Powered By

Note 1
Overview of the Guide
This guide outlines the curriculum for the Bachelor of Science in Nursing Licensing Examination, specifically Paper II. It
includes various units focused on reproductive health topics, including:

● Unit One: Introduction to Reproductive Health

● Unit Two: Pregnancy (Parts One and Two)

● Unit Three: Labour and Puerperium (Parts One and Two)

● Unit Four: Contraceptive Technology

● Unit Five: Gynaecology

● Unit Six: Understanding STIs and HIV/AIDS

Note 2
Unit One: Introduction to Reproductive Health
This unit focuses on reproductive health policies and their application for quality reproductive health services. Key areas
include:

● Policy Guidelines: Strategies set by the Government of Kenya to implement reproductive health programs.

● Youth and Gender Issues: Discussion on adolescent/youth health and gender issues related to reproductive
health rights.

● Safe Motherhood Initiative: An exploration of initiatives aimed at improving maternal health.

● Unit Objectives: By the end of this unit, students should be able to:

● Describe national reproductive health policies.

● Identify adolescent health issues.

● Explain gender issues in reproductive health.

● Understand the Safe Motherhood Initiative.

Note 3
Historical Background of Reproductive Health Policies
This section covers the evolution of reproductive health policies in Kenya. Important points include:

● Family Planning Initiatives: The Kenyan government integrated family planning into national strategies starting
in the 1960s to address high fertility rates.

● Integration of Services: In 1974, child health services were integrated with family planning to improve
efficiency.

● Safe Motherhood Initiative: Launched in 1987 to reduce maternal mortality rates.

● Cairo Conference 1994: A pivotal event where 179 countries endorsed a Reproductive Health Agenda,
emphasizing comprehensive health policies.

● Integrated Reproductive Health: The concept of providing comprehensive reproductive health services at
multiple levels of care.
Note 4
GoK Policy Guidelines for Reproductive Health Services
The Government of Kenya has established policy guidelines to enhance reproductive health services, aimed at:

● Awareness Creation: Promoting the need for high-quality reproductive health services.

● Accessibility: Ensuring that family planning services are available to all.

● Health Burden Reduction: Addressing the socioeconomic impacts of STDs/HIV/AIDS.

● Empowerment: Eliminating discrimination against women and enabling their reproductive health rights.

● Comprehensive Services: Providing sustainable reproductive health services at all levels.

Note 5
Implementation Plan for National Reproductive Health Strategy
This plan aims to operationalize the reproductive health strategy in Kenya from 1999 to 2003, prioritizing:

● Women and Children’s Health: Addressing specific health needs of vulnerable groups.

● Training Health Providers: Enhancing skills and knowledge in reproductive health care.

● Integrated Services: Fostering a comprehensive approach to reproductive health.

● Policy Advocacy: Encouraging policy changes and capacity building in community participation.

Note 6
Safe Motherhood Initiative
The Safe Motherhood Initiative, supported by international organizations, aims to reduce maternal mortality through:

● Access to Emergency Care: Ensuring treatment for complications such as hemorrhage and infection.

● Antenatal Care: Identifying and managing risks associated with pregnancy.

● Postpartum Care: Providing support and education on infant care and family planning.

● Health Education: Promoting hygiene, immunizations, and overall health maintenance.

Note 7
Family Planning
Family planning is crucial for saving the lives of women and children, preventing unwanted pregnancies, and reducing
health risks associated with childbirth and abortion. It allows women, often sole caregivers, to allocate more time to their
own health and their children's well-being.

Characteristics of Good Family Planning Programmes:

● Strong government support

● Well-trained providers: Sensitive to cultural conditions, listen to patients, and exhibit friendliness and empathy.

● Affordable services: Offering a range of contraceptive methods, including:

● Oral contraceptives

● IUCDs

● Injectables

● Implants

● Male and female condoms

 ● Emergency contraceptives

● Voluntary surgical contraception

● Counselling: Ensures informed consent in contraceptive choices.

● Privacy and confidentiality

● Clean and comfortable facilities

● Prompt service

Further details on family planning will be available in unit four of this module.

> 'All couples and individuals have the right to decide freely and responsibly the number and spacing of their children and
to have access to information, education, and the means to do so.'

Note 8
Management of STIs
Women are more vulnerable to STIs than men due to biological factors, with the disease burden more than three times
higher in women. The anatomy of the reproductive tract makes infections easier to transmit to women, and when
symptoms occur, they are often more serious. Low social status and economic dependence prevent many women from
negotiating condom use for STI prevention, contributing to the HIV/AIDS crisis in the country, which has been declared a
national disaster.

Reproductive health programmes can help reduce STIs, including HIV/AIDS, by:

● Providing information and counselling on issues like:

● Sexuality

● Gender roles

● Power imbalances

● Gender-based violence and its link to HIV transmission

● Distributing male and female condoms.

● Preventing, diagnosing, and treating STIs.

● Developing strategies for contact tracing and referrals for HIV-infected individuals.

This topic will be discussed in detail in unit five of this module.

Note 9
Adolescent/Youth Sexual and Reproductive Health
The reproductive health needs of adolescents and youth have historically been neglected. Young people aged 10-24
have unique RH needs that must be addressed through effective services.

To cater to these requirements, services should:

● Recognize the importance of health education: Provide integrated sex education and services that include
family planning, gender relations, STDs, HIV/AIDS, sexual abuse, and reproductive health rights.

● Ensure access to RH services: Healthcare programmes should be accommodating to adolescents.

● Support efforts to eliminate harmful practices: Such as female genital mutilation, sexual abuse, and
trafficking.

● Encourage responsible behavior among boys and young men: Promote respect and responsibility in sexual
behavior (MoH 1996).

More information on this topic is available in section two of this unit.

Note 10
Gender Issues and Reproductive Health Rights
Gender roles in society significantly affect reproductive health, impacting both men and women. Key Points:

● Reproductive health is not solely a women's issue; it involves the entire family and community.

● Unequal power dynamics limit women's control over sexual decisions, exposing them to unwanted pregnancies
and STIs, including HIV/AIDS.

● Adolescent girls are particularly vulnerable in this context.

● Successful reproductive health services must address knowledge, power, and decision-making dynamics in
sexual relationships.

● As a health worker, it's crucial to advocate for reproductive health as a right and educate the community to end
gender inequality and harmful practices.

This topic will be discussed in greater detail in section three of this unit.

Note 11
Cancer of the Reproductive Organs
Cervical and breast cancer are leading cancers among women in Kenya, while prostate and testicular cancers are most
common in men. Early detection is vital in reducing mortality and morbidity rates.

Challenges and Goals:

● Access to cancer screening is limited, especially for rural and urban poor populations.

● Integrating cancer prevention into reproductive health programmes is essential for accessibility.

Objectives to achieve this goal include:

● Reduce morbidity and mortality through early detection and treatment.

● Establish screening and treatment facilities for cervical pre-cancer lesions.

● Ensure 15% of women aged 30-49 are screened annually.

● Maintain and strengthen referral facilities for managing cancer patients.

Note 12
Prevention and Management of Infertility
Infertility remains a significant public health concern in Kenya, affecting many couples and individuals. It is categorized
by the WHO as:

● Primary infertility: The woman has never conceived after 12 months of unprotected intercourse.

● Secondary infertility: The woman has conceived before but cannot do so again within 12 months of
unprotected intercourse.

● Pregnancy wastage: The woman can conceive but cannot produce a live birth.

Gender Implications:

● Women often face blame and social discrimination regarding infertility, regardless of the cause.

Main Goals:

● Advocate for recognition of infertility as a public health issue.

● Reduce secondary infertility prevalence.

● Effectively manage curable STIs, ensuring access to care services and training for infertility management.
Note 13
Care of the Elderly
The elderly population is growing, facing various health issues related to menopause and andropause. Addressing these
issues is crucial for their physical and psychological well-being, impacting their socioeconomic productivity as early as 50
years of age.

Recommendation:

● Integrate care for the elderly, especially issues related to menopause and andropause, into reproductive health
programmes.

Note 14
The Ministry of Health's Approach to Reproductive Health
To address reproductive health components, the Ministry of Health (MoH) focuses on:

● Reorientation of the health care system: Enhanced training for healthcare providers.

● Identification of services: Determine which services to integrate and at what levels.

● Collaboration: Identify and document collaborating institutions and stakeholders.

Holistic Approach:

● Addressing cross-cutting issues is essential for reducing disease burden and enhancing service quality.

● The training material aims to develop capabilities for comprehensive reproductive health care across all service
delivery levels, including government, NGOs, and the private sector.

Note 15
Structure of Reproductive Health Care Services
The Government of Kenya, through the Ministry of Health, aims to improve health services to make them affordable and
accessible. This includes:

Community Level:

● Mobilizing the community for reproductive health services.

● Identifying community resource persons for information dissemination.

● Supervising antenatal care and family planning services.

Local Dispensaries (Primary Level):

● Supervision of IEC materials and provision of RH services, including counselling and clinical services.

Health Centre (Primary Level):

● Managing pregnancies, deliveries, and STIs.

● Using lab facilities for screening and diagnosis.

District Level (Secondary Level):

● Supervising health centres and dispensaries, providing a full package of RH services.

● Offering specialized clinics for managing pregnancy complications and infertility.

National (Tertiary Level):

● Full range of specialists available for all clinical problems referred.

Note 16
Adolescent and Youth Health
Adolescents and youth make up a significant portion of the population, yet their issues have often been overlooked. They
have unique needs, leading to special programs addressing their concerns.

Key Issues Identified:

● Inadequate knowledge about human sexuality.

● Poor information on quality reproductive health services.

● High-risk sexual behaviors.

● Discriminatory social practices.

Government Response:

● Development of strategic communication programs to promote positive behaviors among young people.

Objectives of this section:

● Define adolescence and youth.

● Describe sexual characteristics and reproductive health needs of young people.

● Impart life skills to young people.

● Create plans to improve reproductive health among youth.

Note 17
Key Areas in Adolescent Sexual and Reproductive Health
● Young people, aged 9-24 years, have unique health needs that vary by age group.

● The Government of Kenya emphasizes youth reproductive health due to:

● A significant portion of the population being young people.

● 20% of pregnant women are adolescents (ages 15-19).

● Statistics Highlighting the Need for Services:

● 20% of Kenyan adolescents become sexually active between 9-14 years.

● By age 20, 80% have had sexual intercourse.

● HIV prevalence among 15-19-year-olds: 22.3% females, 4.2% males.

● 10,000 schoolgirls drop out yearly due to pregnancy.

● Common Reproductive Health Problems:

● Early child bearing (70% prevalence) due to educational discrimination against girls.

● STIs/HIV/AIDS (45% prevalence) linked to idleness and peer pressure.

