OBS AND

GYN

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 Introduction:

Man from origin was given the right to procreate and reproduce just like other
animals and plants to ensure life. Women therefore get pregnant so as to deliver
children in fulfillment of this purpose. When women get pregnant they need special
care.

Obstetrics is the science or the branch of medicine that deals with pregnancy and
child bearing i.e. the period when a woman is pregnant, is in labor or in the
puerperium (after birth). At the end of the course the student nurse is require to
know the following

- Physiology of pregnancy
- Antenatal care (ANC)
- Intra-partum care (care during birth)
- post-natal care
- care of the new born
- Breast feeding

The physiology of pregnancy (DT2)

A woman is said to be pregnant when she is caring a fetus in her womb after
fertilization. Pregnancy refers to the period of time in a woman’s life from
conception till delivery. This is usually 280 days calculated from her last menstrual
period or 266 days from the day of fertilization or 40 weeks or 9 months.

Definition of terms

i. Fertilization: This is a process where by a sperm fuses with an egg to form a

zygote
ii. Zygote: A zygote is a fertilized ovum within the first 2 weeks.
iii. Embryo: An embryo is a fertilized ovum from the 3rd week to 8th week
iv. Foetus: It refers to the product of conception from the 9th week till delivery.
v. Gravida: This means to be pregnant. Pregnancy for the first time is referred to
as primigravida or gravida I. pregnancy 2 or more times is referred to as
multigravida. If a woman has been pregnant 5 or more times she is referred to
as a grand multigravida.

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 vi. Parity: This means to deliver. referring to giving birth to a child. Parity refers
only to delivery occurring after the 28 th week of pregnancy. Whether baby is
alive or not. Delivery for the first time is referred to as primipara or para 1.
Delivery, 2 or more times is referred to as multipara. Delivery 5 or more times
the woman is referred to as grand multipara.
vii. Nullipara: A woman who has never given birth
viii. `Nulligravida: A woman who has never been pregnant.

If a woman has been pregnant twice, delivered once this information can be
represented as ffs G2P1. This is known as the 2 digit presentation of obstetrical
information. This naming or presentation doesn’t tell all obstetrical information
about the woman in question e.g. it does not say whether she has had a premature
delivery or whether her child is living or not.

DETERMINATION OF SEX

The man has 22 chromosomes and 1 sex chromosomes XY while the woman
has 22 chromosomes and 1 sex chromosomes XX. When the when the X
chromosome from the man crosses with the X chromosome of the woman the
resulting offspring is a female with XX chromosome. When the Y chromosome from
the men crosses with the X chromosome of the woman the resulting offspring is a
male with XY chromosome.

Therefore the man determines the sex of the child.

GAMETOGENESIS

This is the process by which gametes are produced. Gametogenesis takes

place in the ovaries and in the testis. Gamete are sex cells called ova in the female
and spermatozoa in the male. They are called gamete because hey have only half
the No of chromosome found in a normal body cell (i.e 23 chromosomes). The
normal body cell has 46 chromosomes which is therefore called a diploid cell and
the gametes are called haploid cells. The process by which ova are produced in the
female is called Oogenesis. The process by which sperm cell are produce in male
(testis) is called spermatogenesis.
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 PREGNANCY.

Pregnancy is defined as being with child. This is a condition that begins from
conception to the expulsion of the foetus which an average duration of 280 days or
40 weeks or nine months. This period is counted from the last da of the last
menstrual period.

Pregnancy is the state in which changes occur in all part of the maternal body
due to alteration in hormonal balance, circulation and metabolism. Pregnancy itself
imposes a stress on the maternal organs.
DETERMINATION OF EDD

This is done by adding 7 days and 9 months to the LMP.

E.g LMP 11/12/2017

+07/09

EDD 18/09/2018

LMP 28/02/2017

+7/9

EDD 7/12/2017

OR

By adding 7 days, substracting 3 months and adding 1 year to the LMP

LMP 11/12/2017

+7/-3/+1

EDD. 18/9/2018

DETERMINATION OF GESTATIONAL AGE

The done by substracting LMP from the present date and converting all into weeks according the
Naegele’s theory.

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Naegele’s theory states that age of pregnancy should be stated or presented in weeks and not in
months. Months can be converted into weeks as follows:

1 month= 4 weeks

2 months = 9 weeks

3 months = 13 weeks

In any case the highest number is considered first. If it cannot go, then the next highest is
considered.

4 months of pregnancy can be converted into weeks as follows:

4 months= 3 mths+ 1 mth

3 weeks + 4 weeks= 17 weeks

5 months is considered 22 weeks because it is converted as follow

1) What is the gestational age on the 15/05/2018 when LMP is 05/11/2017

2) A) What is the EDD? B) Gestational age on the 15/05/2018/ LMP: 09/01/2018

OBSTETRICAL HISTORY

5 months = 3 mths + 2 mths

= 13 wks + 9 wks = 22 weeks.

9 months is considered 39 weeks because it is converted as follows:

9 mths = 3mths + 3 mths + 3 mths

M = 13wks + 13 wks + 13 wks= 39 weeks.

The obstetric history, refers to a woman’s medical history related to pregnancy, childbirth, and the
postpartum period. It typically includes information about previous pregnancies, births,
miscarriages, and any complications or medical conditions that may affect pregnancy.
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Common Terms used;

● •Gravidity –number of pregnancies regardless of

● •Gravid –pregnant

● •Gravida –a pregnant woman; subsequent

● number indicates the number of times she has

● been pregnant

● nulligravida –a woman who has never been

● pregnant

● G 1 (primigravida)–means this is the woman’s

● first pregnancy

● G 2 –means this is the woman’s second

● pregnancy

● pregnancy outcome.

