
• Once the baby’s head delivers, ask the woman not to push.
• Suction the baby’s mouth and nose.
• Feel around the baby's neck for the umbilical cord
• Any fight loop should be loosened at this time if it does not get loosened, an attempt
may be made to push it over the baby's anterior shoulder. When even this is impossible,
the cord may have to be cut between a pair of artery forceps.
• Allow the baby's head to turn spontaneously.
• After the head turns, place a hand on each side of the baby's head. Tell the woman to
push gently with the next contraction.
• Reduce tears by delivering one shoulder at a time. Move the baby's head posterior to deliver
the shoulder that is anterior.
• The head then is directed anteriorly toward the sub pubic arch to deliver the posterior
shoulder, and the rest of the baby.

Note: There is difficulty delivering the shoulders, suspect shoulder dystocia.

•The baby should be received in a sterile towel.

•The time should be accurately recorded.
•The baby should immediately be wiped to dry it and kept covered. It should never be left
wet or exposed, which makes it cold.
• Unless Contraindicated the baby is shown to the mother and can be handed over to her for
the beginning of breastfeeding
RECORDS:

• The midwife is responsible for the maintenance of accurate records.

• The time of delivery should be accurately noted.
• The baby should be labeled immediately after delivery in order to avoid any interchange.
• The mother and the relatives are kept informed from time to time about the progress and
complications if any. Drugs given the duration and progress of labor and details of any
perineal repair should be entered in the mother's notes.
• The baby's condition the apgar score und any abnormalities noted in the baby after birth are
duly entered.

THIRD STAGE OF LABOR:-

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DEFINITION:
The period from delivery of the baby to the expulsion of the placenta is designated as the third
stage of labor. The limit of the normal duration of the third stage, is half an hour, both in the pri-
miparous as well as the multiparous patients.

PHYSIOLOGY:

• The uterus becomes smaller in size because of retraction of the uterine muscle fibers after
the delivery of the baby.
• The surface area of the uterus over which the placenta was attached, shrinks and becomes
much smaller, there occurs a shearing-off of the placenta from the uterine wall at the pla-
cental- decidual interface
• Uterine contraction is vital to separation of tbc placenta.
• After the delivery of the placenta the uterine contractions lead to squeezing of the blood
vessels. Thereby stopping the bleeding from the placental bed.
• Uterine contractions are. thus vital for hemostasis in the third stage as well. Recognition of
the signs of placental separation is important for the proper management of the third stage
of labor.

SIGNS OF SEPRATION OF THE PLACENTA:

These are as follows:
 A sudden gush of fresh blood:
While the placenta is separating. there is some amount of blood collected and trapped be-
tween it and the uterine wall. With the separation of placenta this blood finds an outlet and
presents as a sudden gush.
 The uterus feels hard like a cricket ball:
Uterine contractions are judged by the feels of the uterus. As mentioned previously, firm uter-
ine contraction is essential for placenta separation.
 Fundus of the uterus ascends the abdomen:
After the placenta separation, the placenta occupies the lower uterine segment, allowing the
uterus to sit over it. The height of the fundus, thus, is higher than before.

Lengthening of cord:Apparent lengthening of the cord:

 After the delivery of the baby, the cord is usually clamped near the introitus. As the placenta
separates and descends into the lower uterine segment, there is apparent lengthening of the
[Link] attempt at the delivery of the placenta should be made only after the signs of pla-
cental separation have appeared. All the signs may not be present in the same patient. Mis-
management of the third stage of labor is the most common preventable cause of postpartum
[Link] head then is directed anteriorly toward the sub pubic arch to deliver the pos-
terior shoulder, and the rest of the baby.
Note: There is difficulty delivering the shoulders, suspect shoulder dystocia.

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• The baby should be received in a sterile towel.

• The time should be accurately recorded.
• The baby should immediately be wiped to dry it and kept covered. It should never be left
wet or exposed, which makes it cold.
• Unless Contraindicated the baby is shown to the mother and can be handed over to her for
the beginning of breastfeeding
Records:

• The midwife is responsible for the maintenance of accurate records.

• The time of delivery should be accurately noted.
• The baby should be labeled immediately after delivery in order to avoid any interchange.
• The mother and the relatives are kept informed from time to time about the progress and
complications if any. Drugs given the duration and progress of labor and details of any
perineal repair should be entered in the mother's notes.
• The baby's condition the apgal score und any abnormalities noted in the baby after birth are
duly entered.

THIRD STAGE OF LABOR:-

DEFINITION:
The period from delivery of the baby to the expulsion of the placenta is designated as the third
stage of labor. The limit of the normal duration of the third stage, is half an hour, both in the pri-
miparous as well as the multiparous patients.

PHYSIOLOGY:

• The uterus becomes smaller in size because of retraction of the uterine muscle fibers after
the delivery of the baby.
• The surface area of the uterus over which the placenta was attached, shrinks and becomes
much smaller, there occurs a shearing-off of the placenta from the uterine wall at the pla-
cental- decidual interface
• Uterine contraction is vital to separation of tbc placenta.
• After the delivery of the placenta the uterine contractions lead to squeezing of the blood
vessels. Thereby stopping the bleeding from the placental bed.
• Uterine contractions are. thus vital for hemostasis in the third stage as well. Recognition of
the signs of placental separation is important for the proper management of the third stage
of labor.

SIGNS OF SEPRATION OF THE PLACENTA:

These are as follows

 A sudden gush of fresh blood:

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While the placenta is separating. there is some amount of blood collected and trapped between it
and the uterine. wall. With the separation of placenta this blood finds an outlet and presents as a
sudden gush.
 The uterus feels hard like a cricket ball:
Uterine contractions are judged by the feels of the uterus. As mentioned previously, firm uterine
contraction is essential for placenta separation.
 Fundus of the uterus ascends the abdomen:
After the placenta separation, the placenta occupies the lower uterine segment, allowing the uter-
us to sit over it. The height of the fundus, thus, is higher than before.

LENGTHENING OF CORD:
Apparent lengthening of the cord: after the delivery of the baby, the cord is usually clamped near
the introitus. As the placenta separates and descends into the lower uterine segment, there is apparent
lengthening of the [Link] attempt at the delivery of the placenta should be made only after the
signs of placental separation have appeared. All the signs may not be present in the same patient.
Mismanagement of the third stage of labor is the most common preventable cause of postpartum
hemorrhage.
ACTIVE MANAGEMENT OF THIRD STAGE:
Active management of the third stage (active delivery of the placenta) helps prevent postpartum
hemorrhage.
Active management of the third stage of Labour includes :
• immediate oxytocin
• Controlled cord traction
• Uterine massage
OXYTOCIN:
• Within 1 minute of delivery of the baby. palpate the abdomen to rule out the presence of an addi-
tional baby and give oxytocin 10 unit IM
• Oxytocin is preferred because it is effective 2 to3 minutes after injection has normal side effect
and can be used in all women if oxytocin is not available give ergometrine 0.2mg IM Prosta-
glandins .Make sure there is no additional baby(s) before giving these medications.
• Do not give ergometrine to women with pre-eclampsią, eclampsa or ,high blood pressure be-
cause it increases the risk of convulsions and cerebrovascular accident.
• The procedure is recommended for mothers in whom the risk, of postparturn hemorrhage is par-
ticularly high. These include cases of prolonged labor uterine inertia, uterine over distention due
to hydramnios or a big baby, anemic in other, history postpartum hemorrhage in previous labor
and in grand multipara. Active management of the third stage are reduce the chances of postpar-
tum
hemorhage in this high risk group, and helps to prevent maternal morbidity and mortality.

CONTROLLED CORD TRACTION:

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• Clamp he cord close to the perineum using sponge forceps. Hold the clamped cord and end of
forceps with one hand Place the other hand just above the woman's pubic bone and stabilize the
uterus by applying counter traction during controlled cord traction .this helps prevent inversion
of the uterus .
• Keep slight tension on the cord and await a strong uterine contraction (2-3 min)
• When the uterus becomes rounded or the cord length ends, very gently pull downward on the
cord to deliver the placenta. Do not wait for a gush of blood before applying traction or cord.
continue to apply counter traction to the uterus with the other hand
• if the placenta does not descend during 30-40 seconds of controlled cord transection (i.e. there
are no signs of placental separation), do not continue to pull on the cord:
• Gently hold the cord and wait until the uterus is well contracted again. If necessary, use a sponge
forceps to clamp the cord closer to the perineum as it lengthens;
• With the next contraction ,repeat controlled cord traction with counter traction
• Never apply cord traction (pull) without applying counter traction (push) above the pubic bone
with the other hand.
• As the placenta delivers, the thin membranes can tear off. Hold the placenta in two hands and
gently urn it until the membranes are twisted.
• Slowly pull to complete the delivery.
• If membranes tear, gently examine the upper vagina and. cervix wearing high-level disinfected
gloves and use a sponge forceps to remove any pieces of membrane that are present.
• Look carefully at the placenta to be sure none of it is missing. If a portion of the maternal sur-
face is missing or there are form membranes with vessels, suspect retained placental fragments.
• If uterine inversion occurs, reposition the uterus.
• If the cord is pulled off, manual removal of the placenta may be necessary.

UTERINE MASSAGE:
• Immediately massage the fundus of the uterus through the woman's abdomen until the uterus is
contracted.
• Repeat uterine massage every 15 minutes for the first 2 hours..
• Ensure that the uterus does not become relaxed (so)after you stop uterine massage
• Examination for tears
• Examine the woman carefully and repair any tears to the cervix or vagina or repair episiotomy.
EXAMINATION OF PLACENTA:
 A one-minute examination of the placenta performed in,the delivery room provides information
that may important to the care of. both mother and infant, The findings of this assessment
should be documented' the delivery records.
 During the examination, the size, shape, consistency and, completeness of the placenta should
be determined, and'the presence of accessory. lobes placental [Link], tumors and
nodules should be noted.
 The umbilical cord should be assessed for length, insertion, and number of vessels, thrombo-
ses knots and the presence of Wharton's jelly. The color, luster and odor of the fetal mem-

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brane should be evaluated and the membranes should be examined for the presence of large
(velamentoUs) vessels.
 Tissue may be retained because of abnormal lobatíon of the placenta accreta ,placented incre-
ta placenta percreta
 Numerous common and uncommon finding of the placenta umbilical cord and membrane are
associated with the fetal -development and perinatal morbidity. The placenta should be sub-
mitted for pathologic Evaluation if an abnormality is detected or certain indications are pre-
sent.
FOURTH STAGE:-
The fourth stage is the initial recovery period for the mother:
• The clinician immediately recognizes that from a practical perspective, the risk of complications
continues for some period after delivery of the placenta.
• For this reason, many authorities have advocated a so-called fourth stage of labor, which begins
with the delivery of the placenta' and lasts for an arbitrary period afterward.
• The most commonly chosen duration is 1 hour: however. periods as long as 4 hours have been
suggested.
• This stage is really more about getting back to normal than anything else.
• Mother's blood pressure, temperature and heart rate will stabilized, a little at time during the
hour after the placenta is delivered.
• Contractions will cease. Uterus will harden, doing its job to tighten around the blood vessels that
had supplied the placenta and baby with-nutrients.
• Midwife or doctor will keep an eye on mother, make sure the entire placenta was expelled and
take a look at the umbilical cord
• If she had an episiotomy, this is when she'll get a few uterus
• Gently separate the labia and inspect the lower vagina and perineum for lacerations that may
need to be repaired t0 prevent further blood loss (Figure 14):
• Repair lacerations or episiotomy.
• Gently cleans the vulva. perineum, buttocks, and back with warm water and a clean compress.
• Apply a clean pad or cloth to the vulva.
• Evaluate blood loss.
• Explain all examination findings to the woman and. if she desires, her family.

CARE DURING FOURTH STAGE:

• Mother should be monitor closely for first six post partum.
• Check vital signs and firmness of uterus.
Frequency every 15minutes( first 2 hours) Every 30 min(, for 1 hour) and every hour (for
3hours)
• lf Episiotomy is done repair it & check for any haematoma, bleeding or pain.
• Clean perineal area and apply sterile sanitary pad.
• to Make mother comfortable.
• Clean her properly or send her to the bathroom to have Warm shower that will relax her.

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• Offer her hot tea to drink or Juice to regain her energy.

• Initiate breast feeding as early as possible. (within ½ hour of delivery if mother is settle)
COMPLICATIONS OF ALL THREE STAGES OF LABOR:-
Stage one:
 Prolong labor
 Maternal distress
 Fetal distress
 Eclampsia
 •Mild to sever vaginal bleeding (APH)
 Abruption
 Placenta Previa
Stage two:
• Prolong labor
• Prolapsed of cord
• Laceration or tears of perineum
• Bleeding p/v
STAGE THREE:
• Retained placenta
• PPH
• Shock
• Uterine Prolapse

UNIT NO:-7.
NEW BORN BABY
IMMIDIATE CARE OF THE NEWBORN:

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Immediately after a baby is born, the doctor or nurse gently clears mucus and other material from the
mouth, nose, and throat with a suction bulb. The newborn is then able to take a breath .Two clamps
are placed on the newborns umbilical cord, side by side, and the umbilical cord is then cut between
the lamps. The newborn is dried and laid carefully on a sterile warm blanket or on the mother's ab-
domen.

DIAGRAM:

 Soon after a baby is born, two çłamps are placed on the umbilical cord, and the cord is cut
between the clamps. The stump should be' kept clean and dry. Some doctors recommend ap-
plying an alcohol solution (chlorhexadine) to the stump daily. The stump falls off on its own
in a week or two
 The newborn is, the weighed and measured. Examines the newborn for any obvious
 abnormalities or'signs of distress; a full physical examination comes later. The newborn over-
all condition is recorded at 1 minute and al 5 minutes after birth using the Angar score. A low
Apgar score is a sign that the newborn is having difficulty and may need extra assistance with
breathing or blood circulation However, contrary to what people may think, babies with low
Apgar scores are not nor likely to develop certain in problems, Such as cerebral palsy or per-
manent disabilities.

Keeping the newborn warm is critical

 As soon as possible. the newborn is Wrapped in lightweight clothing (swaddled), and the
head is covered to reduce the loss of body heat. A few drops of an antibiotic are placed into

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the eyes to prevent infection from any harmful organism that the newborn may have had con-
tact with during delivery.
 The mother, father, and newborn usually recover together in the delivery room. If the deliv-
ery is in a birth center, the mother, father, and newborn remain together in the same room. If
the mother is breastfeeding, she pus the infant to her breast within the first 30 minutes. Once;
 transported to the nursery, the newborn is placed on his side in a small crib and kept warm.
 Placing the baby on his side prevents fluid or mucus from blocking the airway and impeding
breathing Because all babies are born with low levels of vitamin K. administer an injection of
Vitamin K to prevent bleeding (hemorrhage disease of the newborn).
 About 6 hours or more after birth, the newborn is bathed. The midwife tries not to wash off
the whitish greasy material (vernix caseosa) that covers- most of the newborn's skin, because
this material helps protect against infection.

Avoid Separating mother from baby whenever possible. Do not. leave

unattended at any time.

ASSESSMENTS FOR NEWBORN BABIES:

 Check the baby's breathing and colour every 5 [Link] the baby becomes cyanotic (bluish) or
is hawing difficulty breathing (less than 30 or more than 60 breaths per minute). give oxygen
by; nasal catheter or prongs.
 Check warmth by feeling the baby's feet every 15 minutes:
 If baby's feet feel cold, check axillary temperature:
 If the baby's temperature is below 36.5°C, rewarm the baby
 Check the cord for bleeding every 15 minutes. If the cord' is bleeding, retio cord more tightly.
 Apply antimicrobial drops (1% silver nitrate solution) or ointment (1% tetracycline ointment )to
the baby's eyes,
 Note: Povidone-iodine should. not be confused with tincture of iodine, which could cause
blindness if used
 Wipe off any meconium or blood from skin.
 Encourage breastfeeding when the baby appear steady (begins "rooting"). Do not force the baby
to the breast.
 Each newborn baby is carefully checking at birth for signs of problems or complica-
tions. A complete physical assessment will be performed that includes every body sys-
tem.
 Through out the hospital Stay,physicians, nurses, and other healthcare providers
 Continually assess a baby for changes in health and for signs of problems or illness
Assessment may include
APGAR SCORING:
 The Apgar score , one of the first checks of new baby's health

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 The Apgar score is assigned in the first few minutes s after birth to help identify babies that
have difficulty breathing or have a problem, the needs further care.
 The baby is checked at one minute and five minutes after birth for health and Respiratory
rates, muscle tone, reflexes, and colour.
 A total score of ten means a baby is in the best possible condition.
 Nearly all babies score between eight and ten, with one or two points taken off for blue
hands and feet because of immature circulation. If a baby has a difficult line during delivery,
this can lower the oxygen levels in the blood, which can lower the Apgar score. Apgar scores
of three or less often mean a
Sign score=0 score=1 score=2
Heart Rate absent below100/min above 100/min
Respiratory Effort absent weak,irregular,or gasping good, crying
Muscle Tone flaccid some flexion of arms and legs .we flexed…
Reflex/irritability no response grimace/weak cry good cry
Color blue all over,or pale body pink,hands/feet blue pink all over
BIRTH WEIGHT AND MEASUREMENTS:
A baby's birth weight is an important indicator health. The average weight for term babies
(born between 37 and 41 weeks gestation) is about 7 Ibs. (3.2 kg).
• In general, small babies and very large babies are at greater risk for problems.
• Newborn babies may lose as much as 10 percent of their birth weight.
• Babies are weighed daily in the nursery to assess growth. fluid. and nutrition needs.
• New born babies may lose as much as 10 percent of their birth weight
• Premature and sick babies may not begin to gain weight right away.
This means that a baby weighing 7 pounds 3 ounces at birth might lose as much as 10
MEASUREMENT:
Other is measurements are also taken of each baby. These include the following:
• Head circumference (the distance around the baby's head) - is normally about one-half the baby's
body length plus 10 cm
• Abdominal circumference - the distance around the abdomen length- the measurement from
crown of head to the heel.
PHYSICAL EXAMINATION
A complete physical examination is an important part of newborn care. Each body system is careful-
ly examined for signs of health and normal function.

PHYSICAL EXAMINATION OF A NEWBORN OFTEN INCLUDES THE

ASSESSMENT OF THE FOLLOWING:
VITAL SIGNS:

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• Temperature able to maintain stable body temperature 98.6° F (37° C) in normal room envi-
ronment
• pulse-normally 120 to 160 beats per minute
• breathing rate - normally 30 to 60 breaths per minute
GENERAL APPEARANCE:
Physical activity, tone. posture, appearance and level of consciousness
SKIN:
• Colour,, nails, presence of rashes, skin textures (i.e sticky, smooth, peeling).
• Lanugos.(the soft downy hair on a baby's body) - is absent in immature babies then appears with
maturity. and then disappears again with post MATURITY .
• Plantar creases - these creases on the soles of the feet range from absent to covering the entire
foot, depending on the maturity.
• Breast - the thickness and size of breast tissue and are areola (the darkened ring around each
nipple) are assessed.
• Eyes and cause - eyes fused or open and amount of cartilage age is less of the care tissue.
• Genitals. male - presence of testes and appearance of scrotum, from smooth to wrinkled.
• Genitals, female - appearance and size of the clitoris and the labia.
HEAD AND NECK:
• Appearance, shape. presence of folding (shaping of the head from passage through the birth ca-
nal)
• Fontanels the open "soft spots" between' the bones of the baby's skull)
• Clavicles (bones across the upper chest
• Face - eyes, ears, nose, cheeks
• Mouth - palate, tongue, throat,
• Lungs -breath sounds, breathing pattern
• Heart sounds and female of in the groin) pulses
• Abdomen - presence of masses or hemias
• Genitals and ants for open passage of urine and stool
• Arms and legs movement and development
GESTATIONAL ASSESSMENT:
 Assessing a baby's, physical maturity is an important part of care.
 Maturity assessment is helpful in meeting a baby's needs if the dates of a pregnancy are un-
certain. For example, a very small baby may actually be more mature than it appears by size,
and may need different care than a premature baby.
 Examination evaluates a baby's appearance, skin texture, motor function, and reflexes. The
physical maturity part of the examination is done in the first two hours of birth. The neuro-
muscular maturity examination is completed within 24 hours after delivery. Information often
used to help estimate babies' physical and neuromuscular maturity is shown below.
NEUROMUSCULAR MATURITY:
I. Six evaluations of the baby's neuromuscular system are performed. These include:
2. Posture how does the baby hold his/her arms and legs.

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3. Square window- how far the baby's hands can be flexed toward the wrist.
4. Arm recoil how far the baby's ams "spring back" to a flexed position.
5. Popliteal angle - how far the baby's knees extend.
6. Scarf sign how far the elbows can be moved across the baby's chest.
7. Heel to ear - how close the baby's feet can be moved to the ears.
 A score is assigned to each assessment area. Typically, the more neurologically mature the
baby the higher the score.
 When the physical assessment score and the neuromuscular score are added together. The
gestational age can be estimated. Scores range from very low for immature babies (less than
26 to 28 weeks) to very high scores for mature and post mature babies.
 After immediate care at birth Continue skin-to-skin care and monitor breathing. To keep ba-
bies warm and identify problems early
AFTER CARE OF NEWBORN:
 Mother has just experience a momentous event but here pleasant emotions are mixed with
sense of anxiety about how to look after her baby, The up is aimed at helping mother in
providing scientifically appropriate care to her newborn baby. Newborn need special care &
attention, her ignorance, false beliefs & harmful social rituals can harm her baby. Learn more
about feeding, clothes, bathing, vaccination, and usual complains like vomiting, colic, jaun-
dice, loose motions. early signs of serious diseases and move..
 Newborn needs special care attention. Ignorance, false beliefs & harmful social ritual can
harm baby.
CARE OF CORD:
 Cord usually falls asytime between $-10 days. It should be cleaned with spirit or betadine af-
ter thoroughly washing your hands. Don't apply anything else on it.
CLOTHS:
 Baby should be carefully covered. A vest, a full sleeve frock, a napkin and a cap is required
even in summer : In winters, 2 or 3 additional layers of woolens clothes are necessary &
should be wrapped in woolen blankets. The baby clothes should be of cotton or wool & avoid
synthetic stuff.
 Small babies (weight less than 2.5 kg.) need special care as they are prone to become sick in
cold environment. Room for them must be kept warm with room heaters. Use of fan should
be avoided even in summers.
 The temperature of room is rather warm which is about uncomfortable to the adults. Baby
should wear extra woolens Special attention should be paid to cover head, feet & hands. Keep
the baby next to mother. If soles & palms are cold to touch or arm blue, the baby is either
cold or sick.
BATHING THE BABY:
 There is no need to bath the baby on first day. Both is given on 2nd or 3rd day, Bathing the
baby on first day may suddenly decrease the temperature of baby. Bathing should be done
with warm water, in a, warm room, & during afternoon. Any simple non-medicated glycerine

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soap can be used. Don't use any costly soap. Eyes should be cleaned with wet cotton. Dry the
cord and apply spirit or betadine.
 It can be done with ghee or coconut oil. Don't use perfumed oil. Massaging is usually not
necessary.
 Keep a serial weight record daily weight gain
 Is the only indication of health of baby. Baby gain 30-40 gm. per day during first 3 months
10-20 gm per day (during 3 month to 1 hr.). During first 3 day approximately 200 300 gm
weight is lost by must babies This loss is gained back by 10th day.
VACCINATION RECORD:
 BCG and oral polio (OPV) is given at birth or within 1 month of age,
 First pantavalent & polio .pneumocooccal is given at 1 1 /2-2 months (6 weeks after birth) &
then every monthly for3 doses. With 3 does IPV is given.
 With 1 and 2nd does of pentavalent Rota vaccine is also given
 Measles is dose is given at 9 in months. 2 dose in second year of life
 MMR at 15-18 months & pantavalent + polio booster at 16-24 months.
COMPLEMENTRY FEEDING:
 When breast milk is no longer enough to meet the nutritional needs of the infant, complemen-
tary foods should be added ta the diet of the child.
 The transition from exclusive breastfeeding lo family foods, referred to as complementary
feeding. typically covers the period from 6 to 18-24 months of age, and is a very vulnerable
period.
 It is the time which malnutrition starts in many infants. contributing significantly to the high
prevalence of malnutrition in children under five years of age world wide WHO estimates
that 2 out of 5 children are stunted in low-income countries
INITIATE COMPLEMENTARY FEEDING FROM 6 MONTHS ON WARD
• Initially offer small amount
• Continue breast feeding
• Increase quantity as baby grows
• Avoid food that causes choking
• Complementary feeding should be timely, meaning that all infants should start receiving foods
in addition to breast milk from 6 months onwards.
• It should be adequate, meaning that the complementary foods should be given. in amounts, fre-
quency, and consistency and using a variety of foods to cover the nutritional needs of the grow-
ing child while maintaining breast feeding.
• Foods should be prepared and given in a safe manner, meaning that measures are taken to mini-
mize the risk. of contamination with pathogens. And they should be given in a way it is appro-
priate, meaning that foods are of appropriate texture for the age of the child and applying re-
sponsive feeding following the principles of psycho-social care.
• Feeding young infants requires active care and stimulation, where the [Link] responsive the
child clues for hunger and also encourages the child to eat. This is also referred to as active or
responsive feeding.

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WHO recommends that infants start receiving complementary foods at 6 months of age in ad-
dition to breast milk .
 Initially 2-3 times a day between 6-8 months,
 increasing to 3-4 times daily between 9-11 months and
 12-24 months with additional nutritious snacks offers 1-2 times per day, as desired.
 COMMON PROBLEMS IN NEWBORN:
CONSTIPATION:
 Constipation is defined as the passage of hard, ball-like stools that cause. pain or bleeding
(groaning or Straining is normal) and not so much by how often baby has a bowel movement.
 After the baby is born. he will pass meconium for a few days. which is a dark green or black
substance. Regular bowel movements, which begin being lighter than meconium, usually
start by about the third day of life, At this time. bowel movements also become more fre-
quent, especially for breast feeding mothers. If baby isn't having regular bowel: movements
by the fourth or fifth day of life, or if he is still passing meconium, then that may be a sign
that he isn't getting enough 10 eat.
 Keep in mind that some breast fed babies only have one bowel movement each week or two
after they are 3-4. weeks old. Breastfeed babies are very rarely, constipated if mother is ex-
clusively breastfeeding.
 Constipation in a newborn can be a sign that baby isn't getting enough to eat if new baby is
not having frequent bowel movements. and if it is associated with abdominal distension,
vomiting then doctor should be consult

EYE PROBLEMS:
 Eye problems in newborns can include matting, or a green discharge, which is usually caused
by irritation from the eye ointment that was placed after he was born or by a blocked tear
duct.
 Lt can also be caused by an infection (conjunctivitis), especially 'if the white part of the eye is
red and mother should notify the doctor if the mother had sexually transmitted disease (such
as gonorrhoea or Chlamydia) or if the discharge does not quick clear up.
WATERY EYES:
This is usually caused by a blocked treatment and is not a concern unless the eyes become In-
fected It usually clears up on its own before baby is 12 months old.
SUBCONJUNCTIVAL HEMORRIIAGES:
Occur because of pressure during the birth process it causes a red streaking of the white part
of the eye and it will go away a few weeks.
STUFFY NOSE/SNEEZING:
Having a, stuffy pose or occasionally sneezing is very common in newborns and is usually caused by
irritation from dry air, smoke, or dust. Try to eliminate common irritants. Mother can also try using
humidifier or salt water nose drops as treatment.
THRUSH:

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Thrush is a very mild infection that causes white patches to coat the inside of the checks and tongue
of baby. These patches cannot be easily wiped off and do not come off in-between feedings (like
formula might). It is caused by a yeast infection and is easily cleared up with a prescription medicine
called Nystatin. Thrush does not usually cause any discomfort and baby should continue to feed
normally, even without treatment.
RASHES:
Very common in newborns and includes neonatal acne, drooling rashes, Nappy rashes and flaky skin
that will usually clear up on their own without treatment.
DIAPER RASHES:
Very common and usually clear up in 3-4 days with a diaper rash cream. If it is not clearing up or is
bright red and surrounded by red dots, baby may have a yeast infection and will, need to antifungal
cream to help clear it up. Diaper rashes can be prevented by frequent diaper, changes Increasing air
exposure by keeping the diaper off as much as possible, and using a mild soap only after bowel
movements (rinse with just warm water at other times).
DRY SKIN:
Use a mild soap and a moisturizer once or twice a day.
SPITTING UP:
Many babies spit up (reflux) after cating due to over feeding or Because the valve that closes the up-
per part of the stomach is immature. It is usually not a concern as long as baby is gaining weight and
it is not causing him to cough or choke. Some steps to take to improve this problem are feeding
smaller amounts, more frequent burping during feeds, avoiding pressure on his belly or vigorous ac-
tivity after eating. It improves with age usually without treatment.
BREAST ENGORGEMENT:
It happens in 1" week & it spontaneously disappears in a few days. Avoid local message and fo men-
tation. Never try to express milk
VAGINAL BLEEDING:
It may occur in some females' in 1 week. It goes off its own in few weeks without any
treatment.

FEVER:
Rectal temperature above 100:4 iņ a newborn infant less than two to three months old is considered a
fever and a medical emergency and you should call your doctor immediately.
JAUNDICE: (refer to neonatal jaundice)
EXCESSIVE CRYING:
Cry due to hunger, is understood by most parents. If baby who is not consolable despite putting on
breast is having other problems like, colic. wet napkins, mosquito bites, allergic rash. Nose block,
hard stools, napkin rash or it is cry for attention & cuddling at night, Put the baby on tummy for colic
& put saline nasal drops for blocked nose. If baby continues to cry inconsolably consult your doctor
immediately.
CAUSES OF CRYING:

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If you are breastfeeding and your baby seems to always cry after you eat or drink certain foods, then
it would be reasonable to try and stay away from those foods. A one to two week trial off of dairy
products and/or caffeine in may also help
There are medical problems that can cause. Crying in newbornsbut in general. Infants with these
problems usually cry throughout the day.
If crying always seems to occur during feedings or right after a feeding and your child is spitting up
lot, then he may have reflux esophagitis.
A FORMTULA OR MILK ALLERGY:
May be suspected if the crying always occurs 30-60 minutes after a feeding and your child also has
vomiting and diarrhea and does not seem ta be gaining weight well. In this case a 1-2 weeks trial of'
a soy formula or an elemental formula (such as Nutramagen) can be used.
SOME THINGS THAT YOU MAY TRY TO COMFORT THE BABY INCLUDE:
• cuddling
• Rhythmic rocking
• going for a walk or ride,
• warm baths
• singing
• rhythmic sounds
• Massages
• Using a pacifier, windup swing or vibrating chair.
• Reassure mother and other family members that this is a benign problem that always clears up
on its own without any long time effects.
 None of these measures work or ail children, but one can try one or two at a time until
find what works for baby.
 If nothing work it is okay to just put baby down and let him cry for short periods. And
as a last resort try to take a break by having a family member or friend help care for
baby.

UPPER RESPIRATORY INFECTIONS:

These are very common and include symptoms of a clear or green runny nose and cough and are
usually caused by cold viruses. The best treatment is lo use salt water nasal drops and a bulb Suc-
tioner to keep their nose clear. You can also use an over the counter decongestant, such as Pediacare
Infant Drops Call Pediatrician if child has high fever, difficulty breathing or is not improving in 7-10
days
 COLIC:

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Colic is a common problem, affecting 10-25% of all newborns. It is defined as recurrent inconsolable
crying in a healthy and well-fed infant. It usually begins at about two to three weeks of age, is at its
worst at six weeks of age and then gradually improves and finally resolves on its own by three to
four month.
Most babies with colic have one or two episodes of this type of crying each day. In between these
episodes they usually act fine.
CAUSES OF COLIC:
It is not known what causes colic, but it is not usually thought to be, from abdominal pain. formula
allergies, and the iron in infant formula or gas. It is known normal babies have a fussy period toward
the end of the day that begins when they are two to three weeks old and that this may be their way of
blowing off steam' or dealing with the normal stimulates of their day. It may be that babies with col-
ic are more sensitive to this normal day stimulation. It is also known that babies with colic do not
have more difficult temperature and are not more hypersensitive as they grow older.
MANAGING COLIC:
Unless baby has reflux or a formula allergy, there are no medicines to make colic go away some tips
to help deal with colic until it clears up on Own include:
IMPORTANT REMINDERS:
 Be patient. This is a frustrating problem without good treatment options, but it always im-
proves as your child gets older.
 It can be frustrating taking care of a crying baby, so mother can get help if having trouble
coping with infant's crying: Remember that one should never shake baby, which can cause
shake baby syndrome.
 Avoid frequent changes of babies formula, unless instructed to do so and do not use a low
iron formulae
Call the doctor if child has a rectal temperature over 100.4. has persistent vomiting, if she does not
seem to be gaining weight, or if the crying is not improving or does not go away by the time she is 3-
4 months old.
HICCUPS AND SNEEZING:
These arc common and normal.
STOOL AND URINE NOT PASSED ON DAY 1:
Don't panic, it is normal for first urine to take 48 hours & first stool to take 24 hours to be passed.
BREAST FEEDING:
 Breast feeding is a special gift from a mother to her baby. It not only provides a natural op-
portunity for bonding but also supports the growth and development of the new born.
 Many newborn live are saved because breast milk provides important nutrients and protection
against illnesses and infections.
 If every baby were exclusively breast feed from birth about 1.5 million lives would be save
each year.
ADVANTAGES OF BREAST FEEDENG
FOR BABIES:
It is the best. food for the mental and physical development of the baby.

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It protects the baby from:

• Diarrhoea.
• Coughs and colds.
• Respiratory infections.
• Ear infections.
• Sudden infant death.
LT DEVELOPS CLOSE BONDING BETWEEN MOTHER AND CHILD.
BREAST WILL NOT GET
• A sore bottom
• stomach ache
• constipation
• Too fat
IT DEVELOP BETTER
• jaws
• speech
• Teeth
Breast milk contains fats of the right kind needed for the growth of the baby's brain
FOR THE MOTHER:
Breast feeding helps get:
• Weight back to normal after delivery.
• Womb back to normal after delivery.
Breast feeding gives:
• Pride and satisfaction to the mother.
• Breast feeding does not put extra burden on once budget as it does not cost money.
Breast feeding means a mother can feed her baby:
• Anytime
• Anywhere
• Without any preparation.
• Breast feeding mother develops a loving relationship with her baby,
Breast feeding delays pregnancy, if life baby is fed every 2-3 hours ,morning and evenings.
Remember - almost all mothers can breast feed - only 1 of 2 in every 100 may have problems.
PREPARATION OF BREAST DUIRING PREGNANCY
• The nipple may be massaged 3 or 4 times during the last 2 months of pregnancy.
• Olive oil or any other oil can serve the purpose.
• Wash: or sponge the breast or nipple to prevent crust formation.
• Proper support by a well, fitted brassiere helps the mother to maintain her figure.
BREAST CARE URINGLACTATION:
CLOTHING
SOME DOS
 Wear well fitted brassiere preferably open in front.
 Select well fitting dress opening, in front.

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 Place a clear folded handkerchief or cotton pads in the brassiere to protect against leaking of
breast-milk.
SOME DON'T:
 Padded nylon brassieres should not be used as they prevent nipple drying.
 The mother's clothing should not be too tight over the breast to make her uncomfortable
HYGIENE:
 The breast should be washed once a day preferably while taking a shower.
 Let the breast air dry naturally after breast-feeding.
 Always wash your hands before taking care of the baby.
SUCKING REFLEXES N THE BABY:
THE ROOTING REFLEX:
The baby finds the mother's nipple with this reflex. When anything touches the baby's checks or side
of mouth, a hungry baby turns his/her bead towards the touch.
THE SUCKING REFLEX:
When anything goes into the baby's mouth far enough; he/she sucks it.
THE SWALLOWING REFLEX:
1f the baby's mouth fills with milk he/she swallows it naturally.
HOW DOES A BABY SUCK?
ACT OF SUCKING BY THE BABY:
• Stretching the nipple and are areola to form a teat
• Pressing the stretched are areola with jaws and tongue against the palatę, to press the milk out of
the lactiferous sinus beneath the areola
HOW TO PUT THE BABY ON THE BREAST CORRECTLY?
i. The mother should sit somewhere comfortably. A low seat is usually the breast.
ii. The baby should be held properly so that he/she faces the breast and baby's stomach is against
the mother's body.
iii. Do not just turn the baby's head. The baby on thee whole should face the breast.
iv. Hold the baby at the back of his/her shoulder not at the back of his/her head
v. The mother should first touch the șide of his/her check or mouth to stimulate the Rootig reflex.
vi. The mother should wait until Lịe baby opens his/her mouth to feed:
vii. The mother should offer her nipple with the areola to the baby and not just the nipple.
POSITIONING THE BABY:
Usually the position are adopted by the mother while nursing the baby.
MADONNA ERADLE E HOLD:
• When the mother nurses the baby held in front of her.
• IF the mother wants to breast feed from the right breast; the baby's head lies in the crook of her
right arm.
• Her right hand supports the buttocks of her baby.
• With her left hand she presses the breast around he areola to aid in expression of milk.
DIAGRAM:

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FOOT BALL HOLD:

• The mother rests her arm and elbow towards her back on a pillow by her side
• She rests the baby on her arm
• The baby's head is supported by her hand.
• The baby's buttocks are supported by the crook of the mother's arm and the mother's hip.
• The breast is held by the opposite hand to help express milk for the baby and to allow the baby
to suck at a comfortable angle.
SIDE BY SIDE:
• This position is useful when the mother want to feed the baby in a lying down position:
• The baby is fed from the side facing the mother
• The mother then holds the breast on the side facing the baby with the opposite hand directing the
nipple and are areola towards the infant mouth.
• Any method ,which the mother a baby find comfortable, is recommended.

COMPARISON BETWEEN GOOD POSITION AND BAD POSITION OF BREAST FEED-

IND

SIGNS OF GOOD POSITION: SIGN OF BAD POSITION:

a)The baby,s whole body is close to the a a)The baby,s body may be too far away
mother from the mother
b)The baby,s mouth and chin are close to b)The baby,s mouth and chin are separat-
the breast ed from the breast
c)The baby,s mouth is wide open with the c)One sees the areola, especially below
areola in baby mouth the lower lip
d)The baby can now easily take small d)The baby takes many quick small sucks
deep sucks as the baby is not satisfied with milk flow

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e)The baby is relaxed and happy e)The baby fusses or refuses to suck as
he/she does not get enough milk flow
f) The mother doses not feel nipple pain f) The mother may feel pain in the nipple
when the baby sucks correctly because of bad sucking position

WHEN SHOULD THE FIRST FEED BE GIVEN TO THE BABY ?

breast feeding should be started as soon as possible after delivery preferably at the delivery table or
within 1-2 hours of birth
ADVANTAGES:
• The baby gets valuable colostrum or first watery milk.
• Baby adapts more easily to breast feeding
• It develops a strong bond of love and affection between the mother and the child from the begin-
ning
• The newborn must room in with his /her mother to promote breast feeding and enhance mother -
child bonding
WHAT IS COLOSTRUM AND HOW IS IT BENEFICIAL?
• Colostrum is the first watery bright yellowish milk of the mother. It should be given to the baby
because :
• It is very high in protein
• It contains natural minute bodies (antibodies) which protect the baby from infection:
• Usually colostrum protects the baby from diarrhoea, T.B. and to some extent from polio and skin
infection.
WHEN TO FEED THE BABY?
Allow the baby to be breast fed whenever he/she wants milk because more often the baby sucks, "
more milk is produced.
The baby will cry when he/she needs to be fed . In the beginning, do not fix a precise time for breast
feeding. Usually, during the first few days the baby is breast fed even every two [Link] on, the
interval increases as baby settles down to his/her required needs.
• If the baby sleeps for more than two hours after the last feed, then wake up the baby if your
breast feel heavy.
HOW LONG TO FEED THE BABY?
 Although the infant obtains 85-90%, of his/her feeding in the first 5-8 minutes of vigorous
sucking, he/she should be allowed to nurse for at least 10-20 minutes at a time.
 Research has shown that slow feeders take the same total amount of milk as fast feeders. If
you stop a slow feeder before he/she is ready, he/she may not take enough milk .he she may
not get the energy that is needed to grow well.
WHICH FOODS HAVE AN EFFECT ON BREAST MILK SECRETION?
 Almost every category of food having nutritional value is a lactogogue, which means food
that helps to produce more milk.
 However, in different regions, culturally some foods are avoided by the mothers after deliv-
ery. which include rice, "dal" eggs, roots. leafy vegetables. brinjals, onions, sour. food. fish,

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meat. mustard'oil, etc. In fact these foods do not pause any problems; rather they are im-
portant for the mother's diet.
WHEN AND HOW TO BURP THE BREAST FED BABY?
Mother should burp the breast fed baby after each feed before laying her in the crib.
METHOD FOR BURPING :
The baby should be held over the shoulder or seated erect in mother's lap or lying face downward
and gentle patted or stroked on the [Link], the air that the baby has swallowed will rise to the
top of his /her stomach and be expelled.
SHOULD A BABY BE FED FROM ONE BREAST OR BOTH?
Start nursing the baby on the first breast and after the most vigorous sucking has finished, switch the
baby to the second breast for the last minutes of feeding. Then at your next nursing session, start the
baby on the second breast; let the baby again nurse vigorously and finish on the first! breast.
ADVANTAGES:
 Both the breasts are stimulated so as to produce milk twice as often:
 The baby gets access to ‘twice as much milk;
 The baby's sucking needs may be satisfied without the risk. of nipple injury;
 Many mothers have a "favorite' side. However, if the baby sucks more from one side than the
Other the 'neglected' breast may stop producing milk.
CONSEQUENCES OF SUCKING THE TIP OF THE NIPPLE
When a baby sucks only the tip of the nipple:
 The baby fails to express the milk because he/she does not press on the lactiferous sinus;
 The mother feels pain and the nipple skin may be damaged;
 The baby fails to stimulate the nipple enough to trigger the two necessary hormones of the brain:
 The baby is frustrated and fusses, and refuses to be breast fed
 The mother thinks that the baby is unsatisfied as she does not have enough milk.

BREAST FEEDING AND BOWEL PATTERN:

A breast fed baby may have either of the two types of bowel pattern.
It is common for a breast fed baby not to pass stool for few days. This should not alarm you because
it is not constipation.
It is a sign that breast milk is the perfect food. Breast milk is almost completely absorbed. into the
baby's body and therefore, there is very little waste. Breast fed babies usually pass very [Link]
frequent stools. It is uncommon for them to pass hard stools. Many babies may seem to strain while
passing stool. This is also normal and not a sign That the baby is constipated.
WHAT SHOULD BE THE MAXIMUM OR MINIMUM PERIOD OF BREAST FEEDING?
Breast milk should be fed to the baby for as long possible .
Minimum period of breast feeding is at least one year. Although breast milk continues to be im-
portant for growth in the second year life also .
WEARING OFF BREAST FEEDING:

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Stopping breast feeding, should not be sudden. If a mother wants lo stop breast feeding. She should
do it gradually
CAN CONTRACEPTIVE PILLS BE TAKEN WHILE THE BABY IS BREAST FED?
 Some pilIs reduce the amount of breast milk like combination pills of Oestrogen, Progester-
one.
 However, there are pills which do not suppress the milk rather increase it, like Progesterone
pills Which contain Progestron only.
 Injectable conraceptives, e.g. Depoprovera do not decrease the milk supply and so this
method of contraception can be selected during lactation.
 Physical methods like Intra-uterine Devices (1UD), condoms, diaphragms, etc. can be used
safely.
PREGNANCY, LACTATION AND MENSTRUATION:
 Medically, it is quite safe to breast feed the baby during a new pregnancy;
 Mothers should understand that breast feeding during pregnancy is not harmful to either of the
babies for the first few months of pregnancy;
 If she weans the older child, she should do it very gradually. Sudden weaning is harmful and can
make the older child it
 She must take extra care of her diet because now she is feeding for three people.
 Mother's breast can become tender with new pregnancy. The hormonal changes may decreased
the supply of milk.
 Remember it is quite safe to breast feed during menstruation.
HOW CAN A MOTHER KNOW THAT HER INFANT IS HUNGRY?
Usually infant or newborn shows that he ‘she is hungry by any one of the following signs:
• He/she becomes restless
• He/she cries
• He/she moves his/her head in search of food
• He/she makes sucking movements 'which [Link] relief and are likely to end in crying. As well
fed, contented baby usually goes to sleep for several hours after being fed, awakening when he is
he needs food or is uncomfortable
• Usually an infant cries for two reasons
• Hunger.
• Soiled diapers
HOW CAN A MOTHER CONFIRM THAT THE RABY IS TAKING ENOUGH MILK?
With the help of a doctor, LHV/midwife, a mother can find out that her baby is taking enough milk
by the following tests:
. a) THE WETNESS TEST:
The mother should note how often the baby urinates
• The Baby should urinate six or more times a day
• urine should be colourless or pale yellow. If the mother is not giving water or other drinks, then
then this test is fairly confirmatory

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• If the baby cries after urinating six or more times daily then it means there is some other prob-
lem with the baby.
B) THE WEIGHT TEST:
• Weigh the baby and check his/her weight gain on a growth chart
• A healthy baby should gain between half and one kilo per month or a minimum of 125 gms each
HOW TO INCREASE A MOTHER'S MILK SUPPLY?
Babies. sometimes become fussy during growth; spurts when they require more milk. The problem is
not that the mother's supply is decreasing, but she should increase her milk supply.
The mother can be advised as follows:
• Nurse the baby more often, every hour if necessary
• She (mother) should rest more often
• Try to cut back on tiring outside activities
• Eat properly both in quality and quantity. especially if slie (mother) is malnourished:
• Drink plenty of fluids
• The mother should keep the baby near her and handle him her herself as much as possible.
• The mother should Teed the baby during night also;
• The mother should feed the baby longer than before from each breast:
• If the mother knows of a locally valued lactogogue she should take the too
• Sometimes a doctor needs to be consulted if the mothers milk supply is not increasing .
PROBLEMS ENCOUNTERED BY A MOTHER DURIN BREAST FEEDING
FLAT NIPPLE:
Some women have short, fat nipples. Flat apples are most common in first pregnancy. Most nipples
are protractile (you can pull out ) and quite long! In a
non-protractile nipple there will be difficulty in feeding.
TREATMENT:
Flat nipples should have been discovered in ante-natal visit by LHV/midwife on examination of
breasts and proper measures should be advised al that time.
ANTE-NATAL:
During antenatal period .the mother should press her nipples and pull them gently: She should do this
several minutes every day. By this manoeuvre , her nipples will grow longer as il mimics the sucking
of the baby.
WHILE NURSING :
After the baby is born, nipples can be stretched still further. The mother should squeeze the areola
before putting the nipple in the baby's mouth. If the breast is very full, first express some milk before
doing this.

