TOPIC 1 :ADOPTION

“Adoption is a legal procedure by which a couple qualifying themselves for

adopting a child , adopts a child who has been either deprived or neglected”.

TYPES
 . Open Adoption: There is a contact between t the birth parents
and adoptive parents and possibly between the child and his/her birth
parents as well .
 Closed Adoption : There is no contact between biological parents
and adoptive parents.
METHODS
 Agency Adoption
A couple contacts an agency by first attending an
informational meeting . If the couple decides to apply to the agency , then
they are put on the waiting list for processing . Processing that includes
extensive interviewing and a home visit by an agency . Social worker
determines whether the couple can be relied on to provide a safe and
nurturing environment for an adopted time . Requires more time.
 International Adoption
It is a type of adoption in which an individual or couple
becomes the legal and permanent parents of a child who is a national of a
different country .
 Private Adoption
The adopting parents usually agree to pay a certain
amount of money, part of which presumably goes towards the birth
mother’s prenatal and medical expenses .
AGENCIES
Central Adoption Resource Authority[CARA]
It is an autonomous body under the ministry of women
and child development , Govt.Of India
It function as the nodal body for adoption of Indian children

Authorised Foreign Adoption Agency [AFAA] : It is recognised as a foreign

social or child welfare agency that is authorised by CARA on the
 recommendation of the concerned Central Authority or Government
Department of that country for coordinating all matters relating to adoption
of an Indian child by a citizen of that country .

Specialized Adoption Agency[SAA]

It is recognized by the state government under sub-section4 of
section 41 of the act for the purpose of placing children in adoption.
State Adoption Resource Agency[SARA]
It acts as a nodal body within the state to promote and
monitor adoption and non-institutional care in coordination with central
adoption resource authority.
District Child Protection Unit[DCPU]
It means a unit set up by the state government at district
level under 61A of the act. It identifies orphan , abandoned and
surrendered children in the district and gets them declared legally free for
adoption by child welfare committee.
DOCUMENTS NEEDED FOR ADOPTION
 Birth certificate of adoptive parents.
 Marriage certificate of adoptive parents.
 Certificate of good health from registered medical practitioner.
 Infertility report[if available]
 Letter of recommendation from family and friends.
 Income , employment and property certificate
WHO IS ELIGIBLE TO AD0PT A CHILD?
 The prospective adoptive adoptive parents should be physically,mentally
and mentally stable; finacially capable,motivated to adopt a child and
should not have any life threatening medical condition.
 A single female/married couple can adopt child.
 A single male can only adopt a male child.
*Person who is adopting must be at least 21 years old.

INDIAN ADOPTION LAWS

All matters related to adoption are dealt by the ministry of
welfare[Ministry of social justice and empowerment],Govt . Of India.
1.HINDU ADOPTION AND MAINTENANCE ACT (HAMA),1956.
 A single parent or married couple are not permitted to adopt
more than one child of the same sex[if couple already has a child].This act
provides basic strategies and course of action for adoption to Hindus , Jains ,
Sikhs,Budhists.
2.GUARDIANSHIP AND WARDS ACT,1890.
It gives the full guardianship authority to non-Hindus who are
governed by their religious personal laws like Muslims ,
Christians ,parsis,jews,foreign citizens and NRIs. The guardians have to give a
certain amount of money for the security of the ward . The adoptive parent is
only the guardian of the child until he/she reaches 18yrs of age.
3.JUVENILE JUSTICE ACT,2000
Children who have been abandoned or abused and those who have
not been voluntarily put up for adoption.
PROCESS OF ADOPTION
STEP 1: Registration
Prospective adoptive parents need to get registered with an
authorized agency.
STEP 2: Home Study and Counselling
At the couples residence, assess the couples parenting abilites-
applicants motivations ,preparations ,strengths and weakness on the issues of
adoption. Report is formulated and submitted to court.
STEP 3: Referral of the child
The agency will show medical file, physical examination report and
other relevant information of the child. If they are satisfied , agency will show
the child and allow to spend time.
STEP 4: Acceptance of the child
Once the couple identify the child, they can sign the documents
pertaining to the acceptance of the child.
STEP 5 : Filling of petition
Documentation are made and sent to the lawyer for preparation of
the petition. Once the petition is ready the couple will be called at the court
and sign the same in presence of the court officer.
STEP 6 :Court hearing : The couple attend the hearing along with the child. The
judge may ask simple questions, if satisfied will pass the order and will also
mention the amount to be invested in the child's name.
 STEP 7: Court order
Once the amount is invested and the receipt is shown to the judge
the order will be issued. If adoption is under HAMA ,then a deed of adoption is
prepared.
STEP 8: Follow up
After the final adoption, the agency to submit follow up reports to the
court about the child's wellbeing for (1-2yrs).

TOPIC 2 :PRECONCEPTION CARE & PREPARING FOR PARENTHOOD

Preconception care is the promotion of health and will being of a woman and
her partner before pregnancy.

AIMS OF PRECONCEPTION CARE

 To improve their health status
 To improve maternal and child health
 Opportunities to prevent and control disease
 To secure optional health and nutritional condition.
 To promote the prenatal health.
COMPONENTS OF PRECONCEPTION CARE

1) NUTRITIONAL CONDITIONS : - Screening for anemia and diabetes

- Supplementing iron and folic acid
- Monitoring nutritional status.
- Supplementing energy and nutrient dense food.
- Promoting exercise
- Iodization of salt

2) GENETIC CONDITIONS

- Taking a thorough family history identify risk factors for genetic conditions.
- Family planning
- Genetic counselling
- Appropriate treatment for genetic conditions.
- Community – wide / national screening among population at high risk
3.MEDICAL CONDITIONS
Diabetes Mellitus
Congenital anomalies is 2-6 times commoner in pregnant diabetic patients
compared with non –diabetic pregnant women
Hypertension
- Preconception hypertension should be adequately managed.
Epilepsy
- It is the commonest problem in pregnancy.
4) LIFESTYLE CHANGES
Caffeine
Increased use of caffeine leads to decreased fertility, increased spontaneous abortion
and decreased birth rate. Caffeine is present in most beverages in chocolates
Alcohol
Alcohol consumption during pregnancy cause infertility, spontaneous abortion,
hypertension in severe cases fetal alcoholic syndrome .
Tobacco use
Screening of women and girls for tobacco use at all clinical visits. Screening of all
non-smokers and advising about harm – of second –hand smoke .
Psychoactive substance use
Screening for substance use. Example of drugs are : Marijuana, Heroine, Cocaine
and their effects are LBW, Hyperactivity, fetal distress .

5) ENVIRONMENTAL HEALTH
- protecting from unnecessary radiation exposure in occupational, environmental
and medical setting.
- Avoid unnecessary pesticide use.
6) INFERTILITY
- Screening and diagnosing of couples following 6-12 months of attempting
pregnancy.
- Counselling for individuals / couples diagnosed with unpreventable
causes of infertility.
7) SEXUALLY TRANSMITTED INFECTIONS (STIs)

 Providing age appropriate comprehensive sexuality education and services.

 Promoting safer sex practices such as use of condoms.
 Screening for STIs.
8) MENTAL HEALTH
- Assessing psychosocial problem
- Counselling, treating and managing depressions
- Improving access to education for women of child bearing age.
9) VACCINE PREVENTABLE DISEASE
 Vaccination against Rubella
 Vaccination against Tetanus and Diphtheria.
 Vaccination against Hepatitis B.
BENEFITS
 Reducing unintended pregnancy.
 Prevent birth defects.
 Prevent LBW and prematurity
 Promote family planning.
 Prepare and reinforce parents for parenting.
 Promote healthy behaviour and reduce risks taking behaviours.
PREPARING FOR PARENTHOOD
DEFINITION
Parenting is process of caring for children and helping them grow
and develop.
AREAS FOR PREPARATION
1. Physical preparation
Age : - 18 years for girls.
- 21 years for boys.
Diet : balanced diet, not anaemic not
malnourished.
 No exposure to hazardous substances.
 Free of infections.
 Stop oral contraceptive pills 3 months before.
 Genetic counselling.
2) Psychological preparation -
- Pregnancy is a normal developmental period requiring psychological
adaptation by the new parents.
- Parents need a very good mental preparation for upcoming child, they
should be away from violence and should be mature in their behaviour.
3) Financial preparation
- Ready to meet increasing demands.
- Plan for maternity leave and benefits.
4) Child birth education classes
 Teach pregnant women and husband regarding pregnancy, birth and
parenting.
 Class provide specific comfort technique and breathing sessions
5) Birth settings
-Most preferable and appropriate site for safer birth is hospital than
homes.
6) Preparation for breast feeding
- Half an hour for normal and one hour for C.S regarding its initiation.
- Enlist the advantages of breast feeding.
7) Final preparation for labour and birth
- Have been instructed on signs and symptoms of labour and what to do.

-Know what to do if membrane rupture prior to going into labour.

-Discuss the possibility of CS if complication occurs.

-Selecting the feeding method.
-Have items needed to prepare for newborn’s homecoming.
-Select family planning method to use after the birth.
-Other classes also included prenatal exercise, newborn care, sibling
preparation.

BENEFITS
 Increased fertility
 Healthy conception, pregnancy, birth
 Low risk for postpartum depression
 Successful and long term breast feeding
 Healthy children
ROLE OF A NURSE
 Identify women of reproductive age.
 Education women and non regarding preconceptional health and
parent hood
 Screen for risk factors of all identified women under their care.
  Educate and create awareness in the families and community
about perconception care.
 Provide follow up care.
 Provide intensive care during interconception period.
 Reduce risk for abortion, premature birth, abnormality.

TOPIC 3: AMNIOTIC FLUID EMBOLISM

Amniotic fluid embolism is a life threating emergency.It happens due to
sudden gush to amniotic fluid, fetal cells,Hair and amniotic debry entering the
maternal circulation.
Risk factors
 Advanced maternal age
 Multiparty
 Meconium aspiration
 Cervical laceration
 Polyhyraminos
 Uterine rupture
 Intrauterine rupture
Pathophysiology
 Poorly understood
 Cotton (1996),has proposed a Biphasic model Phase
Amniotic fluid enter in to the maternal circulation➖biochemical
mediators➖ pulmonary artery ➖ pulmonary hypertension ➖elevated
right ventricular pressure ➖hypoxia ➖ myocardial and pulmonary
capillary damage➖left heart failure ➖acute respiratory syndrome
Phase 2
Biochemical mediators➖DIC➖ hemorrhagic phase➖characterised by
massive Hemorrhage and uterine atony.
Clinical features
Symptoms
 Dyspnea.
 Cough
 Headache
 Chest pain
 Signs
 Hypotension
 Fetal distress
 Pulmonary edema
 Cyanosis
 Coagulopathy
 Seizures
 Bronchospasm
Investigation
 Coagulation profile: AFE is associated with DIC in80% cases
 Electrocardiogram: it shows tachycardia, ST segment and T- wave
changes
 Arterial blood gases: changes consistent with hypoxia
 Chest x-ray: consistent with pulmonary edema
 Echocardiogram
Treatment
Symptomatic and supportive
AIM:
 Maintaing oxygenation
 Hemodynamic support
 Correction of coagulopathy
 Restoration of the uterine tone

1.Airway and breathing

 Administer 100%oxygen via a non- breathing mask
 Prompt assessment with control of the airway and ventilation
 tracheal intubation may be essential
2.Circulation
 2large bore IV lines, send blood for coagulation profile,CBC, crossmatch,
arrange blood
 Fluid resuscitation with crystalloid/ colloid
 Left lateral tilt
 An arterial line for continuous blood pressure monitoring is essential
  Continously moniter the patient condition and early consideration
should be given to delivery of baby
 infusion of ionotropes : for maintaining a mean arterial pressure and
adequate urine output
3.Restoration of uterine tone
o Uterine atony is best treated with massage ,uterine packing and
oxytocin or prostaglandin analogues
o Improvement in cardiac output and uterine perfusion helps to restore
uterine tone
o Extreme care should be exercised when using prostaglandin
analogues in hypoxic patient
Complications
o Brain injury
o Lethargy
o Maternal death
o Infant death

