MIDWIFERY

March 2017 nursing class

KENYA MEDICAL TRAINING COLLEGE- MSAMBWENI CAMPUS

PREPARED BY: MR. ALEX M DECHE

Broad module objectives

P a g e |1 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
Graduate skilled birth attendants (SBAs).
Reduce maternal and fetal morbidity and mortality.
COURSE COMPETENCES
 This module is designed to enable the learner to understand the background
and policies of RH and midwifery and anatomy of reproductive organs and apply the
knowledge in provision of comprehensive and quality RH services.
 This module is designed to enable the learner to understand the background
and policies of RH and midwifery and anatomy of reproductive organs and apply the
knowledge in provision of comprehensive and quality RH services.
 This module is designed to enable the learner to understand and develop
knowledge, skills and attitude in dealing with women undergoing labour and
delivery and the newborn.
 Apply the knowledge in provision of comprehensive and quality RH services
and support safe motherhood.
Module outcomes
1. State RH policies, standards and guidelines.
2. Define terminologies in reproductive health.
3. Describe the anatomy and physiology in reproductive health of delivery
4. Describe and care and early detection of complications during preconception,
antenatal, labour and puerperium.
5. Develop skills in the care to the newborn
6. Apply infection prevention procedures

Mode of delivery
 Tutorials
 Self- directed learning
 Group discussion
 Individual and group assignments
 Presentation of assignments
 Demonstrations and return demonstrations in skills lab
 Telephone tutorial with the course lecturer (0722- 315556)
Teaching materials
 Text books
 Policy guidelines
 Computers and internet
 LCDs
 Flip charts
 Manikins
 Simulated patients
Evaluation tools
 Written examination (CATs, final semester examination, FQE)
 Assignments
 Practical assessments
 Case studies

P a g e |2 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
TABLE OF CONTENTS
CHAPTER 1:
INTRODUCTION
CHAPTER2:
Midwifery
- Definition
- History of midwifery
- Terminologies
CHAPTER3:
ANATOMY OF THE FEMALE REPRODUCTIVE
- Draw and label the diagram of the female external reproductive organ - vulva.
- Describe the functions of the parts of the vulva.
- Describe the anatomy and functions of the female internal reproductive
organs (vagina, uterus, fallopian tubes and ovaries)
CHAPTER4:
ANATOMY OF THE MALE REPRODUCTIVE SYSTEM
- Draw and label diagram of male reproductive organ
- Describe the parts and functions
- Describe male hormones
- Describe the physiology of erection.
- Describe spermatogenesis.
CHAPTER5:
THE PELVIS
- Draw and label the diagram of the pelvis
- Describe the general anatomy of the pelvis
- Describe the bones of the pelvis
- Describe the joints of the pelvis
- Describe the parts of the pelvis
- Describe the diameters of the pelvis
- Describe the landmarks of the pelvis
- Describe the types of pelvis
- Describe pelvic abnormalities
CHAPTER 6:
THE BREAST
- Draw and label the diagram of the breast
- describe the functions of the different parts of the breast
- Describe the general anatomy of the breast.
- Explain types of nipples.
- Describe physiology of lactation.

CHAPTER7:
MENSTRUAL CYCLE
- Define menstrual cycle
- Explain physiology of menstrual.
P a g e |3 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
- Describe the phases of the menstrual cycle
- Describe the hormones involved in menstrual cycle
- Explain the abnormalities to the menstrual cycle

CHAPTER 8.
FETAL SKULL
- Draw and label fetal skull
- Describe ossification of the fetal skull bones.
- Describe bones of the fetal skull
- Describe fontanelles of the fetal skull
- Describe sutures of the fetal skull
- Describe landmarks of the fetal skull
- Describe diameters of fetal skull
- Describe regions and landmarks of fetal skull.
- Describe moulding.
- Explain attitude of fetal head
CHAPTER 9
FERTILIZATION
- Define fertilization
- Describe development of fertilized ovum.
- Explain the process of implantation

CHAPTER 10:
PREGNANCY
- Definition of pregnancy
- Period of pregnancy
- Diagnosis of pregnancy
CHAPTER 11:
FETAL DEVELOPMENT.
- Fetal development (chronological) 1- 40 weeks gestation
- Fetal circulation (diagram, temporary parts, after birth)
- Amniotic fluid (origin, composition, functions, abnormalities)
- Placenta (origin, parts, functions, abnormalities, examination- demo)
CHAPTER 12.
PHYSIOLOGICAL CHANGES DURING PREGNANCY
- Changes and adaptations during pregnancy
CHAPTER 13:
MINOR DISORDERS OF PREGNANCY
- Minor disorders and their management

CHAPTER 14.
ANTENATAL CARE
- Definition
- Strategies in ANC
- National guidelines on antenatal care.
- Guidelines on history taking
- Focused antenatal care- FANC.
- National guidelines on malaria control during pregnancy
P a g e |4 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
- National guidelines on EMTCT (Pillars. ARVs e.t.c)
CHAPTER 15:
LABOUR
1. Define the following terms, labour and normal labour.
2. Describe causes of onset of labour.
3. Describe signs of labour.
4. Describe stages of labour.
5. Changes during labour. (physiological and mechanical)

CHAPTER 16:
MANAGEMENT OF NORMAL LABOUR (1ST STAGE)

1. Describe the principals of management of labour.

2. Describe the admission of a mother in labour.
3. Describe history taking during admission
4. Perform physical examination to mother in labour.
5. Describe and perform vaginal examination accurately.
6. Describe the nursing care during first stage
7. Describe use of partograph
CHAPTER 17:
2ND STAGE OF LABOUR
1. Describe physiological changes
2. Describe signs of 2nd stage of labour
3. Describe mechanism of normal labour
4. Describe nursing care management
5. Describe APGAR score
6. Describe episiotomy- indications, types, repair
7. Describe types of perineal tear and principals of management
8. Documentation and reporting.
CHAPTER 18:
3RD STAGE OF LABOUR
1. Describe mechanism of placenta and membrane separation.
2. Describe methods of placenta separation.
3. Describe control of bleeding during 3rd stage of labour.
4. Describe the skill of delivering of the placenta- theory and demo
5. Placenta examination – theory and skill
6. Describe active management of 3rd stage of labour - AMTSL
7. Describe and manage complications of 3rd stage of labour

CHAPTER 19:
4TH STAGE OF LABOUR (IMMEDIATE POSTNATAL CARE)
1. Normal peurperium
2. Physiological changes during peurperium.
3. Return of reproductive organs to their pre- gravid state
4. Lochia- origin, composition, types, abnormalities.
5. Management of the peurperium (targeted postpartum care).
6. Post natal examination- first 48 hours
7. Health education during peurperium
8. Disorders of peurperium (minor and major).

P a g e |5 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
CHAPTER 20:
NEWBORN CARE
1. Physiological adjustments of newborn baby after birth
2. Principles of management
3. Baby’s physical needs
4. Feeding options- Breastfeed
5. Keeping a newborn baby warm after deliver
6. Baby friendly services
7. Daily examination of newborn
8. Minor disorders of the newborn
9. Dangers signs for the newborn
CHAPTER 21:
Prevention of mother to child transmission of HIV- PMTCT
1. Incidence of MTCT.
2. W.H.O case definitions of HIV/aids surveillance in countries with limited
clinical
3. laboratory diagnostic facilities
4. ARVs
5. Consideration for starting ART
6. Drugs in PMCT of HIV
7. Infant testing

MIDWIFERY
Definition
This is the art and science of caring for a woman throughout pregnancy, labour and
delivery and peurperium in order to prevent complications.
Aims of a midwife
1. To promote and maintain physical and psychological health of the pregnant
woman in order to ensure birth of a normal healthy baby without any complications
to either the mother or the baby
2. To ensure a live healthy baby through fetal supervision
3. To prepare the mother through health messages for, lactation and subsequent
care of the baby.
4. To detect early and correct or treat appropriately and promptly any conditions
(medical or obstetrical) that might interfere or endanger the health of the mother or
fetus.
5. To involve the husband and other members of the family in the care of the
pregnant woman and that of the baby after birth.
Code of ethics
This should govern the midwife behavior with women and partners or relatives
 Respect for life
 Be respectful to others and polite
 Confidentiality- keep information given in trust by the patient secret
 To be calm, obedient and control their tempers
 Trustful- the midwife should behave and act in a way that the client can
believe in him/her all through the provision of care.
 Good communication to colleagues, team members, client and relatives.

P a g e |6 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 Punctuality- both on duty and taking actions because delays can cause
irreversible damages.
 Maintain own and others dignity through good moral behavior and respect for
life.
 Exercise equity to all irrespective of their social background and status,
religion, race or beliefs.
Student’s objectives
 to describe the anatomy and physiology of female reproductive system
 Develop knowledge, skills and attitude towards caring of a pregnant woman
and mothers in labor.
 Acquire knowledge, skills and positive attitude towards caring of a woman
after birth.
 Acquire knowledge, skills and positive attitude towards caring of babies at risk
 Acquire knowledge, skills and positive attitude in management of obstetrical
complications.
TERMINOLOGIES
Sexual intercourse: Fusion of male and female sexual organs.
Para: It means having given birth. A woman’s parity refers to the number of times
she has given birth to a child, alive, still or abortion.
Gravid: State of pregnancy
Gravida: The number of times a woman has been pregnant regardless of the
outcome.
Gestation: Period of pregnancy in weeks
Trimester: A period of three months in pregnancy
Nil Para: A woman who has not given birth before.
Primipara: A woman who is giving birth for the first time
Grandmultipara: Given birth more the five times
Presentation: The part of the fetus on the lower uterine segment.
Cephalic: head on the lower uterine segment
Breech: buttocks on the lower uterine segment
Palpation: A manouvre to feel the fetal part by use of hands on the abdomen.
Position: The relationship between the leading part of the fetus to the pelvic brim
Lie: The relationship of the long axis of the fetus to the long axis of the mother.
 Longitudinal lie
 Transverse lie
 Oblique lie
Sperm: The male reproductive gamete.
Ovum: The female reproductive gamete.
Zygote: Name given to the fertilized ovum from 1- 3rd week.
Embryo: Fertilized ovum from 3- 8 weeks pregnancy
Fetus: Name given to the fertilized ovum from 8 weeks to term.
Newborn: Name given to the baby within the first 24 hours
Neonate: Name given to the baby from day one to 28 days
Infant: Name given to the baby after 28 days to one year.
Still birth: A baby born after 24 weeks of gestation with no signs of life.
 Fresh still birth- FSB
 Macerated still birth- MSB

THE FEMALE REPRODUCTIVE SYSTEM

P a g e |7 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
Outcomes
By the end of the session the trainee will be able to,
- Draw and label the diagram of the female external genitalia (vulva), vagina,
uterus, fallopian tubes, and ovaries.
- Describe the anatomy of the parts of the female reproductive system and
their functions (vagina, uterus, fallopian tubes and ovaries ).

VULVA
• Draw and label the diagram of the female external genitalia (vulva).
• Describe the parts and their functions.
• Describe the blood supply, venous drainage, nerve supply and lymphatic
supply to the vulva.

1) Mons pubic (Veneries)

It’s a part of fat lying over the symphysis pubis. Also referred to as mountain of
Venus. It is covered with public hair from the time of puberty.
2) Labia’ majora (greater lips)
Composed of two folds of fat and areola tissue covered with skin and public hair on
the outer surface. They arise in the mon,s pubis and merge into perineum behind.
It contains sebaceous glands which secrete sebum, that keeps the hair soft and
lubricated pliable, shinny appearance provides some water-proofing and act as a
bacterial and fungicidal agent preventing infection, drying and cracking.

3) Labia minora (Lesser lips)

Made up of two folds of skin lying between the labia majora. Anteriorly they divide
to close the clitoris. Posteriorly they fused to form fourchette. It is covered with
hairless skin and less adipose tissue. They surround the lateral sides of the clitoris.
blood supply through the connective tissue gives them their characteristically
pinkish colour.
Their main role is to prevent the vestibule from any dirty. Covers the vestibule and
opens during sexual excitement.
4) Clitoris
It’s a small rudimental organ corresponding to the male penis. It is extremely
sensitive and highly vascularised. It has erectile tissue. It has no reproductive
significance. Its main role is provision of sexual pleasure. An organ supplied with
almost 8000 nerve endings double the ones supplying the penis.
5) Vestibule
The area enclosed by the labia minora in which they are situated the opening of the
urethra and vagina orifice.
6) Hymen

P a g e |8 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 This is a thin layer of mucous membrane that partially occludes the opening of the
vagina. It usually tears during sexual intercourse or during the birth of the 1 st child.
It’s normally allows for passage of menstrual flow.

7) External urethral orifice

A small opening about 2cm below the clitoris. On either side lies the opening of the
skene,s glands.
Functions – Allows passage of urine.

8) Vaginal orifice (introitus of the vagina)

Lies between the labia minora and posteriorly to the urethra partially covered by
hymen before sexual intercourse or 1st childbirth.

9) Vestibular glands (Bartholin,s glands)

Two glands situated posteriorly the vaginal, beneath the labia majora. They have
ducts which open into the vestibule. They secrete mucus which lubricates the
vaginal openings.

THE INTERNAL FEMALE REPRODUCTIVE ORGANS

These includes:
i. Vagina
ii. Uterus
iii. Fallopian tubes
iv. Ovaries

1. VAGINA
Learning outcomes
By the end of the session the trainee will be able to,
2. Draw and label the diagram of the vagina.
3. Describe the parts and their functions.
4. Describe the structure and location of the vagina.
5. Describe the functions of the vagina.
6. Describe its anatomical adaptations.
7. Describe the blood supply, venous return, nerve supply and lymphatic
drainage.

P a g e |9 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
VAGINA
It is a hollow distensible fibro muscular tube that extends from the vaginal orifice in
the vestibule to the cervix at the apex.
When a woman gives birth and during sexual intercourse, the vagina temporarily
widens and lengthens.
The vaginal canal passes upwards and backwards in to the pelvis along a line
approximately parallel to the plane of the pelvic brim. When a woman stands
upright, the vaginal canal points in an upward- backward direction and forms an
angle of slightly more than 45 degrees with the uterus.
Location
Laterally on the upper 2/3rds are the pelvic fascia and the ureters which pass besides
the cervix on the either side of the lower 1/3 area the muscles of pelvic floor.
Structures
 The vagina has 3 layers
- An outer covering of areolar tissue fascia
- Middle layer of smooth muscle
 Muscle layer is divided into inner coat of circular fibres and stronger outer
coat of longitudinal fibres.
 They are no glands in the vagina. It is being moistened by mucus from the
cervix and exudates from seeps out from the blood vessels of the vaginal walls
between puberty and menopause.
 Dordelins bacilli or Lactobacillusacidophilusare present that secrete lactic acid
from their action to the glycogen present in the squamous of vaginal lining
maintaining the pH of vagina between 4.9 and 3.5. The acid prevents growth of
pathogenic bacteria.
 It is approximately 10cms in length and 2 cms in diameter although there is
wide anatomical variation.
 The posterior wall of the vagina is 10cm long and anterior wall is 7.5cm, in
length. This is because the cervix projects into the upper part at a right angle.
 The upper end of the vagina is known as the vault.
 Where the cervix projects into it, the vault forms a circular recess that is
described as four arches or fornices. The posterior fornix is the largest of these
because the vagina is attached to the uterus at a higher level posteriorly than
anteriorly
 The vaginal walls are pink in appearance in black and purple in light people.
 The vaginal walls are thrown in folds known as rugae. These allow the vaginal
walls to stretch during intercourse and child birth.
Functions
i. Allow the escape of menstrual fluids
ii. Receives the penis and ejected sperm during sexual intercourse.
iii. Provides an exit of fetus during birth
iv. Secretes lactic acids that destroy bacterial from orifice.
Adaptation
a. Lactic acid along the vagina inhibits the growth of most microorganisms that
may enter the vagina from the perineum.
b. Presence of ruggae allows the vagina wall to stretch during intercourses and
child birth and promotes sexual pressure.

P a g e |10 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
c. During ovulation the vaginal mucus provides an alkaline environment which
helps the sperm to survive and it also minimizes friction by sexual intercourses
since it acts as an lubricant.
d. The presence of pelvic fascia allows the independent contraction and
expansion of the vagina.
Blood supply, nerve supply and lymph drainage.
Blood supply
The blood supply comes from the internal and external pudental arteries. The blood
drains through the corresponding veins. Lymphatic drainage
This is mainly through the inguinal glands.
Nerve supply
The nerve supply is derived from the branches of pudental nerve.
UTERUS
By the end of the session the trainee will be able to,
 Draw and label the diagram of the uterus
 Name the parts of the uterus
 Describe the layers of the uterus
 Describe the support to the uterus
 Describe the functions of the uterus.
 Describe the blood supply, venous return, nerve supply and lymphatic supply
 Describe abnormalities to the uterus.

It is a hollow pea shaped muscular organ located in the true pelvic between bladder
and the rectum. The position of the uterus in the pelvis is one of ante version and
ante flexion. It bends forward upon itself and this is referred to as ante flexion. It
also leans forward and this is referred to as ante version.
When a woman is standing upright the uterus is at almost horizontal position, the
fundus resting on the bladder. It is about 7.5cm long, 5cm wide and its walls are
about 2.5m thick. It weighs 60 grams.

PARTS
The fundus
This is the dome-shaped part above the cornua.
The body
Main part and narrows inferiorly at the level of internal os where it is continuous
with the cervix.
Cavity

P a g e |11 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
Is a potential space between the anterior and posterior wall. It is triangle in shape
the triangle being uppermost.
The Isthmus
Is a narrow area between the cavity/body and the cervix approximately 7mm long.
It enlarges during pregnancy to form the lower uterine segment.
The cervix (neck of the uterus)
This protrudes through the anterior wall of the vagina, opening into it at the
external os. The upper ½ is supravaginal portion while lower half is infravaginal
portion.

The internal os
It is a narrow opening between the isthmus and the cervix.
The cervical canal
Lies between the two cervical os and is a continuation of the uterine cavity. It is
narrow to each end and wider in the middle.
The external os
It is a small round opening at the lower end of the cervix to the vagina. After
childbirth it becomes a transverse slit.
The cornua
It is the upper outer angles of the uterus where uterine tubes join.
LAYERS OF THE UTERUS
The uterus is composed of 3 layers
 Endometrium
 Myometrium
 Perimetrium
1. Endometrium – inner layer
It is composed of columnar epithelium containing a large number of mucus –
secreting tubular glands. It’s divided functionally into two layers.
- The functional layer is the upper layer. It thickens and becomes rich in blood
vessels in the first half of the menstrual cycle and develop desidual layer. If the
released ovum is not fertilized and does not implant, this layer shed during
menstruation.
- The basal layer lies next to the myometrium, is not lost during menstruation.
It is the layer from which the fresh functional layer is regenerated during each
cycle.
2. Myometrium – middle layer
- Is thick in the upper part of the uterus and is sparser in the isthmus and
cervix. Its fibers run in all direction and interlace to surround the blood vessels. Its
lymphatic pass to and from the endometrium. The outer layer is formed of
longitudinal fibers that are continues with those of the uterine tube. The inner layer
is composed of oblique fibres. The uterine, cervix and vaginal muscle fibers are
embedded in collagen fibres which enable it to stretch during labour.
3. Perimetrium – outer layer
This is peritoneum, which is distributed differently on the various surface of the
uterus. Anteriorly it extends over the fundus and the body where it is folder on the
upper surface of the urinary bladder. This fold of peritoneum forms the vesico-
uterine pouch. Posteriorly the peritoneum extends over the fundus, the body and
the cervix, and then it continues on to the rectum, to form the retro- uterine pouch
(pouch of Douglas).

P a g e |12 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
Laterally only the fundus is covered because the peritoneum forms a double fold
with the uterine tubes in the upper free border. This double fold is the broad
ligament which at its lateral ends, attaches the uterus to the sides of the pelvis.

Relationship of the uterus to other organs

Knowledge of the uterus to the other pelvic organs is desirable

particularly when giving women advice about bladder and bowel care
during pregnancy and childbirth.
- Anteriorly to the uterus lie the uterovesical pouch and the bladder.
- Posterior to the uterus are the recto- uterine pouch of Douglas and
the rectum.
- Lateral to the uterus are the broad ligaments, the uterine tube and
the ovaries.
- Superior to the uterus lies the intestines.
- Inferior to the uterus is the vagina.
Support to the uterus- Uterus ligament
1. The transverse cervical ligaments.
Fan out from sides of the cervix to the side walls of the pelvis.
2. Utero sacral ligaments.
Two folds like extension from the perimetrium from posterior surface of the uterus
to the sacrum one on each side. They help to maintain the antervesion position of
uterus by pulling the cervix.
3. Round ligament
Arise from the cornua of the uterus in front and below the insertion of the fallopian
tubes. It runs between the folds of the broad ligaments and inserted into the labia
majora.
It does not support the uterus as such but it assists to maintain the position of the
ante flexion and antervesion.
4. Broad ligament
Double fold of peritoneum which forms a kind of portion across the pelvic cavity.
It’s suspended between the 2 folds of the round ligaments.
5. Ovarian ligament
It attaches to the ovaries and suspended anteriorly. Gives support the ovaries. In
the process suspends the uterus.
P a g e |13 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 6. Pubo - cervical ligament.
It attaches at the level of the cervix and moves anteriorly to the pubis bone.

Task- Draw a diagram showing the support of the uterus from the level of the
cervix.

Blood supply
It is by the uterine and ovarian arteries which are branches of internal iliac arteries.
Drainage is by the corresponding veins.
Lymphatic drainage
It is by the inguinal glands and internal and external common iliac gland.
Nerve supply
It is by autonomic nervous system from the sympathetic nerve fibres from the hypo
gastric plexus.
Also by parasympathetic nerve especially to the cervix.
Functions of the uterus.
I. Receiving ovum
II. Provides field of implantation
III. Shelter fetus during pregnancy
IV. Provision of nutrition early days.
V. Participates in the expansion of fetus.
ABNORMALITIES OF THE UTERUS
UTERINE TUBES
By the end of the session the trainee will be able to
 Draw and label the diagram of the fallopian tubes.
 Describe the parts of the fallopian tube
 Describe the functions of the fallopian tube
 Describe the blood supply, venous return, nerve supply and lymphatic supply
Also known as fallopian tubes, oviducts or salpinges. They are fine tubes leading
from the ovaries into the uterus.
Position
Extends laterally from the cornua of the uterus towards the side wall of the pelvis.
They arch over the ovaries, the fibrillated ends hovering near the ovaries in order to
receive the ovum.
Anterior posterior and superior to the uterine tubes are the peritoneal cavity and
the intestines.
Lateral to the uterine tubes are the side walls of the pelvis. Inferior to the tubes lie
the broad ligaments and the ovaries.
Medial to the two uterine lie the uterus.

Support
They are held in place by their attachment to the uterus.
Peritoneum folds over them as the broad ligaments and extending to the sides to
form infundibulopelvic ligaments.
Structure
Each tube approximately 10cm long

P a g e |14 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 The lumen of the tube provides an open pathway from the inside to the peritoneal
cavity.

It has 4 portions names;

1. The interstitial portion
It is 1.25cm long and lies within the wall of the uterus. Its lumen is 1mm wide.
2. The isthmus
It is the narrowest part of the tube. It extends for 2.5cm from the uterus.
3. The ampulla
It is the widest portion of the tube where fertilization usually occurs. It is 5cm long.
4. The infundibulum
It is the funnel-shaped fringed end that is composed of many processes known as
fimbriae. One fimbria is elongated to form the ovarian fimbria, which is attached to
the ovary.
Task- Draw a diagram showing the parts of the uterine tubes.

Layers of the fallopian tube

1. The inner layer.
The inner layer forms the lining of the uterine tubes. It is a mucosa of ciliated
cubical epithelium that is thrown into complicated folds known as plicae. These
folds slow the ovum down on its way to the uterus.
In this lining are goblet cells that produce a secretion containing glycogen to
nourish the oocyte.
2. Middle layer
it forms the muscular layer. It consists of 2 layers. The peristaltic movement of the
uterine due is due to the action of these muscles.
Movement of the oocyte in the fallopian tube is by
i. Action of the cilia
ii. Peristaltic movement of the tubes.
Blood supply
Blood supply is via the uterine and ovarian arteries and returning by the
corresponding veins.
Lymphatic drainage
It is drained to the lumbar glands.
Nerve supply
It is from the ovarian plexus
Functions of Uterine tube
1. Propels the ovum towards uterus.
2. Receives the spermatozoa as they travel upwards.
3. Provides a site for fertilization.
4. It supplies the fertilized ovum with nutrition during its continuous journey to
the uterus.

THE OVARIES
By the end of the session the trainee will be able to,
 Describe structure ofthe ovaries.
 Describe functions of ovaries.
 Describe folliculogenesis
 Describe the functions of the hormones produced.

P a g e |15 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
  Describe the blood supply, venous return, nerve supply and lymphatic supply
They are components of the female reproductive system and the endocrine system.

Structure
They are composed of two layers;
a) Medulla
b) Cortex
Medulla
It is the supporting framework which is made of fibrous tissue, the ovarian blood
vessels, lymphatic and nerves travel through it. The hilum where these vessels
enter lies just where the ovary is attached to the broad ligament and this area is
called the mesovarium.