Composition of human milk

S# COMPOSITION HUMAN MILK

1 Calories 67
2 Water 87%

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3 Carbohydrates 7.5%
4 Protein 1.5%
5 Fat 3.5%
6 Lacalbumin:casein ratio 60:40
7 Minerals
Sodium 15mg
Phosphate 15mg
Calcium 30mg
Iron 0.5mg

 DANGER SIGNALS IN NOWBORN:

• Recognize the following early signs of serious disease consult Doctor immediately. -
• Weight less than 2kg or more than 4kg.
• Not gaining weight
• Born before 8 months
• Cried late after birth
• Excessive cry or not crying
• Convulsions ,twitching, eye blinking
• Stiff neck ,body and limbs
• Pus discharge /swelling of cord
• Eye discharge /boils on body
• Feverish or cold baby
• Fast respiration ,loud creaking sound and chest retraction
• Not accepting feed
• Irritable or lethargic
• Pale and jaundiced
• Blue nails, lips or body
• Vomiting & abdomen distension
• Not passed wine within 2 days
• Not passed stool within 1 day
HELPING BABIES BREATHE (HBB)
 HBB can. be used as the resuscitation component in courses teaching Essential Newborn
Care (WHO) and courses in midwifery skills. HBB can be used at all level in the health sys-
tem. It extends resuscitation training to first-level health facilities and health workers in re-
source-limited. settings,where these skills are most lacking.
 It also can be used in high-level health facilities, including tertiary facilities, where it com-
plements; but does not replace, comprehensive resuscitation programs such as the Neonatal
Resuscitation Program (NRP), Both HBB and NRP, teach the same first steps in resuscita-
tion, but NRP also includes the use of supplemental oxygen chest compressions, intubation,
and medications.

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 Helping Babies Breathe® (HBB) aims to help meet Millennium Development Goal 4 target
for reduction of child mortality by addressing one of the most important causes of neonatal
death: intrapartum- related events (birth asphyxia). IHBB is, an evidence -based educational
program which teaches the simple steps that effectively resuscitate the majority of infants
breathing at birth .
 A key concept of HBB is The Golden Minute : Within one minutes of birth , a baby should be
breathing well or should be ventilated with a bag and mask. The Golden Minute, identifies
the steps that a birth attendant must take immediately, after birth to evaluate the baby and
stimulate,breathing.
HBB focuses on the initial steps of resuscitation, including immediate drying of he baby,
providing warmth and additional stimulation to breath. followed by bag and mask ventilation
(BMV) if needed, within the first 60 seconds after birth Golden Minute).
 The initial steps of newborn resuscitation are to maintain normal temperature of the infant,
position the infant in a "sniffing" position the airway. clear secretions if needed with a bulb
syringe or suction catheter, dry the infant (unless preterm and covered in plastic wrap), and
stimulate the infant.
 Approximately I 0% of newborns require some assistance to begin breathing at birth. About
I% require extensive resuscitative measures. Although the vast majority of newly born infant
do not require intervention to male the transition from intrauterine to extrauterine life, be-
cause of the large number of births a sizable number will require some degree of resuscita-
tion.
 Those newly born-infants who do not require resuscitation can generally be identified by a
rapid assessment of the following 4 characteristics:
 Was the baby born after a full-term gestation?
• Is the amniotic fluid clear of meconium and evidence of infection?
• Is the baby breathing or crying"
• Does the baby have good muscle tone?
lf the ,answer to all 4 of these questions is "yes." the baby does not need resuscitation and should not
be separated from the. mother. The baby can be dried, placed directly on the mother's chest, and cov-
ered with dry linen to maintain temperature. Observation of breathing, activity, and colour should be
ongoing.
If the answer to any of these assessment questions is no," there is general agreement that the infant
should receive one or more of the following 4 categories of action in sequence :
Dry thoroughly (If meconium stained amniotic fluid clear the airway)
IF THE BABY IS CRYING:
1. Dry thoroughly- do not routinely clear the airway before drying if meconium is present
2. Keep warm. position Skin to skin and cover head and body.
3. check breathing.
4. Clamp and cut the cord after 1-3 minutes(use clean technique wash hands or change the gloves
Place the bay on mother chest ta encourage breast feeding.
IF BABY IS NOT CRYING

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• Clear the airway if needed and stimulate breathing - suction only

• if secretions block the nose or mouth or if there is meconium in the fluid
• Keep baby warm,
• Position the head-extended the head slightly
• Clear the airway-remove secretion from mouth first then nose.,
• Stimulate breathing -rub the back once or twice
• After clearing the airway and stimulation
• Check if babyish crying well. If baby is still not breathing well cut the cord and
5. Ventilate with bag and mask practice ventilation with chest rise for a full minute
• For ventilation position the head.
• Position the mask on the face
• Make firm seal between mask and face while squeezing the bag to move the chest gently.
• Give [Link]ón breaths per minute
• During ventilation check
6. Is the chest moving or is the baby breathing well -emphasize 2 immediate steps if the chest
does not move with ventilation(reapply the mask, reposition the head)
b. Call for help. improve ventilation-
7. Check for spontaneous breathing before stopping ventilation ;
If baby is crying or breathing well---routine car
If baby is not breathing well Gasping snot breathing at all
Continue ventilation; evaluate heart rate and breathing to decide on advanced care
A baby who has
 Shallow breathing
 Grunting
 Chest in drawing
 Needs close observation and advance care. Transfer the baby with mother to advance care
facility.
 In newly-born babies who continue to have a heart rate below 60/minute and non-
spontaneous breathing after 20 minutes of resuscitation, resuscitation should be stopped.

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DIAGRAM:

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INTEGRATED MANAGEMENT OF NEONATAL CHILDHOOD ILLNESS,

OR IMNCI

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Integrated Management Of Childhood Illness. or IMCI, is a systematic approach to children's

health which focuses on the whole child. This means not only focusing on curative care but also on
prevention of disease. The approach was developed by United Nations Children's Fund and the
World Health Organization in 1995. In Pakistan this initiative was adapted in 1989-2000
Why IMNCI in Pakistan:
• High infant mortality 78/1000 live birth
• High under 5 mortality rate
• Diarrhea
• ARI
• Malnutrition
• Malaria
These Are major cause of deaths e under 5 children
COMMUNITY MNCI (CIMNCI)
The community component of the Integrated Management of Childhood Illness (IMCI) strategy ad-
dresses. family and community child care practices. The family and the community where children
live play a major role in child health and development. There is a long-standing need to involve the
family and community actively and plan and implement child care interventions in both the health
system and the community in parallel.
CIMNCI is presented as a strategy which has three components aiming to:
I. Improve health worker skills:
2.. improve health systems; and
[Link] family and community practices.
IMPROVING HEALTH PROVIDERS' SKILLS:
Improving health providers' skills mostly refer to clinical and communication skills and covers both-
pre-service education and in-service training, public and private sector.
IMPROVING HEALTH SYSTEMS:
 Improving health systems to deliver IMCI concerns policy, planning and management, fi-
nancing, organization of work and distribution of tasks at health facilities, human resources,
availability of drugs, and supplies, referral, monitoring and health information system, super-
vision, evaluation.
 And research. Health sectors reform efforts, although being an Umbrella which covers also
human resources and their capacity, are usually listed under this component.
IMPROVING FAMILY AND COMMUNITY PRACTICES:
Improving family and community practices currently refers to 12 key family and community practic-
es- related to child health and development that , if properly promoted and adopted by the targeted
communities. would potentially contribute to improving child survival, growth and development

IMNC CASE MANAGEMENT PROCESS:

1. Red=Urgent pre-Referral treatment and referral
2. Yellow specific medical treatment and advice
3. Green simple advice on home based management

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IMCI CORE COMPETENCIES

GENERAL
Know how to use the IMCI chart
DANGER SIGNS:
 Know and recognize the general danger signs
 Provide preferable treatment
 Counsel a caretaker about urgent referral
 Provide care where referrals not possible
COMPETENCIES ON MAIN SYMPTOMS:
 Assess and classify for main symptoms: cough or difficult breathing, diarrhoea,
 fever and ear problems
 Provide appropriate pre referral treatment and refer
 Treat with antibiotic and/or antimalarial and other treatments with correct dosage and correct
duration
 Competencies on care of the sick young infant
 Counsel the caretaker of the child on when to return immediately and on follow-up
 Assess young infant from, birth up to two months old for signs of very severe disease or local
infections and treat or refer after pre-referral treatment
 Assess young infant for signs of diarrhea, classify and treat or refer
 Counsel mother about infant feeding Competencies on malnutrition and anemia.
 Check a child for malnutrition and anemia and classify
 Identify the child with severe malnutrition and/or anemia, provide appropriate
 prereferral treatment and counsel caretaker for referral
 Treat child with severe malnutrition, low weight for age and'or anemia
 Counsel the caretaker on when to return immediately and on follow-up
 Competencies on immunization and feeding
 immunize a child presenting to a health facility
 Counsel mother on appropriate feeding

KEY FAMILY & COMMUNITY: PRACTICE

I. EXCUSIVE BREASTFEEDING, Breastfeed infants exclusively for up to 6 months. (Mothers
found to be HIV positive require counseling about possible alternatives to breastfeeding).
2. COMPLEMENTARY FEEDING, Starting at about 6 months of age, feed children freshly pre-
pared energy and nutrient rich complementary foods, while continuing to breastfeed up to two years
or longer.,
3. MICRONUTRIENTS. Ensure that children receive adequate amounts of micronutrients (vitamin
A, iron and zinc. in particular)either in their diet or through supplementation.
4. Hygiene. Dispense of faeces, including children's faeces, safety . and wash hands after defecation
before preparing meals and before feeding children.

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5. IMMUNIZATION Take children as scheduled to complete a full course of immunizations (BCG,

DPT, OPV and measles) before their: first birthday.
6 MALARIA: USE OF BED NETS. Protect children in malaria-endemic areas, by ensuring that
they sleep under insecticide
-treated bed nets.
7. PSYCHOSOCIAL DEVELOPMENT. Promote mental and social development by responding to
a child's needs for care and through talking, playing and providing a stimulating environment.
8. HOME CARE FOR ILLNESS. Continue o feed and offer more fluids, including breast milk, to
children when they are sick.
Horne care for sick children includes several "practices" which are enumerated individually in this
list of 12 key family practices, such as: continuing feeding and offering more fluid practice oral de-
hydration treatment and treatment of fever (practice no. 9), prompt care-seeking (practice no. 10),
and compliance with health provider's advice (practice no. 11
9. HOME TREATMENT FOR INFECTIONS. Give sick children appropriate home treatment for
infections.
10. CARE-SEEKING. Recognize when sick children need treatment outside the home and seek
from appropriate providers.
11. COMPLIANCE WITH ADVICE. Follow the health worker's advice about treatment. follow-
up and referral.
12. ANTENATAL CARE. Ensure that every pregnant woman has adequate adequate care. (This
include having at least four antenatal visits with an appropriate health care provider and recommend-
ed doses of the tetanus toxoid vaccination. The mother also needs support from her, family and
community in seeking care at the time of delivery and during the post-partum and lactation period).
World Health Organization and UNICEE

NOTE: The IMCI chart booklet has proved to be a practical tool. for helping with. Clinical
care. Clinical practice is considered critical element of training and all countries have PRE-
SERVED modifying the course methodology

UNIT:- 8.
THE POSTPARTUM PERIOD /PUERPEREUM
DEFINITION:

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 The post-partum period is defined as that period of time, usually six weeks, in which the
mother body experiences anatomic and physiologic changes that, reverse the body's adapta-
tion to pregnancy; may also be called involution,
 It begins with the delivery of the placenta and ends when all body systems are returned to
nearly 'to, their pregnant state.
 May or may not include the return of the ovulatory/ menstrual cycle.
SPECIFIC BODY SYSTEM CHANGES:
REPRODUCTIVE SYSTEM:
A: UTERUS:
A rapid reversal in size (Involution)
1. Palpated after delivery below the umbilicus, the uterus regress approximately 1 finger breath (l
cm) per day until, by the end of the second week post-partum it is a pelvic organ and can't be palpat-
ed through the abdominal wall.
2. The placental site undergone a site of changes in the post-partum [Link] after de-
livery, the contractions of the arterial smooth muscle and compression of the. vessels by contraction
of the myometrium result in homeostasis. The size of the placental bed decrease by half, and the
changes in the placental bed decreases in the quantity and quality of the lochia that is. experienced.
THE ENDOMETRIAL SURFACE IS SLOUGHED OFF AS LOCHIA, IN
THREE STAGES:
a. LOCHIA RUBRA:
Dark red color, days lz3 after delivery; consist of blood and cellular debris from decidua,
B. LOCHIA SEROSA :
Pinkish brown colour , days 4-10: mostly scrum, some blood and tissue debris.
c. LOCHIA ALBA
Yellowish color, days I1-21; mostly leukocytes, with decidua, epithelial cell, and mucus.
Lochia has a particular, musty odour, foul smelling lochia, however, may indicate infection.
Some small clot may be normal immediately after delivery. Large clot necds investigations.
B: CERVIX:
• Flabby inmediately after delivery, closes slowly.
• Admits one fingertip by end of one week after delivery.
• Shape of external Os changed by delivery from round to slit like opening.
C: VAGINA:
• Edematous after delivery.
• May have small laceration.
• Smooth walls for 34 weak, then rugae reappear.
D: OVULATION/MENSTRUATION:
First cycle is usually anovulatry.
If not lactating menses may resume in 4-6 weeks.
if lactating, menses may resume in 12-24 weeks.
E: BREAST:
LACTATING MOTHER

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a. High level of Prolactin immediately after delivery of placenta continued by, frequent contact with
nursing baby.
b. Initial secretion is colostrum. With increasing amount of true milk appearing b/w 43-96 hours.
C. Milk” let down" reflexes caused by oxytocin from posterior pituitary
2: NON LACTATING WOMAN:
• Prolactin level falls rapidly.
• May still secrets colostrum for 2-3 days.
• Engorgement of breast tissue resulting from temporary congestion of veins and lymphatic circu-
lation occurs on third day, last 24-36)hour usually resolves spontaneously.
F: ABDOMINAL WALL/ SKIN:
a. May need six weeks to re-establish good muscles, tone.
b. Stretch marks gradually disappear or fade to silvery' appearance.
G: CARDIOVASCULAR SYSTEM:
 Normal blood fuss in delivery of single infant is less than 500cc (up to 1000cc normal blood
loss for c-section )
 Haemocrit value usually returns to pre-pregnant value within 4-6 weeks
 WBC Counts increases.
 Increased clotting factor remain for several weeks leaving woman at risk for problems with
thrombi Varicosities regress.
H. URINARY SYSTEM:
a. May have difficult in voiding in immediate postpartum period as a result of urethral edema.
b. Voiding reflex may be altered..Lactosuria may be seen in lactating mothers.
d. Many women may show proteinuria during first 1-25 days of involution.
1. GASTROINTESTINAL SYSTEM:
a. Mother is usually hungry after delivery. good appetite is experience.
b. She may still experience constipation from lack of muscle tone in abdomen and intestinal track
and perineal, soreness.
J. CARE DURING POST PARTUM PERIOD:
The immediate postpartum period most often occurs in the hospital setting, where the majority of
women remain for approximately 2 days after a vaginal delivery and -3-5 days after a caesarean de-
livery.
During this time, women are recovering from their delivery and are beginning to care for the new-
born. This period is Used to make sure the mother is stable and to educator in the care of her baby
(especially. The first- time mother).
• While still in the hospital, the mother is monitored for blood loss, signs. of infection, abnormal
blood pressure, contraction of the uterus, and [Link] void
• Routine practices include a check of the baby's blood type and administration of the Rho GAM
vaccine to the Rh-negative mother if her baby has an Eh-positive blood type.
• At minimum. the mother's Haematocrit level is checked on the first postpartumn day. Women
are encouraged to ambulate and to eat a regular diet.
[Link] INTERCOURSE:

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• Sexuall intercourse may. resume when right red bleeding ceases, the vagina and vulva are
healed. and the woman is physicality comfortable and emotionally ready. Physical readiness
usually rakes about 3 weeks..
• Birth control is important to protection against pregnancy because the first ovulation is very un-
predictable.
MANAGEMENT AND NURSING CARE :
• Substantial, education takes place during the hospital stay, especially for the first-time mother
.The mother (and often and father ) is taught routine care of the baby. Including feeding diaper-
ing and bathing. as well as what can be expected from the baby in terms of sleep urination ,
bowel moments, and eating .
• Provide education. support, and guidance to the breastfeeding mother. Breastfeeding is neither
easy nor automatic. It requires much effort on the part. Of the mother and her support team .
• Breastfeeding should be initiated as soon after delivery as possible: in a normal, uncomplicated
vaginal delivery breastfeeding is possible almost immediately after birth) Encourage the mother
to feed the baby every 2-3 hours (at least while she is awake during the day) to stimulate milk
production. Long feeding are unnecessary, but they should be frequent Milk production should
be well established by 36-96 hours.
• In women who choose not to breastfeed. the care of the breasts is quite. Different: Care should
be taken not to stimulate the breasts in any way in order to prevent milk production. Ice packs
applied to the breasts and the use of a tight brassiere or a binder can also help to prevent breast
engorgement.

 ASSESSMENT:
PHYSICAL:
 VITAL SIGN,
• Temperature over 100.4F after first 24hours. lasting more than 48hours is indicative of infection.
B. FUNDUS,
• Funds should be firm, in mid line and slightly below umbilicus immediately after delivery.
• Immediately after birth: funds (top of the uterus) midline and at the level of the umbilicus to 1
cm above the umbilicus

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• The fundus will fall 1 cm (1 fingerbreadth) each day for next 10 days.
• 9th day post birth: Uterus not palpable
• 12thday: Fundus in pelvis
• 6 weeks after birth: Uterus returns to normal size and function
AS5essment should always be done with client's bladder empty.
C. Lochia
• Color. amount, odor, clots
D. Perineum
a. Healing of Episiotomy
b. Hematoma formation
c. Develops of hemorrhoids
E. Breast
Firmness and condition of nipples
F. Elimination
• Voiding flatus, and bowel
G. Legs pains,
• Warmth tenderness s indicates thrombosis.
PHYSIOLOGIOCAL CARE :
a. Provide emotional support
b. Provide knowledge about infant care & breast feeding
c. Encourage proper rest & sleep
d. Additional family support to parents
e. Provide information about contraception if needed.
f. Prepare for discharge and teach care of infant al hone, instructions about activates, rest, exercis-
es, continuation of sexual intercourse, and return for post partum examination.

UNIT NO 9:
COMPLICATION OF PREGNANCY
Escape of blood from the genital tract (vaginal bleeding) is a cause for concern to mother particularly
those who have a previous experience of vaginal bleeding resulted in vaginal loss
Therefore a midwife should take proper history and make aware to mother for any bleeding
CAUSES OF BLEEDING DURING EARLY PREGNANCY:
1. IMPLANTATION BLEEDING:
Occurs about 7th day after fertilization. It is slight and bright red color bleeding and settled within
three to four days when blastocyst completely embedded.

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2. LOCAL LESIONS OF CERVIX OR VAGINA:

A. Cervical erosion
B. Polyps
C. Carcinoma of cervix
3. ABORTION
4. ECTOPIC PREGNANCY
5. HYDATIDIFORM MOLE

 ABORTION:-
Loss of pregnancy before viability fetus may be spontaneous therapeutic or elective.
It is an expulsion or extraction of all (complete) or part of placenta or membrane: without an identifi-
able fetus or with a fetus alive or dead. Before 22 24 weeks of gestation:.

CAUSES OF ABORTION:
 Faulty implantation of fertilized ovum
 Abnormalities of ovum
 Hormonal disorders
 Acute Maternal diseases such as Rubella. Malaria and, Influenza, which are accompanied By.
fever which interferes with, trans placental oxygenation and precipitate, labor.
 Chronic diseases. e.g. nephritis. hypertension which also interferes with placental circulation.
 Use of drugs e.g. quinine, ergometrine. purgative and Enemas,
 ABO incompatibilities.
 Emotional upset.
 Cervical incompetence.
 Traumas, accident, fall, carrying heavy weight.
 Retroverted uterus.
 Tumor or fibroids.

TYPES OF ABORTION
DIAGRAM

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MISSED ABORTION:

 SPONTANEOUS ABORTION:
It is defined as the loss of a pregnancy before fetal viability(22-24 weeks gestation).
THE STAGES OF SPONTANEOUS, ABORTION MAY INCLUDE
 Threatened abortion (pregnancy may continue )
 inevitable abortion (pregnancy will not continue and will proceed to incomplete/complete abor-
tion);
 incomplete abortion (products of conception are partially. expelled);

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 complete abortion (products conception 'are expelled out completely )

 .THREATENED ABORTION :
There is a threat to pregnancy .it may continue or become inevitable or missed
SIGN AND SYMPTOMS:
There is a threat to pregnancy It may continue. Or become inevitable or missed.
 cervix closed
 Some bleeding and contractions
 Fetus not expelled
 Uterus correspond to dates
INVESTIGATIONS:
Hb. blood group, Rh factor, confirmation by ultra-sound
MANAGEMENT:
Medical treatment is usually not necessary
 Advice mother to
 Avoid strenuous activity but bed rest is not necessary.
 Avoid sexual intercourse.
 If bleeding stops advice follow up in antenatal clinic.
 Prescribe 5mg of folic acid daily.
 If bleeding persists, assess for fetal viability (pregnancy test ultrasound) or ectopic pregnancy
(ultrasound). Persistent bleeding, particularity in the presence of a uterus larger than expected
 may indicate twins or molar pregnancy.
 Do no give medications such as hormones (.g. estrogens or progestin’s) or tocolytic agents
(e.g salbutamol or indomethacin) as they will not prevent miscarriage.
 INEVITABLE ABORTION: (UNAVOIDABLE):
Pregnancy will not continue and will proceed to incomplete/complete abortion)
SIGNS AND SYMPTOMS:
 Cervix open
 Heavier bleeding and stronger contractions
 Loss of fetus usually not avoidable
MANAGEMENT:
 If bleeding is light to moderate and pregnancy is less than 16 weeks use fingers or ring or
Sponge) forceps to remove products of conception protruding through the cervix .
 If bleeding is heavy and pregnancy less than 16 weeks, evacuate the uterus:
 Manual vacuum aspiration is the preferred method of evacuation. Evacuation by sharp curettage
should only be done if manual vacuum aspiration is not available:
 lf evacuation is not immediately possible, give ergometrine 0.2 mg IM (repeated after 15
minutes if necessary) OR Misoprostol 400 mcg orally (repeated once after 4 hours if necessary
 If pregnancy is greater than 16 weeks
 Infuse oxytocin 40 units in I LIV fluids (normal saline or Ringer's lactate)]at 40
drops per minute until expulsion of products of conception occurs;

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 If unessasary , give misoprostol 200 mcg vaginally every 4 hours until expulsion. But do not
administer more than 800 mcg:
Ensure follow-up of the woman after treatment (see below). -

 INCOMPLETE ARORTION:
(Products of conception are partially expelled):
SIGN AND SYMPTOM:
o Expulsion of fetus incomplete
o Membrane or placenta retained
o Cramping, lower abdominal pain
o Heavy vaginal bleeding
o Dilated cervix
o Uterus smaller r than dates
Shock may or may not be present
INVESTIGATIONS:
Hb. blood group and Rh factor
MANAGEMENT:
 In addition to general measures assess vaginal bleeding and arrange to evacuate the uterus.
 Give injection ergometrine 0.2 mg 1/M or injection syntometrine.
 If bleeding is heavy start syntocinon infusion (Add 4O units of injection syntocinon in. 1000 ml
of ringer lactate or normal saline and start at 40 drops per minute)- or give 400 mg or miso-
prostol rectally.
 Evacuate the uterus after stabilize the patient and giving in antibiotics
 Evacuate the uterus to remove products. of conception by MVA (Manual vaccum
 Aspiration).
 Perform evacuation of uterus after stabilize the patient and giving iv antibiotics
 Repair any cervical or vaginal tear.
 1f there is evidence of injury to the uterus, urinary bladder or bowel perform laparotomy.
 Suction evacuation of the uterus should be done at the some time laparotomy should be done in
the health facility where the help of a surgeon if needed is available to deal with injuries of
the bowels bladder etc.
 In case with suspicion of Gas gangrene refer to a tertiary health care center
 If uterus is necrotic or beyond repair performs sub total or Total hysterectomy.
 If the couple family is complete discuss and perform tubal ligation at the time of laparotomy.
 COMPLETE ABORTION: (product of conception is. completely expelled out)
 Evacuation of the uterus is usually not necessary.
 Ensure follow-up of the woman, after treatment.
 Observe for heavy bleeding.
 INDUCED ABORTION:
Is defined as a process which pregnancy is terminated before fetal viability.

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Induce abortion can be therapeutic or criminal unsafe

THERAPEUTIC :
When it is done on medical ground i.e. mother is at risk or Fetus is abnormal.
 UNSAFE ABORTION:
Is defined as a procedure performed illegally either by persons lacking necessary skills or in an envi-
ronment lacking minimal medical standards or [Link] may end up into Septic abortion.
 SEPTIC ABORTION:
 Septic abortion is defined as abortion complicated by infection. Sepsis may result from infec-
tion if organism rise from the lower genital tract following either spontaneous or unsafe abor-
tion.
 Sepsis is more likely to occur if retained products of conception and evacuation has
 been delayed. Sepsis is a frequent complication of unsafe abortion involving instrumentation.

DISTINCTION BETWEEN SAFE AND UNSAFE ABORTION

 Safe Abortion is a procedure and technique performed by trained health-care providers with
proper equipment’s.
 correct technique, and sanitary standards.
 Unsafe abortion is procedure is performed either by persons lacking necessary skills or in an
environment.
 lacking minimal medical standards or both. Sepsis conditions are a frequent complication of
unsafe abortion involving unsterilized instrumentation and procedure (WHO, 2003: 14).
 HABITUAL ABORTION:( Recurrent abortion):
Three or more consecutive pregnancies end up in spontaneous abortion.
SYMPTOMS:
1:Amenorhea /-h/O induced abortion.
2:Foul smelling vaginal discharge /biding.
3:Fever with or without rigors.
4:Lower abdominal pain.
5:May or may not give h/o passing products of conception.
6:Malaise
SIGN:
1: Shock may or not be present.
2:Restless/ anxious /toxic looking dehydration.
3:Tender /rigid abdomen.
4:Rebound abdominal tenderness.
5:Purulent cervical discharge/Os may be open.
6:Tenderness in the fornices and on moving the cervix.
INVESTIGATION:
1:Haemoglobin, total leukocyte count, platelets count and random blood sugar.
2:Blood group and Rh factor.

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3:Pelvic and abdominal ultra-sound.

4:Culture and sensitivity of high vaginal swab (HVS/cervical swab/urine).
5:In case of severe infection blood should also be sent for culture and sensitivity.
MANAGEMENT:
 Give treatment of shock if present.
 Simultaneously obtain relevant history specially history of induced abortion and by worn.
 Sereen all patients with post abortion complications for Rh factor. Administer Rho(D) immu-
noglobulin (RhoGAM) if results indicated that the patient is Rh-negative and unsensitized.
 For patients who are unstable, administer oxygen and insert a Foley catheter.
 If bleeding is heavy give injection Ergometrine 0.2mg IM or injection Ergormetrine 80.2mg+
injection Syntocinon 5 IU I/M and start syntocinon infusion (add 40 units of injection
syntocinon to a liter of normal saline or ringers lactate and start at 40 drops/min)
 In case of mild infection prescribe oral antibiotics
 Tab Augmentin 375mg every 8 hours. Plus
 Tab Metronidazole 400 mg very 8 hours
 If there is evidence of severe infection start iv antibiotics such as:
 Injection Ampicillin 1g i/v every 6 hours plus
 Injection Gentamycin 80 mg ilv every § hours and plus
 Injection Metronidazole 500mg I/ every 8 hours.
 Continue i/v antibiotic till fever free 48 hours. And then, continue oral antibiotics for the. Next 5
,7 days.
 if there is a possibility that the woman was exposed to tetanus and there is uncertain history of
vaccination give tetanus Toxoid (TT) 0.5 ml. M and Anti tetanus serum 1500 units IM (Re-
peat TT after 4 weeks for future protection).
 Look for evidence of retained products of conception remove s if seen or felt in the vagina
/cervical OS
 Look for the presence of foreign body in the vagina eg. herbs, local medications and caustic
substances. Remove the foreign, body and clean the vagina with antiseptics like chlrohexi-
dine solution.
 Look for evidence of injury to genital tract, bowel and urinary bladder etc.
 Perform evacuation-of uterus after stabilize the patient and giving IV antibiotics,
 Repair any cervical or vaginal tear.
 In case with suspicion of Gas gangrene refer to a tertiary health care center
 MISSED ABORTION:
Fetus dies in uterus, but is not expelled and retained for some time.
SIGN AND SYMPTOMS:
 H/o missing period
 Uterus do not correspond to
 Minor disorders may disappear
 Pregnancy TEST is -ve

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INVESTIGATIONS:
 Hb. blood group Rh factor, bleeding time, confirmed by ultra-sound.
MANAGEMENT :
 A wait spontaneous expulsion of product of conception.
 If product of conception is not expelled by tour weeks of diagnosis, plan evacuation of uterus.
 Try medical evacuation of product of conception by using 200mg or two tablets of 100mg
each (available as cytotec) vaginally. Repeat in 4 to 6 hours to a maximum of 800mg. This
usually results in complete evacuation of uterine cavity.
 If some products remain in uterine cavity evacuate the uterus by suction evacuation of curet-
tage.
 Give Anti Rh to Rh negative mother.
 if abortion is of more than four weeks or older perform BT/CT before evacuating the uterus
for the prevention of bleeding disorder.
GENERAL MANAGEMENT OF ABORTION:
 If shock is present or anticipated immediately begin treatment.
 Even if signs of shock are not present keep shock in mind as you evaluate woman further be-
cause, her status may worsen rapidly
 Assess the amount of blood loss.
 If the woman is in shock without obvious heavy bleeding consider Ectopic pregnancy.
 If bleeding heavily or in case of suspected Ectopic pregnancy, insert two large bore i/v canulas
16 or I8 gage.
 From the same canula first collect blood for estimation of hemoglobin (Hb), blood grouping and
cross matching.
 Infuse normal saline or ringers lactate solution. Infuse rapidly if in shock.
 If in pain 50 -100mg of injection Pethidine IM or injection l00mg of diclofenic 75 mg or 1o0mg
of diclofenic rectal suppository.
 Examine to determine the type of Abortion and mange accordingly.
 Exclude the presence of complications.
 Perform bedside clotting test in cases with suspicion of coagulopathy and manage.
 If clinically indicated facilities are available perform ultrasound scan to confirm diagnosis.
 Arrange 2-4 units of blood if bleeding heavily transfuse blood if indicated
 In emergencies and life threatening situations consider transfusing O negative blood or ABO
group specific uncross matched blood.
 If the woman is stable, not bleeding heavily there are no life threatening complications,
Oxygen and i'v fluid are not required.
1. If possible check woman's blood group to determine Rh status in all cases of abortion if she is
Rh negative and pregnancy is less than 20 weeks give. 250 i-u of anti D immunoglobulin IM
within 72 hours. Of abortion. After 20.,weks give 500 i-u. This will prevent formation of RM an-
tibodies, which can have harmful effector subsequent babies.
2. Arrange follow up

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3. If appropriate, advise regarding family planning including emergency contraception.

FOLLOW-UP OF WOMEN WHO HAVE HAD AN ABORTION:
 Before discharge, tell a ‘woman who has had a spontaneous abortion that spontaneous abortion
is common and occurs in at least 15% (one in every seven) of clinically recognized pregnancies.
Also reassure woman that the chances for a subsequent successful pregnancy are good unless
there, has been Sepsis or a cause of the abortion is identified that may have an adverse effect on
future pregnancy (this is rare).
 Some women may want to become pregnant soon after having an incomplete abortion. The
woman should be encouraged ta delay the next pregnancy until she is completely recovered.
 It Important to counsel women who have had an unsafe abortion. If pregnancy is not desired,
certain methods of family planning can be started immediately (within 7 days) provided:
 There are no severe complications requiring further treatment ;
 The woman receives adequate counselling and help is selecting the most appropriate family
planning method.
DILATATION AND CURRATGE:-
 The" Dilation and Curettage" Procedure can be required for several reasons.
 If a miscarriage has occurred then some tissue may remain in the uterus that needs to be re-
moved to avoid infection.
 In the case of a molar pregnancy (mole) the tissue must be removed as completely as possible
to avoid continued growth of the material.
 In both of these cases, a general anesthetic is normally used. A hospital visit is required but
there is usually no need for an overnight stay.
 The D&C procedure can also be used by doctors for other reasons such as the detection of fi-
broids or for discovery of hormonal imbalances or to look for other reasons for abnormal
bleeding .
 In these cases a local anesthetic can sometimes be used and the procedure maybe performed
in a clinic or doctor's office instead of the hospital.
THE PROCEDURE:
In this procedure the cervix is widened and tissue is gently removed from the lining of the uterus in
the case of a mole then a suction evacuator should be used followed by curettage to remove the lin-
ing and remaining tissue. This can be a simple 5 minute operation sometime , but if a mole needs to
be removed then the large amount of material combined with the need to remove as close to 100% of
it as possible will require much more time .
AFTER THE PROCEDURE:
 Practitioner will need to see his /herpatient within a week to check on progress.
 Spotting and some discomfort are usual, for a few days.
 The doctor should be contacted immediately if there is any heavy bleeding. severe pain, fever
or chills.
 Do not have sex until all bleeding stone.

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 Consult your doctor for advice on what activities you can perform and which special care is
advised.
 Women can normal ovulate and become pregnant as soon as 2 weeks after an early
miscarriage.
 1f one does not wish become pregnant again right away then she should talk to her gyneco-
logical about t Birth control.
 If a lady have had molar pregnancy then doctor will probably advise her to not fall pregnant
until one year after the D&C operation.
RH NEGATIVE BLOOD:
If lady's blood is Rh negative she should check with her doctor whether she need a blood product
called Rh immune globulin (Rh1G). This prevents her from developing antibodies that could affect a
future Rh-positive baby.

INCOPETENT CERVIX:-

 DEFINTION:
 A cervix (the structure at the bottom of the uterus) that is incompetent is abnormally weak
and therefore it can gradually widen: during pregnancy. Left untreated, this can result in re-
peated pregnancy losses or premature delivery.
 DESCRIPTION:
 Incompetent cervix is the result of an anatomical abnormality. Normally, the cervix remain
closed throughout pregnancy until labor begins.
 An incompetent cervix gradually due to the pressure from the developing fetus after about the
1 3th week pregnancy, the cervix begins to thin out and widen without any contractions or la-
bor.

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 The membranes surrounding Pending the bulge down into the opening of the cervix until they
break resulting in the loss of the baby are a very premature delivery
 CAUSES AND SYMPTOMS:
 Some factors that can contribute to the chance of a woman having an incompetent cervix in-
clude trauma to the cervix, physical abnormality of the cervix or having been exposed to the
drug diethylstilbestrol (DES) in the mother's womb. Some women have cervical incompe-
tence for no
 DIAGNOSIS:
 Incompetent cervix is suspected when a woman has three consecutive spontaneous pregnancy
losses during the second trimester (fourth, fifth and sixth months of the pregnancy). The like-
lihood of this happening by random chance is less than 1%. Spontaneous losses due to in-
competent cervix account for 0-25% of all second trimester losses. A spontaneous second
trimester pregnancy loss is different from à miscarriage, which usually happens during the
first three months of pregnancy.
 The physician can check for abnormalities in the cervix by performing a manual examination by
an ultrasound test. The physician can also check t0 see if the cervix is prematurely widened
(dilated), Because incompetent cervix is Only one of several potential causes for this, the pa-
tient's past history pregnancy losses must also be considered when making the diagnosis.
 TREATMENT :
 Treatment for incompetent cervix is a surgical procedure called cervical cerclage. A stich (su-
ture) is used to tie the cervix Shut to give it more support. It is most effective if it is per-
formed somewhere between 14-16 weeks into the pregnancy. The stitch is removed near the
end of pregnancy to allow for a normal birth.
 Cervical cerclage can be performed under spinal. epidural, or general anesthesia. The patient
will need to stay in the hospital for one or more days. The procedure to remove the suture is
done without the deed for anesthesia. The vagina is held open with an instrument called a
speculum and the stich is cut and removed 1his may be slightly uncomfortable, but should not
be painful.

 Some possible risks of cerctclage are premature rupture of the amniotic membranes, infection
of the amniotic. sac, and pre term labor. The risk of infection of the amniotic sac increases as
the pregnancy progresses. For a cervix that is dilated 3 centimeters (cm), the risk is 30%.
 After cerclage, a woman will be monitored for any preterm labor. The woman [Link] consult
her obstetrician immediately if there are any signs of contractions.
 Cervical cerclage can not be performed. if a woman is more than 4 cm dilated, if the fetus has
already died in her uterus, or if her r amniotic membranes are torn and her water has broken.
 PROGNOSIS:
The success rate for cerclage correction of incompetent cervix is good. About 80-90% of the time
women deliver healthy infants. The success. rate is 'higher for cerclage done early in pregnancy.
DIAGRAM:

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ECTOPIC PREGNANCY:-

DEFINITION;
Word Ectopic means out of place it is one in which fertilized ovum implants outside the uterine cav-
ity. At least 90% of extra uterine pregnancy occur in a uterine tube but may occur in ovary and ab-
domen.
DIAGRAM

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CAUSES OF ECTOPIC PREGNANCY:

 Anything that interferes with free passage of the ovum through the ovary and the fallopian tube
to the uterus.
 Gonorrhea or tuberculosis: lead to Salphingitis
 Any condition diminishes the Tubal lumen may pre dispose a women to Ectopic pregnancy.
 Sepsis leads to adhesion.
 Spasm of tube.
 Kinking of the tube
 Reduced peristalsis
 Congenital abnormality of tube.
 Migration of ovum to opposite side tube.
OUTCOME OF TUBAL PREGNANCY:
Tubal abortion: Ovum is expelled from fimbriate end to peritoneal cavity.
Tubal mole: Similar to blood mole
Tubal rupture: May occur in to peritoneal cavity.
SIGN AND SYMPTOMS OF ECTOPIC:
History of Amenorrhea (missed 1-2 period)
Intermittent lower abdominal pain (one side )
 Vaginal bleeding.
 Faintness
 Nausea,
 Slight brownish persistent vaginal discharge.

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 Pain with vomiting.

 Abdomen tight and tender to touch.
 HCG titers usually lower than in intra-uterine pregnancy.
 Low hemoglobin and Haematocrit, rising white cells count.
 Bleeding if severe may leave to shock.
NOTE:
Amenorrhoea +lot of bleeding + little pain abortion
Amenorrhiea + little bleeding + lot of pain= Ectopic
SIGNS AND SYMPTOMS OF RUPTURE TUBE:
 Sudden severe pain (abdominal)
 Referred shoulder pain.
 Cold clammy skin.
 Rapid pulse
 Low B.P.
 Breathlessness with vomiting
 Pain e vomiting.
 Abdomen tight and tender to touch.
EFFECT ON PATIENT:
 Woman history of early signs of pregnancy includes Amenorrhea about 6-10 weeks.
 She may have localized pain on one side..
 Then she may have sharper intermitted pain following generalized abdominal discomfort as
blood spell into abdomen.
 Referred pain to shoulder.
 Bleeding p/v due to falling hormonal end
IMMEDIATE MANAGEMENT:
 Cross-match blood and arrange for immediate laparoscopy. Do not wait for blood before per-
forming surgery.
 At surgery , inspect both ovaries and fallopian tubes:
 If there is extensive damage to the tubes, perform salphingectomy (the bleeding tube and the
products of conception are excised together). This is the treatment of choice in most cases;
 Rarely. if there is little tubal damage, perform salphingiostomy (the products of conception can
be removed and the tube conserved). This should be done only when the conservation of fertili-
ty's very important to the woman, as the risk of another Ectopic pregnancy is high
TREATMENT OF RUPTURED ECTOPIC:
 Admit in hospital.
 Report doctor.
 Treat for shock maintain 1/v line
 Immediate replaces of blood.
 Elevate the foor of bed.
 Record B.P and TPR every 15-min.
 Blood grouping.

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 Cross match and arrange for blood.

 Prepare for operation salphingectomy.
DIFFERENTIAL DIAGNOSIS:
The most common differential diagnosis for Ectopic pregnancy is threatened abortion.
 Salphingitis
 Appendicitis
 Abortion
 Torsion of pedicle of ovarian cyst
 Lateral displacement of retroverted uterus.
 Acute or chronic PID
 Ovarian cysts
TREATMENT OF ABDOMINAL PREGNANCY:
 It may be carried out till term and fetus is delivered by laparotomy.
 Or if fetus dies it is also removed by laparotomy cord is clamped and no attend should be
made to remove placenta as uterus is already contracted no bleeding will occur.

HYDATDIFORM MOLE OR MOLAR PREGNANCY:

DEFINITION:
A molar pregnancy is an abnormality of the placenta ít is the result of a genetic error during the ferti-
lization process that leads to growth of abnormal tissue within the uterus.
It has the appearance of a large and random collection of grape-like cell clusters. Molar pregnancies
are rare. occurring in l out of every 1,000 pregnancies.
Molar pregnancies arc also called gestational trophoblastic disease (GTD), Hydatidiform mole o
simply referred to as a "mole." It is a benign tumor.
TYPES OF MOLAR PREGNANCY:
There are two types of molar pregnancies, "complete." and "partial,"
COMPLETE MOLAR PREGNANCY:

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Complete molar pregnancies have only placental parts. (there is no baby). and form when the sperm
fertilizes an empty egg. Because the egg is empty. no baby is formed The placenta grows and pro-
duces the pregnancy hormone, hCG. An ultrasound will show tat there is no fetus, only a placenta.
PARTIAL MOLAR PREGNANCY:
Partial Mole occurs. when the mass contains both the abnormal cells cells and an embryo that has
severe defects. In this. case the fetus will be overcome by the growing abnormal mass rather quickly.
An extremely rare. version of a partial mole is when twins are conceived but one embryo begins to
develop normally while the other is a mole In these cases, the healthy embryo will very quickly be
consumed by the abnormal growth
RISK FACTORS:
1. In the US, approximately 1 out of.000 pregnancies is a molar pregnancy
2. While women in the US are at higher risk than black women
3. Women over the age of.0
4. Women who have had a prior molar pregnancy
5. Women with a history. Of miscarriage
ASSESMENT FINDINGS:
 Woman comes with s/s of early pregnancy.
 Vomiting may be frequent due to high level of HCG.
 Uterus much larger then gestational age.
 Dark red or brownish bleeding may occur after 12 weeks.
 No fetal part palpable.
 No feral movement felt.
 Symptoms of pre-eclampsia.
 Urine pregnancy lest of HCG is positive.
 Anemia often accompanies bleeding.
 Ultrasound shows no fetal skeleton.

IMMEDIATE MANAGEMENT:

Patient is admitted as case of threatened abortion until confirmed.

 Save all pads inspect for pieces of mole.
 Ultrasound to confirm the diagnosis
 If the diagnosis of molar pregnancy is certain, evacuate the uterus:
 If cervical dilatation is needed, use isoprostol/folys catheter
 Use vacuum aspiration. Manual vacuum aspiration is safer and associated with less blood The
risk of perforation using a metal curette is high;
 The uterine contents are copious and it is important to evacuate then rapidly.
 Occasionally, when the mole is extensive and the-woman has decided
 pregnancies. a hysrerectomy may be done.

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 Infuse oxytocin 20 units in | LIV fluids (normal saline or Ringer's lactate) d 60 drops per minute
to prevent hemorrhage once evacuation is under way.
 Provide pre and postoperative care for evacuation of uterus (usually suction curettage)
 Postoperative patient is observed for sign of bleeding.
 Check vital sign.
 Provide emotional support for loss of pregnancy
SUBSEQUENT MANAGEMEVT:
 Any birth control method is acceptable with the exception of an intrauterine device for at
least 1 year to prevent pregnancy). Voluntary Tub Eigation may be offered if the woman has
completed her family.
 Follow up every 8 weeks for at leas 1 year with urine pregnancy tests because of the risk of
persistent trophoblastic disease gr choriocarcinoma. If the urine pregnancy test is not negative
after & weeks or becomes positive again n within the first year. refer the woman to a tertiary
care center for further follow-up and management;
COMPLICATION ÓF HFYDATIDIFORM MOLE:
 Hemorrhage
 future
 Erosion of the uterine wall!
 Chorio carcinoma
 Sepsis

 BLEEDING IN LATE PREGNANCY:

 ANTEPARTUM HEMORRHAGE

DEFINITION:
Antepartum hemorrhage is defined as "bleeding from the genital tract during pregnancy after 24
weeks (WIHO defines it as 22 weeks) and before the birth of the baby.