TOPIC 4: DESTRUCTIVE OPERATIONS

Destructive operations are procedures that reduce the size of the head,
shoulder girdle or trunks of the dead fetus to allow its delivery through the
vaginal route.
PURPOSE
 To reduce baby’s size (head, shoulder girdle,body) and so enable the
vaginal delivery of baby
 To diminish the bulk of the fetus so as to facilitate easy delivery though
birth canal.
CONTRAINDICATION
 Living normal fetus
 Markedly contracted pelvis
 Cervix less than 3/4th dialated
 Obstructing pelvic tumors
TYPES
1. Craniotomy
  It is an operation to make a perforation on the fetal head , to
evacuate the content followed by extraction of the fetus.
 Craniotomy –perforation of the cranium or fetal head
 Cranioclasm-crushing of the fetal head
 Cephalotripsy – crushing of the whole fetal head including the base of
the skull
INDICATIONS
 Hydrocephalus
 Retained after coming head of a dead fetus
 CPD with a dead fetus
CONDITIONS TO BE FULFILLED
 The baby must be dead
 Head must be 2/5 part above the brim
 Head must be impacted
 Cervix should be fully dilated
 The uterus must be intact and not ruptured
CONTRAINDICATIONS
 Contracted pelvis
 Rupture of the uterus
INSTRUMENTS
 Cranioclast forceps
 Oldham’s perforator
 Craniotomy forceps
COMPLICATIONS
 Hemorrhage
 Rupture of the uterus
 Injury to genital tract
 Infection
DECAPITATION
It is a destructive operation where by the fetal head is severed from the
trunk and the delivery is completed with the extraction of the trunk and
that of the decapitated head per vaginam.
INDICATIONS
 Dead fetus with shoulder presentation
 Locked twins
  Fetus with double head
SPECIAL INSTRUMENTS
 Decapitation hook
 Embryotomy scissors
 Decapitation hook with knife
EVISCERATION
 The operation consists in removal of thoracic and abdominal contents
piecemeal through an opening on the thoracic or abdominal cavity at the
most accessible site. The object is to diminish the bulk of the fetus which
facilitates its extraction.
 If difficulty arises , the spine may have to be divided ( spondylotomy) with
embryotomy scissors.
INDICATONS
 Neglected shoulder presentation with dead fetus , the neck is not easily
assessable.
 Fetal malformation such as fetal ascites or hugely distended bladder or
monsters
CLEIDOTOMY
 The operation consists of reduction in the bulk of the shoulder girdle by
division of one or both the clavicles.
 The operation is done only in dead fetus ( anencephaly excluded ) with
shoulder dystocia. The clavicles are divided by the embryotomy scissors
or long straight scissors introduced under the guidance of left two
fingers placed inside the vagina.
SPONDYLOTOMY
It is defined as the division of the vertebral column.
SYMPHYSIOTOMY
It is the process of division of the symphysis pubis with a scalpel.
INDICATIONS
 Special situations or cases where we cannot use LSCS
 Moderate CPD
 Contracted outlet
 Retained after coming head in breech
 Shoulder dystocia with a living foetus
COMPLICATIONS
  Hemorrhage
 Injury to the urethra or bladder
 Vesico vaginal or urethro vaginal fistula
 Stress incontinence
 Sepsis
POSTOP CARE FOLLOWING DESTRUCTIVE OPERATION
 Exploration of the utero-vaginal canal must be done to exclude
rupture of the uterus or lacerations on the vagina or any genital
injury.
 A self retaining catheter is put inside specially following
craniotomy and sympysiotomy for a period of 3-5 days or until
the bladder tone is regained.
 Dextrose saline drip is to be continued till dehydration is
corrected.
 Blood transfusion may be given if required .
 Ceftriaxone 1gm IV infusion is given twice daily.

TOPIC 5: GRAND MULTIPARA

A grand multipara relates to a pregnant mother who has got previous
four or more viable births.
COMPLICATIONS
The complications are present during the time of:
 Pregnancy
 Labor
 Puperium
PREGNANACY
1.Abortion : Spontaneous and induced.
2.Inherent obstetric hazards such as:
a. Malpresentation due to pendulous abdomen and increased pelvic
inclination resulting from associated lordosis.
b. Multiple pregnancy.
c. Placenta previa
3. Medical disorders such as anemia, hypertension,cardiac
disability,hemorrhoids and vericose veins, hiatus hernia.
4. Prematurity.
LABOR
1. Cord prolapse due to malpresentation and high floating head at the
onset of labor.
2. Cephalic disproportion due to :-
a. Increasing size of the fetus
b. Secondary contracted pelvis which is related to ill nourished
mother.
c. Forward projection of the sacrum due to the sacro iliac joints,
thereby diminishing the inlet.
. 3. Medical disorders such as anemia, hypertension,cardiac
disability,hemorrhoids and vericose veins, hiatus hernia.
4. Prematurity
5. Rupture uterus: if obstruction remains undetected and left uncared.
6.Postpartum hemorrhage: due to atonic uterus
7.Shock: due to severe anemia , hemorrhage or unrecognized uterine
rupture
8.Operative interference because of the complication.
PUERPERIUM
1. Increased mobility due to sepsis,intra natal hazards
2. Subinvolution
3. Failing lactation
MANAGEMENT
The cases are considered as high risk . As such they require adequate
antenatal care and should have mandatory hospital delivery.
DURING LABOUR:
Following guide lines are prescribed :
 Pelvic assessment should be done as a routine
 Presentation and position should be checked
 . Undue delay in progress should be viewed with concern.
 Take prophylactic measures against PPH

TOPIC 6 : IMMUNOLOGY IN OB
BASIC IMMUNOLOGY IN OB
 One tissue that is repeatedly grafted and repeatedly tolerated is the
foetus. The mysterious mechanisms of the immune system that prevents
rejection of foetus remain unknown to the immuno biologists.
INNATE IMMUNE SYSTEM
 First line of host defense against infection.
 It works fast one it recognize the pathogen.
 It cannot identify the self vs nonself (nonspecific).
 It involves complement system
 Immune cells involved.
- Phagocytic cells(neutrophils , monocyte and microphages)
- Natural killer cells- Can recognize and distinguish between
normal cells and cells infected with virus or tumor.
ADAPTIVE IMMUNE SYSTEM
 It works as a second line defense against infection.
 It has delayed response-.
 It discriminate self from non self.
 It prevents reinfection through immunological memory.
IMMUNOLOGY IN PREGNANACY
 Pregnancy is not an immuno deficient state. Women are able to respond
to both humoral and cell-mediated immunity against the paternal
antigen.
 Specific type of Natural Killer cells (Nk) are present in the decidua mainly
at the site of implantation.Uterine Nk cells are different from blood Nk
cells.
 These U-Nk cells control the tropoblast proliferation,invasion when they
interact with the tropoblast HLA class 1 molecule.The U-Nk cells depend
on progestrone for survival.U-Nk cells contribute to maternal tolerance
of the fetus and maintance of pregnancy.
 The trophoblast cells from the interface between the foetus and the
mother.Thus the placenta forms an efficient barrier against immuno
competent cells between the foetus and mother.
 During pregnancy,maternal immune response is shifted from Th1(cell
mediated) to Th2(humoral mediated).Th2 responsible for the production
of anti-inflammatory cytokines. ie; immunomodulation
  There is high propotion of Nk cells in fetal circulation.Due to their high
number,early presence and the ability to kill cells,it is likely that these Nk
cells are very important in foetal innate immune system.
 During pregnancy there is production of antibodies of paternal
antigens.These antibodies have no major effect on pregnancy outcome.
 Immunological mechanisms involved in pregnancy are not same as that
of organ transplantation.Immunological tolerance through complement
and cytokines regulation is protective for pregnancy.
ABO HEMOLYTIC DISEASE OF THE NEW BORN
 Jaundice in newborn infant within 24hrs of birth may due to ABO
isoimmunization of the mother. The incidence is higher in group’0’
mother.IgG anti A/anti B are formed more commonly in group ‘0’
mothers.IgM anti A/anti B maternal antibodies are also known to play
some role in bringing about hemolytic disease of newborn.
Rh ISOMERIZATION
 Through entry of fetal blood in maternal circulation can take place at any
time during pregnancy, fetomaternal bleed is common in the third
trimester,particularly during separation of the placenta 0.1 ml of Rh +ve
fetal blood is sufficent to bring about immunization in Rh –ve mother.
 Immunization against RhD antigen is necessary.
 Foetal RhD +ve red cells enters into the circulation of Rh-ve mother take
several weeks to immunize her.
 The mother will form anti-RhD agglutin which will pass again through the
placental barrier into the foetus giving rise to agglutination or hemolysis
of foetal erythrocytes which ultimately may lead to dangerous situation
like hydrops fetalis,icterus gravis neonatrum or kernicterus.
PRE ECLMAPSIA / ECLAMPSIA
In pre eclampsia,the abnormal immunological response develops in two
stages.
A) Abnormal placentation and spiral artery remodeling:
 This is due to decreased placental HLA-G expression.It has major role
in placentation and blood flow development in normal pregnancy.
 The failure of extravillous trophoblast invasion and spiral artery
remodeling .This is due to failure of interaction of extravillous
trophoblast with UNK cells and HLA-receptors.
 B) Pre-eclampsia: Is associated with wide spread systemic inflamation by
endothelial dysfunction.

 There is decrease in regulatory T cells both in number and function.

 Insufficient shift from Th1 to Th2.
 There is higher levels of cytokine abnormailities.
 In eclampsia there is an abnormal maternal foetal immune
interactions.
SPORADIC AND RECURRENT MISCARRIAGE
 Cytokines are immune molecules.Th1 cells produce proinflammatory
cytokines where as Th2 cells produce anti inflamatory cytokines.
 In a normal pregnancy there is a shift of Th1 response to Th2
response.Progestrone has an immunomodulatory role to induce
pregnancy protective shift from Th1 to Th2 cytokine response.
 Women with recurrent miss carriage produce low level of Th2
cytokines.
 They also have decreased population of U-NK cells.This indicate
altered immune environment within the decidua.
ANTIPHOSPHOLIPID SYNDROME
 In SLE antiphospholipid antibodies(lupus anticoagulant
glycoprotein,anticardiolipin).These antibodies act by dysregulation of
coagulation pathway.This causes therombosis of uteroplacental
vessels and poor placental perfusion.
MATERNAL AUTOIMMUNE DISEASE
 Incidence of neonatal thyrotoxicosis is higher in babies born of a
thyrotoxic mother.
 A baby born to a mother with ITP will,in all probability,suffer from the
same disease through transplacental transfer of antiplatelet
antibodies
 Myasthenia gravis is due to transplacental transfer of acetylcholine-
blocking factor.
 Baby born of mother’s suffering from SLE often develop congenital
heart block due to transplacental transmission of anti R0 and anti LA
antibodies.
IMMUNOLOGICAL CONTROL OF FERTILITY
1) Placental hormones: Human chorionic gonadotropin that cross-reacts
with LH,thyroid-stimulating hormones and follicle stimulating hormones
has the subunit,that is nonimmunogenic so as to be coupled with a
hapten for antibody production.Thus the antiplacental antigen has been
focused anti-hcG vaccine. Of the many anti-hcG vaccine,most effective
being the one that is directed against the C terminal peptide on the β
submit of hcG. This antibody does not cross-react with the LH and
thought to be effective up to 12 months.
2) Human sperm antigen
Of numerous sperm antigen,antibodies against LDH-X is being
currently evaluated,and there is a significant reduction of viable
sperm,as well as improper implantation of ovum in experimental
animals,when anti LDH-X antibody is injected into them.
3) Zona Pellucida (ZP):
ZP is the most extesively studied potentially oocyte target
antigen.Antisera to ZP block sperm penitration as it coats the zona
surafce. Sera from infertile women with anti-ZP antibodies can block
invitro fertilization.
4) Anti-sperm antibodies:
Are present either in the serum or in the reproductive
tract.Antibodies present in the female reproductive tract that binds the
sperm surface antigens affect the motility of sperm and
may cause infertility.

