REPRODUCTIVE HEALTH
CONCEPT OF SAFE MOTHERHOOD
Introduction
Safe motherhood is a global public health and human rights concept aimed at ensuring that all
women receive the care, respect, and support needed to go safely through pregnancy,
childbirth, and the postpartum period, and that every newborn has the best possible start in
life.
The concept arose from the recognition that most maternal deaths and disabilities are
preventable with timely, appropriate, and quality healthcare.
Definition of Safe Motherhood
Safe motherhood refers to a set of policies, practices, and services designed to reduce maternal
morbidity and mortality and promote the health and wellbeing of women and newborns
throughout pregnancy, childbirth, and the postpartum period.
GOALS OF SAFE MOTHERHOOD
To reduce maternal mortality
To prevent maternal morbidity and disabilities
To ensure safe pregnancy and childbirth
To promote newborn survival
To protect the rights and dignity of women
PRINCIPLES OF SAFE MOTHERHOOD
The principles guide the planning and implementation of safe motherhood programs.
1. Pregnancy and Childbirth Are Natural but Potentially Risky
Every pregnancy carries some risk
All pregnant women need skilled care regardless of apparent health
2. Every Woman Has the Right to Safe Maternal Care
Maternal healthcare is a basic human right
No woman should die while giving life
3. Prevention Is Better Than Cure
Early identification of risks prevents complications
Emphasis on antenatal care and health education
4. Skilled Attendance at Birth Is Essential
All deliveries should be attended by skilled health professionals
Traditional birth attendants alone are insufficient for emergencies
5. Timely Access to Emergency Obstetric Care Saves Lives
Delays in care lead to maternal deaths
Functional referral systems are crucial
6. Continuum of Care
Care must span preconception → pregnancy → childbirth → postpartum → newborn care
7. Community Participation and Empowerment
Families and communities must support maternal health
Women should be empowered to make health decisions
8. Equity and Accessibility
Services must be affordable, accessible, and culturally acceptable
Special focus on vulnerable populations
COMPONENTS OF SAFE MOTHERHOOD
Safe motherhood is built on five core components, often expanded to include newborn care.
1. Family Planning
Purpose:
Prevent unintended pregnancies
Reduce high-risk pregnancies
Activities:
Contraceptive services
Counseling and education
Birth spacing
2. Antenatal Care (ANC)
Purpose:
Monitor maternal and fetal wellbeing
Detect and manage complications early
Key services:
Blood pressure monitoring
Screening for anemia, infections, hypertension, diabetes
Tetanus toxoid immunization
Nutrition education
3. Skilled Care During Childbirth
Purpose:
Ensure safe labor and delivery
Includes:
Skilled birth attendants
Clean and safe delivery practices
Use of partograph
4. Emergency Obstetric and Newborn Care (EmONC)
Purpose:
Manage life-threatening complications
Basic EmONC (BEmONC)
Parenteral antibiotics
Parenteral oxytocics
Parenteral anticonvulsants
Manual removal of placenta
Assisted vaginal delivery
Neonatal resuscitation
5. Postnatal Care (PNC)
Purpose:
Detect postpartum complications
Support breastfeeding
Promote maternal recovery
Key services:
Monitoring for hemorrhage and infection
Family planning counseling
Mental health support
6. Essential Newborn Care (Expanded Component)
Immediate care at birth
Thermal protection
Early initiation of breastfeeding
Prevention of infections
STRATEGIES FOR ACHIEVING SAFE MOTHERHOOD
1. Strengthening Health Systems
Improve infrastructure
Train and retain skilled health workers
Ensure availability of drugs and equipment
2. Improving Access to Skilled Birth Attendance
Deploy midwives to rural areas
Promote facility-based delivery
3. Enhancing Emergency Obstetric Care
Establish functional referral systems
Improve transportation and communication
4. Community Mobilization and Education
Educate families on danger signs
Encourage early antenatal booking
Promote male involvement
5. Addressing the Three Delays
The Three Delays Model
Delay in deciding to seek care
Delay in reaching a health facility
Delay in receiving adequate care
6. Promoting Women’s Empowerment
Girl-child education
Economic empowerment
Legal protection
7. Policy Development and Political Commitment
Government funding for maternal health
Supportive maternal health policies
8. Monitoring, Evaluation, and Research
Maternal death audits
Data-driven interventions
ROLE OF NURSES AND MIDWIVES IN SAFE MOTHERHOOD
Provide quality antenatal, intrapartum, and postnatal care
Educate women and families
Identify danger signs early
Initiate timely referral
Advocate for women’s rights
IMPORTANCE OF SAFE MOTHERHOOD
Reduces maternal and neonatal mortality
Improves family and community health
Contributes to national development
Supports Sustainable Development Goals (SDG 3)
CHILDBEARING CYCLE
The childbearing cycle (also called the reproductive cycle or maternity cycle) refers to the
continuous, interrelated sequence of physiological, psychological, and social events a woman
experiences from preconception through pregnancy, childbirth, the postpartum period, and
return to the non-pregnant state, including care of the newborn.