CAUSES OF ANTETARTUM IHAEMORRHAGE:

 Cervical lesions
 Cervical polyps
 Cervicitis
 Cervical carcinoma

PLACENTAL BLEEDING:

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 Placenta abruptio
 Placenta Previa
 Placental edge bleeding

UTERINE BLEEDING:
 Lower segment scar rupture
 Rupture of other scars (myomectomy)
 Vasa previa
 Coagulopathy
 Heavy show

PLACENTA PREVIA:
When placenta is implanted, (partially or wholly) in the lower uterine segment is called placenta pre-
via and its separation may result in ante partum hemorrhage.

CAUSES OF PLACENTA PREVIA:

 Sub involution of uterus
 Multiple pregnancy with large placenta
 Multi parity
 High risk over the age of 35 years.
 Placenta membrane (villi embeds in the lower uterine segment.)
 Previous C-section
 Types of placenta preyia

DAIGRAM:

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1. TYPE ONE OR LATERAL:

When placenta is in lower segment but does not reach the internal Os, in this
vaginal delivery is possible and, blood loss usually mild and mother and fetus.
remain in good condition.
2. TYPE TWO OR MARGINAL:

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Placenta is at the margin of the internal Os in this also vaginal delivery is

possible and blood loss is moderate.
3. TYPE THREE OR INCOMPLETE:
4. TYPE FOUR OR COMPLETE:
Center of placenta lies over the center of internal Os, it covers the entire Os even
at fully dilatation. Vaginal delivery is not possible C-section is necessary
CLINICAL FEATURES OR SIGNS AND SYMPTOMS:
 Histories of vaginal bleeding in early weeks of pregnancy occasionally the first bleed may be
very sever.
 Painless, causeless, recurrent and unavoidable bleeding in last trimester of pregnancy oc-
curs.
 Bleeding usually occurs during or in sleep at night without pain and there may be history of
coitus.
 Fetal heart sound and movements are normal and fetus is easily palpable.
 Sign & symptoms of sever hemorrhage shock present.
 On abdominal examination the uterus is felt soft
 If the placenta is found low lying when scan is repeated at 32 weeks. This is due to developed
of lower segment aid relative movement of placenta toward more fundal position and the fe-
tus may have oblique or transverse lie high head or breech presentation.
 There is no rigidity or Tenderness on abdominal palpation.
 Vaginal Examinations never done except in the operation theater with all facilities to perform
immediate c-section.
 Ultrasound identifies the position of the placenta.
ACTIVE TREATMENT DEPENDS UPON:
 Amount of blood loss
 General condition of the mother.
 Whether she is in labor or not.
 Duration of pregnancy,
 Whether fetus is alive or dead.
 Response lo the treatment.
 Place where the pt is seen.
 If she is in hospital immediate admit her
ACTIVE TREATMENT:
 Immediate delivery with blood transfusion.
 Neonatal ICU

CONSERVATIVE TREATMENT:

 Monitor the pregnancy in hospital

 OR As frequent out patient visits

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 Give steroids
 Deliver at or near term
MANAGEMENTAT HOSPITAL:
 Inform doctor.
 Reassurance to the patient, keep her flat in bed
 If sign of shock treat her for shock
 Check vital sign and record it.
 Check her HB% and blood group cross match and arrange two pint of blood.
 If she is in labor and she is G i, ii iv caesarian section should be done.
 No per vaginal examination should be done
 In type I membrane is ruptured to start oxytocin drip for speed up delivery.
 Save pads to assess amoun'of blood loss.
 Shave abdomen:
 Empty her bladder.
 Monitor FHS and administer 02 if fetal distress.
 NPO the patient take consent for operation
 Plugging vagina to control bleeding should be avoided.
 If patient does not response to therapy & she is< 38weeks and not in labor then C- section is
performed.
 After delivery post partum hemorrhage may be controlled by oxytocin drip.
 Hysterectomy may be needed if bleeding is not controlled.
 The most common cause of death in APH is PPH.
 About 10% fetal mortality is due to hypoxia and asphyxia due to placental separation.
 Prematurity is common cause.
 Fetal abnormalities arc also common in placenta previa.
PLACENTAL ABRUPTION
 Bleeding occur due to premature separations of placenta which is normally situated in upper
uterine segment. It is an accidental occurrence of hemorrhage
 Placental abrupt is accidental hemorrhage it is the hemorrhagic due to partial or complete
Premature separation of placenta. normally situated in upper uterine segment after 24 week of
pregnancy.

CAUSES OF PLACENTAL ABRUPTION:

 High parity and anemia

 Pre eclamptic toxenmia and ecampsia.
 Renal disease.
 Trauma such as fall, kick. accident and external version direct below
 Physiological shock, short cord.
 Poly hydramnios.
 Preterm and premature rupture of membrane.

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 Rero placental fibroid

 Or sudden release of poly hydramnios
 Folic acid de deficiency may be the cause

TYPES OF PLACENTAL ABRUPTION:

INTERNAL OR CONCEALED:

 In which vaginal bleeding is not seen through vagina, blood retained in the uterus and may
cause uterine enlargement and extreme pain and coagulopathy and maternal morbidity.

EXTERNAL OR REVEALED

 In this the blood collects as a retroplacental clot behind the placenta. There will be evidence
of external bleeding. This is the most severe form, often the fetus dies in uterus before admis-
sion to the hospital.

MIXED TYPE :

 In this type there are some retro placental collection and the rest trickling out as dark red
Bleeding with clot.

S/S OF CONCEALED HAEMORRHAGE:

 NO bleeding through vagina or bleeding from vagina is slight or may be absent, colour of
bleeding is dark.
 Continuous severs uterus enlargement and sudden abdominal pain Uterus is hard, rigid and
tender.
 Fetal heart sound can be heard with difficulty.
 Fetal parts difficult to palpate.
 Excessive or cessation of fetal movement.
 Rapid and weak pulse and low blood pressure.
 She is restless.
 High incidence of still birth due to large part of placental separation
 Cold and moist skin.

S/S OF REVEALED HAEMORRHAGE:

 Escape of blood through vagina.

 Normally uterus size corresponds to gestational

 Normally consistence.

 No difficulty in fetal part palpation.

 Fetal heart sound can easily be heard.

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 Excessive or cessation of fetal movement

 Slight abdominal pain and discomfort
 Low incidence of still birth due to small portion of placental separation.
 Hx of trauma and Hypertension.

DIFFERENTIAL DIAGNOSIS:

 Ectopic pregnancy.
 Spontaneous rupture of the uterus.
 Acute poly hydramnios.
 Acute appendicitis.
 Peritonitis.
 Intestinal obstruction.

PREVENTIVE TREATMENT:

 Good antenatal care.

 Prevention of anemia.
 Hospital booking for patient liable to have ante partum hemorrhage.
 Avoidance of trauma.
 Avoidance of sudden decompression in Polyhydramnios.
 Early detection and treatment of pregnancy induced hypertension.

CURATIVE TREATMENT:

if fetus is alive:
 Admit patient in labor room for close monitoring.
 Send blood for group and RH factors, cross match. and HB% and FOR BT/CT
 Monitor vital sign and record it
 Monitor FH.S continuously.
 Start a large bore I\V infusion lines with Ringer lactate solution,
 Treat for shack if present.
 Replace blood loss and correct hypovolumic adequate fresh blood Transfusion
 Record TO chart.
 Patient may need oxygen if fetal distress.
 Immediate C-section to save fetus.

ARRANGE FOR BABY:

 Prepare resuscitation trolley and emergency drugs.

 Inform pediatrician.
 No vaginal examination is done to exclude placenta previa

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 1f patient is in labor membrane is ruptured in OT t speed up delivery as early as pos-

sible and
 to avoid hypofibrinogeneamia and renal necrosis
 Syntocinon drip may be started to speed up labor.

AFTER DELIVERY:

 If bleeding continuous concentrate plasma should be given to prevent hypo fibrinoge-

neamia.
 Oxytocin should be given in liberal amount to encourage uterine contraction.
 Biannual compression Tor massage is done to stop bleeding.
 If bleeding doesn’t stop hysterectomy may be performed.

COMPLICATIONS

 Post partum hemorrhage.

 Shock leading to acute renal failure.
 Prematurity
 Hypofebirnogeneamia.
 Anemia
 Intra uterine death Transfusion hepatitis

HYPOFIBRINOGENAEMIA:-
 A low or deficient level of fibrinogen in the blood
 This is a situation in which there is deficiency of fibrinogen in the blood. occurs during or
after delivery (PPH) Dysfibrinogenemia is marked by functional abnormalities of fibrinogen
that may result in either bleeding or thrombosis.

CAUSES:

 Abruption.
 Intra uterine death
 Amniotic fluid embolism
 Missed abortion

DIAGNOSIS:

Clotting of blood normally occurs in 5-10 minute in this clot doesn't from With fibrinogen levels less
than 0.1 g/L, bleeding manifestation ringe from mild to severe. Umbilical cord hemorrhage frequent-
ly provides an early alert to the abnormality (factor Xiii deficiency is the other congenital bleeding
disorder.) Other bleeding manifestations include the following:

 Epistaxis and oral mucosal bleeding

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 Hemothrosis
 Menorrhagia and postpartum hemorrhage
 Traumatic and surgical bleeding
 Spontaneous splenic rupture and intracranial hemorrhage (rare)
 Vaginal bleeding
 In patients with hypofibrinogenemia bleeding episodes are usually mild and, in many cases
no spontaneous clinical bleeding is present; these patients may bleed following trauma or
surgery.

TREATMENT:
PREVENTION AND CAREFUL TREATMENT TO PREVENT PPHMONITOR MATER-
NAL VITAL SIGN

• Note any, sign of renal failure.

 For patients with clinical bleeding associated with afibrinogenemia or dysfibrinogenemia.

replacement of fibrinogen to 'a level of 0,5-0.8 g/L is usually adequate to maintain hemosta-
sis.
 Patients presenting with thrombosis associated with dysfibrinogenemia should be provided
anticoagulation therapy.
 Spontaneous abortion: Recurrent spontaneous abortion may be prevented by routine prophy-
laxis with, fibrinogen replacement therapy during pregnancy.
 To prevent excessive bleeding during surgical procedures, prophylactic treatment to raise fi-
brinogen levels to 0.5-1 g/L is recommended.

TOXEMIA OF PREGNANCY:-
PRE ECLAMPSIA

is a disorder that occurs only during pregnancy and the postpartum period and affects both the
Mother and the unborn baby. Affecting, at least:5-8% of all pregnancies, "it is a rapidly progressive
condition characterized by

 High blood pressure

 Presence of protein in the urine.
 Swelling. sudden weight gain,
 Headaches and changes in vision
 Typically. preeclampsia occurs after 20 weeks gestation (in the late 2nd or 3 rd trimester or
middle to late pregnancy). though it can occur earlier.
 1f it appears in the first half of the pregnancy it is due to Hydatidiform mole In normal preg-
nancy the blood pressure falls below-non pregnant level in the second trimester

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 Proper prenatal, care is essential to diagnose and manage preeclampsia preeclampsia. Preg-
nancy Induced Hypertension (PIH) and toxemia are closely related condition. HELLP Syn-
drome and eclampsia are other manifestations of the same syndrome.
 Preeclampsia and other hypertensive disorders of pregnancy leading global cause of maternal
and infant illness and death.

CAUSES:

Are unknown but patient who suffers from pre eclampsia iš:

 Elderly primi.
 Multiple pregnancy
 Hydatidifom mole.
 Kidney diseases.
 Diabetic Mellitus
 Polyhydraminos
 Hereditary
 Malnutrition especially reduced protein intake.
 Patient of essential hypertension

TYPES OF PREGNANCY INDUCED HYPERTENSION

 POTENTIAL HYPERTENSION:
 Hypertension is the rise of diastolic blood pressure to 90mnHg on two occasions more than
six, hours apart.
 Blood pressure is raised 45mmHg above first trimester or pre-pregnant level.

MILD HYPERTENSION:

 Diastolic B.P 90-99mmHg

 Systolic B.P: 140mmHg.

MODERATE HYPERTENSION:

 Diastolic B.P: İ00-110 mm Hg.

 Systolic B.P: 140 -170 mm Hg.
 There is also oedema the level of protein is 30-300mg / 100ml.

SEVERE HYPERTENSION:

 Diastolic> 110mm Hg.

 Systolic > 170 nm Hg.

There is also associated gross oedema protein is more than 300mg/l00ml.

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SIGN AND SYMPTOM OR CLINICAL FEATURES

1. HYPERTENSION:

 Potential
 Mild
 Moderate
 Severe

[Link] GAIN

 Average weight gain 10-12 kg

 Increase of 2kg per month - 0.5 kg in last trimester .A gain of more. than 0.75kg per week is
 Pathological (due to occult oedema).

3 OEDEMA

 Its appears near the ankles than around the eyes especially on getting up in the morning.
 Fingers may become swollen: fate become puffy then generalized oedema on whole body.
 If patient is confined, to bed then oedema appears on scrum.

4. PROTEIN UREA

 Proteinuria is the result of proteins, normally confined to the blood, spilling into your urine
because the small blood vessels in the kidneys become damaged. A simple dipstick test of
your urine at each prenatal check-up can screen for proteinuria.
 1-10gm protein may be passed in a days. Mid stream urine should be tested as vaginal
 discharge may contain proteins.

[Link] UTERUS MAY BE SMALL FOR DATES.

6. GIT SYMPTOMS

There is nausea, vomiting, epigastric pain hepatic enlargement and tenderness.

7. BLURRING OF VISION.

8. TWITCHING OF MUSCLES.

9. FUNDOSCOPY will show.

Retinal hemorrhagic, retinal detachment, vascular narrowing and shining edematous retina indicate
cerebral oedema and fits.

10. HEADACHES

 Dull, throbbing headaches, often described as migraine-like that just won't go away:

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11. CONVULSION:

 Violent involuntary contraction of voluntary muscles.

 Symptoms are usually late to appear and are headache, vertigo, irritability, convulsion and
coma.

AIMS OF RX

 To control blood pressure.

 Prevent complication
 Detect IUGR & prevent IUD.

GENERAL MANAGEMENT OF PRE-ECLAMPSLA:

1- PREVENTION:

 High protein diet and calcium supplements.

 Early diagnosis and proper management
 Good antenatal care
 Screening and special care for high-risk patients such as primigravida, grandmultipara.
 molar pregnancy and family history of eclampsia and chronic hypertension.

2- MEDICAL

Rest:

 It lowers cardiac out put and blood pressure fall.

 Reduces oedema
 Improves blood circulation to uterus and placenta.
 Rest in let lateral position is recommended due to uterine obliquity and Presence of inferior
venacava on the right side
 Rest also decreases protein urea.

Sedation:

 To facilitate mental and physical rest, Best sedation is

 Phenobarbital orally IM. IV according to severity. It is safe in pregnancy 120-240 mg/day.
 Diazepam,( Valium): second dug of choice Dose 20-40 mg/day.
 Diuretics: should no used as they are harmful to fetus and mother.
 They reduce the blood volume and decrease placental circulation but in severe oedema they
 may be used e.g. lasix-diazide-1

Anti hypertensive: Methyldopa (Aldomat): Is the drug of choice, it reduces both systolic and dias-
tolic blood pressure. Major side effect of aldomat is Sedation, postural hypotension, light-
headedness. bradycardia,hemolytic anemia and depression. It reduces placental blood flow causes

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slowing of fetal heart rate. 0.5 to 5mg can be given in [Link] (Adalat): It is used sublin-
gually in PIH.

[Link]:

it is decided while considering following features,

 Severity of PIH.
 State of cervix,
 Maturity of fetus.
 Parity.
 Obstetrical history

4. DIET:

 High protein diet consisting of milk, meat, fish, fruits, vegetable are recommended.
 Carbohydrates e.g. rice, bread, sweets. are restricted to reduced weight gain.
 If oedema then fluid intake is reduces.
 When inducing labor by using drip the amount of fluid is carefully controlled.
 prenatal vitamins and calcium supplements should be prescribed.

5. BOWELS:

Bowel should move every day but strong purgative and enema should not be used.

 OBSTETRICAL MANAGEMENT:

Obstetrical management will be depending upon the severity of the disease, response to treatments,
stage of pregnancy, previous obstetrical history and condition of the cervix.

"FIRST STAGE OF LABOR:

Labor should be induced by rupturing the membranes at 38 weeks.

Syntocinon drip should be started if there is delay.

Observe for

 Uterine contraction.
 Dilatation, of cervix
 Blood pressure 1/2 hourly.
 Fetal heart sound 1/2 hourly.
 Fluid 1/O chart maintains
 Patient should never be left alone.
 Patient should nurse in left lateral position.
 She should be in complete bed rest.

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 Emergency kit or tray for eclamptic patient should be kept ready in LR.
 Caesarean section if CPD/ precious baby/ failure of surgical induction/Poor Bishop's score!

SECOND STAGE OF LABOR:

 Expedite delivery.
 Forceps delivery is advice to prevent intrapartum eclampsia.

THIRD STAGE OF LABOR:

 Methergin is not used it may rise the blood pressure.

 Fluid overload should be avoided.
 Patient should be observed for postpartum hemorrhage./Active management of 3 stage.
 Baby may need resuscitation

COMPLICATIONS:

1-Maternal

 Eclampsia
 Hepatic failure.
 Anuria and renal failure.
 DIC
 Hyperpyrexia.
 Intracranial hemorrhage.
 Accidental hemorrhage.
 During delivery APH and PPH.

2-Fetal

 Placental insufficiency may cause IUD.

 Placental separation leads to fetal distress.

CHECK FOR PRE-ECLAMPSIA:

ASK: LOOK & FEEL

Measure blood pressure in sitting position
If diastolic blood pressure is 90mmHg or greater
Repeat after 1 hour rest and

DO YOU HAVE-
Severe headache
Blurred vision

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Epigastric pain check protein in urine

IF ABNORMAL

SIGNS CLASSIFY TREAT & ADVISE

Diastolic blood pressure SEVERE GIVE MAGNESIUM
110mmHg or greater and PRE-ECLAMPSIA SULPHATE
3+ proteinuria REFER URGENTLY TO
HOSPITAL
Or

Diastolic blood pressure

90mmHg or greater and
2+proteinuria and any of
Severe headache
Blurred vision
Epigastric pain
Diastolic blood pressure 90- PRE=ECLAMPSIA REFER TO HOSPITAL
110mmHg on two readings
and 2+ proteinuria
Diastolic blood pressure HYPERTENSION ADVISE TO REDUCE
90mmHg or greater on two WORKLOAD AND REST
settings Advise on danger signs
Reassess at the next antena-
tal visit or in 1 week if >8
months pregnant.
If hypertension persist after
1 week or at next visit, refer
to hospital or discuss case
with doctor or midwife if
available

ECLAMPSIA

DEFINTION:
Eclampsia is an extremely dangerous complication of severe pregnancy, induced hypertension (Pre
eclaimpsia). Convulsions and comas. characterize it. it may occur during pregnancy (Antepartum)
during labor (intra partum) after delivery (postpartum)

It is more common in primigravida with a history of eclampsia, hypertension and Twins pregnancy.

CLINICAL FEATURES OR SIGN SYMPTOMS:

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 No improvement in pre-eclampsia
 Severe headache.
 Visual disturbances like blurring of vision and spots of light before eyes.
 Rolling of eyes.
 Twitching of eye lids and face.
 Epigastric pain.
 Vomiting’s.
 Oligouria.
 Massive oedema of face, hands, abdominal walls and legs.
 Restlessness agitation.
 Tachypnea with acidosis.
 Hyperpyrexia is often present.
 Protein urea, Oligouria or even anuria in severe cases
 Fits: commonly occur at irregular interval but in severe cases may occur in rapid succession.
 Coma (unconscious): coma is. assisted by GCS

STAGES OF ECLAMPTIC FITS:

There are four stages of eclamptic fis;

 Premonitory stage
 Tonic stage
 Clonic stage
 Coma stage

[Link] STAGE:

 This lasts 10- 20 seconds, during which:

 The eyes Roll or stare.
 The face and hand muscles may twitch.
 There is a Joss of consciousness.

[Link] STAGE:

 This lasts 10-20 seconds during which:

 The muscles go stiff or rigid.
 The diaphragm is in spasm so that breathing stops and the color of skin becomes blue or
dusky.
 The back may be arched..
 The teeth are clenched.
 The eyes bulge

[Link] STAGE

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 This lasts 1-2 minutes and is marked by:

 Violent contraction and relaxation of the muscles.
 Increased saliva causes "foaming" at the mouth.
 Deep, noisy breathing.
 Inhalation of mucous or salvia
 The face looks congested (filled with blood) and swollen.
 Tongue is bitten by violent action of the jaws.

4. COMA STAGE:

 This is last minutes or hours during this time.

 There is a deep state of unconsciousness.

 Breathing is noisy and rapid.
 Cyanosis of face but the face remains congested and swollen
 Further regains consciousness.

INVESTIGATIONS:

 Hemoglobin estimation and blood film

 Blood urea.
 Serum urea acid.
 Serum creatinine.
 Serum electrolysis is done daily to detect acidosis.
 Platelet count and fibrinogen level are done in patient with increased bleeding tendency
Complete urine analysis.
 High vaginal swab for culture and sensitivity.
 Liver function test is done where indicated.

MANAGEMENT:

The aims of management are as follows

 Prevention of convulsion.
1. To relive the generalized vascular spasm and increase blood flow to kidneys
brain and uterus.
 To decrease sensitivity of brain to external stimulation
 To reduced blood pressure to normal range for the patient.
 To aid in elimination of retained water and electrolytes.
 Timely delivery of the fetus.
 Prevention of complications.

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PREVENTION:

 Eclampsia can be prevented if.

 Proper staffs in antenatal clinic are available to all patients.
 All pregnant women are instructed to attend antenatal clinics regularly from early pregnancy.
 The first signs of pregnancy induced hypertension are recognized and treated.
 Sufficient prenatal beds should be available so that early treatment can be instituted.
 Prophylactic MgS04 in sever Pre-eclampsia.

MANAGEMENT OF PATIENT WITH FITS:

AT HOME:

 The patient should be transferred to hospital as soon as possible.

 Clear the airway.
 Prevent injury.
 Tight cloth loosened.
 Attach bed to the wall
 Never leave patient alone.
 Remove denture and hairpins.
 Turn patient head one side. place a paddle spoon or spatula between teeth to prevent tongue
biting.
1. Sedate á patient with diazepam, Valium Phenergan intra venously or
intra muscular should administrator 30 minutes before moving the pa-
tient.
 Keep patient in lateral position.
 Transfer patient to hospital as soon as possible and midwife should accompany her patient to
hospital.

AT HOSPITAL:

 Receive patient in quite and darkroom

 One staff must remain with patient
 Inform doctors as soon as patient arrives at unit.
 Clear and maintain the patient anyway by insertion of an airway by placing the mother in
semi prone position in order to facilitate the drainage of saliva and vomits.
 Never do any procedure or treatment until the patient is well sedated.
 Record the blood pressure, 1emperature plus and respiration
 Shave the vałva and insert-indwelling catheter to measure urinary out put.
 Examine urine protein.
 Clean the mouth regularly.
 Immediately prepare things to deal and emergency.

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 No enema or suppository should be given until the active convulsion stage is under control,
which is with in 48 hours.

Important consideration in caring for a women with eclampsia or pre -eclampsia

DO not leave the women on her own

 Help her into left side position and protect her fall and injury

 Place padded tongue blades between her teeth to prevent a tongue bite , and secure it to pre-
vent aspiration (do not try this during a convulsion )

THE 0NLY EFFECTIVE TREATMENT FOR ECLAMPSIA IS DELIVERY

 Give magnesium sulphate slowly over 20 minutes. Rapid injection can cause respiratory fail-
ure or death
 If respiratory depression breathing less than 16/min occurs after magnesium sulphate do not
give any more magnesium sulphate. Give the antidote: calcium gluconate 1 gram IV 10ml
of 10 percent solution over 10 minutes.
 Do not give IV fluids rapidly

REFER URGENTLY TO HOSPITAL UNLESS DELIVERY IS IMMINENT

 If delivery is imminent deliver the baby first and accompany the women during transport to
the hospital

 Keep her in the left side position

 If a convulsion occurs during the journey, give magnesium sulphate and protect her from fall
or injury

EQUIPMENT NEEDED FORMANAGEMENT OF ECLAMPSIA.

 BP Apparatus.
 Stethoscope
 Suction apparatus.
 Tracheotomy set
 Block for foot of the bed
 Kidney basin and gauze for wiping of vomiting.
 Tray containing 1- spatula- airways. 3-swab holder 4- gauze pieces.
 Sterile syringes and needles for giving large and small injection.
 Feeding cup.
 Delivery trolley,

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 A cot and equipment for resuscitation of baby.

 Drug the may be required should be made ready.
 Dextrose solution 5% and l0% of (1000cc or 500 cc bags).
 Dextrose 25% ampoules.
 Antibiotic
 Cardiac and respiratory stimulants methodic 10-30mg.

MANAGEMENT DURING LABOR:

First stage:

 Labor should be induced by rupturing the membrane at 38 weeks.

 Syntocinon drop should be start.
 Check patient vital sign (temp . H/R. R/R)
 Check blood pressure 1/2 hourly.
 Check fatal heart chart 1/2hourly.
 Fluid input / out put chart maintain.
 Patient should never leave alone.
 Patient should keep in left lateral position.

Second stage:

 Delivery with forceps or vaccum extractor.

 Never give Methergin

Third stage:

 Active management of 3 stage

 If conditions getting worse C-section performs after fits are under control
 Inform the Peadiatrition If need then resuscitate.
 Check the bleeding.

COMPLICATIONS OF ECLAMPSIA:

 Cerebral hemorrhage
 Cerebral thrombosis.
 Injures to the tongue.
 Fractures.
 Acute renal failure.
 Temporary blindness
 Asphyxia.
 Pulmonary edema
 Bronchia pneumonia

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 Baby may be asphyxiated or still birth.

 Myocardial failure.

CAUSES OF DEATH IN ECLAMPSLA: Cerebral hemorrhage

 Myocardial failure
 Pulmonary oedema
 Acute renal failure
 Aspiration pneumonia

BLEEDING IN LATE PREGNANCY:

DEFINITION:
ANTEPARTUM HAEMORRHAGE
DEFINITION:
Antepartum haenmorrhage is defined as "bleeding from the genital tract during pregnancy after 24
weeks (WIHO defines it as 22 weeks) and before the birth of the baby.
CAUSES OF ANTETARTUM IHAEMORRHAGE:
 Cervical lesions
 Cervical polyps
 Cervicitis
 Cervical carcinoma
Placental bleeding
 Placentał abruptio
 Placenta Previa
 Placental edge bleeding
Uterine bleeding
 Lower segment scar rupture
 Rupture of other scars (myomectomy)
 Vasa previa
 Coagulopathy
 Heavy show
 PLACENTA PREVIA
 When placenta is implanted, (partially or wholly) in the lower uterine segment is called pla-
centa previa and its separatlón may result in ante partum hacmorrhage.
CAUSES OF PLACENTA PREVIA:
 Sub involution of utreus
 Multipie pregnancy with large placenta

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 multiparity
 High risk over the age of 35 years.
 Placenta membrane (villi embeds in the lower uterine segment.)
 Previous C-section

TYPES OF PLACENTA PREYIA

1.
Type one or lateral:
When placenta is in lower segment but does not reach the internal Os, in this
vaginal delivery is possible and, bloód loss usually mild and mother and fetus.
remain in good coudition.
2. Type two or Marginal:
Placenta is at the margin of the internal Os in this also vaginal delivery is
possible and blood loss is moderate.
3. Type three or Incomplete:
4. Type four or complete:
Center of placenta lies over the center of internal Os, it covers the entire Os cven
at fully dilatation. Vaginal delivery is not possible C-section is necessary
CLINICAL FEATUREŠ OR SIGNS AND SYMPTOMS:
 Histories of vaginal bleeding in early weeks of pregnancy occasionally the first bleed may be
very sever.
 Painless, causeless, recurrent and unavoidable bleedingin last trimester of pregnancy oc-
curs.

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 Bleeding usually occurs during or in sleep at night without pain and there may be history of
coitus.
 Fetal heart sound and movements are normtaand fetus is easily palpable.
 Sign & symptoms of sever haemorrhage shock present.
 On abdominal examination the utreus is felt soft
 If the placenta is found low lying when scan is repeated at 32 weeks. This is due to
developed of lower segment aid relative movenent of placenta tovard more fundal position
and the fetus may have oblique or transverse lie high head or breech presentation.
 There is no rigídity or Tenderness on abdominal palpation.
 Vaginal Examinatịonis never done except in the operation theater with all facilities to
perform immediate c-section.
Ulrasound identifies the position of the placenta.
ACTỊVE TREATMENT DEPENDS UPON:
 Amount of blood loss
 General condition of the mother.
 Whether she is in labor or not.
 Duration of pregnancy,
 Whether fetus is alive or dead.
 Response lo the treatment
 Place where the pt is seen.
 If she is in hospital immediate admit her
ACTIVE TREATMENT:
Immediare delivery with blood transfusion.
Neonatal ICU
CONSERVATIVE TREATMENT:
 Monitor the pregnancy in hospital
 OR As frequent out patient visits
 Give steroids
 Deliver at or near term
MANAGEMENTAT HOSPITAL:
 Inform doctor.
 Reassurance to the patient, keep her flat in bed
 If sign of shock treat her for shock
 Check vital sign and record it.
 Check her HB% and blood group cross match anđ arrange two pint of blood.
 If she is in labor and she is G i, ii iv cesaarien section should be done.
 No per vaginal examination should be done
 In type I membrane is ruptured to start oxytocin drip for speed up delivery.
 Save pads to assess amoun'of blood loss.
 Shave abdomen:

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 Empty her bladder.

 Monitor FHS and administer 02 if fetal distress.
 NPO the patient take consent for operation
 Plugging vagina to control bleeding should be avoided.
 If patient does not response to therapy & she is< 38weeks and not in labor then C- section is
performed.
 After delivery post partum haemorhage may be controlled by oxytocin drip.
 Hysterectomy may be needed if bleeding is not controlled.
 The most common cause of death in APH is PPH.
 About 10% fetal mortality is due to hypoxia and asphyxia due to placental separation.
 Prematurity is common cause.
 Fetal abnormalities arc also common in placenta previa.
 Bleeding occur due to premature separations of placenta which is normally situated in upper
uterine segment. It is an accidental occurrence of hemorrhagic.
 Placental abrupt is accidental hemorrhage it is the hemorrhagic due to partial or complete
 Premature separation of placenta. normally situated in upper uterine segment after 24 week of
pregnancy.

CAUSES OF PLACENTAL ABRUPTION:

 High parity and anemia

 Pre eclamptic toxenmia and' ecampsia.
 Renal disease.
 Trauma such as fall, kick. accident and external version direct below
 Physiological shock, short cord.
 Poly hydramnios.
 Preterm and premature rupture of membrane.
 Rero placental fibroid
 Or sudden release of poly hydramnios
 Folic acid de deficiency may be the cause

TYPES OF PLACENTAL ABRUPTION:

INTERNAL ORCONCEALED:

 In which vaginal bleeding is not seen through vagina, blood retained in the uterus and may
 Cause uterine enlargement and extreme pain and coagulopathy and maternal morbidity.

EXTERNAL OR REVEALED

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 In this the blood collects as a retroplacental clot behind the placenta. There will be evidence
of external bleeding. This is the most severe form, often the fetus dies in uterus before admis-
sion to the hospital.

MIXED TYPE :

 In this type there are some retro placental collection and the rest trickling out as dark red
Bleeding with clot.

S/S OF CONCEALED HAEMORRHAGE:

 NO bleeding through vagina or bleeding from vagina is slight or may be absent, color bleed-
ing is dark.
 Continuous severs uterus enlargement and sudden abdominal pain.
 Uterus is hard, rigid and tender.
 Fetal heart sound can be heard with difficulty.
 Fetal parts difficult to palpate.
 Excessive or cessation of fetal movement.
 Rapid and weak pulse and low blood pressure.
 She is restless.
 High incidence of still birth due to large part of placental separation
 Cold and moist skin.

S/S OF REVEALED HAEMORRHAGE:

 Escape of blood through vagina.

 Normally uterus size corresponds to gestational
 Normally consistence.
 No difficulty in fetal part palpation.
 Fetal heart sound can easily be heard.
 Excessive or cessation of fetal movement
 Slight abdominal pain and discomfort
 Low incidence of still birth due to šmall portion of placental separation.
 Hx of trauma and Hypertension.

DIFFERENTIAL DÌAGNOSIS:

 Ectopic pregnancy.
 Spontanous rupture of the uterus.
 Acute poly hydramnios.
 Acute appendicitis.
 Peritonitis.
 Intestinal obstruction.

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 PREVENTIVE TREATMENT:
 Good antenatal care.
 Prevention of anemia.
 Hospital booking for patient liable to have ante partum hemorrhage.
 Avoidance of trauma.
 Avoidance of sudden decompression in Polyhydamnios.
 Early detection and treatment of pregnancy induced hypertension.

CURATIVE TREATMENT:

 1f fetus is alive:
 Admit patient in labor room for close monitoring.
 Send blood for group and RH factors, cross match. and HB% and FOR BT/CT
 Monitor vital sign and record it
 Monitor FH.S continuously.
 Start a large bore I\V infusion lines with Ringer lactate solution,
 Tract for shack if present.
 Replace blood loss and correct hypovolumic adequate fresh blood Transfusion
 Record TO chart.
 Patient may need oxygen if fetal distress.
 Immediate C-section to save fetus.

ARRANGE FOR BABY:

 Prepare resuscitation trolley and emergency drugs.

 Inform pediatrician.
 No vaginal examination is done to exclude placenta previa
 1f patient is in labor membrane is ruptured in OT t speed up delivery as early as possible and
 to avoid hypofibrinogeneamia and renal necrosis
 Syntocinon drip may be started to speed up labor.

AFTER DELIVERY:

 If bleeding continuous concentrate plasma should be given to prevent hypo fibrinogeneamia.

 Oxytocin should be given in liberal amount to encourage uterine contraction.
 Biannual compression Tor massage is done to stop bleeding.
 If bleeding doesn’t stop hysterectomy may be performed.

COMPLICATIONS

 Post partum hemorrhage.

 Shock leading to acute renal failure.
 Prematurity

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 Hypofebimogeneamia.
 Anemia
 Intra uterine death Transfusion hepatitis

HYPOFIBRINOGENAEMIA:-

 A low or deficient level of fibrinogen in the blood

 This is a situation in which there is deficiency of fibrinogen in the blood. occurs during or af-
ter delivery (PPH) Dysfibrinogenemia is marked by functional abnormalities of fibrinogen
that may result in either bleeding or thrombosis.

Causes:

 Abruption.
 Intra uterine death
 Amniotic fluid embolism
 Missed abortion

Diagnosis:

 Clotting of blood normally occurs in 5-10 minute in this clot doesn't from
 With fibrinogen levels less than 0.1 g/L, bleeding manifestation ringe from mild to severe.
 Umbilical cord hemorrhage frequently provides an early alert to the abnormality (factor Xiii
 deficiency is the other congenital bleeding disorder.) Other bleeding manifestations include
the following:
 Epistaxis and oral mucosal bleeding
 Hemothrosis
 Menorrhagia and postpartum hemorrhage
 Traumatic and surgical bleeding
 Spontaneous splenic rupture and intracranial hemorrhage (rare)

VAGINAL BLEEDING:

In patients with hypofibrinogenemia bleeding episodes are usually mild and, in many cases.

no spontaneous clínical bleeding is present; these patients may bleed following trauma or

surgery,

TREATMENT:
PREVENTION AND CAREFUL TREATMENT TO PREVENT PPHMONITOR MATER-
NAL VITAL SIGN

 Note any, sign of renal failure.

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 For patients with clinical bleeding associated with afibrinogenemia or dysfibrinogenemia.

 replacement of fibrinogen to 'a level of 0,5-0.8 g/L is usually adequate to maintain hemosta-
sis.
 Patients presenting with thrombosis associated with dysfibrinogenemia should be provided
 anticoagulation therapy.
 Spontaneous abortion: Recurrent spontaneous abortion may be prevented by routine prophy-
laxis with, fibrinogen replacement therapy during pregnancy.
 To prevent excessive bleeding during surgical procedures, prophylactic treatment to raise
 fibrinogen levels to 0.5-1 g/L is recommended.

TOXEMIA OF PREGNANCY:-

Pre Eclampsia is a disorder that occurs only during pregnancy and the postpartum period and affects
both the Mother aNd the unborn baby. Affecting, ať least:5-8% of all pregnancies, "it is a rapidly
progressive condition characterized by

 High blood pressure

 Presence of protein in the urine.
 Swelling. sudden weight gain,
 Headaches and changes in vision
 Typically. preeclampsia occurs after 20 weeks gestation (in the late 2nd or 3 rd trimester rs or
 middle to late pregnancy). though it can occur earlier.
 1f it appears in the first half of the pregnancy it is due to Hydatidilform mole In normal
 pregnancy the blood pressure falls below-non pregnant level in the second trimester
 Proper prenatal, care is essential to diagnose and manage preeclampsia preeclampsia. Preg-
nancy Induced Hypertension (PIH) and toxemia are closely related condition. HELLP Syn-
drome and eclampsia are other manifestations of the same syndrome.
 Preeclampsia and other hypertensive disorders of pregnancy leading global cause of
 maternal and infant illness and death.

CAUSES:

Are unknown but patient who suffers from pre eclampsia iš:

 Elderly primi.
 Multiple pregnancy
 Hydatidifom mole.
 Kidney diseases.
 Diabetic Mellitus
 Polyhydraminos
 Hereditary
 Malnutrition especially reduced protein intake.

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 Patient of essential hypertension

TYPES OF PREGNANCY INDUCED HYPERTENSION.

Potential Hypertension:

 Hypertension is the rise of diastolic blood pressure to 90mnHg on two occasions more than
six,hours apart.
 Blood pressure is raised 45mnmnHg above first trimester or pre-pregnant level.

Mild Hypertension:

 Diastolic B.P 90-99mmHg

 Systolic B.P: 140mmHg.

Moderate Hypertension:

 Diastolic B.P: İ00-110 mm Hg.

 Systolic B.P: 140 -170 mm Hg.
 There is also oedema the level of protein is 30-300mg / 100ml.

Severe Htypertension:

 Diastolic> 110mm Hg.

 Systolic > 170 nm Hg.

There is also associated gross oedema protein is more than 300ng/l00ml.

SIGN AND SYMPTOM OR CLINICAL FEATURES

1. HYPERTENSION:

Potential mild moderate severe

WEIGHT GAIN

Mild

Average weight gain 10-12 kg

Increase of 2kg per month - 0.5 kg in last trimester .A gain of more. than 0.75kg per week is

Pathological (due to occult oedema).

3 OEDEMA

 Ist appears near the ankles than around the eyes especially on getting up in the morning.
 Fingers may become swollen: fate become puffy then generalized oedema on whole body.

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 If patient is confined, to bed then oedema appears on scrum.

4. PROTEIN UREA

 Proteinuria is the result of proteins, normally confined to the blood, spilling into your urine
because the small blood vessels in the kidneys become damaged. A simple dipstick test of
your urine at each prenatal check-up can screen for proteinuria. 1-10gm protein may be
passed in a days. Mid stream urine should be tested as vaginal discharge may contain pro-
teins.

5The uterus may be small for dates.

6. GIT SYMPTOMS

There is nausea, vomiting, epigastric pain hepatic enlargement and tenderness.

7. BLURRING OF VISION.

8. TWITCHING OF MUSCLES.

9. FUNDOSCOPY will show.

Retinal hemorrhagic, retinal detachment, vascular narrowing and shining edematous retina

indicate cerebral oedema and fits.

10. HEADACHES

Dull, throbbing headaches, often described as migraine-like that just won't go away:

11, CONVULSION:

Violent involuntary contraction of voluntary muscles.

Symptoms are usually late to appear and are headache, vertigo, irritability, convulsion and coma.

AIMS OF RX

 To control blood pressure.

 Prevent complication
 Detect ILUGR & prevent IUD.
 GENERAL MANAGEMENT OF PRE-ECLAMPSLA:
- PREVENTION:

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 High protein diet and calcium supplements.

 Early diagnosis and proper management
 Good antenatal care
 Screening and special care for high-risk patients such s primigravida, grandmultipara.
 molar pregnancy and family history of eclampsia and chronic hypertension.

2- MEDICAL

Rest:

 It lowers cardiac out put and blood pressure fall.

 Reduces oedema
 Improves blood circulation to uterus and placenta.
 Rest in let lateral position is recommended due to uterine obliquity and Presence of inferior
 venacava on the right side
 Rest also decreases protein urea.

Sedation:

To facilitate mental and physical rest, Best sedation is

 Phenobarbital orally IM. IV according to severity. It is safe in pregnancy 120-240 mg

 /day.
 Diazepam,( Valium): second dug of choice Dose 20-40 mg/day.
 Diuretics: should no used as they are harmful to fetus and mother.
 They reduce the blood volume and decrease placental circulation but in severe oedema they
 may be used e.g. lasix-diazide-1

Anti hypertensive:

 Methyldopa (Aldomat): Is the drug of choice, it reduces both systolic and diastolic blood
pressure. Major side effect of aldomat is Sedation, postural hypotension, light-headedness.
 bradycardia,
 hemolytic anemia and depression. It reduces placental blood flow causes slowing of fetal
heart rate. 0.5 to 5mg can be given in severity
 Mifedipine (Adalat): It is used sublingually in PIH.

[Link]:

it is decided while considering following features,

 Severity of PIH.
 State of cervix,
 Maturity of fetus.

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 Parity.
 Obstetrical history

4. DỊET:

 High protein diet consisting of milk, meat, fish, fruits, vegetable are recommended.
 Carbohydrates e.g. rice, bread, sweets. are restricted to reduced weight gain.
 If oedema then fluid intake is reduces.
 When inducing labor by using drip the amount of fluid is carefully controlled.
 Prenatal vitamins and calcium supplements should be prescribed.

5. BOWELS:

 Bowel should move every day but strong purgative and enema should not be used.

OBSTETRICAL MANAGEMENT:

 Obstetrical management will be depending upon the severity of the disease, response to
treatments, stage of pregnancy, previous obstetrical history and condition of the cervix.
 "First stage of labor: Labor should be induced by rupturing the membranes at 38 weeks.
 Syntocinon drip should be started if there is delay.

Observe for:

 Uterine contraction.
 Dilatation, of cervix
 Blood' pressure h hourly.
 Fetal heart sound hourly.
 Fluid I/O chart maintains
 Patient should never be left alone.
 Patient should nurse in left lateral position.
 She should be in complete bed rest.
 Emergency kit or tray for eclamptic patient should be kept ready'in LR.
 Caesarean section if CPD/ precious baby/ failure of surgical induction/Poor Bishop's score!

SECOND STAGE OF LABOR:

 Expedite delivery.
 . Forceps delivery is advice to prevent intrapartum eclampsia,
 Third stage of labor:
 Methergin is not used it may rise the blood pressure.
 Fluid overload should be avoided.
 Patient should be observed for postpartum hemorrhage./Active management of
3 STAGE.

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 Baby may need resuscitation

COMPLICATIONS:
 1-Maternal
 Eclampsia
 Hepatic failure.
 Anuria and renal failure.
 DIC
 Hyperpyrexia.
 Intracranial hemorrhage.
 Accidental hemorrhage.
 During delivery APH and PPH.
 2-Fetal
 Placental insufficiency may cause TUD.
 Placental separation leads to fetal distress.

CHECK FOR PRE-ECLAMPSIA:

ASK: LOOK & FEEL

Measure blood pressure in sitting position
If diastolic blood pressure is 90mmHg or greater
Repeat after 1 hour rest and

DO YOU HAVE-
Severe headache
Blurred vision
Epigastric pain check protein in urine

IF ABNORMAL

SIGNS CLASSIFY TREAT & ADVISE

Diastolic blood pressure SEVERE GIVE MAGNESIU SUL-
110mmHg or greater and 3+ PRE-ECLAMPSIA PHATE
proteinuria REFER URGENTLY TO
HOSPITAL
Or

Diastolic blood pressure

90mmHg or greater and 2=
proteinuria and any of

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Severe headache
Blurred vision
Epigastric pain
Diastolic blood pressure 90- PRE=ECLAMPSIA REFER TO HOSPITAL
110mmHg on two readings
and 2+ proteinuria
Diastolic blood pressure HYPERTENSION ADVISE TO REDUCE
90mmHg or greater on two WORKLOAD AND REST
settings Advise on danger signs
Reassess at the next antenatal
visit or in 1 week if >8 months
pregnant.
If hypertension persist after 1
week or at next visit, refer to
hospital or discuss case with
doctor or midwife if available

DEFINTION:
 Eclampsia is an extremely dangerous complication of severe pregnancy, induced hyperten-
sion
 (Pre eclaimpsia). Convulsions andcomas. characterize it. it may occur during pregnancy
 (Antepartum) during labor (intra partum) after delivery (postpartum)
 It is more common in primigravida with a history of eclampsia, hypertension and wins preg-
nancy.