TOPIC 7: SCREENING AND ASESSMENT OF HIGH RISK

PREGNANCY.
High risk pregnancy is defined as the one where pregnancy is complicated
by a factor or factors that adversely affect the outcome- maternal or
perinatal or both.
INCIDENCE
 About 20-30% of pregnancies belong to high risk pregnancy
 Majority (70-80%) of fetal deaths occur before onset of labor due to
Chronic asphyxia (30%)
 Congenital malformation(15%)
 Complications of pregnancy (30%)
 20% of stillbirths have no obvious fetal,placental, maternal or obstertric
etiology
SCREENING OF HIGH RISK PREGNANACY
 Cases are assessed at the initial antenatal examination(1st trimester)
 Performed in hospital or health center
 In rural areas, done by properly trained paramedical personnel
 From peripheries, cases are reffered for management by specialists
 Cases are reassessed near term and again in labor for any new risk
factors
 Neonates are assessed.
INITIAL SCREENING
 HISTORY
 Maternal age
 Pregnancy is safest between 20-29 years
 Age<16 or >30
 Pregnancy followed by a long period of infertility
 After ovulation induction
Reporoductive history
 Second and third pregnancies after a normal delivery carry the lower risk
 Two or more previous miscarriages or induced abortion
 Previous stillbirth,neonatal death,birth of babies with congenital
abnormalities.
 Pervious preterm labor/IUGR/macrosomic baby
 Grand multiparity
 Previous CS/hysterectomy
 PPH
 Previous infant with Rh-isoimmunisation
MEDICAL DISORDERS
 Pulmonary disease - TB
 Renal disease
 Thyroid disorders
 Psychiatric illness
 Cardiac disease
 Epilepsy
 Viral hepatitis
  Pre-eclampsia,eclampsia
 Anemia
 Infections in pregnancy.
SURGERIES
 Myomectomy
 Repair of complete perineal tear
 Repair of vesicovaginal fistula
 Repair of stress continence
FAMILY HISTORY
 Socioeconomic status : high risk of anemia ,preterm labor
 Diabetes
 Hypertension
 Multiple pregnancy
 Congenital malformation
 Others include malpresentation,twins and hydraminos
DURING LABOR
 PROM
 Prolonged labor
 Hand,feet or cord prolapse
 Placenta retained more than ½ hr
 PPH
 Puerperal fever and sepsis
EXAMINATION
General examination
 Height : <150cm
 Weight: overweight/underweight
 High blood pressure
 Anemia
 Cardiac /pulmonary disease
 Orthopedic problems
Pelvic examination
o Uterine size : smaller/bigger
o Genital prolapse
o Lacerations/dilatation of cervix
o Associated tumors
 o Pelvic inadequacy
COURSE OF PRESENT PREGNANCY
o Reassessed at each antenatal visits
o Pre- eclapmsia
o Anemia
o High fever
o Rh- isommunisation
o Pyelonephritis
o Hemorrhage
o DM
o Large uterus
o Lack of uterine growth
o Twins
o Postmaturity
o Abnormal presentation
o History of exposure to drugs/radiation
o Acute surgical problems
COMPLICATIONS OF LABOR
 Intrapartum fetal distress
 Delivery under GA
 Difficult forceps/breech delivery
 Failed forceps
 Postpartum hemorrhage/retained placenta
 Prolonged interval from diagnosis of fetal distress to delivery.
POSTPARTUM COMPLICATIONS
Mother
 PPH/retained placenta
 Shock
 Inversion
 Sepsis
Neonate
 Apgar score below 7
 Hypoglycemia
 Anemia
  Birth weight <2500g or >4 kg
 Convulsions
 Major congenital abnormalities
 Jaundice
 Fetal infection
 RDS
 Persistent cyanosis
MANAGEMENT
Organisational aspect
 Strengthen midwifery skills,community participation and referral
system
 Proper training of residents, nursing personnel and community health
workers
 Arranging periodic seminars,refresher courses
 Concentration of cases in specialised centres
 Community participation, proper utilization of health care manpower
and financial resources
 Availability of perinatal laboratory for necessary investigations,good
pediatric care
 Improvement of literacy rate,health awareness of community and
economic status
 Complete investigations for HTN,DM,Thyroid disorders and proper
treatment
 To rule out mullerian
abnormality,hysterography,hysteroscopy,laparoscopy
 STD should be treated
 Cervical tears are repaired
 Serology for toxoplasa and corrected appropriately
 Folic acid therapy(4mg/day)
 Advice regarding diet,activities.rest and medicines( minimum).
 Elective CS in high risk cases
 In some,labor induction after 37-38 weeks completion
 Cases go into labor spontaneously/after induction, need close
monitoring for progress of labor and evidence of fetal hypoxia
 Fetal condition assessed by
  FHS
 Passage of meconium in liquor
 Examination of fetal scalp blood for pH values.

TOPIC 8: POST MATURE PREGNANACY

DEFINITION
Any pregnancy which has passed beyond the expected date of delivery, is
called a prolonged pregnancy .
 Post maturity is defined as any pregnancy continuing beyond two weeks of
the expected date of delivery.(>294 days).
ETIOLOGY
 Hereditary-family history.
 Wrong dates : due to inaccurate LMP.
 Maternal facors :primiparity, previous prolonged pregnancy ,
sedentary habits , elderly multipara.
 Fetal factors :congenital anomalies
 Placental factors : surfatase deficiency -----
 low estrogens
PHYSIOLOGICAL CHANGES ASSOCIATED WITH POST TERM GESTATION
 Amniotic fluid changes.
 Placental changes.
 Fetal changes
AMNIOTIC FLUID CHANGES
1.Oligohydramnios
2.Cloudiness of amniotic fluid.
3.Presence of meconium in the amniotic fluid resulting in meconium
aspiration syndrome
PLACENTAL CHANGES
 Senescence ( increased placental grading on USG.)
 Calcification.
 Placental infarcts
FETAL CHANGES
 Macrosomnia
 Intrauterine malnutrition
DIAGNOSIS
Difficult to diagnose when the case is first seen beyond the expected date
CLINICAL GUIDES:
 Menstrual history: reliable diagnostic aid
 Weight record: To reveal stationary or even fall in weight.
 Girth of the abdomen:diminishes gradually because of diminishing
liqour.
 History of false pain.
 Obstetric palpation:
 Height of the uterus,
 Size of foetus,
 Hardness of skull bones..
INTERNAL EXAMINATIION
 Ripe cervix-suggestive of fatal maturity.
 Feeling of hard skull bones either through the cervix or through the
fornix usually suggests maturity.
SONOGRAPHY
Estimation of gestational age by early ultrasound is more accurate than LMP.
AFTER THE BIRTH OF THE BABY
GENEREL APPEARANCE:
o looks thin and old, skin is wrinkled.
o There is absence of vernix
o Body and cord are stained with greenish yellow color.
o Head is hard without evidence of moulding.
o Nails are protruding beyond the nail beds.
o Weight is >3 kg.Length is about 54cm.
LIQUOR AMNII: scanty and may stained with meconium.
PLACENTA: evidences of infarction and calcification.
CORD: diminished quantity of Wharton’s jelly which may precipate cord
compression.
COMPLICATION OF POSTTERM PREGNANCY-
FETAL COMPLICATIONS
DURING PREGNANACY
o Diminished placental function
o Oligohydraminos
 o Meconium stained liquor
DURING LABOR
o Fetal hypoxia and acidosis
o Labor dysfunction
o Meconium aspiration
o Cord compression
o Shoulder dystocia
o Birth trauma
o Increased incidence of CS
o Macrosomia
o Dysmaturity
FOLLOWING BIRTH
o Chemical pneumonitis, atelectasis, pulmonary hypertention
o Hypoxia
o Hypoglycemia
o Convulsion
o Polycythemia
MATERNAL
o Morbidity
o CS
MANAGEMENT
UNCOMPLICATED
o selective induction.
o routine induction
o induction
COMPLICATED
o elective cs
UNCOMPLICATED
1. SELECTIVE INDUCTION
o In this regime the pregnancy may be allowed to continue till
spontaneous onset of labour
o Fetal surveillance is continued with modified biophysical profile twice
a week...
2.ROUTINE INDUCTION
The expected attitude is extended for 7 to 10 days past the expected date and
therefor labour is induced.
3.INDUCTION
o Induction of labour reduces the rate of cs and perinatal mortality.
o If cervix is favourable (ripe)induction is to be done by stripping of the
membrane or by low rupture of the membrane.
o If the liquor is clear, oxytocin infusion is added to be more effective.
o Careful fatal monitoring ismandatory.
o If cervix is unripe., it is made favorable by vaginal administration of PGE2.
This is followed by low rupture of the membrane., oxytocin infusion is
added when required. Cervical length<25mm is a predictive indicator.
CARE DURING LABOR
o More anesthesia required for pain relief.
o Possibility of shoulder dystocia is to be kept in mind.
o Careful fetal monitoring with available gadgets is to be done.
o If fetal distress appears prompt delivery either by CS or by VENTOSE is to
be done.
 INTERAUTERINE DEATH
o Antepartum death occurring beyond the period of viability is termed as
intra uterine death.
Fetal death
o Antepartum IUD- fetal death occurring in the antenatal period.
o Intrapartum IUD- fetal death occurring during the labour.
CAUSES
1.maternal
2,fetal
3.placental
4.iatrogenic
MATERNAL
 Hypertensive disorder
 Diabetes
 Maternal infection
 Hyperpyrexia
 Anti phospholipid syndrome
  Thrombophilia
 SLE
 Post term pregnancy
FETAL
 Chromosomal abnormalities
 Infections
 Rh incompatibility
 Growth restriction
 Non immune hydrops
PLACENTAL
 Antepartum hemorrhage
 Cord accident
 Twin to twin transfusion
 Placental insufficiency
IATROGENIC
 External cephalic version
 Drugs[quinine]
MORBID PATHOLOGY
o The death fetus undergoes an aseptic degenerative process called
maceration.
o The epidermis is the first structure to undergo the process ,where by
blistering and peeling of the skin occurs.
o It appears between 12 and 24 hours after death.
o The fetus becomes swollen and looks dusky red.Gradualy ,aseptic autolysis
of the ligamentous structure and liquefaction of the brain matter and other
visera take place.
DIAGNOSIS
SYMPTOMS: Absence of fetal movement which ever previously noted by the
physician.
SIGNS: Retrogression of the positive breast changes that occurs during
pregnancy is evident after variable period following death of the foetus.
PER ABDOMEN
 Gradual retrogression: of the fundal height and it becomes smaller than
the POG.
 Uterine tone : diminished and uterus feels flaccid.
  Fetal movements are not felt during palpation.
 Fetal heart sound: absent.
 Cardiotocography:flat trace.
EGG SHELL CRACKLING FEEL OF THE FETAL HEART is the later sign.
INVESTIGATIONS
 SONOGRAPHY: (A) Lack of all fetal motions(including cardiac)during a
10 min period.
 STRAIGHT X-RAY: Rarely done at present.
 SPALDING SIGN: The irregular overlapping of the cranial bones on one
another is due to liquefaction of the brain matter and softening of the
liquementous structure supporting the vault. It usually appears 7 days
after death.
 Hyper flexion of the spine is more common.
 Crowding of the ribs shadows with loss of normal palpation.
 Appearance of gas shadows(ROBERT’S SIGN)in the chambers of the
heart and great vessels may appear as early as 12 hours but difficult to
interpret.
 BLOOD: To estimate the blood fibrinogen level and partial
thromboplastin time periodically, when the fetus is retained for>2 wks.
RECOMMENDED EVAUATION FOR STILL BIRTH
 HEMATOLOGICAL EXAMINATION :cbc,abo and rh
incompatibility,vdrl,postprandial blood sugar,hba1c,urea, creatine
estimation, thyroid profile, viral serology,lupers anticoagulant,anticardio
antibodies and thronboplastin levels .
 URINE :casts and pus cells
 INFANT EXAMINATION:malformation,umbilical cord –entanglement, no. of
vessels, whole body photograph, imaging with MRI or radiograph.
 PARENTAL KARYOTYPING should be done .
AUTOPSY AND CHROMOSOMAL studies: for fetus with anomalies and
dysmorphic features.
COMPLICATIONS
 Psychological upset,
 Infections: by gas forming organisms.
 Blood coagulation disorder are rare: if the fetus retained for >4 wks.,
there is possibility of defibrination
  During labour:uterine inertia, retained placenta and PPH.
PREVENTION
 Preconceptional counselling and care.
 Prenatal diagnosis –amniocentesis in selected cases.
 To screen “at risk mother” during antenatal period, careful assessment
of fetal wellbeing and to terminate pregnancy.
MANAGEMENT
 EXPECTED ATTITUDE(Non interference):spontaneous expulsion occurs
within 2 wks. of death.
 REASONS FOR EARLY DELIVERY. Reliable and early diagnosis could be
done with real time Ultrasonography
 Prostaglandins are available.
 Complications should be avoided.
INDICATIONS FOR EARLY INTERFERENCE
 Psychological upset of the patient.
 Uterine infections
 Tendency of prolonged pregnancy (>2 wks.)
 Falling of fibrinogen levels.
METHOD OF DELIVERY
 BY MEDICAL INDUCTION.
 A combination of mifepristone and prostaglandins-as first line choice
 Misoprostol(25 -50 ug) either vaginally or orally)
 Prostaglandins
 Oxytocin infusion:5-10 units in 500ml of RL.