● Unsafe abortion from unplanned pregnancies.

● Many adolescents lack adequate information about their sexuality, leading to increased risks.

● Reproductive Health Needs:

● Information on sexuality and reproductive health.

● Access to family planning.

● Care for prenatal and post-abortion needs.

 ● Safe delivery services.

● Treatment for STIs.

● Protection from sexual abuse.

● Culturally appropriate counseling.

● Education in decision-making and negotiation skills.

Note 18
Principles for Working Effectively With Young People
● Cultural Sensitivity:

● Understand cultural sensitivities regarding health information and services.

● Create awareness in the community for realistic and appropriate counseling.

● Peer Leadership:

● Encourage peer communication since peers are trusted information sources.

● Integration of Services:

● Establish links between health and community services for comprehensive care.

● Privacy and Confidentiality:

● Ensure a private environment for discussions.

● Maintain confidentiality in all dealings with young people.

● Gender of Service Provider:

● Consider the gender of the service provider, referring young people to same-sex providers when possible.

Note 19
Life Planning Skills
● Definition: Life planning skills help young people cope with challenges and make informed decisions.

● Importance of Sex Education:

● Effective sex education promotes safe behavior without increasing sexual activity.

● Skills Development:

● Young people need to learn:

● How to resist peer pressure.

● Assertiveness and negotiation skills.

● Conflict resolution.

● Components of Life Planning Skills:

● Values and Values Verification:

● Understanding personal values learned from family and community.

● Decision-Making Abilities:

● Communication skills are crucial for making informed choices.

● Values:
 ● Values dictate behavior; individuals learn to make decisions aligned with their values.

● Negative community practices (e.g., early marriage, abuse) must be discouraged.

Note 20
Negative Practices and Good Values
● Negative Practices to Discourage:

● Wife Inheritance:

● Risks spreading STIs/HIV/AIDS and causes family discord.

● Wife Beating:

● Leads to severe injuries, stigma, and delayed medical attention.

● Female Genital Mutilation (FGM):

● Risks of infection, prolonged labor, and high morbidity rates.

● Early Girl Child Marriage:

● Complications arise from early pregnancies; increases illiteracy and vulnerability.

● Good Values to Promote:

● Education of the Girl Child:

● Promotes understanding of health issues and economic empowerment.

● Abstinence:

● Encouragement for both genders to abstain from premarital sex to reduce health risks.

Note 21
Factors Influencing Values and Decision Making
● Origins of Values:

● Parents/family instill values.

● Communities reinforce values and offer discipline.

● Religious leaders shape beliefs about good and evil.

● Schools help adolescents reason and check their values.

● Friends influence initial values; peer pressure can lead to deviance.

● Factors Leading to Deviations:

● Experimentation with others' values.

● Peer pressure causing behavior inconsistent with personal values.

● Opportunities for personal gain or rebellion.

● Decision-Making Skills:

● Decision-making involves weighing options and consequences.

● Skills needed include:

● Communication.

● Assertiveness (the right to express and refuse).

 ● Negotiation skills.

Note 22
Community and Government Interventions to Improve Youth Health
● Advocacy:

● Recognize socio-economic and reproductive health needs of youth.

● Youth Advisory Councils:

● Establish councils to coordinate youth health initiatives.

● Targeted Messaging:

● Create specific messages for various groups (parents, youth, etc.).

● Youth-Friendly Services:

● Implement accessible reproductive health services.

● Education on Rights:

● Educate youth about their rights to promote health and self-esteem.

● Research:

● Conduct regular research on youth issues to inform practices.

Note 23
Understanding Gender and Gender Stereotypes
● Gender is often misinterpreted as solely male or female. In fact, it encompasses the economic, social, and
cultural attributes associated with being male or female.

● Gender stereotypes can lead to assumptions that women are weak and unable to perform certain tasks, which
can limit their roles in society.

● Example: Leadership roles are often dominated by men, despite many men failing in these positions.

● Societal expectations dictate how men and women should dress, behave, and work, leading to different roles in
public and private spheres.

● In many societies, men are expected to be the primary breadwinners, while women are tasked with domestic
responsibilities.

● This societal division reinforces the perception of men as leaders and women as caregivers, often
marginalizing women's contributions in broader contexts.

Note 24
Reproductive Health Rights
● Reproductive health rights are based on international human rights declarations and treaties, including the
Universal Declaration of Human Rights and the Beijing Platform of Action.

● The 1994 Cairo Programme of Action defined these rights as the ability for all individuals to make informed
decisions about reproduction without discrimination, coercion, or violence.

● The 1997 Safe Motherhood Action Agenda emphasized the need for greater equity for women in reproductive
health.

● Encouraged interventions include providing formal education for girls, equal employment opportunities, and
empowering women in decision-making within households.
 ● Gender issues are interconnected with reproductive health, affecting the ability of individuals to maintain sexual
health and manage reproductive lives. Poor reproductive health is often a consequence of gender-based
inequality in social power and resource distribution.

Note 25
Gender Inequalities and Discrimination
● Gender inequality refers to unequal access to power, resources, and opportunities, impacting the health and
well-being of women and girls.

● Gender discrimination can lead to chronic health issues, limiting women's participation in society and control over
their own sexual health.

● Historical context shows that women have been subordinated in many societies, with cultural norms dictating
their roles from childhood.

● Examples of gender inequalities include:

● Educational Inequalities: Boys are often prioritized over girls for education due to perceptions of economic
value.

● Inequalities in the Labor Force: Women face barriers in employment and promotion opportunities.

● Health Access: Women often receive inadequate medical care and nutrition compared to men.

● Cultural Practices: Practices such as female genital mutilation (FGM) and polygamy perpetuate gender
inequality.

Note 26
Preference for the Male Child
● In many cultures, there is a historical preference for the male child, viewed as having greater economic value
and being the primary source of family support.

● Boys are often seen as assets who can inherit and provide for their families, while girls are perceived as
liabilities.

● As a result, girls receive less investment in education and health, leading to long-term consequences for their
reproductive health.

● Statistics show a dramatic gender imbalance with girls often being neglected, leading to increased cases of
infanticide in regions with legal restrictions on abortion.

● Parents may also prioritize education for boys, believing girls will eventually leave the family upon marriage.

Note 27
Cultural Practices Affecting Women
● Early Marriages: Girls are frequently married off at young ages for economic gain, exposing them to health risks
and limiting their educational opportunities.

● FGM: This practice continues to affect millions of girls worldwide, with severe health consequences and societal
implications regarding sexual behavior.

● Wife Inheritance: This cultural practice can exploit widows and perpetuate cycles of poverty and disease,
including the spread of HIV/AIDS.

● Polygamy: Common in some societies, polygamous relationships can lead to family conflicts and health risks
associated with sexually transmitted diseases.
Note 28
Gender Violence
● Gender-based violence affects approximately one in three women globally and is often perpetrated by
someone the victim knows.

● This violence is recognized as a significant human rights issue, rooted in societal norms that condone male
dominance and control.

● Forms of Abuse include:

● Physical Abuse: Encompasses various aggressive behaviors that cause injury.

● Emotional Abuse: Involves harm to a person's feelings, often leading to psychological issues.

● Psychological Abuse: Includes threats, isolation, and property destruction, resulting in fear and depression.

● Gender-based violence has severe implications for women's reproductive health, leading to complications like
unwanted pregnancies, STDs, and psychological trauma.

Note 29
Learned Behavior and Aggression
● Violence is often a learned behavior, with many individuals who commit acts of violence having witnessed abuse
in their childhood homes.

● Aggression can be categorized as:

● Hostile Aggression: Driven by anger or frustration.

● Instrumental Aggression: Goal-oriented behavior not necessarily tied to emotional distress.

● Situational factors, such as exposure to violent media, can trigger aggression and influence behavior, especially
in younger individuals.

Note 30
Economic Inequality and Women's Workload
● Workload Distribution: Traditionally, men hold economic power while women and children perform the majority
of labor, often for longer hours.

● Patriarchal Structures: These structures place women in an inferior status across political, social, intellectual,
and economic spheres.

● Materialistic View of Women: Women's value is often perceived in relation to men, such as a girl’s worth being
tied to bridal wealth benefiting her male relatives.

● Multiple Responsibilities: Women manage household chores, low-paid labor, and child-rearing, often carrying
babies to work while their husbands rest.

● Economic Disparity: Women in agriculture receive less pay than men for equivalent work, limiting their access
to better-paying jobs.

Note 31
Challenges Faced by Women
● Limited Economic Autonomy: Many women lack independent income; those who earn make about 75% of
men's salaries (UNDP, 1995).

● Rural Women's Roles: In rural areas, women may head homesteads but have no say in financial decisions
regarding crop sales.

● Inheritance Issues: Cultural norms often prevent women from inheriting land, perpetuating income inequality.
 ● Widows' Economic Abuse: In certain communities, widows face economic exploitation from in-laws, losing
property they helped build.

● Healthcare Access: Women's contributions to family often go unrecognized, and they may struggle to afford
medical care, further diminishing productivity.

Note 32
Sexual Violence and Abuse
● Definition of Sexual Violence: Any sexual act or attempt to obtain a sexual act using coercion or threats,
occurring in various settings.

● Types of Abuse: Includes forced fondling, incest, molestation, and rape, with children being the most vulnerable
victims.

● Incidence of Child Abuse: Many children, often unaware of the abuse, suffer from sexual violence, primarily by
known perpetrators.

● Psychological Impact: Victims may endure lasting psychological scars, leading to issues like depression,
substance abuse, and social deviance.

● Rape as Violence: Defined as unwanted sexual contact, it primarily serves as an expression of power rather
than sexual desire, affecting women across all demographics.

Note 33
Consequences of Gender-Based Violence
● Physical Health Impacts: Include injuries from domestic violence and increased vulnerability to STIs/HIV due to
lack of negotiation for protection.

● Mental Health Consequences: Victims often experience severe depression, PTSD, and may resort to self-harm
or substance abuse.

● Social and Economic Costs: The societal cost of violence against women includes healthcare costs and loss of
productivity, affecting women's economic roles.

● Homicide Risk: Most female homicide victims are killed by intimate partners, highlighting the extreme risks
involved.

● Child Impact: Children in abusive environments often become victims as they attempt to protect their mothers.

Note 34
Improving Women's Rights and Health
● Empowerment and Participation: Women's full participation in decision-making is essential for achieving
equality and development.

● Fertility Control: Women’s ability to manage their own reproductive choices is crucial for their rights.

● Engaging Men: Involvement of men in discussions about gender issues and reproductive rights is necessary for
holistic solutions.

● Strategic Approaches: Advocacy against harmful practices and promoting gender equality in education and
health are key.