Clinical features or sign symptoms:

 No improvement in pre-eclampsia
 Severe headache.
 Visual disturbances like blurring of vision and spots of light before eyes.
 Rolling of eyes.
 Twitching of eye lids and face.
 Epigasiric pain.
 Vomiting’s.
 Oligouria.
 Massive oedema of face, hands, abdominal walls and legs.
 Restlessness agitation.
 Tachypnea with acidosis.
 Hyperpyrexia is often present.
 Protein uria, Oligouria or even anuria in severe cases

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 Fits: commonly occur at irregular interval but in severe cases may occur in rapid succession.
 Coma (unconscious): coma is. assisted by GCS

STAGES OF ECLAMPTIC FITŞ:

There are four slages of eclampti fis;

 Premonitory stage
 Tonic stage
 Clonic stage
 Coma stage

[Link] stage:

 This lasTs, 20 seconds, during which:

 The eyès Roll or stare.
 Thè face and hand muscles may twitch.
 Thẹre is a Joss of consciousness.

Tonic stage:

 This lasts 10-20 seconds during which:

 The muscles go stiff or [Link] diaphragm is in spasm so that breathing stops and the color
of skin becomes blue or dusky.
 The back may be arched..
 The teeth are clenched.
 The eyes bulge

[Link] stage

 This lasts 1-2 minutes and is marked by:

 Violent contraction and relaxation of the muscles.
 Increased saliva causes "foaming" at the mouth.
 Deep, noisy breathing.
 Inhalation of mucous or salvia
 The face looks congested (filled with blood) and swollen.
 Tongue is bitten by violent action of the jaws.

4. Coma stage:

 This is last minutes or hours during this time.

 There is a deep state of unconsciousness.
 Breathing is noisy and rapid.

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 Cyanosis of face but the face remains congested and swollen

 Further regains consciousness.

INVESTIGATIONS:

 Hemoglobin estimation and blood film

 Blood urea.
 Serum uria acid.
 Serum creatinine.
 Serum electrolysis is done daily tỏ detect acidosis.
 Platelet count and fibrinogen level are done in patient with increased bleeding tendency
 Complete urine analysis.
 High vaginal swab for culture and sensitivity.
 Liver function tèst isdone where indicated.

MANAGEMENT:

The aims of management are as follows

 Prevention of convulsion.
 To relive the generalized vascular spasm and increase blood flow to kidneys brain and uterus.
 To decrease sensitivity of brain to external stimulation
 To reduced blood pressur normal range for the patient.
 To aid in elimination of retained water and electrolytes.
 Timely delivery of the fetus.
 Prevention of complications.

PREVENTION:

 Eclampsia can be prevented if.

 Proper staffs in antenatal clinic are available to all patients.
 All pregnant women are instructed to attend antenatal clinics regularly from early pregnancy.
 The first signs of pregnancy induced hypertension are recognized and treated.
 Sufficient prenatal beds should be available so that early treatment can be instituted.
 Prophylactic MgS04 in sever Pre-eclampsia.
MANAGEMENT OFPATIENT WITH FITS:

At home:

 The patient should be transferred to hospital as soon as possible.

 Clear the airway.
 Prevent injury.
 Tight cloth loosened.

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 Attach bed to the wall

 Never leave patient alone.
 Remove denture and hairpins.
 Turn patient head one side. place a paddle spoon or spatula between teeth to prevent
tongue biting.
 Sedate á patient with diazepam, Valium Phenergan intra, venously or intra muscular should
administrator 30 minutes before moving the patient.
 Keep patient in lateral position.
 Transfer patient to hospital as soon as possible and midwife should accompany her patient to
hospital.

At hospital:

 Receive patient in quite and darkroom

 One staff must remain with patient
 Inform doctors as soon as patient arrives at unit.
 Clear and maintain the patient anway by insertion of an airway by placing the mother in semi
prone position in orderto facilitate the drainage of saliva and vomits.
 Never do any procedure or treatment until the patient is well sedated.
 Record the bloodpressure, 1emperature plus and respiration
 Shave the vałva and insert-indwelling catheter to measure urinary out put.
 Examine urine protein.
 Clean the mouth regularly.
 Immediately prepare things to deal and emergency.
 No enema or suppository should be given until the active convulsion stage is under con-
trol,whichis with in 48 hours.

Important consideration in caring for a women with eclampsia or pre -eclampsia

DO not leave the women on her own

 Help her into left side position and protect her fall and injury
 Place padded tongue blades between her teeth to prevent a tongue bite , and secure it to pre-
vent aspiration (do not try this during a convulsion )
 The 0nly effective treatment for eclampsia is delivery
 Give magnesium sulphate slowly over 20 minutes. Rapid injection can cause respiratory fail-
ure or death
 If respiratory depression breathing less than 16/min occurs after magnesium sulphate do not
give any more magnesium sulphate. Give the antidote: calcium gluconate 1 gram IV 10ml of
10 percent solution over 10 minutes.
 Do not give IV fluids rapidly
 Refer urgently to hospital unless delivery is imminent

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 If delivery is imminent deliver the baby first and accompany the women during transport to
the hospital
 Keep her in the left side position
 If a convulsion occurs during the journey, give magnesium sulphate and protect her from fall
or injury

EQUIPMENT NEEDED FORMANAGEMENT OF ECLAMPSIA.

 BP Apparatus.
 Stethoscope
 Suction apparatus.
 Tracheotomy set
 Block for foot of the bed
 Kidney basin and gauze for wiping of vomiting.
 Tray containing 1- spatula- airways. 3-swab holder 4- gauze pieces.
 Sterile syringes andneedles for giving large and small injection.
 Feeding cup.
 Delivery trolley,
 A cot and equipment for resuscitation of baby.
 Drug the may be required should be made ready.
 Dextrose solution 5% and l0% of (1000cc or 500 cc bags).
 Dextrose 25% ampoules.
 Antibiotic
 Cardiac and respiratory stimulants methodic 10-30mg.

MANAGEMENT DURING LABOR:

FIRST STAGE:

 Labor should be induced by rupturing the membrane at 38 weeks.

 Syntocinon drop should be start.

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 Check patient vital sign (temp . H/R. R/R)

 Check blood pressure 1/2 hourly.
 Check fatal heart chart 1/2hourly.
 Fluid input / out put chart maintain.
 Patient should never leave alone.
 Patient should keep in left lateral position.

SECOND STAGE:

 Delivery with forceps or vaccum Extractor.

 Never give Methergin

THIRD STAGE:

 Active management of 3 stage

 If conditions getting worse C-section performs after fits are under control
 Inform the Peadiatrition If need then resuscitate.
 Check the bleeding.

COMPLICATIONS OF ECLAMPSIA:

 Cerebral hemorrhage
 Cerebral thrombosis.
 Injures to the tongue.
 Fractures.
 Acute renal failure.
 Temporary blindness
 Asphyxia.
 Pulmonary edema
 Bronchia pneumonia
 Baby may be asphyxiated or still birth.
 Myocardial failure.

CAUSES OF DEATH IN ECLAMPSLA:

• Cerebral hemorrhage
• Myocardial failure
• Pulmonary oedema
• Acute renal failure
• Aspiration pneumonia
• Give magnesium sulphate
If eclampsia or severe pre-eclampsia
 IVAM combined dose (loadingdose)

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 Insert IV-line and give fluids slowly (normal saline or Ringer’s lactate)
 Give 4 g of magnesium sulphate (20 ml of 20% MgSO4 solution) IV slowly over 5-10
minutes. (Patient may feel warm during injection.
 AND:
 Give 10 g of magnesium sulphate IM: give 5 g (10 ml of 50% MgSO4 solution) IM Beep in
upper outer quadrant of each buttock with 1mlof2%lignocaineinthe same syringe
 If unable to give IV, give IM only(loading dose)
 Give 10 g of magnesium sulphate IM: give 5 g (10 ml of 50% MgSO4 solution) IM deep in
upper outer quadrant of each buttock with 1mlof2%lignocaineinthegalitesyringe.
If convulsions persist/recur
 After 15minutes give an Additional 2g of magnesium sulphate
(10mlof20%MgSO4solution)IV over [Link] convulsions still continue ,give diazepam.

IF REFERRAL IS DELAYED FOR LONG OR THE WOMEN IS IN LATE LABOUR

,CONTINUE TREATMENT

 Give 5 grams of 50% magnesium sulphate solution with 1 ml of 2% lignocaine

every 4 hours in alternate buttocks until 24hours after birth or after last convul-
sion(whichever is later).
 Monitor urine output: collect urine and measure the quantity
 Before giving the next dose of magnesium sulphate, ensure:knee jerk is present
urine output>100ml/4hrsrespiratoryrate>1

Formulation of magnesium sulphate

Dose 50%solution: 20%solution:

Viral containing 5g in To make 10 ml of 20 %solution , add
10ml(1g/2ml) 4mlof 50%solutionto6mlof sterile

IM 5G 10 ml and 1 ml
2%lignocaine

IV 4G 8ml 20ml

IV 2G 4ml 10ml

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After receiving magnesium sulphate a woman may feel flushing, thirst,headache,nausea or may
vomit.

HYPEREMESISGRAVIDUM

DEFINITION:

If the vomiting is sever enough to disturb a woman’s routine activity and required hospitalization, it
is termed Hyperemesisgravidarum.

CLINICALFEATURES:
 Loss of [Link] of dehydration with dry skin.
 Tongue is dry and furred
 Rise in pulse rate .Fall in bloo d pressure .Breat he sme lls o f acet one.
 Epigast r ia t ender ness.
 Temperat ure may st art r ising.
 Jaund ice
 Halment hias is.

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 Drowsiness oron fusio [Link] and ret inal hemorr hage.

 Tenderness in legs with various palsies and signs of peripheral neuritis. Encephalopathy de-
velop sultimately and the patient may become coma tose and die.
INVESTIGATION:
 Electrolytes with show imbalance particularly reduction of plasma, sodium chloride and Po-
tassium.
 Blood urea is raised.
 Urine is concentrated and there is Oliguria.
 Urine contains acetone, albumin and bile chlorides are diminished.
 TREATMENT:-
 Reassurance and explanation.

 Diet Control in early cases should be tried first.

 Small carbohydrate meals should be taken at short [Link] treated

Fatty food is avoided.

 For making sickness something in the form of to astor biscuits should be taken while getting
up from the bed
 Restricting all visitors including husband may cause abrupt recovery.
 Sympathetic attitude of the nursing staff is of great help and may lead to drama improve-
ment when the cause is psychological.
 Hydatidi form mole should be excluded,
 Other possible cause should be excluded i.e. pregnancy induce hypertension, pylo nephri-
tis.
 Gastroenteritis peptic ulcer, intestinal obstruction, appendicitis. infectious hepatitis and
twisted ovarian.
 Fluid balance chart is maintained, normal urinary output and return of weight gain are si-
gnof recovery.
 Antihistamines which are not teratogen 25mg. cyclonite 5Omg or promethazine 25mg
threetime a day should be used. if oral antiemetic are not effective the inject able should
be used.
 Blood pressure should be check at last twice a day
 Intravenous infusion of dextrose salino is given three litters in 24 hours.
 Blood urea and electrolytes are checked and imbalanced is corrected
 Oral feeding is started only when she has stopped vomiting processing to semisolids and
then to full diet.
 Dehydration and ketosis should be corrected
 Adequate sedation is given to ensure rest
 Oral hygiene is looked after by frequent mouth washes
 Neuro pathy is prevented by giving vitamins Bandvitamin B6 100mgper day

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 If above measure fail to control vomiting the possibility of therapeutic abortion should be
considered.

 DISEASES DURING PREGNANCY:

CARDIAC:

 Most common heart lesion seen in pregnancy was mitral stenosis related to rheumatic fe-
ver or chore in childhood, but congenital heart disease (CHD) more formative majority of
cases.
 When patients pregnancy is diagnose das case of heart disease obstetrician refer her to
cardiac specialist for concerned and pregnancy is carried out till term under both supervi-
sion.
 Cardiac disease may worsen in pregnancy due to an increase in body weight,which put
some extra strain on the heart.
 An increase in circulating blood volume and an increase of about 30% in cardiac output
maintain placental circulation.
 Upward pressure of growing uterus on the diaphragm which displaces and rotates the
[Link] the respiration.
 All these will put on additional strain on the heart muscles and cause heart failure, the
greatest strain isat28-32 wks of gestation as the cardiac output reaches its maximum.

GRADES OF DISEASE:

During antenatal visits cardiac patient are placed in one of the following grades.

 GI:Patients have no symptoms and no limitation of physical activity need only extra rest at
home.
 G2: Patient is comfortable at rest ordinary physical activities cause fatigue, palpitations and
dyspnea.G3The patient is comfortable at rest any activity causes palpitation. Dyspnea and
angina pain. G3 patient should be in hospital throughout the pregnancy
 G4: Even when resting the patient is dyspnic the condition of the patient must be assessed at
regular intervals throughout the pregnancy. G4 patients should not always be only in hospital
but on strict bed rest in hospital Diagnose:- It is done by history. sign of cardiac diseases are
Breathlessness Fatigue Swollen ankles Palpitation
 COMPLIACTION:
 Bacterial endocarditis
 Thrombo-emboli Heart failure.
 Fibrillation/Palpitation Cyanosis
 Fetal congenital heart disease

RDS ASPHYXIA MANAGEMENT:

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 Antenatal visit should be more frequent than usual.

 Advice for extra daily rest, as she may develop breathlessness and tachycardia
 Avoid excessive weight gain to avoid strain on heart.
 Weight patient regularly.
 Try to prevent excessive blood volume change.
 Restrict salt intake.
 Give high protein diet.
 Reduce carbohydrate.
 Attend teeth and gums regularly as infection may cause bacterial endocarditis.
 All febrile ill nessare dangerous,sulfonamides may be given as prophylactic.
 Anemia is common and may detoriet the condition so immediately treats it by1/m iron if
necessary. If signs of acute pulmonary edema apperie. Dyspnea, bronchospasm, palpita-
tion, server cough, odema of legs then it requires urgent treatment-

OBJECTIVES:
 Relieve anxiety →→Give sedative.
 Increases oxygenate
 Give O2 by mask
 Reduce blood volume by restricting fluid intake and salt.
 Relieve bronchospasm by I/Vaminophylline 250 mg.
 Control tachycardia by digoxin but watch pulse rate.

NSG CARE DURINGLABOR:

 Anxiety will cause tachycardia and breathlessness give liberal sedation.

 Observe pulse and respiratory rate every15-min.
 Monitor heart rate through out labour.
 Monitor and record colour, fluid balance, B.P, fetal condition and report any deviation from
normal to doctor.
 Encourage patient to adapt position in which she feels comfortable.
 Undue exertion and prolong pushing is dangerous so mid wife should teach patient to open
hermouth take deep breathing and natural urges to bear down will push head down
 She should be taught to cope with stress. Patient should be nursed in propped up position.
 If symptoms of failure occur givecontinueO2. If palpitation give digoxin bur record pulse
very carefully (If pulse is 110 or more & resp24/m).Due 10 possibility of infection.
 Induction of labour should be carried out very, carefully & depending on thc severity of
case,notrial of labor 2 STAGE Bearing down should be avoided, as normal uterine contrac-
tions are sufficient cause descent of the head.
 Episiotomy should be used to prevent any delay when perineum is distended Forceps and
vacuum is only used when delivery has not occurred 20mint after fully dilatation.

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 Cesarean section. If vaginal delivery is not feasible other wiseit should be avoided as strainof
operation & anesthetic succeeds that of vaginal delivery it should be done only in marked de-
lay or obstetric problem [Link] previa.
 3 STAGE Ergometrine are not advisable as a routine.
 Suturing of Epi is carried out under local anesthesia.
 As soon as delivery is complete patient should be propped up.
 During thẹ first 48hrs patient should be kept under observation, vital sign recorded q
[Link] baby forsign here ditary heart disease.
 After consulting cardiologist & obstretition advise her for Suitable family planning.
 The patient should have in hospital until all signs of failure have disappeared.
 The patient have Very little reserve and the effort involve in breast feeding should be avoid-
[Link] 250mg should be given twice throughout labour.
 Patient who is in grade 2 should avoid another pregnancy for couple of years.
 Patient who is in grade 3 or grade 4 should not have another pregnancy & should be offered
TL sterilization. DIABETIC:- It is a disorder of carbohydrate metabolism. It is caused by
lack of Insulin (secreted by pancreas) due to that glucose is not metabolized therefore glucose
increases in the blood & secreted in urine

GESTATIONAL DIABETIC:

 A term applied to diabetic appearing during pregnancy and is due to the insulin antagonis-
tic action of placental lactogenic Hormone and increased serum cortisone [Link]
women risk of developing diabetic during pregnancy.
 Identified,when they show one or more of the following signs
 Diabetes in close family [Link] abortion.
 Congenital abnormalities in previous children.
 Mother has given birth to large babies
 Polyhydramniose Gross obesity.
 Glycosuria finding on two occasions.
 Polyuria.
 Lossofweight.

DIAGNOSIS:

 Increased glucose urea.

 Tiredness.
 Excessive urine. Failure to gain wt.
 Fasting or random plasma glucose estimation.
 Fasting glucose normal value of 105 mg % or above or a random lev-
el120mg%,indicate the need for a full GTT random.

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 IGT Impaired glucose tolerance (amild form of diabetes) GIT Glucose Tolerance
test
 A 50gm oral glucose load is given to patient then blood sample obtained at intervals
for glucose estimation and results are composed with a normal range. If it is equal or
greatertha7.7 mm 01/L after one hour of glucose ingestion then further investigation
are under taken, Urine test Benedict’s test-clinic test.

EFFECT OF DIABETES ON PREGNANCY:

 When diabetes is well controlled its effects may be minimal.

 If control is not good then there may be complications,

During pregnancy: PIH. Polyhydramniose increased risk of abortion, preterm deliv-

[Link]. genito-urinary infection and vulvo-vaginitis.

Effect on fetus:

 IUGR Perinata lmortality increased

 Congenitalabnormalities(heart, kidney) Compensatory polycythemia (result in neona-
tal jaundice)RDS
 Larger babies (extra glucose producing more insulin baby fats and muscle mass)

DURING LABOR:

 Incidence of prolongs labor due to big baby large baby leads to mechanical dysto-
cia shoulder Dystocia,C.P.D,obstructed labor.
 Need for obstetrical intervention leads to forceps delivery C-section.
 During vaginal delivery incidence of injury to perineum and soft part.
 Risk of post partum hemorrhage
 The risk of infection is higher due to prolong labor & injuries to soft tissue.
 During puerperium: Risk of thrombophlebitis Puerperal sepsis
 Failure of establishment of satisfactory lactation

MANAGEMENT & NSGCARE:

 Advice woman to book herself with good hospital.

 Advice her to attend antenatal clinic more frequently usual monthly till 24 weeks-
15 days from 24-32weeks from 32 onwards
 Women should be advised about personal hygienic to prevent pruiriticvulva. She
should be advice to allow diabetic clinic.
 She should be advice to allow diabetic clinic

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 Patient may be admitted in hospital for control of diabetes & for rapid control of
any other obstetric or medical complication.
 Assess her progress in pregnant and detect any abnormality.
 Observe fetal growth and well being she may need repeated sonography.
 Look for medical problem like hydramniose, malpresentation & CPD.
 Regular investigation urine & blood for glucose.
 Teach patient for home monitoring of her blood glucose-level first in morning
then at regular interval.
 Glucose list kit contain a bit like pen, used to prick the end of yours finger and
draw a tiny amount of blood kit gives out a digital reading of blood sugar which
should recorded in diary and bring clear at antenatal clinic.

DIET INDIABETES:
 Avoid sugar in tea & amp; coffee, cakes, biscuits, sweets and junk food,tomato sauce setc.
 Eat highfiber food- peas,beans, vegetables, fruits. Cut down fatty food.
 At last trimester mother need 200cal,
 She can get this by rice, polalous rather than cake and biscuits. Adjust blood sugar levelbe-
low120mg% at all time.
 Teach techniques by disposable syringe. Her insulin self-administration At 37 wks of gesta-
tion a decision has to be made about the need for any obstetric intervention i.e. pregnancy
should be continue any awaiting for spontaneous onset of labor or pregnancy should be ter-
minate by safe method.
 Labor is only induced when baby as too large wait for spontaneous is advised to young prim-
igravdahaving no obstetric or medical complication and diabetes is well controlled with diet
along or requires small doses of insulin, multipara having no baby obstetric history and are
under satisfactory glycemia control.
 Before induction fetal pulmonary maturity should be assessed, glandin, ARM &amp; Oxyto-
cin infusion.

MANAGEMENT DURING LABOR:

CONTROL DIABETES:

 To achieve this 5% D/W infusion started with 10 units of soluble insulin blood glucose
checked regularly and dose of insulin is adjusted according.
 Try to maintain b/w 80-100mg% .
 Control latoacidis: Urine sample for taken bodies if present give 200to400 ml mg of sodi-
umbicarbonate1/v.
 Sedative & analgesic: Analgesic canbeused Epidural analgesic which is recommended dur-
ing labour
 Maintain partograrm: Observe & record all observation.

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 Fetal well-being should be maintained by Doppler or feto scope

 F.H.S should be monitored.
 If no progress in labour C section should be performed C section is also recommended for
diabetic mother because of heavy baby. If mother insist for normal then pelvic assessment
should be done.

In third stage:
 Cord should be clamp early to prevent hypervolemia in the [Link]+ Methergin
may be given to minimum blood lose. Examine placenta cord and membrane after these have
been expelled.

MANAGEMENT OF PUERPERIUM:

 After delivery insulin required so blood sugar should be evaluate and dose of insulin adjust-
[Link] not needed then it should be stopped.
 Encourage early ambulation to prevent thrombophlebitis.
 Prescribe antibiotics like Cap ampicillin 250mg or amoxicillin 250mg O.I.D to protect patient
frominfection.
 Promotelactation.
CARE OF NEWBORN:
 A pediatrician neonatologist should be present at the time of delivery to attend new bon from
the time of delivery.
 Baby should be kept under observation fọr 48 hrs.
 Neonate of a diabetic mother is prone to tie folloing.
 Asphyxia at birth prompt resuscitation is important.
 There is tendency to develop hypothermic, hypoglycemia, and hypocalcimia.
 Hyper billirubinemia and polycythemia.
 Babies are big they are more prone to soft tissue injuries following dystocia.
 So examine the baby for injuries, nerve palsy and intra cranial injuries.
 All babies should get parental vitamin k1
 Start breast feeding early to prevent hypocalcimia & hypoglycemia in case of trauma and
Convulsion Prophyl acticantibiotic
 Avoid unnecessary handling avoid baby bat hand limit visitors.

ANEMIA:
 The mean minimum value for haemoglobin accepted by the World Health Organization is
11.0 g/dl (atsea level).
 A woman with haemoglobin levels below this value that occur during pregnancy has, by def-
inition, anemia in pregnancy.
 Anemia in pregnancy is more common in patients who are already anemic at conception e.g.
patients with haemoglobinopathies, poor diet, with a history of menorrhagia.

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 Women with a multiple pregnancy are more prone to the development of anemia.
 During the antenatal period Hb estimation are routinely taken at booking, 28, 32 and 36
weeks. An iron deficiency anemia will exhibit a low serum iron and raised total iron binding
capacity,with ahypochromic microcytic film and low serumf erritin.

CAUSES:

 Malnutrition i.e. protein deficiency, iron deficiency vitamin C. vitamin B12 and folic acid
Ability of GIT toabsorbiron. Break down of RBC.
 Unhygienic habit such as poverty, poor sanitation, large family size, lack of education, re-
peated pregnancy and multiple pregnancies.
 Blood loss anemia.

TYPES OFANEMIA:

 Nutritional Anemia- duetodeficiencyofironfolicacid,vitaminB12,vitaminC, zin-

candprotein.,Anemia due to chronic blood loss Hook warm infestation (Helminthiasis) bleed-
ing piles.
 Anemia due to destruction of [Link], haemoglobinopathy [Link]
 Miscellaneous-chronic sepsis,drugs like analgesics,aplastic anemia due to bone marrow de-
pression.

EFFECT OF PREGNANCY ON ANEMIA:

 Anemia worsens during pregnancy because of poor nutritional intake.

 Fetal increased maternal tissue demand loss of iron due to expulsion of the placenta &post-
partum bleeding.
 Loss of iron during lactation.

EFFECT OFANEMIA ON MOTHER:

 Mother more prone to infection due to low resistance.

 Preterm labour more frequent.
 Higher incidence of PIH Prone to obstetric shock does not withhold blood loss well.
 Prone to puerperal sepsis. Mother with folic acid deficiencies are prone to placental abruption

EFFECT ON FETUS:

 Higher incidence of preterm delivery.

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 Higher riskofstillbirth.
 Higher risk of occurrence of IUGR.
 Higher Perinatal morbidity &mortality.
 Neonatal anemia more frequent.

SIGN&SYMPTOMSOFANEMIA:

 Patient complaint of lassitude, fatigue anorexia, breathlessness nausea, vomiting gastrointes-

tinal,upsets, palpitation and chest discomfort, tachycardia and tachypnea.
 Patient appears pale, Pallor of skin, nails, pallor tongue, conjunctiva.
 There may be evidence of odema on the feet and puffiness of face.

MANAGEMENT:
Antenatals:

 Patient should be advised for diet,medication and investigation

Prophylactic:

 Early detection HB should be tested on first visit repeated at 28,32,36 wks to detect any fall
in lends.

DIET:

 High protein green leafy vegetable (iron, folic acid) citrus fruits vitamin C.
 Treat helmenthiasis by using anthelminthis.

Supplementary:

 Ferrous Sulphate and folic acid. Curative:

 All patients of HB level of 10gm% or less should be thoroughly investigated for under lying
cause. If Anemia is iron deficiency Hypochromic microcytic.
 If folic acid deficiency→Megaloblastic vitaminB12 deficiency then Hemoglobinopathy.

BLOOD LOSS ANEMIA:

 Anemia associated with blood loss is the direct result of the decrease in circulating red blood
cells(RBCs).
 The average adult has a total blood volume of approximately 5.000 to 6.000 ml (milliliters)
andcan usually lose 500 ml of blood without serious or lasting effects; but, if the loss reaches
1,000 ml ormore, serious acute consequences may result.

CAUSES:

 Blood loss can be as a result of very heavy menstrual periods.

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 Most women lose about 44 ml of blood per cycle, but some may lose considerably
 Blood loss also occurs during child birth or during major surgical procedures.
 Certain health issues may also contribute to iron loss, including chronic bleeding of the
gums,hemorrhoids,or cancer of the stomach.
 In addition,prolonged treatment with certain drugs can cause gastrointestinal bleeding.
 Parasites can also cause anemia as they take blood and nutrients for themselves that are
meant for the human host.

SIGN AND SYMPTOMS:

Early signs are :Weakness Cool moist skin Tachycardia and hypotension.

Later signs include:

 Decreased hemoglobin and haematocrits levels, which may not be evident until several hours
after the blood loss has occurred.
 Post hemorrhagic anemia is a normocytic-normochromic anemia caused by sudden blood loss
in an individual with normal iron stores,
 Hemorrhage may be obvious, that is, after surgery or before a trauma, as in the cases of ma-
lignancies or gastrointestinal disorders.
 It should be noted that minor prolonged hemorrhage does not result in classic post hemor-
rhagic anemia, but rather in iron deficiency anemia

TREATMENT:

 The restoration of the full complement of RBCs after blood loss is slower than repletion of
other blood constituents.
 The effects are the same as those of iron deficiency, but may be more severe depending on
the extent of the blood loss.
 Restoring blood volume through intravenous administration of saline, dextran, albumin, or-
plasma.
 For large blood losses ,transfusion of fresh whole blood is the treatment of choice.
 The anemia itself does not require specific therapy unless it is associated with iron, folate, or
cobalamin(B12)deficiency.
 A normal erythrocyte count is usually evident within four to six weeks, but hemoglobin resto-
ration can take up to eight weeks.

IRON DEFICIENCYANEMIA:

 Anemia is a condition in which the body does not have enough healthy red blood cells. Iron is
an important building block for red blood cells
 When body does not have enough iron, it will make fewer red blood cells or red blood cells
that are too small. This is called iron deficiency anemia, 80%of pregnant suffer for Iron defi-
ciency anemia.

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 Mild: When HB is b/w 10-11.5 gm. Oral iron is treatment of choice- ferrous sulphate
200mg 3 times dayprovides1g/100ml/wt.
 Drawback: Patient dont tolerate oral iron may c/o epigastric discomfort, diarrhea, constipa-
tion vomiting orcolic,Change iron preparation or switch over to parenteral iron therapy.
 Moderate to severe:10%patient should be hospitalized until they have been fully investiga-
tion and therapy started.
 Parenteral iron therapy is indicated in women who dont tolerate oral iron, poor iron absorp-
tion.1/M inform(ironsorbitolcitratecomplex) dailyfor10-12 injections
 Total dose infusion: By this method total iron deficiency is correct by single 1/v infusion of
iron dextran ins 1000ml saline given slowly over several hrs. calculation of dose.
 Severe anemia near time of delivery: Up to 35 weeks parenteral iron may be given, Beyond
this time a blood transfusion may be given if date is near. 1 pint of blood raises 0.7g/100ml
hemoglobin.
 The main reason for blood transfusion is not only correction of anemia but any further loss of
birth at delivery may be dangerous and fatal.
FOLICACIDDEFICIENCY:

 Megaloblastic anemia, about 20% of pregnant women suffer from it.

 Folic acid is needed for cell growth of both mother and fetus tab folicacid1x3=15-20mg/day.
 This can be diagnosed when despite of continued iron therapy the HB value first increased
and then remain static.
 In early there will be no s/s. But in its severe form this deficiency is characterized by Mega-
loblastic anemia.
 Patients are seen with HB level below8gm/100ml.

SYMPTOMS:
 Anemia+ve Breathlessness, giddiness, palpitation.
 Swelling of feet &ankle.
 Sign of nutritional deficiency may be present i.e. glossitis, oral fissure, and irregularities of
nail.
 Spleen is commonly enlarged in severe case there may be vomiting and purpuri crashes.

THALASSEMIA:
 Thalassemia is a blood disorder passed down through families (inherited) in which the body
makes an abnormal form of hemoglobin, the protein in red blood cells that carries oxygen.
 The disorder results in excessive destruction of red blood cells,which leads to anemia. Patient
advised folic acid 5 mg daily and routine iron therapy may be avoided.
 A women at term0.7mg/dl or less fresh blood transfused as to the value 10gm/dl to prevent he
from hypovolemic shock and prepare her for labour.

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CAUSES, INCIDENCE, AND RISKFACTORS:

 Hemoglobin is made of two proteins: Alpha globin and beta globin. Thalassemia occurs when
there is a defect in a gene that helps control production of one of these proteins.
 There are two main types of thalassemia:
 Alpha thalassemia occurs when a gene or genes related to the alpha globin protein are miss-
ing orchanged (mutated).

Beta thalassemia: Occurs when similar gene defects affect production of the beta globin proteins

There are many forms of thalassemia;

Each type has many different subtypes. Both alpha and betathalassemia includes the following two
forms:

 Thalassemia major
 Thalassemia minor
 One must inherit the defective gene from both parents to develop thalassemia major.
 Thalassemia minor occurs if one receives the defective gene from only one parent. Persons
with this form of the disorder are carriers of the disease and usually do not have symptoms.
Beta thalassemia major is also called Cooleys anemia.
 Risk factors for thalassemia include: Family history of the disorder

SYMPTOMS :

 The most severe form of alpha thalassemia major causes stillbirth (death of the unborn baby
during birth or the late stages of pregnancy).
 Children born with thalassemia major (Cooley& page#039anemia) are normal at birth, but
develop severe anemia during the first yearof life.

Other symptoms can include:

 Bone deformities in the face

 Fatigue Growth failure
 Shortness of breath
 Yellow skin(jaundice)
 Persons with the minor form of alpha and beta thalassemia have small red blood cells (which
are identified by looking at their red blood cells under a microscope), but no symptoms.
 Signs and tests:
A physical exam may reveal a swollen (enlarged)spleen.
A blood sample will be taken and sent to a laboratory for [Link] blood cells will
appear small and abnormally shaped when looked at microscope. A complete blood count
(CBC)reveals anemia.

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A test called hemoglobin electrophoresis shows the presence of an abnormal form of hemo-
globin.
MEDICALSCIENCE:
A test called mutational analysis can help detect alpha thalassemia that cannot be seen with
hemoglobin electrophoresis.

TREATMENT

Treatment for thalassemia major often involves regular blood transfusions and folate supple-
ments.
 If you receive blood transfusions, you should not take iron supplements. Doing so can cause a
high amount of iron to buildup in the body which can be harmful.
 Persons who receive significant numbers of blood transfusions need a treatment called chela-
tion therapy to remove excess iron from thebody. A bone marrow transplant may help treat
the disease in some patients, especially children.
 Expectations(prognosis Severe thalassemia can cause early death due to heart failure, usually
between ages 20 and 30.
 Getting regular blood transfusions and therapy to remove iron from the body helps improve
the outcome: Less severe forms of thalassemia usually do not shorten life span.
 Genetic Counseling and prenatal screening may help people with a family history of this con-
dition who are planning to have children. Complications Untreated, thalassemia major leads
to heart failure and liver problems, and makes a person more likely to develop infections.
 Blood transfusions can help control some [Link],they may result in too much
[Link] can damage the heart, liver, and endocrine system. Sign of nutritional deficiency
may be present i.e. glossitis, oral fissure, and irregularities of nail. Spleen is commonly en-
larged in severe case there may be vomiting and purpuri crashes.
AMNIOTIC FLUID ABNORMALITIES:-

 In some pregnancies, however, there may be too little or too much amniotic fluid.
 These conditions are referred to as oligohydramnios and polyhydramnios, respectively.
 Both can sometimes cause problems form other and baby or be a sign of other problems.
 However,in the majority of cases, the baby is born healthy." How are Oligohydramnios
and Polyhydramnios diagnosed? An ultrasound examination can diagnose either too little
or too much amniotic fluid.

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 Doctors commonly measure the depth of thefluid in four quadrants in the uterus and add
them up. This method of measuring amniotic fluid is referred to as the amniotic fluid in-
dex (AFI).
 If the amniotic fluid depth measures less than 5 centimeters, the pregnant woman hasoli-
gohydramnios. If fluid level sad upto more than 25 centimeters,she has polyhydramnios.

OLIGOHYDRAMNIOS:

 About 8 percent of pregnant women have too little amniotic fluid.

 Oligohydramnios can develop at any time during pregnancy, though it is most common in the
last trimester.
 About12 percent of women whose pregnancies last about two weeks beyond their due dates
(about42 weeks gestation) develop oligohydramnios, because the levelof amniotic fluid de-
creasesbyabout half by42 weeks gestation.
 CAUSES: The causes of oligohydramnios are not completely understood. The majority of
pregnant women who develop oligohydramnios have no identifiable cause. The most im-
portant known causes of early oligohydramnios are certain birth defects and ruptured mem-
branes (bagofwaters that surrounds the baby).
 Certain maternal Health problems also have been associated with oligohydramnios. These in-
clude: high blood pressure Diabetes Systemic lupus erythemato-
sus(SLE)(anautoimmunecondition)
 Placental problems A group of medications used to treat high blood pressure, called angioten-
sin-converting enzyme inhibitors (like captopril), can damage the fetal kidneys and cause se-
vere oligohydramnios and fetal death.
 Women who have chronic high blood pressure should consult their health care provider prior
to pregnancy to make sure their blood pressure is under control and that any medications they
take are safe during pregnancy.

TREATMENT:

Recent studies suggest that women who develop oligohydramnios near term probably need
no monitoring. treatment, and their babies are likely to be born healthy. They do, howev-
er,require close monitoring.

 Their health care provider will probably recommend weekly or more frequent
ultrasound examinations to see if the level of amniotic fluid is decreasing.
 If the level of amniotic fluid does drop, she may recommend inducing labor early to
help prevent complications during labor and delivery.
 About 40 to 50 percent of cases of oligohydramnios resolve themselves without
treatment
 Developing babies with poor growth whose mothers have oligohydramnios are at high
risk of complications, such as asphyxia (lack of oxygen), both before and during
[Link] of these babies are monitored very closely, and they sometimes need to be

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hospitalized
 If a woman has severe oligohydramnios near the time of delivery, her provide may
suggest inserting salty water (saline solution) through the cervix into the uterus. This
may help reduce complications during labor and delivery and reduce the need forces
are an delivery.
 Some studies also suggest that women with oligohydramnios can help increase their
levels of amniotic fluid by drinking extra water. Also, many doctors suggest decreas-
ing physical activity or even bed rest.

COMPLICATIONS:

 The problems associated with too little amniotic fluid differ depending on the stage of
pregnancy. Oligohydramnios that occurs in the first half of pregnancy is more likely to
have serious consequences than if it occurs inthe last trimester.
 Too little amniotic fluid early in pregnancy can compress fetal organs and cause birth
defects such as lung and limb defects.
 Oligohydramniosthatdevelopsinthefirsthalfofpregnancyalsoincreas-
estheriskofmiscarriage,pre term birth and stillbirth.
 When oligohydramnios occurs in the second half of pregnancy, it may be associated
with poor fetal growth.
 Near term, oligohydramnios may increase the risk of complications of labor and deliv-
ery including potentially dangerous umbilical cord accidents that can deprive thebaby
of oxygen, and stillbirth. Women with oligohydramnios are more likely to need a cesar-
ean delivery.
 About 7 percent of babies of women with oligohydramnios have birth defects, Birth
defects involving the kidneys and urinary tract are the most likely causes b cause af-
fected fetuses produce less urine (which makes upmost of the amniotic fluid).
 Mothers have oligohydramnios are at high risk of complications,such as asphyx-
ia(lackof oxygen), both before and during birth.

POLYHYDRAMNIOS

About 2 percent of pregnant women have too much amniotic fluid. Most cases are mild ad re-
sult from a gradual build up of excess fluid in the second half of pregnancy. However, as mall
number have a rapid buildup of fluid occurring as early as 16 weeks of pregnancy that usually
results very early delivery.

CAUSES OF POLYHYDRAMNIOS:

 In about two-thirds of cases,the cause of polyhydramnios is unknown.

 The most common known cause of polyhydramniosis

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 Birth defects in the fetus,especially birth defects that hinder fetal swallow-
ing(suchasbirth defects involving the esophagus or gastrointestinal tract and central
nervous system Normally, swallowing by the fetus helps reduce the level of amniotic
fluid helping to balance out the input caused by fetal urination. Heart defects in the baby
also can contributeto polyhydramnios
 Polyhydramnios can be due to maternal-fetal blood incompatibilities (such as
Rhdisease).
 Twin-twin transfusion syndrome(acomplication affecting identical twin pregnancies,in
which one baby gets too much blood flow and the other too little due to connections be-
tween blood vessels in their shared placenta).
 Women with chronic diabetes are at increased risk of polyhydramnios, though they
have fewer complications from it than women without diabetes.

TREATMENT:

 Whenanultrasoundexaminationshowsthatawomanhaspolyhydramnios,she will proba-

bly need additional tests. She will need detail ultrasound examination to diagnose or,
more likely,ruleout birth defects and twin twin transfusion syndrome.
 She also may require amniocentesis (a small amount of amniotic fluid is removed-
through a needle inserted into the mother' sabdomen to test for certain birth de-
fects)and a blood test for diabetes.
 About half the time,polyhydramnios goes away without treatment. In other cases,it
may resolve when the problem can di causing it is corrected.
 Forexample Treating high blood sugar levels in women with diabetes or treating
fetal heart rhythm disturbances (bymedicatingthemother)often reduces amniotic fluid
levels.
o Health care providers usually closely monitor women with polyhydramnios
withweekly (or more frequent) ultra sound examinations to check amniotic
fluid levels.
o If the pregnant woman becomes too uncomfortable, her provider may rec-
ommend a drug called indomethacin. This drug helps reduce fetal urine pro-
duction and reduce amniotic fluid levels Amniocentesis also can be used to
drain off excess fluid. This procedure, which may be repeated a number of
times, can reduce symptoms and may prolong pregnancy.
o If tests show that mother and baby appear healthy, a woman with mild poly-
hydramnios near term usually does not need any treatment.
o While she may have an increased risk of cesarean delivery, she appears to be
at low riskof other complications, and her babyis likelyto be healthy
 Does discolored amniotic fluid pose arisk to the baby?
 Normal amniotic fluid is clear or tinted yellow. Abnormal coloring seen at amniocen-
tesisor at birth can sometimes suggest problems.

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 Green or brown-tinged fluid usually indicates that the baby has passed stool. This can be
a sign of fetal stress. Pink-tinged fluid suggests bleeding while wine-colored amniotic
fluid suggests bleeding in the past.
 These conditions may be of little or no consequence, but tests may besuggested tofind
possible
 COMPLICATIONS FOR MOTHER AND BABY:

Women with mild polyhydramnios may experience few symptoms, those who are mo-
reseverely affected may have:


Abdominal discomfort

Breathing difficulties as a result of the uterus crowding the abdominal organs and
hings Polyhydramnios also may increase the risk of pregnancy complications in-
cluding Preterm rupture of the membranes,
 Preterm delivery,
 Umbilical cord accidents,
 Placental abruption (when the placenta partially or completely peels away from
the uterine wall before delivery), poor fetal growth, stillbirth and cesarean deliv-
ery.
 Women with polyhydramnios may be more likely to have severe bleeding ater
delivery
INTRAUTERINE GROWTH RESTRICTION (IUGR):

Intrauterine growth restriction (IUGR) is a term used to describe a condition in which the fetus is
smaller than expected for the number of weeks of pregnancy..

Another term for IUGR is fetal growth restriction. Newborn babies with IUGR are often described as
small for gestational age (SGA).

A fetus with IUGR often has an estimated fetal weight less than the 10th percentile. This means that
the fetus weighs less than 90 percent of all other fetuses of the same gestational age. A fetus with
IUGR also may be born at term (after 37 weeks of pregnancy) or prematurely (before weeks).

SYMMETRIC AND ASYMMETRIC IUGR:

IUGR is usually classified as symmetric and asymmetric.

Symmetric growth restriction implies a fetus whose entire body is proportionally small.

Asymmetric growth restriction implies a fetus who is undernourished and is directing most of its en-
ergy to maintaining growth of vital organs, such as the brain and heart, at the expense of the liver,
muscle and fat. This type of growth restriction is usually the result of placental insufficiency.

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A fetus with asymmetric IUGR has a normal head dimension but a small abdominal circumference
(due to decreased liver size), scrawny limbs (because of decreased muscle mass) and thinned skin
(because of decreased fat).

If the insult causing asymmetric growth restriction is sustained long enough or is severe enough, the
fetus may lose the ability to compensate and will become symmetrically growth-restricted. Arrested
head growth is of great concern to the developmental potential of the fetus.

SIGNS &SYMPTOMS:

 Newborn babies with TUGR often appear thin, pale, and have loose, dry skin.
 The umbilical cord is often thin and dull-looking rather than shiny and fat.
 Babies with JUGR sometimes have a wide-eyed look.
 Some babies do not have this malnourished appearance but are small all-over.

CAUSES OF INTRAUTERINE GROWTH RESTRICTION (IUGR):

Intrauterine growth restriction results when a problem or abnormality prevents cells and tissues from
growing or causes cells to decrease in size. This may occur when the fetus does not receive the nec-
essary nutrients and oxygen needed for growth and development of organs and tissues, or because of
infection. Although some babies are small because of genetics (their parents are small), most IUGR
is due to other causes.

SOME FACTORS THAT MAY CONTRIBUTE TO IUGR INCLUDE THE

FOLLOWING:

MATERNAL FACTORS:

 High blood pressure

 Chronic kidney disease
 Advanced diabetes
 Heart or respiratory disease
 Malnutrition, anemia
 Infection
 Substance abuse (alcohol, drugs)
 Cigarette smoking
 Multiple gestation
 Low socioeconomic status
FACTORS INVOLVING THE UTERUS AND PLACENTA:

 Decreased blood flow in the uterus and placenta

 Placental abruption (placenta detaches from the uterus)
 Placenta previa (placenta attaches low in the uterus)

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 Infection in the tissues around the fetus

 Infarction
 Circumvallate placenta
 Placenta accreta
FACTORS RELATED TO THE DEVELOPING BABY (fetus):

 Multiple gestation (twins, triplets, etc.)

 Infection
 Birth defects
 Chromosomal abnormality
WHY IS INTRAUTERINE GROWTH RESTRICTION (IUGR) A CONCERN?

IUGR can begin at any time in pregnancy. Early-onset IUGR is often due to chromosomal abnormal-
ities, maternal disease, or severe problems with the placenta. Late-onset growth restriction (after 3
weeks) is usually related to other problems.

With IUGR, the growth of the baby's overall body and organs are limited, and tissue and organ cells
may not grow as large or as numerous. When there is not enough blood flow through the placenta,
the fetus may only receive low amounts of oxygen. This can cause the fetal heart rate to decrease
placing the baby at great risk.

Babies with IUGR may have problems at birth including:

 Decreased oxygen levels

 Low Apgar scores (an assessment that helps identify babies with difficulty adapting after de-
livery)
 Meconium aspiration (inhalation of the first stools passed in utero), which can lead to diffi-
culty breathing
 Hypoglycemia (low blood sugar)
 Difficulty maintaining normal body temperature
 Polycythemia (too many red blood cells)
 Severe IUGR may result in stillbirth. It may also lead to long-term growth problem in babies
and children.
DIAGNOSIS

Fetal size:

During pregnancy, fetal size can be estimated in different ways.

The height of the fundus (the top of a mother's uterus) can be measured from the pubic bone. This
measurement in centimeters usually corresponds with the number of weeks of pregnancy after the

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20th week. If the measurement is low for the number of weeks, the baby may be smaller than ex-
pected.

Other diagnostic procedures may include the following

Ultrasound

Ultrasound (a test using sound waves to create a picture of internal structures) is a more accurate
method of estimating fetal size. Measurements can be taken of the fetus' head and abdomen and
compared with a growth chart to estimate fetal weight. The fetal abdominal circumference is a help-
ful indicator of fetal nutrition.