It is a dynamic process, not a single event, and it involves both the mother and the
fetus/newborn, as well as the family and society.
The childbearing cycle is the series of biological, emotional, psychological, and social
adaptations that occur in a woman and her family beginning from preconception, continuing
through pregnancy (antenatal period), labour and delivery (intrapartum period),
postpartum/puerperium, and extending to neonatal care and return to normal reproductive
function.
Phases of the Childbearing Cycle
The childbearing cycle is traditionally divided into five major phases:
1. Preconception Period
This is the phase before conception occurs.
Key features:
Assessment of physical, psychological, genetic, and social readiness
Optimization of maternal health to ensure a healthy pregnancy
Identification and correction of risk factors
Physiological aspects:
Normal ovulatory menstrual cycles
Adequate nutritional status (especially folic acid)
Control of chronic illnesses (e.g., diabetes, hypertension)
Psychological and social aspects:
Emotional readiness for pregnancy
Partner and family support
Economic and environmental preparedness
Importance:
Reduces maternal and fetal complications
Promotes healthy pregnancy outcomes
2. Pregnancy (Antenatal Period)
This is the period from conception to the onset of labour, lasting approximately 40 weeks (280
days).
Subdivisions:
First trimester (0–12 weeks)
Second trimester (13–28 weeks)
Third trimester (29–40 weeks)
Physiological changes:
Hormonal changes (estrogen, progesterone, hCG)
Enlargement of uterus and breasts
Cardiovascular, respiratory, renal, and musculoskeletal adaptations
Psychological changes:
Emotional adjustments to motherhood
Body image changes
Anxiety and anticipation
Fetal development:
Organogenesis (first trimester)
Growth and maturation (second and third trimesters)
Antenatal care focus:
Monitoring maternal and fetal wellbeing
Prevention and early detection of complications
Health education and birth preparedness
3. Labour and Delivery (Intrapartum Period)
This phase begins with the onset of true labour and ends with the delivery of the placenta.
Stages of labour:
First stage: Cervical dilatation and effacement
Second stage: Delivery of the baby
Third stage: Delivery of the placenta
Fourth stage: Immediate recovery (first 1–2 hours post-delivery)
Physiological aspects:
Uterine contractions
Cervical dilatation
Fetal descent and expulsion
Psychological aspects:
Pain, fear, excitement
Need for emotional support and reassurance
Importance:
Safe delivery of the baby
Prevention of maternal and neonatal complications
4. Postpartum Period (Puerperium)
This is the period from delivery of the placenta until the reproductive organs return to their
non-pregnant state, usually lasting 6 weeks (42 days).
Physiological changes:
Uterine involution
Lochia discharge
Lactation and breastfeeding
Hormonal readjustment
Psychological changes:
Maternal role adaptation
Risk of postpartum blues, depression, or psychosis
Nursing focus:
Monitoring for complications (hemorrhage, infection)
Support for breastfeeding
Education on self-care and family planning
5. Neonatal Period and Parenting Adaptation
Although sometimes discussed separately, this phase is an extension of the childbearing cycle.
Neonatal period:
From birth to 28 days of life
Adaptation to extra-uterine life (respiration, thermoregulation, feeding)
Parenting role
Care of the newborn
Integration of the child into the family
Characteristics of the Childbearing Cycle
Continuous and cyclical – can repeat with subsequent pregnancies
Multidimensional – involves physical, emotional, social, and cultural factors
Family-centered – affects the woman, partner, and family
Influenced by culture, beliefs, and environment
Requires multidisciplinary care – midwives, nurses, doctors, nutritionists, social workers
Importance of the Childbearing Cycle in Nursing and Midwifery
Guides maternal and child health care
Forms the basis for antenatal, intrapartum, and postnatal care
Helps nurses anticipate normal and abnormal changes
Promotes safe motherhood and healthy newborn outcomes
Supports holistic and family-centered care
SIGNS OF PREGNANCY
Signs of pregnancy are objective and subjective changes that suggest pregnancy. They are
grouped into three categories:
Presumptive signs (subjective – felt by the woman)
Probable signs (objective – observed by examiner)
Positive signs (confirm pregnancy – fetal evidence)
This explanation focuses on Presumptive and Probable signs.
1. PRESUMPTIVE SIGNS OF PREGNANCY
Definition
Presumptive signs are subjective symptoms experienced by the woman that suggest pregnancy,
but cannot confirm it, as they may also occur in other conditions.
They are early indicators and are usually reported by the woman herself.