TOPIC 9 : PSYCHOSOCIAL AND CULTURAL ASPECT OF PREGNANCY.

PSYCHOLOGICAL ASPECT OF PREGNANCY
Women become pregnant for a number of reason that is in a part of conscious
conception due to the desire to obtain ‘ genetic immortality’ by prolonging the
parents existence. The way in which couple react to the news of the women
pregnancy will be depend upon the individual situation. Most women and their
partner will be delighted even the pregnancy was unplanned. This joy will be
enlighted if there has been a history of infertility or pregnancy loss.
AREAS AFFECTING IN
PSYCHOSOCIAL ASPECT OF PREGNANCY
 Relationship
Childbirth is a uniquely female experience which in some way alternates
women from opposite sex .Female relationship tend to become more
important in pregnancy, thus close ties may develop between mother and
daughter and with other relatives and friends who experience child birth. The
women’s partner become jealous especially as pregnancy advances and
women increasingly involved in care of developing fetus in womb . The
relation between husband and wife changes from an intense romantic affairs
to the complex relationship of parenthood with its new priority and need . The
roles and responsibility of each person related to pregnant women changes.
 Adjusting to pregnancy
Some women consider pregnancy as a hurdle to get through ,where as other
consider it as a developmental process . The hurdle concept is held by women
regarding pregnancy as a means to an end or deviation from normality and
think that once over they will return to normal state . Other consider
pregnancy as a maturation process and recognize subconsciously that changes
will lead to a reorganization of their personality .
 Importance of information and involvement
It is essential the women and her partner given all necessary information about
such examinations and test to enable them to make informed decision about
whether or not they wish to have them performed . The mother who consider
termination of pregnancy is morally wrong may refuse to test fetal
abnormalities as she wish to continue the pregnancy whatever the outcome . If
there is any fetal abnormalities , they may need counseling with their doctor
midwifery and perhaps with a ministry of religion .
 Reaction to pregnancy
Many women experience fear and fantasies about what is happening inside
their body . They often worry about normal physical and psychological changes
. If she is multigravida invariably compare present pregnancy with past
pregnancy . Vivid dreams are common . The dreams may frequently involves
the baby and care of baby.
WAYS TO PROVIDE PSYCHOLOGICAL SUPPORT DURING PREGNANCY
Women find the stress of motherhood and new responsibilities to be difficult
to handle and voicing their concerns in to supporting group .The support from
family friends and relatives is necessary to cope up with situations. In addition
to this support there are another way to provide psychological support during
pregnancy .The ways are
 Couple therapy
 Meditation
 Deep breathing exercise
 Support from family
COUPLE THERAPY
It can also be helpful when a couple finds that a new baby has placed added
challenges and stresses on their relationship . In therapy couple can voice
concerns or areas of disagreement and resolves any issue in their relationship.
MEDITATION
Meditation is a practice where an individual uses a technique such as mind
fullness or focusing the mind on a particular objects thought or activity to train
attention and awarness and achieve a mentally clear ,emotionally calm and
stable.
DEEP BREATHING EXERCISES
Deep breathing exercise which is consider as a most effective way to reduce
stress and anxiety .Most people take short shallow breath in to the chest . It
can make her to feel relief and increase energy level.
CULTURAL ASPECT OF PREGNANCY
The way in which women become mother is culturally determined and socially
controlled . Girls are strongly socialized to become mother and motherhood
remains as a hallmark of adulthood womanhood and feminity .
Traditionally it has been expected that all women want children ,the
implicit with this norm is that women with in particular age range and have a
partner should have a certain number of babies.
SOCIAL DIFFERENTIATION
Society divides individual in to categories such as race social class and gender
which tends to imply homogenity with in the group such as oversimplification
ignores the complexities of these individual lies and does not account for
difference in life events and an individual’s quality of life.
Some categories of social differentiation are
  Race
Race is a social construct that has more to do with social and power
relationship than with biology . The imbalance of power in society enable the
view of powerful to dominate . It is with in this context that the issue relating
to minority ethics groups often seen in terms of individual pathology rather
than as a result of inequalities , the social structures and this way racism
develops.
 Social class
Social class remains as an enduring theme in sociology.
Difference in class with in capitalist society depends on a process so that the
basic idea behind class comes from economics . The use of class as a social
category has often be accepted critically and taken for granted as a natural
category however the classification focuses on families where an employed
man is the head of the household woman , retired people and the unemployed
are poorly reflected.
 Gender
As a social role social activity and health status are linked to race and class ,
they are also in extractble and it is bound to issue of gender . While
anatomically and physiologically difference between the sexes due to
biologically determined gender may be described as socially and culturally
prescribed status of men and women in society . The associated concept of
feminity and musculanity are socially constructed and as such they are not
fixed.
CULTURAL MYTHS REGARDING PREGNANCY
There are lot of cultural myths present during pregnancy . This is
mostly associated with false believe in human being which affect whole period
of pregnancy . Human feelings are closely associated with pregnancy.
 Don’t inform about pregnancy till the first trimester is over .
The reason behind this is that there is miscarriage or spontaneous abortion
during the first trimester ,so people don’t want to share the news too soon .
 Pregnant women shouldn’t eat papaya :it can cause miscarriage .
Because of this myth pregnant lady’s relative ban all food product starts
with ‘ p ’ it includes pineapple plum etc . Papaya are said to contain latex
substance which is rich in unripen papaya . The latex may mimic human
 hormone can trigger labor . Though you might need to eat papaya to
actually start the labor.
 If you’re glowing ,it is a boy .
It is true that there is changes occur in skin during pregnancy but it is only
because hormonal influence . The change depend up on skin care routiene
and skin type . There is really no scientific connection between glow and
sex.
 The hang of your belly determines baby’s sex .
The belly hang low ,it is a boy and hang up means it is a
girl . But there is no scientific association between belly and sex . The way in
which the belly depend up on the skeletal structure , strength of the
muscle , and the trimester . The belly always hang towards due date.
 Pregnant woman should avoid funerals and homes of the sick .
Funeral and sick home are depressing and pregnant woman are probably
better kept away from such circumstances . Beside there are crowded place
and especially sick homes can spread germs which might harm the fetus .
 Don’t buy anything for the baby before the birth .
This is another superstition that isn’t restricted in India . During the time
when infant mortality is very high ,this rule spared woman from the pain
looking at things brought for their diseased child , that why saying don’t
buy anything for the baby before birth.
 New mother shouldn’t step out of the house or entertain for 40 days .
A new baby’s immune system is underdeveloped and
the baby is vulnerable to infection in those initial weeks . A new mother is
just recovering from the trauma of birth . So it is ideal to consider these
period as a rest period and it avoid from getting infection . It gives a chance
for mother and baby to bond in peace and to settle down in a routines .

TOPIC 10: ELDERLY PRIMIGRAVIDA

Women having their pregnancy at or above the age of 30 years are called
ELDERLY PRIMIGRAVIDA.
There are 2 types of patients:
1)One with high fecundity: A women married late but conceives soon after
marriage.
 2)One with low fecundity : Women married early but conceives long after
marriage.
FACTORS
 Rising education level
 Effective means of birth control
 Increasing no of women in work force
RISKS
Some of the common risks of getting pregnant over the age of 30 are…..
 Genetic Risks: With the advancement of maternal age, the risks of various
genetic disorders in the child increases significantly.
 Miscarriage :Risk increases with maternal age.
 Still Birth :The Still birth is higher in women as the age advances
 Other Risks :Increased risks of gestational DM,Placenta previa,Preterm
birth,Abnormal BW
COMPLICATIONS
DURING PREGNANCY
 Increased tendency to Abort
 Hypertension , Pre-eclampsia.
 Abruptio placenta because of Preeclampsia
 Folic acid deficiency
 Utreine fibroids (the long period of infertility)
 Placenta previa
 IUGR

DURING LABOR

 Labour tends to be longer in Elderly primi than Multipara

 Posterior position of the occiput are also common. Abnormal uterine
action
 Increased incidence of preterm labour, Prolonged labour etc.
 Impaired joint mobility.
 Inelasticity of the soft tissues of birth canal
 Increased caesarean delivery.
 Obstetrical intervention
 Retained placenta
 Intrapartum foetal death.
FETAL RISKS
 Preterm birth
  Prematurity either iatrogenic or spontaneous IUGR
 Fetal congenital malformations(eg :mongolism, hrdrocephaly,anen
-cephaly) with increased maternal age.

PUERPERIUM
Increased morbidity due to operative interference failing lactation.
PROGNOSIS
 The maternal morbidity,mortality –Slightly increased due to
increased complications
 Perinatal mortality - Increased.
MANAGEMENT OF ELDERLY PRIMIGAVIDA
GENERAL MEASURS
 Detailed and careful supervision .
 Sympathetic ,firm, and confident handling of the patient.
 X-ray
 Elective LSCS
SPECIFIC MEASURES
1)Hyperemesis Gravidarum
2) Threatened Abortion
3)Hypertension
4)Premature Labour
5)LSCS Delivery
6)Assisted vaginal delivery
7)Management and vigilance of 3rd stage of labour
8) Early ambutation
9) Anti coagulant therapy.

TOPIC 11 : Neonatal resuscitation

 APGAR scoring is a quantitative method of assessing the infant’s
respiratory, circulatory and neurological status.
 It is done at 1 minute and 5 minutes after birth.

Maximum score is 10
Score >7 = satisfactory
Score 4-6 = moderate4 distress
Score 0-3 = severe distress.
TABC of resuscitation
T Temperature : radiant warmer
A Airway : suctioning
B Breathing : tactile stimulation, positive pressure ventilation
 C Circulation : stimulation, chest compressions, medications.
NECESSARY EQUIPMENTS
 Radiant warmer
 Suction catheters
 Feeding tube
 Ambubag, mask, oxygen
 Laryngoscope with blades
 ET tubes
 Linen
 Stethoscope
 Sterile gloves
 Syringes
 Cord clamp
STEPS OF RESUSCITATION
 TEMPERATURE
 Hypothermia in newborn leads to increased metabolism, increased oxygen
needs and metabolic acidosis.
 So it is very important to prevent hypothermia in newborn.
 Inorder to prevent heat loss, the baby should be :
 Dried immediately
 Placed under radiant warmer
 AIRWAY
Positioning
 Positioned on back with neck slightly extended.
 Rolled towel or sheet can be kept under the shoulders.
 AIRWAY
Suctioning
 Suctioning of mouth and nose is done using bulb syringe or mechanical
suction
 Mouth is suctioned first to ensure that there is nothing for the infant to
aspirate if the baby gasps while nose is suctioned
 While suctioning mouth, tube is inserted till 5 cm
 Introduce suction tube upto 3cm in each nostril for less than 20 seconds.
 BREATHING
Tactile stimulation
 Both drying and suctioning the baby produces enough stimulation
to induce respiration
 If respiration is inadequate, tactile stimulation may be given by
slapping or flicking the soles of feet & rubbing baby’s back.
Positive pressure ventilation
 Bag and mask ventilation is indicated :
 if even after tactile stimulation the infant is gasping and
 Respiration is spontaneous but heart rate is below 100 beats /min
 With infant’s neck slightly extended to ensure open airway, place the mask
on baby’s face and ensure that mask forms a tight seal around chin, mouth
and nose
 If the baby remains apneic, positive pressure ventilation should be started.
 Compress the bag gently and ensure that chest expands with every
ventilation. Ventilate at a rate of 40-60 breaths /minute.
 Response to ventilation will be seen by :
 Improvement in baby’s colour from blue to pink
 Improved respiration
 Heart rate rises to more than 100/minute.
 CIRCULATION
Chest compression :
Blood circulation to be maintained for delivery of oxygen to vital
organs. In a hypoxic baby heart rate slows down and there is diminished blood
flow to vital organs which can lead to irreversible damage to brain, heart,
kidney etc. So measures to be taken to maintain circulation in asphyxiated
baby. This is done mainly by chest compressions.
Indications : heart rate <100/min
Techniques : thumb technique and two finger technique
Location : lower third of the sternum
Rate : 90 chest compressions and 30 ventilation in 1 minute.