● •Para –having given birth; number indicates

● the number of times woman has given birth

● –Includes live or stillborn babies (excludes

● miscarriages)

● –Nullipara –a woman who has never given birth

● –Primipara –a woman who has delivered one baby

● –Multipara –a woman who has delivered >2

● pregnancies to stage of fetal viability; more than

● one baby; Para 2, 3, 4…

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● Multigravida-a woman who has been pregnant >

● 2times

● •Grand multigravida –a woman who has been

● pregnant >5 times; irrespective of outcomes

● •Grand multipara –a woman who has given birth

● >5 times

● Convention for Communicating Gravidity & Parity

● •Standard usage: G_ P_L

● •5-Digit system: GTPAL

● G_ P term_ preterm_ abortions_ living_

Case 1

A mother reports this is her first pregnancy.

•What term describes her?

● What is her G and P?

Case 2

A mother has a history of 5 pregnancies which

Include 2miscarriages and 3 live births.

•What terms describe her?

•How would you describe her gravity and

Parity? (G, P and L)

Case 3

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A mother reports this is her 4th pregnancy with

A history of 1 premature birth and 2 term births

And 2 of her babies died.

•What term describes her?

•What is her G and P?

Case 4

A mother reports she has been pregnant 7 times

Before and had 2 miscarriages, 5 live full-term

Births and has 4 living children.

•What term describes her?

1) Gravida refers to the number of pregnancy and/or being pregnant…

● A woman who has been pregnant once is a primigravida or G1

● Pregnant 2 or more times is a multigravida.

● Pregnant 5 or more times is a grand multigravida.

2) Parity refers to delivery or parturition or the act of giving birth. This is the process by which
the uterus empties is contents at term.
● Delivery for the first time is primipara or P1.

● 2 or more times is multipara

● 5 or more times is a grand multipara

3) Nulligravida referring to a woman that has never been pregnant.

4) Nullipara referring to a woman that has never given birth.
5) Abortion:

PRESENTATION OF OBSTETRICAL HISTORY

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This is done or presented in 5 digits as follows: GaPbcde where it stands for:

G: gravida

A: number of pregnancy.

P: parity

B: number of term deliveries

C: number of premature deliveries

D: number of abortions

E: number of living children

e.g: G4P1112; G4P0030

The process of fertilization

Fertilization occurs at the ampulla of the fallopian tube between the 36 th – 48th
hours after ovulation. The sperm penetrates the ovum. The enzyme called
hyaluronidase dissolve the acrosome and the head of the sperm and the cell
membrane of the ovum.

The 2 nuclei merge together. Their chromosome number is restored to 46.

Sex and genetic inheritance is also established at the same time. The fertilized
ovum or zygote secretes a substance which repels all other spermatozoa.
Fertilization then complete particularly upon the vascular system. This doesn’t
means the person is ill.

Signs and symptoms of pregnancy.

There are divided into three subtopics

1) Presumptive signs and symptoms
2) Probable signs and symptoms
3) Positive signs and symptoms

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 1. Presumptive signs and symptoms

These are those signs of pregnancy which can also present as sign of a disease e.g.

a) Amenorrhea (absence of menses): This may also be seen as a result of fright

(fear), illness etc.
b) Morning sickness: This is a feels of nausea and sometimes vomiting especially
in the morning upon rising from bed. It may also occur in the day when the
stomach is empty.
c) Frequent micturition (urination)
d) Breast changes: e.g. Breast enlarges and attractive looks.
e) Darker area of the nipple, sensitive to touch (tinkling sensation)
f) Vaginal changes: e.g. Bluish colouration of the vaginal wall
g) Quickening
h) Straie gravidarum: This are marks on the abdomen breast, thighs etc. due to
rupture of some supertieval blood vessels as a result of enlargement.
i) Linear nigra: It is a nice black line that appears from the symphysis pubic righ
up to the umbilicus and sometimes above.
2. Probable signs and symptoms

These are those signs that are only detected by specialist or trained health
personnel and by vagina examination.

a) Hegar’s sign: This is one of the earliest sign established as pregnancy is getting
bigger. It shows extreme softness of the lower uterine segment. It shouldn’t
be done unless very necessary for it can cause abortion.
b) Osiander’s sign: This occurs from 6th – 12 weeks of pregnancy. Insert 2 fingers
into the vagina. There is increase pulsation due to marked or increase in
vascularization. There is also a bluish coloration and softness of the cervix.
c) Uterine suffles: This is a soft blowing sound from the uterine blood vessels
similar to the movement of a snake on dry grass.
d) Positive laboratory pregnancy test

Human chorionic gonadotropin hormones can be detected in plasma and in urine.

Positive hormonal test is just a probable sign of pregnancy because other disease
conditions can also show this picture e.g. hydatidiform mole

Enlargement of uterus according to Age of pregnancy

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A pregnancy less than 10 – 12 weeks is known is a pelvic pregnancy. Cannot be felt
on the abodominal position. At 12weeks the uterus is at the level of symphosis
pubis. At 16 weeks the uterus is half way between the symphisis pubis and
umbilicus. At 20 weeks the uterus is 1 finger breath between the umbilicus. At 24
weeks the uterus is one finger, breath above the umbilicus (fundus). At 30 weeks
the fundus is meet way between the umbilicus and the tiphisternum (upper barder
of the four abdomen). At 36 weeks, the fundus is at xisphisternum ( or below). At 40
weeks, the fundus is lower at least 4cm below the xisphistern um.

- Foetal heartbeat is present from the 18 th - 20th weeks of pregnancy. This is

quite distinct and separated from maternal pulse. Feotal heartbeat can be
picked up from about the 12 th week of pregnancy by a machine known as a
Doppler.
- Feotal movement felt by the nurse or midwife.

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 - On palpation various parts of the feotus can be differentiated e.g. The head.
Which is round and harder than the buttocks. The head is also ballotable
(shaking or dancing when palpating.

Physiological changes during pregnancy (DT2)

These are changes that take place in a woman as a result of pregnancy. These
changes occur due to alternation in hormonal production circulation and
metabolism. Pregnancy is more than a growth of the uterus. This affects all the
system of the pregnant woman.