● Legal Reforms: Lobbying for changes in marriage laws and the elimination of violence against women is vital for
progress.

Note 35
Role of Health Workers
● Support for Victims: Health workers should provide emotional support and recognize signs of abuse to aid
victims effectively.
 ● Medical Care and Documentation: Proper medical treatment and accurate documentation of abuse incidents
are essential for recovery and legal action.

● Confidentiality: Maintaining patient confidentiality is critical to protect the victim's privacy and safety.

● Community Involvement: Encouraging victims to report abuse and holding perpetrators accountable are vital
community responsibilities.

● Collaborative Efforts: Involving community leaders and authorities can help break the cycle of violence and
promote healing.

Note 36
Addressing Gender-Based Violence
● Identify potential batterers and assist them in seeking professional help.

● Sex education should be taught at all levels to foster family values, respect, and dignity.

● Stress personal responsibility.

● Promote wholesome relationships and recognize individual rights.

● Society must stand firm against sexual abuse, particularly in cases of rape, child abuse, and domestic violence.

● Male attitudes towards gender arise in boyhood, indicating the need for early intervention with Information,
Education, and Communication (IEC) efforts.

Note 37
Safe Motherhood and Child Survival Initiative
Introduction
● Safe motherhood encompasses more than just maternal mortality; it includes:

● Maternal morbidity

● Health of the newborn

● Positive health of the mother

● The term has evolved since 1987, recognizing socioeconomic status as a root cause of poor maternal health.

● The mandate includes pre-conception care, antenatal care, labor and delivery, postpartum care, and neonatal
care.

● Approximately 15% of pregnant women may face serious obstetric complications that require skilled care
throughout pregnancy and delivery.

Objectives
● Define safe motherhood.

● Explain the Safe Motherhood Initiative (SMI).

● Discuss the eight pillars of the SMI.

● Explain the causes of maternal and perinatal morbidity and mortality.

● Explain essential obstetric care.

Note 38
Definition and Components of Safe Motherhood
● Safe motherhood is defined as a woman's ability to have a healthy pregnancy and delivery.

● Actions required for safe motherhood:

 ● Reduce high-risk and unwanted pregnancies.

● Reduce obstetric complications.

● Decrease high fertility rates among women with complications.

● Key Components include:

● Focused antenatal care to lower maternal morbidity and mortality.

● Safe and clean delivery under supervised care.

● Postnatal care to ensure future safe pregnancies and deliveries.

● Cost-effective post-abortion care.

Note 39
Safe Motherhood Initiative (SMI)
● Launched in 1987 in Nairobi by WHO and partners to address pregnancy and childbirth issues.

● Objectives of the SMI include:

● Reducing maternal mortality by half by 2000.

● Enabling women to choose pregnancy, receive care, access trained birth attendants, and have post-birth care.

● The initiative highlights the intrinsic value of women, focusing on their well-being as a primary goal.

Note 40
Eight Pillars of Safe Motherhood
● To reduce maternal morbidity and mortality, focus on these eight pillars:

1. Family Planning: Access to information and services for timing and spacing of pregnancies.

2. Focused Antenatal Care: Four visits to prevent complications and recognize danger signs.

3. Clean and Safe Delivery: Ensuring trained attendants and proper facilities.

4. Essential Obstetric Care: Availability for high-risk pregnancies and complications.

5. Post Abortion Care: Management of complications from unsafe abortions.

6. Prevention of Mother to Child Transmission of HIV (PMTCT): Protection of unborn babies from HIV.

7. Targeted Postpartum Care: Close follow-up to detect complications early.

8. Neonatal Care: Ensuring survival and health of newborns, especially in home births.

Note 41
Causes of Maternal and Perinatal Morbidity and Mortality
● Maternal death: Occurs due to complications related to pregnancy or labor within 42 days after delivery or
abortion.

● High maternal mortality rate in Kenya: 414 per 100,000 live births, significantly higher in certain regions.

● Approximately 90% of maternal deaths could be prevented with timely, quality obstetric care.

● Recognize risks of pregnancy; increase access to family planning and improve antenatal/postnatal care.
Note 42
Methods for Preventing Maternal Morbidity and Mortality
● Recognize that every pregnancy carries risks.

● Increase access to family planning services.

● Improve quality of antenatal and postnatal care.

● Ensure access to essential obstetric care, including post-abortion care.

● Expand midwifery care in communities.

● Train and deploy skilled health personnel.

● Reform laws to enhance women's access to health services.

Note 43
Reproductive Health Targets in Kenya
● Goals set in the Kenya Sessional Paper No. 1 include:

● Reducing maternal mortality ratio from 414 in 2003 to 230 by 2005 and 170 by 2010.

● Increasing professionally attended deliveries from 44% in 2003 to 90% by 2010.

● Expanding services and improving quality of care.

● High antenatal service utilization, yet low rates of facility-based deliveries (42%).

Note 44
Unit Overview
● This unit covers the anatomy and physiology of the female reproductive system, along with the physiological
changes during pregnancy.

● Completion of this unit enables holistic management of a pregnant woman.

● It includes two sections:

● Section One: Anatomy and Physiology of the Female Reproductive System

● Section Two: Physiology of Pregnancy

Note 45
Unit Objectives
By the end of this unit, you will be able to:

● Describe the anatomy and physiology of the female reproductive system.

● Explain the physiological changes that occur during pregnancy.

Note 46
Section 1: Anatomy and Physiology of the Female Reproductive System
● Understanding reproductive health is crucial for reducing maternal mortality and morbidity.

● This section reinforces knowledge previously acquired during nursing training, preparing for advanced topics.

● Objectives include:

● Describe components of the female reproductive system.

 ● Describe functions of hormones regulating the menstrual cycle and pregnancy.

● Describe obstetric anatomy.

● Outline the anatomy of the foetal skull.

Note 47
Components of the Female Reproductive System
The female reproductive system consists of two parts: external and internal genitalia.

External Genitalia (Vulva)

● Mons Veneris: Fat pad over the pubic bone, covered with pubic hair.

● Labia Majora: Thick folds of fatty tissue merging into the perineum.

● Labia Minora: Thin folds of skin between labia majora, forming the fourchette.

● Clitoris: Sensitive erectile structure at the junction of the labia minora.

● Urethral Meatus: Opening below the clitoris.

● Vaginal Orifice: Introitus of the vagina, partially covered by the hymen in non-sexually active individuals.

● Bartholin's Glands: Secrete mucus for lubrication, located beside the vaginal opening.

● Blood supply from pudendal arteries, drainage through pudendal veins.

Note 48
Internal Genitalia
Internal Genitalia Components
● Vagina: Fibro-muscular canal connecting external genitalia to the uterus.

● Four layers:

● Inner layer of squamous epithelium.

● Vascular connective tissue.

● Muscle layer with inner and outer coats.

● Outer connective tissue layer.

● Uterus: Hollow, muscular organ in pelvic cavity, performs several functions including receiving fertilized ovum.

● Uterine Tubes (Fallopian Tubes): Passages linking ovaries to uterus; site of fertilization.

● Ovaries: Glands producing ova and hormones (oestrogen and progesterone).

Blood Supply and Nerve Supply

● Blood supply to the vagina from internal iliac arteries.

● Nerve supply from the Lee Frankenhauser plexus.

● Ovaries supplied by ovarian arteries, drained by ovarian veins.

Note 49
Hormones Regulating the Female Reproductive System
● Key hormones include:

● Follicle-Stimulating Hormone (FSH): Stimulates follicle development and ovulation.

 ● Luteinizing Hormone (LH): Influences corpus luteum development and hormone production.

● Oestrogen: Produced by ovaries, promotes development of secondary sex characteristics and uterine lining.

● Progesterone: Prepares endometrium for potential fertilization, produced during the luteal phase.

Note 50
The Menstrual Cycle
● The average menstrual cycle is 28 days, divided into three phases:

● Menstrual Phase: Bleeding lasts 3-5 days, shedding the endometrium.

● Proliferative/Follicular Phase: Lasts until ovulation, endometrium thickens under oestrogen.

● Secretory/Luteal Phase: Following ovulation, endometrium prepares for implantation, if fertilization does not
occur, menstruation follows.

Note 51
Obstetric Anatomy
● Normal vaginal delivery requires the foetus to pass through the bony pelvic canal.

● Understanding the structure of the female pelvis and foetal skull is essential for identifying deviations from
normal delivery and managing potential complications during childbirth.

Note 52
The Bony Pelvis
● The normal female pelvis is cylindrical with a slight anterior curve at the outlet, due to the longer posterior body
of the sacrum and coccyx compared to the anterior border (symphysis pubis).

● The dimensions of the pelvis at the inlet, outlet, and mid-cavity levels must be adequate for the foetal head to
pass through.

● The bony female pelvis consists of four bones: two innominate bones, one sacrum, and one coccyx.

● Innominate Bones:

● Form the sides of the basin, joined at the front by the symphysis pubis and separated at the back by the
sacrum.

● Composed of three parts: ilium, ischium, and pubic bone.

● Ilium:

● Large, flaring bone with the upper border known as the iliac crest.

● Features prominent bony landmarks: anterior superior iliac spine, anterior inferior iliac spine, posterior-superior
and posterior-inferior iliac spines.

● The concave anterior surface is called the iliac fossa.

● Ischium:

● Thick lower part of the innominate bone, with the ischial tuberosity supporting the body when sitting.

● Pubic Bones:

● Form the anterior part of the innominate bone, meeting at the symphysis pubis.

● Composed of a body and two projections: superior ramus and inferior ramus.

● Sacrum:

● Wedge-shaped bone made up of five fused vertebrae, with the sacral promontory being a notable feature.
 ● Coccyx:

● Composed of four fused vertebrae, it is the lowest part of the vertebral column and has minimal significance in
obstetric anatomy.

Note 53
Pelvic Joints and Ligaments
● There are four pelvic joints:

● Symphysis pubis: Junction of the two pelvic bones united by cartilage.

● Two sacroiliac joints: Connect the sacrum to the ilium, linking the spine to the pelvis.

● Sacroccygeal joint: Articulates the base of the coccyx with the tip of the sacrum.

● In the absence of pregnancy, these joints have limited movement.

● During pregnancy, hormonal changes soften ligaments, allowing for greater mobility and facilitating the passage
of the foetal head.

● Pelvic Ligaments:

● Interpubic ligament at the symphysis pubis.

● Sacroiliac ligaments.

● Sacroccygeal ligaments.

● Sacrotuberous ligament: Runs from the sacrum to the ischial tuberosity.

● Sacrospinous ligament: Connects the sacrum to the ischial spine.

Note 54
Types of Pelvis
● The pelvis is classified into four types based on the shape of the pelvic brim:

9. Gynaecoid Pelvis:

● Rounded brim, generous fore-pelvis, straight side walls.