Doppler flow:

Another way to interpret and diagnose IUGR during pregnancy is Doppler flow, which use sound
waves to measure blood flow. The sound of moving blood produces wave forms that reflect the
speed and amount of the blood as it moves through a blood vessel. Blood vessels in the fetal brain
and the umbilical cord blood flow can be checked with/Doppler flow studies.

A mother's weight gain can also indicate a baby's size. Small maternal weight gains in pregnancy
may correspond with a small baby.

Fetal movement counting:

Keep track of fetal kicks and movements. A change in the number or frequency may mean the fetus
is under stress.

Non-stress testing:

A test that watches the fetal heart rate for increases, with fetal movements, a sign of fetal well- being.

Biophysical profile:

A test that combines the nonstress test with an ultrasound to evaluate fetal well-being

MANAGEMENT:

Management of IUGR depends on the severity of growth restriction, and how early the problem be-
gan in the pregnancy.

Generally, the earlier and more severe the growth restriction, the greater are the risks to the fetus.
Careful monitoring of a fetus with IUGR and ongoing testing may be needed.

Although it is not possible to reverse IUGR, some treatments may help slow or minimize the effects.

TREATMENTS MAY INCLUDE:

Nutrition:

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Some studies have shown that increasing maternal nutrition may increase gestational and fetal
growth.

Bed rest:

Bed rest in the hospital or at home may help improve circulation to the f

Delivery:

If IUGR endangers the health of the fetus, then an early delivery may be necessary.

PREVENTION OF INTRAUTERINE GROWTH RESTRICTION:

Intrauterine growth restriction may occur, even when the mother is in good health..

However, some factors may increase the risks of IUGR such as cigarette smoking and poor maternal
nutrition. Avoiding harmful lifestyles, eating a healthy diet, and getting prenatal care, may help de-
crease the risks for IUCR Early detection may also help with JUGR treatment and outcome.

INFECTIONS DURING PREGNANCY

SEXUALLY TRANSMITTED INFECTION/DISEASE:

The term sexually transmitted diseases (STDs) are used to refer to a variety of clinical syndromes
caused by pathogens that can be acquired and transmitted through sexual activity. Physicians and
other health-care providers play a critical role in preventing and treating STDs.

VAGINAL DISCHARGE:

The healthy vagina produces a variable amount of physiological vaginal discharge. It is called leu-
corrhoea. It is yellowish white in color and doesn't cause irritation or offensive [Link] contains, a
mixture of secretions from endometrial and cervical glands, vaginal cell, bacterial flora and WBC.

It has a cyclic variation, so women may notice their discharge increases at mid cycle or prior to men-
struation. It may increases in pregnancy and in women who are using CO pills. Both causes benign
hyperplasia of endo-cervical gland.

VAGINITIS:

Vaginitis is usually characterized by a vaginal discharge, vulvar itching and irritation, and a vaginal
odor.

The three most common diseases diagnosed among women with these symptoms include bacterial
vagmosis (40%-45%), vulvovaginal candidiasis (20%-25%)., and trichomoniasis (15%-20%)

In some cases, the etiology may be mixed, and there may be more than one disease present.

Other causes of vaginal discharge or irritation include the following:

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 Normal physiologic variation

 Allergic reactions, e.g., spermicides, deodorants
 Herpes Simplex Virus (HSV)
 Mucopurulent cervicitis-may be related to Chlamydia trachomatis or Neisseria gonorrhoeae
infection
 Atrophic vaginitis-found in lactating and post-menopausal women and related to a lack of
 estrogen
 Vulvar vestibulitis, lichen simplex chronicus, and lichen sclerosis (especially pruritis) For-
eign bodies, retained tampons
 Desquamative inflammatory vaginitis
Sexual History:Ask about:

 C=Character
 O=onset
 L=location
 D=duration
 E=exacerbation
 R=radiation
 R=relieving
 A=associated symptom

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HEALTHY VAGINA

 Glycogen in walls +Lactobacillus-Acid (vaginal environment).

 PH of vagina-acidic.4.5
 Acid is good as it kills some bacteria.
Normal vaginal discharge Abnormal vaginal discharge

Clear or white. Thick Yellowish/curdy or

Frothy

Scant to moderate in amount Moderate to copious amount.

PH<4.5 pH>4.

GONORRHEA
STI caused by gonococci (diplogonococci). It infects the mucous membrane of the cervix. urethra,
anus, rectum and oropharynx.

Infected women may be a symptomatic or may have general malaise Vaginal discharge and dysuria.
If untreated may lead to chronic cervicitis and generalize illness

It may lead to infertility, chronic pain and menstrual dysfunction. During the process of birth baby
may acquire the infection, which manifest as neonatal conjunctivitis.

TREATMENT

Strict personal hygiene

Safe sexual behavior

A single dose of long acting penicillin is I/M (amoxicillin 3g or ampicillin 3.5g).

During pregnancy tetracycline should be avoide

TRICHOMONIASIS:
 Protozoan infection (Trichomoniasis vaginalis)
 The commonest STI
 Complaints of discharge with itching.
 Greenish frothy vaginal discharge
 Vagina is red and sore
 Swelling around groin, cervix may show red spots (strawberry cervix)

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 Recurrence is common
 Individual less than 25 years and those having multiple partners are at great risk.

MANAGEMENT OF TRICHOMONIASIS:

 Tablet Metronidazole (Flagyl) 400mg tds orally for 7 days

 Stress importance of safe sex-condoms for male
 If PREGNAN Nilstat vaginal tablet/ hs for 2 weeks, If pregnancy more than 3 months
Tablet Flagyl given orally..
 Partner should be treated with 2gm Metronidazole
Pregnancy:
Vaginal trichomoniasis in pregnant women has been associated with adverse outcomes such prema-
ture rupture of the membranes, preterm delivery, and low birthweight. Pregnant women with symp-
tomatic trichomoniasis should be treated.

The CDC commendation for treatment of trichomoniasis in pregnancy:

Metronidazole 2g orally in single dose

There is no consistent association between metronidazole use in pregnancy and teratogenic effects,
and treatment may be administered throughout pregnancy

Treatment Failure

 If the recommended treatment fails, the following treatment regimen is recommended:

 Metronidazole 500 mg orally twice a day for 7 days (if initial treatment was 2g orally in a
single dose)
 Tinidazole 2g orally single dose
 With failure of either regimen, consider treatment with:
 Metronidazole or Tinidazole 2g orally once a day for 5 days.
CHLAMYDIA:
Most of the woman have no symptoms and may cause SILENT SALPINGITIS.
May cause scanty Vaginal discharge
Mothers of newborn with conjunctivitis should be considered to have Chlamydia, treat baby
eyes.
 Treat male
MANAGEMENT OF CHLAMADYIA:

 Safe sexual behavior

 Cap: Doxycycline (Vibramycin) 100mgs bid for 7 days
 Baby's eyes should be treated with antibiotic drops bid for 5 days

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 In severe cases refer.

CANDIDIASIS:
Candidiasis is currently the second most common cause, of vaginal after bacterial vaginosis.

 Caused by yeast Candida Albicans

 Peri-vaginal irritation.
 Thick white curdy discharge
 Dysuria and dyspareunia
 External vaginitis and vulvitis (itchy, red and sore)
MANAGEMENT OF CANDIDIASIS:

 Safe sexual behavior

 Clotrimazole pessaries 100mg for 7 days bid
 Or canesten cream/ Miconazole 2% cream intravaginal for 7 days bid.
 Recurrence then treat male with canesten cream on penis.
BACTERIAL VAGINOSIS:
Strong, unpleasant odor (Rotten fish) vaginal discharge is th milky white, but not clear

 Vaginal itching may be present

 Many women do not have any symptoms
MANAGEMENT OF BACTERIAL VAGINOSIS:

 Safe sexual behaviors

 Tablet Metronidazole (Flagyl) 400mgs bd. for 5 days.

PELVIC INFLMMATORY DISEASES (PID):

PID is a progressive infection that harms a woman's reproductive system. It occurs throughout the
pelvic area, the fallopian tubes, the uterus, the uterine lining and ovaries. PID can lead to sterility,
ectopic pregnancy and chronic pain.

 Vague abdominal/ pelvic pain

 Vaginal discharge
 Menstrual irregularity
 Fever/chills
 Dyspareunia

MANAGEMENT OF PID:

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Mild & moderate cases:

 Capsule Doxycycline 100mg bid- 14days +Tablet Flagyl 400mg tds-14 days.
 If no improvement then refer.
Severe acute cases pre referral treatment.

 Tablet Vibromycin 100mg +Inj. Ampicillin 500mg IV +

 Inj. Gentamycin 80mg IV+ Inj. Flagyl 500 IV for 48 hrs till patient is stable followed by oral
therapy.
Spread Of HIV:
 Virus in blood, semen, vaginal fluids and breast milk spreads by Anal and vaginal inter-
course.
 Less commonly transmitted through oral sex
 Sharing unsafe needles
 Unsafe Transfusion of contaminated blood products.
 Unsafe childbirth.
 Breastfeeding high risk to contact the disease
 Accidental pricks with contaminated needles in the course of health care low risk for HIV but
high risk for hepatitis B.
HIV does not spread by:

 Ordinary social contact, sharing clothing or food, touching:

 Kissing and hugging, shaking hands
 Insect bites
 Tears, sweat.
 Living or working with an HIV-infected person.
SYMPTOMS OF HIV INFECTION:

 Unexplained loss of weight

 Diarrhea for several weeks or more.
 Persistent cough, persistent vaginal yeast infection
 Persistent fever or night sweats.
 Lymph adenopathy.
Treatment of HIV/AIDS:

 100% cure not available

 Costly drugs may prolong life or improve quality of life.
 Medications to prevent opportunistic infections.
 Diet
 Hygiene
 Support mental, physical, social aspects

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MANAGEMENT OF STIS:

 Partner treatment
 Condom promotion
 Contact tracing
 Compliance of drug regimen i-e taking full drugs, avoiding other drugs

RUBELLA (GERMAN MEASLE):

Rubella is a mild infective disease causing a macular rash on the body and enlargement of posterior
cervical nodes spread by droplets from one person to other. It is uncommon in pregnancy but the fe-
tus is directly infected by mother through placenta and causes abortion, still birth, premature labour
small for dates, malformation and congenital Rubella.

The incidence of congenital malformation e.g Cardiac, ear and eye defect varies according to the pe-
riod of gestation at the time of disease occurs. If in first month incidence is 50%-60% with multiple
defect and slowly falls until the infection is in sixteenth week it is about 5%. after it fetus may suffer
from growth retardation, mentally retarded or deaf. Baby itself may be source of infection for 2
years.

SIGN & SYMPTOM:

 Malaise, fever law grade up till 101 Fahrenheit. pain near angles of the jaw followed by ten-
der swelling of one or both parotid gland.
 Arthritis (joint pain) especially of distal joints is common complication.
 Spot (rash) on skin pink macules appear first behind the car and forehead, face then spread to
ankle and extremities (generalized within 24-28 hours and disappear within 3 days.
 Incubation period is 14-21 days. During this period virus excreted from nose, throat and
urine.
CONGENITAL ABNORMIALITIES

Eyes-cataract glaucoma
Heart - patent ductus arteriosus
Head-mental retardation microcephaly
Hearing-nerve deafness
Sometimes defect may not be present at birth but appears later so careful follow up is neces-
sary.
PREVENTION & MANAGEMENT:

 Mother's immunity play an important role

 Vaccine is given three months before pregnancy.

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 All mothers should be investigated for rubella anti body during antenatal.
 Pregnancy should be avoided for three months

URINARY TRACT INFECTION:

 Physiological changes during pregnancy bring marked alterations in the renal function.
 Kidney increases in size
 Pelvic area show dilations
 Increase capacity and sluggish peristalsis predisposes to the occurrence of [Link]
great antenatal care patient can manage normal pregnancy till term
 Renal diseases can be diagnosed on history physical examination and urine analysis
particularly first voided urine.
 Radiographic studies should be avoided during pregnancy.

CYSTITIS
 Infection of urinary bladder
CAUSATIVE ORGANISM:

 [Link] E Coli
SIGN AND SYMPTOMS:

 Frequency of micturation
 Dysurea
 Pain over pubic area after passing urine
 Urine contain pus
 High temperature high pulse, high respiration
 In Severe case chill and high fever and hematuria may occur.
TREATMENT:

 Good nursing care

 Record T.P.R 4 hourly
 Mist alkaline
 Adequate fluid by mouth
 Mid stream urine for culture and sensitivity
 Antibiotic according to c/.
 I/O chart maintenance

PYLONEPHRITIS:
It is the Infection of pelvis of kidney.

CAUSATIVE ORGANISM:

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 E-Coli
SIGN & SYMPTOM:

 Chill with high grade fever

 Nausea & vomiting
 Tachycardia (high pulse rate) pain & tenderness in the loins
 Dry furred tongue
 Appearance of dehydration.
 Risk of development of septic shock. It may result in premature labor.
TREATMENT:

 Hospitalization for such patient is very important

 I/V infusion to correct dehydration
 Parental antibiotics e.g. 1gm cafezox
 I/O chart
 Vital signs
 Analgesic for pain
 Urine sample of c/s
 Follow up for recurrence of problem
RETAINATION OF URINE:
It is the inability of bladder to pass urine or holding, it back. It is not uncommon complain in

pregnancy.

CAUSES:

During Pregnancy:

 Incarcerated Retroverted uterus

 Pelvic neoplasm like fibroid or ovarian tumor.
During labour:

 A deeply engaged head during labour

 Uncoordinated uterine activity
 Obstructed labour

During puerperium

 Spasm and painful vulval injuries

 Bruising and edema of bladder neck during difficult child birth
 Simple method to relieve retention
 Hot fomentation

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 Pouring hot & cold water alternately to stimulate bladder

 If not succeed indwelling catheterization under strict aseptic technique
ASYMPTOMATIC BACTERIUREA:
This should be treated promptly as women with asymptomatic bacteriurea show high incidence of:

 Pylonephritis
 PIH
 Preterm labor
 IUGR
And so lead to perinatal morbidity and mortality. Antimicrobial are used such as

Ampicillin and cephalosporin

Sulfonamides have been used in past but the availability of safer drugs These are not commonly
used. Floxacin 500mg/day Urixin.

. TUBERCULOSIS
Tuberculosis (TB) is caused by bacteria (Mycobacterium tuberculosis) that most often affect the
lungs. Tuberculosis is curable and preventable. TB is spread from person to person through the air.
When people with lung TB cough, sneeze or spit, they propel the TB germs into the air.

Anyone diagnosed with tuberculosis needs, treatment to keep the TB infection from becoming a
deadly disease, and pregnant women are no exception. Treatment gets trickier during pregnancy
however, because some medications commonly used to treat tuberculosis infection can harm a de-
veloping fetus or a breastfeeding newborn.

Pregnant women who have active tuberculosis need to be treated right away to prevent serious com-
plications

For mom, leaving the disease untreated could kill her. The right treatment combination poses little
risk to baby while helping to save mom's life.

Pregnant women with active TB should be treated, even in the first stage of pregnancy. Isonia-
zid,rifampin,ethambutol may be used. In the United States, pyrazinamide is reserved for women with
suspected multidrug-resistant TB (MDR-TB).

It's perfectly safe for mothers-to-be to undergo a skin test for TB during pregnancy if untreated, ac-
tive tuberculosis can cause problems for the fetus. Many babies born to mothers with untreated TB
have low birth weight; in rare cases, the child may also have TB.

DOTS: Stands for Directly Observed Treatment, Shart-course. DOTS is a strategy to reduce the
number of tuberculosis (TB) cases. In DOTS, healthcare workers observes patients as they take their
medicine.

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Tuberculosis Medications to Avoid

Certain antibiotics and medications sometimes used to treat TB should not be used during pregnancy.
These include:

 Kanamycin
 Cycloserine
 Ethionamide
 Streptomycin

UNIT:-10. ABNORMAL LABOUR:-

DYSTOCIA
DEFINITION

Any labour/delivery that is prolong or difficult.

CAUSES:

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Usually results from a change in the interrelationship among the 5 Ps.

Power,passage,passenger, placenta and psyche of mother.

The maternal passage or the birth canal consists of two parts

My Bony pelvis 2) Maternal soft tissue like the uterus,cervix Vagina & surroundings organs

PROBLEM WITH DISPROPOTION B/W FETAL HEAD & MATERNAL

PELVIS (PASSAGE)

If disproportion is minimal vaginal birth may be attempt .Caesarian birth is needed if disproportion is
great.

CONTRACTED PELVIS:

A contracted pelvis is one in which any of its essential diameter is so reduced, that it interferes or
after the mechanism of normal labor

CAUSES:

 Generally it is congenital but may be due to

 Malnutrition
 Neoplasm
 Pelvic Fracture
 Disorder of spine or lower extremities
DIAGNOSIS OR CLINICAL FEATURES

 General observation of Gait i.e. women with limp. abnormal gait, or protuberant abdomen
Women with short stature (ht < 4 feet & 10 inches)
 Women with a past history of prolong labor, difficult instrumental delivery, failed trial of la-
bor, baby born with severe or deep asphyxia, baby still birth or history of neonatal convul-
sions, or suspected intracranial damage.
 Presence of mal presentation.
 Fri Para with a head floating at term..
 Poor progression in labor as witness on the Partogram

If contracted pelvis is suspected following test are recommended

 Internal pelvimetry.
 Clinical evaluation for CPD-
 X-ray Pelvimetry.
Soft Tissue Abnormalities:-

Some times, the passage of the baby along the birth canal is hindered by maternal soft tissue

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abnormalities like

 A full bladder may impend the progress

 Cervical edema.
 Scar tissue.
 Cervical Stenosis,
 Thick rigid perineum.
 Fibroid of uterus occupying the pelvis.
 An ovarian cyst.
 Congenital anomalies e.g. bicornuate uterus.
Midwife must find out the cause of non-progression of labour. She should evaluate power, passage
and passenger and carried out appropriate intervention accordingly.

PROBLEM WITH PRESENTATION (PASENGER):

Any presentation unfavorable for delivery breech, shoulder, face, transverse lie and POP Caesarian
birth is usual intervention.

DISFUNCTIONAL UTERINE CONTRACTIONS (POWER)

Contractions may be too weak too short, too far apart and ineffectual.

Progress of labor is affected Progressive dilatation, effacement and descent do not occur in the ex-
pected pattern.

CLASSIFICATION

 Primary Inefficient pattern present from beginning of labor usually a prolonged latent phase.
 Secondary: Efficient pattem that change to inefficient or stop.
ASSESSMENT FINDINGS:

 Progress of labor slower than expected rate of dilation, effacement, descent of head.
 Length of labor prolonged.
 Maternal exhaustion,
 Fetal distress.
MANAGEMENT:

 Find out the cause and treat the cause.

 Provide comfort measure for client,
 Provide clear supportive description and explanation of all action taken,
 Administer analgesia if ordered or indicated.
 Prepare oxytocin infusion for induction of labor if indicated.
 Oxytocin infusion if running may be stopped in case of hypertonic uterine action
 Analgesia also given

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 Monitor mother/fetus condition.

 Maintain Partograph for assessing progress of labor..
 Prepare for c-section if needed.

MULTIPLE PREGNANCIES
DEFINITION:

Multiple pregnancy is a pregnancy with two or more fetuses. Names for these include the following:

 Twins - 2 fetuses
 Triplets-3 fetuses
 Quadruplets-4. fetuses
Carrying more than one fetus overstretches the uterus und an overstretched tract start contracting
before the pregnancy reaches full term: As a result, the babies are usually born prematurely and are
small. In some cases, the overstretched uterus does not contract well after delivery, causing bleeding
in the woman after delivery. Because the fetuses can be in various positions and presentations, vagi-
nal delivery can be complicated Also, the contraction of the uterus after delivery of the first baby
may shear away the placenta of the remaining baby or babies. As a result, the baby or babies that fol-
low the first delivery and later. Have more problems during

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For these reasons, doctors may decide in advance how to deliver twins: vaginally or cesarean section.
Occasionally, the first twin is delivered vaginally but a cesarean sections is considered safer for the
second twin For triplets and other multiple births, doctors usually perform cesarean section.

While multiples account for only a small percentage of all births (about 3 percent)

birth rate is rising. According to the National Center for Health Statistics, the twin birth rate has the
multiple risen 59 percent since 1980, and is currently 30.1 per 1,000 live births.

CAUSES:

There are many factors include the following related to having a multiple pregnancy. Naturally oc-
curring factors

Heredity:

Family history of multiple pregnancy increases the chances of having twins.

Older Age:

Women over 30 have a greater chance of multiple conception. Many women today are delaying
childbearing until later in life, and may have twins as a result.

High Polarity:

Having one or more previous pregnancies, especially a multiple pregnancy, increases the chances of
having multiples,

Other factors that have greatly increased the multiple birth rate in reproductive technologies, includ-
ing the following:

Ovulation stimulating medications such as clomiphene citrate and follicle stimulating hormone,
(FSH) help produce many eggs, which, if fertilized, can result in multiple babies.

Assisted reproductive technologies such as in vitro fertilization (IVF) and other techniques help cou-
ples conceive. These technologies often use ovulation stimulating medications to produce multiple
eggs which are then fertilized and returned to the uterus to develop.

CAUSES OF MULTIPLE PREGNANCIES

Multiple pregnancies usually occurs when more than one egg is fertilized and implants in the uterus:
This is called fraternal winning and can produce boys, girls, or a combination of both Fraternal mul-
tiples are simply siblings conceived at the same time. However, just as siblings often look, multiples
multiples may look very similar. Fraternal multiples each have separate placenta and amniotic sac.

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Sometimes, one egg is fertilized and then divides into two or more embryos. This is called identical
twining and produces all boys, or all girls. Identical multiples are genetically identical. much alike
that even parents have a hard time telling them apart. However. these are like different personalities
and are distinct individuals. Identical multiples may placentas and amniotic sacs, but most share a
placenta with separate sacs. twins share one placenta and a single amniotic sac.

SYMPTOMS OF THE MULTIPLE PREGNANCIES:

The following are the most common symptoms of multiple pregnancy. However, each woman may
experience symptoms differently.

 Uterus large than expected in date of pregnancy.

 Increased morning sickness.
 Increased appetite
 excessive weight gain epescially in early pregnancy
 fetal movement felt in different parts of abdomen at same time
DIAGNOSIS

Many Suspect, they are pregnant, with more than one baby, especially if they have been Diagnosis of
multiple fetuses may be made early in' pregnancy. In addition to reviewing medical history and a
physical examination, diagnosis may be made by:

 Ultrasound
Pregnancy blood testing:

Levels of human chorionic gonadotrophin (hCG) may be quite high with multiple pregnancy.

COMPLICATIONS OF MULTIPLE PREGNANCIES:

Being pregnant with more than one baby is exciting and is often a happy event for many couples.
However, multiple pregnancies have increased risks for complications. The most common complica-
tions include the following:

Preterm labor and birth:

About half of twins and nearly all multiple are premature(born befpre 37 weeks) ,higher the number
of fetuses in the pregnancy, the greater risk for early [Link] baby are born before their bodies and
organ systems have completely mature. Many multiple birth babies will need care in a neonatal in-
tensive care unit (NICU),

Pregnancy-induced hypertension:

Women with multiple fetuses are more than three times as likely to develop high blood pressure of
pregnancy. This condition often develops earlier and is more severe than pregnancy with one baby. It
can also increase the chance of placental abruption (early detachment of the placenta).

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Anemia:

Anemia is more than twice as common in multiple pregnancies as in a Single birth

Birth defects:

Multiple birth babies have about twice the risk of congenital (present at birth), abnormalities includ-
ing neural tube defects (such as spina bifida gastrointestinal, and heart abnormalities. This increased
risk is limited to identical twins.

Miscarriage:

A phenomenon called the vanishing twin syndrome in which more than one fetus is diagnosed but
vanishes (or is miscarried usually in the first trimester is more likely pregnancies. This may or may
not be accompanied by bleeding. The risk of pregnancy loss is increased in later trimesters as well.

Twin-to-twin syndrome is a condition of the placenta that develops only with identical twins that
share a placenta. Blood vessels connect within the placenta and divert blond from one fetus to the
other. It occurs in about 15 percent of twins with a shared placenta.

Abnormal amounts of amniotic fluid:

Amniotic fluid abnormalities are more common in multiple pregnancies, especially for twins that
share a placenta.

Cesarean delivery:

Abnormal fetal positions increase the chances of cesarean birth.

Postpartum Hemmorhage:

The large placental area and over-distended uterus place a mother at risk for bleeding after

delivery in many multiple pregnancy.

Management for multiple pregnancies will be based on:

 pregnancy overall health medical history

 number of fetuses
 tolerance for specific medications, procedures, or therapies
 expectations or the course of the pregnancy
MANAGEMENT OF MULTIPLE PREGNANCIES MAY INCLUDE THE FOLLOWING:

Increased nutrition

Mother carrying two or more fetuses need more calories, protein, and other nutrients, including iron
high gam is also recommended for multiple Pregnancy. The American College of Gynecologists rec-
ommends women carrying twins gain at least 35 to 45 pounds).

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More frequent prenatal visits: (to check for complications and to monitor nutrition and weight gain)

Increased rest:

Some women may also need bed rest either at home or in the hospital depending on pregnancy

Complications or on the number of fetuses. Higher-order multiple pregnancies often require bed rest
in the middle of the second trimester.

Maternal and fetal testing:

Testing may be needed to monitor the health of the fetuses, especially if there are pregnancy compli-
cations.

Tocolytic medications:

These may be given, if preterm labor occurs, to help slow or stop contractions. These may be given
orally, in an injection, or intravenously, Tocolytic medications often used terbutaline and magnesium
sulfate

Corticosteroid medications :

These may be given to help mature the lungs of the fetus. Lung immaturity for problem of premature
babies.

Cervical cerclage:

Cerclage (a procedure use to suture the cervical opening) is used for women with an incompetent
cervix. Some women with higher-order multiples may require cerclage in early pregnancy.

HOW ARE MULTIPLE PREGNANCIES DELIVERED?

 Delivery of multiples depends on many factors including the fetal positions, gestational age,
and health of mother and fetuses. Generally, in twins, if both fetuses are in there in ver-
tex,(head down)position and no vaginal complication then vaginal delivery is possible but if
first is vertex and the second is not then first is delivered vaginally and other is turned to ver-
tex position or delivered in breech(buttocks are presented first).
 Emergency cesarean birth of the second fetus may be needed. Usually, if the first fetus is not
vertex, both babies are delivered by cesarean.
 Most triplets and other higher-order multiples are born by cesarean.
 Vaginal delivery may take place in an operating room because of the greater risks for compli-
cations during birth and the need for cesarean delivery

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 Cesarean delivery is usually needed for fetuses that are in abnormal position, for medical
conditions of the mother, and or fetal distress.
CARE OF MULTIPLE BIRTH BABIES:

 Because many multiples are small and born early, they may be initially cared for in a special
care nursery called the neonatal intensive care unit (NICU). Once babies are able to feed,
grow, and stay warm, they can usually be discharged .Other babies,that are healthy at birth
may need only a brief-check in a special care nursery.
 Breastfeeding multiples is certainly possible and many mothers of twins and triplets are suc-
cessful in breastfeeding all of their babies. Lactation specialists can help mother of multiples
learn techniques for breastfeeding their babies separately and together, and to increase their
milk supply. Mothers whose babies are unable to breastfeed because they are sick or prema-
ture can pump their breast milk and store the milk for later feedings.
 Families with more than one baby need help from family and friends. The first two months
are usually the most difficult as everyone learns to cope with frequent feedings, lack of sleep,
and little personal time. Having help for household chores and daily tasks can allow the
mother the time she needs get to know her babies, for feedings, and for rest and recovery.
MALPOSITIONS AND MALPRESENTATION:
Malposition or abnormal position of the fetal head relative to maternal pelvis. Malpresenation are all
positions of fetus other than vertex.

There are three components that indicate whether a baby is in a normal position They include the:

 Fetal lie,which is the axis of the baby relative to that of the mother's
 presentations which indicates what body part is closest to the pelvic outlet
 flexion attitude which refers to how the head of the baby is flexed

Each these components has variations that indicate whether the baby is in a normal position or is go-
ing to come through the birth canal in an unusual way.

Toward the end of pregnancy, the fetus moves into position for delivery. Normally, the position of a
fetus is facing rearward (toward the woman's back) with face and body angled to one side and the
neck flexed, and presentation is head [Link] abnormal position is facing forward, normal presenta-
tions include face, brow, Breech and shoulder.

THE VERTEX POSITION:

Is when baby's head is positioned one out first, before the rest of the body, at birth. During normal
labor the baby's head rotates so that the baby's face is toward the mother's back and the ton of the ba-
by's head is facing up. When this does not occur it is referred to as malposition, may lead to dificult
labor.

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When a fetus faces up (an abnormal position) the neck is often straight rather than bent and the head
requires more space to pass through the birth canal. Delivery by forceps a vacuum extractor or cesar-
ean section may be necessary

Face presentation:
In face presentation, the neck arches back so that the face presents [Link] brow presentation, the
neck is moderately arched so that the brow presents first. Usually, feuses do not stay in these presen-
tations;they correct themselves.

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Persistent occiput posterior (POP):

Sometimes the baby's head faces the front of the mother's pelvis instead of turning toward the mother
back. This position is called persistent occiput posterior. The baby would then be delivered the ceil-
ing, which is often a more difficult way to deliver. This position occurs more often in women who
having her first baby and women who have a narrow pelvis.

Persistent occiput transverse:

Sometime baby head lie in a sideway position ,this sideways position with the baby facing either the
position is called persistent occiput transverse. It usually occurs because the uterine contractions are
not strong enough to help the baby turn its head to the proper position, or because the mother has a
flattened pelvis. The size and shape of the mother's pelvis may favour sideways passage of baby
head.

Women who have a baby already will usually be able to deliver the baby, but it may be a more diffi-
cult delivery. First-time mothers may need more help from the doctor.

If Cx is fully dilated (cervix is open all the way and having good contractions), but the baby's head
occiput posterior position rotation: the doctor may do following:

Position: May be asked to lie on her side or in the knee-chest position.

Manual Rotation:

When the baby's head can be seen through the opening of the vagina, the doctor may try to turn the
baby's head with her hands, Forceps rotation: If manual rotation doesn't work, the doctor may use
forceps to turn the baby head. Forceps are large steel instruments like tongs that seat The doctor gen-

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tly turns the forceps and the baby's head. When the head is turned, the baby can be delivered in the
normal way.

Forceps Delivery:

The baby can be delivered with its head in the occiput posterior position using forceps. some type of
anesthesia will be given for pain relief. The doctor will place forceps alongside the baby's make a cut
to enlarge the opening of the vagina (episiotomy) and gently pull the baby head down. The cut will
then be stitched closed.

Vaccum Rotation and delivery:

The doctor will place a plastic or metal cup called a vacuum extractor on the baby's head and apply
vaccum. The doctor will pull gently on the baby's head during a contraction while you are pushing
,the doctor may turn baby's head either before or during delivery.

C-section (Cesarean Section):

The doctor may decide to deliver the baby with surgery if:

 Labor has been long and mother cannot push the baby far enough down the birth canal to use
vacuum or forceps safely.
 A forceps or vacuum delivery is tried and doesn't work.
 The doctor decides a forceps or vacuum delivery would be too dangerous for the baby.
 The doctor decides the baby is too big to fit through the pelvis
The following may be done to help with delivery if the baby head turned in position

 A drug called oxytocin may be given intravenously (IV) to make contractions stronger
and help the baby's head come down the birth canal and turn. This may be enough for de-
livery of the baby.
 The doctor may use his or her hands to manually rotate the baby's head.
 The doctor may use forceps or a vacuum extractor to turn the baby's bead and baby.
 Mother and the baby may be checked with a fetal monitor to detect problems the baby's
condition.
 If the doctor expects difficulties with the delivery, a cesarean section may be done.
How long will the effects last?

 If the problems with the baby's head position can be corrected immediately, there may be no
permanent injury. The longer delivery is delayed, the greater the risk of permanent brain inju-
ry or death for the baby
 What a mother should do?
 Remain calm and follow the directions of the doctor and nurse's
 It may help to use the breathing and relaxation techniques learned and practice in prenatal
classes.

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What can be done to help prevent Malposition of vertex?

o There is no general way to prevent malposition of vertex. However, regular prenatal visits
will help the doctor detect problems ahead of time.
PROBLEM:

o The fetus is in an abnormal position or presentation that may result in prolonged or obstruct-
ed labour.

TANSVERSE LIE AND SHOULDER PRESENTATION:

Shoulder presentations are rare-less than one out every 1,000 births and require. Cesarean section
positioning before delivery can continue. Shoulder births do not happen very often. And most babies
end in being delivered by c section. There are very few doctors babies end up being-de who will at-
tempt to reposition shoulder presentation.

 If the women is in early labour and the membranes are intact, attempt external version
 If external version is successful, proceed with normal childbirth
 If external version fails or is not advisable, deliver by caesarean section
 A cord proplapse can occur 20 times more often with a transverse lie than with an oblique or
 Monitor signs of cord prolapse. If the cord prolapses and delivery is not imminent, deliver by
C section..
 Ruptured uterus may occur if the woman is left unattended.
 In modern practice, persistent transverse lie in bour is delivered by caesarean section whether
the fetus is alive or dead.
BREECH PRESENTATION
A breech birth happens when a baby is born feet, knees or buttocks first. "Breech presentation occurs
in 3 to 4 percent of all deliveries. So, if there were to be a malpresentation, it would more than likely
be breech Most babies can be breech as late as 32 weeks into the pregnancy and then move to a ce-
phalic presentation during the last few weeks. If a woman has an ultrasound late in 32 weeks and has
been told her baby is in a breech position, there really is Again, oftentimes babies in the breech posi-
tion later in the pregnancy will labor and delivery beg no assistance from the doctor.

Types of breech presentation: complete, incomplete, and frank.

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Complete breech is when both of the baby's knees are bent and his feet and bottom are closest to the
birth canal

Incomplete breech is when one of the baby's knees is bent and his foot and bottom are closest

EARLY LABOUR

Ideally, every breech delivery should take place in a hospital.

Attempt external version if:

Breech preservation is present at or after 37 works (9 weeks, a successful in is more likely to

spontaneously revert back to breech presentation:
 Vaginal delivery is possible
 Membrane are intact and amniotic fluid is adequate.
 There are no complications (eg fetal growth restriction, arch delivery, uterine fetal abnormali-
ties, hypertension.)
 If external version is successful, proceed with normal birth.
 If external version fails,proceed with vgainal breech delivery or C section.
EXTERNAL CEPHALIC VERSION (ECV)

ECV is one to a baby from breech position to head down position while it call in the uterus. It in-
volves the doctor applying pressure to your stomach to turn baby from outside Sometimes, they use
ultrasound as well.

Many women who have normal pregnancies have ECV. One should not have ECV:

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 Vaginal bleeding
 placenta that is near or covering the opening of the uterus
 A low level of fluid in the sac that sands and protects the baby
 An abnormal fetal heart
 Premature rupture of the membranes
 Twins or other multiples pregnancy.

The doctor may give medicine to relax the muscles in uterus. This can help decrease discomfort and
increase the success of turning baby. The medicine may be given as a shot or through a vein (IV). It
is very safe, with no risk to baby! During ECV mother will lie down and the doctor will place his or
her hands on her stomach After locating the baby's head, the doctor will gently try to turn the baby to
the head first position. After the procedure doctor will monitor baby's heart rate again. If the proce-
dure is successful, father have to stay hospital .if there is a chance that the baby can turn back around
to the breech rate of ECV depends on several factors.

 How much fluid is around the baby.

 Ho w many pregnancies mother have had
 How much baby weighs
 How placenta is positioned
If the procedure is not successful, doctor will talk to mother about delivery. He or she will discuss
pros and cons of having a vaginal delivery or C section. The doctor may suggest repeating
[Link]:

 Early onset of labour

 Premature name of the membranes.
 Minor blood loss for either the baby or the mother.
 Fetal distress leading to an emergency C-section.
VAGINAL BREECH DELIVERY

o A vaginal breech delivery skilled health care provider is safe and feasible under the follow-
ing:
o Complete S204 or frank breech
o Flexed head
o Adequate clinical pelvimetry
o No previous caesarean section for cephalo-pelvic disproportion
o Examine the woman regularly and record progress on a partograph
o If the cord pelapses and delivery is not imminent, deliver by caesarean section.
o If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per minute) or
prolonged labour, deliver by caesarean section.
Note: Meconium is common with breech labour and is not assign of fetal distress if fetal
heart rate is normal.

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The woman should not push until the cervix is fully dilated Full dilatation shoul by vaginal ex-
amination.

CAESAREAN SECTION FOR BREECH PRESENTATION:

o A caesarean section is safer than vaginal breech delivery and recommended in cases of
o Double footling breech
o Small or malformed pelvis
o Very large fetus
o Previous caesarean section for céphalopelvic disproportion
o Hyperextended or deflexed head
Note: Elective caesarean section does not improve the outcome in preterm breech delivery.

COMPLICATIONS:

Fetal complications of breech presentation include:

 cord prolapse
 birth trauma as a result of extended arm or head, incomplete dilatation of the cervix or
cephalopelvic disproportion
 asphyxia from cord [Link] compression, placental detachment or arrested head
 damage to abdominal organs
 broken neck
COMPOUND PRESENTATION:
“A compound presentation occurs when more than one part of the baby enters the pelvic outlet or
Birth canal at the same time” The most common compound presentation is the hand or arm alongside
the head. The risk with a compound presentation is related to the size of the pelvis. If the pelvis is
able to compensate for the extra room needed for a compound presentation, the doctor may allow the
birth to occur naturally, However, if the cervix and pelvis may not able to compensate, an episiotomy
- or a Cesarean section in extreme of emergency may be performed.

GENERAL MANAGEMENT:

Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood
pressure, respiration, temperature).

Assess fetal conditions:

 Asses fetal heart rate immediately after a contraction:

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 Asses fetal heart rate at least once every 30 minutes during the active and 5 minutes during
the second stage
 If heart rate abnormalites (less than 100 or more than 180 beats per min) suspect fetal distress
 If the membranes have ruptured, note the colour of the draining amniotic fluid:
 Presence of meconeum indicates the need for close monitoring and possible management of
fetal distress
 After rupture of the membranes is an indication of reduced volume
 Provide encouragement and supportive care
 Review progress of labour using a partograph.
Note: Observe the woman closely. Malpresentations increase the risk for uterine rupture because of
the potential al for obstructed labour.

SHOULDER DYSTOCIA (Stuck shoulders):

The feat head has been delivered but the shoulders are stuck and cannot be delivered: Shoulder dys-
tocia occurs when one shoulder of the fetus lodges against the woman's pubic bone, and the therefore
caught in the Birth canal: The head comes out, but it is pulled back tightly against the vaginal open-
ing, The baby cannot breathe because the chest is compressed by the canal ,As a results oxygen lev-
els in the baby's blood decrease. This complication is more common with large fetuses particularly
when labor has been difficult or when forceps or a vaccum extractor has been used because the fe-
tus's head has not fully descended in the pelvis

When this complication occurs, the doctor quickly tries various techniques to free the shoulder can
be delivered vaginally. In extreme circumstances if the techniques are ma pushed back into the vagi-
na and delivered by cesarean section.

GENERAL MANAGEMENT:

Be prepared for shoulder dystocia at all deliveries, especially if a large baby is anticipated.

Have several persons available to help.

Shoulder dystocia cannot be predicted.

DIAGNOSIS:

Fetus is delivered but tightly applied to the vulya and contracts and depresses the perineum

Traction of head fails to deliver the shoulder, which is caught behind the symphysis pubis.

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MANAGEMENT:
Make an adequate episiotomy to reduce soft tissue obstruction manipulation.

With the woman on her back, ask her to flex both thighs, bringing her knees as far as possible to-
wards her chest. Ask two assistants to push her flexed knees firmly up onto her chest.

Wear high-level disinfected gloves:

Apply firm, continuous traction downwards on the fetal head to move the shoulder that is anterior
under the symphysis pubis;

Note: Avoid excessive traction on the head as this may result in brachial pl • Have an assistant sim-
ultaneously apply suprapubic pressure downwards to ass the shoulder;

Note: Do not apply fundal pressure. This will further impact the shoulder and can reuterine rupture.

If the shoulder still is not delivered:

 Wear high-level disinfected gloves, insert a hand into the vagina,

 Apply pressure to the shoulder that is anterior in the direction of the baby's sternum to rotate
 the shoulder and decrease the shoulder diameter;
 If needed, apply pressure to the shoulder that is posterior in the direction of the sternum.
If the shoulder still is not delivered despite the above measures.

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 Insert a hand into the vaginal

 Grasp the humerus of the arm that is posterior and, keeping team flex the elbow sweep the
arm, across the chest. This will provide room for the shoulder that anterior to move under the
symphysis pubis.

If above measures fail to deliver the shoulder, other options include

 Fracture the clavicle to decrease the width of the shoulders and free the shoulder that is
anterior
 Apply traction a hook in the axilla to extract the arm that is posterior
PROLONGED LABOUR
Labour is termed longed when it is excced 24 hours; or if delivery is not imminent after 12 and ac-
tion should be taken before complication.

First Stage:

 Power: insufficient uterine contractions.

 Passage pelvic abnormalities e.g. contracted pelvis, pelvic tumors prevent normal progress of
labor.
 Passenger: Malposition and presentation.
 physiological conditions like abnormal tense or apprehensive woman tends to have
Second Stage:

 Hypotonic uterine action

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 Ineffective maternal effort like fear, exhaustion or lack of sensation may inhabit ability to
push and cause delay
 A rigid preneum may prevent advance of fetus
 Reduced pelvic outlet.
 Large Fetus

1. FAULTS IN PASSENGER

 Abnormal positions presenting head

 Abnormal presentations ie, breech brow, face, shoulder and compound
 Size of the fetus macrocosmic+ 4.5 kg wt
 Gross Congenital malformation of the fetus ie. Hydrocephalic.,abdominal tumor conjoint
twins and hydrop-fatalist
2. FAULTS IN PASSAGE.

 Abnormalities of the sizes and shapes of pelvis e.g android pelvis,Anthropoid, platy peloid
 Disease or injuries of pelvic bones. Rickets, softening of the bones in Child,tumor of pelvis,
mal-united fracture: congenital dislocation of hip.
3. FAULTS IN POWER:

Hypotonic uterine [Link] uterine action. Cervical dystocia and contraction ring.

4. FAULT IN PRACTICE

 Unwise induction of labor

 Induction before bishop score 3-lead to prolong labor
 Failure to recognize and treat dysfunctional labor
5. FAULT IN PATIENT'S PSYCHOLOGY

Increase maternal anxiety causes abnormal uterine activity with contraction arising from the, lower
segment rather than from fundus.

These contractions are harmful and to cervical dilatation.

MANAGEMENT

Curative= correct diagnosis of labor.

Patient is in labor if she has uterine contraction, head engagement and cervical dilatation and efface-
ment. Patient with false pain should only be monitor for fetal wellbeing by

 Hospitalized the patient if labor is more than 18 hours.

 Identify cause and decide management
 If membrane is ruptured give antibiotic cover

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 Test urine for Albumin and acetone.

 Maintain I/V glucose and Syntocinon for hypotonic uterine action:
 Keep bladder empties and maintain I/O chart,

 If membrane intact do ARM

 Encouragemnt and psychologic support
 Sytocinion if painful contraction causes effacement but minimal dilatation.
 If patient go in prolong labor after induction of 40 drops / min of Syntocinon for 6 hours –no
progress C section should be performed.
Miantain Patrograph:

Check heart sounds

Check vital signs

Observe amniotic fluid for meconium

COMPLICATIONS:

Maternal:

 Prolong pressure of fetal head on the vaginal and pelvic floor may cause oedema
 Rectocele,cystocele, spina bifida risk increases.
 Retention of urine due to prolong compression of urethra by fetal head
 Recto vaginal fistula.
Fetal Complications:

 Hypoxia
 Intracranial hemorrhage

OBSTRUCTED LABOR
DEFINITION:

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Labor is said obstructed uterine contractions and there condition and fetal le doll

developed.

CAUSES:

Maternal causes:

 Contracted pelvis or CPD.

 Tumor of the pelvis.
 Ovarian or uterine tumor
 Stenosis of vagina and cervix
 Tumor of rectum and bladder
 Formation of contraction ring.
Fetal cause:

 Large or macrosomic baby.

 Malposition e.g. persistent occipito posterior, deep transverse arrest
 Mal presentation e.g. breech. brow.
 Congenital abnormalities of fetus.i.e. hydrop fetalus hydrocephelic.
SIGN OF OBSTRUCTED LABOUR:

CLINICAL FEATURES

 First sign is detoriation in maternal general condition.

 She looked tired and exhausted, anxious and unable to relax between pains.
 Increase temperature, respiration and pulse rate.
 Tongue is dry
 Presenting part doesn't descent in spite of good contractions...
 Slow dilatation of cervix.
 Uterus become molded round the fetus and doesn't relax between contractions.
 A visible retraction (bandle's ring).
 Uterine contraction stops
 Retention of urine.
 Severe fetal distress.
 Dehydration and ketoacidosis.
PER VAGINUM EXAMINATION

 Vagina becomes hot and dry.

 Formation of bag and caput succedaneum
MANAGEMENT:

 Good antenatal care

 Early diagnosis care and treatment.

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 Careful monitoring of labor

 Send blood for cross matching
 Compensate dehydration
 Antibiotic to avoid infections
 Reassure the patient and family
 Care must be taken to correct ketoacidosis as paralytic uterus can cause.
MATERNAL COMPLICATIONS:

 Intauterine infections followed by prolong rupture membrane lead to infertility.