PRESUMPTIVE SIGNS (IN DETAIL)
1. Amenorrhea (Cessation of Menstruation)
Description:
Absence of menstrual periods after conception
Most common early sign
Cause:
Elevated levels of estrogen and progesterone maintain the endometrium
Time of appearance:
Usually from the 4th week of pregnancy
Limitations:
May occur due to stress, hormonal imbalance, malnutrition, or illness
2. Nausea and Vomiting (Morning Sickness)
Description:
Nausea with or without vomiting, often in the morning
Can occur at any time of the day
Cause:
Increased levels of human chorionic gonadotropin (hCG) and estrogen
Time of appearance:
Around 4–6 weeks
Often subsides by 12–16 weeks
3. Breast Changes
Description:
Breast tenderness
Enlargement and heaviness
Tingling sensation
Cause:
Hormonal stimulation (estrogen, progesterone, prolactin)
Associated changes:
Darkening of the areola
Prominent Montgomery’s tubercles
Time of appearance:
As early as 4 weeks
4. Fatigue
Description:
Unusual tiredness or exhaustion
Cause:
Increased progesterone
Metabolic changes and energy demands
Time of appearance:
Early first trimester
5. Urinary Frequency
Description:
Frequent urge to urinate
Cause:
Enlarging uterus pressing on the bladder
Increased renal blood flow
Time of appearance:
Early pregnancy and again in late pregnancy
6. Quickening
Description:
First perception of fetal movement by the mother
Time of appearance:
Primigravida: 18–20 weeks
Multigravida: 16–18 weeks
Importance:
Emotional reassurance for the mother
Still subjective and not diagnostic
7. Skin Pigmentation Changes
Examples:
Chloasma (mask of pregnancy)
Linea nigra
Darkening of nipples and areola
Cause:
Increased melanocyte-stimulating hormone
8. Increased Vaginal Discharge (Leukorrhea)
Description:
Thin, white, non-offensive discharge
Cause:
Estrogen-induced increased blood flow to vagina
2. PROBABLE SIGNS OF PREGNANCY
Definition
Probable signs are objective physical findings detected by a healthcare provider that strongly
suggest pregnancy, but can still occur in other conditions.
They are more reliable than presumptive signs but not diagnostic.
PROBABLE SIGNS
1. Positive Pregnancy Test
Description:
Detection of hCG in urine or blood
Time of detection:
Blood: 7–10 days after conception
Urine: 10–14 days after conception
Limitation:
False positives possible (e.g., trophoblastic disease)
2. Uterine Enlargement
Description:
Increase in uterine size and shape
Cause:
Growth of fetus, placenta, and amniotic fluid
Limitation:
May occur with fibroids or tumors
3. Hegar’s Sign
Description:
Softening of the lower uterine segment (isthmus)
Time of appearance:
6–8 weeks
4. Goodell’s Sign
Description:
Softening of the cervix
Cause:
Increased vascularity
Time of appearance:
Around 6 weeks
5. Chadwick’s Sign
Description:
Bluish discoloration of cervix, vagina, and vulva
Cause:
Increased blood supply
Time of appearance:
6–8 weeks
6. Ballottement
Rebound movement felt when the fetus is pushed during vaginal examination
Time of appearance:
16–18 weeks
7. Braxton Hicks Contractions
Description:
Irregular, painless uterine contractions
Time of appearance:
Second trimester onward
8. Abdominal Enlargement
Description:
Progressive increase in abdominal girth
Limitation:
May be caused by obesity, ascites, or tumors
HIGH-RISK PREGNANCY
Definition
A high-risk pregnancy is a pregnancy in which the life or health of the mother, fetus, or both is
increased above normal due to pre-existing medical conditions, pregnancy-related
complications, obstetric factors, or socio-environmental factors.
Such pregnancies require specialized care, close monitoring, and timely intervention to reduce
maternal and perinatal morbidity and mortality.
AIMS OF MANAGING HIGH-RISK PREGNANCY
To identify risk factors early
To prevent complications
To ensure safe delivery
To improve maternal and fetal outcomes
CLASSIFICATION OF HIGH-RISK PREGNANCY
High-risk pregnancies are classified based on the source of risk:
1. MATERNAL FACTORS
a. Age-Related Risks
Teenage pregnancy (<18 years)
Advanced maternal age (>35 years)
b. Medical Disorders
Hypertension / chronic hypertension
Diabetes mellitus
Cardiac disease
Renal disease
Asthma
Epilepsy
Sickle cell disease
HIV/AIDS
Obesity or severe underweight
c. Nutritional Problems
Anemia
Malnutrition
Vitamin deficiencies
2. OBSTETRIC HISTORY-RELATED FACTORS
Previous cesarean section
History of:
Postpartum hemorrhage
Stillbirth
Preterm birth
Recurrent miscarriages
Grand multiparity (≥5 deliveries)
Short inter-pregnancy interval
3. CURRENT PREGNANCY-RELATED FACTORS
a. Pregnancy Complications
Preeclampsia / eclampsia
Gestational diabetes
Antepartum hemorrhage
Placenta previa
Abruptio placentae
Polyhydramnios / oligohydramnios
Preterm labor
PROM (Premature rupture of membranes)
Multiple pregnancy (twins, triplets)
Infections (UTI, malaria, TORCH)
b. Placental and Cord Problems
Placenta previa
Abruptio placentae
Cord prolapse
True knot of cord
4. FETAL FACTORS
Intrauterine growth restriction (IUGR)
Congenital anomalies
Malpresentation (breech, transverse)
Rh incompatibility
Reduced fetal movements
Post-term pregnancy
5. SOCIO-ECONOMIC AND ENVIRONMENTAL FACTORS
Poor antenatal care attendance
Low educational level
Poverty
Substance abuse (alcohol, smoking, drugs)
Domestic violence
Poor access to healthcare facilities
CLINICAL FEATURES OF HIGH-RISK PREGNANCY
May vary depending on the cause, but can include:
Severe headache
Visual disturbances
Vaginal bleeding
Edema of face and hands
Reduced fetal movement
Severe abdominal pain
High blood pressure
Proteinuria
IDENTIFICATION OF HIGH-RISK PREGNANCY
During Antenatal Care
Detailed history taking
Physical examination
Routine investigations
Risk scoring systems
Continuous reassessment throughout pregnancy
MANAGEMENT OF HIGH-RISK PREGNANCY
1. Antenatal Care
Early booking
More frequent clinic visits
Specialized investigations
Nutritional support
Health education
2. Multidisciplinary Approach
Obstetrician
Midwife
Physician
Pediatrician
Nutritionist
Social worker
3. Monitoring
Blood pressure monitoring
Blood glucose monitoring
Ultrasound scans
Fetal surveillance (CTG, kick counts)
4. Timely Referral
Referral to higher-level care when needed
Planned place and mode of delivery
COMPLICATIONS OF HIGH-RISK PREGNANCY
Maternal Complications
Hemorrhage
Eclampsia
Infection
Anemia
Maternal mortality
Fetal Complications
Preterm birth
Low birth weight
Birth asphyxia
Stillbirth
Neonatal mortality
ROLE OF THE NURSE / MIDWIFE
Early identification of risk factors
Health education and counseling
Close monitoring of mother and fetus
Emotional support
Prompt referral and documentation
PREVENTION OF HIGH-RISK PREGNANCY
Preconception counseling
Adequate antenatal care
Family planning
Nutrition education
Control of chronic illnesses
Avoidance of harmful substances
COMMON COMPLICATIONS IN PREGNANCY
PREGNANCY-INDUCED HYPERTENSION (PIH)
Definition
Pregnancy-Induced Hypertension (PIH) refers to new-onset hypertension (≥140/90 mmHg) that
develops after 20 weeks of gestation in a previously normotensive woman and is directly related
to pregnancy.
Classification of PIH
Gestational Hypertension
BP ≥140/90 mmHg after 20 weeks
No proteinuria or organ damage
Preeclampsia
Hypertension with proteinuria and/or end-organ dysfunction
Severe Preeclampsia
BP ≥160/110 mmHg
Severe symptoms or organ involvement
Eclampsia
Preeclampsia complicated by seizures
Etiology / Risk Factors of PIH
Primigravida
Multiple pregnancy
Previous history of PIH
Obesity
Diabetes mellitus
Renal disease
Family history of hypertension
Extremes of maternal age
Pathophysiology
Abnormal placental implantation
Poor placental perfusion
Release of vasoconstrictor substances
Generalized vasospasm
End-organ ischemia
Clinical Features of PIH
Maternal Signs and Symptoms
Elevated blood pressure
Proteinuria
Edema of face and hands
Headache
Blurred vision
Epigastric pain
Reduced urine output
Fetal Effects
Intrauterine growth restriction (IUGR)
Preterm birth
Placental abruption
Fetal distress or death
Diagnosis of PIH
Blood pressure measurement
Urinalysis for protein
Blood tests (LFTs, platelets, creatinine)
Fetal surveillance (ultrasound, CTG)
Management of PIH
Antenatal Management
Bed rest (left lateral position)
Regular BP monitoring
Antihypertensive drugs (e.g. methyldopa, labetalol)
Magnesium sulfate for seizure prevention
Close fetal monitoring
Definitive Management
Delivery of the baby and placenta
Complications of PIH
Maternal
Eclampsia
HELLP syndrome
Stroke
Renal failure
Fetal
Prematurity
Low birth weight
Stillbirth
GESTATIONAL DIABETES MELLITUS (GDM)
Definition
Gestational Diabetes Mellitus is glucose intolerance of varying severity with onset or first
recognition during pregnancy, usually in the second or third trimester.