● Shallow cavity with a well-curved sacrum and blunt ischial spines.

● Ideal for childbearing, found in women with average build.

10. Android Pelvis:

● Heart-shaped brim with a narrow fore-pelvis.

● Funnel-shaped cavity and prominent ischial spines.

● Least suited for childbearing, often found in short and heavily built women.

11. Anthropoid Pelvis:

● Long oval brim, with the anteroposterior diameter longer than the transverse.

● Found in tall women, usually allows for easy labor.

12. Platypelloid Pelvis:

● Flat, kidney-shaped brim with reduced anteroposterior diameter.

● Wide sciatic notch and blunt ischial spines, generally allows easy descent of the foetal head.
Note 55
Pelvic Measurements and Assessment
● The true pelvis is the canal through which the fetus passes during birth, comprising a brim, cavity, and outlet.

● The pelvic brim is bordered by the symphysis pubis, iliac bones, and sacral promontory, influencing the
engagement of the foetal head.

● Key landmarks of the pelvic brim include:

● Sacral promontory

● Sacral ala or wing

● Sacroiliac joint

● Iliopectineal line

● Superior ramus of the pelvic bone

● Upper inner border of the symphysis pubis

● Diameters of the Pelvic Brim:

● Anteroposterior diameter: Measured from symphysis pubis to sacral promontory (anatomical conjugate: 12 cm,
obstetrical conjugate: 11 cm).

● Diagonal conjugate: Measured from the lower border of the symphysis pubis to the sacral promontory (12-13
cm).

● Oblique diameter: From one sacroiliac joint to the iliopectineal eminence (12 cm).

● Transverse diameter: Between the furthest points on the iliopectineal lines (13 cm).

● Sacrocotyloid dimension: Between sacral promontory and iliopectineal eminence (9-9.5 cm).

Note 56
The Pelvic Floor
● The pelvic floor consists of two muscle layers of pelvic fascia, forming a hammock-like diaphragm.

● Key muscles include:

● Levator ani: Flat muscles forming a sling to support pelvic organs.

● Coccygeus: Triangular muscle behind the levator ani.

● The pelvic floor supports abdominal and pelvic organs and is involved in voluntary micturition and defecation.

● During childbirth, the pelvic floor aids in the movement of the foetus and can become overstretched, potentially
leading to genital prolapse.

● Regular assessment of pelvic capacity is essential for anticipating delivery complications.

Note 57
The Foetal Skull
● The foetal skull is delicate and can be subjected to pressure as it passes through the birth canal.

● Major landmarks include:

● Vault: Composed of thin bones allowing for molding during labor.

● Base: Firmly united bones protecting vital centers in the medulla.

● Face: Composed of small, firmly united bones.

 ● Mentum: Refers to the chin.

● Regions of the skull:

● Occiput: Bounded by the foramen magnum and the posterior fontanelle.

● Vertex: Includes the posterior fontanelle and the anterior eminences.

● Sinciput: The brow area between the anterior fontanelle and orbital ridges.

Note 58
The Foetal Skull - Sutures and Fontanelles
● Sutures are fibrous joints between the skull bones allowing for overlapping during delivery. Key sutures include:

● Lambdoidal suture: Between occipital and parietal bones.

● Sagittal suture: Between parietal bones.

● Coronal suture: Between frontal and parietal bones.

● Frontal suture: Between the two halves of the frontal bone.

● Fontanelles: Points where sutures meet, allowing flexibility.

● Posterior fontanelle: Junction of lambdoidal and sagittal sutures, triangular in shape. Closes at 6-8 weeks.

● Anterior fontanelle: Junction of sagittal, coronal, and frontal sutures, diamond-shaped. Closes between 9-18
months.

● Diameters of the Foetal Skull:

● Biparietal diameter: 9.5 cm between parietal eminences.

● Bitemporal diameter: 8.2 cm between coronal sutures and temples.

Note 59
Key Measurements of the Foetal Skull
● Abbreviations and Diameters:

● SOB: Sub-occipitobregmatic - 9.5 cm

● SOF: Sub-occipitofrontal - 10.0 cm

● OF: Occipitofrontal - 11.5 cm

● MV: Mentovertical - 13.5 cm

● SMV: Sub-mentovertical - 11.5 cm

● SMB: Sub-mentobregmatic - 9.5 cm

● Longitudinal Diameters:

● Sub-occipitobregmatic: Measures 9.5 cm from below the occipital protuberance to the anterior fontanelle.

● Sub-occipitofrontal: Measures 10 cm from below the occipital protuberance to the frontal suture.

● Occipitofrontal: Measures 11.5 cm from the occipital protuberance to the glabella.

● Mentovertical: Measures 13.5 cm from the chin to the vertex.

● Sub-mentovertical: Measures 11.5 cm from chin- neck junction to the vertex.

● Sub-mentobregmatic: Measures 9.5 cm from chin-neck junction to the bregma.

Note 60
Foetal Skull Moulding
● Definition of Moulding:

● Moulding refers to the alteration in shape of the foetal head during passage through the birth canal.

● Mechanism of Moulding:

● The skull bones allow bending and overriding at sutures, reducing the size of presenting diameters while
allowing diameters at right angles to lengthen.

● Vertex Presentation:

● Moulding is crucial to protect the foetal brain, provided it is not excessive, rapid, or unfavourable.

● Types of Vertex Presentation:

● Head well flexed

● Head partially flexed

● Head deflexed

● Potential Damage from Abnormal Moulding:

● Damage may occur to intracranial membranes and venous sinuses, falx cerebri, and tentorium cerebelli if
moulding is abnormal.

Note 61
Physiology of Pregnancy - Introduction
● Overview: This section discusses fertilisation, development of the foetus, and physiological changes during
pregnancy.

● Importance of Understanding Changes:

● Recognizing physiological changes helps in managing pregnancy effectively.

● Objectives: By the end of this section, one should be able to:

● Discuss the fertilisation process and development of the fertilised ovum.

● Describe the development of the placenta and its functions.

● Discuss physiological changes that occur during pregnancy.

Note 62
Fertilisation and Development
● Fertilisation Process:

● Occurs in the fallopian tube when sperm meets the ovum.

● Alkaline mucus from the cervix helps sperm reach the ovum.

● Only one sperm penetrates the ovum, sealing the membrane to prevent others from entering.

● Chromosomal Contribution:

● Each body cell has 46 chromosomes; ovum and sperm each contribute 23 chromosomes.

● X chromosome from ovum; X or Y from sperm determines gender (XX for female, XY for male).

● Zygote Development:
 ● After fertilisation, the zygote travels to the uterus, undergoing cell division until it becomes a blastocyst.

● Implantation occurs around the sixth day post-fertilisation, leading to the formation of the embryo.

Note 63
Formation of the Decidua and Implantation
● Decidua Formation:

● The endometrium transforms into decidua during pregnancy, growing significantly due to increased estrogen.

● It has three layers:

● Basal Layer: Unchanged during pregnancy, regenerates post-delivery.

● Spongy Layer: Rich in secretions and vascular; chorionic villi invade for nutrient access.

● Compact Layer: Surface layer of decidua containing gland necks and stroma cells.

● Implantation Process:

● Blastocyst burrows into the decidua after fertilisation.

● The trophoblast secretes enzymes to digest stroma and secure the blastocyst, now referred to as the embryo.

Note 64
Development of the Placenta
● Placenta Structure:

● A spongy disc about 20 cm in diameter and 2.5 cm thick, weighing around 500 grams.

● Composed mainly of chorionic villi (chorion frondosum).

● Begins developing around the 14th day post-fertilisation and is fully formed by the 16th week.

● Functions of the Placenta:

● Respiratory: Exchanges oxygen and carbon dioxide.

● Nutritive: Supplies nutrients from the mother's diet.

● Excretory: Removes waste products into maternal blood.

● Protective: Acts as a barrier against infections (except some).

● Storage: Stores glycogen, iron, and fat-soluble vitamins.

● Endocrine: Produces hormones like HCG, oestrogens, and progesterone.

Note 65
Anatomical Variations of the Placenta and Cord
● Succenturiate Lobe:

● Extra lobe joined by blood vessels; risk of retention and complications post-delivery.

● Circumvallate Placenta:

● Opaque ring formed by doubled membranes on the foetal surface.

● Velamentous Insertion of the Cord:

● Cord inserted into membranes; risk of detachment and hemorrhage.

● Bipartite and Tripartite Placenta:

 ● Presence of two or three lobes, each with separate cords, potentially complicating delivery.

Note 66
Amniotic Fluid and Its Abnormalities
● The normal amount of amniotic fluid ranges from 600 to 1500 millilitres.

● Conditions related to abnormal fluid levels include:

● Polyhydramnious: when amniotic fluid exceeds 1,500 millilitres.

● Oligohydramnious: when it is less than 1,300 millilitres.

● These conditions can be associated with congenital malformations of the fetus.

Note 67
Development of the Embryo and Foetus
● 0-4 weeks: Formation of primitive central nervous system, heart development, and limb buds.

● 4-8 weeks: Rapid cell division; head and facial features develop; major organs form; early movements visible on
ultrasound.

● 8-12 weeks: Eyes fuse; kidneys function; fetus passes urine; sex is identifiable.

● 12-16 weeks: Rapid skeletal development; meconium in the gut; nasal septum and palate fuse.

● 16-20 weeks: Mother feels fetal movements; fetal heart detectable.

● 20-24 weeks: Most organs function; fetus responds to sound; skin is red and wrinkled.

● 24-28 weeks: Fetus may survive if born; respiratory movements begin; eyelids open.

● 28-32 weeks: Testes descend; fat and iron stored; skin less wrinkled.

● 32-36 weeks: Body rounds due to fat deposits; head hair grows; nails reach fingertips.

● 36-40 weeks: Firm skull contours; birth is imminent.

Note 68
Foetal Circulation
● The fetus receives oxygen and nutrients through the placenta rather than the lungs.

● Five key temporary structures in fetal circulation:

● Umbilical Vein: Carries oxygen-rich blood to the fetus.

● Ductus Venosus: Connects umbilical vein to the inferior vena cava.

● Foramen Ovale: Allows blood to flow from the right atrium to the left atrium.

● Ductus Arteriosus: Connects the pulmonary artery to the aorta, bypassing the lungs.

● Hypogastric Arteries: Return blood to the placenta via the umbilical arteries.

Note 69
Physiological Changes in Pregnancy
● Changes occur in various systems during pregnancy:

● Reproductive Organs: Uterus hypertrophy and hyperplasia; Braxton Hicks contractions begin by week eight.

● Cardiovascular System: Cardiac output increases; blood volume rises; physiological anemia may occur.
 ● Respiratory System: Increased air inhalation per minute.