Medications:
 Neonates who do not improve with chest compressions and ventilation
require medications like adrenaline, soda bicarbonate , naloxone, &
dopamine.
 Indications of medications : heart rate < 80 beats per after adequate
ventilation with 100% oxygen and chest compressions for minimum of 30
secs and in the baby with heart rate ‘Zero’.
 The route of administration : Umbilical vein via a catheter.

TOPIC 12 : SINGLE PARENTHOOD

It refers to the families with the children under age 18 headed by a parent
who is widowed or divorced and not married , or by a parent who has never
married.

ETIOLOGY

 death of a spouse
 divorce
 not married
 military deployment
COMMON PROBLEMS
 Lower level of educational acheivements
 Drop out of school
 To become teen parents
 More conflicts with the parents
 Less supervised by the adults
 High risk of sexual behaviour
 Twice as go to jail
 Get divorced in the adulthood
 Participate in crimes
CHALLENGES TO PARENTS
 Added pressure
 Stress and fatigue
 Behaviour problems
 Lower incomes
 Less access to health centre
 Socially isolating.
POSITIVE STRATEGIES – CHILD
 Time stable and safe child care
 Establish a home routine and stick to it
 Apply rules and discipline
 Allow the child to be a child and not ask him to solve the adult problems
 Get to know the important people in the childs life.
 Answer questions asked by other parents calmly
 Explain the financial problems honestly.
POSITIVE STRATEGIES – PARENTS
 Show your love
 Find quality child care
 Set the limits
 Don’t feel guilty
 Take care of yourself
 Lean to others
 Stay positive
 Get handle on finances
 Stay positive
 Never leaveyour child alone
 Be carefull asking about new friends or partners.
ADVANTAGES OF SINGLE PARENTING
 Greater control
 Manipulative children
 Total financial control
 Less people to care for
 More time to the child
LEGAL RIGHTS IN WORKPLACE
 Pregnancy
 No anti- discriminatory laws
 Religious organisations
 Workers schedule
PREGNANCY
It is illegal to refuse a woman who is pregnant or may become pregnant
It should be treated as a temporary disability and has to provide leave for
their disability.

TOPIC 13 : UNWED MOTHER

Unwed mother is the lady who has become pregnant without legal justification
of physical intimacy between man and woman.
CAUSES
 Poverty
 The foundation of unwed mother lies somewhere in poverty.
 It is well known that very unfortunate parents due to their poverty
sell their daughter.
 The reality of this statement is well established by the newspapers
and news telecast on TV.
 Many of these girls and results is unwed mother
 Prostitution
Prostitution is an individual who for sale of some reward engage in
illegal sexual act with various individual either of same or opposite sex.
The tragedy of this prostitutes is also being unwed mother.
 Teenage mistake
Many teenage girls due to inefficient decision making, lack of proper sex
education, lack of parental supervision become an unwed mother.
Broken homes, psychiatry illness, alcohol, drugs also leads to teenage
mistakes.
 Improper sex education
Due to lack of improper sex education among teenagers and adolescents , the
unwanted pregnancy is an emerging issue.
 Contraceptive failure
 Contraceptive failure can also be a reason of unwed mother.
 If sexual relationship before marriage is made but used contraceptives
doesn't work then it.
Consequences for mother
Being mother before marriage, a mother has to face great consequences like
unwed mother is not socially acceptable in our traditional society.
In traditional society it is believed as a curse, therefore it brings a lot of
personal disorganisation in women who became unwed mother as she lack a
support from the family relatives, society make her living quite hard.
CONSEQUENCES FOR THE FAMILY
 The society boycott the family of unwed mother and family loose their
relationship with the society which leads to isolation and hence results in
psychological trauma on family.
 The parents of unwed mother may feel guilty, may feel exposed the
judgemental attitudes of people over how they could have let this happen.
 ECONOMIC PROBLEMS
As unwed mother lacks support from family and society, therefore she faces
great economic problems.
HEALTH PROBLEMS
 Both mother and child are at great risk of serious health problems.
 This may be due to lack of support both to mother and baby.
 Unsafe delivery practices which are usually conducted at unhygienic
places to hide unwanted pregnancy from society or due to improper
guidance for rearing of child.
LEGAL RIGHTS OF UNWED MOTHER
 Establish paternity
 Unwed mother has a right to raise the case in the court to establish
paternity for her child against men who she is expected that he is father
of her child.
 Support to child
o Once paternity is established, the mother can demand the support from
father to raise her child.
o The support can be in the form of money or in some other forms.
 Custody of child
Even if paternity is established still has the right to understand the custody
of her child if she want it.
PREVENTION
 Peer education
Education regarding sexual and reproductive health can be provided to
them by forming a group of peers.
 Sex education
Well designed and well implemented sexual and reproductive health
education can be provided to young people, so they can engage in a safe and
responsible sexual behaviour.
 Supply of contraceptive

Government has made easy access to contraceptives therefore should take

benefit of it and must take necessary step to prevent the occurrence of unwed
mother.

 Abolition of prostitution

Prostitution mostly results in unwed mother. So in order to prevent this

prostitution should be banned or prostitute should be informed about the use
of contraceptives.

ROLE OF A NURSE
 As a educator
Nurse should play a vital role in providing sex education to youngsters to
prevent occurrence of unwed mother. Nurse can provide knowledge to
youngsters about the evil effect of being unwed mother.

 As an advocate

As a advocator she can advocate the right of unwed mother and can protect
her from further exploitation.She must inform the mother about her legal
rights which are provided by government to them so that mother can take
benefit of them.

 As a helper

Nurse can help the mother to raise her child in the society. Nurse must
provide free service to the mothers which are provided by government
agencies to help them.

 As a researcher

As a researcher she should make research in the best preventive measures to

avoid occurrence of unwed mother.

TOPIC 14 : BIOCHEMICAL PROFILE

 Maternal serum alpha fetoprotein(MSAFP)
AFP is an oncofetal protein .it is produced by yolksac and fetal liver. Highest
level of AFP in fetal serum and amniotic fluid is reached around 13 weeks and
thereafter it decreases. Maternal serum level reaches a peak around 32 weeks.
MSAFP level is elevated in a number of conditions:
 ,Wrong gestational age
 , Open neutral tube defects
 , Multiple pregnancy, Rh isoimmunisation
 Anterior abdominal wall defects
 IUFD
 , Renal anomalies

Low level are found in trisomies(Downs syndrome, Gestational trophoblastic

diseases).Test is done between 15-20 weeks. Normal value is 5ng/ml.
  TRIPLE TEST

It is a combined biochemical test which includes MSAFP, hcG and UE3

(unconjugated oestriol) .It is used for detection of down’s syndrome. In an
affected pregnancy, level of MSAFP and UE3 tend to be low while that of hcG is
high.it is performed at 15-18 weeks Its gives a risk ratio and for confirmation
aminocentesis has to be done. Normal hcG level is 5mIU/ML , UE3 - 0.5ng/ml.

 ACETYL CHOLINE ESTERASE (AchE)

Amniotic fluid AchE level is elevated in most cases of open neural tube
defects. It has got better diagnostic value than AFP. Normal value is 8-18
U/ML.

 Inhibin A

Inhibin A is a dimeric glycoprotein. It is produced by the corpus luteum

and the placenta. Serum level of inhibin A is raised in women carrying a fetus
with Down syndrome . Normal value is 97.5pg/ml.

 Quadruple test

Decrease MSAFP, decrease UE3, Increase total hcG , increase inhibin A, can
detect trisomy 21.

PRENATAL GENETIC DIAGNOSIS

Can be made directly from fetal tissue obtained by amniocentesis,

chorion villus sampling or by cordocentesis. Structural chromosomal
abnormalities ( translocations, inversions, mutations ) can be detected by
Fluorescence In Situ Hybridisation (FISH).

 AMNIOCENTESIS

It is an invasive procedure . It is performed between 14 and 16 weeks

under ultrasonographic guidance. The fetal cells obtained in this procedure are
subjected for cytogenetic analysis. Cytogenetic analysis means
the desquamated fetal cells in the amniotic fluid , obtained by amniocentesis
are cultured, G banded and examined to make a diagnosis of chromosomal
anomalies.
  CHORIONIC VILLUS SAMPLING

It is performed for prenatal diagnosis of genetic disorders. A few villi

are collected from the chorion frondosum under ultrasonic guidance with help
of a long malleable polyethylene catheter introduced transcervically along the
extra ovular space. CVS is performed between 10 and 12 weeks of gestation
are safe and accurate as that of amniocentesis.

 CORDOCENTESIS

Also known as percutaneous umbilical blood sampling . A 22 gauge

spinal needle 13cm in length is inserted through the maternal abdominal and
uterine wall under real time ultrasound guidance using a curvilinear probe. The
needle tip is progressed carefully and it punctures the umbilical vein
approximately 1-2cm from the placental insertion. Generally 0.5 to 2ml of fetal
blood is collected. It is performed under local anesthetic usually from 18 weeks
gestation.

TOPIC 15 : COMPLEMENTARY THERAPIES IN OB

COMPLEMENTARY THERAPIES

Complementary therapies are those used in conjunction with conventional

therapies for example meditation used as an adjunct to analgesics drug.

HOMEOPATHY

❖ There are homeopathic drugs that may help to lessen the pain of natural
childbirth. These are pills with no side effects to be said that have to be taken
at regular intervals throughout the labour. ❖ Though homeopathy is not
recognized as a way of curing an ailment or pain quickly, it can start from the
later months of pregnancy, with the aim of reducing the eventual labour pain.
These drugs only be taken by recognized homeopathy practitioner and
obstetrician.

YOGA
 Yoga, a method of Indian origin, proposes control of mind and body.
Between the different types of yoga, ‘energy yoga’ can be applied to
pregnancy and delivery. Through special training of breathing, it achieves
changes in levels of consciousness, relaxation, receptivity to the world and
inner peace.

According to professionals who use this technique for delivery, yoga shortens
the duration of labor, decreases pain and reduces the need for analgesic
medication.

ACUPUNCTURE

• Acupuncture is well known Chinese practice. In this one uses needles

inserted at specific points to relieve pain this therapy is found beneficial and
relaxing during pregnancy.

• It is used to relieve pain and also to reduce morning sickness .

The placement of the needle will depend on which stage of labor patient is and
kind of pain.

• Advisable to take this treatment with experienced certificate practitioners.

• The basic theory include altering the body’s levels of chemical

neurotransmitters and influencing the natural electrical currents.

MASSAGE THERAPY

Touch and manipulation with the hands has been used in the practice of
medicine since its inception. The value of touch and massage and its positive
effect is well documented. Massage therapy can incorporate in nursing
practice throughout labour to promote relaxation and stress reduction.

Massage has been shown to be factors in promoting labour progress,

decreasing pain perception and increasing the woman’s ability to cope with
labour.

HYDROTHERAPY

❖ The use of hydrotherapy during labour, whether in a shower or a tub, is a

proven means of relaxation and pain relief.
 ❖ The warm water stimulates the release of endorphins, relaxes muscles to
decrease tension, stimulates large diameters nerve fibers to close gate on pain,
and promotes better circulation and oxygenation.