Risk Factors for GDM
Obesity
Family history of diabetes
Previous macrosomic baby
Previous unexplained stillbirth
Advanced maternal age
Polycystic ovarian syndrome
Pathophysiology
Placental hormones cause insulin resistance
Inadequate insulin response
Elevated maternal blood glucose
Excess glucose crosses placenta → fetal hyperinsulinemia
Clinical Features of GDM
Often asymptomatic but may include:
Excessive thirst
Frequent urination
Recurrent infections
Fatigue
Diagnosis of GDM
Oral Glucose Tolerance Test (OGTT)
Fasting blood glucose
Random blood glucose
Screening usually at 24–28 weeks
Management of GDM
1. Non-Pharmacological
Dietary modification
Exercise
Weight monitoring
Blood glucose monitoring
2. Pharmacological
Insulin therapy (gold standard)
Oral hypoglycemic agents (where appropriate)
Complications of GDM
Maternal Complications
Preeclampsia
Polyhydramnios
Operative delivery
Type 2 diabetes later in life
Fetal / Neonatal Complications
Macrosomia
Birth injuries
Neonatal hypoglycemia
Respiratory distress syndrome
Stillbirth
NURSING / MIDWIFERY MANAGEMENT
For PIH and GDM
Early detection and screening
Health education
Monitoring maternal and fetal wellbeing
Medication administration
Emotional support
Preparation for delivery and emergencies
PREVENTION
Preconception counseling
Healthy diet and weight control
Regular antenatal care
Early screening in high-risk woman
FETAL CIRCULATION AND CHANGES AT BIRTH
INTRODUCTION
Fetal circulation is a specialized circulatory system designed to meet the needs of the fetus
while in utero. Because the fetal lungs are non-functional and filled with fluid, oxygenation does
not occur in the lungs. Instead, oxygen and nutrients are obtained from the placenta. To
facilitate this, the fetal circulatory system contains three special shunts that direct blood away
from the lungs and liver.
At birth, profound physiological changes occur to adapt the newborn from placental to
pulmonary respiration.
FETAL CIRCULATION
PURPOSE OF FETAL CIRCULATION
To supply oxygen and nutrients from the placenta
To bypass the non-functioning fetal lungs
To partially bypass the liver
To efficiently distribute oxygenated blood to vital organs (brain and heart)
COMPONENTS OF FETAL CIRCULATION
1. Placenta
Acts as the organ of respiration, nutrition, and excretion
Oxygenated blood from the mother diffuses into fetal blood
Carbon dioxide and waste products diffuse from fetus to mother
2. Umbilical Vessels
One umbilical vein: carries oxygenated blood from placenta to fetus
Two umbilical arteries: carry deoxygenated blood from fetus to placenta
SPECIAL FETAL SHUNTS
1. Ductus Venosus. Connects the umbilical vein to the inferior vena cava (IVC)
Allows oxygenated blood to bypass the liver
Directs blood toward the heart
2. Foramen Ovale
Opening between the right atrium and left atrium
Allows oxygenated blood to pass directly from right atrium to left atrium
Ensures well-oxygenated blood reaches the brain and heart
3. Ductus Arteriosus
Connects the pulmonary artery to the descending aorta
Diverts blood away from the non-functioning lungs
Most blood bypasses pulmonary circulation
PATHWAY OF FETAL CIRCULATION
Oxygenated blood flows from placenta → umbilical vein
Blood passes through ductus venosus → inferior vena cava
Blood enters right atrium
Most blood passes through foramen ovale → left atrium
Blood flows into left ventricle → ascending aorta
Highly oxygenated blood supplies brain and heart
Deoxygenated blood returns to right atrium
Blood flows into right ventricle
Most blood passes through ductus arteriosus → descending aorta
Blood flows to lower body → umbilical arteries
Deoxygenated blood returns to placenta
CHARACTERISTICS OF FETAL CIRCULATION
Right and left ventricular pressures are almost equal
Pulmonary vascular resistance is high
Systemic resistance is low due to placenta
Oxygen saturation is lower than postnatal circulation
CHANGES IN CIRCULATION AT BIRTH
At birth, the newborn must rapidly adapt from placental to pulmonary respiration.
TRIGGERS FOR CIRCULATORY CHANGES
First breath
Expansion of lungs
Clamping of umbilical cord
Increased oxygen tension
Changes in pressure gradients
MAJOR CHANGES AT BIRTH
1. Onset of Respiration
Lungs expand with air
Pulmonary vessels dilate
Pulmonary resistance decreases
More blood flows to lungs for oxygenation
2. Closure of Fetal Shunts
a. Foramen Ovale
Increased blood flow to lungs increases left atrial pressure
Left atrial pressure becomes greater than right atrial pressure
Foramen ovale functionally closes
Permanent closure forms fossa ovalis
b. Ductus Arteriosus
Increased oxygen levels cause constriction
Prostaglandin levels fall
Functional closure within 24–48 hours
Permanent closure forms ligamentum arteriosum
c. Ductus Venosus
Umbilical cord clamping stops placental blood flow
Blood no longer passes through ductus venosus
Closure forms ligamentum venosum
3. Changes in Umbilical Vessels
Umbilical arteries constrict and close
Become medial umbilical ligaments
Umbilical vein becomes ligamentum teres
FUNCTIONS OF THE PLACENTA
INTRODUCTION
The placenta is a temporary but vital organ that develops during pregnancy and connects the
fetus to the mother. It acts as the interface for exchange between maternal and fetal
circulations and plays multiple roles essential for fetal growth, development, and survival.