● Renal System: Urinary flow may slow due to progesterone effects.

● Gastrointestinal Tract: Increased salivation; heartburn and constipation are common.

● Maternal Weight: Expected gain of 12 kilograms total.

● Musculo-Skeletal System: Relaxation of ligaments; unstable pelvic joints may cause back pain.

● Skin Changes: Increased pigmentation; stretch marks may develop.

Note 70
Breast Anatomy and Lactation
● Breast Structure: Composed of glandular tissue; each lobe contains lobules with alveoli that produce milk.

● Nipple Composition: Contains erectile tissue and muscle fibers that control milk flow; surrounded by the areola
with Montgomery's glands.

● Blood Supply: Increased during lactation; drains into mammary and axillary veins.

● Lactation Physiology: Hormones like estrogen and progesterone prepare for milk production; prolactin initiates
milk production; oxytocin causes milk ejection during breastfeeding.

● Breast Function Control: Predominantly hormonal with a poor nerve supply.

Note 71
Diagnosing Pregnancy
● Trimester: A three-month period of pregnancy.

● Gravidity: Total number of pregnancies a woman has had.

● Parity: Refers to deliveries beyond 28 weeks.

● Definitions:

● Primigravida: First-time pregnant woman.

● Primipara: Woman with one delivery.

● Multigravida: Woman with two or more pregnancies.

● Multipara: Woman with two or more deliveries.

● Nullipara: Woman who has never delivered.

● Grand multipara: Six or more deliveries.

● Average pregnancy duration is 266 days from conception or 280 days from the last menstrual period (LMP).

Note 72
Signs and Symptoms of Pregnancy
● First Trimester Symptoms:

● Amenorrhoea (absence of menstruation)

● Breast Changes: Enlargement and tenderness

● Nausea: Commonly known as morning sickness

● Excessive Salivation: Also called ptyalism

● Frequent Urination: Due to pressure from the uterus

 ● Constitutional Symptoms: Tiredness, weakness, and occasional depression

● Symptoms often improve by the 16th week after the last menstruation.

● Breast Changes:

● Montgomery's tubercles appear around the nipple.

● The areola darkens.

● Cervical Changes:

● Jacquemier's sign: Bluish discoloration due to increased blood flow.

● Hegar's sign: Softening of the isthmus felt during bimanual examination.

● Osiander's sign: Increased pulsation in lateral fornices.

● Quickening: First fetal movements felt at about 20 weeks for first-time mothers and 16 weeks for those who
have had previous pregnancies.

● Uterine Changes:

● Uterus can be felt abdominally by the 12th week.

● Fundus reaches umbilicus by 22 weeks and xiphisternum by 36 weeks.

● Fetal Identification:

● Fetal parts felt from 24 weeks.

● Fetal heart sounds detectable around 24 weeks.

● Investigations:

● Pregnancy Test: Detects HCG in urine, most reliable with a morning specimen.

● Ultrasound: Visualizes fetus and cardiac activity from the 6th week.

● X-ray: Shows fetal bones by 16 weeks, but is not recommended due to radiation risks.

Note 73
Antenatal Care Management
● Aim of Antenatal Care: To ensure physical and psychological health of the mother and a healthy delivery for the
baby.

● Key Components:

● Diagnose pregnancy before 24 weeks.

● Conduct regular blood pressure checks, edema testing, and urine examinations.

● Perform regular abdominal examinations.

● Recognize and refer high-risk cases for specialized care.

● Provide immunization against tetanus for the mother and the unborn child.

● Treat minor complications as they arise.

● Creating Trust: Establish a trusting relationship between health workers, the pregnant woman, and her family.

● Education and Guidance:

● Inform mothers about clinic benefits during pregnancy and postpartum.

● Advise on self-care and balanced diet for health maintenance.

 ● Prepare mothers for delivery through counseling and addressing harmful beliefs.

● Provide prophylactic treatment against anemia and vaccination against neonatal tetanus.

● Assist mothers in making an Individual Birth Plan (IBP).

● Help in learning child care physically, psychologically, and socially.

Note 74
Factors Influencing Maternal and Perinatal Mortality
● Maternal Mortality: Death during pregnancy or within 42 days postpartum, with a ratio of 414 deaths per
100,000 live births in Kenya (2003 KDHS).

● Perinatal Mortality: Includes stillbirths after 28 weeks and neonatal deaths within the first week, with a rate of
40 deaths per 1,000 pregnancies.

● Reproductive Efficiency Factors:

● Age of the Mother: Optimal age is 18-35 years; risks increase below 18 or above 35.

● Parity: Risks decrease in subsequent pregnancies but increase after the sixth.

● Physique and Stature: Shorter women (under 150 cm) are at risk for cephalo-pelvic disproportion.

● General Health: Poor health at pregnancy onset increases risks.

● Vulnerability Factors:

● Low social status affects nutrition and healthcare access.

● Large family responsibilities lead to increased stress.

● Poor nutrition from closely spaced pregnancies causes maternal depletion syndrome.

● Increased susceptibility to infections during pregnancy.

● Anemia from various causes, especially in rural areas.

Note 75
Physical Examination of Pregnant Women
● Gait and Height: Observe the woman's gait for any limping. Note that women under 150 cm may have cephalo-
pelvic disproportion.

● Weight Gain: Average weight gain is 2 kg per month, totaling 10-20 kg by the end of pregnancy. Excessive
gain suggests fluid retention (oedema), while insufficient gain may indicate malnutrition. Obesity increases the
risk of gestational diabetes.

● Blood Pressure: Baseline blood pressure is crucial. A reading of 140/90 mm/Hg indicates hypertension, which
can harm the placenta.

● Signs of Anaemia: Check conjunctiva, hands, and tongue for signs of anaemia.

● Oedema: Inspect for swelling in the face, hands, and ankles.

● Breathing and Chest: Observe breathing patterns and look for any abnormalities.

Note 76
Breast Examination
● Palpation: Gently palpate using the flat of the hand to detect lumps. Check if the nipple is protractile.

● Self-examination Education: Teach the woman how to perform a breast self-examination.

Note 77
Obstetric Examination
● Purpose:

● Observe signs of pregnancy.

● Assess foetal size and growth.

● Evaluate foetal health.

● Diagnose the location of foetal parts.

● Identify deviations from normal.

● Procedure: The client should empty her bladder and lie on her back. Inspect the abdomen for shape, size,
scars, and movement. Any abnormalities should be referred for further investigation.

● Fundal Height: Estimate the height of the fundus to assess foetal growth.

● Palpation Techniques: Palpate the abdomen to locate the foetal back and determine position. Use the mother's
help by asking her to bend her knees and breathe steadily to relax the abdominal muscles.

Note 78
Findings of Abdominal Examinations
● Gestational Age: Estimated via fundal size.

● Lie: Relationship between foetus's long axis and mother's; can be longitudinal, transverse, or oblique.

● Attitude: Relationship of the foetal head and limbs to its trunk; typically flexion.

● Presentation: The part of the foetus at the pelvic brim (vertex, breach, face, shoulder, brow).

● Denominator: Name for the presenting part (e.g., occiput for vertex, sacrum for breech).

● Position: Relationship between the presentation's denominator and pelvic brim landmarks.

Note 79
Laboratory Investigations
● Types of Investigations:

● Haemoglobin estimates.

● Urine tests for proteins, sugar, and microscopy.

● Stool examination for ova and cysts.

● Blood tests for syphilis (VDRL).

● Blood group and Rhesus factor.

● Elisa for HIV after pre-test counselling.

Note 80
Health Education
● Immunisation: Tetanus toxoid (0.5 mls) should be given as early as possible in pregnancy, with subsequent
doses as per immunisation schedule.

● Antenatal Clinics: Use clinic visits to educate mothers on health topics; prepare a schedule of topics for each
visit.
Note 81
Nutrition and Care of the Newborn
● Balanced Diet: Essential for the health of the mother and foetus, including proteins, carbohydrates, fats,
vitamins, and minerals.

● Preparation for Newborn: Advise on clothing and preparation for delivery; educate on roles as a new mother.

● Newborn Care: Educate on:

● Exclusive breastfeeding.

● Keeping the baby warm.

● Cord care and signs of infection (e.g., fever, refusal to breastfeed).

Note 82
Breastfeeding Benefits
● Cleanliness: Breast milk is clean compared to powdered milk, which can be contaminated.

● Nutrition: Breast milk is a balanced food; powdered milk can lead to weight issues.

● Availability: Breast milk is always available and free.

● Antibodies: Contains protective antibodies that powdered milk may lack.

● Bonding: Promotes close contact and psychological satisfaction between mother and baby.

Note 83
Complications of Pregnancy
● Common Complications: Excessive vomiting, vaginal bleeding, swelling of ankles and face, persistent
headaches. Emphasize seeking early medical attention.

Note 84
Obstetric Pharmacology
● Drug Effects: Drugs can cross the placental barrier. Lipid-soluble drugs cross less easily than water-soluble
ones. Teratogenic effects are particularly dangerous during organogenesis (first 12 weeks).

● Drug Risks:

● Early pregnancy: Avoid antiemetics, antiparasitics, and strong antibiotics.

● Late pregnancy: Risks include foetal masculinisation from hormones, goitre from iodine, and developmental
issues from tetracycline.

Note 85
Drugs During Labour
● Respiratory Depression: Drugs that depress the respiratory system (e.g., barbiturates, anesthetics) can hinder
newborn respiration.

● General Principle: Avoid using drugs during pregnancy, especially in the first 12 weeks. Provide moral support
instead.

● Safety Evaluation: If drugs are necessary, their safety must be evaluated and used for the shortest duration
possible.

● Reminder: Avoid drugs in the first 12 weeks of pregnancy whenever possible.

Note 86
Uterine Relaxants
● Definition: Uterine relaxants help relax uterine muscles at various pregnancy stages.

● Types:

● Progesterogen:

● Used early in pregnancy to reduce uterine irritability; caution advised due to potential masculinization of female
fetuses.

● Management: Refer patients to hospitals for administration.

● Adrenoreceptor Stimulants:

● Include isoxsuprine, salbutamol (Ventolin), orciprenaline; used late in pregnancy to prevent premature labor.

● Caution due to strong cardiovascular effects.

Note 87
Uterine Stimulants
● Types:

● Prostaglandins: Can contract or relax smooth muscle, used to induce labor or abortion. Administered in various
forms (IV, oral, vaginal).

● Oxytocin: Produced by the pituitary gland; Syntocinon (synthetic) mimics natural oxytocin.

● Uses include labor induction, postpartum hemorrhage management, and evacuation of molar pregnancy.

● Risks: Fetal hypoxia, perinatal death, uterine rupture.