AROMATHERAPY

• Aromatherapy is the therapeutic use of plant derived essential oils to

promote physical and psychological well being .

• Essential oils are lipid soluble and are rapidly absorbed when applied
externally or are inhaled.

• They are excreted through kidneys or expired through the lungs.

• For labor therapeutic grade oils in low doses for massage or as an

environmental fragrance is increasing in health care settings.

eg:peppermint oil may be effective in decreasing nausea and vomiting.

MUSIC THERAPY

The use of music to relieve pain and decrease anxiety has been known to be
helpful for the relief of postoperative pain for same time.Research regarding
the use of music to reduce labour pain has also demonstrated that music may
be used to promote relaxation during the early stages of labour and as a
stimulant to promote movement during later stages, when physical exertion is
required for bearing down process.

BIOFEEDBACK : Biofeedback is a treatment that uses monitoring instruments

to provide visual or acoustic feedback to patient’s physiological information of
which they are normally unaware.

It puts the patient in control and gives them a sense of self-reliance that is an
important factor for laboring woman. For example childbirth classes or
childbirth classes plus video session about coping with labour pain etc.

TOPIC 16 :IUGR
Intrauterine growth restriction is said to be present in those babies whose
birth weight is below the tenth percentile of the of the average for the
gestational age . Growth restriction can occur in preterm, term or post-term
babies.

TYPES

Based on the clinical evaluation and ultrasound examination the small fetuses
are divided into:

1. Fetuses those are small and healthy. The birth weight is less than 10th
percentile for their gestational age. They have normal ponderal index, normal
subcutaneous fat and usually have uneventful neonatal course.

2. Fetuses where growth is restricted by pathological process (true IUGR).

Depending upon the relative size of their head, abdomen and femur, the
fetuses are subdivided into:
a) Symmetrical or Type 1
b) Assymmetrical or Type II
 Symmetrical (20 percent) The fetus is affected from the noxious effect very
early in the phase of cellular hyperplasia. The total cell number is less This
form of growth retardation is most often caused by structural or
chromosomal abnormalities or congenital infection (TORCH).
 Asymmetrical (80 percent):
The fetus is affected in later months during the phase of cellular hypertrophy.
The total cell number remains the same but size is smaller than normal. The
pathological process that too often result in asymmetric growth retardation
are maternal diseases extrinsic to the fetus. These diseases alter the fetal size
by reducing uteroplacental blood flow or by restricting the oxygen and nutrient
transfer or by reducing the placental site.
Etiology
The causes of fetal growth restriction can be divided into four groups:
● Maternal ● Fetal ● Placental ● Unknown
 Constitutional
Small women, maternal genetic and racial background are associated with
small babies. These babies are not at increased risk.
 Maternal nutrition before and during pregnancy- Critical substrate
requirement for fetal growth such as glucose, aminoacids and oxygen are
deficient during pregnancy. This is an important cause of IUGR in women
with undernutrition.
 Maternal diseases:
Anemia, hypertension,thrombotic diseases, heart disease, chronic renal
disease, collagen vascular diseases are the important causes.
 Toxins Alcohol, smoking, cocaine, heroine, drugs
 Fetal
There is enough substrate in the maternal blood and also crosses the placenta
but is not utilized the fetus. The failure of nonutilization may be due to:
1) Structural anomalies either cardiovascular
2) Chromosomal abnormality is associated with 8-12% of growth retarded
infants. The common abnormalities are triploidy aneuploidy. Trisomies (13,
18, 21) and Turner’s syndrome are commonly observed.
3) 3) Infection TORCH agents (toxoplasmosis, rubella, cytomegalovirus and
herpes simplex) and malaria.
4) 4) Multiple pregnancy- There is mechanical hinderance to growth and
excessive fetal demand.
 Placental
The causes include cases
The causes include cases of poor uterine blood flow to the placental site for
a long time . This leads to chronic placental insufficiency with inadequate
substrate transfer. The placental pathology includes: ● Placenta previa ●
Abruption ● Circumvallate ● Infarction ● Mosaicism
DIAGNOSIS
Significant improvements have been made by clinical and biophysical
methods in detecting a growth restricted fetuses.
● Clinical
- Clinical palpation of the uterus of the uterus for the fundal height, liquor
volume and fetal mass may be used for screening. But it is less sensitive.
- Symphysis fundal height (SFH) measurement in centimeters closely
correlates with gestational age after 24 weeks. A lag of 4cm or more
suggests growth restriction. It is a fairly sensitive parameter. Serial
measurement is important.
● Maternal weight gain remains stationary or at times falling during the
second half of pregnancy
● Measurement of the abdominal girth showing stationary or falling values.
 Biophysical: The first examination should confirm the clinical estimation of
gestational age. USG is extremely useful not only to diagnose the growth
retardation but also to identify a fetus of symmetrical or asymmetrical one.
Sonographic predictive values that are commonly used are:
 Head circumference (HC) and abdominal circumference (AC) ratios: In a
normally growing fetus the HC/AC ratio exceeds 1.0 before 32 weeks.
 In symmetric IUGR, both the HC and AC are reduced.
 Femur length (FL) is not affected in asymmetric IUGR. The FL/AC ratio
is 22 at all gestational ages from 21 weeks to term. FL/AC ratio greater
than 23.5 suggests IUGR.
Amniotic fluid volume
● The reduced amniotic fluid is too often associated with assymmetrical IUGR.
● A vertical pocket of amniotic fluid <1 cm suggests IUGR.
● The four quadrant technique consists of measuring the vertical diameter of
the largest pockets of the fluid found in each of the four quadrants of the
uterus.
● The sum of the results in the amniotic fluid index (AFI).
● An AFI between 5 and 25 cm is normal and an AFI less than 5 indicates
oligohydraminous.
Anatomical survey To exclude fetal anomalies by sonography (Aneuploidy,
structural defects).
● Doppler velocimetry: Elevated systolic / diastolic (S/D)ratio and/ or presence
of diastolic notch are associated with IUGR and intrauterine fetal hypoxia.
Uterine artery The presence of diastolic notch suggests incomplete
invasion of placental trophoblasts to the uterine spiral arteries. This also
predicts the possible development of pre-eclampsia. Normally, the
diastolic flow increases as pregnancy progresses. Reduced or absent or
reversed diastolic flow in the umbilical artery indicates fetal jeopardy
and poor perinatal outcome.
● Middle cerebral artery (MCA) Increased diastolic velocity (brain
sparing effect) is observed in a compromised fetus.
● Cerebral Placental doppler ratio is decreased in IUGR.
 ● Ponderal index (PI) The degree of fetal wasting is judged by fetal PI.
The index is determined by dividing the estimated fetal weight (g) by the
third power of crown-heel length (cm) (weight (g)/ length(cm)cube). PI
below 10th percentile is taken as IUGR. Estimation of PI by fetal
sonography has been made. Reduction in fetal facial fat stores has been
associated with IUGR.
Biochemical markers: Elevated levels of MSAFP and hCG level in the second
trimester are the markers of abnormal placentation and risks of IUGR. It is to
be borne in mind that accurate prediction of fetal growth restriction using
sonography has not been achieved.
PHYSICAL FEATURES AT BIRTH
● Weight deficit at birth is about 600g below the minimum in percentile
standard. Every hospital should have its own birth weight-gestational age
chart.
● Length is unaffected.
● Head circumference is relatively larger than the body in asymmetric variety.
 Physical features show dry and wrinkled skin because of less subcutaneous
fat, scaphoid abdomen, thin meconium stained vernix caseosa and thin
umbilical cord. All these give the baby an ‘old man look’. Pinna of ear has
cartilagenous ridges. Plantar creases are well defined.
 The baby is alert, active and having normal cry. Eyes are open.

● Reflexes are normal including moro-reflex

COMPLICATIONS

Fetal

a) Antenatal- Chronic fetal distress, fetal death

b) Intranatal :Hypoxia and acidosis

After birth

Immediate

● Asphyxia, bronchopulmonary dysplasia and RDS.

● Hypoglycaemia due to shortage of glycogen reserve in the liver.

● Meconium aspiration syndrome

● Microcoagulation leading to DIC.

● Hypothermia

● Pulmonary hemorrhage

● Polycythemia,anemia, thrombocytopenia

● Thrombosis

● Necrotizing enterocolitis due to reduced intestinal blood flow.

 Intraventricular hemorrhage (IVH).

● Electrolyte abnormalities, hyperphosphatemia, hypokalemia due to impaired

renal function

● Multiorgan failure

● Increased perinatal morbidity and mortality.

Late
Asymmetrical IUGR babies tend to catch up growth in early infancy. The
fetuses are likely to have

1) Retarded neurological and intellectual development in infancy. The worst

prognosis is for IUGR caused by congenital infection, congenital anomalies and
chromosomal defects.

Other long term complications are:

2) Increased risk of metabolic syndrome in adult life; obesity, hypertension,

diabetes and coronary heart disease (CHD).

3) LBW infants have an altered orexigenic mechanism that causes increased

appetite and reduced satiety.

4) Reduced number of nephrons- causes renal vascular hypertension.

Maternal
Fetal growth restriction does not cause any harm to the mother. But
underlying disease process like pre-eclampsia, heart disease, malnutrition may
be life threatening. Unfortunately for a woman with a growth retarded infant,
risk of having another is two fold.

MANAGEMENT
 Management is based upon the comprehensive diagnostic workup
(discussed before).
 Fetuses that are constitutionally small require no intervention.
 The fetuses that are symmetrically growth restricted, should be
investigated to exclude fetal anomalies, infections and genetic syndromes.
Unfortunately, there is no effective therapy for this group.
 Finally the growth restricted fetus owing to placental disease or reduced
placental blood flow (chronic placental insufficiency), may be given some
treatment. However, assessment of fetal well being is more critical in the
management as in majority there is no definitive therapy.
 General : At present, there is no proven therapy for reversing growth
restriction once it is established.

● However, the following may be tried with some success :

1) Adequate bed rest, specially in left lateral position.

2) To correct malnutrition by balanced diet; 300 extra calories per day are
to be taken;
3. To institute appropriate therapy for the associated complicating
factors likely to produce growth restrictionm
4) Avoidance of smoking,alcohol and tobacco
5) Maternal hyperoxygenation at the rate of 2.5L/min by nasal prong
forshort term prolongation of pregnancy
6) Low dose aspirin (50mg daily) may be helpful in very selected cases with
history of thrombotic diseases, htn, preclampsia or IUGR
7) Maternal hyperalimentation by amino acids can improve fetal growth if it
was due to maternal malnutrition.
8) Maternal volume expansion may be helpful in improving placental
perfusion.
ANTEPARTUM EVALUATION
Serial evaluation of fetal growth and assessment of well being should be
done once the diagnosis is made.
 Ultrasound examination
● Fetal well being
● Doppler ultrasound parameters are to be studied
TIMING OF DELIVERY
The factors to be considered are:
1) Presence of fetal abnormality
2) Duration of pregnancy
3) Degree of growth restriction
4) Associated complicating factor
5) Degree of fetal compromise
6) Previous obstetric history
7) Availability of neonatal intensive care unit.
 Pregnancy >= 37 weeks : Delivery should be done.
● Pregnancy < 37 weeks
a) Uncomplicated mild IUGR. The condition may be reversed and in such
cases the pregnancy is allowed to continue till atleast 37 weeks. Thereafter
delivery is done.
b) Severe degree of IUGR
● Delivery should be planned on the basisof fetal compromise.
● If the lung maturation is achieved by presence of phosphatidyl glycerol
and L:S ratioof>=2 from the amniotic fluid study (amniocentesis) delivery is
done.
● If lung maturity is not yet achieved, intensive care is required.
Betamethasone therapy is given to pulmonary maturation.
● Corticosteroids is also given.
METHODS OF DELIVERY
● low rupture of membranes followed by oxytocin.
● Intrapartam monitoring
● Caesarean delivery without a trial of labor
CARE DURING DELIVERY
Delivery should be in an equipped institution
IMMEDIATE CARE OF THE BABY AFTER BIRTH
● A pediatrician should be available at the time of delivery
 ● The same precaution as outlined in the premature delivery are to be
taken
● The baby should be placed preferably in the neonatal intensive care unit.
Intensive care protocols
The same protocols as conducted in the management of preterm babies.