Cortex
It is the functioning part of the ovary. It contains the ovarian follicles in different
stages of development, surrounded by stroma.
The outer layer is formed fibrous tissue known as the tuning albuginea.
Functions of ovaries.
i. Produce ova.
ii. Produce hormones progesterone and oestrogen.
Effects of oestrogen
1. Stimulate secondary sex characteristics of female.
2. prepares uterus for spermatozoal transport
3. Increases vascular permeability and tissue edema
4. Stimulates growth and activity of mammary gonad and endometrium
5. Prepares uterus for progesterone action
6. Mild anabolic
7. Regulate secretion of gonadotrophins.
Effects of progesterone
1. Prepares uterus to receive embryo
2. Maintain uterus during pregnancy
3. Stimulate growth of mammary gland
4. Suppresses lactation
5. Mild effect o sodium loss via distal convoluted tubule of the kidney
6. Mild catabolic effect
7. Regulate secretion of gonadotrophins

THE MALE REPRODUCTIVE SYSTEM

P a g e |16 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
Outcome:
 Describe the parts and functions
 Describe male hormones
 Describe the physiology of erection

Consists of:-
› 2 testes
› 2 epididymis
› 2 vas deferens
› 2 seminal vesicles
› 1 prostate gland
› 1 Cowper’s gland
› 1 penis

a) scrotum
A deeply pigmented pouch made of skin that lies below the symphysis pubis and
behind the penis.
It is made of connective tissue, fibrous tissue and smooth muscles.
It is divided into two compartments, each containing a testis, epididymis and
testicular end of a spermatic cord.
It main function is to maintain testicular temperatures at 8 degrees below the core
body temperatures

b) testes
They are the male reproductive glands, equivalent to ovaries in females
Each is about 4 cm long, 2.5cm wide and 3 cm thick.
They are suspended in the scrotum by the spermatic cords.
They are surrounded by three layers of tissues:-
› Tunica vaginalis(outer)- which originates from abdominal and pelvic
peritoneum
› Tunica albuginea(middle)- fibrous covering and the outer layer derived
from the septum that divides the scrotum
› Tunica vasculosa(inner)- consist of connective tissues and capillary
network.
Structure of the testis
- Each testis is made up of about 200-300 lobules

P a g e |17 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
- Each lobule has btwn 1-4 convoluted loops composed of germinal epithelium,
called seminiferous tubules
- Between the tubules are cells interstitial cells of Leydig which produces
hormone testosterone.
- The tubules combine at the upper pole to form a single tubule, the epididymis
which leaves the scrotum as the diferent duct in the spermatic cord
- Blood and lymphatic vessels pass to the testes through the spermatic cord.

c) Spermatic cords
- They are two, one on each side.
- They consist of one testicular artery, one testicular vein, 1 deferent duct,
nerves and lymph vessels within a sheath of fibrous connective tissue and smooth
muscles.
- It serves to suspended the testes
- The vas deferens passes through the inguinal canal and ascends medially
towards the posterior wall of bladder.
- They join with ducts from seminal vesicles which together form the
ejaculatory duct.
- Seminal vesicles
- are two fibromascular pouches lined with columnar epithelium in the posterior
aspect of bladder.
- Produce 60% of alkaline semen including fructose to provide energy for
sperms
d) Ejaculatory ducts
- Are two tubes about 2cm long formed from the union of deferent duct and
seminal vesicles
- They pass through the prostate gland and join the prostatic urethra.
- It carries the spermatic fluid and spermatozoa to the urethra
- Prostate gland
- Lies in the pelvic cavity in front of rectum and behind the symphysis pubis,
surrounding the first part of urethra
- It consist of an outer fibrous covering, a layer of smooth muscle and glandular
tissue
- Produces up to 1/3 of the semen & includes nutrients & enzymes to activate
sperm.

e) Cowper’s gland
- A small gland just below the prostate gland.
- Secretes mucous & alkaline buffers to neutralize acidic conditions of urethra.
- Urethra
- It is a tubular passage about 19-20 cm long
- It consist of three parts:-
› Prostatic urethra- from the urethral orifice of bladder through the
prostate gland.
› Membranous urethra- shortest and narrowest part extending from
the prostate gland to the bulb of the penis
› Spongy (penile) urethra- lies within the penis and terminates at
external urethra orifice.
P a g e |18 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
f) Penis
- Formed by erectile tissue and involuntary muscles.
- The erectile tissue is supported by fibrous tissue and covered by skin. It is
highly vascular
- The penis has two lateral columns of tissues made of corpora carvenosa and a
medial column, the corpus spongiosum that contains the urethra
- At the tip, it is expanded into a triangular structure known as glans penis.
- Glans penis is well supplied by autonomic and somatic nerves.
- Parasympathetic stimulation leads to engorgement with blood and erection of
penis
Male hormones
- Unlike in females, male reproductive hormones are not produced in cyclical
fashion.
- Follicle stimulating hormone is produced by the anterior pituitary gland
under the influence of gonadotropin releasing hormone. It causes spermatogenesis
in seminiferous tubules.
- Luteinizing hormone is also produced by anterior pituitary gland and is
carried through blood stream to the testis.It stimulates the interstitial cells(leydig)
to produce the hormone testosterone, the chief male sexual hormone
Testosterone
- Produced by the interstitial cells
- It is responsible for development of male secondary characteristics.
o Deepening of voice
o Maturation of genitalia
o Growth of hair on the pubis, axilla, face and chest
- Spermatogenesis begins at puberty and continues throughout adult life.
- It is stimulated by changes in pituitary gland secretion when it starts releasing
follicle stimulating hormone.
- The mature sperms are stored in the epididymis and released during
ejaculation.
- At each ejaculation, btwn 2-4mls of semen is released, each ml containing
about 50- 130million sperms
Semen
Semen is a milky white, mixture of sperm and secretions from accessory glands.
Functions:
 Acts as a transport media for sperms
 Provides a source of sperm nutrition
 Activates sperms by removing excessive coating increasing capacity and
motility.
 Protects sperms from harm by coagulating them together until they are
delivered into the vagina
 Fructose in seminal vesicles secretion provides ATP for sperms
 Prostaglandins reduce viscosity of mucus in the cervix and reverse peristalsis
in uterus and medial parts of the fallopian tubes.
 Relaxin hormone and enzymes increase motility of sperms.
 Semen has a PH of 7.2- 7.6 providing an optimal environment for the sperms.
Sperms are sluggish under acidic conditions.
 Antibiotic chemical seminal plasmin destroys some bacteria
 Fibrinogen coagulates semen just after it is ejaculated

P a g e |19 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 Fibrinolysin liquefies the stick mass, enabling the sperm to swim in female
tract.
Mechanism of erection
Erection of the penis in an involuntary process controlled by the autonomic nervous
system. Dilatation of arteries pours an increased amount of arterial blood into
cavernous space of the corpora cavernosa, corpus spongiosum and glans. The
enlargement of the tissue generates pressure against the veins, causing them to
collapse thus preventing outflow of blood through them. Expansion of the corpora
stretches the deep fascia .this restricts enlargement of the penis and causes
rigidity. Erection is controlled by parasympathetic nerves (nervi erigentes- S2- 4)
Structure of the sperm

SPERMATOGENESIS
Spermatogenesis is the process by which male primordial germ cells called
spermatogonia undergo meiosis, and produce a number of cells termed
P a g e |20 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
spermatozoa. One of the intial cells in this pathway is called primary
spermatocytes . Each primary spermatocyte divides into two secondary
spermatocytes, and each secondary spermatocyte into two spermatids or young
spermatozoa. These develop into mature spermatozoa, also known as sperm cells.
Thus, the primary spermatocyte gives rise to two cells, the secondary
spermatocytes, and the two secondary spermatocytes by their subdivision produce
four spermatozoa
Spermatogenesis involves three major events: 1) Mitotic proliferation to produce a
large number of cells, 2) meiotic division to generate diversity and to halve the
chromosome number and 3) extensive cell modeling to package the chromosomes
for transport (spermiogensis).
It begins at puberty and continues throughout life of the individual.
1) Mitotic proliferation (Spermtocytosis)
The interphase germ cells of immature tests are activated at puberty to stem cells
(Ao spermatogonia), which enter mitosis. Ao cells proliferate slowly in basal
compartment and serve as reservoir of stem cells from which, at intervals, A1
spermatogonia emerge, marking the beginning of spermatogenesis. A1
spermatogonia undergo a limited number of mitotic divisions, producing a clone of
diploid daughter cells (46XY), each daughter cell slightly different from parent cell,
till they form spermatogonia type B. spermatogonia type B develop and grow to
form resting primary spermatocytes which migrate through the tight junctions at
the base of the Sertoli cells.
2) Meiotic division
Within the basal intratubular compartment, resting primary spermotocytes
duplicate their DNA content and push their way into the columnar intratubular
compartment by disrupting transiently the zonular tight juctions between sertoli
cells. In this environment, the primary spermatocytes undergo two meiotic
divisions. In the first division, pairs of chromosomes come together and exchange
DNA (crossing over) and separate into two haploid cells (23X of 23Y) known as
secondary spermatocytes. Alsomost immediately, a second meitoc division takes
place in which the two chromatids that make up a single chromosome separate.
These haploid cells, thus, contain 23 single half chromosomes and are called
spermatids. The spermatocytes are especially sensitive to damage and widespread
degeneration can occur at this stage. At this stage, they are still simple round cells.
3) Spermiogenesis
After completion of meiosis, all synthetic activity ceases immediately thereafter,
and the spermatid DNA becomes highly condensed or heterochromatic. They are
packed with basic proteins. Major changes in this sage involve remodeling of the
cytoplasm, with generation of the tail for forward propulsion, midpiece-containing
mitochondria, the source of energy necessary for the swimming action, acrosome-
containing enzymes that aid in penetration of ovum and residual body, on which is
deposited the residue supeflous cytoplasm, phangocytosed by sertoli cells after
spermatozoa depart. As meiosis and spermiogenesis proceeds, the cells are moved
slowly towards the lumen of the tubule, until with completion of spermatic
elongation, the sertoli cell cytoplasm retracts from around the cells, releasing then
into the seminiferous tubules lumen. The whole process occurs in close association
with setoli cells and takes approximately 64 days to completion. About 300-600
sperm/gram, pf testis are produced each second. Not all survive though. Hormones
and other external agents do not affect the rate of spermatogenesis, but may

P a g e |21 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
determine whether the process occurs at all. From the seminiferous tubules, the
sperm are washed towards the rete testis which drains into the vasa effentia and
from there into the epididymis.
During the 12 day passage from the testis to the vas deferens, the sperm become
motile and mature to reach full fertilizing ability. As a result of fluid absorption in
the epididymis, sperm also become highly concentrated.
Whilst spermatogenesis is dependent on the hormonal drive from the
gonadotrophins and testosterone, temperature also plays a critical factor in this
process. Normal spertogenesis is impaired if the testis is maintained at normal
body ‘core’ temperature (as occurs in cryptorchidism or through tight clothing). The
temperature of the tastes is normally maintained about 20C lower than core body
temperature because they lie outside the body, moving freely in thesacrotal sac.

A fully functioning testis normally achieved by the age of 16 years has the capacity
to produce over 200 million sperm each day .only one is required for fertilization,
but each tiny sperm (a few thousandths of a millimeter in length) must travel some
30-40cm (100 000 times its own length. This is comparable to a 1.6 meters tall
man swimming a distance of 160KM!!) of the male and female reproductive tract
before it reaches its final destination in the Fallopian tube. Less than 1 in a million
ever completes this journey, though they are helped by the process of ejaculation.
Spermatogenic Wave
Cells at different places in the stretch of the semiferous tubules are at different
stages development. This allows a continuous production of spermatozoa in spite of
the fact that spermatogenesis takes ~ 64 days to complete. Light affects
spermatogenesis-sperm production is maximal in the morning. Release of LH also
occurs in pulsatile pattern.
With age, due to less production of receptors and loss of sensitivity to gonadotropis
and androgens, the effects of the hormone decline. This is attributed to decreased
production of testosterone by Leydig cells.
ABNORMALITIES OF TESTICULAR FUNCTION
Cryoptochidism
The tastes develop in the abdominal cavity and normally migrate to the scrotum
during fetal development. Testicular descent to the inguinal region depends on
MIS, and discent from the inguinal region to the scrotal sac depends on other
factors. Descent in incomplete on one or less commonly, both 10% of newborn
males, the testes remaining in the abdominal cavity or inguinal canal. In most
cases, such testes descend spontaneously, bringing tge proportion of boys with
undescended testes from 10% at birth to 2% at age of 1 year and 0.3% after
puberty. Early treatment or correction is however recommened as undescended
testes carry a higher risk for malignant tumors, and because at puberty, the higher
temperature in the abdomen eventually causes irreversible damage to the
spermatogenic epithelium.
Hypogonadism
The physical features of hypogonadism depend on whether testicular deficiency
develops before or after puberty. If the endocrine function is lost in adulthood, the
secondary sexual characteristics with the exception of laryngeal changes
(associated with deep voice). Regress slowly. When the Leyding cell deficiency
dates from childhood, the clinical picture is that of eunuchoidism – characterized by
tall stature, narrow shoulders, small muscles and a general body configuration

P a g e |22 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
resembling that of the adult female (see gure 6.3). The genitalia are small and the
voice high-pitched. Public and axillary hairs are present; however, the hair is sparse
and the pubic hair has the female “triangle with the base up” distribution typical of
females
Androgen – secreting tumors
‘Hyper-function’ of the testes in the absence of tumor formation is not a recognized
entity. Androgen – secreting Leyding cell tumors are rare and cause detectable
endocrine symptoms only in pre-pubertal boys, who develop procorcious
pseudopuberty (discussed later in this self-instructional material)
Testicular Compartments
The testis makes spermatozoa as well as androgens. Spermatozoa are made within
the seminiferous tubules, while androgens are made between the tubules.
Physiologically, the testis has four compartments with varying degree of porosity to
different substance. The intravascular compartment in in free communication with
the interstitial compartment.
Lymphatics are found here, as are Leydig cells that synthesize androgens. This is
inside the tubule. The tubules are lined by Sertoli cells. The main barrier to
diffusion is not the boundary of the tubule, but the layer of junctional complexes
between sertoli cells. The basal compartment is between the tubular boundary and
junctional complexes. On the other side of the junctional complexes is the
adluminal intratubular compartment. This boundary forms the blood-testis barrier
that provides a controlled environment for the meoitic stages of spermatogenesis,
and prevents leakage of spermatozoal proteins into the blood. Sperms are not
produced until puberty, thus making the material they are made of ‘foreign’ to the
body’s immune system, and would therefore elicit an immune response if they
found their way into the circulation. Further, if an immune response is elicted, the
barrier hinders access of immunoglobulins. Breakdown of the barrier leads to
autoimmune orchitis. The barrier also affects the free-exchange of water soluble
materials, thus maintaining an osmotic gradient that facilitates movement of fluid
into the lumen.

THE PELVIS

P a g e |23 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
Outcome
By the end of the topic the trainee should be able to:
- Draw and label the diagram of the pelvis
- Describe the general anatomy of the pelvis
- Describe the bones of the pelvis
- Describe the joints of the pelvis
- Describe the parts of the pelvis
- Describe the types of pelvis
- Describe the diameters of the pelvis
- Describe the landmarks of the pelvis
- Describe pelvic abnormalities
Is a basin shaped cavity, is bony ring between the movable vertebrae of the
vertebral column which it supports, and the lower limbs that it rests on.
It contains and protects the bladder, rectum and internal reproductive organs.
Some women experience pelvic pain in pregnancy.
Pelvic girdle

Functions
1. Adapted to child bearing.

P a g e |24 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
2. Protects some of the abdominal organs.
3. Allows movement of the body, especially walking and running.
Makes the sacro illio joint to be immensely strong and virtually immobile.
4. Takes the weight of the sitting body onto the ischial tuberosities.

Pelvic bones
Thepelvis has 4 bones. These are,
- 2 innominate bones
- 1 Sacrum
- 1 Coccyx
1. Innominate bones
Contains 3 bones fused together i.e.
 Ilium
 Ischium
 Pubis.
a. Ilium: - large flared-out part. When hands placed on hips they rest on the iliac
crests. At the front of the iliac crest can be felt a bony prominence known as the
anterior superior iliac spine.

b. Ischium: - is thick lower part. It has a large prominence called ischial

tuberosity on which the body rests when sitting.

c. Pubis: - forms the anterior part of the pelvis. It has a body and two oar like
projections, the superior ramus and the inferior ramus.

The innominate bone contains a deep cup to receive the head of the femur termed
the acetabulum, which is composed of the 3 fused bones in the following
proportions, 2/5 Ilium, 2/1 ischium and 1/5 pubis.
In the lower border of the innominate bone are 2 curves, one curve extends from
the posterior inferior iliac spine up to the ischial spine called greater sciatic notch. It
is wide and rounded. The other curve lies between the ischial spine and the ischial
tuberosity and known as lesser sciatic notch.
2. The Sacrum
It isa wedge-shaped bone consisting of 5 fused vertebrae. The posterior surface is
roughened to receive attachments of muscles.
3. Coccyx
Is a vestigial tail consists of 4 fused vertebrae forming a small triangular bone,
which articulates with the fifth sacral segments.
Pelvic joints
There are 4 pelvic joints
a. 2 Sacroiliac joint
b. 1 Sacrococcxygeal joint.
c. 1 Symphysis pubis.
a. Sacroiliac joint
These are strong, weight-bearing synovial joints with irregular elevations and
depressions that produce interlocking of the bones. The joints allow a limited
backward and forward movement of the hip and promontory of the sacrum,
sometimes known as ‘nodding’ of the sacrum.

P a g e |25 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
b. Sacrococcxygeal joint
It is formed where the base of the coccyx articulates with the tip of the sacrum. It
permits the coccyx to be deflected backwards during birth of the fetal head.
c. Symphysis pubis
It is the midline cartilaginous joint uniting the ramis of the left and right pubis
bones. It is the biggest joint of the pelvis.
PELVIC LIGAMENT
Pelvic joints are held together by very strong ligament that are designed not to
allow movement.
During pregnancy the hormone relaxin gradually loosens ligaments allowing slight
pelvic movement providing more room for the fetal head as it passes through the
pelvis.
The ligament connecting the bones of the pelvis with each other can be divided into
four groups.
1. The Sacroiliac ligament: - connecting the sacrum and ilium.
2. Sacrotuberous ligament and sacrospinous ligament: - passing between the
sacrum and ischium.
3. The sacrococcxygeal ligament :- Those uniting the sacrum and coccyx
4. Interpubic ligament: - those between the two pubic bones.
TYPES OF PELVIS
They vary not only in the two sexes, both also in different members of the same
sex. There 4 types of pelvis namely;
1. Gynaecoid
2. Android
3. Anthropoid
4. Platypelloid

1. The Gynaecoid
- Best type for childbearing
- It has a round brim.
- Generous fore pelvis.
- Straight side walls.
- A shallow cavity.
- Well-curved sacrum.
- sub-pubic arch of 900
2. The Android pelvis
- This is also referred to as the male pelvis.
- Its brim is heart-shaped.
- It has a narrow fore pelvis.
- Transverse diameter is situated toward the back.
- The side walls converge, making it funnel shaped.
- It has a deep cavity and a straight sacrum.
3. The Anthropoid pelvis
- Has a long, oval brim.
- Antero- posterior diameter is longer than the transverse diameter.
- The side walls diverge.
- Sacrum is long and deeply concave.
- Women with this tend to be tall, with narrow shoulders.

P a g e |26 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
4. Platypelloid pelvic
- Has a kidney-shaped brim.
- Antero- posterior diameter is reduced and the transverse diameter increased.
- The sacrum is flat and the cavity shallow.
Functions and pelvis
i. Adapted to child bearing.
ii. Transmits weight of trunk to the legs.
iii. Allows movement of the body.
iv. Protects some pelvic organs and abdominal organs.
The True Pelvis
The true pelvis is the bony canal through which fetus must pass through during
childbearing.
Composes of 3 parts
a. Inlet i.e. Brim
b. Cavity
c. Outlet
The Brim
Anteriorly, there’s the symphysis pubis, laterally, there is the iliac bone, posteriorly
there’s the sacral promontory projecting to the brim whereby reducing the anterior,
posterior diameter or fht ebrim as compared to its transverse diameter which
becomes more accommodating to the fetal skull.
The brim has the following fixed landmarks
 Sacro promontory
 Sacro-iliac joint
 Sacro ala wing
 Iliopectineal line
 Iliopectineal eminence.
 Superior ramus of the pubic bone
 Upper inner border of the body of the pubic bone
 Upper inner boarder of the symphysis pubis
Diameters of Brim
o Anterior- posterior diameter – Measured from the tip of the sacro
promontory to the upper border of the symphysis pubis. It measures 11cm.

o Oblique diameter- measured from sacroiliac joint to ilio- pectineal

eminences. We have right and left oblique diameters. It measures 12cm.

o Transverse – measure from points furthest a part on the ilio-pectineal lines.

It measures 13cm. It is the largest diameter of the pelvic brim.
o The sacrocotyloid diameter- measured from the sacro promontory to the
ilio- pectineal eminence. It’s a very important chamber in posterior position of the
occiput. The fetal head can at times be caught at this level it measures 9 – 9.5cm.
NB: Factors affecting the space of the pelvic brim.
o The descending colon
Diameters of the cavity
The anterior wall is the symphysis pubis approximately 4cm and posterior wall is
the sacral bone measuring approximately 12cm.
All diameters measures 12cm.
Diameters of the outlet
P a g e |27 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
The outlet is described in 2 categories
a) Anatomical outlet
b) Obstetrical outlet
Anatomical outlet
Covers lower borders of each bone and together with ligaments.
Obstetrical outlet
It covers the narrow outlet through which fetus must pass during delivery. The
landmarks are fixed and include sacro-coccygeal joint, Ischial spines to lower inner
boarder of the symphysis pubis.
Diameters of obstetrical outlet
o Anterior – posterior diameter
It measures from sacro-coccygeal joint to lower inner boarder of the symphysis
pubis. It measures 13cm.
o Oblique diameter
It is measured from obturator foramen to the junction between sacro-spinous and
sacro tuberous ligaments.It has no fixed points. It measures 12cm
o Transverse
Distance between the Ischial spines. It’s the smallest diameter of pelvic outlet and
measures 11cm.

In summary
Anterior Oblique Transverse
posterior
Brim 11 12 13
Cavity 12 12 12
Outlet 13 12 11

MUSCLE LAYERS OF PELVIS

The pelvic floor is formed by the soft tissues that fill the outlet of the pelvis. They
form the muscles of the pelvic floor. They are divided into 2 categories,
a. Superficial muscle
b. Deep layer muscle.
A. Superficial muscle
 External anal sphincter muscle – encircles the anus and attached to coccyx.

 Transverse perineal muscle- passes from Ischial tuberosity to centre of

perineum.

 Bulbocarvenosus muscle-pass from perineum forward around the vagina to

the carpora cavernosa of the clitoris just under the pubic arch.

 Ischial cavernosus muscle – pass from ischial tuberosity along the pubic arch
to carpora cavernosa.

 Membranous sphincter – composes of muscle passing above and below the

urethra and attached to pubic bone. Not circular but can act to close the urethra.

B. Deep Layer
P a g e |28 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
They are composed of 3 layers of muscle known as the Levator ani. They earntheir
name because they have capability to lift and elevate the anus. These are;
a. R & L – Pubococcygeus muscle: Originate from the posterior inferior pubic
rami and continue posteriorly to the rectum and to its insertion to the coccyx. It
encircles the rectum forming the anorectal ring.
b. R & L – Ischiococcygeus muscle
Originate from the Ischial spines and adjacent sacroiliac fascia. It attaches to the
coccyx and lower sacrum.
c. R & L – iliococcygeus muscle
Originate from the fascia covering the obturator internus muscle. It converges with
the pubococcygeus muscle and attaches to the coccyx.
Functions
o The pelvis flour muscles support the weight of abdominal and pelvic organs.
o Assists in voluntary control of maturation and defecation.
o Play an important role in sexual intercourse.
o Influence passive passage of the fetus during birth. In prolonged labour the
muscle may become overstretched and may lead to prolapsed of reproductive
organs.

Landmarks of the pelvis.

The pelvis has fixed landmarks. These are the features to be used by the midwife to
assess pelvic adequacy. These are,
 The promontory- it should not be prominent
 The curve of the sacrum- it should be well curve.
 The ischial spines- they should be blunt
 The sub pubic angle- it should be <90 degrees or accommodate two finger
breathes
 The intertuberous diameter- it should be more than 8 cms or accommodate 4
knuckles.

Deformities of pelvis
 Poor diet – prevention of health bone formation, Rhichiticpelvis, osteomalacic.
 Injury and diseases – future pelvis may develop callus formation.
 Developmental anomalies e.g. Naegelle,s and Roberts pelvis. Naegelle,s
misses one sacral ala and Roberts misses both sacral ala. This means the sacrum
meets directly the iliac bone. This results into,
o Asymetric diameters
o Engagement prevention
Osteomalacic – deficiency of calcium / skeleton bone soften, weight from body
smash together pelvis bones until brim is Y-shaped. These women must undergo
caesarian section.