● Ergometrine: Affects uterine contractions, primarily used for postpartum hemorrhage; not suitable for labor
induction due to contraction patterns.

Note 88
Risk Factors in Pregnancy
● High-Risk Conditions: Focus on conditions that increase complications during pregnancy or labor, such as
postpartum hemorrhage or chronic diseases like diabetes.

● Importance: Early detection and management are crucial for maternal and fetal health.

● Objectives:

● Manage mothers with risk factors.

● Detect medical conditions during pregnancy.

Note 89
Hyperemesis Gravidarum
● Definition: Severe, continuous vomiting leading to dehydration and malnutrition. Can cause liver and kidney
damage if untreated.

● Associated Conditions: Commonly occurs in cases of multiple pregnancies, hydatidiform mole, or habitual
abortions.

● Management:

● Refer to a hospital for intravenous fluids (5% dextrose, normal saline).

 ● Administer anti-emetics (promethazine, metoclopramide).

● Provide multivitamins and maintain routine care.

Note 90
Polyhydramnios
● Definition: Excessive amniotic fluid (>1500ml); may present with symptoms at 3000ml.

● Associated Conditions: Includes esophageal atresia, neural tube defects, multiple pregnancies, and maternal
diabetes.

● Types:

● Chronic: Develops gradually, usually after week 30.

● Acute: Sudden onset around week 20, often with severe fetal abnormalities.

● Management:

● Hospital admission to determine causes.

● Induction of labor if severe abnormalities are present.

Note 91
Oligohydramnios
● Definition: Abnormally low amniotic fluid (300-500ml or less at term).

● Associated Conditions: Often linked to kidney absence or Potter's syndrome.

● Recognition: Smaller uterus, reduced fetal movements, palpable fetal parts.

● Management:

● Admit for investigations; allow pregnancy to continue if no abnormalities.

● Induce labor if necessary to avoid placental insufficiency.

Note 92
Antepartum Haemorrhage
● Definition: Any bleeding from the genital tract after 28 weeks of gestation.

● Warning: Do not perform vaginal examinations in these cases to avoid severe bleeding.

● Causes: Mainly placenta praevia and abruptio placentae, each requiring specific management strategies.

Note 93
Placenta Praevia
● Definition: Bleeding from a partially separated placenta positioned in the lower uterine segment.

● Types:

● Type I: Upper segment, lower margin dips into lower segment.

● Type II: Partially in lower segment, does not cover internal os.

● Type III: Covers internal os partially.

● Type IV: Centrally covers internal os completely.

● Management: Depends on blood loss and maternal/fetal condition; often requires hospitalization and possible
cesarean section.
Note 94
Abruptio Placentae
● Definition: Premature separation of a normally situated placenta after 28 weeks.

● Associated Conditions: Hypertension, trauma, sudden release of polyhydramnios, etc.

● Management: Focus on stabilizing the mother and preparing for potential delivery; immediate intervention may
be necessary.

Note 95
Types of Abruptio Placentae
● Mixed or Combined: Bleeding is partly revealed and partly concealed.

● Concealed: Blood is trapped between the placenta, membranes, and uterine wall; no visible bleeding.

● External or Revealed: Free (visible) vaginal hemorrhage is present.

Note 96
Signs and Symptoms of Abruptio Placentae
● Revealed Type:

● Slight to severe vaginal bleeding.

● Abdominal pain and tenderness may or may not be present.

● Elevated pulse, low blood pressure or hypertension.

● Concealed Type:

● Severe abdominal pain and shock.

● No vaginal bleeding; uterus is tender and board-like.

● Foetal parts cannot be palpated, no heart sounds.

● Possible oliguria and proteinuria.

● Combined Type:

● Features of both revealed and concealed bleeding.

● Higher shock level than blood loss.

● Tender, rigid uterus with constant pain.

Note 97
Management of Abruptio Placentae
● Immediate Referral:

● Refer the patient to the hospital if in a health center or dispensary.

● Start intravenous drip and inform the hospital if possible.

● Vital Signs Monitoring:

● Take blood pressure and pulse every 15-30 mins; temperature every 4 hours.

● Raise the foot of the bed to prevent vena cava occlusion.

● Pain Management:
 ● Administer IM morphine (15mg) or pethidine (100mg).

● Prepare for Caesarean Section:

● If severe bleeding occurs, treat for shock and prepare for delivery.

Note 98
Conservative Management
● Mild Separation Cases:

● Conduct intra-uterine scanning to assess hemorrhage and continuous foetal monitoring.

● Monitoring:

● If both mother and baby are stable and under 37 weeks, discharge with weekly follow-ups.

● Induction at 37 Weeks:

● Readmit for induction, rupture membranes, start oxytocin drip, and monitor for labor onset.

● Prepare for Caesarean section in case of foetal distress.

Note 99
Complications of Abruptio Placentae
● Serious Complications:

● Excessive hemorrhage from clotting failure in concealed bleeding.

● Renal failure or hypovolemia, puerperal sepsis, anemia, maternal and foetal death.

● Other Causes of Antepartum Hemorrhage:

● Rupture of small vessels, cervical erosion, cervix cancer, severe cervicitis, infected cervical polyp.

● Refer these conditions to the hospital for management.

Note 100
Differences between Placenta Praevia and Abruptio Placentae

Placenta Praevia Abruptio Placentae

Painless vaginal bleeding Painful vaginal bleeding

Recurrent bleeding Non-recurrent bleeding

Bright red blood loss Dark red blood loss

Blood loss correlates with patient condition Minimal blood loss with severe shock

No signs of pre-eclampsia Signs of pre-eclampsia may be present

Foetus is most often alive Foetus is often dead

Soft, non-tender uterus Tender, possibly hard uterus

Easily palpable foetal parts Difficult to palpate foetal parts

Note 101
Pre-eclampsia Overview
● Definition:

● A pregnancy-specific condition occurring after the 28th week, characterized by hypertension, edema, and
proteinuria.

● Risk Factors:

● Primigravida (young or over 35), multiple pregnancies, diabetes, hydatidiform mole, essential hypertension,
polyhydramnios, past history of pre-eclampsia, obesity.

● Importance of History Taking:

● Early detection through thorough history is crucial to managing pre-eclampsia effectively.

Note 102
Diagnosis of Pre-eclampsia
● Cardinal Signs:

● Hypertension:

● Diastolic pressure rises 15-20 mmHg above normal or above 80-90 mmHg on two occasions.

● Proteinuria:

● Detected in midstream urine specimen; indicative of severity.

● Oedema:

● Generalized oedema is significant; physiological oedema in late pregnancy is normal but disappears overnight.

Note 103
Classification of Pre-eclampsia
● Mild Pre-eclampsia:

● Diastolic pressure 15-20 mmHg above basal, possible ankle oedema.

● Moderate Pre-eclampsia:

● Blood pressure 140-160/100 mmHg, proteinuria of 0.5 gm/litre, generalized oedema.

● Severe Pre-eclampsia:

● Blood pressure exceeds 160/110 mmHg, proteinuria over 1 gm/litre, marked edema, headaches, and visual
disturbances.

Note 104
Management of Pre-eclampsia
● General Principles:

● Monitor, provide rest, prolong pregnancy until baby is mature, safeguard the mother’s life.

● Mild Management:

● Advise bed rest, weekly assessments, anti-hypertensives, and sedatives as prescribed.

● Moderate Management:

● Hospital admission, strict bed rest, dietary adjustments, and close monitoring of vital signs and urine.
 ● Consider induction if no improvement by 38 weeks.

Note 105
Active Management of Severe Pre-eclampsia
● Admission Care:

● Quiet, dim room, complete bed rest, maintain strict observations.

● Medication:

● Administer antihypertensive drugs, monitor blood pressure closely, and manage urine output.

● Induction of Labor:

● If proteinuria and high blood pressure persist, induce labor as necessary.

Note 106
Eclampsia Overview
● Definition:

● Acute condition characterized by convulsions and coma, occurs in 0.2-0.5% of pregnancies.

● Incidence:

● Can occur antepartum (20%), intrapartum (25%), and postpartum (35%).

Note 107
Signs and Symptoms of Eclampsia
● Prodromal Signs:

● Serious signs of pre-eclampsia like intense headaches, vomiting, and epigastric pain.

● Stages of Eclampsia Fit:

● Premonitory Stage: Restlessness, rapid eye movements, facial twitching.

● Tonic Stage: Muscle spasms, rigidity, and cessation of respiration.

● Chronic Stage: Convulsive movements, increased salivation, loss of consciousness.

● Coma: Breathing remains stertorous, may last for minutes to hours.

Note 108
Management of Eclampsia
● Immediate Steps at Health Centre:

● Administer IV diazepam/phenobarbitone, insert mouth gag, position mother to facilitate airway drainage, and
prepare for transfer to hospital.

● Hospital Protocol:

● IV drip of dextrose, administer IV antihypertensives, assess delivery method (prefer vaginal unless
contraindicated), continuous monitoring of vital signs.

Note 109
Management of Complications during Pregnancy
● Protect from injury during convulsions; nurse in a semi-prone position to aid saliva and mucus drainage.
 ● Do not restrict convulsive movements.

● Ensure catheter care and keep the airway clear.

● Prepare for delivery or caesarean section as appropriate.

● After a fit, continue oxygen therapy and do not give oral fluids; restrict IV fluids to 2000ml in 24 hours.
Maintain strict fluid intake and output charts.

● Observe for signs of labour; delivery is by vacuum extraction with continued sedation. The baby should be
nursed in the special care baby unit.

Potential Complications:
● Cerebral haemorrhage

● Mental confusion

● Thrombosis

● Acute renal failure

● Liver necrosis

● Myocardial infarction due to pulmonary oedema

● Bronchopneumonia

● Temporary blindness

● Injuries or fractures from falls or restricted movement during a fit

● Tongue biting

● Fetal hypoxia, prematurity, stillbirth

Note 110
Medical Conditions Complicating Pregnancy
Several medical conditions can complicate pregnancy:

● Cardiac disease

● Anaemia

● Diabetes

● Malaria

● Tuberculosis

● Urinary Tract Infections

Cardiac Disease in Pregnancy:

● Increased blood volume by 35%.

● Cardiac output rises by 40% (from 4.5 to 6 L/min).

● Changes begin in early pregnancy, peaking around the 30th week.

Risk Factors:
● Anaemia must be treated vigorously.

● Infections, especially upper respiratory, should be treated with antibiotics.

● Obesity should be managed to avoid extra strain on the heart.

 ● Hypertension and pre-eclampsia should be controlled.

● Smoking cessation is advised for mothers.

● Multiple pregnancies require close monitoring.

● Avoid strain and encourage rest.

● Discourage exercises that induce breathlessness.

● Avoid fatigue.