1. RESPIRATORY FUNCTION
The placenta acts as the fetal lung
Oxygen diffuses from maternal blood to fetal blood
Carbon dioxide diffuses from fetal blood to maternal blood
Facilitated by concentration gradients and large surface area
Importance: Ensures continuous oxygen supply to the fetus
2. NUTRITIVE (NUTRITIONAL) FUNCTION
Transfers essential nutrients from mother to fetus, including:
Glucose (primary energy source)
Amino acids
Fatty acids
Vitamins
Minerals (iron, calcium)
Some nutrients are actively transported
Importance: Supports fetal growth and tissue development
3. EXCRETORY FUNCTION
Removes fetal metabolic waste products such as:
Urea
Uric acid
Creatinine
Bilirubin
These waste products are excreted by maternal kidneys
Importance: Prevents accumulation of toxic substances in the fetus
4. ENDOCRINE (HORMONAL) FUNCTION
The placenta functions as an endocrine gland by producing hormones essential for pregnancy
maintenance.
Major Placental Hormones:
Human Chorionic Gonadotropin (hCG)
Maintains corpus luteum
Supports progesterone production
Progesterone
Maintains uterine lining
Prevents uterine contractions
Estrogen
Promotes uterine growth
Enhances blood flow to uterus
Prepares breasts for lactation
Human Placental Lactogen (hPL)
Alters maternal metabolism
Increases availability of glucose to fetus
Relaxin
Relaxes pelvic ligaments
Softens cervix
5. IMMUNOLOGICAL (PROTECTIVE) FUNCTION
Acts as a partial barrier between mother and fetus
Prevents maternal immune rejection of the fetus
Transfers maternal IgG antibodies to fetus
Provides passive immunity to the newborn
Note: Some pathogens (e.g., rubella, syphilis, HIV) can cross the placenta
6. METABOLIC FUNCTION
Synthesizes:
Glycogen
Cholesterol
Fatty acids
Converts substances into forms usable by the fetus
Importance: Supports fetal energy needs and hormone production
7. STORAGE FUNCTION
Stores:
Glycogen
Iron
Fat-soluble vitamins
Releases them as needed by the fetus
8. BARRIER FUNCTION
Regulates substances crossing from mother to fetus
Prevents passage of many harmful substances
However, allows passage of:
Drugs
Alcohol
Nicotine
Some infections
Clinical significance: Maternal drug use affects fetal health
9. THERMOREGULATORY FUNCTION
Helps maintain fetal body temperature
Protects fetus from sudden temperature changes
10. DETOXIFICATION FUNCTION
Neutralizes certain drugs and toxins
Protects fetus from harmful maternal substances
PHYSIOLOGICAL AND PSYCHOLOGICAL CHANGES IN PREGNANCY
INTRODUCTION
Pregnancy is a normal physiological process that produces profound changes in a woman’s body
and mind. These changes are influenced by hormonal, mechanical, and emotional factors and
are necessary to support fetal growth, prepare the mother for childbirth, and enable lactation.
PHYSIOLOGICAL CHANGES IN PREGNANCY
Physiological changes affect almost all body systems.
1. REPRODUCTIVE SYSTEM
a. Uterus
Increases in size and weight (from ~60 g to ~1,000 g)
Muscle fibers hypertrophy and stretch
Increased blood supply
Braxton Hicks contractions occur
Fundal height increases progressively
b. Cervix
Softening (Goodell’s sign)
Bluish discoloration due to increased vascularity (Chadwick’s sign)
Formation of mucus plug
Cervical glands increase secretion
c. Vagina and Vulva
Increased vascularity → bluish color
Increased vaginal discharge (leukorrhea)
Vulva becomes soft and edematous
2. ENDOCRINE SYSTEM
Increased estrogen and progesterone
Placenta acts as an endocrine gland
Increased prolactin for lactation
Increased insulin resistance due to hPL
3. CARDIOVASCULAR SYSTEM
Blood volume increases by 30–50%
Cardiac output increases
Slight increase in heart rate
Blood pressure slightly decreases in mid-pregnancy
Physiological anemia due to hemodilution
4. RESPIRATORY SYSTEM
Increased oxygen consumption
Increased tidal volume
Diaphragm elevates
Mild dyspnea common
5. GASTROINTESTINAL SYSTEM
Nausea and vomiting (morning sickness)
Decreased gastric motility → constipation
Heartburn due to relaxation of esophageal sphincter
Increased appetite later in pregnancy
6. URINARY SYSTEM
Increased renal blood flow
Increased glomerular filtration rate
Frequency of micturition
Risk of urinary tract infection
7. MUSCULOSKELETAL SYSTEM
Weight gain
Lordosis due to shifting center of gravity
Relaxation of pelvic ligaments (relaxin)
Backache common
8. SKIN CHANGES
Hyperpigmentation (chloasma gravidarum)
Linea nigra
Striae gravidarum (stretch marks)
Increased sweating
9. BREASTS
Increase in size and tenderness
Darkening of areola and nipples
Montgomery’s tubercles prominent
Colostrum secretion in late pregnancy
10. HEMATOLOGICAL SYSTEM
Increased plasma volume
Increased clotting factors (hypercoagulable state)
Slight decrease in hemoglobin concentration
PSYCHOLOGICAL CHANGES IN PREGNANCY
Psychological changes vary with trimester and individual coping mechanisms.