P a g e |29 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
THE BREAST
Outcome
By the end of the session the trainee will be able to
1. Draw and label the diagram of the breast
2. Describe the general anatomy of the breast.
3. Perform an accurate breast examination on a woman
4. Describe physiology of lactation.
5. Explain types of nipples
The diagram of the breast.

Parts and their functions

 Alveoli
 Nipple
 Ampulla
 Lactiferous ducts
 Montgomery’s glands
 Adipose tissue
Physiology of lactation
During childbirth, hormonal production is reduced after delivery of placenta. This
stimulates anterior pituitary gland to increasingly produce prolactin hormone. Once
prolactin is in the blood stream it circulates and stimulates the acini cells in the
alveoli to start the process of manufacturing milk.
Production of prolactin is more accelerated by suckling effect of the baby. Suckling
stimulates posterior pituitary gland to produce oxytocin hormone. Oxytocin is
carried by blood stream to the breast where it causes myoepithelial cells
surrounding alveoli to contract and propel milk along ducts to ampulla for
temporary storage.

P a g e |30 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 The presence of prolactin in circulation inhibits the production of gonadotrophin
releasing hormone by the Hypothalamus which suppresses the production of follicle
stimulating hormone.
Nipples composed of erectile tissue have a sphincter like muscle to control flow of
milk.
Around the nipple is an area of pigmentation known as areola containing
montegomery's glands. The glands produce sebum which acts as a lubricant during
suckling.
Blood supply
It is by internal and external mammary arteries and branches of intercostals
arteries. Blood supply increases during lactation. Drainage is through mammary
and axillary veins.

Lymphatic drainage
For the two breasts, Lymphatic system communicates freely into the lymph nodes
in axilla and sternum. This is why, rapid spread of malignant growth from one
breast to other.
Nerve supply
Have poor nerve supply and most functions are controlled by hormones.
Types of nipples
 Long nipple- In these nipples, baby is able lath milk without drawing breast
tissue leading to poor feeding.

 Short nipples- This is where the baby is able to latch both nipple and breast
tissue, it does not coz problems during breastfeeding.

 Abnormal large nipple – During breastfeeding, the mouth may not be able to
get beyond nipple. Lactation may be initiated by expressing by hand or pump.

 Inverted and flat nipples – If nipple is deeply inverted, it may be necessary to

initiate lactation by expression and delay attempt to attach the baby to the breast
until lactation is full established. Otherwise the nipple may be preparedantenatally.
Common conditions of the breast.
 Cracked nipples
 Breast engorgement
 Mastitis
 Breast abscess
MENSTRUAL CYCLE
Outcome
By the end of the section should be able to,
- Define menstrual cycle
- Explain physiology of menstrual.
- Describe the phases of the menstrual cycle
- Describe the hormones in menstrual cycle
- Explain the abnormalities to the menstrual cycle

P a g e |31 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
Def. Menstrual cycle is the monthly shedding of uterine wall to the basal layer. On
average the menstrual cycle takes 28 days although it varies from 1 woman to
other.
-When woman understands her menstrual cycle, she can better plan, diagnose and
prevent pregnancy.
When heath provider understands menstrual cycle, they can better assist in
planning and preventing pregnancy.
The menstrual has 3 phases.
a. Menstrual phase
b. Proliferative or Follicle phase
c. Secretory or luteal phase.

Menstrual phase
It is characterized by per vaginal bleeding lasting from 3-5 days. Endometrium is
shed to the basal layer along with blood from capillaries and with unfertilized ovum.
Proliferative phase.
It follows menstrual phase until ovulation. It is characterized by re-growth and
thickening of the uterine wall and influence of estrogen hormone. At the end of this
phase, endometrium has 3 layers. (Basal, Functional, cuboidal epithelial cell
Secretory phase
It comes immediately after proliferative phase. It is under influence of progesterone
and oestrogen from corpus luteum. Endometrium thickens and becomes spongy.
Endometrium has a layer of about 3.5cm and there is increase secretion from the
endometrial glands and the end of the cycle. If no fertilization the ovum after 36-48
hrs the endometrim sheds off. If fertilization occurs corpus luteum continues to
grow and produce hormones that support pregnancy (progesterone and estrogen)
HORMONAL INFLUENCE.
Menstrual cycle is regulated in the hypothalamus.
The hormones stimulate the production of hormones progesterone and estrogen.
F.S. H.
It causes the graafian follicle in ovarian cortex to mature. The maturing graafian
follicle produces estrogen hormones.
L.H.
It stimulates the rapture of mature graafian follicle to release an ovum. It
influences the development of corpus luteum to produce low estrogen and high
progesterone for 14 days.
Oestrogen
Produced under influence of follicle stimulating hormone - FSH. It is produced in 3
different parts i.e. placenta, corpus luteum, granulosa cells in the graafian follicles.
Effects
 Responsible for secondary sex characteristics growth e.g. breasts
 Causes proliferation of uterine endometrium in menstrual cycles
 Promotes growth of endometrium
 Suppresses ovulation
 Inhibits lactation
 Assists water and electrolyte retention in the body.
Progesterone

P a g e |32 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
It is produced by corpus luteum by influence of luteinizing hormones and placenta
during pregnancy.
Functions of progesterone
 Causes endomentrium increase in size
 Increase secretion and blood supply in the endometrium in readiness for the
fertilized ovum.
 The period of men’s cycle differs from one woman to the other and in the
same women from time to time.
 This is mostly influenced by several factors:- age, diet, stress (emotions),
climate change use of drugs.
The woman is usually fertile during ovulation (5 days before and 2 days after but
most fertile 1 day before ovulation.
 The following factors may indicate that the woman is ovulating
a. One sided radiating pain which lasts seconds.
b. Rise on basal body temp to 0.2- 0.5 degrees.
c. Change in cervical mucus to increase in quantity, becomes clear, stretch and
slippery
d. Increase in luteinizing hormone in blood circulation
Abnormalities of menstrual cycle.
 Dysmenorrheal
 Menorrhagia
 Spotting
 Amenorrhea
 Metrohhagia

FETAL SKULL
Outcomes.
By end of the section, trainee would be able to
- Draw and label fetal skull

- Describe ossification of the fetal skull bones.

- Describe bones of the fetal skull
- Describe the fontanelles of the fetal skull
- Describe the sutures of the fetal skull
- Describe the landmarks of the fetal skull
- Describe the diameter of fetal skull
- Describe regions and landmarks of fetal skull.
- Explain moulding.
Why learn about fetal skull?
- 90% o babies are born presenting with the head
- Skull holds delicate brain which is subjected to pressure during labour and
delivery
- Fetal head is larger in comparison to / with the true pelvis and some
adaptation between skull and pelvis must take place during labour.
- It’s the difficult part to deliver whether it come first or last.
P a g e |33 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
- It’s the largest part of fetal body.

OSSIFICATION
The bones of fetal skull originate from 2 ways. Facial bones are laid in
cartilages and ossified at birth.
The bones of the vault are laid down in membranes which are flatter and
more pliable. They ossify from centre outwards and this process is incomplete at
birth. This leaves small gas which forms fontanel’s and sutures.

The ossification centers appear as a protuberance or eminence. For example

parietal eminence, frontal eminence and occipital eminence.

Vault.
It is the large doomed shaped part containing the brain. It extends from orbital
ridge to the nape of neck. It consists of 5 main bones namely.
- 2 parietal
- 2 frontal
- 1 occipital
Frontal bones
They form the forehead (sinciput). The bone extends from orbital ridge to coronary
sutures. Have 2 bony eminences at the centre of each bone.
Parietal bone
It is the largest bones in fetal skull. They cover parietal lobe of brain. They lie on
either side of skull. Their ossification centre of each bone is known as parietal
eminences. They are joined by sagittal suture.
Occipital bone
Lies behind the parietal bones and covers occipital lobe of brain and cerebrum. It is
joined by the lambdoidal suture. Contain foramen magnum that protects spinal cord
as it leaves the skull.
Other bones
- Temporal bone comprised of united bones to form a small part of the vault.
- The base, comprised of bones, firmly united to protect the vital centre of
medulla oblongata
- The face is comprised of small bones firmly united together and are not
compressible.

P a g e |34 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
Suture
It’s a cranial joint formed where 2 bones meet. Sutures of obstetrical importance
are
- frontal sutures
- Suggittal suture
- Coronary sutures
- Lambdoidal sutures.
Saggittal suture: - lies between the 2 parietal bones.
Frontal suture:- lies between the 2 frontal bones.
Lambdoidal suture: - separates the occipital bone from 2 parietal bones
Coronial suture: - separates frontal bones from parietal bones.
Fontanelles
These are membranous spacesformed between 2 or more suture. Significant ones
are posterior fontanelle (lambda) and anterior fontanelle (bregma)

Anterior fontanelle (bregma)

- Situated at the junction of coronary, suggital and fontal sutures.
- It is diamond shaped.
- Has length of 3 – 4cms and width of 2.5cm.
- Closes by the age of 18 months.
- It’s recognized vaginally because a suture leaves in each of 4 cones.
- Pulsation of cerebral vessels can be felt through.
Posterior fontanelle (lambda)
- Situated at the junction of lambdoidal and sagittal sutures.
- It is triangular in shape.
- Closes by the 6th wks.
-
NB: Suture and fontanels allow for overlapping of fetal skull bones during delivery
due to their membranes space reducing the preventing diameter of fetus in cephalic
presentation. The overlap is referred to asmoulding.
Degrees of moulding.
It can be assessed vaginally on digital examination. The finding could be:
 1st degree moulding- sutures apposed.
 2nd degree moulding – sutures overlapped but reducible.
 3rd degree moulding- The overlapped but not reducible.
Regions of Fetal skull / landmarks
P a g e |35 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 Occipital region
It lies between foramen magnum and posterior fontanelle.
The part below the occipital eminence is known as the sub-occipital region. At
the centre is the occipital protuberance
Vertex
 Lies between posterior fontanelle, anterior fontanelle and the two parietal
eminencies. The baby will present will this region if in cephalic and head well flexed.
Sinciput / Brow / forehead
 Extends from anterior fontanelle, coronary sutures to the orbital ridges.
The face
 Extends from orbital ridge and root of nose to the junction of neck and chin
(mentum).

Diameters of fetal skull.

It has eight measurements that can be described. Two are transverse diameters
and six longitudinal or anterior posterior diameters.
1. Transverse diameter.
- Bi-parietal diameter- measured between 2 parietal eminencies. Measures 9.5
cms.
- Bi- temporal- measured between the furthest corners of the coronal sutures.
Measures 8.2 cms.
2. Longitudinal or anterior posterior diameters.
i. Sub-occipito bregmatic
Measured from blow the occipital protuberance to the centre of anterior fontanelle
(bregma).
It measures 9.5cm

ii. Sub-occipital frontal.

Measured from below occipital protuberance to centre of frontal suture.
It measures 10cm
iii. Occipito- frontal
Measured from occipital protuberance to the grabella.
It measures 11.5cm
iv. Mentovertical
Measured from point of chin to the highest point on the vertex, slightly nearer to
posterior than anterior fontanel.It measures 13.5cm.
v. Submentovertical
Measured from the junction of the chin and the neck to the highest point of the
vertex.It measures 11.5cm
vi. Submentobregmatic
Measured from the junction of the chin and the neck to the centre of the bregma. It
measures 9.5cm

In summary
diameter Abrev. measuremen
t
Sub occipito bregmatic SOB 9.5 cms
Sub occipito frontal SOF 10 cms

P a g e |36 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 Occipito frontal OF 11.5 cms
Mento- vertical MV 13.5 cms
Sub- mento vertical SMV 11.5 cms
Sub- mento bregmatic SMB 9.5 cms
Bi- temporal 8.2 cms
Bi- parietal 9.5 cms

Attitude of fetal head in cephalic prevention.

The term attitude is used to describe the degree of flexion or extension of fetal
head on the neck. Attitude of head determineswhich diameters the fetus will present
with in labour, therefore influence outcome and movement of fetal head.
a) Vertex presentation
The presentation when the head is well flexed. The chin (mentum) is in contact with
chest. The presenting longitudinal diameter will be sub- occipital bregmatic
9.5cm.The bi-parietal diameter 9.5cm will be the transverse diameter. The sub-
occipito- frontal diameter, 10cm will sweep the perineum during the delivery of the
head.
b) Brow presentation
This is when the head is neither extended nor flexed.
Mento-vertical, 13.5cm will be the anterior post diameter.
BI-temporal 8.2cm will be transverse presentation
Brow presentation is rarely born.
c) Face presentation
Here the attitude of the fetal head is of full extension. The occiput is touching the
back. Presenting diameter is sub- mento bregmatic 9.5 cms.
Aerial view of fetal skull when full flexed

PREGNANCY AND ANTENATAL

CARE
COITUS
Definition: Union between a male and a female genitalia involving insertion of the
penis into the vaginaaccompanied by rhythmic movements.
Other forms of sexual intercourse include:
 Heterosexual

P a g e |37 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 Anal sex
 Oral sex
 Lesbianism
 Masturbation
 Fowl play
Coitus has a social as well as a sexual function in humans.
Response to sex stimulation is primarily an autonomic nerve reflex which is
reinforced or prohibited by psychological factors. Sexual response is in a cycle and
consists of four phases in what is often referred to as the EPOR model in humans.
Excitement phase: in this phase, sexual arousal occurs as a result psychogenic or
somatogenic stimuli. Can last for minutes or hours and characterized by;

 Muscle tension increases.

 Heart rate quickens and breathing is accelerated.

 Skin may become flushed.

 Nipples become hardened or erect.

 Blood flow to the genitals increases, resulting in swelling of the woman’s
clitoris and labia minora (inner lips), and erection of the man’s penis.

 Vaginal lubrication begins.

 The woman’s breasts become fuller and the vaginal walls begin to swell.

 The man’s testicles swell, his scrotum tightens, and he begins secreting a
lubricating liquid.

Plateau phase: in this phase, arousal is intensified. If stimulation is sufficient and

prolonged, orgasm occurs.

 The changes begun in phase 1 are intensified.

 The vagina continues to swell from increased blood flow, and the vaginal walls
turn a dark purple.
 The woman’s clitoris becomes highly sensitive (may even be painful to touch)
and retracts under the clitoral hood to avoid direct stimulation from the penis.

 The man’s testicles are withdrawn up into the scrotum.

 Breathing, heart rate and blood pressure continue to increase.

 Muscle spasms may begin in the feet, face and hands.

 Tension in the muscles increases.

Orgasm phase: this is a brief moment of involuntary climax characterized by

intense pleasure and often involving myotonia.

 Involuntary muscle contractions begin.

P a g e |38 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 Blood pressure, heart rate and breathing are at their highest rates, with a
rapid intake of oxygen.

 Muscles in the feet spasm.

 There is a sudden, forceful release of sexual tension.

 In women, the muscles of the vagina contract. The uterus also undergoes
rhythmic contractions.

 In men, rhythmic contractions of the muscles at the base of the penis result in
the ejaculation of semen.

 A rash, or "sex flush" may appear over the entire body.

Resolution phase: in this phase sexual arousal fades. Pelvic hemodynamics return
to normal. It occurs rapidly (minutes) following orgasm but may also take hours.
This is followed by a resolution phase where in men they can go into orgasm again.
Resolution phase varies depending on age and psychological factors.

FERTILIZATION
Also known as conception.
Fertilization is the fusion of the sperm with the secondary oocyte.
It takes 24hrs and takes place at the ampulla.
After ovulation the ovum moves towards the uterus by the aid of cilia and peristaltic
muscle movement of the tube. The cervix will secret an alkaline fluid which attracts
spermatozoa. Around 30milion sperms are deposited in vagina. The sperms travel
and fertilize the ovum.
During the journey, sperms continue maturing and are able to release enzyme
HYALURONIDASE which will break the cell membrane of the ovum.
One sperm enters and the membrane is sealed and ovum becomes fertilized, and it
is known as zygote.

OUTCOMES OF FERTILIZATION
1. The ovum completes the late telo phase
2. Restoration of the diploid number of chromosomes
3. Initiation of the process of cell division or cleavage
4. Sex determination
DEVELOPMENT OF FERTILIZED OVUM.
It occurs in stages as follows:
Day 1- fertilization
Day 2- cleavage
Day 3- compaction
Day 4- differentiation
Day 5- cavitation
Day 6- bilaminar disc formation
Day 7- cell mass differentiation
Day 8- implantation
Day 9- zona hatching

P a g e |39 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
Day 10- mesoderm formation
Day 11- mesoderm spreading
Day 12- amniotic sac enlargement

 Zygote travels to uterus, takes 3-4 days. Cell division continues and divides
into 2,4,8,16 until it forms a structure known as Morulla
 Division happens after every 12hrs, leading to formation of blastocyst. The
blastocyst is surrounded by a single cell layer Trophoblast which has ciliated
projections. The remaining cells arrange in one corner form an inner cell masses.
 Inside this structure is a fluid filled area blastocele. The trophoblast
develops to placenta and chorion while inner cell mass becomes fetus, amnion
and umbilical cord
 In uterus the blastocyst will be free for 2 – 3 days. The trophoblast next to
inner cell mass becomes sticky and attaches itself to the endomentrium. “Then it
begins to secrete substances that digest the endometrial cells, allowing the
blastocyst to become embedded in the Endometrium. Embedding sometimes known
as nidation (nesting) is normally complete by the 11 th day after ovulation (Myles
text book for midwives)”. Nourishment of blastocyst will be by circulatory glands.

TROPHOBLAST
Small projections start to appear (chorionic villi) and become more prolific at the
point of contact with the desidua. The trophoblastic cells form three layers. These
are;
 Sinciotrophoblast (outer layer)
 Cytotrophoblast (middle layer)
 Mesoderm (inner most layer)

P a g e |40 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
Sinciotrophoblast
Composed of nucleated protoplasm which breaks down the decidual tissues in the
process of embedding to provide nutrients to the embryo from the maternal
circulation.

Cytotrophoblast
A single layer of well defined cells which produce a hormone human chorionic
gonadotrophin (HCG) which informs the corpus luteum pregnancy has already taken
place.
Functions of HCG
1. Maintenance of the corpus luteum until placenta is fully developed.
2. Prevents immunological rejection of the fetus.
Mesoderm
Consists of loose connective tissue similar to that of inner cell mass.Helps in chorion
formation.

INNER CELLS MASS

It forms fetus, umbilical cord and amnion. The cell differentiates into 3 layers.

a) Ectoderm
Mainly forms the skin and nervous system.
b) Mesoderm
Forms the muscles, skeleton, dermis of skin, connective tissues, arogenital glands,
blood, blood vessels and lymph lymphatic system.
c) Endoderm
Form mucus membranes and glands.
Note:The three layers together are known as embryonic plate

THE PLACENTA AND UMBILICAL CORD

PLACENTA:
 Develops from part of trophoblast called chorion frondosum. Its dark red in
colour and composes of chorionic villi.
 The placenta has chorionic villi. There are 2 types, short and long. The
shorter ones lie under maternal blood absorbing food, oxygen and are known as the
nutritive villi. The longer ones provide anchorage to the placenta and are less in
number and are known as anchoring villi. Each villi is covered with fewer layers of
tissue or layers which makes it impossible for maternal blood to mix with fetal
blood. These are,

 Develops after 14 days of fertilization it is fully formed by the 12 th week of

gestation.
 At term, the placenta is a round flat mass about 20cm in diameter and 2.5cm
thick at its centre. It weighs approximately 1/6 of baby’s body weight.

P a g e |41 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
  It has maternal and fetal surfaces.

a. Maternal surface.
It is next to uterine wall. Its dark- red in colour due to maternal blood and part of
the basal decidua will have separated with it. The surface is arranged in about 20
cotyledons (lobes) which are separated by sulci (furrows) into which the decidua
dips down to form septa (Walls).
Cotyledons are made of lobules, each contains a single villus with its branches
sometimes deposits of lime salts may be present on the surface making it slightly
griffy.

b. Fetal surface
Fetal surface of the placenta has a shiny appearance due to amnion covering it.
Branches of umbilical vein and arteries are visible spreading out from the insertion
of the Umbilical cord at centre.

 The placenta has two membranes

1. Amnion
2. Chorion.

Characteristics of chorion
I. Lies on the maternal surface
II. It is easy to tear
III. Separates to the edge of the placenta
IV. Opaque
V. Thick
Characteristics of the amnion
I. Lies on the fetal surface
II. Had to tear
III. Separates to the point of cord insertion
IV. Translucent
VI. Thin
VII. Produces amniotic fluid.

FUNCTIONS OF PLACENTA
1. Respiration
No pulmonary exchange of gases can take place in inter uterine life, so the fetus
obtains oxygen from maternal blood through the placenta.

2. Protection
Placenta provides a limited barrier to infection.
Few bacteria, viruses, chemicals and antibodies can penetrate. Has layers of tissues
making it impossible for maternal blood to mix with fetal blood.

3. Storage
The placenta metabolizes glucose, stores it in the form of glycogen and reconverts
it to glucose when required. It also stores iron and fat-soluble vitamins.
4. Excretion

P a g e |42 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 Fetal waste products e.g. carbon dioxide, bilirubin, urea and uric acid are excreted
through the placenta.

5. Endocrine
i. Human chorionic gonadotrophin hormone (HCG) is produced by
cytotrophoblastic layer of the chorionic villi. HCG forms the basis of the many
pregnancy tests available as it is excreted in the mother’s urine by the 2 nd week. It
is antagonistic to gonadotrophin releasing hormone.
Function: - Stimulate the growth and activity of the corpus luteum.

ii. Oestrogen: Secreted in large amounts throughout pregnancy, produced by

the placenta as the activities of the corpus luteum declines. The amount of
oestrogen produced is an index of feto- placenta well-being.

iii. Progesterone: made in the sinciotrophoblastic layer of the placenta in

increasing quantities until immediately before the onset of the labour when its level
falls.
Functions.Known as the pregnant hormone.Prevents contractions and relaxation
of smooth muscles.
iv. Human Placental lactogen (hpl) has a role in glucose metabolism in
pregnancy. As the level of HCG falls, the level of hpl rises and continues to do so
throughout pregnancy.
v. Human placental insulinase- It is antigostic to natural insulin and maintains
blood diabetogenic environment.
vi. Alpha fetal proteins- Its levels may be used to detect fetal congenital
abnormalities.
Task – Draw a well labeled diagram showing a mature placenta

Placental circulation
Maternal blood is discharged in a pulsatile fashion into the intervillous space by 80 –
100 spiral arteries in the deciduas basalis. It spurts towards the chorionic plate and
flows slowly around the villi, enventually returning to the endomentrial veins and
maternal circulation.
Fetal blood, low in 02 is pumped by the fetal heart towards the placenta along the
umbilical arteries and transported along their branches to the capillaries of the
chorionic villi, where exchange of nutrients takes place between mother’s and fetus
blood.
Having released Carbon dioxide and other waste products, it picks oxygen and
nutrients and returns to the fetal circulation via umbilical vein.

Anatomical variations of the placenta

 Placenta suncenturiata
 Placenta circumvalanta
 Placenta bipartita
 Placenta tripartita

Task- discuss the above anatomical

variations

P a g e |43 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
THE UMBILICAL CORD
Extends from the fetal surface of the placenta to the umbilical area of fetus.
Formed by 5th week of pregnancy.Originates from the duct that forms between the
amniotic sac and yolk sac and transmits the umbilical blood vessels (two arteries
and one vein). Has an average length of 50cm with a diameter of 1- 2 cms. Below
40 cms is a short cord and above 60 cms is a long cord.
Dangers of a long cord.
 Cord round the neck
 Cord presentation/prolapse
 Formation of a true knot
Dangers of a short cord.
 Poor descend
 Placenta abruption
 Uterine inversion
Structure
o Contains 2 arteries and one vein, which are continuous with the blood vessels
in the chorionic villi of the placenta.
o Blood vessels are enclosed and protected by a jelly like substance known as
Wharton’s jelly. This is a gelatinous substance formed from mesoderm.
o It is covered in a layer of amnion that is continuous with that covering the
placenta.
o No nerves in the umbilical cord, so cutting it following the birth of the baby is
not painful.
Types of cord insertion.
The cord is inserted to the placenta in different forms to include,
- Central insertion.
- Lateral insertion.
- Battledore insertion.
- Lavamentous insertion.
Functions of Umbilical cord.
It has blood vessels which,
1. Transport O2 and nutrients 2 developing fetus.
2. Removes waste products from the fetus.