1. The uterus

This increases in size and changes its position and weights. It leaves from the pelvic
to the abdominal cavity. The pregnant uterus at term weights 120g, but the non-
pregnant one weights 60g. As the uterus grows out of the pelvic, it pushes all
abdominal organs out of the way and occupies the abdominal space, enlarges the
abdomen making the woman to lean backward.

2. Neurological changes

The growing pregnancy comprises the pelvic nerves and the blood vessels leading to
the stasis (accumulation). Some women complain of sensory changes in the legs e.g.
numbness, cramps, etc. some women occasionally may become irritable,
quarrelsome and cry easily. This is due to hormonal changes.

3. Hormonal changes

If fertilization occurs the human chorionic gonadotrophin produced by the

blastocyst caused the corpus luteum to persist and because of this the first apparent
sign of pregnancy is most usually amenorrhea. This hormone reaches maximum
production at about the 12th week of pregnancy after which the Corpus Luteum
gradually declines as the placenta assumes responsibility for the production of
progesterone. Chorionic gonadotrophin is excreted by the kidneys and can be
detected in the urine from the early weeks of pregnancy; this is the basis of the
biological and immunological pregnancy.

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Some may develop different flavor or even dislike some food or have an urge to eat
certain food.

4. The muscular system

As the uterus grows out of he pelvic it also inccrfease in weight. This causes marked
alternation in the posture at the pregnant woman. There is an exaggerated Lumbo-
sacral curve (curving backward). This also changes the walk of the pregnant woman
referred to as the proud walk of pregnancy. There is weakness of joints and
sometimes gaping because of the influence of hormones

5. Changes in the breast

The breast tissue enlarges give a tinkling sensation, nipples enlarges and are more
sensitive to touch. The breast becomes highly pigmented, feels nodular, lumpy, and
superficial blood vessels becomes more prominent and the breast start to secrete a
fluid as early as the 26th weeks of pregnancy.

6. Metabolic Changes

The activity of the body increase during pregnancy, the growing demands of the
fetus and maternal tissues result in increase basal metabolic rate (BMR) this results
to increase in weight because the pregnant woman DEVELOPS love for certain
foods. The average weight of the foetus at term is 3.4kg. Placental at term weights
averagely about 450g (0.45kg)

7. Skin changes

The skin of the abdomen and other part stretches as the uterus enlarges, this result
in some tearing of the deeper layer of the skin (dermis and subcutaneous),
superficial blood vessel marking of the skin known as stravae gravidanum (stretch
marks) presence of linear nigra which disappear after delivery during the period of
puerperium. As said above, pregnancy affects all the system and organs of the
human body.

Care of the pregnant woman

Introduction: considering that pregnancy is precious and is a state at which the

woman experiences physiological changes or involve minor disturbances. A

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pregnant woman need to be given proper care in DT2 by well train health personnel
so as to ensure the life of the mother and the unborn baby.

Care of the pregnant woman is divided into 3 phases

a) Pre-natal or antenatal care

b) Intra-partum care
c) Post-partum care

Pre-natal care (A.N.C)

Def: Antenatal care (A.N.C) is the care given by a specialized train personnel to a
pregnant woman and her families using certain activities to ensure a healthy baby
and mother at the end of the pregnancy.

Aim of A.N.C

- To promote and maintain good physical and mental health of a pregnant

woman.
- to detect early and treat disease that may endanger the life of the mother
and that of the unborn baby.
- to prepare woman for labour and subsequent
- to meet the woman psychological need care of herself and the baby (via
health education)
- to ensure a save delivery of a normal baby at term
- to prepare the woman for successful lactation (breast feeding)
- To meet the woman’s nutritional need so that she is not short of iron,
vitamins and other nutrients.
- To help the woman understand simple ways of preparing a well balance diet
- To vaccinate the pregnant woman against tetanus so that the foetus gains the
immunity.

Booking clinic

This is a first meeting or contact of a gravida with a midwife after she discovered
that she is pregnant.

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Component (activities of) ANC

- History taking
- Examination
- Consultation and Rx
- Health education(IEC)
- Supervision (monitor or Evaluation)

History taking

Aims:

- To have accurate knowledge of clients background socially, medically and

obstetrically.
- To decide if client should deliver in the hospital or in the health centre.

Various histories taken in booking clinic

i. Social History: this is to be able to identify a patient. This include her

names, age, address, marital status.
certain religious practices hinters normal pregnancy e.g. Jehovah witnesses
refuse blood transfusion. Such religious information is very important to
know how to healed patient background.
A pts social history can influence the pt status e.g. a woman married to
one man is more settled in mind than a woman who is married to a man
with other wives.
ii. Family history: A family which is poor, full of disease can implicate the
woman's pregnancy. Many disease turn to run in families and the woman
cannot be an exception. Pregnancy and disease can give rise to
complication. inquire about hereditary and communicable diseases in the
family e.g diabetes, hypertension, pulmonary TB, leprosy, epilepsy, asthma
etc this is from her family and that of her husband.
iii. Medical History: find out if she has been hospitalized or if she is having
any medical condition if she is on a special medication. Present medical
condition couple with pregnancy can make the pregnancy pathologic. Find

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 out if she has diabetes, hypertension epilepsy, asthma etc. All this
conditions can interfere with pregnancy.
iv. Surgical history: inquire about surgery especially involving,the uterus,
abdomen and pelvic. find out if she has had blood transfusion
v. Past Obstetrical History: a complicated past obstetrical history may
complicate the present pregnancy for example previous abortions and age
of the pregnancy, previous bleeding during pregnancy, previous pre-
eclampsia, previous complicated labour etc.
vi. present Obstetrical history: Here her last Menstrual Period (LMP) is
established by asking her the first day of her (LMP). Date is to calculate or
estimate expected date for delivery. various formulae may be used e.g.
counting ahead 9 months and adding 7 days

for example:-

LMP = 02/01/1977

EDD = +7/+9 = 09/10/1977

Example 2:

LMP = 22/09/2010

EDD = +7/+9/ = 29/06/2011

How to calculate the age of pregnancy

This is possible according to Naegel’s theory which states that the age of gestation
should be presented in weeks and days, that months can be converted to weeks as
follows

- 1 month is 4 weeks
- 2 month is 9 weeks
- 3 month is 13 weeks

In every case the highest No of months is considered if it cannot go then the next
lower number is used. The age of gestation is calculated as such. When the LMP is

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known e.g. if the LMP is of 05/05/07, what will be the pregnancy as of 07/12/2007.
It will only subtract LMP from the present date.