 Trauma bladder due to pressure of fetal head
 Trauma to vagina due to forceps
FETAL COMPLICATIONS:

 Intrauterine hypoxia
 Still birth
 Intracranial hemmorhage
 Malpresentation

TRAIL OF LABOR
DEFINITION:

It is the test of labor conducted on chces when are avusic to vagina is possible or not. It is d

INDICATION:

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Minor to moderate contraction of pelvis and engaged fetal head in a healthy primigravida to avoid C-
section

CONTRA INDICATIONS

 Elderly primigravida
 Bed obstetrical history.
 Severe pre eclamptic toxemia
 Diseases eg cardiac disease, hypertension
DURATION OF TRAIL OF LABOR

 If progress is good.
 With contractions there is decent of head, dilatation of cervix
 Good fetal and maternal it can continued but if o progress
 Despite of good contraction, there is no dilatation
 Cervical dystocia
 Presenting part fails to decent,
 Incoordinate uterine contraction
 Fetal and maternal distress it should be discontinued
NURSING CARE

 Ensure that woman's moral is high

 Close monitoring of fetus and mother Maternal vital signs,featl heart rate on CTG
 Assessment of effacement and dilatation of cervix
 Maintain maternal hydration and nutrition
 Strict Aseptic technique should be observed.
 Progress of labor is assessed periodically
 Report and record any sign of fetal and maternal distress
COMPLICATIONS:

 Prolong labor may cause frustration,

 Disordered uterine action may cause fetal distress and asphyxia
 Maternal distress.
 Puerperal sepsis if membrane ruptured earlier.

COMPLICATIONS ON PUERPEREUM:
POSTPARTUM HEMORRHAGE:
Loss of Blood more than 500 ml at the time of delivery.

OR

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it is defined as excessive bleeding from genital tract at any time following baby's birth up to 6 weeks
after delivery. It is the major cause of maternal mortality..

Primary:Occurs within first 24 hours of delivery

Secondary:It occurs 24 hours of birth up till 6 weeks postpartum

CAUSES

Major causes include: 4TS

T1=TONE

T2=TEAR

T3=TISSUE

T4=THROMBIN

(a)T1=TONE:

muscle tone in uterus may be the result of over distension,"

polyhydramnios, large baby Multiple pregnancies

Mismanagement of 3rd stage of labor over massage:

(b) T2aceration the birth canal (Tears or laceration of cervix, vagina, labia, perineum.)

(c)T3:Retained placental fragments

 Placenta acereta:
It occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the
uterine muscle. This is the most common accounting for approximately 75% of all cases.
 Placenta Increta:
It occus when the placenta attaches even deeper into the uterine wall [Link] penetrate into
the muscles This accounts for approximately 15% of all cases.
 Placenta perceta:
It occurs when placenta penetrates through the entire uterine wall,and attaches to another or-
gan such as bladder and this is the least common of the three conditions accounting for ap-
proximately 5% of all cases.
Placenta accretes:

 Requires manual removal of the placenta

(d) T4-Thrombin-DIC Coagulation failure

 Intrauterine, death with retained fetus

 Severe pre-eclampsia

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 Premature separation of the Placenta

 Retained placenta
 Amniotic fluid embolism (usually pot able to be determined until autopsy)
 Hemorrhagic shock
 Transfusion reaction
 Following sever Antepartum hemorrhage
That is failure of blood to clot. It can occurs with
ASSESSMENT FINDINGS:
[Link] uterus relaxed state medicating atony
2. If uterus is firm, with excess bleeding mawind care ace
3. Dark red blood with clots,
4. Large amounts with atony
5. Steady trickle with lacerations.
6. Hemorrhage immediately after delivery with atony or lacerations
7. With retained placental fragments, delay of up to two weeks
8. With severe blood loss, signs and symptoms of shock
9. Full bladder may displace uterus and prevent it from contracting firmly.
NURSING INTERVENTIONS
Basic principle of apply :
 Call for help
 Stop bleeding (rub the uterus empty bladder' breast feeding, oxytocin)
 Resuscicate the mother
1. Identify clients at risk for condition.
2. Monitor fundus frequently if bleeding occurs when stable every 15 appropriate inter-
vals
3. Monitor maternal vital signs for indications of shock
4. Administer medications IV-fluids as ordered
5. Measure I&O
6. Remain with client for support and explanation of procedures.
7. Keep client warm
8. Prepare for client's return to delivery room if needed for repair of laceration, or re-
moval of placental fragment
9. Express any clot
10. Keep the linens and pads to assess the blood loss.
11. MonitorforsignofDIC(bedsideclottingtime,freshfrozenplasma&fibrinogen
12. Bimanualcompressionofplacenta
13. If bleeding persist than prepare the mother for theater
14. Continued rip with 100 micronoxytocinat 10-20dropsperminutes
15. Keep mother under observation for 24 hours

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THROMBOPHLEBITIS:

General Information:

 Formation of thrombus when vein wall is inflamed

 Often occurs in leg during pregnancy
 It may be due to trauma surgery or prolonged activity.

Assessment Findings:

 Pain/discomfortinareaofthrombus(legs,pelvis,abdomen)
 If injury severe pain,edema redness over affected area
 Elevated temperature and chills
 Peripheral pulses may be decreased.

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Nursing Intervention

 Maintain bed rest with leg elevated on [Link] raise knee gatchonbed
 Apply moist heat as ordered
 Administer analgesics as ordered
 Teach client not to massage legs
 Allow client to express fear sand reactions to conditions
 Observe client for the signs of pulmonary embolism
 Continue to bring baby to mother for feed in gand interaction

SUB-INVOLUTION OF UTERUS:

General Information

 When involution is impaired or retarded it is called subinvolution.

 The uterus is most common organ affected
 Involution is a process where by the genital organs revert back approximately to the
state as they were before pregnancy
Assessmentfindings:

 Uterusremainsenlarge
 Fundushigherintheabdomenthananticipated
 Lochiadoesn’tprogressfromrubratoserosatoalba
 Ifcausedbyinfectionpossibleleucorrheaandbackache

NursingIntervention

 Teach client to recognize usual bleeding patterns

 Teach client usual patterns of uterine involution
 Instruct client to reporta bnormal bleeding to physician
 Administer oxytoxic medications ifordered.

MASTITIS:

General Information

 Infectionofthebreastusuallyunilateral
 Inflammation of mammary gland in thebreast or udder typically due to bacterial-
infection.

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 The main cause of mastitis is trapped milk in the breast.

Assessments Findings:

 Redness,tenderness or hardened area in the breast.

 maternalchills,malaise
 Elevated vital signs especially temperature

Nursing intervention:

 Teach/stress importance of hand washing to nursing mother and wsh own hands
beforetouchingclient’s breast.
 Administer antibiotics asordered
 Apply ice if ordered between feedings
 Empty breast regularly: baby may continue to nurse or have mother. The mother
should nurse more frequently as the inflamed area needs to be kept empty
 Begin breast feeding with the affected area
 Apply moist hot packs to the breast
 Take mild analgesic
ENGORGED BREAST:

The breast usually becomes swollen when the amount of milk produced is more and baby is too
weak tosucktoempty thebreast.

SIGN AND SYMPTOMS:

 If the breast is not emptied normally, then it will become full and swollen with
milk it becomes engorged.
 Even the baby is not able to suck because the skin of the breast becomes tight and the baby
cannot put the areola in his/her mouth.
 Sucking also becomes painful for the baby.

Prevention and treatment of engorged breast:

 Do not let the baby miss the feed

 Mother should wake even a sleeping baby when she feels the needs to breast feed the baby.
 Express milk by breast pump or hand expression to remove the excess milk and make
the breasts of tso that the babycan grasp it easily
 Take hot showers
 Let the baby begin nursing on the fuller breast first

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 Rest
 Well supporting brassieres should be worn.

CRACKED OR SORE NIPPLES:

Nipples soreness is more pronounced at the beginning of breast feeding or during early lactation.

i.e on the second or third day. Once the let-down reflex initiates milk flow, tenderness
usually lessens.
CAUSES:
 Inappropriatenursingtechnique
 Friction due to strong sucking at the initiation of lactation Incorrect positioning during breast
feeding.

SOME REMEDIES ARE:

1. Nurse the baby before he/she is very hungry to avoid hardsucking.
2. Massage the breast to stimulate let-down reflex
3. Start feeding on the less painful breast
4. Alternate position for each feeding
5. Check to make sure that baby has both nipple and areola in his/her mouth
6. With water wash there residues of thebaby's saliva from the breast after feeding.
7. Let the nipple dry thoroughly before covering it.
8. Betweenfeedings expose nipple tothe airorwear aloose blousethat allowstheairtocirculate
9. When nipples are dry,apply pure lanolin vitamin oil or breast milk.

BREAST ABSCESS:-

 Breast abscess causes fever and a clearly defined, red, hot, painful area
in the [Link] may follow breast infection, especially if nursing is dis-
continued during infection.

 The mother must continue breast feeding on the unaffected [Link]

may pump her breast on affected side and discard the [Link] must
see her do tor immediately.

 Prior to hospital discharge,the mother should receive specific educa-

tion

WHITE LEG

A condition uncommon now days of puerperal femoral thrombophlebitis or phlebothrom-

bosis associated with venous obstruction or reflex arterial spasm. The leg is swollen and
very [Link] consist immobilization and giving antibiotics only if the condition

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is caused by thrombophlebitisin cases anticoagulantsmay begivenin addition.

VVF (Vesicco Vaginal Fistula) RVF (Rectovaginal Fistula)
VVF is an obstetric fistula is the breakdown of tissue in the vaginal wall Communicating into the
bladder (vesico-vaginal fistula - VVF) or the rectum (rectovaginalfistula-RVF) .It is one of the most
degraing morbidities. Resulting from pregnancy and child birth.

CAUSES OF VVF:

 Approximately 80% of VVF cases reported are due to relieved obstructive labor during
childbirth.
 Obstructing labor is directly related to the custom of early marriage (frequently below the
age of 18 and sometimes before the onset of menstruation, as early as11years old).
 Early marriage invariably leads to car sexual contact and subsequent pregnancy at a
time when a young girl is not adequately physically developed to permit the passage of
a baby with relative ease. This can lead to a prolonged and obstructed labor and damage
leading to VVF.

PHYSICAL CONSEQUENCES:

 The immediate physical consequences of VVF are urinary incon-

tinence and / or fecal incontinence (due to RVF)and related con-
ditions, such as dermatitis.

SOCIAL CONSEQUENCE:

 The social consequences for those who suffer from VVF are severe.

 Many victims of obstructed labor, in which the fistulae subsequently occur will also have
given birth to a still born baby,thus leaving the woman childless

 In some areas, a high percentage of fistula occur during the first pregnancy, If the fistula is
not repaired,and the woman remain incontinent and childless, she is likely to be abandoned
by her husband, on whom she is economically dependent.

 In addition, she may be ostracized by society as being considered to have brought shame
on her family. Victims ,therefore, becomes social out casts.
 VVF leaves such women physically, emotionally and socially traumatized.

 With no education, no vocational training, no gainful employment or visible means o

livelihood, they travel a long road of rejection and pain.

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APPROACHES TOWARDS ELIMINATING VVF:-

 In the short term, better use of existing obstetric services and increased provision of
effective healthservices in rural are as will lower the incidence of VVF.
 However, in the longer term there is a need for an holistic approach to address both
the direct and indirect causes of VVF and other maternal morbidities.
 Ultimately, improving the education and economic empowerment of young women will-
remove theconditionsthat lead totheoccurrenceof VVF.

 Such improvements would lead women to seek safer obstetric practices, including
the use of family planning,delay child bearing, and seek prenatal and antenatal care
during pregnancy.

 It has been found that women with a formal education have a maternal morality rate
one fourththat ofwomenwith no formal education.

 Other possible complications of puerperal infection include:

 Pelvic thrombophlebitis Paralytic ileus

 Disseminated intravascular coagulation

 Formation of a pelvic abscess

UNITNo:-12.
COMPLICATIONS OF NEWBORN
WHAT IS A BIRTH INJURY?

Occasionally during the birth process, the baby may suffer a physical injury that is simply the
result [Link] issometimescalledbirth traumaor birth injury.

CAUSES OF BIRTH INJURY:

 A difficult birth or injury to the baby can occur because of the baby's size and the
postion of thebaby during labor and delivery. Conditions that may be associated
with a diffcult birth [Link] notlimitedtothefollowing:
 large babies –birthweightover about 4,000grams(8pound13ounces)
 prematurity - babies born before 37 weeks (premature babies have more fragile bodies and
may bemoreeasilyinjured)
 cephalopelvic disproportion-the size and shape of the mothers pelvis is not adequate for the
baby to be born vaginally

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 dystocia - difficult labor or

child birth prolonged labor
 abnormal birthing presentation"such,asbreech(buttocksfirst)delivery

THE FOLLOWING ARE COMMON BIRTH INJURIES:

CAPUTSUCCEDANEUM:

Caput is severe swelling of the soft tissues of the baby's scalp that develops as the baby trav-
elsthroughthe birth [Link] have some [Link] swelling usually disap-
pears in a few days,without [Link] delivered by vacuum extraction are more likely to
have this condition.

CEPHALO HEMATOMA:

 Cephalohematoa is an area of bleeding underneath one of the cranial bones.

 It often appears several hours after birth as a raised lamp on the baby'shead.
 The body resorbs the blood.
 Depending on the size,most cephalo hematomas take twoWeeks to three months to disap-
pear completely. lf the area of bleeding is large, some babies may develop jaundice as die
red blood cellsbreak down.

BRUISNG FORCEPS MARKS:

 Some babies may show signs of bruising on the face or head simply as a result
of the trauma of passing though the birth canal and contact with the mother's
pelvic bones and tissues. Force psused with delivery can leave temporary marks
or bruises on the baby's face and head. Babies delivered by vacuum extraction
may have some scalp bruising or ascalpl acerarion(cut).

SURCONJUNCTIVAL HEMORRHĄGE:

Subconjunctivalhemorrhage is the breakage of small blood vessels in the eyes of a beby.

one orboth of the eyes may have a bright red band around the iris. This is very commonand
does not cause damage to the [Link] redness is usually absorbed in a week to ten days.

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FACIAL PARALYSIS:
 During labor or birth,pressure on baby's face may cause the facial nerve to be injured.
 Thismay also occur with the use of forceps for delivery.
 Thẹ injury iš often seen when the baby cries.
 There is no movement on the sideof the face withthe injury and the eye cannot be [Link]
the nerve was only bruised, the paralysis usually improves a few weeks. If the nerve was
torn, surgery may be needed.

BRACHIALPALSY:

 Brachia l pals y occurs when t he brachial plexus (t he group o f ner ves t hat
supplies t he ar ms and hands) is [Link] is most co mmo n whent here is dif-
ficult y deliver ingt he baby's shoulder,called shoulder dyst ocia. T he baby
lo ses t he abilit y t o flex and rot at e t he ar m. I f t he injur y caused bruis ing
andswelling around t he ner ves, mo vement should ret urn wit hin a few
mo nt hs.
 Tear ing of t he ner ve ma y result in per manent ner ve damage. Br achia l pals y
is t reat ed wit h a brace orsplint .Special exercises are also used tohelp main-
t ain t he rangeo fmot ion o f t he ar m.

FRACTURES:

Fracture of the clavicle or collar bone is the most common fracture during labor and [Link]
clavicle may break when there is difficulty delivering the baby's shoulder or during a breech deliv-
[Link] baby with a fractured clavicle rarely moves the arm on the side of the break. Then may be
bruising over the broken bone. Simply immobilizing the arm and shoulder is the recommended
treatment and healing begins quickly.

BIRTHASPHAXIA:

Birth asphyxia occurs when a baby does not receive enough oxygenbefore, during or Just [Link]
an infant does not breathe well by 1 minute after birth, the infant is said to have ASPHYXIA(Birth
asphyxia or asphyxianeonatorum). There are many reasons that birth asphyxia may occur.

CAUSES OF BIRTH ASPHYXIA:

Some of the causes of decreased oxygen before birth or during the birth Process may include:
 Inadequate oxygen levels in the mother's blood due to heart or respiratory problems
 Lowered respirations caused by anesthesia.
 Low blood pressure of the mother.
 Inadequate relaxation of the uterus during labor that prevents oxygen circulation
to the placenta

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 Early separation of the placenta from the uterus,called placenta abruption

 Compression of the umbilical cord that decreases bloodflow
 Poor placenta functions that may occur with high blood pressure or in pregnacies that are
post-term, particularly those that are longer than42Weeks.
 Premature<30weeks
 Prolongedlabor
 Malpresentation(abnormalfetalposition)
 SGAorIUGR
 Difficultdelivery
 Caesareansection
 Shortorprolongedsecondstage(<10minor>2hours)
 APH
 Cordprolapsed
 Meconiuminliquor
 Infantof adiabeticmother
 Severerespiratorydistress
 Intrapartum infectio

 FACTORS THAT MAY LOWER OXYGEN IN THE BABY AFTER BIRTH IN-
CLUDE:

 Severe anemia, or a low blood cell count, that limits he oxygen-carrying ability of the
blood
 Low blood pressure or shock
 Respiratory problems that limit oxygen intake
 Heart or lung disease.

SIGNS AND SYMPTOMS

The following are the most common symptoms of birth asphyxia. However, Each baby may
experiencesymptomsdifferently.

BEFORE DELIVERY SYMPTOMS MAY INCLUDE:

 Not breathing or very weak breathing.

 Skincolor that is bluish,gray,or lighter than normal.
 Low heart rate.
 Poor muscle tone.
 Weak reflexes.

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 Too much acid in the blood(acidosis)

 Amniotic fluid stained with meconium(firststool)
 Seizures.

FRACTURES:

Fracture of the clavicle or collar bone is the most common fracture during labor [Link]
clavicle may break when there is difficulty delivering the baby's shoulder or during a breech de-
[Link] baby with a fractured clavicle rarely moves the arm on the side of the break. Thenmay
be bruising over the broken bone. Simply immobilizing the arm and shoulder is the recommended
treatment and healing begins quickly.
BIRTH ASPHAXIA:
 Birth asphyxia occurs when a baby does not receive enough oxygenbefore, during or Just
afterbith.
 If an infant does not breathe well by 1 minute after birth, the infant is said to have AS-
PHYXIA(Birth asphyxia or asphyxianeonatorum). There are many reasons that birth as-
phyxia may occur.
CAUSES OF BIRTH ASPHYXIA:
Some of the causes of decreased oxygen before birth or during the birth Processmayinclude:
 Inadequate oxygen levels in the mother's blood due to heart or respiratory problems
 Lowered respirations caused by anesthesia.
 Low blood pressure of them other.
 Inadequate relaxation of the uterus during labor that prevents oxygen circulation
to the placenta
 Early separation of the placenta from the uterus,called placenta abruption
 Compression of the umbilical cord that decreases blood flow
 Poor placenta functions that may occur with high blood pressure or in pregnan-
cies that are post-term,particularly those that are longer than 42 Weeks.
 Premature<30weeks
 Prolongedlabor
 Malpresentation(abnormalfetalposition)
 SGAorIUGR
 Difficultdelivery
 Caesareansection
 Shortorprolongedsecondstage(<10minor>2hours)
 APH
 Cordprolapsed
 Meconiuminliquor
 Infantof adiabeticmother

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
Severerespiratorydistress
 Intrapartum infection
 Factors that may lower oxygen in the baby after birth include:
 Severe anemia, or a low blood cell count, that limits he oxygen-carrying ability of theblood
 Low blood pressure or shock
 Respiratory problems that limit oxygen intake
 Heart or lung disease.

SIGNS AND SYMPTOMS

The following are the most common symptoms of birth asphyxia. However, Each baby may
experiencesymptomsdifferently.

BEFORE DELIVERY SYMPTOMS MAY INCLUDE:

 Notbreathingorveryweakbreathing.
 Skincolorthat isbluish,gray,or lighte rthan normal.
 Lowheartrate.
 Poormuscle tone.
 Weak reflexes.
 Too much acidinthe blood(acidosis)
 Amniotic fluid stained with meconium(firststool)
 Seizures.

PREMATURITY:-

INTRODUCTION:

 Preterm birth is a leading cause of perinatal death and disability and is an important
public healthproblem globally. Preterm birth occurs most commonly in economical-
ly disadvantagedCommunities andthosewithhighrates;ofurinary and genital tract in-
fection.
 Pre-term delivery of low-birth-weight(PLBW)babies is considered a major peri-natal
problem
 In many countries and is contributing substantially to infant mortality and to child-
hood handicap.
 There is a reported incidence of pre-tem delivery of low-birth-weight (PLBW) ba-
bies of 37 of all livebirthsin Pakistan.(JPMA)

DEFTNITION:

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 The length of a normal pregnancy or gestation is considered to be 40weeks (280 days)

from the date ofconception. Infants born before 37 weeks gestation are considered prema-
ture and may be at risk ofcomplications.
 In addition to being [Link] babies are develop mentally unpreparedfor
life,which can Result in physical and mental [Link] babies are more likely
to have respiratory problems during childhood, as well as a higher incidence of learning
disabilities and problems withspeec,[Link] good news is that in many cas-
es prematurity can be prevented.

CAUSES OF PREMATURITY:

The causes of prematurity may include:

MATERNAL CAUSES:

 Prematurérupture of the membranes

 Premature labor
 An incompetent cervix(problems with the uterus neck)
 Intrauterine growth retardation(whereababydoesnot developsatisfactory)
 Preeclampsia(ahighbloodpressure-relatedcondition)
 Rh disease(a blood-relateddisorder)
 Multiplepregnancies (includingtwinsandtriplets)are at an increased risk of Prematurity
 Mothers who have a history of miscarriages or who have given birth to a premature infant
 Drug abuse,particularly cocaine by the mother
 Teenage pregnancy
 Malnutrition & poor standard of living(severe anemia)
 Infection (such as group B streptococcus, urinary tract infections, vaginal infections, in-
fections ofthefetal/placental tissues)
 Abnormal structure of the uterus
 Polyhydramnios(toomuchamnioticfluid)

PLACENTAL CAUSES:

 Placentaprevia(placenta-relatedproblems)
 PlacentaAbruptio
 Hydatidiformmole
 Abnormal or decreased function of the placenta

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FETAL CAUSES:

 Chromosomalabnormalities
 [Link]

DIAGNOSIS OR SIGN & SYMPTOMS:

 The head appear relatively larger for the body.

 Small baby,often weighing less than 2500 grams(5pounds &ounces)
 Little bodyfat.
 Little scalp hair,but may have lots of lanugo (soft body hair)
 Weak cry and body tone
 Genitals may be small and under developed
 Skin appearsred shiny & smooth.
 Infant lies in frog leg position with thighs abducted & ankle flexed due to hypotonic.
 Edema is usually present on the leg.
 Baby sleeps most of the time & cry is feeble
 Respiration is irregular & periodic spells of apnea may occur.
 Abilityto suck is absent or feeble
 Average heart rate is 140b/mif
 Respiratory rateis40/min
 Body temperature, blood pressure,and heart rate may be difficult to regulate in premature
infants
 Ear cartilage is poorly developed.
 Breast nodules arè not palpable or small in size.
 Testis has not descent into the scrotum.
 Skin creases on the sole of foot are deficient or few are present anteriorly.

COMPLICATIONS:

 Infants prematurely may experience major complications due to their low

birth weight andthe immaturity of their body systems. The lungs, digestive
system, and nervous system(includingthebrain) areunderdeveloped in prem-
ature babies.
THESE INCLUDE:

 Jaundice (yellow discoloration of the skin and whites of the eyes due to hy-
perbilirubinemia).Hypothermia,hypocalcaemia.
 Apnea (a long pause inbreathing),Inabilitytobreastor ottle fed.
 Body temperature, blood pressure, and heart rate may be difficult to regulate
in prematureinfants

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 Respiratorydistresssyndrome(RDS)
 Necrotizing enterocolitis (NEC) is a further complication of prematurity. In this condition,
parts of thebaby'sintestinesaredestroyed as aresultof bacterial infection.
 Intraventricular hemorrhage (IVH). It is a condition in which immature and fragile blood
vessels withinthe brain burst and bleed into the hollow chambers (ventricles) normally
reserved for cerebrospinal fluidandintothe tissuesurroundingthem ,moresevere IHVcan
resultinhydrocephalus.
 Apnea of prematurity is aconditionin which the infant stops breathing for period lasting
 up to 20 seconds. it is often associated with a slowing of the heart rate. The baby may
become pale, ortheskincolormaychangetoa blueorpurplish.
 Patent ductus arteriosus is a condition in which the duct that channels blood between
twomain arteries does not close after the baby is born. In some cases, a drug indometh-
[Link] to [Link] iftheductdoes notclose on its

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Own as the baby develops.

 Retinopathy of prematurity is a condition in which the blood vessels in the

baby's eyes donotdevelopnormallyandcaninsomecases,resultinblindness.
 Premature infants are also more susceptible to infections, They are born with fewer an-
tibodies, whicharenecessary tofightoffinfections
 Poormuscle tone

 Seizures -maybe duetobleedingin thebrain

 These premature infants are at higher risk for death or serious complications,
which include heartdefects,respiratory problems, [Link].

TREATMENT:

Treatment may inchude:

 PRENATAL CORTICOSTEROID THERAPIES

 One of the most important parts of care for premature babies is a medication called
acorticosteroid. Research has found that giving the mother a steroid medication at
least 48 hourspriorto delivergreatlyreducestheincidenceandseverityof respirato-
rydiseaseinthe baby..
 Another major benefit of steroid treatment is lessening of intraventricular hemor-
rhage (bleedinginthebaby brain).andPDA.(Patent ductusarteriosis)
 Mothers may be given steroids when preterm birth is likely between 24 and
34 weeks [Link] ime,or [Link] is notef-
fective.
 Betamethasone12mg12hourty2dosesin24hours
 Premature babies usually need care in a special nursery called the Neonatal Inten-
sive Care Unit(NICU)
 TheNICU combines advanced technology and trained health professionals to pro-
videspecialized care for the tiniest patients. The NICU team is led by a neonatolo-
gist, who is apediatricianwith additional trainingin thecareofsickandprematureba-
bies.

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 CARE OF PREMATURE BABIES MAY ALSO INČLUDE:

 Temperature-controlledbeds(Incubators)

 Monitring of temperature, blood pressure., heart and breathing rates, and Oxygen levelsGiv-
ingextraoxygenbyamask or with a breathingmachine
 Mechanical ventilators (breathing machines) to do the work of breathing
for the babý intravenous (IV) fluids-when feedings cannot be giv-
en,orformedicationsPlacement of catheters (small tube) into the umbilical
cord to give fluids andmedicationsandtodraw blood
 X-rays(fordiagnosingproblemsandcheckingtube placement)special feedings of breast milk or
formula, sometimes with a rube into the stomach if ababy cannot suck. Breast milk has many
advantages for premature babies as it containsimmunities fromthemother andmany important
nutrients.
 Medicationsandothertreatments forcomplications,suchasantibiotic
 Kangaroo Care - a method of caring for premature babies using skin to skin contact withthe
parent to provide contact and aid parent-infant attachment. Studies have found thatba-
bieswho"kangaroo"may haveshorterstaysin theNICU

WHAT IS KANGROO CARE?

 Kangaroo care is placing a premature baby in upright position on a mother's bare

chest allowing tummy to tummy contact and placing the premature babyin be-
tweenthe mother's breasts.
 The baby’s head is turned so that the ear is above the parent’s heartMany studies
have shown significant benefits.
 In developing countries where advanced equipment and even electricity may not
be available orreliable, simple measures such as kangaroo care (skin to skin
warming) encouragingbreastfeeding, and basic infection control measures can
significantly reduce preterm morbidity and mortality.

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 According to Krisanne Lariner, author of"Kangarooing Our Little Miracles",

Kangaroo care has been shown tohelp premature newbornswith:
 Body temperature: Studies have shown that mothers have thermal synchrony
with theirbaby The study also concluded that when the baby was cold, the moth-
er's body temperaturewouldincreasetowarmthe baby upandviceversa.
 Breastfeeding- Kangaroo care allows easy access to the breast and skin-
to-skin contactincreasesmilklet-down.
 Increaseweight gain-Kangaroo care allows the baby to fallin to a deep sleep-
whichallowthe Baby to conserve energy for more important things. Increased
weight gain means shorterhospitalstay.
 increased affection and attachment_ Kangaroo care initiate bounding be-
tween mother andbaby

WhenCanA PrematureBaby GoHomeFromTheHospital?

 Prematurebabiesoftenneedtime tocatchup"inbothdevelopmentandgrowth.
 In the Hospital, this catch-up time may involve learnıng to eat und sleep, as well as steadily
gaining [Link] on their condition, premature babies often stay in the hospital
until they reach the pregnancy due date.

DIAGNOSED OF POST MATŲRITY:

Postmaturity is usually diagnosed by a combination of assessments, including the

following baby'sphysicalappearance length of the pregnancybaby's gestational age

TREATMENT OF POST MATURITY:

 Specific treatment for Postmaturity will be determined by baby's physi-

cian based on;Baby'sgestationalage,overall health, andmedicalhistory
 Extentofthecondition
 Baby'stolerance forspecific [Link],or therapies
 In a prolonged pregnancy,testingmaybedonetocheckfetalwell-beingandidentifyproblems.
 Tests often-include ultrasound, non-stress testing (how the fetal heart rate respondsto fetal ac-
tivity), andestimationof theamniotic fluidvolume.
 The decision to induce labor for post-term pregnancy depends on any factors.
 During laborthe fetal heart rate may be monitored with an electronic monitor to
help identify changes inthe heart rate due to low oxygenation.
 Changes in a baby condition may require a cesareandelivery.

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SPECIAL CARE OF THE POST MATURE MAY INCLUDE:

 Checking for respiratory- problems related to meconium( baby’s first bow move-
ment)aspiration
 Blood tests for hypoglycemia(low bloodsugar).

PREVENTIONOFPOSTMATURITY:

 Accurate pregnancy due dates can help identify babies at risk for
Postmaturity.
 Ultrasoundexaminations early in pregnancy help establish more accu-
rate dating bymeasurementstakenofthefetus.
 Ultrasoundisalsoimportantinevaluationtheplacentaforsignofaging

NEONATAL JAUNDICE
DEFINITION:
 National Jaundice is an excessive amount of bilirubin in the blood. Bilirubin is the yellow-
ishsubstance in the blood that is removed from the bloodstream by the liver.
This yellowish substancecan make the baby's skin appear yellow or very tan. Jaundice is not a

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disease,but it is a goodindicatorthat there couldbeother problemsin [Link] inabout50-

80%ofnewborn babies (depending whether term or preterm respectively). It is also known as
hyperbiirubinacmia. It isnotsomuch the jaundice but ratherthe reasonforthejaundice thatis im-
portant

PATYPHYSIOLOGY:

 Normally red blood cells survive in the circulation for about 120 days before they
are removedand broken down by the body
 The hemoglobin released is converted tobilirubin and carried tothe liver where it is
further processed and excreted in the bile.I n the uterus the baby has a largenumber
of extra red cells to help transport oxygen from the placenta to the baby. After
birth,when the baby starts to breathe and use the lungs. The see xtra cells are nolong-
er needed and are broken down. This means that the newborn baby will in fact have
relatively increased load of bilirubin toclear.
 About 50 percent of all newborn babies have a problem with jaundice. it is more
common inpremature infants. While the baby is still in the womb the mother.
Through the placenta rids thebaby'sbodyofexcessbloodcells.
 When the baby is out of the womb normally,the liver can cope with this bilirubin
load If the load becomes too great, or the processes within the liver slowdown,or
thereis sorne, obstruction to the öut-flow of the bile from the liver then bilirubin wil-
laccumulate in the blood.
 Some of the bilirubin in the bile in the intestine is normally re-absorbedIf there is a
significant delay in the passage of stools then a greater amount of bilirubin will en-
[Link] reach a levelwhereit is
deposited in the skin to căuse the yellow colour and turns the whites of the yes a
yellow colorAbaby willbefine afterfew dayswithjaundice.
 The liver will mature and catchup quickly to filtering out the bilirubin. But if the
baby can not eliminate it quickly, this can be dangerous. Toomuch bịlirubin can
harm brain cells.
 This is why it is important for doctors to monitor any babywith jaundice carefully
by doing bilirubin tests to find out the level of bilirubin in the blood

 CAUSES OF NEONATAL JAUNDICE:

HAEMOLYSIS

 Most of the cases are not serious and are basically due to immature liver [Link] are
the result of disease causing excess breakdown (haemolysis) of the baby's red blood cells
such ashemolytic disease of the newborn. Another reason is hepatitis caused by either a viral
orbacterialinfectionwhichcan leadstoobstructivejaundice.
 There are many other causes of hemolysis. One of them is when there is a defi-

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ciency of anenzyme necessary for the integrity of the red blood cells. This en-
zyme is known as glucose-6-phosphatedehydrogenase(G-6-PD)

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TYPES OF JAUNDICE:-
PHYSIOLOGICAL
JAUNDICE:
 Whist the baby is in the uterus,the liverisassistedinitsfunctionsbytheplacen-
ta,Includingthe processing of the bilirubin. At birth the liver is on its own and sud-
denly has to cope with thebilirubin. It normally takes a few days before the liver is
fully functional. If it takes a longerperiodthenthebilirubinlevelscanbecome
highenoughto depositoutin theskinto give the [Link] babiesare under-
standablymorepronetothisproblem.
 Thisformof neonatal jaundice is referred to as "physiological jaundice" because it
is essentially a prolongation of normalprocess

BREASTFEEDING JAUNDICE:


Breast milk jaundice becomes apparent after a few days; the TSB rarely exceeds
275 mmol/l but itIsa cause of prolonged jaundice; the baby remains completely
well, and continue to thrive. It isnota reasontostop breastfeeding.
PATHOLOGICAL JAUNDICE:


Moreseriousformsofjaundicearcreferredto as"pathologicaljaundice”Onevery important
cause isexcessivebreakdownofthe red bloodcellsandis knownas hemolytic disease of the-
newborn.
 This occurs when there is a difference (incomptaiibility) between the mother and her ba-
by'sblood groups.
RH INCOMPATIBILITY:

 Therhesus(Rh) Factorisone [Link] Thisdiseasethe Mother Is rh

 Negative But Her Baby Is Rh Positive The Mother Becomes Sensitized And
Produces Antibodiesthat Cross Through The Placenta And Destroy The Red
Blood Cells Of The Baby. The Degree Ofhaemolysis, Will Depend On The Stag-
es Of The Pregnancy And The Amount Of Antibodies That Crosso-
[Link] Bythebilirubinproducedandthebabybecomesjaun-
[Link]
 Destruction Of Large Numbers Of Red Blood Cells Means That The Baby Also Be-
comes Anemic Which Adds Tothe Trouble.
 This Rarely, Happens With The First Pregnancy As It Usually Requires Two
Or Three Incompatiblepregnancies For The Mother To Become Sensitized. If
The Mother's Rh Factor Is Known After Herfirst Pregnancy She Can Be Given
Anti-D (Rh) Immuno-Globulin Immediately After Delivery To Tryandpre-
ventsensitizahonwhenevershecarriesa Rh Positive Baby

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ABO INCOMPATIBILITY:

A second situation where there may bé incompatibility between mother and baby is
with themajor blood groups- the ABO factors. This also leads to breakdown of the red
blood cells but isusuallynotasserveastheabove.
INFECTOUSJAUNDICE:

 If the baby has an infection resulting in hepatitis then jaundice may appear.
This happensbecause the inflamed liver cells are not able to process the biliru-
bin as efficiently as [Link] also swell up and tend to block the very small
ducts in the Iiver that carry the processedbilirubin away lo the larger bile ducts.
The bilirubin accumulates and eventually leaks back intothebloodstream.

OBSTRUCTIVE JAUNDICE:
 In very rare instances a child may be bon without functioning bile ducts.
 All the bilirubin processed by the liver therefore can only escape by leaking back
into the blood. This condition is known as biliary atresia and the childrenhave
severe obstructive jaundice
SIGNS AND SYMPTOMS:
 The signs and symptoms will depend largely on the cause.
 In the physiological group the jaundice is only noted an the second or
 The baby feeds willbehaves normally and there is no enlarged liver or
spleen onexamination
 .The urinemaybedarkbutthestoolsare normalcolour.
 The bilirubin levels are not significantly raisedbelow 275 mmol/l The jaundice re-
solves overTwotothreeweeks.
 In the pathological group the jaundice occurs witlhin the first 24
hours after [Link] even bejaundiced at birth.
 Thebabymaybeunwellonexamination;
 Have anenlarged liverorspleen:have arash;havepale stoolsorbe pale.
 The bilirubin level can be very high yell above 275mmol/linhemolytic disease.
 jaundice lasting more than twoweeks is considered to be prolonged jaundice and
requiresfurtherinvestigation.
INVESTIGATIONS:

 .Totalserumbilirubin(TSB).
 4 Routine tests are the mother's blood group and screening for syphilis (an im-
portant cause ofNeonatljaundice) andthebaby'sbloodgroup.
 Checkingthebaby'sbloodfor anemia,
 Comb'stest(screeningforantibodiesthatmaybecausinghaemolysis).

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
Assaying for G-6-PD, tests for liver function or a "septic work-up (screen-
ing the baby forcommoncongenitally acquired infections).
TREATMENT:

 Most cases will not require any treatment because the bilirubin levels are
usually below 275mmol/landclear withintwotothreeweeks.
 Ensuing that the baby feeds early andr egularly willstimulate the intestine so that there-
Absorption of the bile is minimized.
 Neonatal jaundice is related by means of photoțherapy. When unconjugated biliru-
bin is subječted,to specific fluorescent light-waves its structure is changed and it
becomes water-soluble.
 This means that the excess canals becleared in the [Link] undergoing photo-
therapy the baby's eyes must be protected against the light.
 The baby must be fed regularly to keep up a good urine output and to prevent de-
hydration. The baby may have loose stools whilst undergoing phototherapy and
may also become"tanned".
 In severe hemolytic disease if the unconjugated levels rise to >350 - 400
mmol/l it may yenecessarytodoanexchangetransfusion.
 Here an attempt is made to "wash-out" the baby's own blood,the bilirubin, and the antibod-
ies causingthe hemolysis,and to replace with donor [Link] exchange transfusion may be
performed in other circumstances where the unconjugated bilirubin is excessively
raised of there isSevere anaemia.
.

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OUTCOME OF NEONATAL JAUND1CE:

 Inmajorityofcasesthere arenocomplicationsassociatedwithneonataljaundice.
 The problem with unconjugated (fat-soluble or Indirect) bilirubin is that if the levels are
veryhigh especially when caused by hemolytic disease, it can penetrate into the brain and
cause brain [Link] is knownas("It is rare because allat-risk babies are treated earlywith
phototherapy and, in the unlikely event of thatnotreducingtheTSBadequatelywith an ex-
change transfusion.
 Anemia can be a problem in some babies following hemolytic jaundice and they may need
oneortwobloodtransfusionsinthe months after antibodies have been cleared
.
HEMORRHAGIGDISEASEOFTHENEWBORN:

Hemorrhagic disease of newborn was first described over a hundred years ago but its re-
lationship tovitaminKwas notrealizeduntil40years lgater.

 Vitamin K is required for the production of an essential factor involved in the normal clotting
of blood, it is present i some plants and is also synthesized by some E. coli in the gut.

 All newborn infants have low levels of vitamin K and are at risk of developing hemorrhagic
disease of thenewbornHDN.HDNmayoccurwithin24hoursofbirth(early),betweenday1and day
7 of life (classicHDN)or between weeks 2 and 12 of life (late HDN).

 LateHDNcanresult insignificant morbidity and mortality (25%jduetointracranialbleeds, and

has resulted in most developed countries having in place a protocol for the giving of supple-
mental vitanin Ktoall newborn babies

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PRESENTATION:
EARLY HDN

 Is limited to babies whose mothers received various drugs during pregnancy, and due to rou-
tineant-natal care is now extremely rare.
 Early HDN presents with bleeding at sites related to theTraumaof birth Bleeding from scalp
monitor site Cephalo hematoma
 Intracranial bleeding, irritability, convulsionsIntrathroacic bleeding,
 Blood stained sputum
 Intra-abdominal bleeding,
 Melena
 Tachycardia

CLASSICAL HDN:

It occurs both in babjes whose mothers were receiving various forms of medication
during Pregnancy, and also babies who are exclusively breast fed.
The bleeding in classic HDN mostoftenaffectsnon-vitalorgans such as:
 Gastrointestinal Bleeding
 Bleeding from skin and mucous membrane e.g,nose and gums
 Prolonged
 Bleeding following circumcision
 Bleeding from umbilical stump

LATE HDN
 Occurs predominately in exclusive breastfeeding infants but may also occur in babies
withmalabsorption syndromes who are unable to absorb the fat soluble vitamin K e.g,
cystic fibrosis,persistent diarrhea, cholesystic jaundice etc.
 Children on long term antibiotics may also develop alteredgutflorawith decreased syn-
thesisof vitaminK by [Link].

DIFFERENTIAL DIAGNOSIS:
The differential diagnosis must include other causes of bleeding in young babies such as:
 Haemophilia
 Trauma
 Accidental or N-Accidental injuryDisseminated Intravascular Coagulopa-
thy Thrombocytopenia
 Necrotising EnterocolitisIntussusecptionLeukemia
INVESTIGA-
TIONS:

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 Pregnancy history especially drugs, gestation at delivery, type and length

of [Link] [Link] fedor
bottlefed FBC
 Clotting screen including prothrombin time coagulátion time and partiai
tbromboplastin timechest x-ray
 CXR or Ultrasound scan may confirm intra thoracic bleed.
 CT or MRI scan intracranial hemorrhage or other major hemorrhage
suspected, to as certain the extent of the bleed.

MANAGEMENT:

Immediate management


When HD is suspected, vitamin K should be given as a supplement as
soon as possible which will result in a reduction in the bleeding time
with in a fewhours.
 Babies with severe bleeding or intracranial bleeding may require fresh fro-
zen plasma to begivenin addition to vitaminK in order to arrest the bleeding
as soon as possible.
 Babies who have lost a large percentage of their circulating volume into a
blęed may require transfusions with whole blood.
LONG TERM MANAGEMENT:

 Babies with late HDN who have suffered intracranial bleeds willr equire as-
sessment from a specialistteamto help minimize the long term sequelae of
the bleeding.
 They wil' require early and continuing physiotherapy to minimize spasticity and retainfunc-
tion,they may requirenutritional assistanceif unabletoswallow orsuck,
 They may require surgery or intracranial shunts to reduce intracranial pressure.

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COMPLICATIONS:

The complications of HDN mainly relate to bleeds involving the central nervous sys-
tem and40% of children who survive HDN will be have some form of long term neu-
rological 'handicap.
PROGNOSIS:
In a review of all reported cases, of HDN up to 1993, 14% of al! cases died and 40%
had longtermneurologicaldeficit

PREVENTION:

 The incidence of all foms of HDN haš been considerably reducèd by the greater
understandingof the role that Vitamin K plays in the disease, and also the factors
such as drugs taken by bothmother and child which may affect the levels of vita-
min K.
 Routine antenatal screening of allmothers has allowed for the early identification
of babies who may be at risk of early HDN, and where possible therapeutic re-
gimes are altered.
 The largest reduction has been brought about by the routine supplementation of vit-
amin K inal new born babies, usually at birth.
 This is given either in the form of an intramuscular injection ora seriesoforalsup-
plements

THINGS TO REMEMBER:

 VitaminK is needed for blood clotting.

 Newborn babies are given vitamin K injections to prevent a serious
disease called hemorrhagic disease of the new born(HDN).
 Vitamin K can be given by mouth if preferred, but oral doses aren't use ffective.

BIRTH DEFECTS IN NEW BORN(CongenitalAbnormalities):

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DEFINITION:

Birth defects are physical abnormalities that are present ať birth; they also are called
congenital [Link] than 3,000 have been identified.
DESCRIPTION:

Birth defects are found in 2-3% of all newborn infants, Almost 20% of deaths in new-
borns arecausedby birthdefects. Abnormalities can occur in any major organ orpart of
the body.
CDC LISTS TOP 6 TYPES OF BIRTH DEFECTS

 Genetic defects(Downsyndromeandotherconditions):6,916 babies per year.

 Mouth/facial defects(cleft lip and or cleft palate):6.776 babies per year.
 Heart defects:6,527 babies per year
 Museuloskeletal defects (including arm/leg defects)
 Stomach/intestinal defects: 2.833 babies per
year.
These defects include:
 Anophthalmia/Microphthalmia
 Anotiä!
 CleftLip/ CleftPalate:
 Congenital Heart Defects
 Atrial Septal Defect
 Atrio ventricular Septal Defect
 g-. Coarclation of the Aorta (narrowing of Aorta)h-
 D-Transposition of the Great Arteries
 Hypoplastic Let Heart Syndromej-Pulnonary Atresia
 Tetralogy of. Fallot (Tetralogy oF Fallot is made up of the our defects of the heart and its
blood vessels)
 m- TricuspidAtresia
 1-TotalAnomalousPulmonaryVenousReturn
 TruncusArteriosus
 6- Ventricular Septal Defect
 p-Craniosynostösis
 q-Diaphragmatic
 Herniar-Down Syndrome
 S-Esophageal Atresia
 Gstroschisis u- Hypospad asy-Microcephaly
 w-Neural tube defectsx-Anencephaly
 y-EncephaloceleZ -Spina bifidaaa-Omphaiocele

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 bb-Upper and Lower Limb Reduction Defects

CAUSES AND SYMPTOMS:

The specific cause of many congenital abnormalities is unknown, but several

fators associated with pregnancy and delivery can increase the risk of birth de-
fects.
Teratogens:

 Any substance that can cause abnormal development of the egg in the mother's
womb is called ateratogen.
Drugs:

 Only a few drugs are known to cause birth defects, but all have the potential to
cause harm.
 Forexampłe, use of topical (local) corticosteroids in the first trimester of preg-
nancy may be associated with cleft lip.
 thalidomide is known to cause defects of the arms and legs severalothertype-
salsocauseproblems.
Alcohol:

 Drinking large amounts of alcohol while pregnant causes a cluster of defects

called fetal alcoholsyndrome, which includes mental retardation, heart problems,
and growth deficiency,Antibiotics:
 Certain antibiotics are known teratogen. tetracycline affects bone growth and dis-
colors the [Link] used to treat tuberculosis can lead to hearingproblems and
damage to a nerve in the head(cranialdamage).