AMNIOTIC FLUID
A clear alkaline and slightly yellowish liquid contained within the amniotic sac.
Origin
The source is thought to be both fetal and maternal.
1. Some fluids are exudates from maternal vessels in the decidua and some
from fetal vessels in the placenta.
2. Also secreted by amnion, especially the part covering placenta and umbilical
cord.
3. Fetal urine from 10th week of gestation.
4. Fetus sheds skin cells, vernix caseosa & lanugo into the fluid.
Constituents
99% is water and the remaining 1% being dissolved solid matter including food
substances and waste products. Fetus sheds skin cells, vernix caseosa & lanugo
into the fluid.
Water in amniotic fluid is exchanged 3 hourly.
P a g e |44 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
Volume
During pregnancy, amniotic fluid increase in volume as the fetus grows. It is
greatest at approximately 38 weeks gestation, when there is about I litre and then
diminishes slightly until term, 800ml remains.
Polyhydromnous: - when total amount of fluid exceeds 1500 mls.
Oligohydromnous: – when total amount of fluid is less than 300ml.
Dangers of Polyhydromnous
- Cord prolapse
- Premature labour
- Premature rupture of membranes
- Maternal discomfort- dyspoea
- Amniotic fluid embolism (afe)
- Uterine inversion in spontaneous rupture of membranes
- Uterine atony leading to haemorrhage after child birth
Dangers of Oligohydromnous
- Intra uterine pressure syndrome.
- Intra uterine fetal distress.
- Intra uterine growth retardation
Functions of amniotic fluid
1. Distends amniotic sac allowing for growth and free movement of fetus and
permitting symmetrical musculoskeletal development.
2. Equalizes pressure and protects fetus from jarring and injury
3. Maintains a constant intrauterine environment.
4. Gives small quantities of nutrients to the fetus as it contains special amino
acids, glucose and minerals.
5. Protects the placenta and umbilical cord from the pressure of uterine
contractions.
6. Aids in cervix effacement and dilatation, particularly where the presenting
part is poorly applied.
7. It contains chemicals which are bacteriostatic, preventing infection.lps
8. Helps in breathing movements of fetus. Swallowing and expelling facilitates
thoracic movement.
9. It acts as a diagnostic tool in fetal well being e.g.
a) Presence of meconium
b) Elements of fetal skin, hair, osmotic, vernix, osmolarity- Maturation
c) Lung maturity- lecithin and surfactants
d) Hemolysis- presence of bilirubin
e) Genetic studies.

FETAL DEVELOPMENT
This is the process in which a human embryo or fetus gestates during pregnancy,
from fertilization until birth. Often, the terms fetal development or embryology
are used in a similar sense.

After fertilization embryogenesis starts. In humans, when embryogenesis finishes,

by the end of the 10th week of gestational age, all the major organs of the body

P a g e |45 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
have been created. Therefore, the following fetal period is described strictly
chronologically by a list of major occurrences by weeks of gestational age.
0 – 4 weeks after conception
Formation of the embryonic plate.
Primitive central nervous system forms
Heart develops and begins to beat
Covered with a layer of skin
Limb bubs form
Gender determined
Weighs 1gm and 1cm length.

4 – 8 weeks
Very rapid cell division
Head and facial features develop
All major organs are laid down in primitive form
Blood is pumped around the vessels
Early movement
Visible on ultrasound from 6thweek
Weight 4gm and length 3cm.

8 – 12 weeks
Eyelids fuse.
Kidneys begin to function and the fetus passes urine from bulk
Fetal circulation functioning properly
Suckling and swallowing begin i.e. amniotic fluid
Finger nails develop
Lanugo appears
Moves freely (not felt by mother)
Some primitive reflexes present (swallowing & suction reflex)
60gm & 10cm

12 – 16 weeks
Rapid skeletal development – visible on x-ray
Meconium present in gut
Gender distinguishable
Nasal septum and palate fuse
170grms and 15cm

16 – 20 weeks
Quickening – mother feels fetal movements
Constant weight gain
Fetal heart heard on auscultation
Vernix caseosa appears- creamy substance on the skin
Skin cells begin to be renewed
Fingernails can be seen
400grms & 20cm

20 – 24 weeks
Most organs become capable of functioning

P a g e |46 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
Eyes complete
Ear apparatus developing
Periods of sleep and activity
Responding to sound
Skin red and wrickles
700gm & 30cm

24 – 28 weeks
Fetus viable and survival may be expected if born
Eyelids open
Respiratory movement
1kg and 36cm

28 – 32 weeks
Begins to store fats and iron
Testes descend into scrotum
Lanugo disappears from face
Skin becomes paler and less wrinkled
1.5kg and 40cm

32 – 36 weeks
Increased fat makes the body more rounded
Lanugo disappears from the body
Head hair lengthens
Nails reach tips of fingers
Early cartilage soft
Plantar creases visible
Skin becomes pink
Weigh 2.5kg and 40 cm length
Weight gain 25 gms per day.

36 – 40 weeks after conception

Term is reached and birth is due
Contours rounded
Skull formed but soft and pliable
Skin becomes pink
Weights 3.2kg and 50cm
FETAL CIRCULATION
Fetus derives oxygen from placenta. In addition, placenta is the source of nutrition
and site of elimination of waste.
Fetal lungs are inactive and oxygenation of blood takes place in placenta. There
are 5 temporary structures adapted to fetal circulation. These are:
1. Umbilical vein
2. Ductus venosus
3. Ductus arteriosus
4. Foramen ovale
5. Hypogastic arteries

P a g e |47 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
1. The Umbilical vein
This vein leads from the umbilical cord to the underside of the liver and carries
blood rich in oxygen and nutrients. It has a branch that joins the portal vein and
supplies the livers.

2. The ductus venosus

This connects the umbilical vein to the inferior vena cava. At this point the blood
mixes with deoxygenated blood retuning from the lower parts of the body. Blood
becomes partially oxygenated.

3. The foramina ovale (ovale opening)

This is a temporary opening between the atria which allows majority of blood
entering the heart from inferior vena cava to pass across into the left atrium. The
reason for this diversion is that the blood does not need to pass through the lungs
for oxygenation.
From left atria, blood is pump out through the aorta via the left ventricle.

4. The ductus arteriosus (from an artery to an artery)

This leads from the bifurcation of the pulmonary arteries to the descending arch of
aorta entering it just beyond the point where the sub- clavian and carotid arteries
leave. It carries deoxygenated blood from head and upper limbs.
5. Hypogastric arteries
2 vessels branching off from the internal iliac arteries and become umbilical arteries
when enter the cord. They return impure blood for oxygenation (replenishment).

P a g e |48 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
FETAL CIRCULATION BLOOD FLOW

Blood from placenta which is oxygenated is carried by umbilical vein which

connects with inferior vena cava via the ductus venosus. Some of blood passes to
liver through portal vein.
At the inferior vena cava oxygenated blood mixes with deoxygenated blood from
limbs making it partially oxygenated. At the heart most of the blood passes to the
left atrium through foramen ovale and some trickles to the right ventricle. The
blood in the right ventricles is pumped to pulmonary where it meets the ductus
arteriosus that passes most of this blood to the descending aorta. Some of blood is
taken to lungs for nourishment and maintenance of patency.

Blood from the lungs returns to heart through the pulmonary vein. In the left atrium
is pumped to left ventricle then to the aorta. The arch of Aorta branches off to 3
arteries i.e. carotid, sub-clavian and coronal which supply the head and upper limbs
and returned to heart via superior vena cava.

The descending Aorta branches off the other arteries in different parts of the body
and further down it forms the R & L. hypogastric arteries.
The hypogastric arteries branch off from internal iliac arteries and take
deoxygenated blood to placenta via umbilical arteries for oxygenation.

Changes in Fetal circulation at birth

When the baby is born blood is drawn into the lungs when it makes an effect to cry.
The expansion of lungs attracts a large supply of blood from PA. The blood which
has been passing through ductus arteriosus to descending aorta now follows to PA
to lungs. The DA ceases to function within 5 minutes and complete anatomical
closure is attained by 2 years. It will contract and becomes a cardiac ligament
(ligamentum arteriosum)
The blood from lungs is now oxygenated and enters left atrium and into L. ventricle
and distributed all over the body by Aorta. The change of blood flow equalizes the
pressure between the right and left atrium making foramen ovale to closes,
stopping direct flow of blood from R. to left side of heart.
The ceassation of placental circulation also deprives the functions of the temporary
structures.
They instead become:
1. Ligamentum teres
2. Ligamentum venosum
3. Ligamentum arteriosum
4. Fossa Ovalis
5. Obliterated hypogastric arteries

P a g e |49 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
PREGNANCY
Definition
This is a state in which a living fertilized ovum is embedded on the uterus.
Period of pregnancy is 280 days, 40 weeks, 9 calendar months or 10 lunar months.
Diagnosis of pregnancy
The diagnosis of pregnancy is made from a group of signs and symptoms which can
be captured through history, physical examination and investigations. They are
categorized in to:
 Possible
 Probably
 Positive signs.
1. Possible signs
 Breast enlargement
This occurs 3rd- 6th week of gestation after conception. Other causes could be
contraceptive pills.
 Morning sickness
It occurs between the 4th- 14th week of pregnancy. It is characterized by nausea and
vomiting. It is associated with the introduction of HCG.
Other causes can include gastro intestinal disorder, drugs and illness.
 Bladder irritation
There is increased frequency in maturation. It occurs between 6 th – 12 week of
gestation and seen again towards term. It is usually due to pressure of the growing
fetus on the bladder.
Other causes can include infections, pelvic tumors or growth.
 Amenorrhea
This occurs after 4 weeks from last menstrual bleeding if the woman is experiencing
regular menses.Other reasons could be
 Hormonal imbalances
 Diseases
 Emotional stress
 Changes in climate.

P a g e |50 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 Quickening
This refers to the 1st fetal movements felt by the mother. Usually occurs between
16th – 20th weeks of gestation. It is usually felt when the fetus has risen from the
pelvis and is in contact with the abdominal walls.
Other causes can be intestinal movement with gas or psychological.
 Skin changes
Involves the development of striae gravidarum and linea nigra.
Other causes could be weight gain or infections.
2. Probable signs
a) Presence of HCG hormone
It is present in blood on the 9th and 10th day and in urine on the 14th day.
Other causes include
 Chorio amnionitis
 Turmor of the chorionic membrane
 Hydatidform mole

b) Abdominal enlargement
In pregnancy this is due to enlargement of the fetus in the uterus. The abdomen
becomes soft and globular in shape and occurs from 8 th week of gestation.
Other causes include
 Fats
 Flatus
 Fluids
 Food
 Fetus
 Turmor
c) Braxton hicks contractions
These are false contractions. In pregnancy they occur from 16 th to 20th week of
gestation. They are painless though might be uncomfortable. They in about every
15 minutes and increases in intensity at 38 th week. They are irregular, take a short
time, pain does not increase and pressure does not build.
Functions.
 Facilitate blood circulation in the uterus
 Assist in the formation of upper and lower uterine segment
 Assist in the circulation of fluid within the uterus
 Assist in cervical effacement
 Prepare the Myometrium cells for labour.

d) Softening of the cervix

Starts from the 10th week onwards. The consistency feels like lips. The cervix of a
non- gravid uterus feels like the top of the nose.

e) Internal ballottement
Two fingers are inserted into the vagina. The cervix os given a sharp tap and this
causes the fetus to float upwards into the amniotic fluid and hit the fundus.

P a g e |51 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 f) Positive Hegar,s signs
Present from 6th to 12th week. Fingers are inserted into the vagina and the other
hand is placed behind the uterus abdominally. With minimal pressure both hands
almost meet because of extreme softness of the isthmus.

g) Positive Osiender,s sign

There is increased pulsation is the lateral fornices of the vagina due to increased
vascularity. It starts on the 8th week onwards. Other causes can be the presence of
a turmor.

h) Positive Jacquimer,s signs.

This is bluing of the vagina. Vaginal mucosa appears blue in blacks and purple in
whites. Starts from the 8th weeks.
3. Positive signs
a) Visualization of the fetus.
Done through
i. Ultra sound by the 6th week which can reveal a fetal sac.
ii. X-ray by 16th week gestation can reveal fetal skeleton

b) Fetal heart sound

Heard through
i. Ultra sound by 6th week
ii. Use of Doppler by the 8th week.
iii. Use of fetal scope by 20th to 24th week

c) Palpation of fetal parts by the 20th week

d) Visualization of fetal movements towards term.

PHYSIOLOGICAL CHANGES DURING PREGNANCY

In the body every tissue organ reacts to the stimulus of pregnancy.
The normal body’s metabolic, chemical & endocrine balance is altered. Therefore
changes are not only confined in the reproductive system.
1. CHANGES TO THE REPRODUCTIVE SYSTEM
A. AMENORRHOEA
This is the absence of menses, interrupted according to regularity of menses before.
B. THE UTERUS
It enlarges and gives nourishment to the fetus. This is brought about by the
development of desidua which is under the influence of progesterone and oestrogen
hormone.
It provides glycogen rich environment for the blastocyst to develop until the
trophoblastic cells begin to form the placenta.
Changes to the myometrium
(a) Size
The muscle fibres atrophy and increase in size which is called hypertrophy.
(b) Number
The muscle fibres increase in number in a process known as hyperplasia.
(c) Measurement
The uterus increases from 7.5x5x2.5 to 30x23x20cm.

P a g e |52 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
(d) Weight
Non- gravid uterus which is around 60gms will increase to 900gms.
(e) Shape
It is globular at 12th week and will change to ovoid at term.
(f) Blood supply/Vascularity
Blood supply to the uterus increases.
C. CERVIX
The cervix and isthmus develop to form the lower uterine segment.
The cervix becomes softer under the influence of progesterone hormone, it’s
secretes, which is thicker and is more during pregnancy which forms a cervical plug
called operculum.
Functions of operculum
(a) Acts as a barrier to ascending micro – organisms.
The oestrogen increases cervical vascularity making it look bluish in blacks & purple
in white people.
Growth and development of the uterus during pregnancy (fundal height)
1 – 8 Week
The uterus is not palpable since it is still a pelvic organ.
12th Week
The uterus grows and rotates to the right due to a descending colon.
The fundus of the uterus can now be palpated abdominal at the level of pubic line,
shape becomes globular.
18 Week
The fundus of the uterus is palpable between the symphysis pubis and umbilicus
when the woman is lying down.
20th Week
Fundus is palpable on the mid line of the umbilicus.
24th Week
Fundus is palpable on the upper margin of the umbilicus. The midwife can feel fetal
parts on palpation.
28th – 30th Week
Fundus is palpable at the midway between umbilicus and xiphisternum.
37 – 40 Week
Fundus starts descending at a rate of 1cm per week (accommodating 1 finger per
week) and this is referred to as lightening.
Lightening is due to:-
a) Softening of the pelvic floor muscles.
b) Softening of pelvic joints.
c) Reduction in the amount of liquor.

P a g e |53 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
D. VULVA AND VAGINA
During pregnancy there is increased collagen tissue in the vagina, resulting to
increase in volume.
There is increased blood supply which makes the epithelium to appear blue and
blacks.
Potential hydrogen level (PH) changes from acidity to alkalinity.
Vagina becomes moist and more glucose.
Length of vagina increases.
E. THE BREASTS

3rd – 4th Week

There is needle like sensation around the nipple.
6th Week
There is development of ducts and glands causing the breast to enlarge & become
painful tender.
8th Week
Surface veins are becoming visible. Montgomery’s tubercles develop which are
about 20.
12th Week
There is darkening of primary areolar about 4cm from nipple some fluid can be
expressed from the breast.
16th Week
Colostrum can be expressed. Secondary areolar appears. During late pregnancy
colostrums may leak from the breast. Progesterone will cause the nipple to become
more prominent.

2. CHANGES TO CARDIOVASCULAR SYSTEM

a) The heart
It may be displaced upwards to left side due to the increased pressure of the
growing and raised diaphragm. The heart size may slightly increase.
b) Cardiac output
It increases from 5 – 7 liters per minute. It is increased by 40% by the 16 th week
gestation. This is because of dilation of blood vessels caused by progesterone and
haemodilution.
P a g e |54 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
c) Blood cells (RBC)
The blood cell volume of RBC in circulation increases due to increased O 2
requirement made by maternal and placental tissue.
Haemoglobin is lowered due to un-proportional increase of plasma to red blood cells
Plasma volume
Increases from 6th – 8th week gestation and reaches maximum 32nd – 34th week until
term.
This increase in plasma volume is not directly to the increase of RBC leading to a
condition known as Haemodilution. The blood becomes less thick so that it can
diffuse effectively on placental bed and also reduce cardiac load.
Hemoglobin level should be checked to all pregnant women during the first visit and
between 28th – 35thweek of gestation.
d) Iron
Its demand is greatest in the last 4 weeks of gestation. This is to coup up with the
growing needs of fetus.
e) Clotting factors
Clotting factors and fibrinogen increases accompanied by reduction in plasma
fibrinolytic activity.
From 12 weeks gestation there is an increase of 50% in the synthesis of plasma
fibrinogen concentration. It is critical in the prevention of haemorrhage at the time
of placental separation.
f) White blood cells
The neutrophils and immunoglobins decreases. This leads to lowered body
immunity.
3. Changes to respiratory system
The amount of air inhaled increases from 7 – 11c per min. The blood volume and
vasodilatation leads to hyperraemia and oedema of the upper respiratory mucosa.
This can lead to nasal congestion, epistaxis and changes of voice.
Over 70% of women with no known respiratory tract problem might experience
some shortness of breath.
The ribcage is displaced with around 4cm upwards due to enlarged fetus.
The shape changes with antero- posterior diameter increasing by 2cm result into 5 –
7cm.
The elevation of diaphragm reduces chest cavity by 5%.
The ribs will flayer out leading to increased alveolar expansion during respiration
thus enhances gaseous exchange.
Towards term the breathing becomes more diaphramic.

4. Changes to urinal system/Renal

Due to the increase in total blood volume renal blood flow increases, this cause a
swelling of the kidneys so that they appear large on ultrasonography.
The overall dimensions of the kidney increases by approximately 1cm and renal
volume increases by as much as 30%.
The dilated collecting system can hold up to 300ml of urine, serving as an excellent
reservoir for bacteria.
As the uterus rises out of the pelvis it rests on the ureters laterally displacing and
compressing them at the pelvic brim.

P a g e |55 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 During the last half of pregnancy, the upper portion of the ureters above the pelvic
brim elongate and become more tortuous, being thrown into single or double curves
of varying sizes.
Dilatation of the ureters is possibly due to mechanical compression by the enlarging
uterus and ovarian plexus.
Dilation is more marked on the right side than on the left, because of the cushioning
effect of the sigmoid colon.
In summary the changes are:
 Dilatation of the ureters
 Compression/ kinking of the ureters
 Increased micturation
 Back flow of urine
 Elongation of the ureters
5. Physical changes to nervous system
There are emotional and psychological adjustments which may lead to:-
 Mind depression
 Inability to coup with emotional stress.
 Irritability
6. Psychological changes to the gastro-intestine tract
Usually nutritional requirements increase e.g. vitamins and minerals.

The woman might experience the following changes

(i) Gingivitis (iv) Slow peristalsis (vi) Pica
(ii) Ptyalism movement (vii) Hemorrhoids
(iii) Heartburn (v) Constipation (viii) Nausea and vomiting
 Gingivitis
This is inflammation of the gums. They may bleed easily and tooth decay may
occur. All this is due to increased systematic oestrogen and lack of vitamin C.
 Ptyalism
Excessive salivation, there is increased salivation and is common due to indigested
starch and hormonal changes in the body.
 Pica
This is when there is eating of unfoods. There is craving for natural substances e.g.
starch, clay, soil, ash, soap, charcoal, unripe mangoes, chalk.
 Heartburn
It is associated with gastric reflex due to relaxation of cardiac sphincter muscle in
the oesphagus. Progesterone will relax the smooth muscle of the gastro-intestinal
tract and can lead to this. During late pregnancy the pressure of the growing fundus
on the uterus may predispose to the same condition.
 Constipation
This is due to slow gastric motility.
 Hemorrhoids
These are as a result of relaxing effect of progesterone hormone on the smooth
muscles of the walls of the veins in the rectum. Constipation may also contribute to
this condition.
 Nausea and vomiting
This is mostly associated with introduction of human HCGH. It is severe when the
woman is carrying more than one fetus or in cases abnormalities. However other
causes can also lead to this condition.
P a g e |56 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
 7. Changes in the endocrine system
FSH and LH hormones are inhibited due to the levels of oestrogen and progesterone
in circulation.
More insulin is produced to ensure certain glucose level of the fetus.
There is introduction of placental hormone and other hormones which includes:-
(a) Human chronic gonadotrophic hormone- analog to LH. Prevents immunological
rejection of the fetus. Maintains placental development.
(b)Oestrogen and progesterone
(c) Human placental lactogen. General body levels of these hormones increase.
(d)Human placental insulinase.
(e) There is production of corticosteroids leading to increased glucose in urine
(glucosurial)
(f) Production of glucocorticoids (corticosterone and cortisol) by the fetal adrenals.
(g)Production of prolactin- in pregnancy to maintain life of corpus luteum and
lactogenic after delivery.
(h)The increased production of oxytocin hormone.
(i) Prostaglandins (alpha a beta) from the fetal membranes and cervix.
(j) Increased insulin production
(k) Others include placental TSH, placental ACTH and peptides such as relaxin.
There is high maternal metabolism due to increased consumption of O 2 by the fetus.
8. Physical changes to the skin
They include:-
(i) Striaegravidarum
(ii) Linear nigra
(iii) Chloasma/melasma gravidarum.
(iv) Sweating.
 Striae gravidarum
These marks are dark during pregnancy and change to silver white after delivery.
They appear like lines across the abdomen, can be found in the breast, abdomen
and thighs. On subsequent pregnancy appears glittery silver lining.
Causes
 Increase corticosteroids.
 Deep layer of epidermis rapture and is thinned out to produce these scars.
 Linear Nigra
Pigmented line developing from the pubis to umbilicus.
It becomes well marked during pregnancy.
 Chloasma
These are patch colouring on the face and are also known as marks of pregnancy.
They fade a few months after delivery and can intensify in a repeated pregnancy.
 Sweating
This is due to presence of increased blood supply to the skin and progesterone
raising body temp by 0.50c
9. Oedema
Oedema is classified into two classes:
(i) Psychological oedema
(ii) Pathological oedema
 Psychological oedema
P a g e |57 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
This comes in as a result of pregnancy alone.
This oedema disappears with rest and is rarely present in the morning. In about
40% of women pregnant have oedema of the ankle.

Causes include:-
(a) Reduction of plasma protein.
(b) High progesterone level.
(c) Poor veins return

PATHOLOGICAL OEDEMA
It is associated with medical condition e.g. disease during pregnancy i.e. cardiac
disease, hypertension, anaemia, malnutrition.
Sites for oedema
 Face  Ankle  Feet
 Abdomen  Wrist  Toes
 Sacrum  Tibia  Vulva

P a g e |58 March 2017 class- Supporting reduction of maternal and newborn morbidity and mortality
MINOR DISORDERS IN PREGNANCY AND THEIR MANAGEMENT
Disorders of GIT include
 Indigestion
 Ptyalism
 Nausea and vomiting
 Hemorrhoids
 Pica
 Constipation
1. INDIGESTION
• Usually accompanied by pain in the lower chest or abdomen after eating.
• Progesterone hormone causes relaxation of the gut and decreases peristalsis.
• The growing uterus also applies some pressure
Management
• Take oral fluids, fresh fruits, vegetables and high roughages.
• Advice the mother to take a glass of warm water before taking breakfast
• Encourage on exercise.
• Give the mother anti acids because indigestion can cause heart burn.
2. PICA
• Craving for non-food.
• Find out the type of food being craved for if harmful to the body.
• Advice the mother to take a balanced diet.
• Give iron and folic acid supplements.
3. PTYALISM
• Excessive salivation
• It is caused by hormonal changes
• Listen and explain to the mother.
• Re assure the mother
• Ask the mother to avoid drugs
• Emphasize on hygiene.
4. NAUSEA AND VOMITING
• Caused by the presence of HCGH.
• Also referred to as morning sickness but can be seen throughout the day.
• Advice the mother to avoid spiced foods
• Eat small quantities frequently
• Eat salads
• Take adequate fluids to avoid dehydration.
• Increase sugar intake for prevention against hypoglycemia.
• Mother to avoid fried, high fat content foods.
• Also can be prescribed anti- emetic drugs
• Do a blood slide to rule out malaria
• If the condition becomes severe the woman should be admitted in the ward.
• If unmanageable advocate for an abortion
• If severe can lead to liver damage.
5. HEART BURN
• This is a burning sensation in the esophagus.
• Caused by relaxation of the cardiac sphincter and pressure of the growing
uterus.
• Avoid fatty foods
• Take smaller meals more frequently
• Avoid foods causing heart burn
• Not to lie flat
• Take anti acids
• Take sips of milk
6. CONSTIPATION
• Caused by lack of roughages, dietary changes during pregnancy, inadequate
fluids and effect of estrogen and progesterone.
• Iron supplements to be administered
• Take diet rich in fiber
• Adequate fluid intake to keep stool soft and easy to pass.
• Exercise regularly
• Eat whole grain and raw unpeeled fruits.
• Eat bananas bulking
• Eat honey for lubrication of the rectum
• Abdominal massage with mandarine oil from pubic bone to umbilicus to
facilitate defecation.
7. HEMORRHOIDS
• Varicose veins on the lower rectum and anus.
• Caused by constipation during pregnancy.
• The woman can use lubricants.

ANTENATAL CARE
This is the routine care provided to a pregnant woman and her unborn
baby from conception until delivery which involves regular check- up by
a medical practitioner or midwife.
Objectives of antenatal care.
1. Monitor the health of the mother during pregnancy.
2. Identify the high risk cares and appropriate management.
3. Prevent development of complications.
4. Detect associated medical, surgical, and gynecological disorders.
5. Decrease maternal and infant mortality and morbidity.
6. Remove the stress and worries of the woman regarding the
delivery process.
7. Prepare the mother for labour and delivery
8. Advice about child care and family planning.
9. Care of under-fives accompanying pregnant mothers.
10. Screen for cancer of breast and genital tract.