Solution
LMP = 05/05/2007
Date of visit = 07/12/2007
2/7/ = 30 + 2 weeks
What is her EDD?
= LMP = 05/05/2007
= +7/+9/
EDD = 12/02/2008

Example 2
LMP = 28/02/2006
What was the age of her pregnancy on the 07/07/2006 and what was her EDD
Solution
LMP = 28/02/2006
Date of visit = 07/07/2006
37/07/2006
37 days – 28 days
9days/04months/0
1 + 2 weeks + 17weeks 18+2 weeks
EDD = 07/12/2006

Example 3:
Consider LMP 26/05/2011. What was the age of this woman’s pregnancy on the
13/10/2011. What is her EDD?
Solution
LMP = 26/05/2011
Date of visit = 13/10/201143/10/0
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2+2 + 17 = 19+3 weeks
EDD = 26/05/2011
+7+9
= 02/03/2012

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Example 4
1. Consider LMP 29/07/2011
2. What is the woman’s age of pregnancy today?
Solution
LMP = 29/07/2011
+7 +91
EDD = 05/05/2010
LMP = 29/07/2011
16/11/2011
47/10/2011
18/3/0
2+2 weeks + 13 = 15+4weeks

Assignment
Consider the LMP 07/12/2011
a) what is the EDD
b) What is the age of pregnancy

Examination

Two types of examination are carried out

Physical and paraclinical examination

Paraclincial examination include weight, BP, laboratory investigation (urine

analysis and blood examination. all vital signs constitute paraclinical examinations.

The weight, height and BP are recorded during the booking clinic as base line
information on with subsequent assessment will be compared to see if pregnancy is
growing or not. Lab tests are carried out using blood and urine as specimens. Blood
is usually examine for:

- Blood group
- Rhesus factor
- Haemoglobin level (HB carries O2)
- V.D.R.L (Veneral disease research laboratory)
- HIV etc

Urine is examined for albumin, sugar and sometimes acetone.

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 Physical examination is systematic approach from head to toe done in other
not to miss any important information. It is done to;

Identify signs of pregnancy and to detect any physical abnormality or problem that
may interfere with the progress of pregnancy and labour e.g. anaemia, breast
problems, vaginal discharges, oedema etx.

Abdominal examination is done with special attention paired to the first

steps: Inspection, palpation and auscultation respectively.

This examination is done to determine the age of pregnancy, life of the foetus in the
uterus whether the foetus is alive or not and also to confirm pregtnancy.

Health Education (I.E.C.)

During clinic visits the pregnant women are given individual or group teaching to
enable them care for themselves, their babies and other children some of the
important topic treated in the clinic include: personal hygiene, nutrition in
pregnancy, signs of labour, preparation for labour, prevention of home accident,
disease in pregnancy, the important of attending clinic etc.

Consultation and Rx

Here, the midwife discusses the result of the examination and lab test with
the woman. She finds out more information from her concerning her health. Rx is
prescribed for common illnesses discovered e.g. worms malaria, anaemia etc.

There are routine drugs a are also prescribed for a pregnant woman e.g. folic
acid, fansida, ferrous sulphate etc. the women are also vaccinated against neonatal
[Link] are 7 components of ANC that is blood pressure measurement,
provision of a blood sample, provision of urine sample, tetanus vaccination,IPTs
administration including number of times,dewarming treatment and iron-folic acid
supplements.

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Schedule for immunization of women against tetanus

Dose Interval between doses Duration of protection

T T1 First contact No protection
T T2 4 weeks after T T1 1 – 3 years
T T3 6 months after T T2 5years
T T4 7 years after T T3 10years
T T5 1 year after T T4 For the rest of the child
bearing age.

Supervision of monitoring

monitoring involves following up of the pregnant woman regularly to

determine her health situation and that of her unborn child. this is suallydone
during subsequent visits.

Timing of visits.

After the booking visit which shed between the 2 nd and 4th month of pregnancy the
woman comes for subsequent visits as follows.

- once every 4 weeks until the 28th week of pregnancy.

- once every 2 weeks until 36week
- once every week until the 40th week
- twice a week if woman is not yet in labour until labor starts.

Today however there is what we call focalized ANC which says that a pregnant
woman should attend clinic at least 4 to 8 times before delivering i.e. at 16 weeks, at
28th weeks, at 32 weeks and at 36th weeks.

During subsequent visits the midwife reads the pts notes and ask her how she
feels and opportunity is given to the woman to talk so that any problem or anxiety
may be understood. the woman is properly examined during subsequent visit (both
physical and paraclinical examination)

During examination more attention is taken to detect any sign of pre-eclamsia

(P.E.) eg. Increase BP. Albumin (protein) in urine, Oedema.

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 The weight of the woman is schedule to compare with the last record. The
total weight gain during pregnancy is about 11kg. expected weight gain in the first
trimester is 1-2kg, in the 2 nd trimester 8-9kg and the woman is expected to gain 350
– 400g weekly.

NB: Any weight gain more than 500g/week is also normal. This is suggesting
possible signs of pre-eclaimsia. urine is examine for sugar and albumin. Every
subsequent visit. Albumin or sugar present in urine suggests that there is a problem.

BP is checked during every subsequent visit if possible using the same

instrument and positions. A rising blood pressure could be an indication of
preeclampsia. Oedema of the face, eyes, upper limb, lower limb, vulva etc is
checked.