1. FIRST TRIMESTER
Ambivalence about pregnancy
Anxiety and mood swings
Fatigue and irritability
Emotional sensitivity
Fear of miscarriage
2. SECOND TRIMESTER
Acceptance of pregnancy
Increased emotional stability
Positive body image
Increased interest in fetus
Feeling fetal movements enhances bonding
3. THIRD TRIMESTER
Anxiety about labor and childbirth
Fear of pain or complications
Concern about baby’s health
Sleep disturbances
Desire for support and reassurance
FACTORS INFLUENCING PSYCHOLOGICAL CHANGES
Hormonal fluctuations
Cultural beliefs
Social support
Economic status
Previous pregnancy experiences
Marital relationship
NURSING IMPLICATIONS
Provide reassurance and emotional support
Educate about normal changes
Encourage antenatal clinic attendance
Identify signs of anxiety and depression
Promote family involvement
MANAGEMENT OF THE MOTHER AND NEWBORN DURING PUERPERIUM
INTRODUCTION
The puerperium (postnatal period) refers to the period beginning immediately after delivery of
the placenta and lasting for six weeks (42 days). During this time, the reproductive organs return
to their pre-pregnant state, and the mother adapts physically, psychologically, and socially to
motherhood. Proper management ensures the health and survival of both mother and
newborn.
4.1 DEFINITION OF NORMAL PUERPERIUM
Normal puerperium is the physiological period following childbirth during which:
The uterus involutes
Lochia is expelled
Lactation is established
The mother regains her non-pregnant state
The newborn adapts to extra-uterine life
Duration: Approximately 6 weeks
SUBSEQUENT CARE OF THE NEWBORN
A. GENERAL CARE
Keep the baby warm (thermoregulation)
Maintain cleanliness and hygiene
Observe breathing, color, and activity
Early initiation of breastfeeding
Rooming-in encouraged
B. EXCLUSIVE BREASTFEEDING
Feeding the baby only breast milk for the first 6 months
No water, glucose, or herbal mixtures
Advantages:
Provides complete nutrition
Boosts immunity
Prevents diarrhea and infections
Promotes mother–child bonding
Prevents postpartum hemorrhage (via oxytocin release)
C. CARE OF THE UMBILICAL CORD
Keep the cord clean and dry
Do not apply harmful substances
Clean with clean water or recommended antiseptic if needed
Fold diaper below the stump
Observe for signs of infection (redness, discharge, foul smell)
POSTNATAL CARE (CARE OF THE MOTHER)
A. GENERAL CARE
Adequate rest and sleep
Balanced diet with high protein and fluids
Good personal hygiene
Early ambulation to prevent thrombosis
B. UTERINE INVOLUTION
Fundus descends daily
Uterus returns to pelvis by day 10
Encourage breastfeeding to enhance involution
C. LOCHIA
Lochia rubra (1–3 days): blood-stained
Lochia serosa (4–10 days): pink/brown
Lochia alba (after 10 days): whitish
Abnormal lochia indicates infection or retained products.
D. PERINEAL CARE
Keep area clean and dry
Sitz baths if necessary
Pain relief as prescribed
Observe episiotomy for infection
E. BREAST CARE
Wash breasts with clean water
Correct breastfeeding technique
Prevent cracked nipples
Express milk if breasts are engorged
4.4 POSTNATAL FOLLOW-UP AND REFERRAL
FOLLOW-UP VISITS
Within 48 hours
At 1–2 weeks
At 6 weeks postpartum
REFERRAL TO HEALTH FACILITIES IF:
Excessive bleeding
Fever
Foul-smelling lochia
Severe abdominal pain
Depression or abnormal behavior
FAMILY PLANNING COUNSELLING
Lactational Amenorrhea Method (LAM)
Barrier methods
Oral contraceptives (as advised)
Injectables and implants
IUCD after 6 weeks
CONDITIONS AFFECTING THE NEWBORN
A. NEONATAL JAUNDICE
Yellow discoloration of skin and eyes
Due to immature liver
Managed by phototherapy in severe cases
B. NEONATAL TETANUS
Caused by unhygienic cord care
Presents with inability to suck, stiffness, convulsions
Prevented by maternal tetanus toxoid and clean delivery
C. OPHTHALMIA NEONATORUM
Eye infection occurring within first week
Causes redness and discharge
Prevented by prophylactic eye drops
D. CONGENITAL ABNORMALITIES
Structural or functional defects present at birth
Examples: cleft lip, spina bifida
Early detection and referral essential
COMPLICATIONS IN PUERPERIUM
A. PUERPERAL SEPSIS
Definition: Infection of the genital tract after childbirth
Signs and Symptoms:
Fever
Lower abdominal pain
Foul-smelling lochia
Malaise
Prevention:
Aseptic techniques
Good perineal hygiene
Early treatment of infections
B. PUERPERAL PSYCHOSIS
Severe mental disorder after childbirth
Confusion, hallucinations, abnormal behavior
Requires urgent psychiatric care
C. BREAST CONDITIONS
Breast Engorgement
Due to milk stasis
Managed with frequent breastfeeding
Mastitis
Painful, red, swollen breast
Treat with antibiotics and continued breastfeeding
Breast Abscess
Collection of pus
Requires drainage
EMERGENCY OBSTETRIC CARE (EmOC)
INTRODUCTION
Emergency Obstetric Care (EmOC) refers to the timely provision of medical and surgical
interventions to manage complications during pregnancy, childbirth, and the postpartum
period. It is critical to prevent maternal and perinatal morbidity and mortality. Globally,
obstetric emergencies account for a significant proportion of maternal deaths, often
preventable with prompt intervention.