Strategies
1. Creating rapport/ good interpersonal relationship.
2. Good communication skills
3. Provide a woman centered approach
4. History taking.
5. Physical examination.
6. Routine investigations/ screening.
7. Provision of relevant health messages.
8. Promote effective referrals.
9. Male involvement
10. Conducting clinic and home visiting.
Underlying cause of maternal and neonatal mortality
There are three levels of delay that contribute to maternal morbidity
and mortality
 Delay in deciding to seek appropriate care.
 Delay in reaching an appropriate health care facility.
 Delay in receiving adequate emergency care at the facility.

FOCUSED ANTENATAL CARE

- It is personalised care provided to a pregnant woman which emphasises on
the woman’s overall health, her preparation for childbirth and readiness for
complications (emergency preparedness).
- It is timely, friendly, simple and safe service to a pregnant woman.
 FANC emphasizes that a woman should have at least four visits to the clinic
during pregnancy.

ELEMENTS OR AIMS OF FANC

1. To promote and maintain good physical, mental and social health during
pregnancy. This is done by education on:-
 How to recognize danger signs,
 what to do, and where to get help
 Good nutrition and the importance of rest
 Hygiene and infection prevention practices
 Risks of using tobacco, alcohol, local drugs, and traditional remedies
 Breastfeeding
 Postpartum family planning and birth spacing.
2.To detect early and treat any arising complications during pregnancy (medical,
surgical or obstetrical)
o This is done through good history taking, observations, investigations,
examination and follow-up care.
3.To promote safe delivery of a healthy baby with minimal stress and injury to the
mother and the baby.
This is possible through monitoring, encouraging pregnant women in ANC,
monitoring fetal growth and well- being during pregnancy, advising mothers to
avoid harmful substances and promoting rest.
4. To prepare mothers for labor, lactation and normal peurperium- teach the woman
about labor, child care and events that follows child birth
5. To ensure that the pregnant woman makes an individual birth plan-counsel and
educate the woman on delivery, need to plan for delivery i.e. emergency
preparedness, where she plans to deliver, mode of transport, financial arrangement,
e.t.c.
Booking visit
 This is the first visit a pregnant woman makes to the antenatal clinic.
Objectives of the visit
1. To assess the level of health by taking a detailed history and employing
screening tests or appropriate tests that are necessary.
2. To make baseline recordings of weight, height, blood pressure and
haemoglobin levels in order to assess normality. These values are used for
comparison in subsequent visits
3. To indentify risk factors by taking accurate details of past and present
obstetric and medical history.
4. To provide an opportunity for the woman and her family to express any
concerns they might have regarding the pregnancy and previous obstetrical
experience.
5. To give advice on general health matters and those pertaining to pregnancy
in order to maintain the health of the mother and development of the fetus.
6. To begin building a trusting relationship in which realistic plans of care are
discussed.
Activities during the first antenatal visit
1. Registration and triage
2. Weight and height measurements
3. Taking history
4. Physical examination
5. Laboratory investigations
6. PMTCT
7. Prophylaxis treatment/ net provision
8. Immunization
9. Management of minor disorders
10. Health education
11. Booking for the next visit

REGISTRATION AND TRIAGE

Once the antenatal woman arrives at the clinic registration will be done. She will be
given registration number. The health worker will at the same triage the woman she
comes so as to take any necessary action if required. In case the woman is fitting,
bleeding per vaginal, draining liquor e.t.c. then an immediate action will need to be
 taken and the woman will not be left to queue. All the people working at the
antenatal clinic need to have this information.
WEIGHT AND HEIGHT MEASUREMENTS
The heath worker will take the woman’s weight. This will form a baseline in the
management of the woman during the follow up visits. An average weight gain of
12.5 kg is expected during pregnancy. 3.5kgs during the first 20 weeks and 9 kgs
during the last 20 weeks. This is to detect any complications.
Height is important to be recorded. Women with a height below 145 cms are
associated with cephalo pelvic disproportion.
HISTORY TAKING.
Welcome the woman, create good rapport and then take
history in a quiet, private way.
GUIDELINES FOR HISTORY TAKING.
Several forms of history are taken:-
1. PERSONAL HISTORY
 Name
 Age
 Nationality
 Marital status
 Occupation- self/husband’s/parents
 Residential address
 Home address
 Physical address
 Phone number
 Educational level
 Staple food
 Social behavior e.g. hobbies, smoking and drinking- self/ husband
2. FAMILY HISTORY
 History of multiple pregnancies.
 History of chronic illnesses e.g.
I. Diabetes
II. Hypertension
III. Tuberculosis
IV. Asthma
V. Epilepsy
VI. Psychiatric disorders
VII. Sickle cell
VIII. Known HIV status
3. MEDICAL/ SURGICAL HISTORY
 Past and present illness
 chronic illnesses
 Any admission
 Major operations done
 Any transfusion
 Drug reaction
 Blood transfusion
 Diseases or operation involving the pelvis
 Immunization history
 History of FGM
4. PAST OBSTETRIC HISTORY
 Menarche
 Age at first pregnancy
 Number of pregnancies
 Any abortion/ miscarriage and whether MVA/ D&C was done
 Clinic attendance
 Mode of delivery- SVD/CS and indication
 Gestation at birth
 Duration of labour
 Dates of birth
 Place of birth- hospital/ home
 Sex of children- male/ female
 Weight at birth
 Fate of children- alive/ dead/ any congenital abnormalities
 Third stage of labour
 Peurperium
 Any family planning method use

5. PRESENT OBSTETRIC HISTORY

 Parity
 Gravida
 Last monthly period- LMP
 Expected day of delivery- EDD
  Maturity by dates
 Clinic attendance
 Present complaints/ complications

NOTE:
History of pregnancy related illnesses, other risks such as multiparity, age above 35
years or below 16 years and any history of harmful habits such as smoking.
Calculate the maturity by date
OBSERVATIONS
a) Take the height at first visit only and record it in the clinic card. Women of
150 cm and below, those who are limping or have abnormal gait are at risk of
having contracted pelvis.
b) Weight- should be taken as early as possible in pregnancy and then compared
with that of subsequent visits
c) Blood pressure- should be recorded as early as possible and then comparison
done during subsequent visits.

PHYSICAL EXAMINATION
 A general head to toe examination is carried out to:-
a) Help detect abnormalities and take appropriate action.
b) Help give advice, health education, psychological support and reassurance in
line with the findings.
c) To help students develop competency in the examination.
Refer to procedure manual for general examination procedure.
ABDOMINAL EXAMINATION
 Aims:
1. To observe signs of pregnancy
2. To assess fetal size and growth
3. To diagnose the location of fetal parts
4. To detect any deviation from normal

Preparation.
Conduct general examination first. Abdominal examination is done with mother
lying in a supine position. She should empty the bladder first and privacy
maintained
METHOD APPLIED
1. Inspection
2. Palpation
3. Auscultation
i. Inspection.
 Inspect the abdomen for:
 Size-
 Shape
 Fetal movements
 Contour of the abdominal wall
 Skin changes- note any stretch marks, presence of linea nigra, fenesteal scars
e.t.c.
ii. Palpation
A maneuver done on the abdomen of a pregnant woman with clean and warm
hands to determine:
a. Fundal height
b. Fetal presentation
c. Lie
d. Position
e. Level of engagement
METHODS OF PERFORMING ABDOMINAL PALPATION.
1) Fundal palpation
2) Lateral palpation.
3) Pelvic palpation.

a. FUNDAL PALPATION
Done to estimate fundal height and thus, gestation.
Place your hand below the xiphisternum, pressing gently and move down until you
feel the curved upper boarder of the fundus. Note the number of finger breaths that
can be accommodated between the two surfaces.
To determine the presentation, the fundus will contain either the head or breech.
The head is distinctive in shape and more firm than the breech which is soft and
irregular.
b. LATERAL PALPATION.
- To determine the position, the fetal back should be located and this is
achieved through lateral palpation.
- The midwife places her hands at either side of uterus at the level of umbilicus
- Apply pressure with alternate hands in order to determine which side of the
uterus offers greater resistance.
- The back is marked out as a smooth continuous resistant mass from the
breech to the neck and the limbs as parts that slip about under the examining
fingers. One hand should steady the uterus while the other palpates

c. PELVIC PALPATION.
- This is to ascertain presentation, engagement and attitude.
- Ask the woman to relax and slightly bend her knees, and steadily breathe
through open mouth.
- Grasp the sides of uterus just below the umbilicus between the palms of the
hand with fingers held close together pointing downwards and inwards.
- The head is felt as a hard mass with a distinctive round smooth surface.
- To estimate the engagement, feel how much of the head is palpable above
the pelvic brim. Alternatively, Pawliks maneuver is used- grasp the head between
the fingers and the thumb and find if it is movable.
Note:
Gestation age- predicted gestational age should correspond to the fundal height. In
singleton pregnancy, the uterus reaches the level of umbilicus at 20-24 weeks and
at the sternum at 36 weeks. Multiple pregnancy should be diagnosed by 24 th week.
LIE
- It is the relationship between the long axis of the fetus and the long axis of
the uterus.
 - The lie may be:-
 Longitudinal-the fetus lies along the uterine long axis. occurs in 99.5%
 Oblique- the fetus lies diagonally across the long axis of the uterus
 Transverse- the fetus lies at right angles to the long axis of the uterus
Attitude
- This is the relationship of the fetal head and limbs to its trunk.
- The attitude can be that of flexion or extension or neutral.
Presentation
- Refers to the part of the fetus that lies at the lower uterine pole/ segment.
- Presentation can be:-
› Vertex- 96.8%
› Breech- 2.5%
› Shoulder-0.4%
› Face-0.2%
› Brow- 0.1%
- Brow, face and vertex are all cephalic presentations.
Denominator
It is the name given to the part of the presentation which is used when referring to
the fetal position. Each presentation has a different denominator.
Presentation denominator
› Vertex occiput
› Breech sacrum
› Face mentum
› Shoulder acromion/dorsum
Position
 It is the relationship between the denominator of the fetal skull and the fixed
six positions (land marks) of the pelvic brim e.g. in the left occipital anterior (LOA),
the occiput points to the left illio- pectineal eminence and the saggital suture lies in
the oblique diameter of the pelvis
 Assignment- read and make notes on other positions i.e. ROA, ROP, ROL, LOP,
ROL
Presenting part
- The part of the fetal head that lies over the cervical os during labor
Engagement
- Said to occur when the largest diameter has passed the pelvic brim. It can be
assessed as descent abdominally or in relation to the ischial spines.
- All the findings are recorded and appropriate action taken according to the
findings.
iii. Auscultation.
- Used to assess fetal well-being.
- Done using Pinard’s fetal scope.
- Move the fetal scope around until the point of maximum intensity is
determined.
- The fetal heart beats are more rapid than the mother’s.
- Ask the mother about fetal movements. Cover the mother and explain the
findings to her.
LABORATORY INVESTIGATIONS- ANTENATAL PROFILE
a) Urinalysis- test urine for
-Leukocytes to rule out infection
- Proteins to rule out pre- eclampsia
- Sugar to rule out diabetes in pregnancy
b) Blood tests to check for
-Blood grouping and Rhesus factor
- Hemoglobin level
- Khan test to rule out syphilis
- HIV test
- Blood slide (BS) to check for malaria parasites.
c) Stool- test for ova of cyst to rule out hookworm.
NOTE: stool for ova and cyst is not part of routine antenatal profile. It is indicated to
all pregnant women with history of gastro enteritis or diagnosed with severe
anemia.
d) Rule out tuberculosis.
Take history suspected for tuberculosis by evaluating the following:
- Cough for more than 2 weeks.
- Loss of weight
- Night sweats
- Fever
- Enlarged lymph node.
In case you suspect tuberculosis refer the woman for sputum examination.
NOTE: The following test can be done at the antenatal room as rapid diagnostic
tests (RDT)
- Blood slide for malaria parasites
- Hiv test
- Hemoglobin level
- Urinalysis
- Khan test (RPR)

PREVENTIVE SERVICES
 Administration of mebendazole stat 500mg after 1st trimester.
 Provision LLNT/ ITN and advice on use
 Provision of heametenics- ferrous sulphate and folic acid.
 ARVs for reactive mothers as per latest guidelines.
 Administration of tetanus toxoid as per guideline. The objective is to prevent
maternal and neonatal tetanus, which is one of the causes of maternal and neonatal
mobidity and mortality.
Schedule for tetanus toxoid administration.
Dose Tetanus toxoid to non- Tetanus toxoid to
gravid women pregnant women
1st dose At contact At contact
2nd dose 4 weeks after 1st dose 4 weeks after 1st dose
3rd dose 6 months after 2nd dose During 2nd pregnancy
4th dose 1 year after 3rd dose During 3rd pregnancy
5th dose 1 year after 4th dose During 4th pregnancy

 Administration of SP every 4 weeks after quickening.

The Ministry of Health Guidelines on Malaria in pregnancy directs us to give SP to
pregnant women in endemic malaria areas, at least twice during each pregnancy,
even if she has no physical signs and her haemoglobin is within normal range.
SP is a combination of two different drugs.
One tablet of SP contains 500 mg of Sulfadoxine and 25 mg of Pyrimethamine.
A single dose consists of 3 tablets of SP taken at one time.
Fansidar is the most common brand name.
Note: all women from endemic areas with fever should be treated as malaria in
pregnancy and receive treatment regardless of results from MrDT.

POINTS TO REMEMBER WHILE PROVIDING SP TO A PREGNANT WOMAN.

 Ask client about gestational age to determine that client is at least 16
weeks pregnant. If she is not certain of her dates, ask her if and when she felt the
baby move (Quickening). Quickening is a rough estimate of the onset of the
second trimester.
 Ask about a history of severe skin rash or mucous membrane ulceration
with sulpha drugs (If she has had a severe reaction to sulpha drug, do not give SP
and make sure allergy is clearly marked on her antenatal card).
 Give client 3 tablets of SP as DOT with clean and safe drinking water ( can
be given on an empty stomach )
 Withhold high dose of folic acid use for 2 weeks.
 If HIV positive and on seprin (cotrimoxazole) prophylaxis she should not
receive SP.
 Ask client to return for the second dose after 4 weeks.
 She should also come back if she has side effects.
DISCUSS WITH THE MOTHER THE FOLLOWING HEALTH MESSAGES
 Dangers signs
 Individual birth plan
 Contraceptive services
 HIV and AIDS
 Breast feeding
 Clinic attendance
 Hospital delivery
 Nutrition
 Newborn care
 Importance of ANC card/ booklet
 Effects of FGM to child birth
Recording the findings
 Recording should be done on ANC card and clinic book.
 The mother should carry the card home and instructed to always carry it to
the clinic during the visit.
 Always advice the mother to maintain the card well.

WORLD HEALTH ORGANIZATION (WHO) RECOMMENDED ANTENATAL

APPOINTMENTS.

First contact

When you realize you are pregnant you need to visit the clinic. The activities during
this visit include:

 Confirming pregnancy
 Screening for infections
 Rule our risk factors e.g. pregnancy related conditions during previous
pregnancy

 advocate for folic acid administration

 Counsel on stoppage of smoking, taking alcohol and un prescribed drugs.

 confirm immunization status

 Some tests, such as screening for sickle cell and thalassaemia

 advice on diet

8- 12 weeks

 educate on diet
 test for protein in urine

 take blood pressure

 check BMI

 counsel on benefits antenatal clinic attendance

 do a scan to confirm when baby is due

 Take history/ assess level of risk

 educate you about pregnancy

8- 14 weeks

This is the ultrasound scan to estimate when your baby is due, check the physical
development of your baby, and screen for possible abnormalities including Down's
syndrome.

16 weeks

The following will be done,

 Counseling on the anomaly scan to be done on the 18- 20 weeks visit.

 review, discuss and record the results of any screening tests

 measure your blood pressure and test your urine for protein

 consider an iron supplement if you're anaemic

18- 20 weeks
The following activities will be carried out,

 Anomaly scan
 Screen for HIV, syphilis, and hepatitis B

 Administration of whooping cough vaccine.

 Review results from routine tests done.

25 weeks

 use a tape measure to measure the size of your uterus

 measure your blood pressure and test your urine for protein

28 weeks

 use a tape measure to measure the size of your uterus

 measure your blood pressure and test your urine for protein

 offer more screening tests

 offer your first anti-D treatment if you are rhesus negative

 Consider an iron supplement if you're anaemic.

31 weeks

 review, discuss and record the results of any screening tests from the last
appointment
 use a tape measure to measure the size of your uterus

 measure your blood pressure and test your urine for protein

34 weeks

Your midwife or doctor should:

 Discuss about labour recognition, birth plan and pain management.

 review, discuss and record the results of any screening tests from the last
appointment

 use a tape measure to measure the size of your uterus

 measure your blood pressure and test your urine for protein

 offer your second anti-D treatment if you are rhesus negative

 Information about caesarean section.

36 weeks
Midwife should give you information about:

 breastfeeding
 caring for your newborn baby

 vitamin K and screening tests for your newborn baby

 your own health after your baby is born

 The "baby blues" and postnatal depression.

 Use a tape measure to measure the size of your uterus.

 Check the position of your baby.

 Measure your blood pressure and test your urine for protein.

 offer external cephalic version (ECV) if your baby is in the breech position

38 weeks

 Midwife will discuss the options and choices about what happens if your
pregnancy lasts longer than 41 weeks.
 use a tape measure to measure the size of your uterus

 measure your blood pressure and test your urine for protein

40 weeks

 You will have an appointment at 40 weeks if this is your first baby.

 Your midwife or doctor should give you more information about what happens
if your pregnancy lasts longer than 41 weeks.

 use a tape measure to measure the size of your uterus

 measure your blood pressure and test your urine for protein

41 weeks

Your midwife or doctor should:

 use a tape measure to measure the size of your uterus

 measure your blood pressure and test your urine for protein

 offer a membrane sweep

 discuss the options and choices for induction of labour

42 weeks

If you have not had your baby by 42 weeks and have chosen not to have an
induction, you should be offered increased monitoring of the baby.

LABOUR AND CHILD BIRTH

CHAPTER 1: LABOUR.
By the end of the session the trainee is should be able to,
1. Define the following terms, labour and normal labour.
2. Describe causes of onset of labour.
3. Describe signs of labour and diagnose a woman in labour.
4. Describe stages of labour.
5. Describe changes during labour- physiological and mechanical.

1.1.1 Labour
It is the onset of coordinated, involuntary, sequent, painful uterine contractions
accompanied by cervical effacement and dilatation after 24 weeks of pregnancy.
1.1.2. Normal labour
It is the onset of coordinated, involuntary, sequent, painful uterine contractions at
term accompanied by progressive cervical effacement and dilatation to expel the
fetus, placenta and membranes through the birth canal spontaneously with fetus
presenting by vertex and the process does not exceed 19 hours or 12 hours of
established labour with no complications to the mother and baby.
Note:
Normal labour is aimed at delivering a normal baby with minimal trauma to the
mother. Labour is painful so the midwife caring for the mother in labour should be
able to provide good psychological and emotional support so that the mother will be
able to cooperate throughout labour.

1.2 causes of onset of labour

What causes labour is not known but the main factors thought to be causing labour
are divided into two:-
a. Mechanical factors
b. Hormonal factors

1.2.1 Mechanical factors

1. Labour starts at term due to overstretching and over distension of uterus.

This explains why mother for example will multiple pregnancies or a condition such
as polyhydromnous tend to go into premature labour.

2. The pressure of the presenting part on the nerve ending of the cervix.
Lightening plays part of bringing about onset of labour e.g. labour is more likely to
start when the presenting part is engaged than when it is still high.

1.2.2 Hormonal factors

1. Diminished efficiency of the placenta.
The placenta efficiency is diminished toward term resulting in reduction in levels of
oestrogen and progesterone hormones. Progesterone being the hormone that
supports pregnancy is withdrawn. The uterus becomes sensitive to this effect
leading to onset of labour.

2. Oxytocin stimulation on uterus

The main sources of oxytocin are the brain and placenta. The placental production
of oxytocin increases towards term much more so as labour to start. The number of
oxytocin receiptors in the myometrium also increases a hundred- fold during labour.
Also due to low production of oestrogen and progesterone hormones, oxytocin from
the posterior pituitary gland is produced which binds with the oxytocin receiptors at
the myometrium stimulating action on a pregnant uterus to cause onset of labour.

3. Production of prostaglandins.
Prostaglandins are thought to be produced in the desidua and placental membranes
and myometrial cells at term in response to the withdrawal of oestrogen by fetal
placental unit. The local release of prostaglandins from the desidua causes of onset
of labour. Prostaglandins facilitate cervical ripening. It causes an effect on the
mucopolysaccharide forming part of the basic cervical substance hence softening
the ready for dilatation. It also influences vasoconstriction and entry of calcium
intercellular space initiating electrical connections and contractions.
Natural can also be found in semen and amniotic fluid.
Note: in the market there is synthetic form of prostaglandins e.g. misoprostal
administration of prostaglandins can be IV, oral, vaginal, rectal or intramyometrial.

4. Fetal adrenals
Fetal adrenals produce glucocorticoids e.g. corticosterone and cortisol. The
production starts as early as 8 weeks gestation and increase during pregnancy. At a
certain level of high fetal adrenal steroids it triggers the mechanism leading to
onset of labour.
5. The onset of labour is also associated with hyperpyrexia, stress and cyanosis.
1.2 Signs of labour
The signs of labour are grouped into 2:-
i. Premonitory signs
ii. True signs
1.3.1 Premonitory signs
These are signs that the woman is likely to experience when the woman is
approaching the end of the road to the pregnancy and onset of labour to begin.
Some of them might make a woman who is pregnant for the first time report to the
labour ward. However these signs do not signify labour. These include,
1. Lightening
It occurs 2 – 3 weeks before onset of labour. This is the sinking of the uterus into
the pelvis. The fundus on longer presses the diaphragm and breathing becomes
easier. The heart and the stomach functions become better. The pressure from the
uterus on the urinary bladder increases causing frequency in micturation. Walking
is difficult as the symphisis pubis is more mobile. There is backache and discomfort
in the lower abdomen, groin and thighs.

2. Frequency in micturation.
This is due to pressure from the presenting part on the urinary bladder limiting its
capacity.

3. False pains.
Towards term the woman may experience but not related to labour. These pains are
irregular, intermittent causing the uterus to contract and relax with no cervical
dilation and effacement. There is no increase in frequency, intensity and duration
of the contractions. The pain may be localized on the abdomen and groin and can
be stronger when the woman is lying down in bed and may be reduced by
ambulation. However this pain is very important since it assist in the ripening of the
cervix and preparation of the myometrium for labour. Show is absent.

4. Talking up to the cervix.

The cervix becomes soft and drawn up and gradually emerges into lower uterine
segment.

5. Loss of maternal weight.

Most of the pregnant women tend to lose weight towards the end of the pregnancy.
1.4 Stages of labor
There are four stages of labour namely:-
a. 1st stage
b. 2nd stage
c. 3rd Stage
d. 4th stage
1.4.1 1st Stage of labour
- It is from the onset of labour to full cervical dilatation (10cm)
- It takes 19 hours or 12 hours of established labour.
- It is dominated by contractions and retractions with progressive cervical
dilatation.
- It is divided into 2 phases
(a) Latent phase (early labour) It is from the onset of labour until cervix is 3 cm
dilated. It takes 8 hours or less.
(b) Active phase
Starts from 3 cm of cervical dilation to 10cm (fully cervical dilation)

1.4.2 2nd Stage

 - Starts with compete dilation of cervix and ends with delivery or baby.
- It is characterized by the woman having an urge to push.
- It takes 15 -30 minutes and should not exceed 1 hour.
1.4.3 3rd Stage
- Begins with the birth of the baby to the expulsion of the of the placenta and
membranes
- It takes - 15 minutes.

1.4.4 4th Stage

- Period of one hour following the birth of he child and the placenta and membranes
N/B: The duration of labour varies widely and is influenced by parity, birth
intervals, psychological state, presentation and position of the fetus to the pelvic,
pelvic shape and size and character of the uterus contractions. Not forgetting the
nursing management will also have an effect to the duration of labour.

1.5 Changes during first stage of labour.

The normal changes taking place to the woman during first stage of labour are
categorized in to:
I. Physiological changes
II. Mechanical changes.
1.5.1 Physiological changes.
These are normal changes that occur during pregnancy and brought about by the
pregnancy. Although these changes are many and occur at different stages during
pregnancy, the once that specifically take place during first stage of labour i.e. the
period from onset of labour to full cervical dilatation are,

1. Contractions and retractions of the uterus.

The uterus begins to contract and retract. Contractions do not pass off entirely but
muscle fibres retain some of the shortening of contraction instead of becoming
completely relaxed. This is called retraction. The upper segment of the uterine
becomes gradually shorter and thicker and its cavity diminishes. This assists in the
progressive expulsion of the fetus.
- The nature of the contractions is that they are rhythmic and gradually
increase in length, frequency and duration from mild, moderate to strong. Mild
contractions last for less than 20 seconds, moderate last for 20- 40 seconds while
strong last for 40- 60 seconds. The obstetrician or midwife can assess strength or
the contractions by placing a hand on the abdomen timing the beginning and the
end of the contraction. A feeling of hardness is usually felt during the beginning of a
contractions and the hardness disappears at the end of the contraction.