It should be noted that during physical examination of a pregnant woman. the

woman is stripped completely necked and covered with 2 sheets to ensure privacy.

Abdominal examination of a pregnant woman

Aims

1) To confirm pregnancy
2) To make sure the uterus is growing according to the age of the pregnancy.
3) To find out whether the foetus is alive or not

Method of examination

This involve 3 steps viz inspection palpation and Auscultation

1. Inspection

This involve the rise of the eye to note the size, shape, appearance of straie
gravidarium, linear nigra, scars etc the midwife uses here sense of sight and looks at
the abdomen for the above signs. Multiple pregnancy or poly hydramnios increases
the length and breath of the uterus more than the age of the pregnancy. Inspection
helps the midwife to detect the life of the foetus. If the foetus is lying longitudinally,
the shape of the uterus will be Ovoid (normal shape of pregnancy abdomen). If the
foetus is lying transverse the shape of the uterus will be round or broad (not
normal)

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 2. Palpation

The midwife uses her hands to feel the foetus in the uterus. through palpation one
can determine the presentation, position and whether foetus is alive or not.
abdominal palpation is done by

a) Dox a fundal palpation: This is touching to feel what is on the upper segment
of the uterus
b) Lateral Palpation: This involves touching to feel what is on the side of the
uterus
c) Pelvic palpation: Touching the lower segment of the uterus to find out what is
there.

All this is not easy before the 16th week of pregnancy. This examination the
woman empties her bladder if not wrong result will be obtain since a full bladder
will distained or push the uterus upwards. Privacy is maintain during this process by
either closing the door or screening the couch(examination bed or table). the
midwife washes her hands and explains the process to the pts or woman before
palpation. the midwife stands on the right side of the woman and talks to her as she
works.

During palpation a measuring tape is used to measure the height of the fundus.
In the absence of a tape 2 fingers breading is used.

Fundal height is checked by placing a tape on the upper boarder of the

symphysis pubic to the highest point of the fundus.

3. Auscultation

This involves the use of some instruments to listen to the sound in the uterus e.g.
feotal heart sound. The instruments use are:- the Stethoscope, foetoscope and
electronic devices (Doppler). The normal rate of foetal heart beat is 120 - 160

beats/minutes(b/m). Any foetal heart beat less than 100 and more than 160 beats
per minute is an indication of feotal distress. feotal heart beat can be heard from
the 18th to 20th week of pregnancy using a foetoscope. But can be heard as early as
10 – 12 weeks using a Doppler. Heart beet more than 160 beet/minute is referred to
as foetal tarchycardia and heartbeat less than 100 beats/minute is referred to as
foetal Brady cardia.
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Definition of some terms used during pregnancy

a) The lie: This refers to the relationship between the long axis of feotus and the
long axis of the uterus (not the spine or abdomen). If the long axis of the
feotus is parallel to the long axis of the uterus the lie is longitudinal. If the
long axis of the foetus lies across the long axis of the uterus the lie is transvers
and if the long axis of the foetus is diagonal to the long axis of the uterus the
lie is oblique.
b) presentation: This refers to the part of the foetus which is lower most to the
birth canal. If the head is lower most, the presentation is said to be (vertex)
i.e. Phallic. If the buttock is lowermost the presentation is said to be (Podalic)
breech presentation. We can also have compound presentation in the case
where 2 or more parts are presenting e.g. head and hand or leg.
c) Position: This re3fers to the rlatiosip of a given part of the foetus to the six
areas of the maternal pelvic. this given aprts is knowna as the denominator or
the leadingpart.
in nomnal p osition, we have:-
- Right occipito antertor (ROA)
- Right occipito lateral (ROL)
- Right occipito postertor (ROP)
this is because in a normal position, the denominator is on the right side of
the maternal pelots. If the denominator is on the left side, we will have:-
- Left occipito antertor (LOA)
- Left occipito lateral (LOL)
- Left occipito postertor (LOP)
If the elading part is the face then the denominator is the chon (mentum)
(RMA) etc.
d) Altitude: This refers to the relationship of the foetal lymphs and head to the
trunk. A normal altitude is that of complete flexion. When there is complex
flexion in a cephalic presentation the occiput must be the leading part. Any
other altitude apart from this is abnormal e.g. incomplete flexion; extension
etc.

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 e) Engagement: This refers to as situation here the largest of greatest diameter
of the presenting part has entered into the pelvic brim. When there is
engagement the presenting part will be fixed upon palpation i.e immovable.

Preparation of a gravida for labour

In the ANC, mothers are usually advised on what to buy for themselves and
babies in preparation for delivery. Each maternity unit must have a list of things
required depending on its environment. However some materials are common or
standard

a) Materials for the baby

- Cotton wool
- Spirit (alcohol)
- Olive oil
- Two towels
- Baby set (wrapper, cap, sucks, sweater etc)
- Baby’s dresses (inner wear, gown etc)
- Vaseline
- Bathing soap
- Two dozens of napkin
- Plastic pants (paper napkin)
b) Materials for the mother
- ANC Card
- Microlax (two tubes)
- 3 to 4 pairs of sterile gloves, size 7.5 or 8
- Money (about 50,000frs)
- Toilet tissue
- Ergomethrine or oxytocin injection
- La croix (javel water)
- Surgical blade
- Pad
- Slippers
- Night g own
- Bed sheets, blanket, syringes, a pair of loin cloth (wrapper)
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Psychological preparation of woman for labour

This involves preparation of the mind of a pregnant woman. Women are anxious
when expecting a baby. Their minds are disturbed by some fear whether they will be
able to deliver safely. The pregnant woman might also be worried in mind by some
marital problems and social problems e.g. a woman who has been abandoned by
her husband, a woman who needs a particular sex of child etc.

The nurse can only succeeds in this after careful history taking. In
psychological preparation for delivery, the nurse or midwife interacts with the
woman trying to identify her problems, she tries to solve them.