TOPIC 17 :CAUSES OF ONSET OF LABOR

LABOR
The series of events that take place in the genital organs in an effort to expel
the viable products of conception (the fetus, placenta& the membranes) out of
the womb through vagina into the outer world.
CAUSES OF ONSET OF LABOR
➢Endocrine, biochemical and mechanical stretch pathways as obtained from
animal experiments has put forth the following hypothesis:
1. MECHANICAL
 Uterine distention theory
 Stretch of the lower uterine segment by the presenting part
 Mechanical stretching of cervix &stripping of fetal membranes.
2.BIOCHEMICAL
 Oxytocin
 Prostaglandins
 PAF
 Angiotensin II
 Histamine
 Serotonin & others
1. UTERINE DISTENSION
➢Stretching effect on the myometrium by the growing fetus and liquor
amnii is relevant in case of twins or polyhydraminos.
➢Uterine stretch increases the gap junction proteins, receptors for
oxytocin & specific CAP.

2.FETOPLACENTAL CONTRIBUTION

➢Cascade of events activate fetal hypothalamic-pituitary-adrenal axis

➢Increased CRH ➢Increased release of ACTH

 ➢Fetal adrenals
➢Increased cortisol secretion
➢Accelerated production of estrogen & prostaglandin from placenta
3.ESTROGEN
✓Increase release of oxytocin
✓Promote synthesis of myometrial receptors
✓Accelerate lysosomal disintegration in the decidual and amion cells
✓Stimulate synthesis of actomysin
✓Increase excitability of myometrial cell membranes
4.PROGESTRONE
✓Fall before birth
✓Alteration in estrogen
5 .PROSTAGLANDIN
➢Initiate & maintain labor
➢Uterotonin
➢Sites synthes: amnin, chorion, decidual cells & myometrium
➢Synthesis triggered by estrogen , glucocorticoids, cytokines, rupture of
membranes
➢Reaches peak during birth of placenta
6. OXYTOCIN
➢Oxytocin receptors:
❖More in fundus than in lower segment and cervix
❖ during pregnancy & reach maximum during labor
❖ sensitivity during labor
➢ stimulate synthesis & release of PGs
7.NEUROLOGICAL
➢Athoughthe labor starts in denervateduterus labor may also be initiated
through nerve pathways .
➢Both alpha & beta receptors are present in myometrium
➢Estrogen alpha receptor
➢Progesteron beta receptor
➢Contractile response alpha receptors of the prostaganglionic nerve fibers

TOPIC 18: TORCH

 DEFINITION : Torch syndrome may sound like a Single illness,but actually it
stands for a group of infectious diseases That can cause problems.

 HIV
Almost all U.S children age 13 who have HIV got it from their mothers during
pregnancy.
● HIV positive tests might not show that your baby has it at birth.
● Symptoms like delayed growth, pneumonia or swollen lymphnodes.
 SYPHILIS
● Pregnant women in the first or second stage of this sexually transmitted
disease pass it to their babies.
● 75% of the time if it’s not treated
 FIFTH DISEASE
● This disease is caused by parvo virus B19.
●His seldom a problem for pregnant women or their babies.
● Women are immune to the virus. So their babies won’t get fifth disease.
 RUBELLA
● It is also known as GERMAN MEASELS.
● Signs are low grade fever,sore throat and rash.
● At pregnant and get rubella in your first trimester.
 CYTOMEGALOVIRUS
● It is an infection in the herpes virus group.
● CMV is the most common viral infection passed on the babies in the about
1in 150 births.
● Hearing and vision loss,jaundice, small birth size,lung problems.
 HERPES SIMPLEX
● It is a life long infection but it can be inactive for periods of time.
● Also very common-More than 50% of people in the have it by the time they
reach their 20s.
 UTI
● A urinary tract infection happens in the body’s urinary system which
includes kidney’ureters,bladder and urethra.
● Most UTI cause by bacteria.
●UTI may lead to preterm labour and low birth weight.
SYMPTOMS
● Burning feeling
● A burning sensation or cramps in your lower back or lower belly.
● Urine that looks cloudy or has an odour.
TREATMENT
● Antibiotics for 3-7 days.
-Amoxicillin,erythromycin and penicillin.
● Ciprofloxacin,sulfamethoxazole,tetr acycline or trimethroprim.
PREVENTION
● Drink atleast eight glasses of water a day.
● Don’t douche.
● Wipe yourself from front to back.
● Avoid soap or deodorants.
● Wear cotton underwears.
● Don’t wear pants that are too tight.
SEXUALLY TRANSMITTED DISEASES
● Pregnant women with a STD may infect their baby before,during or after the
baby’s birth.
SYMPTOMS
● Bumps,sores or warts near the mouth.
● Swelling or redness near the vagina.
● Painful urination.
● Weight loss,loose stools,night sweats.
 Skin rash.
● Fever and chills
● Yellowing of the skin(jaundice)
● Bleeding from the vagina other than during the monthly period.
● Severe itching near the vagina.
● Developing baby can occur chlamydial infections
TREATMENT
● Antibiotics
● Use condoms everytime you have sex.
● Limit your number of sex partners.
● Don’t use alcohol or drugs before you have sex,especially when pregnant.
PREVENTION
● Follow your health care provider instructions.
● Use condoms whenever you have sex.
● Not having sex is the only sure way to prevent STDs
HIV
● HIV is a virus that attacks the body’s immune system.
● The immune system protects the body from infections.
● It controls and kill CD4 cells(also called T cells)
● These cells help your immune system fight disease.

SPREAD OF HIV

● Direct contact with body fluids.

● Contact with objects like dishes,toilet seats.

● Body fluids are blood,breastmilk, semen or preseminal fluid e.t.c.

PROTECT FROM HIV

● Don’t have sex. ● Limit the number of sex partners. ● Use a condom. ● Don’t
share needles and syringes

PROTECT BABY FROM HIV

● Treatment getting before and during pregnancy usually can prevent infection
in your baby.
● HIV medicines are given your baby throughout pregnancy,labour and birth.
● During labour and birth through contact with mom’s blood and vaginal fluids.
● After birth through breast milk.
SYMPTOMS
● Fever ● Malaise ● Headache ● Sorethroat ● Lymphadenopathy and
maculopapular Rash
DIAGNOSIS
● Detecting HIV viral RNA in blood by PCR testing.
● ELA test
● Western blot or HIV RNA PCR.
MANAGEMENT
● Prenatal care
● Integrated counselling and testing (ICD) in the antenatal clinic.
● In seropositive cases
● Test further STDs such as hepatitisB andC viruses.
● Serological testing for cytomegalovirus and toxoplasmosis.
 Counselling with education to the patient
● Progression of the disease is assessed by
● CD4+ T lymphocyte counts.
● HIV RNA
● Patient should have T.lymphocyte count in each trimester.
● Highly active antiretroviral therapy.

PRINCIPLES OF HARRT
 Suppress viral multiplication maximally.
 Reduce perinatal transmission
 Reduce the risk of drug resistance.
 Prophylactic antibiotics.
ANTENATAL CARE
● Women on HARRT should be screened for GDM.
● Screening against opportunistic infections.
● Screening for aneuploidy anomaly Scan.
INTRAPARTUM CARE
● Women presenting in labour.
● Zidovudine
● Elective cesarean delivery
● Amniotomy and oxytocin augmentation.
POSTPARTUM CARE
● Neonatal care.
● Antiretroviral therapy should be given to all neonates within 4hrs of birth.
● HIV antibody test is done at 18 months.
 Zidovudine syrup

TOPIC 19:LABOR PAIN RELIEF

GENERAL PRINCIPLES
 . Women are more satisfied when the have control over the pain
experience.
 . Caregivers commonly underrate the pain.
 . Women who are prepared for labor usually report a more satisfying
experience than those who are not prepared.

TECHNIQUES OF PAIN RELIEF

Mainly two Types

 . Non pharmacological method

 Pharmacological method

Non pharmacological method

a) Psychological support

. Proper psychological support throughout the pregnancy is an important

factor.

. Fear potentiates pain. So women who is free from fear and has confidence
requires smaller amount of pharmacological methods.

b) Educate

Educate on the process of labor and pain relief methods. If they receive
adequate knowledge regarding what to expect there will be less fear.

C) Relaxation techniques

 . Breathing exercises
 . Attention focussing
 . Positioning and movement
 . Touch and massage
 . Water therapy

Advantages:

 . Non invasive.
 . Addresses emotional and spiritual aspects of birth.
 . Promotes women's sense of control over pain.
 Disadvantages:
. Requires special training.
. Not effective for all.
Pharmacological method
a) analgesics and sedatives
The use of these medicines is to reduce the sensation of pain.
These causes a sense of relaxation for the women.
It includes:
 Meperidine: 50-100mg with promethazine 25mg ; IM; over 3-4 hrs.
 Nalbuphine: 10-20mg;IM; 3-6hrs.
 Butorphenol: 1-2mg; IM or IV; over 3-4hrs.
Advantages:
. Provides an increased abilityto the women to cope with labor.
. Nurse administered.
Disadvantages:
. Side effects such as nausea ,vomiting, drowsiness etc.
. Pain is not eliminated completely

b) Anesthetics
1. Regional anesthesia
It includes:
 . Epidural anaesthesia
 . Spinal anaesthesia
 Pudendal anesthesia

2. Local anesthesia

3. General anesthesia.

Topic 20: TEENAGE PREGNANCY

‘Sexual violence is any act, attempting to obtain a sexual act, unwaranted
sexual comments or advances or act to traffic or other wise directed against a
person’s sexuality using coercion, by any person regardless of their relationship
to the victim in any setting, including but not limited to home and work.’
(WHO, world report on sexual violence and helath, chapter 6).

FORMS OF SEXUAL VIOLENCE

 Rape or sexual assault

 Child sexual abuse

 Sexual harassment

 Sexual exploitation

 Sex trafficking

Sexual assault or rape

The term sexual assault refers to sexual contact without explicit consent of the
victim or by force. Force doesn’t always refer to physical pressure, but may
also include emotional blackmailing or even psychological.

Child sexual abuse

Child sexual abuse, also called child molestation, in which an adult or older
adolescent uses a child for a sexual stimulation. Child sexual abuse can occur in
a variety of settings, including home, school, or work. Child marriage is one of
the main forms of child sexual abuse; UNICEF has stated that child marriage
"represents the most prevalent form of sexual abuse and exploitation of girls".

FORMS OF CHILD ABUSE

1. Exhibitionism: It is a form of paraphilia. Exhibitionism is exposing one’s own

sexual organs to become sexually exited or having a strong desire to be
observed by other people.

2. Frondling with unwanted sexual touching

3. Sharing pornographic images or video’s

4. Sex trafficking

WARNING SIGNS
 1. Physical signs:

 Bleeding, bruises or swelling in genital area’s

 Torn or stained clothes

 Difficultly walking or sitting  Recurrent UTI  Pain

2. Behavioral changes:  Changes in hygiene( reluctance or even excessive

bathing etc.)
Development of phobias
Depression or PTSD
Suicidal thoughts
Night mare’s
Bed wetting
Over protective or assuming caretaker roll of siblings
Rebel behaviour
Running away from school or house

Drug facilitated sexual assault

DFSA, occurs whem alcohol or other drugs are used to compromise an
indivisuals ability to resist or prevent them from remembering the assault
or abuser. Alcohol is the most commonly used substance qnd other includes
anxiolyrics, sedatives, tranqulizers etc.
SIGNS OF BEEN DRUGGED
 Breathing difficultly  Feeling drunken when not consumed alcohol or
drugs  Nausea  Loss of bowel or bladder control  Sweating and
blurred vision  Waking up with no memories or missing large portion of
memory.
Sexual harassment
Unwelcomed sexual advances, request and other verbal or physical conduct
of a sexual nature, even unreasonable interference in an individuals life,
work or hostile environment with a sexual desire.
It may include:
 Unwanted pressurefor sexual favors
 Unwanted sexual looking, leaning over, touching etc.
 Sexual comment or jocks
  Hanging around a person
 Speading rumors about persons, sexual life
Sexual exploitation:
It is actual or attempted abuse of a position of vulnerability, power, or trust
for sexual purpose. It includinge:  Sexual assault or force prostitution 
Refuse to use safe sex practice  Making sexual relationship a condition for
assistance ( financial or privileges ).
STRATEGIES TO PREVENT SEXUAL VIOLENCE APPROACH
STOP SEXUAL VIOLENCE
S : social norms
 T : teach
 O : opportunity
 P : protective
 SV : support victims
SUPPORTING ORGANIZATION
 Azad foundation
Focusses on women who continue in abusive relationship because of their
financial dependence on the abuser. Aasraya A Crisis intervention center
for the lonely, distressed and suicidal. This confidential helpline is been
answered by professionally trained volunteers. The mission is to prevent
and manage mental illness by providing voluntary professional and essential
care and support to the depressed and suicidal.
 Nirbhaya centre
The justice Varma committee, set up the organization after 2012 nirbhaya gang
rape case. The organization stands for the immediate medicine, legal qnd
psychological needs of Sexual violence survivors.