2. Formation of upper and lower segment

- By the normal anatomy the parts of the uterus include the cervix, isthmus,
body and fundus. During pregnancy by the 16 th week there develops the Braxton
hicks. The Braxton hicks bring about a contractile effect to the uterus. Their role is
assist in movement of amniotic fluid within the uterus, assist in blood circulation
within the uterus and formation of upper and lower uterine segment and
preparation of the myometrium for contraction during labour. So by the end of
pregnancy, the body of the uterus has divided into 2 segments the upper and lower.
However this is very much seen and developed during onset of labour and within
the first stage of labour.
- The upper segment is concerned with contractions and retractions. It is thick
and muscular and most of the uterine muscle is concentrated here while the lower
segment is prepared for distension and dilatation and becomes thinner and thinner
as labour progresses. The retracted longitudinal fibres in the upper segment pull on
the lower segment causing it to stretch.

3. Development of Retraction ring

- When the thick upper and thin lower uterine segments have formed, the
junction between them is known as the retraction ring. The ring is normally strong
but it is not marked enough to be visible above the symphysis pubis. When it is
visible it is referred to as bundle’s ringand is a danger sign during labour likely to
mean impending rupture to the uterus maybe as a result of abnormal uterine
action.

4. Cervical effacement
- Usually the cervix is long before pregnancy. Half of it is occupying the vaginal
canal, almost 1/3 of it. On vaginal examination it feels like the tip of the nose.
During pregnancy it is taken up gradually until it is completely or partially part of
the lower uterine segment in late weeks of pregnancy
- During labour due to contraction and retraction of upper uterine segment
draws upwards muscle fibres surrounding internal os and the cervix completely
emerge into the lower uterine segment.
5. Cervical dilatation
- This is due to uterine action and counter pressure applied by bag of
membranes and presenting part the cervix dilates gradually as labour progresses.
- During labour this dilatation is measured in cms. A cervical dilation of less
than 3 cms is regarded as not established labour and of above 3 cms as established
phase of labour. Full cervical dilatation is 10 cms. Cervical dilation is assessed by
use of finger breadths. One finger breadths is estimated at 2 cms of cervical
dilatation.
- During labour the rate of cervical dilation is influenced by several factors to
include parity, nature of uterine contractions and pressure of presenting part to the
cervix and existing cervical abnormalities e.g. dystocia.
6. Show
- It is blood strained mucoid discharge seen a few hours before or within a few
hours after labour has started.
- It is shed from the cervical os as it dilates.
- It is the operculum which seals the cervical canal during pregnancy. Usually
during pregnancy the inner layer of the cervical canal become soft and secrets
some mucoid fluid under the influence of progesterone hormone. This fluid occupies
the cervical canal. Its main function is to prevent any entry to the uterine cavity
during the period of pregnancy and it is a sign of labour when it presents as show at
term.

7. Formation of bag of waters

It is formed when the lower segment stretched to the chorionic membrane become
detached from the uterus. This is when the cervix starts dilating.
- The increase pressure of uterine contraction forces loose area of the bag of
fluid to bulge downwards into the dilating cervix occupying the space created.
- The flexed fetal head fits into the dilating cervix dividing the fluid into fore-
waters (fluid ahead of presenting part) and hind waters (fluid surrounding body of
fetus).
- This division is important because it prevents pressure from uterine
contractions to be applied directly into the fore waters and thus preventing early
rupture of membranes during normal labour.
1.5.2 MECHANICAL CHANGES.
1. Rapture of membrane
- A normal physiological change during labour indicating that the cervix no
longer supports the bag of waters and the woman has full cervical dilatation. It is a
presumptive sign of second stage of labour.
- However membranes may rupture early in cases of abnormalities e.g. if
presenting part does not fit well into the cervix or the uterus is over-distended as in
big baby, multiple pregnancy, polyhydraminous or weakness to the membranes
themselves.

2. General fluid pressure

This is experienced when membranes are still intact. The pressure of the uterine
contraction is exerted on the fluid and since the fluid is not compressible the
pressure is equalized throughout the uterus and over fetal body.

3. Fundal dominancy
Contractions start in the fundus and last longer then spread across downwards and
over the whole uterus. The fundus dominates most of the work.

4. Fetal axis pressure

The uterus is reared forward during a contraction and the force of the fundal
contraction is transmitted to the upper part of the fetus, down axis the fetus and is
applied by the presenting part to the cervix.

CHAPTER 2: MANAGEMENT OF NORMAL LABOUR (1ST STAGE)

Outcomes:
By the end of the chapter the trainee will be able to:

1. Describe the principals of management of labour.

2. Describe the admission process and admit a mother in labour.
3. Describe history taken and take history to a woman during labour.
4. Perform correctly physical examination to mother in labour.
5. Describe and perform vaginal examination accurately.
6. Describe the nursing care during first stage.
7. Describe and use the partograph during management of labour correctly.
8. Describe complications of 1st stage of labour.
2.1 THE BASIC PRINCIPLES OF MANAGEMENT OF LABOUR INCLUDE:-
 Meeting physical, psychological and emotional needs
The midwife must give general comfort, psychological and emotional support and
be able to relieve pain.

 Mental relaxation
Midwife should create good interpersonal / relationship, give companion and
communicate adequately the progress of labour.

 Vigilant observation
Midwife should make observations of maternal, fetal and progress of labour to
detect early deviations from normal.

 Maintain nutritional status

Provide light diet for the mother to provide energy and prevent dehydration.

 Infection prevent
Provide good personal and environmental hygiene
Maintain good aseptic technique throughout out labour and when performing
procedures.

2.2 ADMISSION OF A MOTHER IN LABOUR

• Every woman in labour should be treated with dignity and respect and a right to
privacy and confidentiality at all times. All women should be given the choice of having a
companion (partner, friend or relative) during labour and childbirth.
- As soon as the mother comes into admission room do general observation for
gait posture and facial expression
- Greet the mother with a calm and friendly manner and give her a seat
- When the mother comes in labour, the health service provider must evaluate her
condition and that of the fetus through history taking and physical examination. Ensure
privacy during history taking and physical examination explaining each procedure that you
expect to perform. Encourage the woman to empty her bladder and provide a urine
specimen for testing (protein).
- It is important to make the mother feel welcome and as comfortable as possible,
letting her sit or lie down, depending on her choice. The health service provider should
explain that he/she needs to ask some questions about her labour. The initial questions that
should be asked, while observing her physical condition include,
22.1 History taking
Take complete history to include:-
a. Person history
b. Social history
c. Past and present obstetric history
d. Family history
e. Medical history
1. Personal History (bibliographical data)
This includes name, age, residence, address, educational level and nationality.
2. Social history
This includes marital status, occupation (herself and husband), staple food, social
habits (smoking and drinking).

3. Family history
Ask for any chronic illness that may have an influence to pregnancy e.g. diabetes,
hypertension, cardiac disease, T.B. and multiple pregnancies in family.

4. Medical/ surgical history

Ask whether she has suffered from any chronic disease or whether she has been
admitted in hospital. Note any history of blood transfusion.
5. past obstetric history
- Take history of previous pregnancies
 parity
 Labour
 Weight of the babies.
 Sex of previous babies.
 Find out whether she was attending pre-natal clinic and check whether there
was any problem identified.
 Mode of delivery, where and when.
 Fate of the children (alive or dead).
 Ask whether puerperium period was normal or had complications

6. Present obstetric history

Take history of this labour regarding:-
• When did your labour pains begin? ( Time of onset of contractions)
• Nature of contraction that is intensity, duration and frequency.
• How long has the woman been in labour? E.g. 2 hours, sun rise to sun set, e.t.c.
• How is she doing?
• Has your bag of waters (membranes) broken? If the water has broken, it is important
to know how much time has elapsed, approximate amount and what the fluid looked like
(clear? greenish? blood-stained?). if the membranes have ruptured you can give the
mother a sanitary pad to enable nurse to assess the amount and colour of Amniotic
fluid
• Have you bled from your vagina since you started feeling labour pains?
• Did you have any bleeding during your pregnancy?
Any bleeding during pregnancy or labour is a danger sign.
• Do you perceive fetal movements? Ask if fetal movements are normal or have
reduced. If they are reduced find out if they are less than 10 in a day. Find out how long
ago she felt the last movement
• Have you attended antenatal clinic? If the woman has been attending antenatal
clinic, examine her record for information about her history. Ask about the gestation at first
visit, the number of visits, and presence of complications e.g. vaginal bleeding, high blood
pressure etc. Check on immunization and results of antenatal profile and Past obstetric
history.
If she has not attended any antenatal clinic, she may have more untreated or unidentified
problems. Additional questions include
- How old are you?
- Is this your first pregnancy?
- How many times have you been pregnant?
Capture the fate of the other pregnancies. Ask any abortions, their gestation, when
and where they took place and the likely cause.
- Have you had any discharge or bloody mucus (show)? Unlike blood, the show is often
sticky and stretches. It is a sign of early labour. It may be blood-stained
- When did you last eat? If she has not eaten, she may not have much strength for the
labour. It is good to encourage the woman to eat small amounts of fluid foods during early
labour.
- Have you taken any medicine, herbs or other treatment? It is important to explore
what other medicines or herbs may have been taken. Some may have a stimulating effect
on labour and counteract anaesthetic action.
- Have anyone given you care at home? If yes, what kind of care was given?
- Are you accompanied by your partner, friend or relative?
• Explore the need for psychological support during labour and delivery.
- Enquire the L.M.P., calculate E.D.D. and period of gestation

2.2.2 Physical examination.

2.2.2.1 Head to toe examination

- Explain to the mother that you will examine her from head to toe so let her
change into examination gown.
- Ask the mother to pass urine and test for albumin acetone and sugar

- Take observation to include temp, pulse, respiration, blood pressure, weight,

height and record.
- Put the mother on the coach and do a general assessment on whether ill
looking, dehydrated or excited
- Perform physical examination from head to toe (As per guideline) to exclude
conditions such as anaemia, signs of pre-eclampsia, thyroid disease, cardiac
disease e.t.c.
- Do abdominal examination and apply the following terms: - inspection,
palpation and auscultation.
On abdominal inspection note:
 Size
 Shape
 Colour changes
 Scars
 Fetal movements

On abdominal palpation note:

 Fundal height
 Lie
 Presentation
 Position
 Engagement of the presenting part.
 Assess the uterine contractions for strength duration and frequency as they
occur. Note: The strength of the contractions cannot be judged by the reaction of
the woman but by laying a hand on the abdomen and rating the degree of hardest
during contraction and by timing its length. Contractions begin painless, then pain
then painless again.

On auscultation note:
 Fetal heart sound for rate, regularity and strength.

- Record the finding on the patient’s notes and partogram

- Explain to the mother that you are going to do a vaginal indications for the
vaginal examination
2.2.2.2 VAGINAL EXAMINATION IN LABOUR
- A lot of information can be obtained through vaginal examination which is not
possible to attain through abdominal examination e.g. cervical dilation.
- The examination is very uncomfortable to the mother so the midwife should
be gentle when doing the procedure.
GENERAL INDICATIONS OF VAGINAL EXAMINATION ON ADMISSION
1. To confirm labour through cervical dilatation
2. To assess stage of labour
3. To rule out rupture of membranes
4. To rule out cord presentation when the membranes are intact and cord
prolapsed when the membranes are ruptured.
5. To asses for pelvic adequacy for normal vaginal delivery
6. To confirm presentation
7. To confirm axis of the fetus

Indications of repeat vaginal examination during labour include:

a. As routine examination four hourly to assess progress of labour.
b. To confirm second stage after rupture of membranes
c. With signs of 2nd stage e.g. urge to push.
d. To rule out cord prolapse after rupture of membranes.
e. To confirm presentation of 2nd twin after rupture of 2nd amniotic sac.
f. 1 hour after 2nd stage in case of prolonged second stage of labour.
g. To confirm 3rd stage of labour and separation of the placenta in case of
delayed 3rd stage.

DIGITAL VAGINAL EXAMINATION PROCEDURE ON ADMISSION.

1. Indications
- To diagnose labour
- Assess stage of labour
- To assess the pelvic adequacy
- To confirm and assess the progress of labour
- Rule out cord prolapsed when membranes are intact and cord prolapsed when
membranes are ruptured.
2. Requirements
A. Top shelf of trolley
- A bowl
- A gallipot
- 10 cotton wool swabs
- Sterile pads
- Two towels
B. Bottom shelf of the trolley
- A pair of sterile gloves
- A lubricant – obstetric Hibitane Cream
- A disinfectant – Hibitane/Savlon
- A pus swab if a vaginal swab is to be taken
C. Accessory
- A pedal bin for soiled swabs
3. Preparation
i) Patient
- Explain the procedure to the mother.
- Ask her to empty her bladder if necessary.
- Assist her lie on her back with one or two pillow under her head.
- Fold up her gown and cover her with a blanket or sheet.
ii) Equipment
- Clean the trolley and disinfect the top shelf
- Place the sterile vaginal examination pack f top of the shelf
- Complete setting the trolley, with the equipments stated above
iii) Environment
- Screen the bed for privacy
- Close the nearby windows
- Put the pedal bin near the bed
- Wheel the trolley to the mother/patient’s bedside
B. Method – two nurses required
- wash your hands with soap and water and dry them.
Uncover the sterile top shelf and ask the assistant to pour some lotion into the bowl. Scrub
up
- Wear gloves- double glove.
- The assistant exposes the mother/patient and puts her in dorsal position with knees
flexed, legs apart and heels together.
- Take swabs with your right hand dip them in the solution, squeeze then to avoid
dripping lotion
- Put one swab at a time into your left hand
- Inspect the vulva
On inspection check for;
 cleanliness
 scars
 dirt
 oedema
 presence of varicose veins
 lice
 Any discharge (show, liquor amni, blood – whether liquor is clear, meconium
(grade 1, 2, 3) or blood stained.
Note: Soak the vulva and perineum using antiseptic lotion e.g. salvon or hibiten at
correct concentration but if not available use cool boiled water
- Swab each labia majora with a downward stroke starting with the furthest
- Swab the labia minora with the same downward stroke. Lastly swab the vestibule
with the right hand.
- Remove the top gloves and put on another pair.
- Put the sterile towel under her buttocks without contaminating your gloved hands
- Drape the abdomen
- Lubricate the index and middle finger of the right hand
- Insert the fingers obliquely inside the vagina with the thumb facing the symphysis
pubis
- Ask the mother to breathe in and out while you perform the digital examination.
- Examine the following:
Vagina
 Warm and moist
 Hot and dry
 Whether its firm or lax

Cervix
 Check for oedema, thickness and thinness, effacement and dilatation.
 At the level of membranes observe whether intact or ruptured.
 Rule out cord presentation when membranes are intact or prolapsed when
ruptured. (Check whether cord is pulsating or not).
 Check whether membranes are flat or bulging.
Presenting part
 Check whether its head, breech, shoulder.
 If it is the head check for the size, fontanelles and sutures.
 Check whether presenting part is well applied to the cervix.
 Check moulding
Pelvic adequacy
 Try to tip the sacro promontory.
 Assess the curve of sacrum.
 Feel for the ischial spines.
 Assess the sub pubic angle which should accommodate 2 fingers.
 Assess inter tuberous diameter which should accommodate 4 knuckles.

- Inspect the discharge on the gloved fingers and feel for the smell.
- Apply a pad if required.
- Change the draw sheet if soiled.
- Inform her findings and congratulate her.
- Leave the mother/patient in a comfortable position
C. Clearing
- Remove the pedal bin and keep it in place
- Wheel the trolley to the disinfection room
- Remove the screen
- Open the nearby windows
- Decontaminate the equipment
- Clean the equipment with soap and water and send them for sterilization
- Disinfect the trolley and keep it in place

D. Record, interpret and report

- Interpret findings
- Record in the Cardex/ notes/ partograph
- Report finding to the Doctor if necessary.
2.3 NURSING CARE DURING 1ST STAGE OF LABOUR
2.3.1 Objectives
1. To monitor the progress of 1st stage of labour
2. Prepare the mother physically and psychologically for labour and delivery
3. To prevent and detect complications early and take appropriate actions
4. To prepare equipments for 2nd stage of labour
2.3.2 Nursing Care
1. Admit the mother.
2. Reassure and communicate about her condition.
3. Take and record observations- start the partograph.
a. Fetal heart rate – ½ hourly and note the rate (btw 100 -180 beats per min),
regularity and strength.
b. Uterine contractions ½ hourly and note the frequency, duration and strength
c. Check for moulding of the foetal skull 4 hourly
d. Check for liquor if membranes are ruptured 4 hourly for presence of
meconium
e. Check cervical dilatation 4 hourly
f. Check B.P. Respirations and temp 4 hourly
g. Maternal pulse rate ½ hourly
h. Test urine 2 hourly for albumin, sugar and ketone bodies
i. Check descent of presenting part 4 hourly

4. Nutrition
Labour requires energy. Encourage mother to take light easy digested diet in early
labour and oral fluids in established labour. Rehydrate the mother using normal
saline or ringers lactate.
 5. Bladder care
Encourage mother to empty bladder 2 hourly. If she has not passed urine for the
last 6 hours catheterization can be done. A full bladder predisposes to prolonged
labour.
Test urine and record for;
 Presence of ketone bodies
 presence of infection
 Measure volume.
6. Relieve of pain.
Let mother be told that labour is actually painful and to expect this. The health
worker should work towards relieving the pain to make the labour more comfortable
to prevent complications. Varies methods for relieving pain can be applied e.g.
i. Reassuring and support.
ii. Back rubbing.
iii. Change of position or ambulate
iv. Attention diversion.
v. Drugs can be given e.g. analgesics e.g. morphine, pethidine, paracetamol.
7. Ambulation/ Lamaze
Encourage mother to ambulate in early labour and if membrane are still intact. If
membrane ruptures let her stay on bed. This will improve the progress of labour.

8. Maintenance her personal and environmental hygiene.

Encourage mother to take bath at onset of labour. Change wet linen and soiled
pads and provide clean linen. Wash the vulva before examination and wash hands
with soap before examining the mother and ensure a clean environment.
“Maintain the 4 cleans- clean hands, clean coach, clean perineum and
clean procedure.”

9. Health messages
Teach her on her role during labour and especially during 2 nd stage of labour e.g.
breathing through the mouth during a contraction and relax when it goes when in
1st stage. Positioning and pushing with every contraction during 2 nd stage.
10. Psychological and support – give support to the mother mostly to
allay anxiety. Allow birth partner in your labour ward.
11. Prepare for 2nd stage of labour.
As you monitor the women progressing to 2nd stage of labour, be conscious about
the short second stage of labour. Prepare equipments (Delivery Park), rescusitaire,
pre - warmed baby cot, assistant, environment and yourself ready for delivery.
II.4 PARTOGRAPHY
2.4.1 Definition
This is a tool designed to monitor and interprete the progress of labour, maternal
and fetal conditions during labour
o The aim of partograph is:
 early detection of abnormal progress of labour and prevention of pro-longed
labour

 It helps in management of labour alone but fails identify other risk factors
which may be present before labour started e.g. contracted pelvis.
o Start partograph when you have checked that there are no complications of
pregnancy that require immediate action e.g. inadequate pelvis, cord prolapsed,
bleeding e.t.c.

o Users of partograph should have adequate training in midwifery and should

be able to:-
a. Monitor effectively progress of labour.
b. Perform a cervical examination and give correct dilatation.
c. Be able to plot cervical dilatation against time accurately.

2.4.2 Advantages of a Partograph

1. It is able to detect deviation from normal labour that is developing as labour
progresses.

2. It serves as an early warning system and assists in early decision on transfer

(referral), argumentation and termination.

3. Helps in early detection of abnormal progress of labour leading to prevention

of prolonged labour.

4. It’s a very clear way of recording all labour observations on one chart making
it easy to detect any abnormality.

5. It increases the quality and regularity of all observation of labour, fetus and
mother and aid in cognition of problems on either.

6. It is cheap, effective and can be used in a variety of settings e.g. at all levels
of health facility.

7. Can be used to give a report on labour.

8. When need be can be used as a legal document.

2.4.3 Features of partograph
o The alert line
It is drawn from 4cm to 10cm representing rate of cervical dilation. In normal
labour cervical dilatation will remain on the alesrt line or on to its left side.
If cervical dilatation moves to the right of the alert line it indicates prolonged labour
and if in a health centre refer the mother to the hospital
o The action line
- It is drawn 4 hours from the alert line. If a mother in labour, the cervical
dilatation reaches this line a decision must be made about the cause of the slow
progress ad action be taken
- When labour progress is well, the dilatation should never move to the right of
the alert line.
Latent phase (outdated)
o It is from onset of labour until cervical dilatation reaches 3cm
o On admission cervical dilatation is not plotted on the partograph until 4 cm of
cervical dilation (in the active phase)
o It lasts 8 hours or less and if more than 8 hours, it means slow progress of
labour so if in a health center refer the mother to hospital
Active phase
o It starts from 3 cm of cervical dilatation to 10cm
o It is a faster period or cervical dilatation at a rate of 1cm per hour to
primigravidas and 1.5cm per hr to multipara’s women
o It normally takes 7 hours or less, more than 7 hours indicates a problem which
should be identified and action be taken.
2.4.4 When to start a partograph
o Start partograph only when a woman is in labour that is having 3 or more
uterine contractions in 10 minutes each lasting 20 sec or more with a cervical
dilation of 4 cm.
o Make sure you have checked that there is no condition or complication that
requires immediate action.

2.4.5 Components of a partograph

They are:
a. Biographical data
b. Fetal condition
c. Progress of labour
d. Maternal condition
e. Summary of labour.
2.4.6 Observations plotted on the partograph
They include:
1. Biographic data
a. Name
b. Parity
c. Residence
d. Age
e. Hospital number
f. Date and time of admission
2. Fetal condition
a. Fetal heart rate done ½ hour
b. Moulding of fetal skull done 4 hourly
c. State of liquor if membranes are ruptured

3. Progress of labour
a. Cervical dilatation - on vaginal examination 4 hours.
b. Descent of head / presenting part.
c. The nature of uterine contractions.
4. Maternal condition
a. Take pulse ½ hourly
b. Pulse, temperature, blood pressure, respiration
c. Urine output, ketone bodies, protein
5. Drugs and IV fluids
a. 10% dextrose
b. Normal saline
c. Syntocinon
6. Summary of labour
a. Time labour took
b. Blood loss
c. Number of vaginal examinations

2.4.7 Using the Partograph

 Patient information: Name, gravida, para, hospital number, date and time of
admission, and time of ruptured membranes
 Fetal heart rate: Record every half hour. (•)
 Amniotic fluid: Record the color at every vaginal examination:
- I: membranes intact
- C: membranes ruptured, clear fluid
- M: meconium-stained fluid
- B: blood-stained fluid
 Molding:
- 1: sutures apposed
- 2: sutures overlapped but reducible
- 3: sutures overlapped and not reducible
 Cervical dilatation: Assess at every vaginal examination (4 hourly), mark with
cross (X)
 Alert line: Line starts at 4 cm of cervical dilatation to the point of expected full
dilatation at the rate of 1 cm per hour
 Action line: Parallel and 4 hours to the right of the alert line
 Descent assessed by abdominal palpation: Part of head (divided into 5 parts)
palpable above the symphysis pubis; recorded as a circle (O) at every vaginal
examination. At 0/5, the sinciput (S) is at the level of the symphysis pubis
 Hours: Time elapsed since onset of active phase of labor (observed or
extrapolated)
 Time: Record actual time.
 Contractions: Chart every half hour; palpate the number of contractions in 10
minutes and their duration in seconds.

Strong >40 sec

Moderate construction 20 – 40 sec

Mild contraction < 20 sec

 Oxytocin: Record amount per volume IV fluids in drops/min. every 30 min.

when used
 Drugs given: Record any additional drugs given
 Temperature: Record every 2 hours
 Pulse: Record every 30 minutes and mark with a dot (•)
 Blood pressure: Record every 4 hours and mark with arrows
 Protein, acetone and volume: Record every time urine is passed.
2.5 Complications during 1st Stage of Labour
a. Fetal distress
b. Maternal distress
c. Cord prolapsed / presentation
d. Ante partum haemorrhage (APH)
e. Uterine rupture
f. Cervical Dystocia (Cervix refuses to open)
g. Amniotic fluid embolisim
h. Hypotonic / hypertonic uterine contractions
i. Uncoordinated uterine contraction
j. Prolonged labour
k. Obstructed labour
CHAPTER 3: 2ND STAGE OF LABOUR
Outcomes
By the end of the session the trainee should be able to,
1. Describe the physiological changes in second stage of labour
2. Describe the signs of 2nd stage of labour
3. Describe the mechanism of normal labour
4. Describe the nursing care management
5. Describe the SOP and perform and repair an episiotomy
6. Describe APGAR score and able to score a newborn
7. Documentation and reporting in maternity unit.