The aim of psychological preparation is to

- Avoid ignorance
- Eliminate fear and tension
- Restore, maintain and promote her peace of mind to enhance a comfortable
delivery.

High Risk Pregnancies (HRP)

Some pregnancies pose a problem to both the woman and the midwife. Such
pregnancies where the life of the mother is at risk are referred to as high risk
pregnancies.

Every woman with a HRP should be referred for a specialist’s care and delivery in
the hospital.

The women concerned are informed of the risk and encouraged to follow
insructions gien to them.

Some of the HRPs are:

- Pregnancies with bad obsterica history e.g. previous operation (CS) previous
premature delivery etc.
- History of post partum haemorrahage
- Prolonged labour
- Habitual abortions
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 - Stillbirth (babies delivered dead)
- Too young a woman ≤ 16years
- Too old a woman for the 1st pregnancy ie.≥ 30 years
- Too short a woman≤ 150cm
- Very sick woman
- Grand multi glavida or grand multi para

Changes that occur in the uterus after fertilization

After fertilization the uterus makes preparations to receive the fertilized ovum. The
ovary becomes less fxnal and there is development of a body called corpus luteum
(yellow body). This body is hormonal in nature and secretes estrogen and
progesterone. These hormones helps to suppress F.S.H. and maintain the inactivity
of the ovaries. The presence of the above hormones change the endometrium and
cause the formation of decidua (the inner lining of the uterus prepared for
pregnancy). The endometrium secretes a fluid looking like a weeping rock it
becomes softer and vascular giving a fertile ground for implantation. After this time
the endometum is divided into 3 layers:- The compact, spongy and basal layers. The
fertilised ovum is implanted into the spongy layer. After fertilization segmentation
of the cells takes place immediately. On the way through the tube the fertilised
ovum divides in an organize manner. First into 2, then 4, 8, 16, 32 until a whole
compact of cells is developed known as morula. Later during its journey still in the
fallopian tube some cells are arranged on one side and some are pushed to the
periphery to the 2 layers and the inside is filled with fluid. This structure is known as
a blastocyst. the cell arranged around are known as the trophoblast. Those cells
pushed to one side forms the inner cells mass. It is at this time or stage that the
fertilized cell enters the endometrium after about 7 days.

Implantation

On the 7th day (day of fertilization) the blastocyst enters the endometrium.
The trophoblast secretes an enzyme (hyaluronidase) which either erodes or shifts
the cells of the endometrium casing the blastocyst to find itself into the spongy layer
of the endometrium. Bleeding may occur which is sometimes mistaken for menses.
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When implantation takes place the area of entry is cloted (endometrium). The area
bulges into the canesty of the uterus and implantation is complete

Differentiation of the inner cell mass

The inner cell mass arranges itself into 2 layers; the outer layer is known as
the ectoderm and the inner layer is the endoderm. Where the 2 layers meet they
form the mesoderm. The outer layer cells of the trophoblast starts to arrange
themselves into finger-like projections carrying 2 layers of cells. Some of them grow
deep into the endometrium and are buried forming the placenta. The inner layer of
the trophoblast forms the feotal sac that encloses the ectoderm, endoderm and
mesoderm. The cells that are facing this layer widens, forming a sac known as the
chorton the feotal sac is called amnion.

Formation of the foetus

Two little cavities appear in the centre of the blastocyst. the 1 st supper most
cavity is filled with fluid i.e the amniotic sac. The corner most cavity is known as yolk
sac. The space between the 2 cavities embryonic lpate or area.

The amniotic sac expands taken part of the embryonic area and part fo the
yolk sac enclosing them and expanding outward to meet with the inner surface of
the trophoblast to form feotal membrane (Amnion and Chorion)

a) Chorion: This is the outer minb which lies the amnion. It’s derived from the
trophoblast. The chorion is thick opaque, fragile and diff to the inner mmb but
can be seperated right up to the ingestion of cord. This is that mmb that
usually is retained when the placenta is delivered because its fragile.
b) Amnion: This lines the Chorion. Its derived from the inner cell mass, its
smooth, tough and made from the tissues like that of the umbilical cord and
doesn’t tear easily.
c) Amniotic fluid: This is fluid in the amniotic sac. it’s clear and have a pale
colour. The foetus floats in the fluid. The fluid is present in this sac in the early
weeks of pregnancy. The fluid continues to increase steadily until term. it
ranges from 600ml(at term)–800ml (at 34weeks)

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Origin of Amniotic fluid (source)

This fluid is produced from foetal and maternal sources. This mmb forms the
foetal source of the placenta and produce about 95% of the fluid. The umbilical cord
produces some amount of the fluid. Foetal urine for about the 10 th week of
pregnancy also adds the fluid. The rest of the 5% diffuses from maternal blood
vessels.

Consistency of the Amniotic fluid (what is made up of)

- Water makes up 95%

- The fluid contains various mineral salt which renders the alkaline nature
- Urea, protein, foetal hair, and some body cells are present.
- Some oily substances known as sebum, whitish oil on the foetus which is
known as vermix caesiosa.

When the amniotic fluid is more than 1000ml a pathological condition will exist
called polyhydraimnios. If is less than 500ml the condition is known as
oligohydrammnios.

Function of Amniotic fluid during pregnancy

- It distend the sac and gives room for the growth of the foetus
- It allows free foetal movement like a fish in water
- Its serves as a shock absorber for the foetus
- It lubricates the foetus and keeps it clean
- It acts as nourishment and water for foetus to drink

Function of Amniotic fluid during labour

- It direct uterine pressure into the cervix

- The fluid prevents marked interference of the placenta side
- The fluid washes and lubricates the birth canal before baby I s delivered

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The umbilical cord

It extend from the foetal surface of the placenta to the umbilical region of the
foetus. It is made from the inner cell mass. The cord carries 2 arteries and one vein.
The Artery(s) carry deoxygenated blood and the veins carry oxygenated blood.