Note 111
Classification and Management of Cardiac Disease in Pregnancy
Cardiac Disease Classification:
13. Grade I: No symptoms; heart murmur detected.

14. Grade II: Symptoms during ordinary activity, none at rest.

15. Grade III: Symptoms during mild activities; unable to perform daily tasks.

16. Grade IV: Symptoms even at rest; signs of heart failure.

Effects of Cardiac Disease:

● Increased blood volume and body weight strain the heart.

● Maximum cardiac output at 30 weeks; rest is crucial.

● Risks include thromboemboli, bacterial endocarditis, and maternal mortality due to impaired blood flow.

● Fetal risks include growth retardation and congenital heart disease.

Management:
● Follow-up by obstetricians, cardiologists, haematologists, and anaesthetists.

● Prenatal management for mild disease (Grades I & II) includes:

● Careful examination and history taking.

● Regular check-ups; admission for rest between 29-32 weeks.

● Prompt treatment of infections and anaemia.

● Health messages on balanced diet and rest.

● Possible administration of digoxin and diuretics as needed.

● Complete bed rest at 38 weeks.

Labour Management for Grades I & II:

● Normal admission procedures; inform obstetrician and cardiologist.

● Vigilant observations every 15-30 minutes.

● Administer prophylactic antibiotics and mild sedation.

Management for Grades III & IV:

● Admit on first contact; provide total nursing care, especially between 23-32 weeks.

● Monitor fetal heart and placental blood flow; administer a low-salt diet.

● Psychological reassurance and address emotional needs are crucial.

Note 112
Acute Heart Failure in Pregnancy
Signs of Acute Heart Failure:
● Cyanosis

● Rapid irregular pulse

● Cold sweating extremities

● Cough with blood (haemoptysis)

● Pulmonary oedema with tachycardia, dyspnoea, bronchospasm, and frothy mucus.

Management:
● Nurse propped up in bed; low-salt diet.

● Restrict fluid intake and maintain strict fluid charts.

● Encourage passive leg movements.

● Monitor vital signs every 15 minutes; report severe breathlessness, cyanosis, and increased pulse or respiration
rates.

Labour Management for Acute Heart Disease Cases:

17. First Stage:

● Prop up in bed; administer Valium for anxiety; morphine for pain.

● Observe every 15 minutes; rehydrate slowly.

18. Second Stage:

● Ensure a short, easy delivery; continuous oxygen; avoid pushing; perform episiotomy under local anaesthesia.

19. Third Stage:

● Monitor for potential collapse; manage uterine contractions carefully to avoid heart overload.

Note 113
Anaemia in Pregnancy
Definition:
● Anaemia is a deficiency in red blood cells, reducing oxygen-carrying capacity; diagnosed when hemoglobin is
below 10gm/dL.

Symptoms:
● Pallor, breathlessness, dizziness, fatigue, fainting, headaches, anorexia, and vomiting.

Effects of Anaemia:
● Mother: Reduced enjoyment of pregnancy, increased infection risk, postpartum haemorrhage risk, and treatment
side effects.

● Fetus: High perinatal mortality, intrauterine hypoxia, growth retardation, and increased risk of sudden infant
death.

Degrees of Anaemia:
● Mild: Hemoglobin 8.1-9.9 gm/dL.
 ● Moderate: Hemoglobin 5.1-8.0 gm/dL.

● Severe: Hemoglobin < 5 gm/dL.

Types of Anaemia:
● Physiological Anaemia: Normal increase in plasma volume during pregnancy.

● Iron Deficiency Anaemia: Increased iron demand during pregnancy; essential for red blood cell production.

● Folic Acid Deficiency Anaemia: Needed for cell growth; caused by low dietary intake or absorption issues.

Management:
● Mild Anaemia: Iron supplements and dietary changes.

● Moderate Anaemia: Intravenous iron; monitor hemoglobin levels.

● Severe Anaemia: Emergency care; complete bed rest; monitor and investigate causes.

Note 114
Management During Labour
● Blood cross-matching is essential before transfusion to avoid cardiac overload.

● Emergency drugs should be ready.

● Oxygen administration is crucial during the second stage of labour.

● Vacuum extraction may be performed if necessary.

● Syntocinon (40-60 units) in half a litre of 5% dextrose is administered by pump.

● Contraindication: Avoid ergometrine due to its vaso-constrictive effects.

● Minimize blood loss by massaging the uterus and using controlled cord traction for placenta delivery.

● The mother should avoid exertion during this time.

● Monitoring continues every quarter hour.

Note 115
Post Natal Care
● The mother receives antibiotics to prevent infection and haematinics for three months.

● Haemoglobin checks are scheduled at three and six weeks postpartum.

● Family planning and good nutrition are encouraged.

● For folic acid deficiency, provide supplements and oral iron.

● If vitamin B12 deficiency is detected, administer 100mg of vitamin B12 injections weekly until corrected.

Note 116
Prevention of Anaemia in Pregnancy
● Health Education: Advise mothers on the importance of a balanced diet and proper disposal of faeces to
prevent hookworm infestation.

● Encourage child spacing to allow recovery time for the body between pregnancies.

● Regular visits to the antenatal clinic should be emphasized.

● Prophylactic Medication:
 ● Ferrous sulphate (200mg three times a day).

● Folic acid (5mg daily).

● Prophylactic anti-malarial medication.

● Ensure early detection and treatment of malaria, anaemia, and postpartum complications.

Note 117
Diabetes in Pregnancy
● Definition: Diabetes mellitus is characterized by hyperglycaemia due to insufficient insulin.

● Primary Diabetes: Abnormality of the pancreas, often called juvenile diabetes.

● Secondary Diabetes: Develops later, possibly due to pancreatic disease or pregnancy.

● Classification:

● Insulin Dependent Diabetes Mellitus: Controlled by insulin therapy.

● Non Insulin Dependent Diabetes Mellitus: Controlled by diet alone.

● Gestational Diabetes Mellitus: Develops during pregnancy.

● Potential Diabetes: Increased risk due to factors like family history or previous large babies.

Note 118
Carbohydrate Metabolism in Pregnancy
● Changes in fasting blood sugar: Decreases from 4 to 3.6 mmol/l by the 10th week of pregnancy.

● Ketoacidosis risk: Increases in the third trimester due to fat utilization.

● Hormonal effects: Human Placental Lactogen (HPL) causes insulin resistance, raising blood sugar levels longer
than in non-pregnant states.

● Glycosuria: Increased renal filtration and lowered threshold for glucose reabsorption during pregnancy may lead
to glycosuria without indicating diabetes.

● Potential Diabetes Indicators: Family history, large previous babies, chronic obesity, or glycosuria.

Note 119
Diagnosis of Diabetes During Pregnancy
● Assess obstetric history for indicators like unduly large babies or stillbirths.

● Glycosuria testing: Using reagent strips two hours post-meal.

● Full Glucose Tolerance Test (GTT):

● Fasting blood sample for glucose level.

● 50g glucose load.

● Blood glucose levels monitored at intervals (1, 2, and 3 hours post-ingestion).

● Diagnosis is confirmed if two out of four samples exceed the normal thresholds during GTT.

Note 120
Management of the Diabetic Case During Labour
● Induction of Labour: Artificial rupture of membranes and oxytocin infusion regulated by contractions.

● Nutritional needs: 10% dextrose drip set at 20 drops per minute to prevent hypoglycaemia.
 ● Insulin administration: Soluble insulin given via syringe pump, adjusted based on blood sugar levels.

● Blood sugar must be checked hourly:

● If <4mmol/l, reduce insulin by half.

● If >4mmol/l, double the dose and check again in 30 minutes.

● Monitoring: General condition, uterine contractions, foetal heart rate, and maternal vitals should be assessed
regularly.

● Paediatrician presence: Necessary during delivery for immediate newborn care.

Note 121
Postnatal Care of the Diabetic Mother
● After delivery, insulin requirements decrease; reduce the insulin dose by half immediately.

● Maintain intravenous infusion until the next meal, checking blood sugar levels continuously.

● Increased carbohydrate intake may be needed during breastfeeding.

● Monitor for infections as diabetic mothers are at higher risk.

● Health messages upon discharge should cover diet, insulin administration, postpartum check-ups, and baby
care.

Note 122
Management of Complications in Pregnancy
● Attendants must be vigilant in identifying complications during pregnancy and manage the mother appropriately.

● Determine the mode of delivery:

● Per vaginal

● Elective caesarean section

● In cases where the mother has not gone into spontaneous labour at term, induction of labour should be
supervised by:

● An obstetrician

● A diabetician

● A paediatrician

**

Note 123
Malaria in Pregnancy
● Malaria is prevalent in Kenya and can significantly affect pregnancy.

● Effects of malaria on pregnant women and foetuses:

● Haemolysis of red blood cells leading to anaemia and jaundice.

● Hyperpyrexia (very high fever) that may result in abortion or preterm labour.

● Malaria parasites affect the placenta, impairing nutrition and potentially causing intra-uterine growth
retardation, stillbirth, or abortion.

Management Steps:

● Treat malaria to reduce pyrexia:

 ● Administer a full course of Fansidar (three tablets stat).

● Provide a mild analgesic (e.g., paracetamol).

● Daily folic acid (5mg).

● Prevention measures:

● Use of chemoprophylaxis.

● Administer two presumptive treatments at the beginning of the second and third trimesters.

● Encourage preventive measures (e.g., taking ferrous sulphate, clearing bushes, draining stagnant water, using
insecticide-treated mosquito nets).

**

Note 124
Tuberculosis in Pregnancy
● Tuberculosis incidence is rising in Kenya, particularly in association with HIV/AIDS.

● Clinical presentation may be asymptomatic, but common symptoms include:

● Night sweats

● Evening fever

● Weight loss

● General weakness

● Loss of appetite

● Productive cough

● Occasionally, haemoptysis.

● Women with advanced tuberculosis may experience:

● Anaemia

● Risk of premature labour

● Severe breathlessness due to complications like pleural effusion.

Diagnosis Methods:

● Sputum smear

● Chest x-ray

● Mantoux test

Management:

● Aim to make the mother sputum negative before delivery.

● Common therapies include:

● Streptomycin (60 days) and Thiazina (18 months).

● An alternative short-term regimen of rifampicin, ethambutol, isoniazid, and PAS for 6-9 months.

**
Note 125
Urinary Tract Infections (UTIs) in Pregnancy
● UTIs are common in pregnant women, presenting in forms such as:

● Asymptomatic bacteriuria

● Acute cystitis

● Acute pyelonephritis

● Asymptomatic bacteriuria is especially prevalent and can lead to acute pyelonephritis if untreated.