Second stage of labour is the period from full cervical dilatation till the
delivery of the baby. It is divided in to transient and push phases.

1. Physiological changes
- Contractions become more frequent and stronger with a longer duration
than1st Stage. Contractions are more frequent about 3 – 4 strong contraction in 10
min each lasting 60 – 90 sec.

- When some of the amniotic fluid escape the uterus become more applied to
the fetus causing some irritation, the force of the contraction is transmitted through
long axis of the fetus which directs its through the birth canal.

- The fetal axis pressure causes more head flexion thus reducing diameter of
presenting part.

- At this time there is involvement of contraction of abdominal muscles and

diaphragm which help to create expulsive contractions.
- The expulsive action is referred to as bearing down.

- Initially the contractions are aided by voluntary efforts of the mother but as
soon as the presenting part touches the pelvic floor, the expulsive action becomes
involuntary.
2. Displacement of pelvic floor
- This is when bladder is drawn up into the abdomen where there is less risk of
injury by the descending head
- The advancing head dilates the vaginal causing some bleeding, the rectum is
compressed by the head and any fecal contents are expelled

- More space is created in the pelvis for the fetus to pass through

- The triangular perineal body is flattened and becomes think

3. Expulsion of the fetus
o The head is seen at the vulva advancing with each contraction until crowning
takes place.

o The head is then born by extension and the body follows with the next
contraction along with reminder of the amniotic fluid
SIGNS OF 2ND STAGE
Probably signs
a) Expulsive uterine contractions
b) Trickling of blood (heavy show)
c) Rupture of membranes
d) Presenting part appearing
e) Bulging of the perineum
f) Spotting and gaping of the anus
g) Vulva gaping
h) Tenderness and tenseness between coccyx and anus
Positive signs
a) Full dilatation of cervical OS
MECHANISM OF LABOUR
It is a series of passive movement of the fetus in its passage through the birth canal
fetus in its passage through the birth canal as result of expulsive action of the
uterus, abdominal muscles, diaphragm and the resistance offered by the pelvis,
cervix and pelvic floor muscles.
- The movement of the fetus during labour are as follows:-
a. Descending
b. Flexion
c. Internal rotation of head
d. Crowing
e. Extension
f. Restitution
g. Internal rotation of shoulder
h. Lateral flexion
a. Descend
- This takes place all through until the baby is born

b. Flexion
- The head is usually flexed at the beginning of labour with sub-occipital frontal
diameter lying at the brim

- The flexion increases as descent take places and therefore sub-occipital

bregmatic diameter engages
c. Internal rotation of the head
- When the head touches the pelvic floor it rotates forward 1/8 of a circle

- This rotation makes the body of the fetus to enter into lower curve of the
pelvis. The occiput lies under the symphsis pubis

d. Crowing
- Is said to have taken place when the occipital eminence and by parietal
eminencies escape under the symphysis pubis. The head does not reside between
the contractions and is seen on the vulva.

e. Extension
- In this step the flexion of the head is undone and the head is born. The nape
of the neck pivots under the lower border of symphysis pubis while the sinciput face
and chin sweeps the perineum.

f. Restitution
- The twist in the neck of the fetus which resulted from internal rotation of the
head is now corrected. The occiput moves 1/8 of a circle towards the side from
which it started.

g. Internal rotation of the shoulders

- The shoulders undergo a similar rotation to that of the head to lie in the
widest diameter of the pelvic outlet (anterior posterior – 13cm)

- The anterior shoulder reaches the levator ani muscles and rotates enteriorly
to lie under the symphysis pubis

- The anterior shoulder will escape flexion s the spine bends sideways through
the cured birth canal.

h. Delivery of he baby
- The baby is born by the action of lateral flexion
Management of second stage of labour.
1. Objectives
- To ensure birth of a live and healthy baby
- To ensure live healthy mother
- To deliver mother with minimal trauma

2. Indications
- Mother in second stage of labour

3. Requirements
A. Top shelf of trolley

A sterile ideal delivery pack.

- 1 gown
- 1 hand towel
- 1 gallipot
- 6 dressing towels
- 1 pair of episiotomy scissors (Mayo’s)
- 1 Mayo’s artery forceps
- 2 perineal pads – 1 for supporting the perineum, 1 for delivery
- 2 cord clamps/ligatures
- 2 kidney dishes – 1 for instruments, 1 for receiving placenta
- 1 medium bowl for lotion
- Cotton wool swabs (at least 10)
- Gauze swabs (at least 10)
- 1 pair of blunt point scissors – for shortening the baby’s cord

B. Bottom shelf trolley

- Small injection tray with syringes and needles i.e. 2 c.c. and 10 cc.
- Syntometrine ready drawn in a receiver
- Spirit swabs in a tin
- Fetoscope
- 1% procaine hydrochloride or lignocaine 0.5% - 1% 3 pairs of sterile gloves
- Lotion e.g. Savlon 1:8 or habitane in water
- Extra Linen
- Lubricant e.g. KY jelly.

C. Accessories
- Mechanical sucker
- Baby’s cot/pre-warmed incubator
- 1 bucket with jik 1:6 for soiled linen
- Pedal bin/bucket for dirty swabs
- Receiver for sharps
- Oxygen at hand
- Resuscitation tray
4. Procedure
A. Preparation
i) Mother:
- Confirm second state of labour and inform her she is ready to deliver
- Explain to her what you are going to do
- Position her on the delivery couch
ii) Assistant:
Instruct the assistant on the following:
- Positioning the mother
- Checking fetal heart after each contraction
- Checking maternal pulse and time contractions
- Encourage mother to push with each contraction
- Mopping the mothers face and brow
- Giving syntocynon within 1 minute after delivery of the baby.
- Immediate care of baby

B. management of the mother in 2nd stage of labour.

- Wear a mask
- Wash hands
- The assistant open the pack
- Dry hands with sterile towel
- Put on gloves- double glove
- Remind the mother on what is expected of her
- Ask assistant to pour lotion into the swabbing bowl
- Swab the vulva then drape the mother starting with the bottoms, furthest thigh,
nearest -thigh and the abdomen
- Catheterize the mother if necessary
- Encourage mother to bear down with contraction
- Support the perineum with a pad using the right hand
- Flex the head with the palm of the left hand
- If the perineum is tight, infiltrate with local anesthesia
- As the head crowns perform an episiotomy
- Continue flexing the head and supporting the perineum until the bi-parietal
diameter is born
- Extend the head until the face and chin escape under the perineum
- Check for the cord around the neck using the right hand
- Wipe the eyes, nostrils and mouth with gauze using the right hand
- If there is a cord around the neck, instruct the mother to breath in and out to
avoid pushing
- If it is loose, slip it over the head, if tight, clamp it using 2 artery forceps at least 3
cm apart then cut it between
- Release it from the neck
- When restitution has taken place, support the head at the parietal bones with the
palms of your hands.
- Deliver the anterior shoulder with a downward traction till the mid- arm then the
posterior shoulder with an upward traction then the trunk by lateral flexion
- Note time of birth
- Score the baby at one minute
- Place the baby on the mothers abdomen and clear the airway and dry the baby
- If the cord was not clamped and cut, clamp it at 3cm and 5cm from umbilicus and
cut in between
- Show the mother the sex of the baby and congratulate her
- Give your assistant a dressing towel and hand the baby over to the assistant for
further management
NB: Clearing, recording and reporting after the third stage of labour

EPISIOTOMY
It is a surgical incision which is done by the midwife or doctor to quicken 2 nd stage of
labour.
- It is done on a tight perineum which can tear during delivery
- It involves fourchette, superficial muscles of the perineum and posterior
vaginal wall
- It is done at a point about 2.5cm from the rectum. Local anaethesia is given
before the incision to prevent pain when cutting. It can therefore successfully
speed the delivery if the presenting part is directly applied to these muscles. If
episiotomy is done early part and haemorrhage may occur
INDICATION OF AN EPISIOTOMY
1. Tight rigid perineum
2. Cord prolapsed in 2nd stage of labour
3. Fetal distress in 2nd stage
4. Maternal distress in 2nd stage
5. Pre-eclampsia and eclampsia
6. Medical condition e.g. cardiac disease, hypertension etc
7. Breech delivery
8. Shoulder dystocia
9. Vacuum extraction
- Episiotomy can be planned or unplanned
Planned episiotomy
- This is when the need is identified before onset on 2 nd stage of labour e.g.
Mother with a premature labour, breech delivery, vacuum extraction

Unplanned episiotomy
This is when the need for an episiotomy is identified when the woman is in 2 nd stage
e.g. cord prolapsed in 2nd stage, fetal / maternal distress in 2nd stage or a rigid
perineum.
TYPES OF EPISIOTOMY
1. Medial lateral
2. Median
3. J-shaped
4. Lateral
1. Medio- lateral episiotomy
- It is recommended for midwives
- The incision is started from the centre of fourchette or penname is directed
postero- lateral
- It stops just before the anal sphincter
Advantages
- Less bleeding
- Easy and successful repair
Disadvantages
- There is risk of incision reaching the anal sphincter during delivery
- In case of a vaginal manipulation there is no enough room created
2. Median episiotomy
3. J-shaped episiotomy
The incision is started at the center of the fourchette and directed posteriorly for
about 20cm and then directed outwards towards the 7’ o’clock.
Advantages
a. The incision is directed outwards hence it will not each the anal sphincter
Disadvantages
a. Suturing is very difficult
4. Lateral episiotomy
The incision begins 1 -2 cm above centre of the fourchette and is directed towards
the mother’s side.
Disadvantages
- Can lead to injury to the bartholins glands
- Bleeding is profuse
- Suturing is more difficult
- The mother has a lot of discomfort
PERINEAL TEAR
This is a tear on the perineum of a woman during delivery.
Classification
1st degree
Laceration of the vaginal mucosa alone
2nd degree
Laceration of the vaginal walls involving the vaginal muscles
3rd degree
Complete laceration of the perineum involving the anal sphincter.
4th degree
Complete laceration of the perineum involving the anal sphincter and the rectal
mucosa.

PROCEDURE

1. Objectives
- To repair episiotomy/ tear

2. Indications
- Mother with an episiotomy/ tear

Principals of surgical repair

 The universal precautions, aseptic technique and sterile equipments.
 Use needle holder and dissecting forceps.
 Local anaesthesia with 0.5% lignocaine
 Ensure good exposure- good lightning.
 Define type of laceration i.e. extent, may need to do a rectal exam.
 If rectal examination is done, change gloves before proceeding to repair
 Start suturing above the apex of the tear.
 Minimize use of suture material- minimal knots.
 Ensure haemostasis- close dead space
 Ensure alignment of the hymenal remnant and fourchette
3. Requirements

A. Top shelf of trolley

Suture pack containing:
- 2 sterile towels
- Needle holder
- Dissecting forceps
- Small scissor
- Vaginal pack
- Sterile gauze swabs
- Sterile pad

B. Bottom shelf of trolley:

- Lignocaine 0.5% or 1%
- 10ml. syringe
- 2 needles gauge 21
- Cutgut 2/0 or No. 1
- 1 packet of sterile gloves
- Antiseptic lotion – 1% Savlon/Hibitane

C. Accessories
- Portable lamp/light
- Receptacle for used swabs

4. Procedure

A. Preparation
i) Mother
- Explain to the mother that you are going to repair the episiotomy (cut) under local
anaesthesia
- Put her in a dorsal position

ii) Equipments
- Clean the trolley. Set it with requirements stated above

iii) Environment
- Place the receptacle next to the couch
- Wheel the trolley next to the couch
- Position the portable light
B. Procedure for repair of episiotomy
- Open the pack
- Ask the assistant to give you the syringe and needle
- Withdraw 10 mls of lignocaine
- Swab the vulva
- Place a sterile towel under her perineum
- Identify the depth of the episiotomy
- Infiltrate the episiotomy with 7-10 mls of lignocaine and ensure lignocaine is not
injected into a vein
- Starting from the apex of the episiotomy. Use continuous stitches on the vaginal
mucosa
- Lastly suture the skin with interrupted stitches
- Inspect and clean the wound
- Remove the pack or gauze swabs used (confirm the number)
- Place a sterile pad in position
- Insert a finger into the rectum to exclude any involvement
- Health educate mother on care of episiotomy
- Make the mother comfortable

C. Clearing
- De-contaminate the linen, instruments, pack, gauze etc
- Dispose off swabs and pack
- Clean the instruments
- Send to the C.S.S.D.

D. Record, interpret and report

- Record in the notes and cardex that the episiotomy has been repaired
- State the condition of the episiotomy in the cardex
- Give a verbal report

AP GAR SCORE
This is a method used to determine the condition of the baby and chances of
survival after birth. Assessment is done at 1 minute, 5 minutes and 10mintes. It
involves consideration of five signs and the degree in which they are present or
absent.
This scoring system was discovered by Dr. Virginia Apgar. Apgar in an acronym
which stands for,
A – Appearance
P – Pulse
G – Grimance
A – Activity
R – Respiration
Scoring
Parameter Check for Score 0 Score 1 Score 2

Appearanc Colour Blue or pale Blue Pick the whole

e the whole extremities body
body and pink
body
Pulse Heart beat Absent <100 beats >100 beats per
per minute minute
Grimance Response Absent Respond Cry
under
stimulation
Activity Muscle tone Limp Weak or Active
localized

Respiration Breathing Absent Irregular, Breathing

gasp, <30, spontaneously
>60, chest
in- drawing,
apneic.
Routine care for all newborn babies after delivery. (and for neonates
born outside and brought to the hospital) ref: basic paediatric protocol,
pocket book for hospital care for children, WHO.
1. Establishment of respiration
2. Scoring the baby
3. Keep the baby dry, in a warm room and well covered.
4. Keep the baby and the mother rooming in.
5. Administration of vitamin K (phytomenadione) according to the national
guidelines 1 mg once (0.5 mg if <1500gms)
6. Apply tetracycline eye ointment both eyes once.
7. Initiate breastfeeding within the first 1 hour
8. Let the mother breastfeed on demand if able to do so.
9. Perform first examination of the baby
10. Labeling of the baby
11. Weighing the baby
12. Keep umbilical cord clean and dry
 COMPLICATIONS ASSOCIATED WITH 2ND STAGE OF LABOUR
I. Prolonged 2nd stage of labour
II. Maternal distress
III. Fetal distress
IV. Bleeding
V. Amniotic fluid embolism
VI. Cord prolapsed
VII. Uterine rupture
VIII. Shoulder dystocia
IX. Retained twin

Chapter 4: 3RD STAGE OF LABOUR

Outcome
By the end of the session the trainee will be able to
1. Describe the mechanism of placenta and membrane separation.
2. Describe the methods of placenta separation.
3. Describe the process and control of bleeding during 3 rd stage of labour.
4. Describe the methods and perform procedure for delivering of the placenta.
5. Examine a placenta effectively
6. Describe the SOP and perform active management of 3 rd stage of labour
7. Assess blood loss accurately
This starts after fetal expulsion to expulsion of placenta and membranes. The
physiological changes that take during this time are:-
a. Separation and expulsion of placenta
b. Control of bleeding
These physiological changes occur as a result of mechanical and haemostatic
factors.

MECHANISM OF PLACENTA SEPARATION

The separation of the placenta is brought about by contractions and retractions of
the uterine cavity which thickens the wall and reduces the capacity of the upper
uterine segment thus reducing area of the placental site.
- As soon as the baby is delivered there is a marked reduction of the uterine
size.

- When the placental site is diminished by half, the placenta becomes thicker
and compact and it then sheds of the uterine wall.

- After separation some blood collects between maternal surface of the

placenta and the desidua to form a retro-placental clot.

- Then the placenta is forced out of the upper to the lower uterine segment by
the increasing weight of the clot. As the placenta is falling it peals off the
membranes and falls with them. And so the placenta and membranes get detached
from the uterus.

METHODS OF PLACENTA SEPARATION

- There are 2 methods by which the placenta peels off the uterine wall
a. Schutz method
b. Mathew Duncan’s method
A. Schutzmethod
- Separation takes place at the centre of the placenta
- Fetal surface appears at the vulva with membrane behind like an inverted
umbrella.
- Makes the delivery clean and is referred to as “clean schutz”.

B. Mathew Duncan’s method

- Separation starts at the lower edge of the placenta and slips down sideways
and maternal surface appears first on the vulva.
- This makes the delivery dirty and is referred to as “dirty Duncan”.
MECHANISM OF CONTROLLING BLEEDING
Detachment begins in 1st stage when separation occurs around internal cervical os.
In 3rd stage complete separation takes place by the weight of the descending
placenta which peels the membranes off the uterine wall.
METHODS OF PLACENTAL DELIVERY
They include:-
a. Controlled cord traction
b. Maternal effort
c. Fundal pressure
d. Manual removal

A. Controlled cord traction

Grasp the cord firmly and apply gently downward traction, as you support the
uterus.
B. Maternal effort
It is the natural method of placental delivery, when the uterus contracts the mother
is instructed to hold the breath and bare down and the placenta is delivered.
C. Fundal pressure
The placenta must be separated and line in the lower segment or vagina. The
contracted fundus is used as a piston to push the placenta out.
D. Manual removal
The placenta is removed manually and mostly in theater.
Management of 3rd stage of labour.
The midwife applies principles of active management of 3 rd stage os labour (AMTSL).
They include:-
1. Give sytocinon 10 i.u. within I min following the birth of the baby.
It should be given deep intramuscularly and for 1 minute.

2. Controlled cord traction.

Gasp the cord and roll in your right hand and apply downward controlled cord
traction while supporting the uterus with your left hand. When the placenta appears
at the vulva, position a receiver and with both your hands receive and it and turn it
anticlockwise to aid the delivery of the membranes. Place the placenta in the
receiver.

3. Massage the uterus and expel clots.

Massage the uterus to initiate a contraction and expel clots. Tell the woman the
importance of massaging the uterus every 15 minutes for the next 2 hours.

PLACENTAL EXAMINATION.

Outcome
1. State objectives of placental examination
2. Describe the procedure for placental examination.
Objectives
1. Check for completeness
2. Check for abnormality
3. Assess blood loss.
Procedure
Prepare a trolley for placenta examination
Top shelf
- A tray
- A kidney dish with placenta
- Measuring jug
- Galipot with swabs
Bottom shelf
- Paper bag
Accessories
- Weighing scale

Procedure
- Wheel the trolley to the side
- Separate the placenta from blood
- Put the placenta on a flat surface
- Hold the placenta by the cord and assess the membranes and state whether
complete, incomplete or ragged.
- Place it back on the flat surface
- Hold the tip of the cord
- Assess for the blood vessels i.e. 2 arteries and one vein.
- Assess for the distribution of the whatsons jelly
- Assess for presence the true and false knot
- Assess for the length of the cord.
- Assess for point of insertion of the cord to the placenta (central, lateral,
battledore and valamentous)
- Leave the cord.
- Check the fetal surface for colour, distribution of blood vessels and
abnormalities e.g. circumvallata, infarcts, bi- partitta and tri- partitta.
- Spread the membranes and check for any blood vessels running to the
membranes.
- Separate the amnion and chorionic membranes
- Turn the placenta to the maternal surface and assess for colour, oedema and
infarcts.
- Measure the depth and diameter
- Count the number of lobes.
- Put the placenta in the paper bag
- Weigh the placenta
 - Discard the placenta
- Collect the blood and separate clots from liquid blood
- Measure the volume of liquid blood and record
- Measure the volume of clots and multiply the figure by two
- Assess the gauze( full soaked estimate 5mls, ½ soaked estimate 2.5 mls)
- A full soaked pad estimate at 70 mls.
- Note the total amount of blood loss.
- Discard the blood and disinfect the instruments
- Record your findings.

COMPLICATIONS OF 3RD STAGE OF LABOUR

I. Bleeding
II. Retained placenta
III. Uterine inversion
IV. Amniotic fluid embolism

CHAPTER 5: 4TH STAGE OF LABOUR (IMMEDIATE

POSTNATAL CARE)
This is the care given to the mother during the 1 st hour after 3rd stage of labour
The midwife should ensure the following is done,

 Observe vital signs of the mother (TPRBP) ¼ hourly

 Check uterus if well contracted and advise the mother to massage the uterus
every 15minutes for 2 hours.

 Check the vaginal loss

 Encourage mother to pass urine / empty bladder 2 hourly

 Observe for any blood loss

 Offer a hot drink or food as desired by the mother.

 Observe the baby for colour, bleeding from the cord and vital signs.

 Check and security of the cord and note any bleeding

 Provide warmth to the baby

 Weigh the baby

 Initiate breastfeeding

 Encourage rooming in

 Notify the birth

 Document
a. All drugs given
b. Amount of blood loss
c. Nature of birth
d. Completeness of placenta and membranes
e. Period of labour.
f. Counter sign

CHAPTER 6: NORMAL PUEPERIUM

This is the period from the delivery of the baby and placenta
up to 6 weeks.
6.1 Physiological changes during puerperium.
The main physiological changes during this puerperium include:-
1. Reproductive organs return to their pre- gravid state mainly uterus
(involution), cervix and vagina.
2. Establishment of lactation

3. Recovery from the physical and emotional experience of child birth

In this period the women requires rest but should not be confined in bed.

6.2 Return of reproductive organs to their pre- gravid state

6.2.1 Uterus

The return of uterus into its pre- gravid state is known involution.
The greater reduction is seen in 1st week where the uterus looses half of its weight
due to the process of autolysis (self digestion) and ischemia (localized anaemia)

- The fundus at completion of labour is 2 inches below the umbilicus, 24 hours

later the fundus goes to the umbilicus due to the return of the muscle tone to the
previous collapsed muscles. The fundus will decrease at a rate of 1cm per day and
by the 12th day it is felt at the symphysis pubis (line of public hair). By the time the
mother returns for the 2nd postnatal check-up the uterus will not be felt and will be a
pelvic organ.
- The uterus by the end of the 6th week it will have gone back to its pre- gravid
state and weighs 60 grams.

Task: Diagram of normal uterine

involution.

6.2.2 Cervix

- After delivery the cervix is soft and flabby

- After one week it admits two fingers
- After 2 weeks it is admitting one finger
- After 6 weeks it is felt like a slit(“parous os”)

6.2.3. Desidua

- The spongy layer degenerates (sheds away)

- At the end of the 8th week the placental site is completely healed
- Menstruation can occur as from the 6th week post partum.

6.2.4. Breasts
- The breasts are filled with colostrum.
- Lactation is established and by the 3rd-4th day and milk is present in the
breasts.

6.3. LOCHIA
- Lochia is the term used for discharge from the uterus during puerperium.
- It varies in quantity from one woman to the other.
- It has unpleasant smell but not offensive, it is alkaline in nature so a good
media for growth of micro-organisms.

6.3.1. Types of Lochia

Are three types namely:-

a. Lochia rubra
b. Lochia serosa
c. Lochia alba
a. Lochia rubra (red)
- It occurs between the 1st to the 3rd day after delivery
- Slight flow of blood is sometimes present
- It has debris from healing process of uterus an vagina
- Also contains cervical mucus
b. Lochia serosa (pink)
- Occurs between 4th – 9th day after delivery
- Discharge contains less blood and more serum and leucocytes
c. Lochia Alba (whitish)
- Occurs from 10th – 14th day. It contains leucocytes cervical mucus and debris
from healing process from the uterus and vagina
- N /B: persistent red lochia is a warning sign to retained products of
conception and can lead to puerperial haemorrhage
6.3.2. Abnormalities of the Lochia
a. Amount
- Excessive lochia can mean retained products of conception
- Scanty lochia can mean poor drainage
- Scanty with fever can mean infection (puerperal sepsis)

b. Colour
- Persistent red means danger of haemorrhage mostly due to retained products
of conception
- Brown and profuse with bulky uterus can mean sub-involution of the uterus
c. Consistency
If the lochia has remained or pieces of placenta or membranes it mean retained
products of conception

d. Odour
- If it is offensive it can mean retained products of conception which can lead to
sepsis.
- If offensive with offensive with fever (pyrexia) it can mean puerperial sepsis or
localized uterine infection.

6.4. MANAGEMENT OF THE PUERPERIUM. (TARGETED

POST PARTUM CARE)
• Postnatal care
This is care given to meet the needs of both the mother and the baby from birth to
reduce the complications and deaths as well as promote the health of the mother
and baby
The post- partum period for the mother starts after the expulsion of the placenta up
to 42 days after delivery (6 weeks)
• However it is now recommended to extend the follow up of both mother and
baby regularly until at least the first year

6.4.1 Goal of postnatal care

To improve maternal, newborn and infant health status through increasing
the proportion of women receiving essential postpartum, newborn care
and family planning service.