TOPIC 21 : OB EMERGENCIES & MGMT

An emergency is defined as serious situation that happen unexpectedly and
demands immediate action.Preaparation and prevention should always be
used to reduce the risk of emergency occuring.
 CAUSES
 Maternal: Haemorrhage,Hypertensive disorder,Amniotic fluid
syndrome,Shock,Hypoglycemia,Inversion of uterus ,Rupture of uterus.
 Fetal :Placenta previa, Shoulder dystosia, Vasa previa,Abruptio
placenta,Cord prolapse .
Obstetrics Emergencies are:
1.CORD PROLAPSE
 DEFINITION :Umbilical cord comes out of the uterus with or before the
presenting part of the baby or descent of the umbilical cord by the side of
presenting part .
CLINICAL TYPES
 Occult prolapse: The cord is placed by the side of presenting part and
is not felt by the fingers
 Cord prolapse: The cord is lying inside the vagina or outside the vulva
following rupture of membrane
 Cord presentation:The cord is slipped down below presenting part
and is felt lying in the intact bag of membrane.
ETIOLOGY
1. Malpresentations: Most common in being transverse
2. Contracted pelvis
3. Prematurity
4. Twins
5. Hydraminos
6. Iatrogenic: low rupture of membrane.
DIAGNOSIS
Occult prolapse :Difficult to diagnose. Persistent variable deceleration of fetal
heart rate.Detected on continuous feral monitoring.
Cord prolapse :Cord pulsation cease during contraction ,return after this pass
off.
MANAGEMENT
Management protocol is guided by
1. Baby living or dead
2. Maturity of the baby
3. Degree of dilatation of cervix.
 Baby living
1. Definitive treatment: Cesarean section
2.. Immediate safe vaginal delivery: If head is engaged, delivery is by forceps. If
breech delivery, is by extraction.
3. Immediate safe vaginal delivery is not possible: First aid management:
Patient is prepared for assisted delivery transferred to an equipped hospital.
If oxytocin infusion is on, stop this and start IV fluids and O2 by face mask.
 Bladder filling :To raise the presenting part Filled the bladder with 400-
750ml of NS with foley s catheter.
 Lift presenting part: By gloved fingers introduce into the vagina
 Postural treatment: Elevated sim ’s position with a pillow under the hip .
 Replace cord into vagina: To minimize vasospasm due to irritation
  Baby is dead
Labour is allowed to proceed awaiting spontaneous delivery.

.INVERTION OF UTERUS
DEFINITION
It is an extremely rare but a life threatening complication in third stage in
which the uterus is turned inside out partially or completely.
VARITIES
 First degree: There is dimpling of the fundus,which still remains above
the level of internal os
 Second degree: The fundus passes through the cervix but lies inside
vagina
 Third degree: Endometrium with or without the attached placenta is
visible outside the vulva.
ETIOLOGY
1. Spontaneous: Localised atony of placental site over the fundus
associated with sharp rise of intra abdominal pressure as in
coughing,sneezing etc.
2. Iatrogenic: Mismanagement of 3rd stage of labour such as pulling of
cord, faulty technique in manual removal etc.
3.Risk factors: ■ prolonged labor ■ short umbilical cord ■ uterine
malformations ■ fetal macrosomia
DANGER SIGNS
1. Shock: due to peritoneal irritation and tension of nerves.
 2. Hemorrhage: after detachment of placenta.
3. Pulmonary embolism
4. If left uncared it lead to Infection ,Uterine sloughing
5. Acute lower abdominal pain
6. Abdominal examination shows
! cupping and dimpling of fundal surface
! pear shaped mass protrude out side the vulva with broad end
pointing downward locking reddish purple in colour.
MANAGEMENT
* Call for extra help.
*Before shock develop urgent manual replacement even without
anaesthesia, If it is not readily available, is the essence of treatment by
skilled one.
Principal steps
Patient under general anesthetia:
! To replace that part first,which is inverted last with the placenta
attached to the uterus steady firm pressure exerted by the finger.
! To apply counter support by the other hand placed on the abdomen.
! After replacement,hand should remain inside the uterus until the
uterus become contracted by parenteral oxytocin.
! Placenta is to removed manually only after uterus contracted.
 After shock develops
! The treatment of shock – NS infusion and blood transfusion.
! Foot end can be raised
! Replacement of uterus by hydrostatic method(O sullivan’s)

RUPTURE OF UTERUS.
DEFINITION : Disruption in the continuity of the all uterine layers
(endometrium,myometrium and serosa) any time beyond 28wks of
pregnancy is called Rupture of uterus.
ETIOLOGY
Broadly divided into
* Spontaneous rupture.
* Scar rupture.
* Iatrogenic rupture
Spontaneous rupture.
During pregnancy:
*previous damage to uterine wall followed by D and C operation
*congenital malformations During labor:divided into Obstructive and non
obstructive rupture.
Obstuctive rupture. :
*Following obstructed labor
*Pelvic tumour
Non obstructive rupture.
* Grand multipara
* Congenital malformations of uterus
Scar Rupture During pregnancy:
*CS scar
*Hysterectomy
*Previous removal of D and C During labor
*Mymectomy scar
*Repair of previous obstructive rupture
Iatrogenic rupture During pregnancy:
*Injudicious administration of oxytocin
*Use of prostaglandin for induction of abortion or labor
*Motor vehicle accident During labor
*Manual removal of placenta
*Vaginal operative delivery
DIAGNOSIS
Scar rupture:
During pregnancy
*Complaints of dull abdominal pain
*Slight vaginal bleeding
*Tenderness
*FHS irregular
*Acute abdominal pain and collapse
During labor
*Dull abdominal pain
*Tenderness
*Confirmation by laparotomy
 Spontaneous Rupture :
During pregnancy
*Acute abdominal pain with fainting attacks
*Features of shock
*Tenderness
*Absence of FHS
*Rupture due to use of oxytocis: abdominal pain,vaginal bleeding may
occurs.
During labor :
:In obstructive case
 Premonitory phase
*Pain continuous and confined in suprapubic region
*On examination patient dehydrated and exhausted
*Pulse rate and temperature rise
*FHS absent
*On vaginal examination:presenting part is jammed in pelvis vagina become
edematous.
 Phase of rupture
*Constant pain is changed to dull aching pain
*General examination shows exhaustion and shock
*Abdominal examination revels absence of uterine contour and FHS
*Vaginal examination revels degree of bleeding.
In non obstructive case
*Usually rare
*Bursting pain followed by a relief with absence of contraction.
*Presence of shock
*Tenderness over uterus
*Varying degree of vaginal bleeding
*Rupture followed by instrumental delivery: shock,peritonitis may occur
MANAGEMENT
Prophylaxis
*The risk of mother likely to rupture should have mandatory hospital delivery
*Judicious selection of cases with previous history of Cesarean section for
vaginal delivery
 *Attempted forceps delivery through incompletly dilated cervix should
avoided
*Destructive vaginal operation is by skilled persons.
Treatment
●Resuscitation ●Laprotomy
Laprotomy : any of 3 procedure adopted following laprotomy .
 Hystectomy:for ruptured uterus
 Repair:applicable for scar rupture
 Sterilisation: clean cut scar rupture with desired number of
children.

SHOCK IN OBSTETRICS
DEFINITION
Defined as a state of circulatory inadequacy with poor tissue perfusion
resulting in generalised cellular hypoxia.
CLASSIFICATION
☆Hypovolumic shock Hemorragic Non hemorragic
☆Septic shock
☆Cardiogenic shock
☆Extracardiac shock
☆Hypovolumic shock :Circulatory blood volume is inadequate resulting in
Hemorragic and Non hemorragic shock.
Hemorragic shock
■ Early phase:Mild vasoconstiction,normal BP and tachycardia
■ Intermidiate phase:Hypotension,patient become pale and tachycardia
■ Late stage:Hypotension,extremities cold and clammy,metabolic acidosis
coagulopathy,associated with ectopic pregnancy.
Non hemoragic
■ Fluid loss shock: vomiting,diarrhoea and removal of amniotic fluid
■ Supine hypotensive syndrome.
Septic shock
■Hypotension: sytollic BP <90mmHg
■Associated with septic abortion ☆Cardiogenic shock
■Myocardial infarction cardiac arrest
☆Extracardiac shock
■Massive pulmonary embolism,amniotic fluid syndrome
MANAGEMENT
☆Hemorragic shock
■ Restore circulatory volume.
*Crystalloids :NS has infused
*Colloids:polygelatin solution isotonic with plasma
*Dextrans
■Maintenance of cardiac efficiency
* 6L of crystalloids may be needed for loss of 1L of plasma
* Packed BBC combined with NS
■Admisistration of O2 to avoid metabolic acidosis
■Pharmacological agents:vasoactivedrugs,inotropes, corticosteroids
■ Control of hemorrage
☆Endotoxic shock Principles
*Correct hemodynamic instability
*Appropriative supportive care
*Remove source of sepsis
■Antibiotics
*Commonly due to gram-ve organisms
*Ampicillin 2gm ,Gentamycin,Metronidazole.
■IV fluids
*2wide bore canula are sited
*Isototic solutions,liberal infusion and blood transfusion.
 Correction of acidosis
*Bicarbonte should be administered
■Maintenance of blood pressure
*Inotropic agents –adrenaline,noradrenaline,dopamine
*Vasodilator therapy- to improve stroke volume
Treatment of myocarditis
*Digitalis given
■Intensive insulin therapy
*Given in patient with septic shock to maintain normal blood glucose level
■H2 blocker
*To reduce stress ulcer
 Diuretic therapy
  Corticosteroids
 Heparin therapy

.Vasa previa
DEFINITION
Condition which fetal blood vessels cross or run near the internal opening of
uterus.These vessels are at risk of rupture when supporting membranes ,as
they are supported by the umbilical cord or placental tissue.
Causes and risk factors
*Velementous placenta : This is when the umbilical cord goes into the
membrane,resulting in vessels that are unprotected leading to the placenta.
*Risks include
!placental previa
!previous uterine surgery
!pregnancy occurred through in vitro fertilisation
Symptoms
In many cases there are no symptoms:
*Painless vaginal bleeding
*Blood is very dark
*Fetal bradycardia
*The blood of foetus is naturally lower in O2 than that of mother.
DIAGNOSIS
 Trasvaginal scan combined with colour doppler: Thus allows colour to be
added to the image to enable the technician to see which way the blood
is flowing and what speed.

MANAGEMENT

Mainly depend on fetal gestational age, severity of bleeding resistance or

reccurence of bleeding:

*Patient with confirmed case previa needs antenatal admission at 28 -32

wks of gestation.

*Continuous monitoring of NST every 6-8 hrs at about 32 wks

*Antenatal corticosteroids for increasing lung maturity

 *Bleeding case previa,emergency Cesarean section should be done.

*If vaginal bleeding continues,done premature rupture of membrane

*A case confirmed case previa at term should be delivered by elective

cesarean section prior to onset of labor.
 .