OBJECTIVES OF EMERGENCY OBSTETRIC CARE
Recognize life-threatening obstetric conditions early.
Provide immediate interventions to stabilize mother and fetus.
Prevent complications in mother and newborn.
Reduce maternal and perinatal mortality.
Educate mothers and families on danger signs.
CLASSIFICATION OF EMERGENCY OBSTETRIC CARE
1. BASIC EMOC (BEmOC)
Provided at primary health centers, includes:
Administration of parenteral antibiotics
Parenteral oxytocics for hemorrhage
Parenteral anticonvulsants (e.g., magnesium sulfate for eclampsia)
Manual removal of placenta
Removal of retained products (e.g., manual vacuum aspiration)
Assisted vaginal delivery (vacuum or forceps)
Neonatal resuscitation
2. COMPREHENSIVE EMOC (CEmOC)
Provided at secondary/tertiary hospitals, includes all BEmOC functions plus:
Surgery (e.g., Cesarean section)
Blood transfusion
COMMON OBSTETRIC EMERGENCIES
1. POSTPARTUM HEMORRHAGE (PPH)
Definition: Blood loss >500 mL after vaginal birth or >1000 mL after Cesarean.
Causes:
Tone (uterine atony) – most common
Tissue (retained placenta)
Trauma (perineal, cervical, uterine rupture)
Thrombin (coagulation disorders)
Signs:
Excessive vaginal bleeding
Pallor, tachycardia, hypotension
Shock if untreated
Management:
Call for help
Establish IV access and fluid replacement
Administer uterotonics (oxytocin, misoprostol)
Massage uterus
Repair trauma, remove retained tissue
Blood transfusion if needed
Surgery as last resort (e.g., hysterectomy)
2. ECLAMPSIA AND SEVERE PREECLAMPSIA
Definition:
Preeclampsia: hypertension + proteinuria after 20 weeks gestation
Eclampsia: occurrence of seizures in preeclampsia
Signs:
Severe headache
Blurred vision
Epigastric pain
Seizures
Management:
Place mother in left lateral position
Administer magnesium sulfate to control seizures
Control BP with antihypertensives (labetalol, hydralazine)
Monitor fetal status
Prepare for emergency delivery if indicated
3. OBSTRUCTED LABOR
Definition: Labor does not progress due to mechanical obstruction.
Causes:
Cephalopelvic disproportion
Malpresentation (breech, transverse)
Pelvic abnormalities
Signs:
Arrest of labor
Severe pain
Bandl’s ring or caput
Management:
Immediate referral if not in hospital
IV fluids and monitoring
Preparation for Cesarean section
Avoid excessive traction or unskilled maneuvers
4. UTERINE RUPTURE
Definition: Tearing of uterine wall before or during labor.
Risk factors:
Previous Cesarean section
Traumatic labor
Multiparity
Signs:
Sudden severe abdominal pain
Vaginal bleeding
Shock
Abnormal fetal heart pattern
Management:
Emergency surgery
Blood transfusion
Stabilization with IV fluids
Monitor mother and baby
5. MATERNAL SHOCK
Causes:
Hemorrhage, sepsis, trauma, anaphylaxis
Signs:
Hypotension, tachycardia
Cold, clammy skin
Reduced urine output
Management:
Identify cause
Restore circulating volume
Oxygen therapy
Emergency intervention as needed
6. NEONATAL EMERGENCIES
Birth asphyxia
Meconium aspiration
Hypothermia
Neonatal sepsis
Management:
Neonatal resuscitation (airway, breathing, circulation)
Warm environment
Antibiotics if infection suspected
Supportive care
PRINCIPLES OF EMERGENCY OBSTETRIC CARE
Early recognition of complications
Rapid stabilization of mother and fetus
Timely referral to higher-level care
Team approach (nurse, midwife, doctor)
Documentation and communication
Health education for mother and family
NURSING INTERVENTIONS
Assess vital signs and bleeding frequently
Monitor fetal heart rate
Prepare emergency drugs and equipment
Educate mother on warning signs
Emotional support and reassurance
Maintain aseptic technique
Record fluid intake, output, and interventions.