Ànti covulsants:
Drugs given to prevent seizures can cause serious problems in the developing fetus,
including mental retardation and slow growth

Anti psychotic and anti anxiety

Several drugs given for anxiety and mental illness are known to cause specific defects.

Anti neo plastic agents:

 Drugs given to treat cancer can cause major congenital malformations, especially cen-
tral nervous system defects the also may be harmful to the health care worker who is
giving them while pregnant.
Hormones:
 Male hormones may cause masculinization of a female fetus, a synthetic estro-

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gen (des)given inthe 1940s and 1950s caused an increased risk of cancer in the
adult female children of themotherswhoreceived [Link]
 Environmental chemicals such as fungicides, food additives, and pollutants
are suspected ofcausingbirth defects, thoughthis is difficultto prove.
Radiation:
 Exposure of the mother to high levels of radiation can cause small skull size
(microcephaly),blindness, spina bifida, and cleft palat,how severe the defect is
depends on the duration andtimingof theexposure.
Infections:

Three viruses are known to harm a developing baby: rubella, cytomegalovirus (cmv),
and herpes Simplex.
 [Link] can be contractedfrom undercooked meat,from dirt or
from handling he feces of infected cats, causes serious problems.
 Un treated syphilis in themotheralsoisharmful.
GENETIC FACTORS:
 A gene is a tiny, invisible unit containing information (DNA) that guides how
thebody formsandfunctions.
 Genes are influenced by chemicals and radiation, but sometimes changes in tic
genes are unexplained accidents.
 Birth defects causeby dominant inheritance include a form of dwarf-
ism called achondroplasia.

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 Recessive diseases are severe and may lead to an early death. They in-
clude sickle cell anemia.
 Some disorders arc linked to the sex-determining chromosomes passed along
by parents.
 Hemophilia,a conditionthat prevents blood from clotting Genetic defects also
can take place when the egg or sperm are forming if the mother or father
passes a long some faculty gene [Link] is more common in older
mothers.
 The most conmon defect of this kind is Down syndrome a pattern of mental re-
tardation andphysical, abnormalities, often including heart defects, caused by
inheriting three copies of a chromosome rather than the normal pair.
 A serious illness in the mother, such as an underactive thyroid or diabetes
mellitusin which her body cannot processs sugar also can cause birth defects in
the child
 An abnormal amount of anniotic fluid may indicate or cause birth defects. Too
little of this fluid can interfere with lung or limb development.
 Too much amniotic fluid can accumulate if the fetus has a disorder that inter-
feres with swallowing.
 Obese women were about three times more likely to have an infant with spina
bifida oromphalocele (protrusion of part of the intestine through the abdominal
wall) than women ofaverage weight. Women who were overweight or classified
as obese also were twice as likelyto have an infant with héart defect or multiple
birth defects than women classified as averageweight.

DIAGNOSIS:

Family history:

If there is a family history of birth defects or if the mother is over 35 years old, then screening tests
can be done during pregnancy to gain information about the health of thebaby.

Alpha-feto protein test:

This is a simple blood test that measures the level of a substance called alpha-feto protein that
Is associated with some major birth defects.

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ULTRASOUND:

 The use of sound waves to examine the shape. function. and age of the' fetus is a common
procedure. It also can detect many malformations, such as spina bifida, limb defects, and
heart and kidney problems..

AMNIOCENTESIS:
 This test usually is done between the 13th and 15th weeks of pregnancy
 A small sample ofamniotic fluid is with drawn through a thin needle inserted
into the mother's abdomen.
 Chromosomal analysis can rule out down syndrome and other genetic condi-
tions.

TREATMENT:

 Treatment depends on the type of birth defect and how serious it is.
 When an abnormality has been identified before birth delivery can beplanned at a health care
facility that is prepared to offer any special care needed.
 Some abnormalities can be corrected with surgery.
 Experimental procedures have been used successfully in correcting some defects, likeExces-
sive fluid in the brain (hydrocephalus) even before baby is born,
 Early reports haveshown success with fetal surgery on spina bifida paints,By operating on
these fetuses whilestill in the womb, surgeons have prevented the need for shunts and im-
proved outcomes [Link],long-termgudiestill areneeded.
 Patients with complicated conditions usually needthe help of experienced medical andeduca-
tionalspecialists with anunderstandingofthe disorder.

PREVENTION:

 Pregnant women should eat nutritious diet.

 Taking folic acid supplements before and during pregnancy reduces the risk of having baby
with serious problems of the brain or spinalcord (neural tubedefects).
 It is important to avoid any teratogen that can harm the developing ba-
by, including Alcohol and drugs.
 When there is a family history of congenital defects in either parent,
genetic couselling and testing can help parents plän for future children.
Often, counselors can determine therisk ofa genetic condition occur-
ring and the availabilityof tests for it.
 Talking to a genetic counselor after a child is born with a defect can
provid parents with information about medical management and avail-
able communitresources.

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ANOMALIES:
 MicratiaAnotfa and microtía are birth defects of a baby's ear.
 Anotia happens when theexternal ear (the part of the ear that can be seen) is
missing compļetely. Microtia happens whentheexternalear issmallandnot formed
property.
 Anophthalmia and microphthalmis are birth defects of a baby'seyes).
 Anophthalmiaisa birth defect where a baby is born without one or both eyes. Microphthal-
mia is a birth defect inwhichoneorboth eyesdidnot developfully: sotheyare small.
 Total Anomalous Pulmonary Venous Return is a birth defect of the heart in
which the veinsbringing blood back from the lungs pulmonary veinsdon't con-
nect to the left atrium like [Link] goto theheartbywayofanabnormal
(anomalous)connection.
 Craniosynostosis is a birth defect in which the bones in a baby's skull join
together too early,This happens before the baby's brain is fülly formed. As
she baby's brain grows, the skull canbecomemoremisshapen
 Truncus Arteriosus also known as common truncus, is a rare defect of the
heart in which asingle common blood vessel comes out of the heart, instead of
the usual two vessels (the mainpulmonaryarteryandaorta).
 Omphaloceleisabirthdefectofthe abdominal(belly)[Link] infant'sintestinesliveror
Other organs stick out side of the belly through the belly button.
The organs are covered in at thin Nearly transparents act hathardly ever is open or broken.
 Gastroschisis is a birth defect of the abdominal [Link] baby’s intestines are-
found outside of the baby's body exiting through a hole beside the belly button.

CLEFT PALATE AND CLEFT LIP

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Cleft, means 'split' or 'separation'. During early pregnancy separate areas of the face devel-
opindividually and then join together. The lip usually closes by 5 to 6 weeks after concep-
tion, andthe palate by 10 weeks, If some parts do not join properly, the result is a cleft. The
cleft will varyto both type and severity. Cleft lip and cleft palate comprise the fourth most
common birth defect.

CAUSES OF CLEFT LIP OR CLEFT PALATE

Although a complete under standing of why cleft lip or cleft palates occur is not known,there

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 Appears to be an association with a combination of genetic or environmental factors.

 Geneticrisk factors dependonthenumber ofaffectedpeoplein a family,theclosenessof
 affected relatives, and the severity of theclefts. Keep. in mind that sometimes clefts run in
families, andsometimesa babywillbebornwitha cleftwithoutanyoneelseinfamily havingone.

TREATMENTS OF CLEFT LIP OR CLEFT PALATE:

 Cleft lips and cleft palates are usually related through a combination. of surgery,
dental, andorthodonticcare.

ŠPINA BIFTDA:
 Spina Bifida is a neural tube defect that develops during the first month of pregnancy
when the spinalcolumn does not close Spina bifida is a condition which affects the verte-
brac, or backbones, and sometimes the spinal cord. 70% of spina bifida cases are prvent-
able by taking adequate amounts of folate vitamin during [Link].
 There are several forms of spina bifida. The mildest form is occulta, where the only visi-
ble evidence is a tuft of hair on the back.
 The next two forms are spina bifida with meningocele andspina bifida with meningomye-
locele. In these two cases a cyst-like sac protrudes from the back,in the first case only
containing cerebral spinal fluid, but in meningomyelocele, the cyst contains part of the
spinal cord. In the most severe form, spina bifida with myeloschiscis, the cyst is openand
the spinal cordisexposed totheoutsideelements.
 The defect usually can be repaired at birth if it is small and isolated. Experimental
surgery is also being done now while the baby is still in the womb.

EFFECTS OF SPINA BIFIDA

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 The effects of Spina Bifida are different for every person. Up to 90 % of children
with the worstform of špina bifida have hydrocephalus (fluid on the brain) and
must have surgery to insert a"shunt" that helps drain the fluid--the shunt stays in
place for the lifetime of the person.
 Other conditions include full or partial paralysis, bladder and bowel control diffi-
culties. Learning disabilities,depression,latex allergy, social and sexual issues.
CONGENITAL LIMB DEFECTS:

 Congenital limb defect is a term used to describe any number of defects affecting
the upper orlower limb.
 These defects may range in severity from mild to severe. In some cases; such
assyndactyly of the toes, the defect is often left alone and the _baby will grow ùp
with no [Link] require surgeryor possibly prosthesis(artificial
limb)

SOME COMMON CLASSIFICATIONS OF LIMB DEFECTS ARE:

 Phocomelia - The limbs are smaller or much shorter
than normạlPolydactyly -Extra toesorfingers.
 Syndactyly-Commonlyseenas"webbed"toesorfingers.
 Absent radius -The radius, one of the bones in the forearm, is small or
missing altogether causing the forearm to shorten and curve
CLUB FOOT
 Refers to a condition in which the baby's foot is tuned inward and downward at
birth.
 It can be mild or sever and can affect one or both fact. In many cases, thę defect
can be corrected using Casts on the child's feet and legs.
 Some cases may require surgery,however, the outcome isUsuallyexcellent
andthè child will goontoliveanormal healthy life.

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HYDROCEPHALUŠ

 Hvdrocebhalus is a condition in which there is excessive fluid accumulation in the brain

 Cerebral spinal fluid is what surrounds the brain and spinal cord and cushions them.

 When there is too much cerebral spinal fluid it can build up in the ventricles, or spaces, in
the brain.

 This can Cause pressure on the tissues of the brain as well as case the baby's head to en-
large.

 Hydrocephalusismos to ften treated with a surgically placed shunt.

 The shunt diverts the cerebral spinal fluid away from the brain and to another part of the
body where the fluid can be safelyand effectively absorbed.

DOWNS SYNDROME(TRISOMY21):
 Down syndrome is a chromosomal disorder which causes physical and intellectual
delays in Development and occurs when there are 3 chromosome 21's, resulting in
47 total chromosomesinstead of the normal 46.
 The most common clinical features are short neck and flat face, upwardslanting
eyes, low muscle tone and a single crease across the palm of the hand. Congenital
heartdefects accompany Down syndrome in about 40% of the cases. Vsion and
hearing problems arealsocommon.

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o
PERINATAL MORTALITY

Perinatal mortality is defined as the number of perinatal deaths per 1000 births. The Perina-
talperiod starts as the beginning of fetal viability (22 weeks gestation or 1000g) and ends at
the endofthe 7th day after delivery. Perinatal deaths are the sum of stillbirths plus early ne-
onatal [Link] deaths petf000 total(live andstillbirths)in thatyear.

THEPNMRISTHEMOSTSENSITIVEINDICATOROFOBSTETRICCARE:

 Stillbirth: No sign of life immediately after expulsion /delivery from mother after
22nd week ofgestation.
 Neonatal mortality: is the number of deaths of infants less than 28 days of aga
per 1000 livebirths.
 Infantmortality:isthe numberofdeathsofinfantsunderIyearof age perl000live birth
 FetalDeaths:is deathinuterus after22weeksormore gestation.

FACTORS RESPONSTBLE FOR THE DEATHS IN NEW NATES:

 Inadequate antenatal care

 Age of the mother (under the age of 20 and over 35)Parity,in primi and grand multipara
 Complications during pregnancy
 Toxemiapfpregnancy,APH,Cordcompressionhydramnios,
 Prematurity. post maturity, male presentation, congenital abnormalities, Placentalinsufficien-
cy.
 Complication of labor
 Prolong labor. Breech delivery
 Instrumental deliveries.

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 Medical diseases of
mother severe pyrexia
due to infections
 maternal hypoxia and
 hypotension,
 maternal chronic and
acute infections
 Sever dysentery
Neonatalcauses:
 RDS, Neonatal sepsis,
 neonatal jaundice,
 Birth Asphyxia.
 Prematurity.
 Hemolytic diseases,
 congenital abnormalities

 PREVENTIONS:
 Good antenatal care. early detection and treatment of fetal, maternal and neo-
nate'scomplications.
 Correction of nutritional deficiencies,
 managing maternal hypotension and hypoxia,
 In case of cord prolapsed correction of position.
 Family planning, Avoidance and care of premature labor.
 Carefull instrumental deliveries,
 Prevention and care of infections.

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UNITNO13.
OBSTETRICAL OPERATIONS

EPISIOTOMY

 It isdeliberate incision made into the perineum to widen the introitus with a view of pre-
ventingirregułartearsof theperineumduringdelivery.
 An episiotomy is a surgical) incision made along the perineum - the area of skin
and muscle between the vagina and rectum-to aid in the safe delivery of child or
to simply speed delivery

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INDICATIONS OF EPISIOTOMY:

 Rigid perineum
 Bigbaby.
 Before any instrumental delivery in order to provide adequate space
 Prolong second stage, where it is thought that it is because of soft tissue re-
sistance of the Perineum.
 In practice most of the primigravida patient receives an
[Link] when there is clinical need such as in-
strumental birthSuspectedfetal compromise
 Serious riskof2ndor3rd degreetearsTo less on the efforts of them other especially in eclamptic
and cardiac condition.
 To speed up delivery if there is fetal distress when only perineum is holding up deliv-
[Link] damage duringpre-temandbreech delivery
 In malpresentation like breech or face presentation

TYPES OF EPISIOTOMY:

 [Link]-LATERAL:
 Begin at the mid point of forchette and directed at 45 degree angle to the mid line towards
[Link] most commonly played. It widens the inroitus and rarely extends into the rectum
and significant blood loss, stretch on the edges leads to post delivery pain,

 MIDLINEORMEDIAN:
It follows the natural insertion of perinial muscle. Area is a vascular and hence blood loss is-
minimum edges fall together without tension so post delivery pain is minimum. Disadvantage
is that it can extend directly into the rectum.
 LALERAL J SHAPED:
It runs laterally from vagina.
 WHENTO PERFORMAN EPI:
 The correct timing for performing an episiotomy must be identified. Too late Epi defeats the
Purpose as tear may already have occurred. Too early Epi leads to excessive blood loss
andunnecessary Interventions to hurry up the second stage.
 When there is expulsive uterine contractions when the presenting part is seen at the in troitus
without separating labia and when the bony head has descends up to the perineum. It is time
to perform an EPi.

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METHOD OF INCISTON:

 Position Lithotomy
 Generally done under local anesthesia
 The vulva washed with soap and antiseptic [Link] procedureto the patient
 Reassurance is necessary.
 During contraction the first two glove fingers of left and are inserted in the
vagina in b/wtheperineumandthefetälhead.
 Two percent, lignocane is infiltrated at the posterior forchette and along
the line of the Proposed incision
 Care must be taken to aspirate before injecting thexylocain in order to avoid ac-
cidentalinjectionintothebloodvessels.
 When it is certain that head is going to deliver within next few contractions
head is [Link] should be made, labium should not be incised.

REPAIR OF EPISIOTOMY:

 The incision should be repaired soon after delivery

 If the effect of the anesthesia has warned off fresh local anesthesia can
be infiltrated.
 Thevaginal mucosa is inspected fortheothersitesofinjuries.
 The apex is visualized.
 Area is cleaned off blood clot with anti septic solution.
 Half of the sterile pad or big cotton swab is inserted into vagina to keep bleed-

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ing coming out"fromuterus

 The first stitch is applied at the apex of the incision, the complete stitching to
mucosa edgesusinga continuous runninginterlockingcatgut [Link] is tied as
introitus.
 The perineal muscles are then approximated using interrupted-
cat gut suture.
 PadfromVagina is removed.
 Finally the skin edges are approximated using interrupted or sub-
cutaneous stitch.P/v is dọnetocheckthemucosa.
 One finger is put into rectum tomake sure no suture has penetrated the rectal mucosa.

STITCHES USE:
 Chroniccatgut0-1.
 Dexan or vicryl some rime Silk on the skin is may [Link] clean the area,sterile pad is ap-
plied
 Remove the leg both to get her to avoid injuries on hipjoint.
 CARE OF EPI:
 [Link] care must be taken toclean-
the areaafter passing urine/stool.
 As in Medico lateral Epi due to tension there is pain in sutures, mother should ad-
vice to emptyherbladder frequented.
 The bowl' should be open by Enema at 3day if not spontaneously open Or
mother is asked to avoid constipation by using roughage diet,increase fluid-
intake and hot milk
 Systemic analgesic and anti inflammatory drugs maybe used.
 Local application of ointment including antibiotic. anti inflamma-
tory and localeffects.
 Localheatisveryuseful.
 If patient c/opain Epi should be inspected for presenceof any edema or hema-
toma and infection.
 Avoid touching the open wound. Spreading germ can cause àn infection tha
will significantly increase discomfort. Always wash your hands prior t apply-
ing any medicationtothe affectedarea
 Apply an ice pack on perineum as soon as mother is in recovery room. The cold
will decrease swelling.
 Alternate silting and walking can be a good exercise to increase blood circula-
tion and speed healing,but it should not be over done in first week of recovery.

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 Make mother sit in warm bath three to four times aday. Thewarm water will soothe the
 Perineum and help to clean the wound.

COMPLICATIONS:

 To early Epi may lead to excessive [Link] due to extension of Epi.

 Hemorrhage dueto delayingthe [Link] hematomaformation.
 Extension can go high into cervix or into broad ligaments cause PPH
 Extensionof tear toanalsphincteror analmucosa
 Improper suturing or failure of identifying of button-hole kind tear may lead to fistula and fe-
cal incontinency.
 Non union of incisions can result into"gapping:
 Constipation
 Infection and hematoma are cause of gaping also poor personal hygiene.
 Anemia, poor healthy capacity, infection any where else in the body are also contributing fac-
tors
 Retention of urine due to sever pain
 Constipation

TEARS

PERINEAL TEARS:

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 In case where Epi is not given or not considered necessary, the perineum may be I jured.
 Such injury is called perineal tear
 If the skin of perineum or the mucosa is toor it is called 1" degree tear.
 A Tear which also include perineal muscles is called 2 nd degree tear.
 At ear of the anal sphincter is term as 3" degree perincal tcar.
 Any tear extending into the anal mucosa is referred as "complete or 4" degree
periteal tear though it is also includcd' on 3degrec tear generally.
 Tears can also occur at other sidc c.g. paraurethral néar the [Link] can lead
into considerable bleeding because of rich blood [Link] to clitoris also
bleed profusely

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 REPAIR OF FIRST AND SECOND DEGREE TEARS:-

 Clean with aniseptiosolution, infiltrate with local anaesthetic (e.g. Lignocainc) and wait for
it to work.
 Make sure,that you include the very top end of the tear (the apex) as this area often
bleedsthe most. Start to sugure the vaginal mucosa 1cm above the apex using a continuous
2/0suture
 Close the perinial muscle using a 2/0 inter rupled suture and finally close the skin with In-
terrupted or subcuticul arsuures.
 REPAIR OF 3RD AND R4THDEGREE TEAR:
 Ifthe tear in the anal sphinctcr is not repaired properly the woman can lose control over her
bowel function leading to tie unintentional passage of stool or gas (faecal incontinence).
 If a tear in therectal mucosa is not repaired she may get a recto-vaginal fistula (a hole be-
tween the rectum andvagina leading to stool leaking from the vagina) or infection.
 It is crucial that appropriately trained professional repair these tears and have a very good
view of all the edges of the [Link] regional or general anaesthetic may be required.
Antibioics and laxatives should be given afterwards.

 FORCEPS:
DEFINITION:
Obstetrician's use of special spoon-shaped instruments to effect delivery of the baby and
shorten the second stage of labor.
TYPES:
 Lowor outlet:Presenting partat vagina lintroitus
 Mid foreeps: presenting part is at or belowischial spine. Oftèn difficult procedurce
rarely done.
 High forceps: Presenting part is above ischial spines. This process has been re-
plaçed bycaesarian births.
 REQUIREMENTS FOR APPLICATION OF FORCEPS:
 Fully dilatcd cervix.
 Presenting part engaged Vertex or face presentation
 Ruptured membrane.
 No pelvic contractiactures or dis-
propotions.
 Bowel and bladder emptied.

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 INDICATIONS:
 Maternal exhaustion
 Fetal distress
 Failure of internal rotation nerve root anesthesia (client can not push)
 Maternal heart disease
 Management.
 Poor descent of fetus through birth canal.
 Anticipate request for forceps if possible.
 Monitor fetal heart sound
 Explain procedure to the client.

 VENTOUSE
 The ventouse has a cup attached to a small vacuum pump. The cup, which fits on top
and slightlytowards the back of your baby's head, may be made of metal or silicone
plastic.
 The soft cups areless likely to cause damage to baby's head. but the metal cups are
less likely to slip off and haveto bereattached.
 The type of cup used may depend on the baby's position
 Now adays,many doctors prefer the ventouse,or vacuum [Link] assisted
 This is because the ventouse is less painful for the mother both during and after the birth.
 There's less risk of bladder or bowel function being damaged than with forceps,and moth-
er might not to have an episiotomy:
 It used to be said that a baby could be delivered faster using forceps manventouse,but re-
search shows that this isn'ttrue.
 HOW TO APPLY VANTOUSE:
 Motherwill beaskedtoputher legs in supports.
 The doctor (or, sometimes, a specially trainedmidwife) will place the ventouse cup
on the baby's head inside the vaginaedand then suck the airout of the cup using a
foot-controlled vacuum pump or a hand-held pump.
 Once the cop issecurely fixed, the doctor will ask mother to push. with her next
contraction, and she will pull onthe cup to help the baby out.
 Occasionally the cup comes off the baby's head, especially if thebabyis largeor in-
apositionwherethecupdoesnot fix węll,and has to be reapplied.
 If the baby is in a position that makes delivery more difficult thena metal cup or
semi-rigid plastic cup ventous may be used in preferences toan ordinary plastic

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cup because these types are less likely to come off.

AFTER THE BABY IS BORN:-

 Babies sometimes have cone-shaped headfor a couple of days when they've been
born with Ventouse .
 A Cephal haematoma or blood blister, may form on top of the baby's head, but
thisusually disappears in a week; the baby's head may be slightly grazed.
 Babies born-using aventouse are not more likelytộ need phototherapy than babies
from usingforceps.

CAESARIAN SECTION

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DEFINITION:
A Cesareansection (C-section) is surgery to deliver a baby. The baby is taken out
throughthemother's abdomen.
INDICATION:
 Cephelo pelvic disproportion.
 Fetal distress
 Malpresentation
 Maternal diabetics
 Breech presentation in prim gravida
 Placenta previa' placenta abruption
 Prolapsed cord
 Ineffective uterin con-
tractions
 Multiple births
 Previous cesarean births
 Other obstetrics emergencies and conditions

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TYPES:
CLASSICAL;

Vertical incisions made into both in abdomen and uterus

Used when rapid delivery is important in fetal distressprolapsed cord, placentaabrup on.
Maternal bleeding greater with this method, client may have increase risk of uterine ruptureof
scar tissue with future pregnancy, not usually a candidate of vaginal birth in future pregnan-
cies
LOW CERVICAL/ LOWER [Link]:
 Transversincisions made in abdomen (above pubic hairline) and in uterus.
 Most common method used.
 Procedure maý take longer than classic because of need to deflect bladder but blood loss is
Lessened and adhesions are fewer.
 Vaginal births after this type is possible

PREOPERATIVEPREPARATION:

 Explaintheproceduretothe client.
 Release herfear, feeling of powerlessness and disturbance in self concept.
 Provide emotional support to client and family.
 Shave her abdomen and pubic area.
 Insert retention catheter into bladder.
 Administer preoperative medications as ordered.
 Complete all preoperative charting responsibilities.

POST OPERATIVE PREPARATION:

 Assess for and maintain patent airway turn her faceon side to facilitated secretions.
 Check for presence or absence of gag reflex maintain artificial airway in place un-
till gag reflex has returned
 Assess colour and temperature of skin, color of nail beds and [Link] IV infu-
sions; condition of site; type of solution and flow rate
 Encourageclienttocoughanddeepbreathafterairway is removed
 If spinal anesthesia is used keep client flatand check for sensations and move-
ment in lowerextremities
 Transverse incisions made in abdomen (above pubic hairline) and in uterus
 Most common method used.
 Procedure maý take longer than classic because. of need to deflect bladder but
bloodloss is Lessened and adhesions are fewer.

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 Vaginal births after this type is possible.

MAINTAIN VITAL SIGNS.:

 Assess level consciousness/return of senstion.

 Maintain I/ochart.
 Givepostoperativemedications asordered
 Check fundal firmness and dressingfor any bleeding, intactness and
drainage.
 Checki/vline and other drainage tubings and secure them properly.
 Observe lochia for color amount clot.Assessforbowelsoundevery4-
hour.
 Check for abdominal distention passage of flatus
 Keepclient NPO as per order.
 Encourage ambulation ASAP.
 Assist mother with baby care and handling as needed

COMPLICATIONS:
 Common complications of respiratory system are pneumonia and atelectasis.
 Complications of cardiovascular system are DVT, pulmonary embolism and shock.
 Complications of genitourinary system are urinary retention and UTI.
 Complication of GIT is paralytic iluss.
 Wound infection

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INDUCTION OF LABOR

DEFINITION:
It is the termination of pregnancy by artificial means after 24 weeks of gesta-
tional to securevaginal delivery
OR
 It is initiation of labor by artificial means, Labor is induced when it is considered
that the health of mother or fetus would be adversely affected by continuation of
pregnancy.
GENERAL PRINCIPLES RELATED TO THE PRACTICE OF INDUCTION OF
LABOR:
 Induction of labor should be performed only when there is a clear medical
indication for itandtheexpected bnefitsoutweighitspotentialhams.
 In applying there commendations,consideration must begiven to the actual condition,wishes
and preferences of each woman, with emphasis being placed on cervical status. The specific
method of induction of labor and associated conditions such as parity and rupture of mem-
branes.
 Induction of labor should be performed with caution since the procedure carries the risk
ofuterine hyper stimulation andruptureandfetaldistress.
 Wherever induction of labor is carried out, facilities should be available for assessingmater-
nalandfetal well-being.
 Women receiving Oxytocin. misoprostol or, other prostaglandins should never be leftunat-
tended.
 Failed induction of labor does hot necessarily indicate caesarians section.
 Wherever possible, induction of labor should, be carried out in facilities where cesareansec-
tion can be performed. (Ref: WHO recommendations for induction of labor)

INDICATIONS:

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MATERNAL:
 Pregnancy induced hypertension & [Link].
 Diabetes mellitus37-38wks.
 Polydramnios.
 Essential hypertension
 Jaundice when there is sign of toxemia.
 Minor degreeofCPD.
 Prolong pregnancy(after42wks).
 Spontaneous rupture of membrane after 36 weeks and labor doesn’t start after 12
hrs of therapture ofthemembrane.
 Abruption placenta.
 Elderly prim gravida.
 Abortion.
FETAL
 fetal abnormalities i.e, anencephaly, [Link]
 IUGR.

BISHOP'S SCORE FOR INDUCTION

 To be successful, Bishop's Score should be greater than 9. Be sure to ask your caregiver for
your Bishopsscore.

Cervix Score0 Score1 Score2 Score3

Position Posterior Midposition Anterior -----
Consistency Firm Medium Soft -----
Effacement(%) 0-30 40-50 60-70 >80
Dilation(cm) Closed 1-2 3-4 >5
Station -3 -2 -1 +1,+2

METHODS OF INDUCTION:
MEDICAL METHOD:

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 Castor oil (laxative).

 Oxytocin
 Prostaglandin(vaginal pessary,vaginal tablet,vaginalgel
 SurgicalMethod:
 Sweeping of membrane (It releases prostaglandin & initiate labor).
 ARM or amniotomy (Done under aseptic technique tostimulate uterine contractions)

PREPARATION AND MANAGEMENT:

 Explanation.
 Determine lie and presentation by abdominal examination Empty the bladder.
 Lithotomy position.
 Membrane is swept off the lower uterine segment & ruptured with kockcr. Liquor is
drained& color,& quantity is not
 After ARM fetal heart sound are [Link] cord should be exclude.
COMPLICATIONS:
 Failure of induction.
 Prolapsed of cord.
 Placental separation.
 Infection.
 AFE..
 Induction is most affected if cervix is dilated and effaced presenting part is engaged & more
liquor is drained.
 Bishop score,records progress
IV INFUSION OF SYNTOCINON:
 15dropsmin=1ml /min:
Nursing care include 4-hrly vaginal examination.

COMPLICATIONS:

 Hypertonic uterine action records progress.

 Fetal distress & asphyxia.
 AFE
 Increase rate of operative deliveries

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UNIT:NO14
OBSTETRICAL EMERGENCIES

DEFINITION:
Obstetrical emergencies are life-threatening medical conditions that occur in pregnancy or
during or after labor and delivery.

DESCRIPTION:

 There are a number of illnesses and disorders of pregnancy that can threaten the well-being
ofboth mother andchild..
 Obstetrical emergencies may also occur during active labor, and after delivery-
postpartum),Abnormal bleedingDuring pregnancy, brown or white to pink vaginal discharge
is normal,bright red blood or blood containing large clots is not. After delivery continual
blood loss ofover500mi indicates hemorrhage.
 Leaking amniotic fluid. Amniotic fluid is straw-colored and may easily be confused
withurineleakage, but canbedifferentiated byitsslightsweetodor.
 Severe abdominal pain. Stomach or lower back can indicate preeclampsia or änundiagnosed
ectopic pregnancy. Postpartum stomach pain can be a sign of infection orContractions. Regu-
lar contractions before 37 weeks of gestation can signal the onset ofPreterm laborduetoobstet-
rical complications.
 Abrupt and rapid increase în blood pressure. Hypertension is one of the first signs oftoxe-
mia.
 Edema. Sudden and significant swelling of hands and feet caused by fluid retention fromtox-
emia
 Unpleasant Smelling vaginal discharge. A thick, malodorous discharge from the vagina
canindicatea postpartuminfection.
 Fêver. Fevermayindicateanactiveinfection.
 Loss of consciousness: Shock cue to blood loss (hemorrhage) oramniotic embolism canpre-
cipitatea lossof consciousness inthemother.
 Blurred vision and headaches. Vision problems and headache are a possible symptom of
[Link] deliveries.

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CAUSES:
Obstetrical emergencies can be caused by a number of factors, including :

 stress,
 trauma,
 [Link] other variables.
 In some cases, past medical history. including previous pregnancies and deliv
 ies,may help an obstetrician anticipate the possibility of complications.
SIGNS AND SYMPTOMS:
 Signandsymptomsofanobstetricalemergencyinclude,but are not limited to Diminished fetal ac-
tivity,
 In the late third trimester, fewer than ten movements in a two hour period may indicate
that the fetus is in distress.

DIAGNOSIS:

 Diagnosis of an obstetrical emergency typically takes place in a hospital or other urgent care
facility.A specialist will take the patient's medical history and perform a pelvic and general
physicalexamination.
 The mother's vital signs are taken, and if preeclampsia is suspected, blood pressure may be-
monitored overa periodoftime.
 The fetal heart beat is assessed with a Dopples stethoscope
 Diagnostic blood and urine tests of the mother may also be performedincluding laboratory
analysisfor proteinand/orbacterialinfection.
 An abdominal ultrasound may aid in the diagnosis of any condition that involve smalposi-
tioned placenta,such as placenta previa or placenta abruption.
 Incaseswhereanobstetricalcomplicationissuspected,
 Afetalheartmonitorispositionedexternallyonthemother'sabdomen.
 If the feta heart rate is erratic or weak, or if it does not respond to, movement, 1he
fetus [Link] physical profile (BPP) may also beperformed to eval-
uate the health of thẹ fetus.
 TheBPP uses data from an ultra sound examination to an alyze the ftus
size,movement,heart rate,and surrounding amnioticfluid.
 If the mother's membranes have ruptured and her cervixes partially dilated, an in-
ternal fetal scalp electrode can be inserted through the vagina toassess heart rate.

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UNITNO15:
OBSTETRICAL EMERGENCIES DURING PREGNANCY:-
 EctopicPregnancy:
 An ectopic,or tubal,pregnancy occurs whenthefertilizedeggimplantsitselfinthefallo-
piantube rather than the uterine¢ wall. If the pregnancy is not terminated at an early
stage, thefallopian tube will rupture, causing internal hemorrhaging and potentially
resulting in permanentinfertility
 Treatment:
 Treatment of an ectopic pregnancy is laparoscopic surgical removal of the fertilized ovum. If
thefallopian tube has burst or been damaged, further surgery will benecessary.
PlacentalAbruption
 Also called abruption placenta, placental abruption occurs when the placenta separates from
the uterusprematurely, causing bleeding and contractions. If over 50% of placenta separates,
both the fetus andthemother areattherisk.
 Treatment:
 In mild cases of placental abruption, bed rest may prevent further separation of th placenta
andstem bleeding. If a significant abruption (over 50%) occurs, the fetus may have to be de-
liveredimmediatelyandabloodtransfusionmayberequired.
 PLACENTALPREVIA:
 When the placenta attaches to the mouth of the uterus and partially or completely blocks
thecervix, the position is termed placenta previa (or low-lying placenta). Placenta previa can
resultinprematurebleedingandpossiblepostpartumhemorrhage.
 TREATMENT:
 HospitalizationorHighly restrictedat-home bedrest is usually recommended if placenta previa
is diagnosed after,the twentieth week of [Link] the fetus is atleast 36 weeks old and the
lungs are mature,a cesarean section is performed todeliver the baby.
 PRE-ECLAMPSIA/ECLAMPSİA:
 Pre eclampsia (toxemia), or pregnancy-induced high blood pressurecauses sever ede-
ma(swelling due to water retention) and can impair kidney and liver function. The condition
occursin approximately 5% of all United States pregnancies.
 If it progresses to eclampsia, toxemia is potentially fatal formother and child.

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 Treatment:
 Treatmentofpreeclampsiadepends uponthe ageofthefetusandtheacuteness ofthecondition.
 A woman near full term who has only mild toxemia may have labor induced to deliver the
childas soon as possible. Severe pre eclampsia in a woman near term also calls for immediate
deliveryof the child as this is the only known cure for the condition. However. if the fetus is
under 28weeks, themothermay behospitalizedandsteroidsmay be administeredtotrytohas-
ten,lung development in the fetus. If the life of the mother or fetus appears to be in danger de-
liveredimmediately,usually bycesareansection
 PREMATURE PRELABOUR RUPTURE OF MEMBRANES (PROM):
 Premature rupture of membranes is the breaking of the bag of water amniotic fluid beforecon-
tractions or labor begins.
 The situation is only considered an emergency if the break occursbefore thirty-seven weeks
and results in significant leakage of amnioticfluid and or infection oftheamniotic sacandprem-
aturedelivery
ASSESSMENT AND FINDINGS:
Report ofdischargeof fluid from mother/family
NURSING INTERVENTIONS
 Monitormaternal/fetal vitalsigns.
 Calculate gestational age
 Observe forsignof infectionandonsetoflabor
 If sign of infection is presentgive antibiotics as per doctor order and pr pare forimmediatede-
livery
 If no maternal infection labor may be delayed.
 Observe and record color,odor, amount of amniotic: fluidExaminemother for signsof pro-
lapsedcord thola byis Provide explanations of procedures and findings and support moth-
er/familyPreparemother/family forearlybirthifindicated
 If PROM occurs before 37 weeks and/or results in significant leakage of amniotic fluid,
acourseofintravenousantibioticsis started.
 A culture of the cervix may be taken to analyze for the presence of bacterial infection.
 If the fetus is close to term, labor is typically induced if contractions do not start within
24hours of rupture
.

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PROLAPSED CORD:
Displacement of umbilicus cord in a downward direction, near or ahead of the presenting part, orinto
the vagina. May occur when membranes are rupture Associated with breech presenta-
tion,unengagedpresenting partandpremature labor.
A prolapseoftheumbilicalcordoccurswhenthe cordis pushed downintothecervixorvagina.
If the cord becomes compressedthe oxygen supply to the fetus could be diminished, regulating in-
braindamageor possible death.

GENERAL MANAGEMENT:
Give oxygen at 4-6 L per minute by mask ornasal cannula.

SPECIFIC MANAGEMENT:

Pulsatingcord:

 If the cordis pulsating the fetus isalive.

 Diagnose stage of labor by an immediate vaginal examination

 If thewomanisithefirststageoflabor,inallcases:

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 Wearinghigh-level,disinfectedgloves,inserthandintothevaginaandpushthepresenting part up to
decrease pressure on the cord and dislodge the presenting part fromthe pelvis
 Place the other hand on the abdomen in the suprapubic region to keep the presenting partoutof
thepelvis
 Once the presenting part is firmly held above the pelvic brim, remove the other
handfromthevagina.
 Keep the hand on the abdomen until caesarean section
 Ifavailable,gives albutamol 0.5mgIVslowly over 2minutes to reduce contractions
 Perform immediate caesarean section.

IF THE WOMAN-IS IN THE SECOND STAGE OF LABOR:

 Expeditedeliverywithepisiotomy,andvacuum extractionorforceps
 If breech presentation perform breechextraction and apply Piper or long forceps to the after
cominghead.
 Prepareforresuscitationofthe newborn.

 Cord not pulsating: If the cord is not pulsating, the fetus is dead. Deliver in the manner
that is safest forwomen.

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PREMATURE LABOR

DEFINITION
Premature labor is the term to describe contractions of the, uterus that begin at weeks 20-36
ofpregnancy.

CAUSES AND SYMPTOMS

Infection of the urinary or reproductive tract may stimulate premature labor and premature
[Link] (twins, triplets,etc.) aremorelikelytoresultinto premature labor.
 Smoking,
 Alcohol use
 ,drug abuse.
 Poor nutrition can increase the risk of premature labor
and birth
 Adolescent mothers are also at higher risk for premature
delivery.
 Women who have had previous surgery on the cervix.
SYMPTOMS OF PREMATURE LÀBOR:
 Contractions of the uterus or tightening of the abdomen, which occurs every ten minutes sim-
ulatepremature labor andthesecontractionsusually increasemorefrequently.
 These contractions usually increase in frequency, duration, and intensity and may or may not
bepainful..
 Other symptoms includeMenstrual-likecramps.
 Abdominal cramping with or without diarrhea..
 Pressure or pain in the pelvic [Link].
 Change inthe colororamount ofvaginaldischarge.
 Aslaborprogressespremature (whenthewaterbreaks)mayalsooccur.
 DIAGNOSIS:
 A vaginal examination is the only way lo determine if the cervix has started to dilate orEfface.
 Urineandbloodsamplesmay becollectedto screenforinfection.
 A vaginal culture (a cotton-tipped swab is used to collect some fluid and cells from theVagi-
namaybe donetolook foravaginal infection.
 Fetal heart monitor may be placed on the mother's abdomen to record the heartbeat of thefe-
tusandtotimethecontractions
 A fetal ultrasound may be performed to determine the age and weight of the
fetus, theconditionoftheplacenta,andto seeifthere ismorethanonefetus pre-
sent.

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 Amniocentesis will sometimes be performed for Analysis of the amniotic

fluid to determineifthe baby'slungs aremature.
 TREATMENT:
 The goal of treatment is to stop the premature labor and P revent the fetus from being deliv-
ered before it is fullterm.
 A first recommendation may be for the woman with premature contractions to lie downwith
feetelevatedandtodrinkjuiceorotherfluids.
 If contractions continue or increase medical attentionshouldbesought.
 In addition to bed rest, medical care may include intravenous fluids
 Sometimes, thisextrafluidisenough tostopcontractions.
 Insome cases,oralorinjectable drugsliketerbutalinesulfate,ritodrine,magnesium
 Sulfateornifedipinemustbegiventostopthe,contractions.
 These are generally very effective however, as with any drug therapy, there
are risk of Side effects. Some women may need to continue on' medication
for the duration of thepregnancy. Antibiotics may be prescribed if a vaginal
or urinary tract infections [Link] the membranes have already ruptured, it
may be difficult or impossible to stoppremature labor.
 If infection of the membranes that cover the fetus (chorioamntonitis) devel-
ops, the babymust bedelivered.

PROGNOSIS:

 If premature labor is managed successfully the pregnancy may continue normally for
thedelivery of a healthy infant.
 Once symptoms of preterm labor occur during the pregnancy, themother and fetus
need to be monitored regularlysines it is likely that premature labor will occuragain.
If the preterm labor cannot be stopped or controlled, the infant will be deliv-
eredprematurely.
 These infants that are born prematurely have an increased risk of health problemsin-
cluding birth defects, Lung problem, mental retardation, blindness, deafness, andde-
velopmental disabilities
 If the infant is born tooearly,itsbody systems may not be mature
 enough for it to survive. Evaluatingthe infant's lung maturity is one of the keys to
determining itschance of survival. Fetuses delivered further into pregnancy and
those with more mature lungs are morelikelytosurvive.

PREVENTION:

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 Smoking poor nutrition and drug or alcohol abuse can increase the risk of prema-
ture labor andearly delivery.
 Smokinganddrugor alcoholuseshouldbe stopped.
 A healthy diet and prenatal vitamin supplements(prescribed by the health care
provider) areImportant for thegrowthofthefetus andthehealthof themother.
 Pregnant women are advised to see a health care provider early in the pregnancy
and receive regular prenatal examinations throughout the pregnancy.
 The healthcare providers houldbe informed of any medications that the mother is
receiving and any health conditions that existbeforeand during the pregnancy

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UNIT:16
OBSTETRICAL EMERGENCIES DURING LABOR & DELIVERY:
 This condition occurs when amniotic fluid enters the maternal circulation. Usually inconjunc-
tion with a hypertonicintense uterine contractions, Either naturally or oxytocin induced.
 Thefetalcellspresentinthe fluidthenblockorclogthe pulmonaryartery,resultinginheart
 attack.
 This complication can also happen during pregnancy, but usually occurs in the presence of
strongcontractions.
 It causes acute cardio-respiratory compromise aswell as coagulation defect.

SIGNS&SYMPTOMS:

The Patient experiences the sudden onset of severe chest painDifficultyin breathing

 She may become pale and cyanosedTachycardia

 Hemorrhage due to coagulation failure in conjunction with a hypertonic, intense uterine-
contractions.

CAUSES:

 Premature rupture of membrane

 Rapid labor
 Defect in placental siteVaginal and C-section

MANAGEMENT:ARTIFICIAL RESPIRATIONCPR

 I/V steroid
 Administer medications to cotrol bleedingAnalysisof coagulationstatus
 Baby is unlikely to survive so initiate NVD after stabilization of maternal condition
 Maternal mortality with Amniotic fluid embolism is 90% So care full oxytocicadministration
 Excessiveuterinecontractionshouldbeavoided.

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FETAL DISTRESS

FETAL DISTRESS IN LABOUR:

PROBLEMS:
 Abnormal fetal heart rate(less than100ormorethan180beats per minute )
 thickmeconium-
 stained amniotic fluid
COMMON CONTRIBUTING FACTORS ARE:
 Cord compression
 Placentalabnormalities
 Preexisting maternal diseases

ASSESSMENT AND FINDINGS:

 Decreasedfetalheartsound
 Meconium stained liquor with avertex presentation

GENERAL MANAGEMENT:
Prop up the woman or place her on her left [Link] it is beingadministered.

NURSINGINTERVENTION:
 Check fetal heart sound properly
 Conduct vaginal examination for presentation and position
 Place mother in left lateral position
 Administeroxygen
 Check for prolapsed CordInformphysician
 Support mother and family
 Prepareoremergency C-section ifindicated.