● Symptoms of acute pyelonephritis include:

● Fever

● Nausea and vomiting

● Headache

● Urinary frequency

● Dysuria

● Shivering/chills

● Lower abdominal pain

● Dehydration

● Renal angle tenderness

Management:

● Refer suspected cases to an obstetrician for further investigation.

● If referral is difficult, administer ampicillin (500mg every six hours for two weeks) and monitor progress.

● Advise proper hygiene to prevent contamination.

**

Note 126
Pregnancy and HIV
● Pregnancy presents unique challenges for HIV-positive women, necessitating careful management.

● Effects of pregnancy on HIV:

● In the early asymptomatic phase, pregnancy has little impact.

● For those with weakened immune systems, pregnancy can hasten progression to AIDS.

● HIV's effects on pregnancy can include:

● Increased risk of growth retardation, prematurity, and stillbirth.

● 30% chance of mother-to-child transmission during pregnancy, childbirth, or breastfeeding.

HIV Screening During Pregnancy:

● Screening should involve mutual agreement between the healthcare worker and the woman, with adequate pre-
and post-test counselling.

● Benefits of knowing HIV status include:

● Monitoring for HIV-related infections during pregnancy.

 ● Informed management decisions.

● Possible termination or planning of future pregnancies.

● Testing partners and adjusting sexual practices.

● Challenges of testing include emotional distress and relationship issues.

Management Considerations:

● Regular check-ups for HIV-positive women during pregnancy.

● Watch for opportunistic infections and provide necessary counselling.

● During delivery, minimize trauma to the infant to prevent HIV transmission.

● Encourage alternative feeding methods to breastfeeding when safe.

**

Note 127
Lightening
● Lightening occurs 2-3 weeks before labor when the lower uterine segment expands, allowing the fetal head to
descend into the pelvis.

● This descent provides more space for lung, heart, and stomach function.

● The symphysis pubis widens and the pelvic floor softens, facilitating further descent into the pelvis.

● Increased pressure from the fetal head may cause frequent urination and stress incontinence due to lax pelvic
floor muscles.

● This can also lead to backache from pelvic joint relaxation.

Note 128
Uterine Contractions
● Contractions of the uterus are coordinated by two pacemakers located at the cornua, where fallopian tubes join
the uterine body.

● Contractions begin at the top and spread downward; during pregnancy, they are intermittent and not strong
enough to cause cervical dilation.

● As pregnancy progresses, contractions become more frequent and painful, with multiparas experiencing 'false
labor' days before true labor begins.

● The retraction ring forms between the upper and lower uterine segments, normal as long as it is not visible
above the symphysis pubis.

● Fundal dominance allows for effective cervical dilation and expulsion of the fetus during contractions.

Note 129
Contraction Characteristics
● Contractions during labor are categorized by strength (weak, fair, strong), duration, and frequency.

● A weak contraction lasts 10-30 seconds, a fair contraction lasts 30-40 seconds, and a strong contraction lasts
40-60 seconds.

● Frequency refers to intervals between contractions; for example, a contraction every 45 minutes has a frequency
of 1:45.

● The cervix must efface and dilate to allow for the passage of the fetus.
 ● Effacement involves the cervix becoming thinner and merging with the lower uterine segment, ultimately leading
to full dilation.

Note 130
Stages of Labor
● First Stage: Begins with regular contractions and is characterized by cervical thinning (effacement) and dilation.

● Duration: 8-12 hours for primigravida, 6-8 for multiparous.

● Progress should not exceed 14 hours.

● Second Stage: Full dilation of the cervix leads to the expulsion of the fetus.

● Involves overcoming resistance from the pelvic floor and requires coordinated voluntary muscle action.

● Third Stage: Involves the delivery of the placenta and membranes, accompanied by uterine contractions to
control bleeding.

● Fourth Stage: The immediate postpartum period involves monitoring for complications like hemorrhage and
establishing maternal-child bonding.

Note 131
Physiological Changes in Labor
● During the first stage, the uterus undergoes significant muscular work through involuntary contractions.

● Contractions initially occur every 10-15 minutes and increase in frequency and strength.

● Relaxation phases are crucial for both maternal and fetal well-being; continuous contractions can lead to
maternal exhaustion and fetal anoxia.

● Energy supplementation may be necessary if the mother cannot eat.

● Cervical dilation occurs until the cervix is fully dilated at 10 cm, allowing the uterus to become a continuous
cavity with the vagina.

Note 132
Management of Labor
● Proper management is vital to identify and address issues during labor.

● Upon admission, assess the patient's history, conduct examinations, and gather necessary information to
determine labor progress.

● Check the antenatal card for risk factors and past medical history.

● If not in labor, advise the patient to wait at home; if in labor, monitor progress closely.

● Normal labor is not assumed complete until the fourth stage has successfully concluded.

Note 133
History Taking
● A detailed personal history should be recorded during pre-natal care. If not done, gather this information now.

● Ensure names are correctly spelled to avoid registration issues.

● Review the last menstrual period to calculate the expected date of delivery.

● Gather the following information:

● Presence of show
 ● Presence or absence of contractions

● Onset of contractions and their characteristics

● Activity of the fetus

● Rupture of the membranes

● Any treatment given

● Food taken in the last four hours

● After taking the personal history, assess the mother's general condition and labour progress, including vital
signs and blood pressure.

● Test urine for protein, glucose, and ketones. Report any abnormalities.

Note 134
Head to Toe Physical Examination
● Explain to the mother that you will perform an examination.

● Respect her psychological needs and support her during this time.

● Check for:

● General condition (exhaustion, anaemia, pain, dehydration, oedema)

● Vital measurements: blood pressure, pulse, temperature, respiratory rate

● Conduct an abdominal examination to check for:

● Height of fundus

● Over-distension of the abdomen, scars, or other abnormalities

● Over-distension of bladder

● Possible presence of twins or multiple pregnancies

● Characteristics of contractions (frequency, length, type, strength)

● Lie of fetus: longitudinal, oblique, or transverse

● Foetal heart rate: rate and rhythm

● Assess presentation: Check if the presenting part is a head (cephalic) or buttocks (breech).

● Evaluate the attitude of the fetus and check the position of the foetal occiput relative to the mother.

Note 135
Vaginal Examination in Labour
● A vaginal examination is key for gathering information not obtainable from abdominal examination.

● Perform with care to avoid discomfort and infection.

● Sterilization: Scrub hands, wear gloves, and use antiseptic solution.

● Purpose of vaginal examination:

● Check if the patient is in labour and the stage of labour

● Assess the progress of labour

● Determine the degree of effacement and dilation of the cervix

● Ensure no cord prolapse upon membrane rupture

 ● Contraindications: Do not perform if ante-partum haemorrhage is present unless in an operating theatre due to
placenta praevia risk.

Note 136
Management of First Stage of Labour
● Follow these guidelines for managing the first stage of labour:

● Admit the patient, reassure her, and explain procedures at each stage.

● Offer an enema if in early labour to reduce risk of faecal soiling.

● Allow a warm bath and change into a hospital gown.

● Encourage walking and frequent bladder emptying.

● Provide fluids with sugar or glucose for energy; avoid solid foods.

● Monitor maternal and fetal health regularly:

● Foetal heart rate

● Uterine contractions (strength, type, frequency)

● Maternal pulse, BP, and temperature

● Urine output and tests for albumin and acetone

● Observe for signs of foetal distress and document findings in a partogram.

Note 137
Second Stage of Labour
● The second stage of labour begins with full cervical dilation and is characterized by the descent and
expulsion of the baby.

● Duration:

● Primigravida: 1-2 hours average.

● Multipara: Approximately 30 minutes.

● Abnormal if it exceeds 2 hours.

● Contractions during this stage become stronger (lasting 40-60 seconds) with a 1-minute recovery interval.

● The uterus contracts to push the fetus into the pelvis; during relaxation, the pelvic floor assists in maintaining
progress.

● The presenting part moves down until it reaches the pelvic floor, often causing the urge to bear down.

● Crowning occurs when the head passes through the bony outlet of the pelvis, and the perineum stretches
significantly.

● An episiotomy may be performed if necessary during this stage.

Note 138
Mechanism of Second Stage of Labour
● Lie: Refers to the fetus's relation to the uterus' long axis (longitudinal, oblique, or transverse).

● Presentation: The presenting part is usually the vertex; 95% of presentations are cephalic.

● Position: Describes the relationship of a selected fetal part (e.g., occiput for vertex presentation).

● Attitude: The fetus adapts to the pelvis shape during descent.

 ● The three 'Ps' influencing labour:

● Power: Stronger contractions lead to better outcomes.

● Passage: The birth canal's size and shape can speed up/slowing down delivery.

● Passenger: The size, lie, and presentation of the fetus affect labour duration.

● The presenting diameter is the smallest (9.5 cm) and requires the head to be flexed on the neck.

Note 139
Cardinal Movements of Labour
● The mechanism of labour for a cephalic vertex presentation includes:

20. Engagement and Descent: The head enters the pelvic brim.

21. Internal Rotation: The head rotates 1/8th of a circle as it descends.

22. Birth by Extension of the Head: The head extends forward as it emerges.

23. Restitution: The head rotates back to its original position.

24. External Rotation of the Shoulders: Shoulders rotate during descent.

25. Lateral Flexion: The body bends to follow the birth canal's curve.

● A mnemonic to remember these movements: "Every Decent Family In Europe Eats Eggs".

● Descent occurs continuously throughout labour, with the vertex being the most common presenting part.

Note 140
Management of the Second Stage of Labour
● Equipment Preparation:

● Trolley with sterile delivery pack, decontaminating instruments, and necessary supplies.

● Ensure proper arrangement of sterile equipment before the procedure.

● Procedure Steps:

● Instruct the mother to take deep breaths and push during contractions.

● Encourage her throughout the process and explain the progress.

● Monitor fetal heart rate and maternal pulse regularly.

● Prepare for potential episiotomy if the perineum does not stretch adequately.

● Assist with the delivery of the head and shoulders, ensuring the baby's airway is clear.

● After delivery, perform immediate newborn assessments and care, including the APGAR score evaluation.

Note 141
APGAR Score
● The APGAR score assesses the newborn's condition at one and five minutes after birth.

● It evaluates five criteria:

26. Appearance: Color (0: pale/blue, 1: body pink/extremities blue, 2: pink all over).

27. Pulse: Heart rate (0: absent, 1: <100/min, 2: >100/min).

28. Grimace: Reflex response (0: none, 1: slight, 2: good grimace).

29. Activity: Muscle tone (0: limp, 1: some flexion/movement, 2: active).

30. Respiratory Efforts: Breathing (0: none, 1: weak/gasping, 2: good/vigorous cry).

● Each criterion is scored from 0 to 2, with higher scores indicating better health.

● Documentation of findings is essential for medical records.