The length of the cord

it is averagely 55 – 70 cm. If less than 40cm(35-40cm) is short, more than

60cm is too long and too long a cord may have true knot or false knot. It should be
noted that false knot can be seen in any cord long or short. a long cord may also go
round the neck of the foetus and cause strangulation. It can sleep in front of the
presenting part when mmbs are still intact (cord-presentation). When membranes
rupture the cord escape through the cervix to the vagina which is known as cord
prolapse.

Cord insertion

The normal insertion is usually central known as central insertion but it can fine
insertion at the edge or side or margin which is known as Battle dore insertion.

The placenta

When it is fully form it is known as afterbirth. When you look at it, it is round, flat,
tapling at its edges. It is about 20cm in diameter and 2.5cm thick. It weighs about
1/6 of infant’s weight; it is dark reed in colour made up of 2 surfaces, the maternal
and foetal surfaces. The placenta is derived from the trophoblast (source).

Maternal surface

This is the side or part attached to the endomendrtium. This part is arranged
in cotyledons (lobes) and each cotyledon is separated from the other by a salli or
forrow. The colour is reddish blue derived from the maternal blood supply. The
surface is covered by a thin layer of cells. The cotyledons ranges from 15-22 in
numbers. Occasionally lime salt can be deposited on the surface of the cotyledon.
This is known as calcification. It appears whitish and feels harsh to touch.

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 Foetal surfaces

This is that part the faces the foetus. it is smooth whitish and shiny. It is
continuous to the insertion of the umbilical cord.

Placenta circulation

Blood from the foetus circulates from the foetal heart supplying the foetus
with oxygen. In need of oxygen, blood is carried from the foetal to the placenta
through two arteries in the umbilical cord. oxygenated blood is then brought to the
foetus from the placenta through one umbilical vein.

Function of the placenta

The placenta has range functions as it mix up withal the needs of the foetus.

a) Nutritional needs or functions: The placenta metabolises glucose and stores

in the form of glycogen. It converts it into glucose when required, certain
substances for example mix vitamins pass directly from maternal blood to the
placenta and then to the foetus. The placenta continues to perform its
nutritional function until the liver of the foetus matures.
b) Respiratory functions: Actual pulmonary respiration does not occur in the
uterus. Oxygen from maternal blood diffuses to the placenta and then to the
foetus through the umbilical vein. Carbon dioxide from the foetus is taken to
the maternal blood through the umbilical arteries.
c) Excretory functions: Waste products from the foetus is collected through the
placenta and excreted into the maternal circulation.
d) Endocrine function: Human Chorionic Gonadotrophin (HCG) hormones are
produced by the placenta. They consist of estrogen and progesterone.
Progesterone relaxes the smooth muscles of the body while estrogen
increases vascularity of the endometrium. these two hormones suppresses
F.S.H and prevent activity of the ovaries.

The placenta also functions as a barrier to pathogens. However some

substances like the rubella virus. Some drugs also can pass through the
placenta of the baby e.g. sedations, antibiotic, analgesic etc.

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The Human Pelvic

31
Def: This is a bony ring that is supported by the lower extremities and in turn bears
the weight of the trunk and the upper body. the bony pelvic is made up of it main
bones viz the right innominate bone, left innominate bone, The sacrum and the
coccyx.

An innominate bone is made up of 3 fused bones viz ilium ischium and pubis

The innominate bones are also called the hip bone the fusion of the 3 bones
occurs after puberty.

The sacrum: This is composed of 3 fused bones (vertebra bone). The centre of the
upper surface of the first circular vertebra is known as the promontory of the
sacrum.

The coccyx: it’s a small bone made of 4 fused vertebral known as fail bone. The two
innominate bones forms the sides and front of the bony passage. The sacrum and
the coccyx from the back below the ilium is the ischium which ends posteriorly in
the rounded region known as ischial tuberosity which bears the weight of the body
in the sixth position.

There are sharp projections called Ischial spine from the posterior outer
to the cavity. These spines may be blond or prominate or long. They have the
following importance

- The distance between the 2 spines is the narrowest diameter of the pelvic
cavity.
- They serve as a land-mark to determine the descent of the foetus during
labour.

The pelvic is divided in 2 parts i.e. the false and true pelvic. The false pelvic is that
part above the brim and consist mainly of the flared-out iliac bone. It has very little
obstetrical importance. i.e.

The true pelvic is the curve bony canal through which the foetus must pass
out.

The true pelvic consist of 3 pelvic plane viz the inlet (brim), cavity (midpelvic) and
outlets.
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The pelvic is made of 4 main joints: i.e. symphysis pubis, left illio-sacral joint, right
ilio – sacral joint and sacro coccyx joint.

There are 4 basic types of pelvic i.e.

1) Gynaecord (2) Anthropoid (3) Platypeliod (4) Android

1) Gynaecord Pelvic: Is known as the female pelvic well settled for child bearing.
The brim (inlet) is round except When its encroach upon by the promontory
of the sacrum. The cavity is shallow with broad will curve sacrum
2) Android Pelvic: is a heart shape pelvic and also known as the male pelvic with
a funnel shape.
3) Anthropoid Pelvic: Has an oval brim ie. narrow and transverse.
4) Platypeliod Pelvic: Has a flatten and kidney shape brim, narrow in the
anterior- posterior direction.

The ffx area are very important in the study of the pelvic.

1) Iliac crest and supperion anterior spines

2) Sacral promontory
3) The sacrum and coccyx
4) The ischial spine
5) Ischial tuberosity
6) Side-walls
7) Sub-pubic arch
8) Symphysis pubis.

Pelvic ligament

The ligaments binding the sacrum anal ilium are the strongest in the whole
body (Sacroiliac ligament). The interpubic ligament strengthens the syphysis pubis.

The Sacro-tuberous ligament forms an attachment between the sacrum and

the ischial tuberosity. The sacro-spinus ligament connects the sacrum with the spine
of the ischium and both ligaments from the posterior wall of the pelote outlet.