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ABNORMAL FETAL HEART RATE:

 Anormal fetal heart rate may slowly during a contraction but usually recoversto normal
as soon asthe uterusrelaxes.
 A Very slow fetal heart rate in the absence of contractions or persisting after
contractions isSuggestiveof fetal distress.
 Arapidfetalheart ratemaybearesponsetomaternalfever doescausingrapidmaternal
 Rate([Link] drugs), hypertension or amnionitis, In the absence of a rapid ma-
ternal heartrate a rapidfetalheartrateshouldbeconsidereda sign of fetaldistress
 Ifamaternalcause isidentified(e,[Link],drugs)initiateapproprıatemanagement
 If maternal cause is not identified and the fetal heart rate remains abnormal throughout at
least threecontractions,performavaginalexanimationtocheckfor explanatory signssof
distress:
 Ifthere isbleedingwithintermittentorconstantpain,suspectabruptio placenta:
 If there are signs of infection (fever, foul-smelling vaginal discharge) give an-
tibiotics as for,amnionitis:
 Ifthecordis below the presentingpartorinthevagina,manage as prolapsedcord.
 If fetal heart rate abnormalities persist or there are additional signs of distress( thickmeconi-
um-stainedfluid),plandelivery
 If the cervix is fully dilated and the fetal head is not more than 1/5 above the sym-
physispubisortheleadingbonyedgeoftheheadis
at0station,deliverbyvacuumextractionor forceps
 Ifthecervixisnotfully dilatedorthefetalheadismore thanI/5above the symphysispubis
Or the leding bony edge ofthe hed is above station,deliver by caesarean section

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MECONIUM:
 Meconium staining of amniotic fluid is seen frequently as the fetus mature-
and, by itself isnotanindicatorof fetal distress.
 A slight degree of meconium, without fetal heart rate abnormalities is warn-
ing of the needforvigilance.
 Thick meconium suggests passage of meconium in reduced amniotic fluid and
may indicatethe need for expedited delivery and meconium management of the
neonatal upper airway atbirthtopreventmeconium aspiration
 In breech presentation. meconium is passed in labor because of compres-
sion of the [Link]
itoccursin earlylabor.
RUPTURE OF UTREUS

 During labor, a weak spot in, the uterus (such as a scar or, a uterine wall that
is thinned by amultiplepregnancy)may tear,resultinginauterinerupture.
 It is the most serious complication in obstetrics. It usually take place during labor
but may occurLastweekof pregnancy.
Principal risk factor of rupture uterus:
 Previous C-section
 Multi parity Oxytosic agent
 Previous gynecological operation:
 Congenital abnormalities of uterus. (septet uteus)Directblow
 Perforating injuries

MATERNAL MORTALITY:
 10%indeveloping country but in develop country 0.3%
 ItsriskIncreases when oxytocin agent is given to multipara withpreviousC-Section,
 Fetalmortality:
 100%The common findingof ruptured uterus is fetal distress.

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TYPES OF RUPTURE OF UTERUS

COMPLETE RUPTURE:

 Peritoneal coat is torn, uterine contents including the fetus and placenta may be dis-
charged intotheperitonealcavity.

INCOMPLETE RUPTURE:

 Usually startss in the lower uterine segment where retraction is deficient.

Bleeding may becontinues pervagina, b/wlayersofbroadligamentsand retroperi-
toneal.
DURING PREGNANCY:
 Weak previous C-section scarPerforminginjuries
 Directblow

DURING LABOR:

 Obstructed labor due

to CPDPelvictumor
 Strictureofcervix
 Intra uterine manipulation e.g. internal version, manual removal of placenta
and forciblecervical dilatation.
 Some time cervical tear in normal delivery may extend to
the [Link]
 Externalcephalicversion

CLINICAL FEATURES OF RUPTURE UTERUS

 Pain

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 Bandle’sring can be seen through adominal wall Tenderness is localized to scar region
 Riseof pulse later falls in B.P
 Loss of presenting part from its former position.
 In acute case labor pains stop and there is continuous pain leaing to shock,
 Fetus
 IUDIncomplete ruptureemptyuterus forms swellingonone side.

MANAGEMENT:

Prophylactic:

 EarlyrecognitionofCPD.
 Obliquelie shouldbecorrectearly.
 Al pregnancies after C-section or previous myomectomy should be delivered in hospi-
tal/Incaseof previousclassicC-sectionelectiveC-sectionshouldbeperformed
 Cervixshouldnotbeforciblydilated.

Curative:

 Emptythebladder
 Empty the stomach with ryle,stube.
 Resuscitatethe patient
 Bloodtransfusion.

Operative:

Total or sub total Hysterectomy depending on situation and size of injury.

COMPLICATIONS:-

 Prolapsed of bowel.
 Hypofibrinogeneamia
 Amnioticfluidembolismandsepsis,

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ACUTE INVERSION OF UTREUS

DEFINITION:-

 It is turning of inside out of uterus partially or completely, before or after delivery

of placenta.
 In certain circumstances, a portion of placenta may stay attached to the wall and
will pull theUterusoutwith [Link] culleduterineinversion.
 It is averyear condition but great emergency in obstetricand may cause postpartum shock.

DEGREE OR STAGES OF INVERSION:

Stage 1: Fundus of uterus is inverted into the cavity of uterus but stays at the level of internal Os.

Stage2:Tie Fundus passes through the cx and lies into the vagina. Rim of the cx is felt around the
uterus

Stage3: Wholeofthe uterus andcx is

Turned inside out completely and hang outside the vulva, upper part of vagina may also becomein-
verted.

CAUSES:

Mismanagementoffirststage

 Applying fundal pressure when it is relax

 Puling of cord when uterus is not well contractedVigorouspushingor bearingdown
 Atonyutreus
 Seven Coughing or, sneezing during labor Cervical tear
 Short cord

SIGN AND SYMPTOMS:

 Suddenshock
 Cold and [Link]

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 Bleedingmayormaynotbe present
 On abdominal examination the body of the uterus is absent from its position
on [Link] dimplingorirregularityofupper surface
 On p/v, examinationbig purple spongy mass is felt protruding through
cervix or lyingOutside the vulva
 TREATMENT:

 As soon as it is recognized it should be replaced manually with placen-

ta still attached
 No attempt should be made to separate placenta in this position.
 An oxytocin agent is given to separate placenta manually
 The part,whichprotrudeslast, shouldreplacedfirst?
 Treät the shock by IV drip of
plasma or D/W Crosshatch the
blood for transfusion.
 Ifthemanualreplacementisdifficult thenit isdoneunder G/A

PERCIPITUS LABOR:
GENERALINFORMATION

Laborof less than3hours

Emergencydeliverywithoutclient'sphysicianormidwife

ASSESMENTANDFINDINGS:


As labor is progressing quickly assessment may need to be
done rapidly
 Client may have history of previous precipitous labor and
deliveryDesire topush
PROLAPSEDUMBILİCALCORD:(refertopage#254)

SHOULDERDYSTOCIA:(refertopage#228)

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SHOCK:
DEFINITION:

Shock is an emergency condition. It can occur when blood flow or blood volume is too low tomeet
the body's needs. With shock, areas of the body aredeprived of oxygen.. The result isdamagetopartsof
the body suchasthe limbs, lungs,heartandbrain.

CAUSES OF SHOCK:

Heart attack

Severeorsudden bloodloss from aninjuryor seriousillness

Large drop in body fluids such as following a severe burn or severe vomitingdiarrhea

Blood poisoning from major [Link] to extreme heat or cold for too long

OTHER THINGS THAT LEAD TO SHOCK ARE:

 Fractures of a large boneAsevereallergicreaction

 Very low blood sugar such as occurs with diabetes (insulin shock)
 Excessive drinking of alcohol
 Drug over dose

SIGNS AND SYMPTOMS OF SHÖCK:

 Weakness. tremblingRestlessness, confusionCoolandmoist skin

 Pale or blue colored lips, skin and/or fingernailsWeakbut fastpulse
 Rapid, shallow breathingNausea,vomiting
 Enlarged pupilsExtremethirst
 Lossofconsciousness.
 Shockcannotbereversedonce ithappens,butfirst aidcanhelpkeepitfrom gettingworse

MANAGEMENT:

Immediatemanagement:

SHOUT FOR HELP:

 Urgently mobilize all availablep ersonnel

 Monitor vitalsigs(pulse,bloodpressure,respiration,temperature).
 Turn the Woman onto her side to minimize the risk of aspiration if she vomits and to ensures
That an airwayis open,.

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 Keep the woman warm but do not overheat her as this will increase peripheral circulation an-
dReduce bloodsupplytothevitalcentres
 Elevate the legs to increase return of blood to the heart (if possible. raise the foot end of
thebed).

Specific management:

 Start an IVinfusion (two if possible) using a large-bore (16-gauge or largest available)cannula

or needle.
 Collect blood for, estimation of haemoglobin, immediate cross-match andbesidesclot-
ting(seebelow)just beforeinfusionoffluids.
 Rapidly infuse TV fluids (normal saline or Ringer lactate) initially at the rate of 1L in 15-
20minutes.
 Note:Avoid using plasma [Link]).
 There is noevidence that plasma substitutes are superior to normal saline in the resuscitation
of a shocked women and dextran can beharmfulinlargedoses.
 Give at cast 2 L of these fluidthe First hour. This is over and above fluid replacement forOn-
goinglosses.
 Donot give fluid by mouth to women in shock

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IF A PERIPLIERAL VEIN CANNOT BE CANNULATED PERFORM A VENOUS CUT-

DOWN

 Continue to monitorvital signs (every I5 minutes) and blood lossCatheterize theblad-

derandmonitorfluidintakeandurine output.
 Giveoxygenat6-8L perminutebymaskornasal cannulae.
 Bedsideclottingtest
 Assessclottingstatususingthịsbedsideclottingtest
 Take 2 ml of venous blood into, a small, dry, clean, plain glass test tube(approx. 10mmx
75mm)Holdthetubeinyourclosedfist to keepitwarm(+37°C);
 After4minutes,tip thetube slowlyto seeif aclot isforming

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UNIT:17.
OBSTETRICAL EMERGENCIES IN POSTPARTUM PERIOD:
POSTPARTUMHEMORRHAGE&INFECTION

 Severe bleeding or uterine infection occurring after delivery is a serious,

potentially fatalSituation.
TREATMENT:

 The source of the hemorrhage is determined, and blood transfusion and IV flu-
ids are given asnecessary.
 Oxytocicdrugsmay be administeredto encouragecontractionoftheuterus.
 Retained placenta is a frequent cause of persistent bleeding, and surgical
removal of theremainingfragments(curettage)maybe required.
 Surgicalrepairoflacerations tothebirthcanalor uterus maybe required.
 Drugsthatencourage coagulation(clotting)ofthe bloodmay beadministeredto-
stemthebleeding.
 Infrequently,hysterectomyisrequired.
 Incasesofinfection, acourse ofintravenousantibioticsisprescribed
 Mostpostpartum infectionsoccurintheendometrium,orliningoftheuterus,andmaybealso
caused by a piece of retained placenta,if this is the case it will also require surgicalremoval

PLACENTAACCRETA:(page#53)

PROGNOSIS OF OBSTETRICAL EMERGENCIES:

 If a fetus is close to full-term (37 weeks) and the complication is detected early
enough, theprognosis is usually good for mother and child.
 With advances in neonatal care, approximately85% of infants weighing less than
3 lbs 5 oz survive, and these infants are being delivered at 28weeks and younger.
 However, preterm infants have a greater chance of serious medicalproblems, and
developmental disabilities occur in 25-50%. They also have a higher incidence
oflearning disorders, and are four to six times more likely to be diagnosed with
attention-deficithyperactivitydisorder (ADHD).

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PREVENTION:
 Proper prenatal care is the best prevention for obstetrical emergencies.
 When complictions of pregnancydoarise,pregnantwomenwhoseetheirOB/GY
 Non aregular bas is are more likely to get an early diagnosis, and with it, the best chance for
fast and effective treatment. In addition,cating right and taking prenatal vitamins and supple-
ments as recommended by a physician willalsocontributetothehealthof bothmother andchild.

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UNIT18.
ANESTHESIA AND ANALGESIA
 Pain relief is often required during laborand is requiredduringandafteroperativeprocedures.
 Methods ofpain relief discussed. Below: include analgesic- drugs and methods of support
during laborlocalanesthesia, general principle for using anesthesia and analgesia and post-
operativeanalgesia

ANALGESICS DURING LABOUR:

 The perception of pain varies greatly with the woman's emotional state. Support-
ive care duringlaborprovidesreassuranceanddecreasestheperceptionofpain.
 If the woman is distressed by pain, allow her to walk around or assume any com-
fortable [Link] hercompaniontomassage herbackorsponge herface be-
tweencontractions.
 Encourage the use of breathing techniques and allow the women to take a warm bath or
shower if shechooses.

FORMOSTWOM-
EN,THISISENOUGHTOCOPEWITHTHEPAINOFLABORIFNECESSARY,GIVE:

 pethidine 1mg/kg bodyweight (but not more than 100 mg) IM or IVslowly every 4 hours as
needed orgivemorphine0.1mg/kg bodyweight IM
 Promethazine 25mgIMorIV ifvomitingoccurs.

DANGER

 Note:Barbituratesandsedativesshouldnotbe usedtorelieve anxietyinlabor.

 If pethidine or morphine is given to the motherthe baby may suffer from respiratory depres-
[Link] anidote
 Note: De not administer naloxone to néwborns whose mothers are suspected of hav-
ing recentlyabusednarcotic drugs.
 Iftherearesignsofrespiratorydepressioninthenewborn,beginresuscitationimmediately:
 -After vitai signs have been established, give naloxone 0.1 my/kg body-
weight IV to henewborn;
 If the infant has adequate , peripheral circulation after successful resuscitation, na-

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loxone can begivenIMRepeated dosesmayberequiredtopreventrecurrent respirato-

rydepression.
 Ifthere are no signs of respiratory depression in the newborn; but pethidine or mor-
phine wasgiven within 4 hours of delivery,observe the baby expectantly for signs of
respiratory depressionandtreatas aliveiftheyoccur.
 Do hot administer diazepam with pethidine in the same syringes, as the mix-
ture forms [Link].
COMPLICATIONS

PREVENTION OF COMPLICATIONS:
All local anesthesia drugs are potentially toxic.

 Major complications from local anaesthesia arehowever,extremely rare.

 Thebestwaytoavoidcomplicationsis to preventthem
 Avoidusingconcentrationsoflignocạinestrongerthan0.5%.
 Ifmorethan40mLoftheanestheticsolutionistobeused, addadrenalinetodelaydisper-
sion.
 Procedures that may require more than 40 ml of 0.5% lignocaine are caesarean
section or repair ofextensiveperianaltears.

USE THE LOWEST EFFECTIVE DOSE.

 Observe the maximum safe dose. For an adult, this is 4 mg/kg body' weight of lig-
nocaine. Theanaesthetic effect should last for at least 2 hours, Doses can be re-
peated. if needed after 2 hours
LOCAL ANAESTHESIA
 Local anesthesia (lignocaine with or without adrenalinę) is used to infiltrate tissue
and Block thesensorynerves.
 Because a woman with local anesthesia- remains awake and alert during, the
procedure. it isespeciallyimportant toensure
 -Counselingtoincreasecooperationonandminimizeher fears.
 Good communication throughout the procedure as well as physical reassuance from thepro-
vider,if necessary
 Timeandpatienceaslocalanestheticsdonottakeeffectimmediate

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Thefollowingconditionsarerequiredforthe safeuselocalanesthesia:

- All members of the operating team must be knowledgeable and experienced in the use
of localanesthetics
- Emergency drugs and equipment (suction. oxygen resuscitation equipment) should be
readilyavailable, and should be in usable condition, and all members of the operating
team trained intheir use.

- LIGNOCANE:
-
- Lignocaine operations are usually 2% or 1% and require dilution bfore use.
- For most obstetricsprocedures,the preparation ns diluted to 0.5%which gives the maximum ef-
fects with the least toxicity.

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- GENERALPRINCIPLESFORANAESTHESIAANDANALGESIA
-
 The keysthemainmanagementand comfortofthewomanare:
 -Supportiveattentionfromstaffbefore,duringandafter
 -Aproviderwho iscomfortableworkingwithwomen
 -The selectionof anappropriatetypeandlevelof painmedication.
 .TIPS FOR PERFORMING PROCEDURES ON WOMEN WHO ARE AWAKE INCLUDE:
 Explaineachstepoftheprocedurebeforeperformingit
 Use adequate premedicationincasesexpectedto lastlongerthan30minutes:
 Give analgesics or sedatives at an appropriate time before the procedure 30 minutes be-
fore forIMand60minutesbeforefororalmedication)sothatmaximum relief will beprovided
 during,the procedure.
 Use dilute,solutions inadequate, amounts;
 Check the level of anesthesia by pinching the area with forceps. If the women
feels thepinch,wait2minute andthen retest.
 Wait a few seconds after performing each step or task for the woman to prepare
for theNextones.
 Moveslowlywithout jerkyor quickmotions
 Handle tissue gently and avoid undue retraction pulling of pres-
sure,"Useinstruments with confidence;
 Avoid saying things like "his, won't hurl in fact. it will hurt; or I’m
almostfinished"whenyou are not
 Talkwiththewomanthroughouttheprocedure.

 The need for supplernentalanalgesic sedative medications (by mouth, IM or V)
willdependon:
 Theemotionalstateofthewomen:
 Theproceduretobeformed
 The anticipatedlengthofthe procedure
 Theskillofthe providerandthe assistanceofthestaff.

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 POSTOPERATIVỀANALGESIA:

 Adequate postoperative pain control is important. A woman who is in severe pain

does notRecoverswlel
 NOTE: Avoid over sedation as this will limit mobility, which is important during the
postoperativePeriod.
 GOOD POST-OPERATIVE PAIN CONTROL REGIMENS INCLUDE:
 Non-narcoticmildanalgesicssuchas.paracetamol500mgbymouthasneeded;
 narcotics such as pethidine I mg/kg body weight (but not more than 100 mg) IM or IV
slowly ormorphine0.1mg/kg bodyweight IM every4hours asneed-
ed;combinationsoflowdosesof narcoticswithparacetamol.
 Note: If the women is vomiting, narcotics may be combined with anti-emetics
such apromethazine25mgIMorIVevery4 hours as needed.

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UNITNO.19
EXPANDED PROGRAM ON IMMUNIZATION(EPI)
 The Expanded Program on Immunization (EPI) was launched by the World
Health Organizationin1974.
 Immunization Schedule is carried under EPI. EPI is a WHO and UNICEF
assisted [Link] on Immunization is Vaccine Prevent-
able Program and there areEightTargetedDiseases:
o ChildHoodTuberculosis
o Poliomyelitis.
o Measles.
o Diphtheria.
o Pertussis(WhoppingCough)
o Tetanus
o Hepatitis-B.
o PneumoniaandMeningitis.

TETANUS TOXOID IMMUNIZATION IN PREG-

NANT WOMENTETANUSTOXOID (TT)

o Giveduringpregnancyto preventtetanusofmother-
[Link] Toxoid 2 Doses, are given 4
weeks apart dose is 0.5ml intra muscularTTI-
Firstcontactor .firstẠNC visit,TT2-4weekslater.

FOR LIFE LONG PROTECTION,

GIVE5 DOSES OF TT USING THE FOLLOWING SCHEDULE:

o TTI and TT2 as aboveTT3-6 months after TT2TT4-1yearafterTT3

o TT5--1yerafter4thdose

IMMUNIZATIONS GIVEN TO THE MOTHER ARE NOT HARMFULTO HER BABY..

[Link]]dose
0.5mlisgivenafter12weeksof pregnancy
EFFECT OF TT VACCINE:

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o FirstDose noeffect
o Twodoses three
years
o Threedoses 5 years
o Four doses 10 years-
Fivedoses 20 years
[Link] HOOD TUBERCULOSIS:

 In Childhood tuberculosis is communicable disease caused by Mycobacterium Tuber-

culosis.
 This spreads fromT.B patient's Respiration and Cough through air to other children.
 Thechildren are usually affectedwhen Tubercle Bacillus enters the body and goes to
lungs andlymphnodesetcandgrowthere,theTuberculosis canbe ofany part.
o [Link]:

 Tiredness , Fever with sweet in night, cough with sputum and when child will be-
come seriousbloodwill comeinthesputum.
 The main signs in the children of this disease are that weight does not increase
actcording to the age
 Signsincluded-
cough>3weeks,mildfeverwithSweating,weightloss,[Link] is treatable
disease (Dots) and medicine is free of cost from government diagnostic and-
Treatment units
 Patient needs support,love andgood dietBreastfeedingallowedduringtreatment

THERE ARE TWO TYPES OF T.B (PULMONARY, EXTRAPULMONARY)

 Pulmonary tuberculosis (TB) is caused by the bacteria Mycobacterium tubercu-

losis ([Link]).
 One can get TB by breathing in air droplet from a cough or sneeze of an infect-
[Link] called primaryTB.

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EXTRA PULMONARY TUBERCULOSIS:

 Extrapulmonary tuberculosiscanbe:
 Renal tuberculosis
 peritonitis tuberculosis;
 pericarditis tuberculosis
 lymphnodeTB
 bone and joint tuberlocusgastrointestinaltuberculosis
 liverTB;
 TBmeningitis
 Extra pulmonary tuberculosis has become chronic and presents several complications for the
[Link] illnesses such as meningitis: and peritonitis may be, dangerous for the patient life
from thebeginning. It requires diagnostic urgent treatment. In the past, node, tonsillar, bone and
gut tuberculosiswas caused by consumption of unpasteurized milk, infected by a virus similar
to Koch bacillus. Today,however,bymilkpasteurization,this risk has decreased.
 Extra pulmonary tuberculosis affects people with weak immune system, diabetes, HIV,
ormalnourished people, very young children or elderly, those undergoing prolonged
treatment withchemotherapy or cortisone.
 Among the most common forms of extra pulmonarytuberculosis arenode tuberculosis,
osteo-articular, renal and skin tuberculosis.
 Meningitis may accompanypulmonary tuberculosis or be an independent disease,
 Commonly it occurs in children betweenone andfiveyears andaffecttheelderly peopletoo
 it is manifested by fever, headache, nausea, dizziness, subsequent neurological symp-
toms andcoma
 IF ANY CHILD SUFFERS FROM TB THERE WILL BE TWO TYPES OF COMPLICA-
TIONS:
 MiliaryTB inwhichWhole lungis destroyed.
 T.B Meningitis in which Brain membranes arc [Link] two complications can cause the
death of children

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 POLIOMYELITIS:
 This is communicable. disease caused by the Poliovirus which affects mostly the young
children. Thepoliovirus enters through the mouth and goes to the throat and then to the in-
testine where it growsfrom5to34 [Link] child will have the symptoms of:Fever,
 Tiredness
 Headache
 Vomiting
 constipation (Sometimes diarrhea),painin legs
 tenderness in neck muscles.
 Then this virus through blood affects the nervous system, causes paralysis in thechild
which isusuallypermanent.:
 ThePolio isthemajor cause ofdeath&disability.

MEASLES:
 Thisiscommunicablecausedbythe virus,calledMeaslesvirus.
 The viruses of this disease spread in Air through respiration and coughfrom infected patient and
infect other children. The secretions of nose& throat canalsocausethe disease directly

The signs & symptoms initially

are
 low gradefever

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 redness of eyes.
 cold&coughetc

AFTER 07 DAYS THERE ARE

 Red spots first on face then whole body,there are also spot sinside the cheek in the mouthThe
Complications of measles are Pneumonia, Diarrhea, infection of ears and nervous sys-
[Link]&disability.
DIPHTHERIA:
TheDiphtheriaiscommunicable diseasecaused byCorne Bacteriumdiphtheria
It spread from one patient to other, this is mostly common in winter season and affects under 15
yearschild,whoare not protectedwithvaccines(Non-immunized)
This affects mostly nose, throat usually Tonsils & Produce a membrane whose sides are swol-
lenAndred
THE SIGNS & SYMPTOMS ARE

 severe pain in throat and Involvement of cervical

lymph nodesthechildwillhavefever&tiredness,
 the toxins are released by the bacteria within 02 to 06 weeks and will enter in
the blood andwillaffectthenervoussystemandcauseparalysisalso,
 sometimes affect the hear t& cause death even.

PERTUSSIS:(WHOOPINGCOUGH)

The pertussis, also communicable disease caused by bacteria (Brodetella Pertussis) it is common
in smallchildren.

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SIGNS AND SYMTOMS ARE:

 Irritation & swelling of Air passages and will produce Paradoxsisms of cough
which childwithout taking the respiration goes on coughing, this cough is tir-
ing and at the end of cough,
 there isavoicecalled "whoop", this is why it is called whooping cough.
 Initially Paradoxsisms of cough are severe which becomes less afterwards the
cough can be with sputum and there is sometimes vomitingalso.
TETANUS:

 This, disease is caused by the bacteria called Clostridium Tetani, these bacteria
Harbor in [Link]
andspreadinairas
 Spores and enter in the body of human beings through cut or infection and release the toxins
there.
 The newborns gets this disease through umbilical cord the time of Birth through un steri-
lizedinstruments or application of Ghee, Mud, Faeces and ash on the, umblical Cord, It
enters the Mother'sbodyifthereis nocleanlinessduringdeliveryandcausetetnus.

THE SIGN AND SYMTOMS OF NEONATAL TETNUS IN NEWBORNS ARE:

 Thechillwill remainnormal for02to3däysafterbirth.

 Thensuddenlythechildstoptakingmilk andcloses his,mouth
 Tightly this is called lock jaw the neck muscles & other body becomes tender, then child
develop fits 80to90%children dieduetothis disease.

THE SIGN AND SYMTOMS OF TETNUS IN THE MOTHER:

 Closing of mouth difficulty in swallowing.

 Tenderness of muscles and fits are common and mostlycauseTetanus.

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7. HEPATITIS-B: This is caused by virus,of Hepatitis-B.

MODE OF SPREAD:

TheHepatitis-BvirusfrominfectedpersonspreadthroughBlood,Sputum,Semenandothersecretions.

VIRUS USUALLY SPREAD BY:

 Injection with contaminated syringe (usually when same syringe is(usually when
same syringe isusedformultipleinjections).
 Blood transfusion with contaminated blood.
 From infected mother to her newborn. directly in children through scratches, in-
fection, cuts e.g. while piercing the earandnosewith contaminated instrument.
 Barber when uses the contaminated instruments.
 Sexualcontact withinfected partner.
 The virus after entering the body will produce the signs & symptoms after
06 weeks to 06months.

THE SIGNS & SYMPTOMS ARE

If the child is young he will not show any sign symptom but he Can transmit the disease toother-
sandlateronhe/she can be thevictim of liver diseaseseven Cancer.
THESYMPTOMSINTHISDISEASEARE.
 weakness,
 abdominal problems
 coryza & running nose.
 Dark colored urine and light colored faeces
 If child has jaundice the skin-& eyes will be yellow, these signs, & symptoms may contin-
uefor many weeks, weakness and tiredness may be for many months. T
 helaboratory test willconfirm whetherchildis sufferingfromdiseaseor not
 Elderly patients usually get completely treated and few can be carrier, but in chil-
dren,ofyounger age group these signs & symptoms may be serious but there arè more chances
thatthosepatientswho have nosigns& symptomsbut cantransmit thediseaseinothers.

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COMPLICATIONS:

Serious disease can produce the complications, like liver swelling i.e. Chronic Hepatitis. Liver cirrho-
sis and Failure.
PREVENTIVEMEASURES:
There is no complete treatment available but if Hepatitis B vaccine if given at proper time and
properintervalwill preventthe disease

8. MENINGITIS&PNEUMONIA:

 This is communicable disease causeby Bacteria called Haemophilus influenza

Type b (Hib-Bacteria).It causesPneumonia,Meningitis andEpiglositis.
 The Bacteria from infected child will go through Respirationcough and sneezing
in Air, willenter into the other children and infect them, the Bacteria can go di-
rectly from secretions, ofthroatandhosetootherchildren.
 Thisiscommoninover-crowdedhouseholdsandwherethese infectedchildrenpassmoretime
 [Link] carecenters,Nursery homés.

SIGNSANDSYMPTOMS:

 Fevercough
 pain in joints
 pain in Ears
 Pneumonia
 involvement of central nervous, system and
 complications of Meningitis,cancausedisability andDeath even

The death rate in under 5 years children due to other diseases is 17% due to
thls [Link] VACCINES?
The vaccines are the immunogenic substances which contain antigen and are prepared. The virus
orbacteria’s (live or dead) which cause: the disease. or toxins of bacteria which are attenuated
Weakened)andCan prevent thediseaseandnotproducethedisease.

HOW IMMUNITY IS PRODUCED?

Before Birth:

From Mother's BLOOD, [Link] through umbilical cord

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AfterBirth:
Frommothersmilkespeciallyfrom firstMilk(Colostrum)
All the immunoglobulins (antibodies) are received to child except childhood tuberculosis ad hepatitis
[Link] whychildhoodtuberculosis andhepatitis bvaccine are given justafter birth.

AFTER SUFFERING FROM THE DISEASE:

When child gets the disease and after, recovery from the disease. the antibodies against thatDis-
easeare producedinthebodywhichwillprotect him fromthatdisease infuturelife.
ThroughVaccination:
We give vaccines to child which containantigen produce the antibodies, which willProtecthimin
thefuture lifefromthosediseases
WHY INSPITE OF IMMUNIZATION DISEASE IS PRODUCED?
InfewchildrenduetolessImmunitysevereinfectionmostlyinthosechildren,whoare not onBreastFeedThe
childwillsufferfromthedisease,butit willbelesssevereandcalledModified form.
 In spite of vaccination 10-15% children will not develop the Immunity, because none of
thevaccineproduce100%immunity.
IntroductionofSeconddose ofMeaslesVaccination
THESE COND DOSEOF MEASLES VACCINE IS GIVEN BECAUSE:

One dose of Measles vaccine is producing Immunity upto 80%

to 85%.Theseconddosewillproduce Immunity upto99%

 Thefirstđoseisgiven justafter09monthsofage.
 Theseconddose isgiven06monthsafterthefirstdose (upt0 24months).
 if child comes for first dose during 2nd year of life, then he/she should be provid-
ed first [Link] seconddoseshouldbegivenatleast04weeksinterval fromthefirst
dose.
 There will be wide option for the 2nd dose during the whole 2nd year of life, this
will not onlyavoid denial of service just because the child is not at right age, but al-
so allow the vaccinators toavailanyopportunityforalongerperiodforvaccination
with2nddose.

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NEW IMMUNIZATION SCHEDULE:

Disease Causeof Vaccine doses Ageof

infection administrartions
ChildhoodTB Bacteria BCG 1 Soonafterbirth
Poliomyelitis Virus OPV 4 OPV0:after
birthOPV1:6
week-
sOPV2:10week
s
OPV3:14weeks
Diphtheria Bacteria PENTAVALENTVAC- 3 Penta1: 6wks
CINE Penta2: 10wks
(measDTP+HepB+Hib+P Penta3: 14wks
neumococcal+Rota)
Tetanus Bacteria
Pertussis Bacteria
Hepatitis B Virus
PCV Bacteria
Pneumococcal
Rota Virus
Hibpneumonia Bacteria
andmeningitis
Measles virus Measles 2 One dose
justafter9mont
hs
2nd dose from
15to24months

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UNIT20:
POST ABORTION CARE:
DEFINITION:

 Care Post abortion care is a package of services provided to women who have had a miscar-
riageor an induced abortion. PAC comprises three core components, which should be imple-
mented ina systematic way the three core components of the PAC Model are:
 1Emergency treatment forcomplicatio sof spontaneousoninducedabortion.
 2Familyplanningcounselingandservice provision and were there is prevalence and resources
are available, STI evaluation and treatment andHIV counseling and/or referral for testing.
3,Communityempowerment viacommunity awareness andmobilization.

BENEFTS OF PROVIDING POST-ABORTIONC ARE

 PAC has been shown to benefit clients and programs in the following ways;PACcontributes
toa highercontraceptive acceptanceate when post abortion family planning counseling and
services are available at the same timeand in thesame site as emergency treatment, women are
more likely to Use contraceptives.
 Family planning counseling can increase the proportion of women who agree to use a fami-
[Link] increases access to family planning in-
formation and informed method choice:ImprovingFP counseling and clinical skills can in-
crease the proportion of women beingdischarged withacontraceptivemethodandanexpanded
methodmix..PACbringscostsavingslofacilities andclients
 Using vacuum aspiration (VA) instead of dilation and curettage (D&C) for
PA can resultin cost savings lo the facility (fewer personnel lab, drug and
anesthesia costs) and to theclient(less expensivemedication,reducedhospital
stay)
 PAG reduces repeat abortion:
 High quality FP services can reduce the umber of unplanned pregnancies and
can result in aReductioninthenumberof repeatabortions

COMPONENTSOFPOSTABORTIONCARE:
Component
Emergency Treatment:
 This first componentoutlines a guideline for triage and emergencytreatment-
basedonthe levelofthehealthcare [Link]

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treatment ofabortion complications, which may include retained products of con-

ception (resulting inhemorrhage and/orinfection),injuryto internalorgansandother-
relatedproblems suchasshock.
 The aspects of emergency treatment provided also depend on the woman's condi-
tion but often includestabilization,uterine evacuation an dmanagementofpain,
bleedingand infection.
 Component2:
 Family Planning Counseling- and Provision, and where there is disease prevlence
andresources are available, STIEvaluation and Treatment, and HIV Counseling
and/or Referral forHIVTestingThe secondcomponentisatthecoreofpost abortioncare.
 Whiletimelyemergency
 Treatmentsisvitalto thereductionofmaternalmortality, postabortion familyplanningisthe
 care services that is critical for the reduction of future mistimed pregnancies and repeat
abortions. Postabortion family planning can assist in addressing the unmet need for family
planning, which is often arootcausefor induced abortion.
 Component3:
 Community Empowerment
 through Community Awareness and Mobilization Effectivecommunity awareness
and mobilization are needed to empower the community to provideanddemandhigh-
quality, effective post abortionservices
 Here, the term community includesgovernments, ministries of health and education
private voluntary organizations (PVO’s),NGOSwomen'sgroups,professional organi-
zations,communityassociations,maleleadership
 based organizations (FBOs), traditional providers, community-based distribu-
tors.,donors andotherstakeholders [Link]
should:
 identify its health needs as they relate to post abortion carePlan for resources
necessary to meet identified health needsWork with stakeholders to mobilize re-
sources to provide PACDetermine how tomakecareaccessible inthe community
 Educate fellow community members about consequences of bleeding in the
first half ofpregnancy,.inducedabortionand thedelays in seeking careand
 Establish relationships with health care providers/facilıties on all levels to ensure
comprehensiveservices delivery for postabortioncare.

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MANAGEMENT OF SPONTANEOUS ABORTION:

THREATENED ABORTION:

1. Medicaltreatmentisusuallynotnecessary
2. The woman is advised to avoid strenuous activity and sexual intercourse, but bed rest isnot nec-
essary
3. Ifbleedingstops:
4. Follow-up in antenatal clinic.
5. Reassess if bleeding recurs
6. If bleeding persists:Assess for feta lviability (pregnancytestorultrasound)
7. Orectopic pregnancy(ultrasound).
8. Do no tgive hormones because they will not prevent miscarriage.
9. Persistent bleeding, particular in the presence of a uterus larger than expected, may indi-
catetwinsormolarpregnancy

INVITABLEABORTION:
 If pregnancyis less than16weeks:PlanforMVAofuterinecontents
 Arrange forevacuationofuterus assoon apossible.
 Ifevacuation is not immediately possible: Give ergometrine 0.29% mg IM (repeated af-
ter15minutes if necessary)OR misoprostall400ugbymouth.(repeatedonceafter4
 hoursifnecessary)
 AwaitspontaneousexpulsionofPOCand thenevacuatetheuterustoremove anyremainingPOC.
 If necessary, infuse oxytocin 40 units in IV fluids (normal saline
 Ringer’slactateat40drops perminute)tohelpachieveexpulsionofPO
 Ensurefollow-upofthewoman aftertreatment

INCOMPLETE ABORTION:

 If bleeding is slight to moderate and pregnancy is less than 6 weeks: Use fingers or ringor-
sponge) forcepsto removePOCprotrudingthroughthecervix,
 If bleeding is heavy and pregnancy is less than l6weeks: Evacuate the uterus:MVAis
 the preferred method of evacuation. Evacuation by sharp curettage should only be

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done ifMVAis not available:

 If evacuate is not immediately possible: Give ergometrine 0.2 mg IM (repeated after
15 minutes ifnecessary)"ormisoprostol400ugorally:(repeated.onceafter4 hoursif nec-
essary).
 Ifpregnancy isgreater than16weeks
 Infuseoxytocin40units in1LIVfluids(normalsalineorringer’ssulphate)at40dropperminuteUntil
expulsionof POCoccurs.
 If necessary give misoprostol 200 g vaginally every 4 hoursuntill expulsion, butdo not ad-
ministermore than800 ug
 Evacuateany remaining POC from the
[Link] follow-up of the woman after
the treatment.

 COMPLETEABORTION:
 Evacuation of the uterus is not necessary
 Observe for heavybleedin
 Ensurefollow upofthewomenaftertreatment

 MANAGEMENT OF INDUCED ABORTION PERFORMED IN UNSAFE ENVI-

RONMENT
 Any woman,who hasexperienced,anincomplete abortion,particularly ifit istheresultofan
 Unsafe abortion, may also suffer from one or more serious conditions: shock, severe vag-
inal bleeding,infectionsorsepsisor intra-abdominalinjuryincludinguterineperforations.
 EMERGENCY TREATMENT OF POST-ABORTALCOMPLICATIONS INCLUDE:
 Aninitialassessmenttoconfirmthepresenceofabortioncomplica-
tionsSupportingthewomenwhileassessingherconditionandexplainingthe treatmentplan
 Medical evaluation (brief history, limited physical and pelvic examination, history of exces-
sive bleeding,easy bruising or known blood disorder that could be due to coagulopathy and
risk for excessivebleeding).
 Prompt referral and transfer if the women requires treatment beyond the capacity of the facili-
ty whereshe is seen
 Stabilization of emergency condition and treatment of any complications, present before
treatment and those occurring during or after thtreatment procedure.
 Assessment of the sign and symptoms of septic abortion such as:
 fever >38C 48 hours following:
 Abortion,chills or
 sweats foul-smelling

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 vaginaldischarge,
 lower abdominal.
 Tenderness and/or pain, mucous from the cervix,
 prolonged bleeding (for more than &8 hours) general-discomfort,
 flu-like symptoms,
 hemodynamic and acid-based equilibrium changes,
 As theconditionworsens,the patient is less alert with tachycardia, hypoten-
sion, pripheries pale and clammy, nausea, vomiting, anddiarrhea
 If a septic abortion with hypotension out of proportion of the blood loss
seen shock should be suspected(SeeManagementofSeptic Shock)
 Uterine evacuation to remove retained POC

POST-ABORTALFOLLOW-UP:

 Women who have had a spontaneous abortionMust besupportedpsychologically.

 Should be informed that spontaneous abortion is common and occurs in at least
15%(1every7)of clinicallyrecognized pregnancies.
 Mustbe,reassuredthattheirchancesforasubsequentsuccessfulpregnanciesaregood
 unless there has been sepsis of a cause of abortion that has been identified as the adverse ef-
fects onfuturepregnancies.(this is rare)
 Must be counseled on family planning methods that can be started immediately (within
7days).
 FamilyPlanningServicesasanEssentialPartofPost-AbortalCare
 Must be referred to any other reproductive health services that may be needed
RhoGAM,tetanus prophylaxis or tetanus booster, treatment for, sexually transmittedinfec-
tions,cervicalcancer screeningetc.
 Must be invited to express their feelings and tears related to the circumstances of the unwant-
edpregnancy,suchas rape,failed contraception, lackofaccesstocontraceptionetc.

POSTPARTUM FAMILY PLANNING(PPFP):

 WhatIsPostpartum FamilyPlanning(PPFP?)
 PPFP is, the initiation and use, of family planning methods after delivery through
the first [Link]ıderations:
 Healthy timing and spacing of pregnancy for optimal outcomesReturntosexual ac-
tivity
 Breast feeding stațhs
 Lactational amenorrheamethod (LAM)and transition to another family plan-

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ning methodTheneedtocontinuebreastfeeding
 Riskof pregnancywithreturntofertility
 Integrationintoexistingservices,tailoringtolitwithtimingandservice

HEALTHY TIMING AND SPACING OF PREGNANCY(HTSP)

 What is Healthy Timing and Spacing of Pregnancy (HTSP)?Forthe healthiest pregnancy

Outcome
 Youngwomenshouldwaituntilthey areatleast18beforeconceiving
 After give birth
 , couples should wait at least two years(24 months) before conceiving againAfteramiscarriage
coupleshouldwaitatleast sixmonths before conceivingagain.
 Return to fertility if not breast feeding
 Fertility return as early as three weeks(21 days) postpartum If breastfeed-
ing:lfusingLAMaccurately:Fertilityreturnssometimeafter sixmonths(variable)
 If not usingLAM: Fertility returns even before six months (variable, but the average is45days)
 5%-10% breastfeeding women' get pregnant in first year postpartum Remember: Fertili-
tyreturnsbeforemensesreturn

POST PARTUM IUCD INSERTION:

 IUCDinsertedatpostpartum
 Right after birth = Post placental (10 minutes after delivery of placenta)Soon after birth =
Immediate postpartum (<48 hours after delivery)Duringcesarean section=Trans cesarean
 Fourormore weekspostpartum
 IUCDsshouldnotbe insertedbetween48hoursandfourweeksafterdelivery

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 WHO MEDICAL ELIGIBILITY CRITERIA:

 Medical eligibility for post-abortal contraceptive use

 When providing contraception to a womanin a PAC setting, health care providers
need to consider her medical eligibility for each method.
 In general, all modern contraceptive methods can be use immediately following
PAC provided:
 There are no severe complications requiring further treatment. The client receives
adequatecounseling
 The provider screens for any precaution for using a particular contraceptive meth-
[Link] addition it is recommended that women not hare intercourse until post-abortal
 Bleeding stops (usually 5 to 7 days) and any complications are resolved. Natural family
planningmethodsarenotrecommended:until are gula rmenstrual pattern returns.
 Somesituationsrequirea delay in the use of certain methods.
 During certaincounseling session, health care providers shouldinform women as to which
contraceptive method is appropriate for them, based on their medicalcondition. The Ipas
women centered post abortion care: Reference Manual lists all available methods. Insum-
marythemost appropriatecontraceptivemethods forvarious clinicalconditionsmayinclude:
 Identify which contraceptive or family planning method can be safely used in the
presence ofgiven characteristiconmedicalcondition
 Category1:Norestrictionstouse
 Category 2: advantages generally outweigh risks; general-
ly use
 Category 3:Risk generally outweigh advantages; general-
ly do not use
 Category4:Too risky to use do not use session,healthcare
providers

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MISOPROSTOL FOR TREATMENT OF INCOMPIETE ABOR-

TION &MISCARRIAGE:
BACKGROUND:
 Misoprostol is a prostaglandin El analog generally registered for prevention and treatment of-
gastric ulcers resulting from chronic administration of non-steroidal anti-inflammatory Drugs.
 Becausemisoprostolalso inducesuterinecontractions,it iscommonly usedoff-label for treatment
of early pregnancy failures,including incomplete andmissedabortions
 Studieshavedemonstrated that misoprostol can be used effective and safely for these indica-
tions.
 This information ispresentedforthe guidanceoftrained health careproviders.

INDICATIONANDUSAGE:

 Misoprostol is indicated or treatment of incomplete abortion and miscarriage for women

withuterine sizelessthanor equal to12 weeksLMPat presentation.
 Useofmisoprostolforincomplete abortionhassuccessrate of66%-100%usingthe
 Recommended dose Use of misoprostolfor missed abortion has success rate of 60%-93% us-
ing therecommendeddose.

CONTRAINDICATIONS:

 Historyofallergytomisoprostolorotherprostaglandin
 Suspicionofectopicpregnancy
 Signsofpelvicinfectionand/orsepsis
 Symptomsofhemodynamicinstabilityorshock

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PRECAUTIONS:

 Women eligible for misoprostol, but with an IUD in place, should have the IUD removed before
drugadministration.
 Caution is advised when treating women with known bleeding disorders or currently takinganti-
coagulants.
 Misoprostol may be used with caution in patients with uterine size larger than 12 weeks LMPbut
with a known gestational age less than or equal to 12 weeks (e.g. uterine enlargement dueto fi-
broids).
 Small amounts of misoprostol or its active metabolite may appear in breast [Link] areno
known consequences of this and no adverse effects on nursing infants have been reported.

EFFECTSAND SIDE EFFECTS:

Prolonged or seriouse ffects and side effects are rare

BLEEDING:

 After administration of misoprostol, bleeding typically lasts up to 2 weeks, with Additional

days ofspotting that can, last until the next menstrual period.
 Woman should be instructed to contact a healthcare provider if anyof the following occur.
Then if she soaks more than two extra-largesanitary pads an hour for more than 2 consecutive
hours.
 If she suddenly experiences a heavy onset of bleeding after bleeding has slowed or
 Stopped for several days after taking misoprostol,If she has bled continuously for sever-
al weeks and begins to feel dizzy or light-headed.

 CRAMPING:
 cramping usually starts within the first few hours and may begin as early as 30minutes after
misoprostol administration
 The pain may be stronger than thatexperienced during a regular period.
 Non steroidalanti-inflammatory drugs or otheranalgesiacan used for pain relief without af-
fecting the success of th emethod.

FEVERAND/ORCHILLS:
 Chills are a common side effect of misoprostol but are [Link]
notnecessarily indicateinfection.
 An anti pyretic can be used for relief off ever,if [Link] fever or chills persist beyond 24
hours after taking misoprostol, the woman may have an infection and should seekmedicalat-

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tention.
 NAUSEA ANDVOMITING:
 Nausea and Vomiting may occur and will resolve 2 to 6 hours after taking miso-
[Link] can be used if needed.
 DIARRHEA:
 Diarrheamayalsooccurfollowingadministrationofmisoprostolbutshould resolvewithina day.
 DOSAGEANDADMINISTRATION:
 Incompleteabortion:
 The recommended regimen for treatment of incomplete abortion with misoprostol is a sin-
gledoseof600ngmisoprostolorally.
 MISSED ABORTION:
 In the instance where diagnosis of missed, abortion is certain and/or the cervix, is firmly
closedtherecommended regimen is a singledoseof800ugmisoprostolvaginally
 Highes tsuccess rates are achieved with extended follow up(7-14days)to allow completion of
 the process of expulsion. Surgical intervention is not recommended before7 days of treatmen-
ta dministration unless medically necessary
 NOTES:
 There is also evidence that a repeated dose may increase efficacy.
 Misoprostol probably also works well when placed between the cheek and gum (buccally)
orunderthe tongue(sublinguall)

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