Elements of targeted postnatal care

 Prevention of complications of mother and baby including vertical

transmission of diseases from mother to baby
 Early detection and treatment of problems and Complication readiness
 Counselling for HIV and testing
 Counselling for contraception (Birth spacing) and resumption of sexual
activity
o Health promotion using health messages and counselling
 Provision of care to mother and baby by skilled attendant
 Assist the mother and her family to evaluate/develop a personalised PNC plan
 Referral of mother and baby for speciality care when necessary (CCC, TB, CD4
count FP)

6.4.2 Factors contributing to maternal and newborn

death:

 Women and families are not aware of the danger signs in

pregnancy, childbirth and postnatal period
 There is delay in making decisions at home
 No plans for transport have been made
 No plans on how to pay for any emergency referral within the
home, community or facility
 There is delay in receiving care in the health facility

6.4.3 Four scheduled personalized postnatal visits for

mother and baby.
1st consultation: < 48 hours (on Postnatal Ward)
2nd consultation: within 2 weeks (in MCH)
 3rd consultation: within 6 weeks (in MCH)
And any other time that mother is concerned about herself or her baby or
requires FP

5.2.2 Key elements & timing of postnatal care

<48 hours Within 2 weeks 4-6weeks

Baby  Establishing  Weight
 Breathing, warmth breastfeeding  Continue
 Breastfeeding within  Infection prevention exclusive
one hour of birth  Routine examination breastfeeding
 Cord care  Immunization
 immunization  PCR for HIV
 CTX
prophylaxis
Mother  Breast care  Recovery
 Blood loss  Temperature/infection  Anaemia/
 Pain relief prevention check Hb
 Uterine involution  Lochia  Counseling for
 BP, Vitamin A  Mood FP
 Counseling on danger  Counseling on danger  Refer for ARV
signs, PMTCT,FP signs, PMTCT, FP if indicated
 Refer for ARV if  Refer for ARV if
indicated. indicated

6.4.4. POST NATAL EXAMINATION FIRST 48 HOURS OR BEFORE

DISCHARGE FROM THE WARD.
As health worker, before the mother is discharged home from the post natal ward
there is a standard checklist of activities of which must have been done to the
mother. This applies to even women who have delivered at home and referred to
the facility within the first 48 hours. Though for the ones from home might be
attended from the maternal child health clinic.

Ensure the following has been done,

- Temperature, pulse, respiration and blood pressure are taken and are within
normal range.

- Haemoglobin level has been checked and is normal

- Breast examination has been done

- Examine the Uterus and indicate whether normal, tender, sub involution.

- Check for post partum haemorrhage- indicate whether present or absent.

 - Examine caesarean section scar- indicate whether normal, bleeding or
infected.

- Observe lochia- indicate whether normal, foul smelling or excessive

- Examine the episiotomy or tear- whether repaired, healed, gaping or infected.

- Check the HIV status of the mother- indicate whether positive or negative.

- Indicate whether the mother has been tested and received results.

- Establish whether the mother has been referred for comprehensive care.

- Establish whether counseled for neonatal care. Indicate yes or no.

- Establish whether counseled for FP. Indicate yes or no.

- Establish whether mother on cotrimoxazole prophylaxis.

- Establish whether mother on ARVs. Indicate yes or no.

- Establish whether mother on any treatment e.g. haematenics, multivitamins.

Capture all this information and record in the post natal register before the mother
is discharged home. Give the service you identify to have been missed. The midwife
can also refer where appropriate.

6.5. Health education during puerperium

The mother is supposed to receive health messages during peurperium to improve
on her care.

This includes information such as:

I. Clinic attendance as per targeted post natal policy.

II. Breastfeeding

III. Resumption of sexual intercourse

IV. Personal hygiene

V. Family planning and child spacing

VI. Immunization

VII. Balanced diet

VIII. Rest

6.5. DISORDERS OF PUERPERIUM.

The puerperium is bound to come with its own complications/ disorders. They are
divided into minor and major complications.
5.3.1 Minor disorders during peurperium.

They mostly appear immediately after the birth of the baby and can easily be
observed by the health worker. These include;
 Sore perineum
 After pains
 Excitement
 Puerperial chills
 Retention of urine.
 Breast engorgement

5.3.1 Major disorders during peurperium.

 Haemohage
 Sepsis
 Depression
 Pyrexia
 Mastitis
 Breast abscess
 Anaemia
 Fistula formation

5.3.2 Danger signs during puerperium

These appear any time during the puerperium period. An intervention need to be
taken. If at home and the woman gets these conditions should be referred to a
health facility for care by a skilled health worker. They include:
• High fever, lower abdominal pain and foul smelling discharge (infection)
• Severe headache blurred vision, High BP, (pre-eclampsia)
• Convulsions or fits (eclampsia)
• Heavy vaginal bleeding (PPH)
• Urinary or fecal incontinence (obstetric fistula)
• Extreme tiredness, Anaemia
• Anxiety and depression (puerperal psychosis)
• Breast problems: sore, cracked bleeding or inverted nipples Note: Most cited
reason for stopping breastfeeding
• Stress incontinence (long second stage)
• Backache (long second stage, epidural analgesic)
• Pelvic pains /pain in symphysis and or legs (relaxation of pelvic joints during
pregnancy)
• Hemorrhoids (long 2nd stage, heavier babies, forceps delivery)
• Perineal pain / dyspareunia (assisted vaginal delivery, episiotomy)
Constipation.
 CHAPTER 7: THE BABY.
Babies are like “wet paints” and are supposed to be handled with care. The first 24
hours after birth they are referred to as newborn. After that time up to 28 days are
referred to as neonate. From that period until one year are referred to as infants.

7.1. PHYSIOLOGICAL ADJUSTMENTS OF NEWBORN BABY AFTER BIRTH

i. Respiration
- It is the first and most important adjustment the baby makes.
- The following factors aid in the establishment of respiration:-
a. Reduced oxygen content in blood circulation during labour. Led to high level
of Co2 to circulate resulting into stimulation of the respiration centre in the medulla
oblanganta and this stimulates the baby to start breathing.
NB: High level of Co2 in circulation might end in depressing the respiratory centre
instead of stimulation.

b. Compression of chest
- During 2nd stage the chest is compressed against birth canal. The lung fluid is
expelled from chest cavity leaving a vacuum as a result air gashes into the empty
space, breathing is initiated.

c. External stimuli
- These include handling of the baby, extra uterine environment which is cold
stimulate the baby to cry and initiate breathing. Normal rate being 36 – 40 beats
per minute.

ii. Circulation
 Immediately after birth when respiration is established fetal circulation seizes,
normal circulation is established and baby gains a pink colour. Heart beat –
120beat per minute
HB – 18 – 19 grams per mill
- RBCs are broken down between 2nd and 5th day of life, and the level of
bilirubin in blood increases.
- Accumulation of bilirubin as a result of destruction of excessive RBC leads to a
condition known as physiological jaundice.
- The umbilicus dries and falls off by about the 6 th to 7th day.

iii. Digestive system

- The baby has swallowing and sucking reflect and is able to feed immediately
after birth and is able to pass meconium within the first 12 hours(Dark green in
colour composed of bile segment and mucus)
- The gut is sterile at birth and the stomach has a capacity of around 16 – 30
mils and increases rapidly within first weeks
- The cardiac sphincter is weak at birth, the intestines are long and contain
large number of secretory glands and large areas of absorption of nutrients
- On the 2nd day the meconium is greenish brown
- On the 3rd day is brownish yellowish
- On the 4th day is soft yellow.

iv. Temperature regulation

- The baby has unstable temperature due to:-
a. Unstable temperature regulatory centre
b. Low metabolic rate
c. Baby is also losing a lot of heat through the processes of conductive,
evaporation, radiation and convection
- The normal neonate is enclosed with brown adipose tissue which assist in
rapid metabolism of heat

7.2. Principles of Management

The principles of management of a new born baby will include:-

a. Provision of warmth
b. Establishment of respiration
c. Nutrition
d. Prevention of infection
e. Do daily physical examination
f. Daily observations

7.2. Baby’s physical needs

1. Warmth
Let the baby be kept warm by covering it especially when it has not started feeding
well.
All this is aimed at prevention of hypothermia

2. Nutrition
Provision of breast milk for nutrition and maintenance of body fluids

3. Sleep
Let the baby sleep for 20 hours out of 24 hours in first 2 months.
Avoid any form of noise e.g. loud voices; radio because this might produce
irritability to the baby

4. Fresh air
Avoid very warm air. When there is too much heat, the baby can be taken out for
fresh air.

5. Exercise
Let arms and legs be free to move. Do not tighten the baby: movement of hands
and legs stimulate some circulation and strengthen the muscles ready for sitting,
standing and walking later in life.

6. Love and affection

Rooming in will provide an opportunity for mothering and bonding. As long as the
mother is not having respiratory tract infection let her stay with the baby longer.

7. Protection
From infection, suffocation from inhaled vomitus, bright light, strong winds etc.
Protect the baby from being chocked from milk that flows too quickly, avoid use of
extra pillows since baby can roll and suffocate

7.4. THE FIRST BREASTFEED

To help a baby successfully breastfeed soon after birth, we should:

• Give the baby to its mother for skin-to-skin contact

• Let the baby feed when it is ready.

• Check the position and attachment when the baby is feeding.

• Let the baby feed for as long as it wants on both breasts.

• Keep the mother and baby together for as long as possible after delivery,

• Delay tasks, such as weighing, washing etc until after the first feed.

7.5. KEEPING A NEWBORN BABY WARM AFTER DELIVER

There are several ways of ensuring the baby is kept warm after delivery. These
include:

• Provide a clean, warm, draught free room for delivery at 25-28 0C.

• After birth immediately dry baby with a clean, dry, warm cloth.

• Put baby on mother’s abdomen or a warm, clean, dry surface.

• Give baby to its mother for skin-to-skin contact.

• Put naked baby between mother’s naked breasts, cover them both (as long as
immediate medical care is not needed by either).

• Cover baby’s head.

• Encourage breastfeeding as soon as possible after birth

• If mother and baby are separated wrap baby in warm covers and place in a
cot, in a warm room.

• Use a radiant heater if the room is not warm or baby is small.

7.6. BABY FRIENDLY SERVICES

THE BABY FRIENDLY HEALTH INITIATIVE (BFHI) – hospital providing antenatal
and delivery services are categorized to be baby friendly if they are evaluated and
seen to be practicing the steps for successful breastfeeding in line with the
breastfeeding policy. Once they meet these criteria they are referred to as proving
baby friendly services. Hospital breastfeeding policy promotes,supports and
encourages breastfeeding as the optimal way for a woman to feed her
baby. WA Health acknowledges that breastfeeding offers important health benefits
for both the mother and child.
WA Health recognises and supports the importance of creating and delivering a
health care environment in hospitals with maternity facilities, where breastfeeding
is
encouraged, promoted and supported by all staff to parents.
WA Health hospitals with maternity facilities should follow and appropriately
educate
and train all staff on the ‘Ten Steps to Successful Breastfeeding’. WA Health staff
should not discriminate against any woman in her chosen method of infant feeding
and should fully support her when she has made that choice.
The policy recognises that all mothers have the right to receive clear and impartial
information to enable them to make a fully informed choice as to how they feed and
care for their babies after birth. Mothers should be supported to feed their infants in
all areas of the hospital. Signs should be displayed throughout the hospital
informing
all staff and parents that breastfeeding is welcome.
Staff members wishing to return to work while continuing to breastfeed are entitled
to flexible lactation breaks and management support consistent with the
Department
of Health’s Workplace Policy and Guidelines for Breastfeeding.

2. Aims of the policy

1. To ensure the health benefits of breastfeeding and the potential health risks
associated with formula feeding are discussed with all women and their families
as appropriate in hospitals with maternity facilities, so they can make an
informed choice about how they will feed their babies.
2. To enable WA Health staff to create an environment where more women choose
to breastfeed their babies, and are given sufficient information and support to
enable them to breastfeed exclusively for six months, and then as a part of their
infant’s diet beyond the first year of life.
3. To promote consistency between all health professionals and develop a
breastfeeding culture throughout WA Health hospital’s with maternity facilities to
avoid conflicting advice.
4. To encourage consistent, comprehensive and evidence based breastfeeding
information is provided to parents by all health care professionals working in
hospitals with maternity facilities.
5. To adhere to the World Health Organization Code (WHO) code of marketing of
breast milk substitutes.
6. To encourage WA Health hospitals with maternity facilities to demonstrate a
Commitment to breastfeeding by seeking BFHI accreditation status.
WHO/UNICEF. (2006)
 Ten steps to successful breastfeeding
1. Have a written breastfeeding policy that is routinely communicated to all
health care staff.

2. Train all health care staff in skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of

breastfeeding.

4. Help mothers initiate breastfeeding within one half-hour of birth.

5. Show mothers how to breastfeed and maintain lactation, even if they should
be separated from their infants.

6. Give newborn infants no food or drink other than breast milk, unless
medically indicated.

7. Practice rooming in - that is, allow mothers and infants to remain together 24
hours a day.

8. Encourage breastfeeding on demand.

9. Give no artificial teats or pacifiers (also called dummies or soothers) to

breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer mothers
to them on discharge from the hospital or clinic.

7.7 DAILY EXAMINATION OF NEWBORN

Objectives
1. To asses baby’s growth
2. To rule out infection
Daily will be examination for:
o Colour – checking for jaundice, pallor, and cyanosis and confirming if baby is
still pink.
o Activity – check if baby is active or dull or kicking or sleeping most of time.
o Respiration – will check if baby is breathing normally
Normal chest expansion
Observe for good air entry

7.8. Procedure for daily physical examination

Head

o In case there was any caput check whether its growing or reducing
o Check for the sutures whether they are becoming close together
o Check for any bulging or depression to the fontanelles

Eyes
o Examine for any discharge incase of infection e.g. naesseria gonorrhea
o In case of any pus take a swab to the lab for culture and sensitivity
o Check for jaundice and pallor
Ears
o Examine if ears are clean or dirty
o Examine for any discharge which can indicate an infection

Nose
o Check for nostrils are dirty or blocked
o Clean with a wet cotton wool swab

Mouth
o Examine for oral thrush, pallor on the gums and any somatitis, if any infection
is present arrange for treatment

Neck folds
o Check in between folds for cleanliness or dirty and emphasize to the mother
to be cleaning be keen when bathing the baby and leave them dry.

Chest

o Observe for the chest movement and examine for any breast swelling which
could be a sight of breast engorgement.

Axxillar

o Check for any dirty and clean

Arms
o Check for pallor

Abdomen
o Examine for distension, check for any discharge especially around the stump
area.

Groin
o Check for any dirt and rash

Genitalia

o For females check for any abnormal discharge e.g. pseudo- menstruation and
reassure the mother.

Lower limbs
o Check for oedema, dirt in between toes and advice accordingly.
Buttocks
o Check for soreness, dirt, check for bowel habits pallor of the stool, smell and
frequency and advice accordingly.

7.9 MINOR DISORDERS OF THE NEWBORN

These include:-

1. Breast engorgement
2. Pseudo menstruation
3. Vomiting
4. Abnormal stool
5. Septic spots
6. Umbilical infection
7. Oral thrush

Breast engorgement

- May appear in both male and female by about 2 – 5 th day of life, which is due
to withdrawal of oestrogen hormone.

- No treatment is needed, advice the mother not to handle the breast and
reassure her.

Pseudo menstruation
- This is the passage of blood from the vagina (usually mucus mixed with blood)

- It is mostly due to withdrawal of oestrogen.

- Reassure the mother since it will clear on its own.

Vomiting

- It is mostly due to weakness to the cardiac sphincter or overfeeding.

- Assess if there is need to do sunction

- Leave the baby to lie on the side

Abnormal stool

- The stool looks frothy and these could be due to too much sugar, if the
mother is breastfeeding encourage exclusive breast feeding and if not
breastfeeding reduce sugar content.

- If the stool is dark yellow and of small amount mostly it is due to

underfeeding. Advice the mother to increase the amount of feed.

- Offensive greenish blue stool, this is a sigh of infection, advice the mother to
improve hygiene and can refer for medical aid.

Septic spots

- There are scattered white spots mostly caused by streptococcus or

staphylococcus aureus.

Management

- Isolate the baby

- Take push swab for culture and sensitivity
- Clean the baby with antiseptic e.g. hibiten
- Give antibiotics and change according to the results for culture and
sensitivity.

Umbilical infection
o Usually there is an offensive odour and pus discharge around the stump. The
infection can ascend and cause septicemia and led to a condition known as
neonatal sepsis.

o Neonatal sepsis may present with jaundice and diagnosis of neonatal jaundice
may be made.

Management

a) Take a swab from the discharge for culture and sensitivity

b) Start baby on broad spectrum antibiotics and change according to the results
from the lab.
c) Clean the cord with spirit twice daily
d) Isolate the baby.

Oral thrush

Usually caused by Candida (fungal infection) of the tongue, mouth or in cheeks.

- They are greenish whitish patches and the responsible micro- bacteria is
usually Candida albicans.

- In most cases the baby gets the infection form the mother.

Management

a) Treat the mother with broad antifungal drugs e.g. canesten once a day for
three days.
b) Give the baby oral nystatin three drops OD for 3/7
c) Paint mouth with G.V.
d) Apply Vaseline on mouth of baby prevent dryness
e) Advice mother to maintain proper personal hygiene
f) Advice midwife or any person handing baby on washing of hands before and
after handling the baby
g) Treat all vaginal discharge antenatal properly
h) Give mother vaginal pessaries incase of discharge.

Constipation

This is when the baby stays too long before passing stool. It is common in babies
on artificial feed.

- Encourage mother on exclusive breastfeeding

Sore buttocks
- It is an irritation on the skin of baby’s which causes burning effect.
- Improve baby’s hygiene by frequent change of napkins
- Disinfect napkins
- Refer incase of a complication e.g. diarrhea
- Apply petroleum jelly
- Expose baby for fresh air

7.10. DANGERS SIGNS FOR THE NEWBORN

• Baby refuses to feed, poor sucking

• Poor body temperature control (baby feels very hot or very cold)
• Difficulty breathing (grunting or wheezing, fast breathing, in-drawing of
chest, blue around mouth)
• Wet cord with blood/ pus & swelling around cord
• Swollen eyes, pus draining from eye or ear
• Jaundice – yellow body, eyes or palms
• Lethargic/floppy
• Convulsions
• Congenital anomalies –, e.g. spina bifida, hydrocephalus
• Imperforate anus (no passing of meconium)
• fontanelles (bulging or sunken)
• Birth injuries such as arm palsy, facial palsy, fracture (Breech delivery,
difficult birth, forceps delivery)
Mother’s and family’s knowledge of the danger
Signs and where to seek help saves lives. Ref: moph&s pop council draft on
maternal and newborn health.
Chapter 8: Elimination of mother to child transmission
of HIV- EMTCT

8.1: incidence of MTCT.

The national prevalence rate for HIV is at…….Without intervention the rate of
transmition of the virus from other to baby is at 40%. This means that not all babies
born by mothers who are infected will get the infection from the mother even if
nothing at all is done to prevent them from becoming infected. If the right
interventions are put in place the prevalent rate drops to less than 2 %. However
with the very many challenges in place in the implementation of the programme,
the target currently is to have less that 5% of HIV exposed babies be born
uninfected.

The pillars of safe motherhood are:

1. Prevention of infection.
2. Missed family planning opportunities.
3. EMTCT interventions.
4. Care and support.

Prevention of infection.
Missed family planning opportunities.

EMTCT interventions.

Care and support.

All pregnant women diagnosed to HIV positive are supposed to be started on HAART
irrespective of;

1. Viral load
2. CD4 count
3. Gestation

The woman will start on a combination of three drugs Tinofovir (TDF) 300mg,
Lamivudine(3TC) 300mg, Efavirenz (EFV) 600mgs. Sometimes others replace
Efavirenz with niverapine (NVP)

When the baby if born start the baby on niverapine syrup for 12 weeks is the
mother is on HAART or until 1 after breastfeeding was stopped if the mother was
nor on HAART. In case the mother had stopped HAART then 12 weeks from the
time the mother started HAART.

For the same babies cotrimoxazole prophylaxis should be started one week

after delivery until the baby has no further exposure to risk of being infected
through breast feeding of the final HIV results following complete ceasation from
breastfeeding is negative.

The baby will be tested according to the national guidelines at 6 weeks, 9 months
and 18months of age.
2.8 Nevirapine Dosing For HIV Exposed Infants

Age Nevirapine dose

0-6 weeks Birth weight <2500g – 10mg (1.5ml) once daily
6weeks – 14 weeks Birth weight 2500g – 15mg (1.5ml) once daily
14 weeks – 6 months 20mg (2ml) once daily
6 months – 9 months 30mg (3ml) once daily
9 months – 12 months 40mg (4ml) once daily
>12 months 50mg (5ml) once daily

2.9 Cotrimoxazole dosing for HIV exposed infants and HIV infected children

Weight (kg) Suspection 240mg per Single strength table Double strength table
5ml 480mg (SS) 960mg (DS)
1-4 2.5ml ¼ SS tab -
5-8 5ml ½ SS tab ¼ DS tab
9-16 10ml 1 SS tab ½ DS tab
17-30 15ml 2 SS tabs 1 DS tab
>30 (adults and - 2 SS tab 1 DS tab
adolescents)

Age Kind of test Results

6 weeks PCR If positive refer the baby for care. If negative
continue with follow up.
9 months Antibody If negative continue follow up. If positive perform
test DBS and if it turns positive refer for care.
18 months Antibody If negative continue discontinue follow up and
test discharge. If positive perform DBS and if it turns
positive refer for care.
Testing schedule

Notes: in HIV exposed infants, contrimoxazole prophylaxis should only be discontinued when
there is not further exposure to HIV through breastfeeding and the final HIV result following
complete cessation of breastfeeding is negative.
For HIV-infected children, cotrimoxazole should be continued for life.
CHAPTER 9: INFECTION PREVENTION

Broad objective:
To make the health worker appreciate how good how good infection
prevention practices protect him/her, the client and the community at
large.

9.1 Outcome:

• Demonstrate knowledge of the principles of infection control

• Recognize gaps in infection control infrastructure
• Recognize ways to address gaps in infection control infrastructure in different
situations

Without proper precautions your health care facility can actually cause the spread
of infection and disease. When providing health care it is essential to prevent the
transmission of infection at all times.
While reducing the risk of all infection is important, of particular concern in health
care setting are infections that cannot be cured, such as hepatitis viruses and HIV
which causes AIDS.

NOTE: Over the past few years the world has experienced outbreaks that
were at one given time better controlled and the introduction of new
infections causing incurable disease such as HIV hepatitis. Infections in
maternity units can be prevented and even eradicated.

9.2 Areas of infection in delivery units

 Dirty or contaminated delivery couch

 Dirty delivery room
 Poor methods of preparation of disinfectant
 Poor procedures in decontamination and waste disposal
 Repeated vaginal examinations
 Unsterile supplies e.g. suction tubes, masks, linen.
 Unsterile procedures e.g. vulva toilet, delivery, repair of episiotomy, cutting
cord.
 Unsterile delivery sets
Although we do not often think about it, health care facilities are ideal settings for
transmission of disease because whenever clinical procedures are performed,
clients are at a risk of infection during and immediately following the procedure.
Service providers and other staff are constantly exposed to potentially infectious
material as part of their work.

IX.3 Advantages of infection prevention

 Prevent post procedure infection

 Provision of high quality and safe service
 Reduce length of stay in hospital
 Prevent infection to service providers and other staffs
 Protect the community from infection that originates from the health care
facilities.
 Prevent the spread of antibiotic resistant microorganisms.
 Prevents human suffering.
 Prevents costs of health care services from extra investigations, extra drugs
and extra bed days e.t.c.
 Prevention is cheaper than treatment.
 Prevents death

9.4 How are infections transmitted?

Infections are caused by microorganisms which are tiny organisms that can only be
seen under a microscope. If you would look at your environment under a
microscope, you would see that microorganism are everywhere- on your skin, in the
air you breathe, in people, in water, buckets, on clothes, on surfaces e.t.c. when
these microorganisms are transferred to potential areas of infections e.g. vaginal
lacerations, row perineum, intravenous cannulas, or newborn baby can cause an
infections. To the health also in case of broken skin, scratches, rash, acne, fungal
infection e.tc.

9.5 Summary of standard precautions

 Wash hands
 Wear gloves
 Wear gown, masks (personal protective equipments-PPE)
 Prevent injury with sharps
 Correct processing of instruments
 Maintain correct environmental cleanliness
 Handle, transport and process used/ soiled linen correctly.
Others
 Covering open wound

Note: standard precautions should be followed with every client regardless of

whether or not you think the client might have an infection.

9.6 Procedure for decontamination.

The delivery rooms usually have of sets three set buckets for high level
decontamination.
The first step is immersing the dirty instruments in the first bucket which contains
10 % chlorine diluted at a ration on 6 parts of water and 1 part of chlorine (6:1). The
dirt/ contaminated instruments are dipped in chlorine for 20 minutes.
The second step is the removal of the instruments to the second bucket containing
soapy water. Here instruments are cleaned.
The third step is putting in the third bucket which contains clean water. In the clean
water the instruments are rinsed.
After the instruments are rinsed they are dried and packed for sterilization.
The chlorine requires to be changed after every 10 hours or when it becomes dirty
especially in very busy delivery wards.

Buckets
 Make use of the waste buckets allocated to you. Segregate waste as follows:

Black Yellow Red bucket- Placent Sharp Grey Toilet

bucket – bucket- highly a box bucke
non- infectious infectious/ bucket. t
infectiou pathological
s.
Glove Used Blood Placenta Needles, food Stool
papers, swabs, contaminated . syringes,
unused used swabs, gloves, branulas.
swabs, gloves, urine bag,
catheter used giving used catheter
covers, sets, used
suture i.v. fluid
boxes bottles.