Pelvimetry: This refers to the measurement of dimension and proportions of the

pelvic to determine its capacity and ability to allow the passage of the foetus via the
birth canal.
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The oblique diameter.

a) Anterior – posterior diameter

This is made up of

a) The true conjugate

b) The diagonal conjugate
c) The obstetrical conjugate

1) The true conjugate: it is 12cm or more and it is the distance from the upper
margin of the symphysis pubis to the promontory of the sacrum.
2) The diagonal conjugate: It is 12.5 – 13cm and it is the distance from the lower
boarder of the symphysis pubis to the sacral promontory.
3) The obstetrical conjugate: It is 11.5 – 12cm and it is the distance between
inner surface of the syphysis pubis slightly below the upper boarder, to the
sacral promontory

b) Transverse diameter
The transverse diameter of the inlet is 13.5cm. This is the widest part of the
brim.
c) The oblique diameter: It passes from the sacro-ural. it is the opposite ilo-
pectonal eminence. They measure 12cm.

The pelvic cavity is the curve canal between the inlet and the outlet. It’s anterior
wall is 4cm and is the depth of the pubic bone. The posterior wall is 12cm and is the
length of the sacrum and the coccyx.

The pelvic outlet

The ischial spine forms the upper boarder for the pelvic outlet. The distance
between the two spines is known as bi-spinus diameter and measures 10cm. The
lower border of the pelvic outlet is diamond shaped and is bounded anteriorly by
the sub public arch within the gynaecoid pelvic forms and angle of 90 o. Laterally it is
bounded by the ischial tuberosity and posteriorly by the coccyx and sacro-tuberious
ligaments.

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 The pelvic floor

This is made up of short tissues mainly muscular tissues but skin fats.

Brief Analysis of the Breast

The breast are two secretory glands made up of glandular tissues made up in lobes
about 20 in number. The lobes are sub divided into lobules which consist of alveoli
line by special productive cells accini cells which produces breast milk. This accini
cells are surrounded by myo-epithelial cells which are responsible for contracting
and propelling breast milk from the alveoli. This small duct called lactiferous ducts,
to larger ones called lactiferous sinus (Ampulae) which are secreted under the
35
Areola darker area at the breast around the nipples). This ampulae act like temporal
reservoirs or stores for breast milk. The nipples is made up of an erectile tissue and
is composed of plane muscles fibres which act as a sphincter in controlling the mild
flow.

The areola is highly pigmented and contains montgo mery’s gland which
produces sebum-like substance while lubricating the nipple and areola varies
considering the size from one woman to another. The breasts are supplied with
blood from the internal and external mammalian arteries. During pregnancy
oestrogen and progesterone induces growth of the alveoli and ducts as well as
stimulate secretion of colostrum (yellow body)

Effect of fertilization

After fertilization the zygote develops into or blastocyst which embeds itself
into the walls of the uterus within 8 days of ovulation. These trophoblastic cells
covering the blastocysts, they secrete the hormone Human chorionic gonadotropin
(HCG) which has the effect of

a) Prevent the breakdown of Corpus Luteum. Corpus Luteum continues to

secrete progesterone and estrogen whose effects brings about increase
growth and vascularization of the endometrium.
b) Prevents breakdown (loses) of the endometrium and so no menstruation
(earliest sign of pregnancy, hence presence of HCG in urine is the
immediate test of pregnancy).

From the 10th week of pregnancy, the placenta takes over the secretion of oestrogen
and progesterone from corpus luteum.

If the Corpus Luteum fails by the 10 th week before the placenta takes over a
miscarriage occurs.

Development of the embryo in the uterus

Two cavities appear within the inner cell mass. The cells lining the cell mass gives
rise to 2 further membrane amnion and yolk sac. The amnion covers and protects
the embryo. The amniotic cells secrets the amniotic fluid whose function is to
support cushion and protect he embryo from shock.

36
 In birds and reptiles, the yolk sack absorbs food from the separated sacs and
transfer to the gut of the developing embryo

Cells of the inner mass between the amnion and the yolk sack form the
embryonic sic which gives rise to the embryo cells of the disc differentiate and form
an outer layer of cells known as ectoderm and an inner layer endoderm. A
mesoderm forms the 3rd germ layer later. These layers finally differentiate to give
rise to all the tissues of the developing embryos. Development of these 3 germ
layers is known as gastrulation occurring between the 10 th and 11th day after
fertilization. The brain and spinal cord arise from the neural tube which originates
from the ectoderm. An allantois (earlier stage of the umbilical cord) devleops later
and contributes in exchange of material.

After 6 weeks the embryo is known as the foetus. The period between
conception and birth is known as gestation period which last for 9 months I humans.
Different species have different gestation periods.

The placenta consists of the maternal foetal cells. The chorionic villi of the
foetus (which increases surface are for absorption) are embedded in the placenta.
The chorionic villi are embedded by the umbilical vein and artery which form
capillaries networks inside. These blood vessels linking the uterus walls and the
foetus in the umbilical cord.

The maternal part of the placenta are projections from the endometrium.
These are linked to the chorionic villi by spaces supplied by the maternal blood.
Blood flows thrush the spaces from the arterioles to the venules in the uterus wall.
There is no direct connection between the mother’s blood and the foetal circulation.
hence

importance of placenta

- The foetus is not expense to relative high blood pressure of the maternal
circulation.
- It prevents mixing of foetal and maternal blood which may be of different
blood groups that are not compatible or any other abnormality.
- It prevents foetus from some toxic materials such as drugs, pathogens,
nicotine, tar, etc from the mother.

37
- The foetus obtains nutrients, oxygen, iron antibodies, water etc from mother
through the placenta and passes excretory waste to the mother for
elimination.
- It secretes hormones such as estrogen and progesterone (HCG) human
chorionic Gonadotropin Hormone and Human Placental Lactogen (H.P.L.)
which stimulates growth and breast in preparation for lactation.

Materials pass through the placenta by any of the following mechanisms:

facilitated diffusion, active transport, endocytosis, osmosis.

38